Fractures, Head, Neck & Back Injuries

A three-year-old has fallen from a climbing frame and is crying and holding her forearm. Which finding most strongly suggests that the bone is broken rather than bruised?

• AThere is a small graze on the back of her hand
• BShe is frightened and does not want to be looked at
• CThe child is crying loudly and asking for her mum
• DThe forearm looks bent out of its normal shape✓

Answer: Deformity — a limb that looks bent, twisted or the wrong shape — is one of the classic signs of a fracture, alongside pain, swelling and being unable to use the limb. Crying, fear and a minor graze can follow any fall and do not by themselves point to a broken bone. Treat an obviously deformed limb as a fracture.

A four-year-old's lower leg is obviously deformed after he fell from a wall. While you wait for the ambulance, how should you manage the injured leg?

• ALift it onto a chair to raise it above the hip
• BStraighten it gently so it lies flat and level
• CWalk the child to a bench so he can sit down
• DSupport it in the position in which you found it✓

Answer: A suspected fracture is supported exactly as found so that the broken bone ends do not move and cause more damage or pain. Straightening a deformed limb, lifting it or walking on it can all worsen the injury and the bleeding around it. Use padding to keep the leg still until the ambulance arrives.

An 18-month-old fell from a low sofa an hour ago. There is no obvious deformity or swelling, but he refuses to put any weight on one leg and screams if you touch it. What does this behaviour most likely indicate?

• ATiredness after the fall that a nap will resolve
• BA normal toddler tantrum that will pass once he is comforted
• CA simple bruise that only needs a cold compress
• DA possible fracture that needs a hospital assessment✓

Answer: A young child who will not use a limb after a fall may have a fracture even when nothing looks deformed, so the leg is treated as broken and the child assessed in hospital. A tantrum, tiredness or a simple bruise would not usually stop a toddler bearing weight an hour after the event. Do not test the leg by making him walk on it.

A five-year-old has a suspected broken forearm with no wound. What is the best way to immobilise the arm before you take him to A&E?

• ASupport it against the body in a sling✓
• BMove it through its full range to test it
• CWrap it firmly in ice packs and a towel
• DHold it straight out at shoulder height

Answer: A sling holds the injured arm still against the body, which limits movement of the bone ends and eases pain on the journey to hospital. Holding the arm out or moving it to test it will hurt and may worsen the break, and wrapping a limb firmly in ice packs is not a way of immobilising it. Padding around the injury adds further support.

A child has fallen from height and the shin bone has broken through the skin, with bleeding around the wound. Apart from calling 999, what should you do about the wound?

• APush the bone end back under the skin before dressing it
• BRinse it under a running tap for twenty minutes first
• CCover it with a sterile dressing without pressing on the bone✓
• DLeave it fully uncovered so the ambulance crew can see it

Answer: An open fracture wound is covered to reduce the risk of infection and to help control bleeding, with any pressure applied around the protruding bone rather than on it. Pushing the bone back or rinsing the wound for a long time would cause pain and further damage and delay care. Leaving it uncovered invites contamination and gives the crew nothing they need.

A child with a suspected broken wrist asks for a biscuit and a drink while waiting to go to hospital. What should you do?

• AGive nothing to eat or drink in case surgery is needed✓
• BGive a light snack but hold back on any drinks
• COffer a small sugary drink to keep her energy and spirits up
• DAllow sips of water only until the pain settles

Answer: A fracture may need to be set under anaesthetic, and a child who has recently eaten or drunk faces added risks during surgery, so nothing is given by mouth. Sugary drinks, snacks and even sips of water could all delay her treatment. Reassure her and explain why she needs to wait.

For which of these suspected injuries should you call 999 rather than take the child to A&E yourself?

• AA suspected fracture of the wrist
• BA suspected fracture of the thigh bone✓
• CA suspected fracture of a finger
• DA suspected fracture of the left collarbone

Answer: A broken thigh bone is a serious injury that can bleed heavily internally and needs the child kept still and moved by paramedics, so 999 is called, as it would be for a suspected pelvis or spine fracture or any open fracture. A collarbone, finger or wrist can usually be supported and the child taken to A&E by staff or parents.

A six-year-old has twisted her ankle in the playground and it is swelling, but she can still wiggle her toes and bear some weight. For how long should a wrapped ice pack be applied at a time?

• A10 to 20 minutes✓
• B2 to 5 minutes
• C30 to 40 minutes
• D45 to 60 minutes

Answer: For a sprain or strain the ice is wrapped in a cloth and applied for 10 to 20 minutes at a time, never longer than 20, alongside rest, a comfortable support and raising the limb. A few minutes is too short to reduce swelling, while 30 minutes or more risks cold damage to the skin. Ice is never placed directly on bare skin.

According to NHS advice, a fall from more than what height counts as a reason to call 999 after a head injury?

• ATwo metres
• BThree metres
• CHalf a metre
• DOne metre✓

Answer: The NHS lists a fall from more than one metre, or from more than five stairs, among the head-injury findings that need a 999 call because of the risk of a serious brain injury. Waiting until a fall of two or three metres would miss children who need urgent assessment, and half a metre is a lower threshold than the guidance sets.

A child banged his head hard on a concrete step. Which of these findings means you should call 999 rather than NHS 111?

• AHe cried for several minutes afterwards
• BHe complains of feeling a bit dizzy
• CHe has vomited once since the fall
• DClear fluid trickling from one ear✓

Answer: Clear fluid from the ears or nose after a head injury can be fluid from around the brain and is a 999 sign, as are being knocked out, a seizure, bruising behind the ears, weakness, or problems walking or speaking. Vomiting and dizziness are reasons to call NHS 111 for advice, and crying after a painful bump is expected.

A nine-month-old rolled off a changing mat onto the floor and now has a small bruise on the side of her head, but she is smiling and feeding normally. What should you do?

• AWatch her closely for two hours and ring NHS 111 if she vomits
• BNote it in the accident book and tell the parents when they collect her
• CCall 999 because of the bruise on the head of a baby under one year✓
• DApply a wrapped cold pack and carry on with the day as normal

Answer: The NHS says any bruise, swelling or large cut on the head of a child under one year is a reason to call 999, because serious injury can be hidden behind a baby who seems well. A cold pack, a period of observation or simply recording the fall would delay assessment that this age group needs. The incident is also recorded and the parents told.

A three-year-old bumped her head on a table at nursery, cried for a minute and has a small lump, but is otherwise her usual self. It is now nap time. Which approach is correct?

• ASend her home straight away and ask the parents to keep her up
• BWake her every ten minutes to be sure she can still be roused
• CKeep her awake for the rest of the day so she cannot drift off
• DLet her sleep but have an adult stay with her and check on her✓

Answer: A child with a minor head bump does not need to be kept awake; the NHS advises rest, a wrapped cold pack for short periods and an adult staying with the child for 24 hours. Forcing her to stay awake, waking her every few minutes or telling parents to keep her up are outdated ideas that only upset the child. Paracetamol can be used for pain.

A seven-year-old has fallen from the top of a climbing frame and is lying on his back, conscious and saying his neck hurts. He is breathing normally. What should you do first?

• ASit him up slowly against the frame so he can be checked over
• BRoll him into the recovery position so that he cannot choke
• CHold his head still in line with his body and keep him where he is✓
• DCarry him indoors to the first aid room to examine him properly

Answer: A suspected neck or back injury is not moved, because movement can damage the spinal cord; the head is steadied in line with the body while an ambulance is called. The recovery position is used only if his breathing is at risk, and sitting him up or carrying him indoors could turn a stable injury into a permanent one. Keep him warm and reassured where he lies.

A two-year-old at nursery bumped his head on a cupboard door, needed only comfort and a cold compress, and recovered quickly. What does the EYFS require the setting to do?

• ATell his parents only if the bump is still visible at home time
• BNotify Ofsted within 14 days because any injury to the head is serious
• CRecord the injury and first aid given and tell his parents that day✓
• DRecord it only if the child later shows signs of concussion

Answer: EYFS paragraph 3.78 requires a written record of any accident or injury and the first aid given, and parents to be informed the same day or as soon as reasonably practicable, however minor the bump. Waiting to see whether a mark remains, or recording only if symptoms appear, would breach this. Ofsted notification applies to serious accidents, illness or injury, not a routine bump.