Traction in Orthopaedic

Traction produces a reduction through the surrounding soft parts, which

align the fragments by their tension. When the shaft of a long bone is fractured the
elastic retraction of muscles surrounding the bone tends to produce over-riding of
the fragments
This tendency is greater when
 The muscles are powerful and long bellied as in the thigh
 When the fracture is imperfectly immobilised, so that there is pain
and therefore muscle spam 
 When the fracture is mechanically unstable, because the fragments
are not in apposition or because the fracture line is oblique
Continuous traction generated by weights and pulleys, in addition to
causing reduction of a deformity, will also produce a relative fixation of the
fragments by the rigidity conferred by the surrounding soft tissue structures when
under tension It also enables maintenance of alignment, while at the same time it
is possible to devise apparatus, which permit joint movement Traction may be
applied through traction tapes attached to skin by adhesives or by direct pull by
transfixing pins through or onto the skeleton. Traction must always be apposed by
counter traction or the pull exerted against a fixed object, otherwise it merely pulls
the patient down or off the bed. Traction requires constant care and vigilance and
is costly in terms of the length of hospital stay and all the hazards of prolonged
bed rest must be considered when traction is used :
 Thromboembolism
 Decubiti
 Pneumonia
 Atelectasis
Excessive traction which leads to distraction of the fracture is undesirable.
Once the fracture is reduced a decreasing amount of weight is required to maintain
a reduction once the muscle stretch reflex has been overcome and the fracture
immobilised. For a femoral fracture no more than 10 lbs should be used and for
fractures of the tibia and upper limb less weight is required
Traction modalities
Skin Traction
 Traction is applied to the skeleton through its attached soft tissue and in
the adult should be used only as a temporary measure
  Skin is designed to bear compression forces and not shear
 If much more than 8 lbs is applied for any length of time, it results in
superficial layers of skin pulled off
 Other difficulties such as migration of the bandage may occur with lower
weights
Skeletal Traction
 First achieved by the use of tongs
 The application of traction applied by a pin transfixing bone was
introduced by Fritz Steinmann
 Now a threaded Denham pin is preferred to prevent early loosening of the
device
 The threaded portion of the Denham pin is offset, closer to the end of the
pin held in the drill chuck and should engage only the proximal cortex of
the recipient long bone
Traction by Gravity
 Only applies to fractures of the upper limb (hanging cast)
Traction categories
Traction on a limb demands either a fixed point from which the traction may be
exerted (fixed traction) or an equal counter-traction in the opposite direction
(balanced traction)
Fixed Traction
 The length of the limb remains constant 
 There is continuous diminution of traction force, as the tone in the muscles
diminishes and no further stimuli results in activation of the muscle stretch
reflex
 Pull is exerted against a fixed point, e.g. tapes are tied to the cross piece of
a Thomas splint and the leg pulled down until the root of the limb abuts
against the ring of the splint
 Pins in plaster is a form of fixed traction
Balanced Traction
 In weight traction, it is the tension in the apparatus which remains constant
and the length depends on the amount of tearing of the intermuscular
septum and fibrous tissue of the limb
  The pull is exerted against an opposing force, provided by the weight of
the body when the foot of the bed is raised
Combined Traction
 May be used in conjunction with fixed traction, where the weight takes up
any slack in the tapes or cords, while the splint maintains a reduction
 This combination facilitates less frequent checks and adjustment of the
apparatus
Sliding Traction
 First introduced by Pugh by applying traction tapes to the limb and
fastening them to the raised foot of the bed which was then inclined head
down
 He utilised this traction in the treatment of conditions such as Perthes,
where only one limb was fastened to the end of the bed enabling the pelvis
on the opposite side to slide down the bed more; thus creating traction and
abduction
 The extent to which the patient slides down on the bed is limited by the
friction of the body against the mattress
 The traction was subsequently modified by Hendry using a mattress on a
sliding frame, which resulted in the same amount of traction with an
inclination of 10o, as on a normal mattress at 30 - 40o inclination
 This is also really a form of balance traction, where the amount of weight
is determined by the inclination of the bed
Specific Types of Traction
1. Thomas Splint Traction
 Hugh Owen Thomas introduced his splint which he called "The Knee
Appliance" in 1875
 The method of Hugh Owen Thomas uses fixed traction with the counter
traction being applied against the perineum by the ring of the splint
 This is in contrast to other methods using weight traction which is
countered by the weight of the body
 Backward angulation of the distal fragment can never be corrected by
traction in the axis of the femur which only results in elongation with
persistence of the deformity
 A Thomas splint and fixed traction is only capable of maintaining a
reduction previously achieved by manipulation
  The use of supports enables correction of angulation caused by muscle
tension
 Placement of a large pad behind the lower fragment acts as a fulcrum over
which backward angulation is then corrected by the traction force
 The pad should be 6" in width, 9" long and 2" thick, applied transversely
across the splint under the distal fragment and popliteal fossa
 It is the splint which controls alignment and not the traction
 The tension in the apparatus should only be that sufficient to balance
resting muscle tone
 Suspension of the splint using an overhead beam enables the splint to
move easily with the patient when they move in bed
 Its use in combination with a Pearson Knee-flexion piece enables
mobilisation of the knee, while maintaining traction, alignment and
splinting of the fracture
2. Hamilton Russell Traction
 Robert Hamilton Russell wrote "Fracture of the femur: A clinical study" in
which he described his traction in 1924
 Sling under the distal 1/3 of the thigh provides upward lift, as well as
longitudinal traction in the line of the tibia
 The sling under the distal fragment controls posterior angulation and the
lifting force is related to the main traction force through the medium of
pullies
 No rigid splinting is used in this method
 Combines a means of suspending the lower extremity and a means of
applying traction in the axis of the femur
 Many other varieties of both skeletal and skin traction result in a similar
effect
3. Buck Traction
 Buck introduced simple horizontal traction in 1861
 Traction is analogous to Pugh's traction only the inclination of the bed is
replaced by the application of weights over a pulley
4. Bryant's traction
  Vertical extension traction was described by Bryant in 1873 and applied to
the management of femoral fractures
 The development of ischemia of the lower leg through reduced perfusion
resulted in limitation of its application to the short term management of a
fractured femur
 A modification of his traction has been shown to reduce the risk of limb
ischemia and may be applicable where prolonged traction is required in an
infant
5. Braun Frame
 This is merely a cradle for the limb
 Disadvantage is that the position of the pulleys cannot be altered and the
size of the splint often does not fit the limb as might be wished
 Lateral bowing is common as the splint and the distal fragment are fixed to
the frame, while the patient and the proximal fragment can move sideways
leaving the frame behind
6. Perkins Traction
 Here no splinting is used at all
 The posterior angulation of the thigh is controlled by a pillow 
 The alignment and fixation depend entirely on the action of continuous
traction
7. Fisk Traction
 Hinged version of a Thomas splint is arranged to allow 90o of knee
movement
 It is particularly attractive as it allows active extension of the knee joint
 Fixation and alignment is dependent entirely on the weight traction and the
splint merely applies the motive power for assisted knee movement
8. 90 - 90 Traction
 The thigh is suspended in the vertical plane by weight traction pulling
vertically upwards
 The ill effect of gravity as the cause of backward angulation of the
fragments is thus eliminated
9. Charnley
  Strongly recommends the use of a BK POP incorporating the Steinmann
or Denham pin in the upper end, in order to reduce pressure on the soft
structures around the knee
 Benefits of POP/Traction unit (Charnley) :
 Foot supported at right angles to the tibia
 Common peroneal nerve and calf muscles protected from pressure
against the slings of the splint and the splint itself
 The tibia is suspended from the skeletal pin inside the POP, so that
an air space develops under the tibia as the calf muscles loose their
bulk
 External rotation of the foot and distal fragments is controlled
 The tendo achilles is protected from pressure sores
 Comfort; The patient is unaware of the traction when applied
through the medium of a nail
10. Upper Limb
 A number of skin traction methods have been described and a number
more utilised without documentation in the literature
 Ingerbrightsen's overhead skin traction (A); Dunlop's side arm skin
traction (B); and Graham's extension skin traction (C) are but a few
 Skeletal pin traction can also be utilised :
 Overhead (A)
 Overhead with secondary distal forearm traction directed cephalad
(B)
 Side arm pin traction (C)