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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
• Eventually immobilizes the fracture
“Harmful” effects of operative
• ischemia
• osteogenic activity
• prior to refinement
of AO technique-->
failure of internal
“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
• 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
Failed ORIF
“Harmful” effects of closed
• “few”
• angulation
• stiffness
Mechanics of reduction
• ‘mental picture’ of reduction
• Importance of intact soft-tissue envelope
• 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
Mechanics of casting
• 3-point fixation
• Not just a passive mold
• Padding must be at appropriate thickness
and placement
3-point Mold
“Law of Closed Treatment”
After the fracture of the shaft of a long bone,
the associated joints will tolerate fixation
for the duration of normal union without
either permanent or significant loss of
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.”
Triple sequence
1. Examination and rehearsal
2. Reduction
3. Plastering and molding
1. Examination and Rehearsal
• Effect of gravity
• Amount of force
• Range of excursion
• Key point to hold reduction
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
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
Finger trap traction
• Finger traps on IV
• Thumb, index and
middle finger separate
• Elbow at 900
• If long traction is not
enough, increase
deformity and
• Enclose thumb to IP joint
• Allows opposition but does not displace
• 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
Casting vs. Splinting
• Garfin et al, 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
Colles fracture
• Dorsal shift and tilt, radial shift
• Volar soft-tissue rupture
• Dorsal soft-tissue hinge
• Elderly: dorsal comminution
Hematoma block
• Area is prepped and draped
• Hematoma aspirated and 5-10 ml of local
anesthetic without epinephrine is injected
Increased risk of infection?
• Johnson et al, Orthopaedic Review, 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
Reduction: disimpaction
• analagous to
meshing of two
• Volar flexion and
• Pronate forearm to
stabilize fragment
• Ulnar deviation
• Start with radial slab
• 3-point fixation
• Ulnar deviation
Fractures of the femoral shaft:
• 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
• Longitudinal incision
• Hold leg in neutral
• Hand drill only
Thomas BST
• Pearson attachment to
Thomas leg splint at
• Forms cradle for leg
Thomas BST
• Sequence
of suspension:
1. Proximal ring
2. Distal Pearson
(fracture suspension)
3. Traction bow
(holds reduction)
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, correct rotation, no
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
Spica cast
• General anesthetic vs.
conscious sedation
• Spica table
• shoulder and upper
thorax on table, pelvis
on perineal post
Spica Cast
• Cast extends from
xyphoid process to
metatarsal head
• closed reduction of
femur under fluoro
• extra padding on
ASIS, sacrum, ribs
• Allow other hip to flex
Hip Spica
Cast Wedging
• Correct fracture
• uniplanar or biplanar
• opening--> lengthens,
• closing--> shortens
Central Hinge Wedging
• neither shortens nor
• Hinges cast directly
over fracture site
• Technique involves
marking location of
fracture site on cast
• Combination of
opening and closing
Literature Review
• Infante et al, CORR, 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
• Ferguson et al, JPO, 2000
• prospective study, 101 children treated with
immediate spica casting
• excellent results with few complications
• 8 with unacceptable shortening
• Control of alignment not a problem
Immediate spica vs. traction
• Wright, Canadian Journal of Surgery, 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
Yandow et al, JPO 1999
• 181 fractures over 10 year period
• 59 underwent spica casting within 48 hours
• 122 underwent traction and delayed casting
• Average follow-up 8.9 years
Yandow et al, JPO 1999
• No significant clinical difference in limb-
length inequalities, or rotational or angular
• Average hospital stay 17.3 (traction) vs. 2.2
days (casting) (P<0.001)
• 83% increase in patient charge in traction
Summary: Traction and Casting
• Mental rehearsal of reduction
• Understand forces and anatomy of fracture
• mechanics of soft-tissue hinge and 3-point
• concept of traction/suspension
• muscle relaxation essential……..