Compound fractures in childhood

I N the treatment of compound fractures in chiIdren, the surgeon must bear in mind that conservative judgment is demanded if one is to obtain the best resuIts. Hasty decisions of a radica1 nature may resuh. in the Ioss of a Iimb or even in the death of the patient. FoIIowing a severe accident, a chiId rapidIy passes into a state of acute shock, from which he may succumb if subjected, before reaction has occurred, to anesthesia and further trauma in a proIonged operative procedure. ConsequentIy, it is often advisabIe to deIay such procedures and treat the patient by supportive measures unti1 his condition becomes favorabIe. Though a chiId enters into a state of shock more easiIy than an aduIt, his recovery from this condition is more rapid, and his response to supportive measures is most remarkabIe. In many cases when a chiId is paIe and puIseIess, judicious treatment for shock often produces resuIts that are almost miraculous. One who has had experience in the treatment of traumatic injuries in chiIdren soon Iearns that conservative judgment is important in choosing the procedure to be used in treating fractures or any compound injury. An injury to a Iimb, of a type which in an aduIt wouId without doubt caI1 for an immediate amputation, wiI1 in the chiId, if treated conservativeIy, often hea so that the part retains its use and function. A deformity resuIting from a fracture in a chiId, though at first it may cause disabiIity, usuaIIy improves as growth occurs, and in time the improvement in function is such that the disabiIity is aImost negIigibIe. In other cases, when the maximum return of function has occurred, a reconstruction operation some years Iater may return the part aImost to normaI. A hasty decision to amputate is sure to crippIe the chiId for Iife; a deIay in making a decision wiI1 often save the Iimb which, though it may not regain its fuI1 function, wiI1 become a usefu1 member. Such deIay shouId not increase the danger to Iife. With the deveIopment of mechanica forms of Iocomotion, the incidence of compounded injuries has increased tremendousIy. FormerIy most of the wounds were caused from within, through a protrusion of a fragment of bone; today, in the greater number of cases, there is a compounding directIy from without, as in the case of a whee1 passing over a Iimb. The Iatter type of trauma produces a more serious wound than the former, in which a sharp fragment of bone cuts through the tissues Iike a knife and the wound seIdom is grossIy contaminated. When, however, the compounded injury is produced from without and the wound and fracture are the resuIts of direct vioIence, the part is crushed, the tissues are disorganized, the bone is cornminuted, often Iarge areas of skin have been avuIsed, and the surface of the wound is grossIy contaminated. It is this Iatter type of injury to chiIdren that wiI1 be discussed here for the most part, for it is in these cases that sane judgment is demanded. No two patients can be treated in exactly the same manner. I have seen cases in which the skin and subcutaneous tissues have been entireIy avuIsed from above the knee to beIow the ankIe, the muscIes, vesseIs and nerves being exposed as though dissected, and the bone comminuted. By means of conservative care, however, compIete heaIing was secured, and these chiIdren have retained their extremities, which, though scarred, are stiI1 usefu1 Iimbs.