The Closed Treatment of

Fractures: Traction and Casting
Dr. Michelle Ghert
McMaster University

Major Resources
• “The Closed Treatment of Common
Fractures”, John Charnley, 1961
• “Operative Orthopaedics”, Chapman, 2001

Biology of Closed Treatment
• Movement at fracture site stimulates callus
“sleeve”
• Eventually immobilizes the fracture

“Harmful” effects of operative management ischemia • osteogenic activity • prior to refinement of AO technique--> failure of internal fixation • .

“Supracondylar Fracture of the Adult Femur”. Neer et al. JBJS 1967 • • • • • 110 supracondylar femur fractures 1942-1966 internal fixation in 36 Clinical outcomes ‘satisfactory’ outcome still possible with <20 degrees of motion .

Results • 43/48 (90%) excellent or satisfactory in casting • 15/29 (51%) excellent or satisfactory in ORIF • Complications: – 7 in casting – 36 in ORIF • Conclusion: operative management not indicated .

Failed ORIF .

“Harmful” effects of closed
treatment
• “few”
• angulation
• stiffness

Mechanics of reduction



‘mental picture’ of reduction
Importance of intact soft-tissue envelope
LIGAMENTOTAXIS
Increase initial deformity

Intact Soft Tissue hinge

Intact Soft Tissue Hinge .

Mechanics of traction • • • • Reduction Splinting ‘hydraulic’ effect on soft-tissue envelope Secure fixation of fracture yet preserve joint function .

Mechanics of casting • 3-point fixation • Not just a passive mold • Padding must be at appropriate thickness and placement .

3-point Mold .

the associated joints will tolerate fixation for the duration of normal union without either permanent or significant loss of motion. .“Law of Closed Treatment” After the fracture of the shaft of a long bone.

” .Cast padding • • • • Introduced in Italy 1948 Accommodates for swelling reduction Firmer grip on limb “it must not obscure the shape of the limb by being put on in careless and ugly lumps.

Reduction 3.Triple sequence 1. Plastering and molding . Examination and rehearsal 2.

Examination and Rehearsal • • • • Effect of gravity Amount of force Range of excursion Key point to hold reduction .1.

2. Reduction • Relaxation of muscles is essential • Recreate deformity • 3-point hold .

3. Casting and molding • 3-point molding • Maintain reduction .

Traction: History • Guy de Chauliac 600 years ago • Sir Hugh Owen Thomas in 1890 .

Traction: History • Gurdon Buck 1861: Buck’s traction .

Traction: History • Combination of traction and suspension introduced by Nathan Smith 1867 .

Traction: History • Traction by skeletal pins introduced by Fritz Steinmann of Switzerland in1907 .

Traction: Indications • • • • Vertical instability fractures of pelvis Fractures of the hip. femur and tibia Posterior hip dislocations Emergency measure prior to operative stabilization .

Traction: Principles • Traction suspension: splint takes second place to action of traction force • Thomas method: traction holds reduction and alignment is controlled by splint .

.

Split Russell Traction .

Split Russell Traction .

Balanced Suspension with Thomas Splint .

Balanced Suspension with Thomas Splint Pearson attachment .

Balanced Suspension with Thomas Splint • “ The major part of the count-traction is taken against the perineum and the fatty folds of the buttock.” .

Specific fractures • Both bone forearm in children • Colles • Femoral shaft .

Radius and Ulna in Children • • • • Middle 1/3 Vertical traction technique Counter traction by gravity Patient anesthetized for relaxation .

increase deformity and straighten .Finger trap traction • Finger traps on IV stand • Thumb. index and middle finger separate • Elbow at 900 • If long traction is not enough.

Casting • Enclose thumb to IP joint • Allows opposition but does not displace radius .

Casting • 3-point bend in cast: • a curved cast means a straight bone • Shape of cast will be opposite of deformity .

Mold in oval cross-section .

JBJS 1981: ‘Quantification of Intracompartmental Pressure and Volume under Plaster Casts’ • Canine model • Significant intracompartmental pressure increase with casting • 65% reduced if cut and split • 80% reduced if webril cut as well .Casting vs. Splinting • Garfin et al.

radial shift Volar soft-tissue rupture Dorsal soft-tissue hinge Elderly: dorsal comminution .Colles fracture • • • • Dorsal shift and tilt.

Hematoma block • Area is prepped and draped • Hematoma aspirated and 5-10 ml of local anesthetic without epinephrine is injected .

1991: • 132 distal radius fractures treated with hematoma block and reduction • Compared to 100 patients treated with either general anesthesia or IV regional • No infections or complications .Increased risk of infection? • Johnson et al. Orthopaedic Review.

Reduction: disimpaction • analagous to meshing of two gear-wheels .

Reduction • Volar flexion and translation • Pronate forearm to stabilize fragment • Ulnar deviation .

Casting • Start with radial slab • 3-point fixation • Ulnar deviation .

Fractures of the femoral shaft: Adults • Dorsal angulation is well-tolerated • Varus/valgus <100 tolerated by knee joint • Traction indicated as provisional measure in unstable patient .

Tibial pin insertion • Sterile technique • Insert pin from medial to lateral (minimize risk to peroneal nerve) • Level of tibial tubercle .

Tibial pin insertion • Anesthetize skin and deep tissues down to periosteum with local anesthetic • Longitudinal incision • Hold leg in neutral rotation • Hand drill only .

Thomas BST • Pearson attachment to Thomas leg splint at knee • Forms cradle for leg .

Traction bow (holds reduction) .Thomas BST • Sequence of suspension: 1. Distal Pearson (fracture suspension) 3. Proximal ring (counter-traction) 2.

Pediatric Femoral Shaft Fractures • Tend to shorten due to pull of thigh muscles and ballooning of fascia • distal fragment displaces posteriorly secondary to gastroch • AIM: 1 cm shortening. no angulation . correct rotation.

Pediatric Femoral Shaft • 2 weeks in Thomas traction then spica casting vs immediate spica • If in traction: check films and adjust .

Spica Casting • Latin word ‘spica’=“ear of wheat” • v-shaped crossing resembling spike of grain .

conscious sedation • Spica table • shoulder and upper thorax on table. pelvis on perineal post .Spica cast • General anesthetic vs.

ribs • Allow other hip to flex 900 .Spica Cast • Cast extends from xyphoid process to metatarsal head • closed reduction of femur under fluoro • extra padding on ASIS. sacrum.

Hip Spica .

• closing--> shortens .Cast Wedging • Correct fracture alignment • uniplanar or biplanar • opening--> lengthens.

Central Hinge Wedging • neither shortens nor lengthens • Hinges cast directly over fracture site • Technique involves marking location of fracture site on cast • Combination of opening and closing wedge .

2000 • 190 immediate hip spica casts on children with isolated femoral shaft fractures • Conscious sedation/general anesthesia • All united within 8 weeks • No significant residual deformities • No complications .Literature Review • Infante et al. CORR.

2000 • prospective study. JPO. 101 children treated with immediate spica casting • excellent results with few complications • 8 with unacceptable shortening • Control of alignment not a problem .Literature Review • Ferguson et al.

2000 • Meta-analysis of 15 cohort studies comparing methods of management of children with femur fractures • Results: costs and malunion rates of early application of a hip spica cast were lower than for traction . traction • Wright.Immediate spica vs. Canadian Journal of Surgery.

JPO 1999 • • • • 181 fractures over 10 year period 59 underwent spica casting within 48 hours 122 underwent traction and delayed casting Average follow-up 8.Yandow et al.9 years .

001) • 83% increase in patient charge in traction group . JPO 1999 • No significant clinical difference in limblength inequalities. 2.2 days (casting) (P<0.Yandow et al.3 (traction) vs. or rotational or angular deformities • Average hospital stay 17.

. .Summary: Traction and Casting • Mental rehearsal of reduction • Understand forces and anatomy of fracture • mechanics of soft-tissue hinge and 3-point mold • concept of traction/suspension • muscle relaxation essential…….