Injury Vol. 26, No. 9, pp. 609-610. 1995 Elsevier Science Ltd

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Children with fractures.. . should they attend school?

N. Hyder and D. L. Shaw Orthopaedic Department, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire, UK

Injury, Vol. 26, NO. 9, 609-610, 1995 Table I. Response of schools

Introduction ‘Can my child attend school?’ We often have to face this question when treating fractures in children. Parents are understandably worried about their child missing school. There are no rules to help doctors running the fracture clinics. We found no guidelines by the Health Department regarding this important issue. It is, therefore, up to the doctor to decide whether or not it is safe for a child to attend school. The question has never been addressed before and we found no reference in the literature about this subject.

From the medical standpoint, there is no reason to keep a child out of action, once the fracture has been immo- bilized and the area protected by a plaster-of-Paris cast. It was our impression that the advice given to parents varied widely and did not seem to be related to the severity of injury or the degree of restricted mobility with which it was associated. This study was undertaken to clarify the schools’ attitudes to attendance of pupils with skeletal injury.

Methods Questionnaires were sent to 70 schools in the Bradford area, asking the advice of the school Headteacher. The questionnaire (see Appendix) consisted of two parts. The first part described three pupils with different fractures immobilized in three different plaster casts. The second part requested advice as to whether these children should either attend school with a normal time-table, a modified time-table, or should not attend school. They also had to specify a time period in the cases of the latter two of the three options.

Results Fifty-three schools (75.7 per cent) responded to the questionnaires. Most schools recognized the importance of maintaining continuity in education and the fact that absence from school can cause considerable disruption in work. They also stressed that these children needed some form of supervision when attending school.

Regarding pupil I, with a dominant-sided, above-elbow

Attend school Modified Not attend normally time- table school

Above-elbow cast 83% 17% - Below-knee cast 87% 13% - Above-knee cast 45% 25% 30%

cast, 83 per cent of schools said that this child should attend school as normal and 17 per cent advised a modified time-table (Table I). About pupil II, with a below-knee cast, 87 per cent of schools advised school as normal and 13 per cent advised a modified time-table. Regarding pupil III, with an above-knee cast, mobilizing on crutches, the opinions varied widely. Forty-five per cent of schools suggested that this pupil should attend school as normal, 25 per cent advised a modified curriculum and 30 per cent said that he/she should not attend school for a period varying from two weeks up to the removal of the cast.

Discussion Swelling of the soft tissue around fractures is the rule rather than the exception. In children, since most fractures are caused by low-energy trauma, it is often minimal. How- ever, it is wise to rest the fractured limb as much as possible in the ‘three-four days after injury, not only to reduce soft tissue problems, but also to reduce pain. Most children are therefore advised to keep their legs elevated or their arms rested in a broad arm-sling, depending on the site of fracture. A plaster-of-Paris cast provides adequate protec- tion of the fracture once fully dried. Although setting may just take a few minutes, drying roughly takes 36 h for an arm cast and 48-60 h for a leg castI. It seems reasonable therefore, for children to stay off school for the first three-four days. Once they are familiar with their caits and the use of crutches, there is usually very little need to keep them away from school.

Younger children cannot be left unsupervised and this can be a deterrent in some schools against accepting children particularly with above-knee casts. However, many schools have lifts and wheelchair facilities for children with poor mobility and are more willing to accept them. Although most children are able to climb stairs with their crutches, they often require some assistance. In our

610 Injury: International Journal of the Care of the Injured Vol. 26, No. 9, 1995

survey, most schools remarked that they would take these children once they were able to climb stairs. First schools with pupils from three to nine years of age were generally unwilling to take children with above-knee casts and some of them wanted parents to sign that they would take responsibility before allowing their children to attend, once again emphasizing the need for Government legisla- tion regarding this matter.

In some cases, where mobility is a major problem, work can be sent home to avoid the child falling behind in his/her studies. Modification of the time-table to most schools meant not only avoidance of PE and games, but also that these children are pardoned from technology and practical lessons and they are allowed to come a few minutes after the start of school and leave a few minutes before the bell, to avoid the rampage. All these children are excused from PE and games. Below-knee plaster does not usually present any problems with mobility and therefore the majority of schools were happy to allow them to attend. So far as children with dominant-sided, above- elbow casts are concened, they can use computers or type-writers for their work, which are now provided in most schools.

We now advise parents to liaise with schools about their children, particularly if they have an above-knee cast. Regarding children with a below-knee or an upper limb cast, the school should be informed and it is envisaged that for these children there would not be any difficulty in attending school.

Appendix Questionnaire

WHAT ADVICE WOULD YOU GIVE?

PUPIL 1 A boy/girl who has broken forearm bones and he/she is in a plaster cast immobilizing his/her right wrist and elbow. He/she is right-handed and is wearing a sling. His/Her parents expect him/her to be in the cast for at least a month.

PUPIL 2 This pupil has a below-knee cast on, to support a fracture in his/her foot. He/She is able to walk on the cast and expects to be in plaster for three weeks.

PUPIL 3 Another boy/girl with a fractured tibia. He/She is in an above-knee cast and has been given crutches. He/She is not allowed to put weight through his/her injured leg. He/She is right-handed and is wearing a sling. His/Her parents expect him/her to be in the cast for at least a month.

Please indicate the advice you would give to each pupil and his/her parents. It is assumed that these pupils will be excused games and PE.

Not attend school

For how long? Attend modified

time-table For how long? Attend normal

school

Pupil 1 Pupil 2 Pupil 3

Reference I Mills K, Page G and Morton R. A Cohr Afb of Phsfering

Technique. London: Wolfe Medical Publications, 1986; p. 7.

Paper accepted 15 June 1995.

Reqwsts for reprints shotrid be addressed foe: N. Hyder FRCS, I St Matthew’s Grove, Wilsden, Bradford, West Yorkshire BD15 OLF, UK.