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Fracture Symptoms and Treatment

What is a Fracture

Fractures are broken bones. Anyone who has had a fracture knows how very painful they are. Fractures in children who are still growing need special attention to be sure the bone heals normally and continues to grow properly. Children’s bones fracture differently from adults’ bones, because they have less mineral and more protein, and because they are still growing. Fortunately, most children’s fractures heal well with good care.

Doctors use both physical examinations and X-rays to diagnose fractures. A “simple fracture” is one in which the bone breaks in only one clear area. A “complex” fracture is one in which the bone breaks in several areas or has more than 2 pieces. A “compound” or “open” fracture is one in which bone fragments break through the skin from the inside. These are among the worst kinds of fractures because there is a high risk of infection in the bone itself. Doctors use the “Salter-Harris” (SH) system of terms for fractures in a bone that is still growing. Fractures in SH categories 1 and 2 do not threaten future bone growth. SH categories 3 through 5 are increasingly severe kinds of injuries, and need special attention to give the bone the best chance for proper healing and future growth.

What is the biggest concern?

There are several important concerns in children and teenagers with fractures:

  • Pain is usually the most immediate concern for the child and parents. Bones and the tissues around them have nerves in them that feel pain, and a broken bone is very painful. Any kind of movement that causes the broken parts of the bone to move against each other is especially painful. If other structures like nerves and blood vessels are injured, they may cause additional pain.
  • Because large arteries and veins often run right along a bone, doctors are always concerned about the possibility of damage to them. Blood vessel damage can reduce or even stop blood flow to the part of the arm or leg farther away from the body. This can cause severe pain, and if it lasts long enough, tissue may begin to die from lack of oxygen and nutrients. In severe cases, this kind of injury can make an amputation necessary.
  • Large and important nerves also run along bones. Nerves can also be damaged by bone fragments. Because nerves heal very slowly, nerve damage is a very serious concern in any fracture. Nerve damage that goes either undetected or that can’t be repaired can leave a body part weakened, paralyzed, or without normal feeling.
  • Short- and long-term function of the injured body part is another concern. Kids and parents need to know how long they will be unable to walk, run, jump, dance, play sports, etc, while the bone heals. They also need to know about any permanent disability that may result from the fracture.

Fortunately, with prompt and skilled care, your child with a broken bone can have minimal pain and is quite likely to have a good to excellent outcome. Careful attention to your doctor’s instructions about immediate care, follow up, and warning signs can make a big difference for you and your child.

How to treat a Fracture

Casts and Splints

The most important part of treating any broken bone is to “immobilize” it. That means to make certain that the bone fragments don’t move against each other or against important things like blood vessels and nerves. Immobilization markedly reduces the pain of a fracture as well. You or someone else probably immobilized your child’s injured arm or leg as soon as possible after the injury. Your doctor then probably took some X-rays to find out exactly what bones were injured. Doctors often X-ray bones or joints near the injury as well, to be sure there isn’t a hidden additional injury. Your doctor also did a physical examination to be sure your child didn’t have any nerve or blood vessel damage. When doctors suspect that kind of damage, they usually consult with orthopedic surgeons, who may recommend an operation. If that was the case with your child, you have probably spent quite a bit of time in a hospital recently.

After the X-rays and other tests or procedures, your child probably had a cast or a splint put on the injured arm or leg. The purpose of these devices is to maintain immobilization of the bone for enough time that the bone can heal. They also prevent the bone from slipping back into an abnormal position, which could cause damage to nerves and blood vessels that escaped injury the first time. A cast is a solid wrapping that goes all the way around the injured body part. It has the advantage of providing very good immobilization, and being impossible for the child to remove him or herself. The disadvantages of casts are that they take longer to apply than splints, and that they carry a small risk of cutting down blood flow to the area as tissue swells. Splints are solid strips of material that go along each side of an injured part, but don’t wrap all the way around it. Splints are fast and easy to put on, and they do not carry any risk to blood flow. Their down side is that they can’t provide as solid support as a cast, and an uncooperative or curious child can remove a splint him or herself.

Doctors make casts and splints out of several different materials. Plaster and fiberglass are the most common materials for casts. Splints are usually made of plaster, or they may come pre-made out of solid plastic or similar material. Your doctor will have made the best choice of material for your child based on age, activity level, and the amount of time the cast or splint will be required.

Plaster casts need to stay dry – the plaster will rapidly melt and fall apart if it gets wet. Fiberglass casts are water-resistant, but they are not waterproof. The padding material inside either kind of cast is soft, absorbent cotton. If it gets wet it “wads up” and can cause painful pressure. It can also start to grow mildew and cause itching and irritation. If it gets bad enough, wet padding can cause breakdown of the skin, and the cast may need to be removed. Most doctors recommend wrapping the cast in a plastic bag secured with some tape whenever the child takes a bath or a shower. Never let the cast or splint go completely under water. If this happens, please call your doctor immediately.

Slings

Since casts and splints interfere with movement, we usually need to give some support to help the child or teen move around and function. Doctors give slings to people with arm, wrist, hand, and shoulder fractures. The sling helps support the arm, and prevents the child from dangling it at the side, which could make any swelling worse. The sling also provides a handy reminder that the arm is injured, and that the child should not try to use the arm. Please be sure to remove the sling whenever your child lies down to sleep, to prevent tangling and possible suffocation.

Crutches

Crutches help people with broken hips, legs, knees, ankles, and feet. Used properly, crutches can help your child get around easily, and even go up and down stairs. Used improperly, though, crutches can cause discomfort, pain, and even make another fracture likely if the child falls. Your doctor or nurse determined the height of your child’s crutches based on your child’s own standing height. The top of a properly fitted crutch reaches to two to four finger-breadths below the armpit. A taller crutch will dig into the child’s skin and cause soreness and pain, and can even cause nerve injury to the arm. A shorter crutch will cause your child to hunch over and can cause back and neck strain. Unless your doctor specifies otherwise, your child should always use both crutches. There are very few times that a single crutch is useful, and it can cause injury to the other leg.

It is important that your child not “dangle” from the crutches. This can damage the nerves in the arm, and is an unstable position that can cause a fall. If you see your child dangling from the crutches, please check to make sure the crutches are not too long. If they are, adjust them to be the proper height (please see above). If the crutches are the proper height, please go over correct use of the crutches with your child.

There are two ways to use crutches. Your doctor will have told you which is best for your child.

Non-Weight-Bearing

Most of the time doctors recommend “non weight-bearing” at first. To use crutches this way, have your child stand up on the “good” leg, with the injured leg off the ground slightly. Have your child imagine a solid bar that connects the tips of the crutches to the foot on the injured side. The child takes his or her first step onto the crutches with the injured leg off the ground or barely touching. Have the child then take a step forward onto the good leg. When all the weight is on the good leg, the child lifts the crutches off the ground and swings them, along with the “connected” injured leg, forward and puts the crutches back on the ground. This can take some practice. Many younger children tend to start off doing it backwards. If you see your child hopping along, chances are s/he is using the crutches backwards, and will need some more practice.

Partial Weight-Bearing

After the bone has healed and the cast is removed, your doctor may recommend “partial weight-bearing.” This is a good way to have the child start using the leg again. The child imagines a solid bar again connecting the crutch tips with the injured leg. This time, though, s/he puts the crutch tips and the injured leg on the ground at the same time, supporting weight on the tips and the leg. S/he then swings the good leg forward and steps onto it normally, and then lifts the crutches and the injured leg together for the next step.

Sitting down and getting up again will also take some practice. You can use these illustrations as a guide. To sit down, have your child put both crutches on the same side as the injured leg. Using the good leg for support, place the other hand onto the arm of the chair or couch. Your child can then lower him or herself onto the seat.

To get up, just reverse the process. Again using the two crutches on the injured side, the child stands up onto the good leg, using the arm on that side for support and control. S/he then starts to walk as above.

Using stairs – If your child’s school has an elevator, please get permission for him or her to use it. When stairs are unavoidable, follow these instructions:

  1. Don’t try to carry anything up or down stairs when using crutches.
  2. To go up stairs, start by getting right up close to the bottom step. Take the first step onto the stair with the good leg. While standing on that leg, bring the crutches and the injured leg to the same step. Repeat this for each step. Please remember that youhave to take stairways one step at a time!
  3. To go down stairs, start by putting the crutches and the injured leg onto the first step down. Next, step down onto that stair with the good leg. Repeat this, again taking one step at a time.
  4. An easy way to remember which leg to start with is: “up with the good, down with the bad.”
  5. If you can find stairways with strong hand-rails, use them. Test the hand-rail before putting all of your weight on it to be sure it won’t break.
  6.  Put both crutches under the arm away from the handrail, and then use the handrail and crutches to support the injured leg. Take the stairs up or down as described above.

Pain Management for a Fracture

The worst pain of a fracture usually goes away after casting or splinting. Most children will need some pain relief for a few days. You can give your child acetaminophen (Tylenol®) or ibuprofen (Advil® or Motrin®) as directed for the next several days to help relieve pain. For the first few days, most doctors will offer a mild narcotic pain medicine like codeine, hydrocodone (Lortab® and others), or mixtures such as Tylenol 3®, Tylenol® with Codeine, or Vicodin® and others. These medications are very safe when used as directed.

Dangerous Fracture Symptoms

Most fractured bones heal normally and without problems. The most common problem with a cast is that the tissue underneath it swells for up to 48 hours after the injury. This can put pressure on areas that were fine when the cast was first put on. Here are a few things to watch out for that could suggest that a problem might be developing:

 

 

 

  • Pain at the area of the fracture that gets worse rather than better over several days
  • Pain in a place other than the fracture
  • Numbness, tingling, pain, swelling, weakness, or discoloration of a body part beyond the cast.
  • Complaint that the cast feels “too tight” or otherwise uncomfortable
  • A splint that shifts its position or comes off
If any of these occur, please be sure to call your doctor’s office right away. If your child or teen has severe pain, numbness, tingling, or blue or pale extremities, please go directly to the emergency room.

Other points of concern

Most hospitals that care for children use some form of sedation and pain relief while a cast or splint is being applied. The drugs that they use for sedation are very safe and have few side effects, but once in a while a child may have an unusual reaction. Many children feel dizzy or uncoordinated for a few hours. Until you get home and get the child into bed, please keep one hand on his or her arm as you walk to and from your car, and be ready to steady the child if s/he staggers or slips. Vomiting is a fairly common effect after sedation. Please offer sips of clear liquids and cool compresses. Most children stop vomiting within a few hours. Rarely, older children and teens have nightmares or vivid dreams for a few nights after certain kinds of medications. If this happens, please call your doctor.

Casts often cause itching, and children may try to reach inside the cast with an object to scratch the itch. Most doctors have had to remove more than one cast after a pencil, comb, or other object disappeared down the cast. These objects can cause severe irritation, and they must come out, which is no fun for anyone involved. Many doctors recommend getting a ruler or another long thin object that is several inches longer than the cast. Your child can use this (supervised) to scratch, and it cannot get lost in the cast. You can give your child diphenhydramine (dye-fen-hi-drah-meen; Benadryl® and many others) for relief of itching. The main side effect of diphenhydramine is drowsiness, which is actually often helpful to a child whose itching is making him or her frantic.

Other Conditions that Might Be Present

Any injury that can cause a broken bone can cause other kinds of damage to a child. Your doctor will have done a thorough physical examination, but some kinds of injuries are hard to detect at first. If your child complains of headache, dizziness, blurred vision, seems disoriented or sleepy, or has abdominal pain or back pain, please call your doctor right away.