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ORTHOPAEDIC TRACTION

Bodla
PG(PIMS)

Dr. Srinivas
Ortho

Definition

Traction is the application of a
pulling force to a part of the body

History

Skin traction used extensively in Civil
War for fractured femurs
Skeletal traction by a pin through bone
introduced by Steinmann and Kirschner
Hippocrates- treated fracture shaft of
femur and of leg with the leg straight in
extension
Guy de chauliac- introduced continuous
isotonic traction in the fracture of femur

History
Percival pott- fractured limb should be
placed in the position in which muscles are
most relaxed
 Josiah crosby – isotonic skin traction for
treatment of shaft of femur
 Thomas Bryant- Braynt’s traction for
treatment of fracture shaft of femur in
children
 Thomas – Thomas splint, used for applying
fixed traction

 .History Malgaigne introduced the 1st effective traction which grasped the bone itself.  Lorenz-Bohler – ‘The Father of Traumatology’ popularised skeletal traction by means of steinmann pins after he devised Bohler stirrup. He used malgaigne’s hooks  Fritz-Steinmann introduced a method of applying skeletal traction to the femur by means of two pins driven into the femoral condyles.

General Considerations      Safe and dependable way of treating fractures for more than 100 years Bone reduced and held by soft tissue Less risk of infection at fracture site No devascularization Allows more joint mobility than plaster .

Adhesive and Non-adhesive skin tractions  Skeletal traction Applied directly to the bone either by a pin or wire through the bone.Types  Skin traction The traction force applied over a large area of skin .Steinmann pin. kirschner wire) . denham pin. (eg.

and immobilize fractures reduce deformity increase space between opposing surfaces .Advantages      decrease pain minimize muscle spasms reduce. align.

Disadvantages   Costly in terms of hospital stay Hazards of prolonged bed rest      Thromboembolism Decubiti Pneumonia Requires meticulous nursing care Can develop contractures .

Understanding traction .

.Principles Of Effective Traction    Countertraction must be used to achieve effective traction. Countertraction is the force acting the opposite direction. Usually. the patient's body weight and bed position adjustments supply the needed countertraction.

by applying force against a fixed point of body. Ex:  fixed traction by thomas splint  Roger Anderson well leg traction  .Counter traction Fixed traction.

by tilting bed so that patient tends to slide in opposite direction to traction force Ex:  Hamilton russell traction  Tulloch Brown traction  Agnes Hunt traction  Perkins traction  .Counter traction Sliding traction.

APPLIANCES .

Beds And Frames    Standard bed has 4post traction frame Ideal bed for traction with multiple injuries is adjustable height with Bradford frame Mattress moves separate from frame .

Beds and Frames   Bradford frame enables bedpan and linen changes without moving pt Alternatively bed can be flexible to allow bending at hip or knee .

Knots    Ideal knots can be tied with one hand while holding weight Easy to tie and untie Overhand loop knot will not slip .

down and over. up and through .Knots   A slip knot tightens under tension Up and over.

types      Clover hitch Barrel hitch Reef knot Half hitch Two half hitches .Knots .

25cm diameter with 6cm diameter axles are preferrable .Pulleys    To control the direction of weight By altering site and by using more than 1 pulley the force exerted by a given weight can be increased Pulleys of 5-6.

Weights Amount of weight required depends upon  Wt of the appliance  Wt of part of body suspended  Amount of friction present in the system  Mechanical advantage of the system employed for suspension .

SKIN TRACTION .

deep fascia and intermuscular septa For better efficiency the traction force is applied only to the limb distal to the fracture . Force applied is transmitted from skin to the bones via superficial fascia. this spreads the load and is more comfortable and efficient.Skin traction    The traction force is applied over a large area.

7 kgs  depending on size and weight of the patient .Weight  Skin damage can result from too much of traction force.  Maximum weight recommended for skin traction is 6.

cover them with cotton padding and do the strapping.  Avoid placing adhesive strapping over bony prominences.Application  Adhesive skin traction: Prepare the skin by shaving as well as washing & applying tincture benzoin which protects the skin and acts as an additional adhesive.  . if not.  Leave a loop of 5 cm projecting beyond the distal end of limb to allow movement of fingers and foot.

 .5 kgs. must not be more than 4.Application  Non adhesive skin traction Useful in thin and atrophic skin  Frequent reapplication may be necessary  Attached traction wt.

Indications      Temporary management of # of NOF and IT # Management of # .Femoral shaft of older and hefty children Undisplaced # of acetabulum After reduction of dislocation of Hip To correct minor fixed flexion deformities of hip and knee .

Contraindications



Abrasions and lacerations of skin in the
area to which traction is to be applied
Varicose veins, impending gangrene
Dermatitis
When there is marked shortening of the
bony fragments as the traction weight
required is greater than which can be
applied through the skin

Complications



Allergic reactions to adhesive
Excortication of skin
Pressure sores
Common peroneal nerve palsy

SKELETAL TRACTION

Skeletal traction

It may be used as a means of reducing
or maintaining the reduction of a
fracture
It should be reserved for those cases in
which skin traction is contraindicated

Steinmann Pin  Rigid stainless steel pins of varying lengths 4 – 6 mm in diameter. Bohler stirrup is attached to steinmann pin which allows the direction of the traction to be varied without turning the pin in the bone .

This threaded portion engages the bony cortex and reduce the risk of the pin sliding Used in cancellous bone like calcaneum and osteoporitic bones .Denham Pin   Identical to stienmann pin except for a short threaded length in the center .

Kirschner wire    They are easy to insert and minimize the chance of soft tissue damage and infections It easily cuts out of the bone if a heavy traction weight is applied Most commonly used in upper limb eg. Olecranon traction .

 Identify the site of insertion and make a stab wound  Hold the pin horizontally at right angles to the long axis of the limb. .Application  Follow regular OT procedures  Use GA or LA  Paint the skin with iodine and spirit  Mount the pin/wire on the hand drill  Hold the limb in same degree of lateral rotation as the normal limb and with ankle at right angles.

SC tissue and bone avoiding muscles and tendons .Application  Apply small cotton woolen pads soaked in tincture around the pins to seal the wound  The pin should pass only through skin.

Complications      Introduction of infection into bone Distraction at fracture site Ligamentous damage Damage to epiphyseal growth plates Depressed scars .

VARIOUS TRACTIONS .

SPINAL TRACTION    Used to treat the unstable spine Pull along axis of spine Preserves alignment and volume of canal .

Gardner Tongs      Easy to apply Place directly cephalad to external auditory meatus In line with mastoid process Just clear top of ears Screws applied with 30 lbs pressure .

Gardner Tongs      Pin site care important Weight ranges from 5 lbs for c-spine to about 20 lbs for lumbar spine Excessive manipulation with placement must be avoided Poor placement can cause flex/ext forces Can get occipital decubitus .

Crutchfield Tongs     Must incise skin and drill cortex to place Rotate metal traction loop so touches skull in midsagittal plane Place directly above ext auditory meatus Risks similar to Gardner tongs .

Halo Ring Traction     Direction of traction force can be controlled No movement between skull and fixation pins Allows the pt out of bed while traction maintained Used for c-spine or tspine fx .

Halo Ring Traction     Ring with threaded holes Allow 1-1.5 cm clearance around head Place below equator Spacer discs used to position ring  Central anterior and 2 most posterior .

Halo Ring Traction  Two anterior pins    Two posterior pins   Placed in frontal bone groove Sup and lat to supraorbital ridge Placed posterior and superior to external ear Tighten pins to 5-6 inch-pounds with screwdriver .

Halo Traction     Traction pull more anterior for extension more posterior for flexion Use same weight as with tong traction .

Halo Vest    Major use of halo traction is combine with body jacket Allows pt out of bed Can use plaster jacket or plastic. sheepskin lined jacket .

Head Halter traction     Simple type cervical traction Management of neck pain Weight should not exceed 5 lbs initially Can only be used a few hours at a time .

Outpatient head halter traction      Used to train neck pain and radicular symptoms from cervical disc disease Device hooks over door Face door to add flexion Use about 30 min per day Weight 10-20 lbs .

.Halo pelvic traction   To immobilize the spine. To slowly correct or reduce the deformities of the spine such as scoliosis.

UPPER EXTREMITY TRACTION    Can treat most fractures Requires bed rest Usually reserved for comatose or multiply injured patient or settings where surgery can not be done .

Forearm Skin Traction     Adhesive strip with Ace wrap Useful for elevation in any injury Can treat difficult clavicle fractures with excellent cosmetic result Risk is skin loss .

Double Skin Traction       Used for greater tuberosity or prox humeral shaft fx Arm abducted 30 degrees Elbow flexed 90 degrees 7-10 lbs on forearm 5-7 lbs on arm Risk of ischemia at antecubital fossa .

Dunlop’s Traction     Used for supracondylar and transcondylar fractures in children Used when closed reduction difficult or traumatic Forearm skin traction with weight on upper arm Elbow flexed 45 degrees .

25 inches distal to tip Avoid ulnar nerve .Olecranon Pin Traction      Supracondylar/distal humerus fractures Greater traction forces allowed Can make angular and rotational corrections Place pin 1.

Lateral Olecranon Traction     Used for humeral fractures Arm held in moderate abduction Forearm in skin traction Excessive weight will distract fracture .

pass the wire at right angles to the long axis of the ulna to avoid ulnar nerve.  .Olecranon traction Point of insertion: just deep to the SC border of the upper end of ulna (3cms) This avoids ulnar joint and also an open epiphysis  Technique: Pass K-wire from medial to lateral side .

Metacarpal Pin Traction     Used for obtaining difficult reduction forearm/distal radius fx Once reduction obtained. pins can be incorporated in cast Pin placed radial to ulnar through base 2nd/3rd MC Stiffness intrinsics common .

the wire traversing 2nd and 3rd metacarpal diaphysis transversly.Metacarpal pin traction   Point of Insertion: 2-2. Pass the K-wire at right angles to the longitudinal axis of the radius. .5 cms proximal to the distal end of 2nd metacarpal Technique: push the 1st dorsal interosseius muscle volarly and palpate the subcutaneous portion of the bone.

Finger traps     Used for distal forearm reductions Changing fingers imparts radial/ulnar angulation Can get skin loss/necrosis Recommend no more than 20 minutes .

LOWER EXTREMITY TRACTION     Can be used to treat most lower extremity fractures of the long bones Requires bed rest Used when surgery can not be done for one reason or another Uses skin and skeletal traction .

Buck’s Traction     Often used preoperatively for femoral fractures Can use tape or premade boot No more than 10 lbs Not used to obtain or hold reduction .

Upper Femoral Traction    Several traction options for acetabular fractures Lateral traction for fractures with medial or anterior force Stretched capsule and ligamentum may reduce acetabular fragments .

Must avoid suprapatellar pouch.Femoral Traction Pin  Lateral surface of femur (2. NV structures.5cm) below the most prominent part of GT midway between the anterior and posterior surface of femur  A coarse threaded cancellous screw is used. and growth plate in children .

Split Russell’s Traction    Buck’s with sling May be used in more distal femur fx in children Can be modified to hip and knee exerciser .

Bryant’s Traction     Useful for treatment femoral shaft fx in infant or small child Combines gallows traction and Buck’s traction Raise mattress for countertraction Rarely. if ever used currently .

90-90 Traction     Useful for subtroch and proximal 3rd femur fx Especially in young children Matches flexion of proximal fragment Can cause flexion contracture in adult .

Distal Femoral Traction    Alignment of traction along axis of femur Used for superior force acetabular fx and femoral shaft fx Used when strong force needed or knee pathology present .

2nd line from below upwards anterior to the head of the fibula. In an average adult this point lies nearly 3 cm from the lateral knee joint line  .Distal femoral traction Draw 1st line from before backwards at the level of the upper pole of patella. where these two lines intersect is the point of insertion of a Steinmann pin  Just proximal to lateral femoral condyle.

.Proximal Tibial Traction  Used for distal 2/3rd femoral shaft fx  Femoral pin allows rotational moments  Easy to avoid joint and growth plate  2cm distal and posterior to tibial tubercle  Pin should be driven from the lateral to the medial side to avoid damage to the common peroneal nerve.

Treatment of # of femur from the subtrochanter region and distally. Denham pin is inserted through upper end of tibia for # of femur. Trochanteric # of femur in pts under 45-50yrs age. . the mid tibia for #of condyles of tibia.Perkin’s traction:     Treatment of # tibia.

Balanced Suspension with Pearson Attachment    Enables elevation of limb to correct angular malalignment Counterweighted support system Four suspension points allow angular and rotational control .

Pearson Attachment  Middle 3rd fx had mild flexion prox fragment   30 degrees elevation with traction in line with femur Distal 3rd fx has distal fragment flexed post     Knee should be flexed more sharply Fulcrum at level fracture Traction at downward angle Reduces pull gastroc .

midway between the anterior and posterior borders of the tibia Avoid saphenous vein Place through fibula to avoid peroneal nerve Maintain partial hip and knee flexion .Distal Tibial Traction      Useful in certain tibial plateau fx Pin inserted 5 cm above the level of the ankle joint.

5 inches (4cms) inferior and posterior to medial malleolus Do not skewer subtalar joint or NV bundle Maintain slight elevation leg .Calcaneal Traction     Temporary traction for tibial shaft fx or calcaneal fx Insert about 1.

MANAGEMENT .

Management of patients in traction      Care of the patient Care of the traction suspension system Radiographic examination Physiotherapy Removal of traction .

The patient  Blood loss # Tibia -500-1000ml #Shaft of Femur-1500-2000ml #Pelvis -2000ml #Humerus -500-2000ml    Chest complications Urinary tract Bowels .

wrist or finger movement .The patient Care of the injured limb• Pain • Parasthesia or Numbness • Skin irritation • Swelling • Weakness of ankle. toe.

The traction suspension system          Bed and Balkan beam Splints Slings and padding Skin traction Skeletal traction Stirrups Cord Pulleys Weights .

Radiographic examination      2-3 times in first week Weekly for next 3 weeks Monthly until union occurs After each manipulation After each weight change .

6wks .6 wks .Removal of traction     Elbow # with olecranon pin wks Tibial # with calcaneal pin 6wks Trochanteric # of femur Femoral shaft # with cast brace without external support -12wks -3 .3.

THANK YOU .