Early inflammatory stage

In the inflammatory stage a haematoma develops from the fracture site in the immediate aftermath of the fracture. Macrophages, monocytes, lymphocytes, polymorphonuclear cells and fibroblasts infiltrate the bone under prostaglandins mediation (Kalfas, 2001). Granulation tissue forms and mesenchymal cells arrive at the injured site. Nutrients and oxygen supply are provided by the exposed cancellous bone and muscle.

Repair stage (Fig. 15.3)

Vascular ingrowth is supported by the presence of fibroblasts. A collagen matrix is laid down and osteoid is secreted and mineralises with calcium salts, which leads to the formation of very soft callus around the fracture. On X‐ray this has a cloud‐like appearance. The callus is very weak and needs to be protected during this stage, which usually takes 4–6 weeks by internal fixation, traction or a cast. Failure to protect the newly formed callus could result in unstable fibrous union leading to deformity. The callus then ossifies and a bridge of woven bone is formed between the ends of the fracture fragments.

Remodelling

Remodelling is when the fractured bone has healed to its original shape, structure and strength (Kalfas, 2001; McRae & Esser, 2002; McRae, 2006). This is a slow process and takes place over a period of months to years. The amount of stress placed on the bone during this phase is important in remodelling. Bone is laid down where it is required as the fracture site is exposed to the axil loading force. Adequate strength is normally achieved within 3–6 months.

Traction

The use of traction has somewhat gone into demise as technology has evolved to produce fixation devices that allow partial or full mobility. Surgical interventions are now used more frequently further reducing the length of time and use of traction. However, it is important that the healthcare professional understands the principles of traction to be able to provide appropriate care for children who may still be required to be immobilised by this method.

Traction means to pull and in order to be effective there must be a counter‐traction (pull in the opposite direction) (Fig. 15.4).

The general purpose of traction is to provide rest to a limb, treat a dislocation or correct a deformity, immobilise a specific area of the body, promote alignment either pre‐ or post‐operatively.

Traction can be applied to the upper extremities, lower extremities or to the cervical area (Table 15.2). It can be applied manually by hand, directly to the skin surface via adhesive bandages, or to the skeleton by wire, pins or tongs inserted through the diameter of the bone.

Traction	Type
Upper extremity	Overhead Dunlop traction
Lower extremity	Gallows/Bryant Bucks Russell 90/90 Balanced Skeletal
Cervical	Halo brace Halo vest Crutchfield tongs

The care of a child in traction includes:

• Checking the traction system daily to ensure weights are hanging freely, cords and knots are intact, pulleys are working effectively, that counter‐traction is being maintained and end of the bed is elevated.
  
• Outer bandages should be removed at least daily, limb inspected, washed and dried and outer bandage reapplied.
  
• Neurovascular status should be assessed and documented.
  
• Pressure area care administered.
  
• Passive and active exercises performed along with breathing exercises, e.g., blowing bubbles, balloon to prevent chest infections.
  
• General physical and personal care needs will be delivered in conjunction with parental/carer involvement.
  
• Relief of boredom is also an important aspect of care as is maintaining educational needs.

Distraction

Distraction is the process of separating opposing bone to encourage regeneration of new bone. Distraction osteogenesis is used to treat non‐union of fractures, for limb lengthening and malalignment. The bone is surgically ‘broken’, K wires are inserted proximal and distally to the fracture. Manual distraction is achieved by adjusting the telescopic rods on the rings to increase the distance between the rings. A percutaneous ostomy is performed to create a false growth plate at the same time. Histogenesis of muscle, nerves and skin occurs simultaneously with the development of the new bone (Ilizarov & Rozbruch, 2007). The Ilizarov frame (Fig. 15.5) has been used since the 1960s and its use has been extended to manage acute trauma to the limb where skin integrity has been reduced.

Scrupulous pin care is essential and the child and family will often assume responsibility for this once the child has recovered post‐operatively. They will need to be taught to recognise signs of infection and for loosening of the pins. The child and family will also learn how to adjust the frame to achieve distraction. The child will be able to mobilise partially weight‐bearing on crutches. As the Ilizarov frame will be in situ for months, the child will need support to return to their normal activities of living. Significant support is often required as the device is obvious, thus body image and self‐esteem are challenged. The Ilizarov frame is removed under general anaesthetic and the child will need to carry on using crutches post removal for up to 4–6 weeks.

Care and management

A systematic and holistic assessment is required and initial interventions are directed at assessing and managing airway, breathing, circulation, disability and exposure prior to dealing with the fracture (Frazer, 2007). Once the child is stable the fracture can be assessed.

The extent of the injury may be assessed using the 5 Ps to identify vascular compromise. These are:

• Pain – administer analgesia
  
• Pulse – palpate pulses distal to the fracture
  
• Pallor – the limb
  
• Paresthesia – sensation distal to the fracture site
  
• Paralysis – movement distal to the fracture site.

Neurovascular status should be rechecked on a frequent basis.

The principles of management are the same for all fractures:

• reduction – to restore normal alignment
  
• immobilisation – to promote healing of the bone
  
• rehabilitation – to normal function or to assist with impaired mobility.

Open wounds should be covered with a sterile dressing initially. It is likely that open wounds will require surgical intervention. Antibiotics will need to be administered to prevent infection and the development of osteomyelitis.

Avoid moving the affected limb if possible, particularly if it has not been splinted. Soft splints, such as folded towels, may be used until a more definitive splint is applied. The child may require sedation prior to the application of any splinting device and will need continuous cardiovascular monitoring during this procedure.

The child and family are likely to be very anxious and traumatised by the events that have brought them to the hospital and they will need reassurance and an explanation of the plan of care. Once the plan of care is established, it is likely that parental involvement will be significant in relation to personal care, play, and in passive exercises of the limbs. Education in the use of mobility aids will be required as will preparation for discharge.

Slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) is a relatively common disorder of the child or young person’s hip, but it is a condition where correct diagnosis and immediate treatment is critical if bone integrity is to be maintained (Katz, 2006). There is displacement of the epiphysis of the femoral head postero‐inferiorly (Fig. 15.6) (Lissauer & Clayden, 2007). The metaphysis also slips downwards and backwards.

Occurrence is more common in boys than girls, usually between 10 and 16 years of age. A downward trend in the age of occurrence has been reported, and the suggested rationale for this is the phenomenon of children maturing at a younger age (Azzopardi, Sharma & Bennet, 2010). The risk of SCFE is increased in children who are obese. Children with Down syndrome, adiposogenital syndrome, hypothyroidism, pituitary tumours and decreased growth hormone levels are also more predisposed to developing SCFE.

One hip or both may be involved, with 20% of children having bilateral involvement. Of the children who present with one‐sided SCFE initially, 20–30% will develop a contralateral SCFE within 12–18 months (Nettina, 2010).

The child may present with hip pain, mid‐thigh pain, knee pain, sudden, insidious onset of a limp and a decreased range of motion in the hip.