ORTHOPAEDIC TRACTION

Dr. Srinivas Bodla Ortho PG(PIMS)

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. 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.

Lorenz-Bohler – ‘The Father of Traumatology’ popularised skeletal traction by means of steinmann pins after he devised Bohler stirrup.

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

Types Skin tractionThe traction force applied over a large area of skin- Adhesive and Non-adhesive skin tractions

Skeletal tractionApplied directly to the bone either by a pin or wire

through the bone. (eg- Steinmann pin, denham pin, kirschner wire)

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

surfaces

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.

Counter traction Fixed traction- by applying force against

a fixed point of body. Ex: fixed traction by thomas splint Roger Anderson well leg traction

Counter traction Sliding 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

APPLIANCES

Beds And Frames

Standard bed has 4-post 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

Knots

A slip knot tightens under tension

Up and over, down and over, up and through

Knots - types

Clover hitch Barrel hitch Reef knot Half hitch Two half

hitches

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 5-6.25cm diameter with 6cm diameter axles are preferrable

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

Skin traction The traction force is applied over a large area,

this spreads the load and is more comfortable and efficient.

Force applied is transmitted from skin to the bones via superficial fascia, deep fascia and intermuscular septa

For better efficiency the traction force is applied only to the limb distal to the fracture

Weight Skin damage can result from too much of

traction force.Maximum weight recommended for skin

traction is 6.7 kgsdepending on size and weight of the patient

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.

Avoid placing adhesive strapping over bony prominences, if not, cover them with cotton padding and do the strapping.

Leave a loop of 5 cm projecting beyond the distal end of limb to allow movement of fingers and foot.

Application Non adhesive skin traction

Useful in thin and atrophic skin Frequent reapplication may be necessary Attached traction wt. must not be more

than 4.5 kgs.

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

Denham Pin Identical to stienmann pin except for a

short threaded length in the center . This threaded portion engages the bony cortex and reduce the risk of the pin sliding

Used in cancellous bone like calcaneum and osteoporitic bones

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

ApplicationFollow regular OT proceduresUse GA or LAPaint the skin with iodine and spiritMount the pin/wire on the hand drillHold the limb in same degree of lateral rotation

as the normal limb and with ankle at right angles.

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 Apply small cotton woolen pads soaked in

tincture around the pins to seal the woundThe pin should pass only through skin, SC

tissue and bone avoiding muscles and tendons

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 t-spine 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

Placed in frontal bone groove

Sup and lat to supraorbital ridge

Two posterior pins 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

Olecranon Pin Traction Supracondylar/distal

humerus fractures Greater traction

forces allowed Can make angular

and rotational corrections

Place pin 1.25 inches distal to tip

Avoid ulnar nerve

Lateral Olecranon Traction

Used for humeral fractures

Arm held in moderate abduction

Forearm in skin traction

Excessive weight will distract fracture

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 - pass the wire at right angles to the long axis of the ulna to avoid ulnar nerve.

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

Metacarpal pin traction Point of Insertion: 2-2.5 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. Pass the K-wire at right angles to the longitudinal axis of the radius, the wire traversing 2nd and 3rd metacarpal diaphysis transversly.

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 pre-made 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

Femoral Traction Pin

Lateral surface of femur (2.5cm) below the most prominent part of GT midway between the anterior and posterior surface of femur

A coarse threaded cancellous screw is used. Must avoid suprapatellar pouch, NV structures, 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

Distal femoral traction

Draw 1st line from before backwards at the level of the upper pole of patella,2nd line from below upwards anterior to the head of the fibula, where these two lines intersect is the point of insertion of a Steinmann pin

Just proximal to lateral femoral condyle. In an average adult this point lies nearly 3 cm from the lateral knee joint line

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.

Perkin’s traction: Treatment of # tibia. Treatment of # of femur

from the subtrochanter region and distally.

Trochanteric # of femur in pts under 45-50yrs age.

Denham pin is inserted through upper end of tibia for # of femur, the mid tibia for #of condyles 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

Distal Tibial Traction Useful in certain tibial

plateau fx Pin inserted 5 cm above

the level of the ankle joint, 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

Calcaneal Traction

Temporary traction for tibial shaft fx or calcaneal fx

Insert about 1.5 inches (4cms) inferior and posterior to medial malleolus

Do not skewer subtalar joint or NV bundle

Maintain slight elevation leg

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

The patientCare of the injured limb- • Pain• Parasthesia or Numbness• Skin irritation• Swelling• Weakness of ankle, toe, wrist or finger

movement

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

Removal of traction Elbow # with olecranon pin - 3

wks Tibial # with calcaneal pin - 3-

6wks Trochanteric # of femur - 6wks Femoral shaft # with cast brace - 6 wks without external support -

12wks

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