Think of the skeleton as the strong frame (like the iron bars in a building) on which the entire body is built. Without bones, the body would be like a bag of water - soft and shapeless.

Remember: P-S-M-R

• Storage: The bone "bank" is controlled by hormones. Parathyroid Hormone (PTH) stimulates Osteoclasts (bone-crushing cells) to break down bone and release calcium into the blood when levels are low. Calcitonin stimulates Osteoblasts (bone-building cells) to pull calcium from the blood and store it in the bone.
• Hematopoiesis: In children, almost ALL bones contain active Red Bone Marrow. As we age, this converts to Yellow Marrow (fat), and RBC production is restricted to flat bones (pelvis, sternum, skull).

Bones are living organs - they are NOT dead like dry sticks. They have their own blood vessels (to bring food and oxygen) and nerves (to feel pain). Bone tissue is also called osseous tissue ("os" means bone in Latin). Bones have three layers:

1. Periosteum: Outer covering like the skin of the bone, rich in blood vessels and pain receptors.
2. Compact bone: Hard, dense outer layer (like the shell of an egg). Composed of osteons.
3. Spongy bone (Cancellous): Inner layer with holes like a sponge, contains the bone marrow.

Children's bones are like green tree branches - they bend before they break. Adult bones are like dry twigs - they snap easily.

• The growth plate is the most vulnerable part of a child's bone.
• It is made of cartilage (soft tissue) where new bone is produced.
• It is located at the ends of long bones (between the epiphysis and the metaphysis).
• By late teens, the growth plate closes - cartilage is replaced by bone tissue.
• The epiphyseal line (where the plate was) can be used to estimate a person's age.

Nursing Alert: Injuries to the growth plate (Salter-Harris fractures) can cause permanent shortening or deformity of the limb.

The epiphyseal plate grows via Endochondral Ossification. It has distinct microscopic zones:

1. Resting zone: Inactive cartilage cells attaching to the epiphysis.
2. Proliferating zone: Cartilage cells multiply rapidly, stacking up like coins to lengthen the bone.
3. Hypertrophic zone: Cells swell up and mature (this is the weakest zone where most fractures occur!).
4. Calcification zone: The matrix calcifies, cells die, and osteoblasts turn it into true bone.

By the end of this section, you should be able to: Define what a fracture is; Classify different types of fractures; Understand general management principles; Identify common nursing diagnoses; Manage fractures following nursing diagnoses.

A fracture is a complete or incomplete break in the continuity of a bone. Think of it like a break in a stick - it can be cracked but not fully broken (incomplete) or snapped into two (complete).

• Fractures occur frequently in children and adolescents.
• 42% of boys and 27% of girls will suffer a fracture during childhood.
• Most common sites: Forearm and wrist (because children put their hands out when they fall).
• Overall rate: 12-36 per 1,000 children per year. Children under 5 years: 4.38 per 1,000 per year.

Remember: D-C-T-M

• Falls from trees (common in rural areas)
• Road traffic accidents (Boda-boda injuries)
• Sports injuries (football, running)
• Home accidents (falling from beds, chairs)
• Physical abuse (always consider in children with unexplained or spiral fractures!)

• What happens: The bone bends significantly but does NOT break.
• Like: Bending a green tree branch - it curves but doesn't snap.
• Common in: Young children (under 10 years).
• Treatment: May need gentle straightening (reduction) and casting.

• What happens: The bone buckles (wrinkles) like crushing a paper cup.
• Cause: Compression injury - the bone is squeezed together.
• Common in: Children under 10 years. Usually caused by: Fall on an outstretched hand (FOOSH).
• Characteristics: Inherently stable (won't move out of place). One side of bone is compressed, the other bulges out.
• Treatment: Immobilize in Plaster of Paris or backslab (half cast). Follow-up in fracture clinic within 2-3 days. Remove plaster in 3-4 weeks. Then mobilize.

• What happens: Incomplete fracture - the bone bends on one side and tears slightly on the other.
• Like: Breaking a green stick from a tree - it cracks on one side but stays connected.
• Most common type of fracture in children.
• Why it happens: The energy from the injury is not enough to break the bone completely through both sides. (Physiology note: The convex side undergoes tension and fractures, while the concave side is under compression and remains intact).
• Treatment: May require manipulation under anesthesia (MUA) - doctor gently straightens the bone while child is sleeping. Then apply cast. Healing time: 3-6 weeks.

• What happens: Broken bone sticks out through the skin.
• Danger: High risk of infection (osteomyelitis) because bone is exposed to outside environment.
• Nursing Priority: Cover wound with sterile dressing immediately. Do NOT push bone back in. Give IV antibiotics urgently. Administer Tetanus prophylaxis. Prepare for emergency surgery (washout and fixation).

• What happens: Bone is broken but skin is intact.
• Advantage: Lower risk of infection. Treatment: Reduction (straightening) and immobilization.

What happens: Break goes across the entire cross-section of the bone. The bone is broken into two separate pieces.

Types by pattern:

• Transverse: Break is straight across (like cutting a log straight).
• Oblique: Break is at an angle (like cutting a log diagonally).
• Spiral: Break goes around the bone like a spiral staircase (caused by twisting force - highly suspicious for child abuse if unexplained).

• What happens: Bone is shattered into three or more pieces.
• Like: Breaking a biscuit into many crumbs.
• Cause: High-energy trauma (road accidents, falls from severe height).
• Treatment: Usually requires surgery (ORIF - Open Reduction Internal Fixation) to fix pieces together.

• What happens: Broken ends of bone are not aligned properly.
• Non-displaced: Bone is broken but still in correct position.
• Displaced: Bone ends have moved apart or overlapped (causing limb shortening).
• Treatment: Must be realigned (reduced) before casting.

Nursing Assessment Tip: Always compare both sides of the body. If the right arm looks swollen, compare it to the left arm.

Before looking at the broken bone, ensure the child is stable!

• Airway - Is the child breathing?
• Breathing - Is breathing adequate?
• Circulation - Is there severe bleeding? (A femur fracture can hide 1+ liters of blood inside the thigh!)
• Disability - Is there head injury? (Assess GCS/AVPU).
• Exposure - Examine the whole body.

• History Taking:
  • How did the injury happen? (Mechanism tells you what type of fracture to expect).
  • When did it happen?
  • Is the child left or right handed? (Important for upper limb fractures).
  • Any previous fractures? (Multiple fractures? Think Osteogenesis Imperfecta or abuse).
  • Any medical conditions?
• Physical Examination:
  • Is the fracture open (bone sticking out) or closed (skin intact)?
  • Is the limb neurovascularly intact? (Check: pulse, color, temperature, sensation, movement).
  • Is there compartment syndrome? (See below - EMERGENCY!)
  • Is there associated joint dislocation?
• Immediate Care:
  • Splint the limb for comfort and to prevent further damage.
  • Give analgesia (pain relief) - do not wait for X-ray!
  • Elevate the limb to reduce swelling.
  • Apply ice packs (wrapped in cloth) to reduce swelling.
• Imaging & Referral:
  • X-ray the affected bone. X-ray the joint above and below.
  • Consider CT/MRI for complex fractures.
  • Liaise with orthopedic team urgently. Open fractures = emergency surgery.

1. Acute Pain: Related to fracture, soft tissue injury, muscle spasm. Evidence: Child cries, guards limb, refuses to move, increased heart rate.
2. Impaired Physical Mobility: Related to fracture, cast, traction, pain. Evidence: Cannot move limb, needs assistance with activities.
3. Risk for Infection: Related to open fracture, surgical wounds, pin sites. Especially high in open (compound) fractures.
4. Risk for Neurovascular Compromise: Related to swelling, tight cast, compartment syndrome. This is a MEDICAL EMERGENCY.
5. Anxiety/Fear: Related to pain, unfamiliar environment, separation from parents. Common in children.

• Immobilization: Keep the fractured limb still. Use splints, casts, or traction as ordered. Immobilization reduces pain by preventing bone ends from grinding against nerves.
• Analgesics (Pain medicines):
  • Paracetamol/Acetaminophen: First line for mild pain.
  • NSAIDs (Ibuprofen): For moderate pain and inflammation.
  • Opioids (Morphine, Pethidine): For severe pain.
  • Remember: Give pain medicine BEFORE procedures (like X-ray or cast application).
• Elevation: Raise the limb above heart level to reduce swelling and pain.
• Ice packs: Apply for 15-20 minutes at a time (wrap in cloth, not directly on skin to prevent frostbite). Ice causes vasoconstriction, limiting edema.
• Distraction techniques: For children: toys, games, storytelling, singing. Involve parents in comforting the child.

• Maintain asepsis (clean technique): Wash hands before and after touching wound. Use sterile dressings for open wounds. Clean pin sites daily with antiseptic.
• Wound management: Irrigate (wash out) open wounds with copious sterile saline. Debride (remove dead tissue) as soon as possible. Cover with sterile dressing.
• Antibiotics: Give prophylactic (preventive) antibiotics for open fractures within the first hour! Usually started in ED; continue as prescribed.

Every nurse must check these regularly. Frequency: Check every 15 minutes for first hour, then every hour for 4 hours, then every 4 hours.

• Elevate the limb above heart level. Remove tight clothing/jewelry before swelling increases. Apply ice packs. Do NOT apply tight bandages over a fresh fracture.
• Monitor temperature (fever = infection), pulse/BP (tachycardia/hypotension = hypovolemic shock from internal bleeding), and respiratory rate (rapid = pain or fat embolism).

• What it is: A hard shell that keeps the bone in place while it heals.
• Types: Full cast (covers all around), Backslab/Half cast (allows for acute swelling), Walking cast (has a sole for weight-bearing).
• Nursing Care: Keep cast dry. Do NOT insert objects inside cast to scratch (can cause hidden abrasions/infections). Check for signs of pressure sores under cast (bad smell, staining, "hot spots"). Elevate limb. Teach parents cast care.
• Complications: Compartment syndrome, pressure sores, Cast syndrome (Superior Mesenteric Artery Syndrome: stomach/duodenum compression from a tight body cast leading to vomiting/bowel obstruction), joint stiffness.

• Bracing: Removable support that allows some movement and hygiene. Used for stable fractures.
• Splinting: Temporary immobilization. Used in emergency department. Allows for swelling (unlike tight cast). Usually converted to cast after swelling reduces.

• What it is: Applying a pulling force to align bones and reduce muscle spasm.
• Physiology Note: When a bone breaks, the surrounding muscles go into violent spasms, causing the bone ends to overlap. Continuous traction fatigues the muscles until they finally relax, allowing the bone ends to meet face-to-face.
• Types: Skin traction (pull applied through tapes/bandages on skin, e.g., Buck's traction) vs. Skeletal traction (pull applied directly through a pin drilled into the bone).
• Nursing Care: Maintain correct weight and alignment (never lift weights off the floor!). Check ropes/pulleys. Clean pin sites to prevent osteomyelitis. Prevent pressure sores. Perform neurovascular checks.

• Starts after cast removal to restore movement and strength.
• Teach safe crutch use: Ensure proper height (2-3 finger widths below the armpit, hand grips at wrist level). Caution: Resting weight directly on the armpits crushes the brachial plexus nerves, leading to "crutch palsy"!

• Thick periosteum provides excellent blood supply.
• High metabolic rate.
• Active bone growth naturally occurring.
• Better remodeling capacity (the bone can easily correct mild angulations as the child grows).

1. Hematoma formation (0-1 week): When the bone breaks, blood vessels rupture. A massive blood clot (hematoma) forms around the fracture site. Macrophages rush in to clean up dead tissue, triggering an intense inflammatory response.
2. Fibrocartilaginous callus (1-3 weeks): Fibroblasts and chondroblasts invade the hematoma. They secrete a soft, rubbery matrix of collagen and cartilage, forming a "soft callus" that acts like internal biological glue holding the bone ends together.
3. Bony callus (3-6 weeks): Osteoblasts (bone-building cells) arrive and begin replacing the soft cartilage with spongy bone. This creates a hard, bulging "bony callus" that is visible on an X-ray, confirming clinical union.
4. Remodeling (months to years): Osteoclasts (bone-crushing cells) shave down the excess bulge of the callus, while osteoblasts lay down strong compact bone along the lines of mechanical stress. The bone eventually reshapes to normal!