TREATMENT ANT) PROGNOSIS OF FRACTURES In children we must frequently apply different means of treatment than in adults, and we will therefore confine ourselves more, in the following, to give the necessary or desirable differences from the treat ment of fractures in the adult, rather titan go into the details of the treatment of every single fracture.
(a) The Fractures in Infants This branch of the treatment of fractures has heretofore been sorely neglected. The tender skin of the infant, its round agile body, its mov able cover of fat which envelops the soft bones, offer considerable diffi culties to an exact therapy, to which is added the difficulty of keeping any complicated dressings clean.
Most text-books only allude to seine possible modifications of the bandages and thus hardly aid the practitioner when he has to deal with a birth-injury, for instance.
The upper arm, the clavicle, and the thigh are the favorite locations of obstetrical fractures.
On the arm we usually find a transverse fracture in the middle of the diaphysis (Fig. 165a, Plate 19).
The usual mode of treatment is to place the arm alongside the body in extension; also shoulder bandages (Desault, Vclpeau) are used. We had also tried to place the arm in a longitudinal splint, but all our efforts were in vain owing to the shortness of the arm and the soft motile body which did not offer much hold to the splints. Placing the arm upon a triangular splint is by no means easy with an arm only a few centimetres in length; nor is permanent extension an easy procedure in infants, as the little arm is hard to grasp and the fingers swell quite readily.
Nowadays we fix the arm flexed at the elbow to a right angle in horizontal elevation upon a longitudinal splint, using the sound arm for support (Fig. 165b, Plate 19). The whole splint runs behind the back from one hand to the other, thus holding the fracture in sufficient fix ation. The child will soon bo accustomed to this position and can be carried around in the splint. Should a dislocation threaten, then we
can combine this method with elastic or weight extension.
In fractures of the clavicle (Fig. 1136a, Plate 19) we use a similar splint, with the difference that not the upper arm but the forearm is fixed upon it in rectangular flexion. By rotating the shoulder outward and by tension upon the anterior capsule of the shoulder-joint the fractured ends are pulled apart and angular union (from drooping of the shoulders) is prevented (Fig. 166b, Plate 19).
We make use of a similar principle in the fractures of the femur. Here also In we make use of the sound limb for support (Figs. 167a, 167b, Plic, Plate 20).
Formerly we treated fractures of the femur in children in such a manner that the thigh was strongly flexed in the hip and the leg ex tended in the knee and so fixed to the holy that the foot was placed over the shoulder of the sound side. Besides the inconvenience of thus encircling the whole body this kind of bandage does not prevent a permanent deformity of the leg.
We now take two iron hoops about 21 cm. wide and join them at one end on their flat surface with a rivet (Fig. 167b, Plate 20). The place of union corresponds to the end of the sternum. The legs are abducted and in this position the rods are moulded to the anterior surface of the legs, following the favorite position of the legs in infants (flexion in both hip- and knee-joints). To this splint both legs are fixed by bandages (Figs. 167b, 167c, Plate 20). The spreading helps to hold the splint in place and the elevation of the legs prevents soiling.
In older infants, who have a more resistant skin, we apply vertical suspension (Schede), which we can fix On any bed or go-cart with a hoop and two pulleys (Fig. 167e, Plate 20).
The question of the amount of weight for extension is easily answered: It should be heavy enough to just raise the buttock of the injured side from the bed, while the sound side still rests on the bed.