Fracture facts

All the facts on fractures

While all children aren’t as talented as my spouse, who racked up four broken arms (including two at once!) before puberty, fractures are as much a part of childhood as monkey bars. According to one survey, fractures accounted for 22 percent of injuries in boys and 27 percent in girls over a one-year period. So clearly, it makes sense to arm yourself with a few fracture facts.

Is it broken?
Unless your son’s shin is suddenly bent into an L, it’s not always possible to tell if a bone is broken without an X-ray, even for ER docs. (One lucky break: Serious fractures are so painful they’re next to impossible to overlook, and if a cracked or bent bone doesn’t cause enough discomfort to get detected immediately, it will likely heal properly or not lead to complications.) But certain clues do make the presence of a fracture more probable — so get your child checked out if you spot these warning signs following a collision or fall:
• swelling
• persistent, localized pain
• your child stops using the limb or holds it guardedly

You should also call your doctor if, two or three days after taking a tumble, your kid complains the pain isn’t subsiding. “Most bumps and bruises settle down after 48 to 72 hours,” notes David Warren, a paediatric emergency consultant at the Children’s Hospital of Western Ontario in London, Ont. “If your child is still limping or not using the arm after that period of time, he needs to be checked out.”

Fracture first aid
So, you suspect your daughter has broken her arm — what next? If bone is poking through the skin or your child is clammy and unresponsive, keep her warm and call an ambulance. Otherwise, here’s how to make the drive to hospital or clinic more comfortable:

Rest and elevate Do what you can to ensure the area doesn’t have to move or bear weight. Elevate the limb slightly (for example, use a pillow or bundled coat to hold an injured forearm 10 or 15 degrees higher than the elbow) to minimize swelling.
Ice Apply an ice pack, ice wrapped in a towel or bag of frozen veggies to keep swelling down and help ease pain. (Don’t place directly on skin.)

Splint Make a support with a long, narrow object — cardboard, a rolled-up Today’s Parent or even a pillow. (Pad hard material with something soft like a piece of clothing.) Place the splint alongside the limb, securing it with strips of fabric or tape. “Make sure it’s fastened firmly, but not tightly,” says Stephen Tredwell, professor and head of orthopaedics at BC Children’s Hospital in Vancouver.

Pain relief It’s OK to give acetaminophen or ibuprofen with a swallow of water, but…

No snacks or drinks Food or more fluid in the stomach makes it riskier to give general anaesthetic (which may be needed while doctors reposition the bones) and can thus delay treatment.

Splint, cast, surgery… or nothing?
How a fracture is treated depends on several factors, including the location and severity of the break, and the child’s age. Happily, kids’ bones knit faster than adults’ and, if set at a less-than-perfect angle, will straighten out as they grow.

Nothing Certain fractures rarely need treatment. Surrounding tissue provides sufficient support for a single broken toe; unless a collarbone break is unusually bad, a sling is all that’s needed.

Splints Other breaks need only minimal bracing. Most finger fractures are strapped with splints, and doctors have also begun splinting buckle fractures. (Buckle fractures occur when newly grown bone scrunches under pressure, forming a kink. This commonly happens to the bone in the outer forearm, when a child throws out his arms to break a fall.)

“If the bone is fractured only on one side, most emergency department doctors will splint it,” explains François Bélanger, division chief of paediatric emergency at Alberta Children’s Hospital in Calgary.

Casts In most other cases, a cast will be needed to keep the broken ends of the bone together and shield it from further injury. Doctors now have two choices of casting material: plaster or fibreglass. While plaster is cheap, easy to mould and more flexible, fibreglass is light, durable and water-resistant. (Fibreglass casts aren’t truly waterproof — the skin still breaks down when moisture is trapped underneath. Special liners can overcome this problem, but these can cost $200 to $300 and aren’t covered by most provincial health plans.)

So how does the doctor decide? If the limb is swollen, plaster may be used and replaced when the swelling subsides. In other cases, it depends how much wear and tear the cast is expected to endure and how hard it is to shape a cast around the specific injury. For example, a rambunctious preteen who’s broken a couple of plaster casts is a good candidate for fibreglass! But doctors have a bit of time to decide since it takes about a week for the bone to begin to knit.

Surgery open fractures (where the skin is broken) must be washed out in the operating room to prevent infection. Doctors surgically repair broken bones with screws and plates or rods when a child has other injuries that need monitoring, or when a cast can’t keep broken bones in the correct position. Breaks involving a joint, or a growing zone are also more likely to need a surgeon’s skill, explains Unni Narayanan, a paediatric orthopaedic surgeon at Toronto’s Hospital for Sick Children. (Called “growth plates,” segments of bone responsible for growth are found near ends of long bones — for example, above the ankle, knee and wrist.)

When a school-aged child breaks a femur (thigh bone), the family may be offered a treatment called external fixation as an alternative to a chest-to-toes cast. Fastening the bones in place with screws (they stick out through the skin and are connected by metal bars) poses a small risk of serious infection and produces scars — but allows much greater mobility because kids can bend the knee and hip. After a few weeks, they can probably even go back to school under the right circumstances, although clothing options will be limited to long skirts and tear-away track pants.

Pain control
A cast or splint alone usually offers a lot of relief. Any lingering discomfort usually responds to “acetaminophen, elevation and TV — some form of distraction is fantastic,” says Tredwell. (If an over-the-counter pain reliever doesn’t provide enough relief, your child’s doctor will probably prescribe an acetaminophen-codeine combo. None of these medications will mask the pain of potential complications, Bélanger reassures.) If the pain gets worse, however, head back to emerg —the cast may be too tight.
Casting calls

1. Don’t get it wet! Use a plastic bag secured with an elastic, or a Velcro-sealed cast cover (available at home health care stores) to keep the cast dry during showers or sponge baths. Soaking in the tub is out, unless it’s possible to drape the cast over the edge.

2. Do not let your child stick anything inside to relieve that itch — a scratch can easily become infected. Since sweating causes most itchiness, set a blow-dryer on cool and direct air under one end, then the other.

3. Call your doctor if the cast becomes loose, or if an object becomes trapped underneath it. (Even a penny can damage the skin over time.) And keep the cast as clean as possible — remember, you’ll be living with it for some time!

4. How long? There are no hard and fast rules — it depends on the kind of break and the child’s age (the younger the child, the quicker bones repair themselves). A simple buckle fracture in a toddler may mend in two or three weeks, while a teen’s broken femur can take six to eight.

5. What should you expect when the cast comes off? Stinky skin and weakened muscles. While the smell should clear up within a few days, physical therapy may be needed to help rebuild strength and balance. (Occasionally, body hair grows in longer or darker than usual, but hair growth typically returns to normal within a few months.) Be sure to heed your doctor’s recommendations about resuming activities like sports, since recently healed bone is a little stiffer and vulnerable to reinjury.

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