It is necessary to watch the tender skin carefully on account of the danger of bed-sores.
Combination with Bier's congestion is advisable, because this favors union of the bone, which is frequently delayed,especially in rachitic children, when we apply suspension (Deutschhinder).
After two or three weeks we discontinue the suspension and dismiss the little patient with an external hook-splint (Fig. 167d, Plate 20). This is made of the same hoops as the hinged brace only about 5 or 10 cm. of its end is bent off at a right angle over its edge. This brace is moulded to the outside of the abducted leg, so that the hook-like end lies on the outside of the foot, and the straight end reaches up. into the axilla. Strips of sheet-iron are fixed to it transversely to secure its position. Should a convex deformity of the femur threaten or the bones be very soft, we prefer the hinged splint or suspension for the after-treat went.
In this manner we succeed in curing our cases without much deform ity, except in eases of raehitis, where the treatment of fractures in infants requires the greatest patience.
The prognosis of fractures in infants is always favorable. Konig observed that even considerable deformities caused by fractures dis appeared during growth (disappearance of the callus, new formation of bone in the axis of gravitation); only the so-called "hyperphysiologic flexions" of the foot leave an Achilles heel. Deformities in this region have always a tendency to progress.
In older children the treatment will approach nearer to that in adults, but at present, when there is still considerable discussion about the superiority of fixation bandages or functional treatment with exten sion, we should always keep in mind the peculiarities of childhood. The active temperament of children makes a protracted treatment in bed very difficult; the extension bandages require a great deal of watching and severity, which the children will at time learn to escape, thus mak ing the result doubtful. We, therefore, prefer in fractures of the lower limbs well-moulded plaster casts in the form of bandages, in which we can easily combine extension and keeping off of the weight, if they are applied carefully.
On the upper limb we will require extension treatment in those cases which might suffer a dislocation or diminished function near the upper end of the humerus. As we have stated before, especially for the treatment with extension in children, admission into a hospital is man datory; treatment at home is possible only when the parents are highly intelligent and when the physician can keep the patient under careful supervision and make daily calls. The complicated splints of former
times are now supplanted by simpler measures, because the varying measurements in children would necessitate a large number of splints and thus a great outlay of money.
We must be especially careful with the para-articular and intro articular fractures.
To obtain as good a function of the joint as possible is our principal object. We must adapt the separated pieces as carefully as possible, and place the joint in a position that would be most serviceable if the joint became ankylosed,—namely, in the shoulder, elevation; in the elbow, flexion; in the knee, extension; in the hip, abduction.
After a few days, as soon as the process of healing permits, we can dispense with the primary position in the bandage, and from now on we apply bandages in extreme positions which are changed daily (see Frac ture of the Elbow). It is advisable to combine massage, electricity, active and passive motions with this treatment, always with the neces sary caution that good anatomical repair, and especially the restitution of the best possible function, is our highest aim.
When small pieces of bone are broken off inside a joint, for instance, the elbow, then we will not be able to do much for its union in its miginal place, but by daily changing the extreme positions (flexion and exten sion) we will force it to attach itself in a position which will not interfere with the function. Should we not be able to succeed in this by manipu lation, then opening of the joint and silver-wire suture of the bone will still be left us as the final means to repair the mechanism of the joint.
Badly healed bones demand rebreaking in those eases in which the deformity is in a place where it would give a bad prognosis; for instance, at the apex of physiological curvatures, or near a joint, when it inter feres with the function of the joint.
Old ankyloses of joints after intra-artieular fractures may he cured by osteoplastic resections (13ardenheuer, Payr, Iforra). The reunion of the resected ends of the bones is prevented either through transplanta tion of pieces of cartilage (Hoffmann), or by the interposition of fat or flaps of fascia. We should always remember that in the upper extremity the greatest motility is desired, in the lower limb the greatest firmness. A shaky, unsafe knee-joint is less useful, in spite of its motility, than a fixed, stiff knee.
(b) Cursory Surrey of the Methods to be Recommended in the Treatment of Fractures in Children