Tractions In Orthopaedics

Dr. Parth Chaudhary

Definition

•Traction and suspension setups are arrangements of bars, pulleys, ropes, and weights which exert a pulling force on a part or parts of the body, or serve to suspend or “float” a part of the body-most frequently a limb

Introduction

•When a limb is painful as a result of inflammation of a joint or fracture of a bone the controlling muscles go into spasm

•The antagonistic muscles in a limb are not all equally powerful hence the action of more powerful muscle produces deformity which may seriously impair the future function of the limb

Introduction

•Traction when applied to a limb can over come the deforming force and thus can be used to reduce a fracture or dislocation of a joint

•In addition by overcoming muscle spasm traction can relieve pain andallows the limb to be rested in best functional position

Purpose•The purpose of any traction setup is one or

more of the following :

1. To prevent or reduce muscle spasm

2. To immobilize a joint or part of the body

3. To reduce a fracture or dislocation

4. To correct soft tissue contractres

•To achieve these purposes, the traction setup must:

1. Align the distal fragment to the proximal fragment

2. Remain constant

3. Allow for adequate exercise and diversion

4. Allow for optimum nursing care

Anatomical Considerations

• Figure illustrates a fracture femur. The muscle groups have pulled the broken parts out of alignment.

• The pull of the muscle group is overcome by a new force (traction) created with weights and pulleys.

• Weights provide a constant (isotonic) force; pulleys help establish and maintain constant direction.

• The forces thus applied must remain constant in amount and direction until the fracture fragments unite.

Anatomical Considerations

•Figure illustrates the same femur after traction has been applied to realign (approximate) the broken parts

Anatomical Considerations•During an extensive period of healing, the limb must

be supported to assist in maintaining fragment alignment, but the patient should still be able to move about as much as possible until union is achieved

•This is why a second system of weights and pulleys called “balanced suspension” is often used

•Balanced suspension permits the limb to “float” over the bed, and facilitates bed pan use and changing of bed linen with minimal disturbance of the fracture

Anatomical Considerations

•Countertraction, which is the resistance of the body to move in the direction of the forces exerted by a traction device, is a factor which is built into each setup by utilizing the patient’s body weight

•When necessary, the countertraction of the patient’s body weight may be increased by elevation of the foot of the bed or using blanket rolls, sand bags, etc

•THREE BASIC TYPES:

1. Manual Traction

2. Skin Traction

3. Skeletal Traction

Manual Traction

• In manual traction, the hands are used to exert a pulling force on the bone which is to be realigned.

• Generally, this type of traction is reserved only for very stable fractures or dislocations prior to splinting or immobilization in a cast.

• It also may be used prior to the application of skin or skeletal traction or surgical reduction.

Skin Traction•Mechanism : •The traction force is applied to large area

of skin

•This spreads the load and is more comfortable and efficient

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

Skin Traction

• In treatment of fractures the traction force must be applied to limb distal to fracture site otherwise the efficiency of traction force is reduced

• The maximum traction weight that can be applied is 15 lb (6.7kg) depending on the size and age of the patient

• Methods :• Adhesive Skin Traction • Non Adhesive Skin Traction

Adhesive Skin Traction• Application :• The limb is prepared, shaved and tincture

benzoin can be applied which protects the skin and acts as an adhesive

• Adhesive strapping is applied on each side of the limb with cotton padding over the bony prominence

• A loop of two inches kept beyond the distal end of limb to allow movement of fingers / foot

Adhesive Skin Traction•In lower limb the strapping is applied to

lateral aspect must lie slightly behind and parallel to a line in between greater trochanter and lateral malleoli on the medial aspect it should lie in front of the above line to encourage medial rotation of the limb

Adhesive Skin Traction• Always leave free skin between the straps to

prevent any tourniquet effect

• The extension tapes are then bandaged to limb with help of crape bandages which must not be too loose or too tight

• Suport the limb to prevent edema and heel should be leave free

• Skin traction can be safely used for 4-6 weeks

Adhesive Skin Traction

Non Adhesive Skin Traction• These are used in thin and atrophic skin or

when there is sensitivity to adhesive

• It is applied in Similar fashion as Adhesive skin traction

• As the grip is less secure frequent reapplication is required

• Attached traction weight shouldn’t be more than 4.5 kg

Indications of Skin traction • Temporary management of femoral neck # and

Intertrochanteric #

• Management of femoral shaft # in older patients and in children

• Undisplaced fracture of acetabulum

• After reduction of a dislocated hip

• To correct minor fixed flexion deformities of hip and knee

• In place of pelvic traction in management of low back ache

• After Gulliton amputation to approximate the tissues

Contraindication to Skin Traction• Pre-existing health problem which predisposes the skin to

damage and poor healing (DM, varicose ulcers and use steroid drug)

• Any wounds or sores in the area where traction to be applied

• Marked swelling in the area

• A history of hypersensitive skin

• Impairment of the circulation – varicose vein or impending gangrene

• Dermatitis

• When there is marked shortening and required traction weight is more than what can be applied through skin

Complication of Skin Traction•Allergic reaction to adhesive – Most common

agent causing allergy is Zinc oxide

•Excoriation of the skin from slipping of adhesive Strapping

•Pressure sores around malleoli and over tendo achillis

•Common Peroneal nerve palsy

Skeletal Traction

•Here the traction is applied directly to the bone by the means of pins and wires driven through the bone

•It is rarely used to manage upper limb fractures

•It should be reserved for those cases in which skin traction is contraindicated

Equipments•Steinmann Pin : They are rigid stainless pins of

varying lengths and 4-6mm in diameter•They are attached to Bohler Stirrup which

allows the direction of traction to be varied without turning the pin in bone

Equipments

•Denhamm Pin : It is identical to steinmann pin except short threaded part situated in center

•This threaded part engages the bony cortex and prevents pin sliding

•It is used in : 1) Cancellous bone like calcaneum

2) Osteoporotic bones

Equipments• Kirschner wire:• Advantages : They are easy to insert• Minimize the chance of soft tissue damage

• Disadvantages : If improper stirrup is used then they can cut through osteoporotic bones

• Although they are thin if special stirrup is used they can withstand large traction force because stirrup provides longitudnal tension forces which increases the rigidity of the K wire

• Uses : Most often in upper limb traction like olecranon traction

Equipments

Bohler Stirup K Wire Tractor

Common Sites for Application of Skeletal Traction

• Metacarpals : Placed through diaphysis of 2nd and 3rd metacarpals

• Point of insertion : 2-2.5 cm proximal to distal end of 2nd metacarpal

• Technique :• Push the 1st dorsal interosseus muscle

volarly and palpate subcutaneous portion of bone

• Pass the K wire at right angle to longitudinal axis of the radius traversing diaphysis of 2nd and 3rd metacarpals transversly

Common Sites for Application of Skeletal Traction

• Olecranon :• Point of insertion :• It is just 3cm from

subcutaneous border of upper end of ulna

• This avoids the joint and epiphysis

• Technique : Pass K wire from medial to lateral side and avoiding ulnar nerve injury

• Do not place the pin too distal as it may cause extension of elbow joint

Common Sites for Application of Skeletal Traction

• Upper end Femur (Greater trochanter) :

• Lateral Femoral traction

• Point of insertion : • Lateral Surface of femur

2.5cm below tip of GT and midway between anterior and posterior surface of femur

• Course threaded Cancellous screw or Screw eye is used

Common Sites for Application of Skeletal Traction

• Lower end of femur:• Point of insertion : 2 ways to determine• At the intersection of two lines one passing transversly

at upper pole of patella and other vertically above anterior to head of fibula

• 3cm proximal to lateral knee joint line

• Technique : • Pass as anteriorly as possible to avoid neurovascular

structures

• Disadvantages:• Prolonged immobilzation can cause knee stiffness due

to fibrosis of extensor mechanism of knee

Common Sites for Application of Skeletal Traction

•Lower end of femur:

Common Sites for Application of Skeletal Traction

• Upper end of Tibia:• Point of inseertion• 2cm below and lateral to tubercle of tibia

• Technique :• Pin should be inserted from lateral to medial side to

avoid injury to common peroneal nerve

• Lower end of Tibia :• Point of insertion:• 5cm above the level of ankle joint and midway

between anterior and posterior border of tibia

Common Sites for Application of Skeletal Traction

•Upper end of Tibia:

Common Sites for Application of Skeletal Traction

• Calcaneus:• Point of insertion:• 2cm below and behind

lateral malleolus• Or 3cm below and behind

medial malleolus

• Disadvantages:• Subtalar joint stiffness• Infection• Frequent loosening

Complications of Skeletal Traction• Pin tract infection

• Incorrect placement of pin/wire may:

Allow pin/wire to cut out

Make control of rotation difficult

Make application of splint difficult

Result in uneven pull leading to movement of pin in bone and hence causing infection and ischaemic necrosis of surrounding skin due to pressure by Bohler stirrup

Complications of Skeletal Traction• Distraction at the fracture site

• Ligamentous damage if kept through a joint for long time

• Damage to epiphyseal growth plate

Counter Traction•Goal of Counter traction is to relieve muscle

spasm and hence correcting the deformity

•Types of counter traction:

•Fixed Traction: Here counter traction is applied by force against a fixed point in the body proximal to the attachment of muscles in spasm

•Sliding or Balanced traction: Here counter traction is applied by weight of all or part of body acting under influence of gravity

Thomas Splint•Described by Hugh Owen Thomas in

1876

•Selection of Thomas splint

Measure the oblique circumference of thigh immediately below the gluteal fold and ischial tuberosity

Measure the distance between crotch and heel and add 6-9 inches

Thomas Splint•Preparing a Thomas splint:Attach sling to the side bars on which the limb can

rest - Pass the length of bandage around inner bar and then both end above the outer side bar

- The poximal sling leaves a unsupported triangular area which can be obliterated with passing the bandage around the ring and around side bar

Thomas Splint

- The distal sling must end 2.5 inches above the heel to avoid pressure sore over tendo- achillis

Line the sling with gamgee tissuePut a large pad under lower part of thigh to

maintain normal anterior bowing of femur

Thomas SplintIf the leg is to be supported in a knee

flexion piece the hinge must coincide with axis of movement of knee that is at level of adductor tubercle of femur

After the splint has been fitted bandage the limb to splint

Fixed Traction in Thomas Splint

•Here the traction is exerted from fixed points of patient’s pelvis

•The extension tapes pull the limb down to the splint which is prevented from moving in opposite direction by resistance of the splint against ischial tuberosity

• It is use to maintain reduction not to obtain the reduction of fracture

Fixed Traction in Thomas Splint• The ring of thomas splint is well upto the groin and snugly fits around the root of the limb

•The malleoli are well padded to avoid pressure

•The outer traction cord passes above and the inner traction cord passes below its respective side bar

•The traction cord are tied at the end of Thomas’s splint

•The counter traction force thus passes along the side bars to the root of limb

Fixed Traction in Thomas SplintAdvantages :• It balances the pull of muscle and as the

muscle pull and heamatoma decreases the traction also decreases

• Distraction at the fracture site less likely to occur

• As traction doesn’t depend on gravity patient can be lifted and moved without the risk of displacement of fracture

Fixed Traction in Charnley’s Traction Unit

•It is modification of Thomas Splint•It consist of Upper tibial steinmann pin

incorporated in a light Below knee POP cast

•Advantages:•Compression of tissue of upper calf and

peroneal nerve doesn’t occur•Equinus deformity at ankle is prevented•Tendo achillis is protected with padded cast•Rotation of foot and distal fragment is

controlled

Fixed Traction in Charnley’s Traction Unit•Charnley’s traction unit consist of skeletal wire incorporated into short leg cast with cross bar fixed at the sole

•The traction force is adjusted using the windlass

•The extra padding under thigh and traction at the end of Thomas splint relieves skin pressure on the proximal thigh

Roger Anderson’s well leg traction

• Uses : • In correcting either abductor or adductor deformity at the

hip• Applied before an Extra articular arthrodesis is carried out

• Principle : With an abduction deformity at hip, the affected limb

appears to be long so the traction is applied to normal limb and affected limb is simultaneously pushed up by counter traction hence reducing the deformity

Reversing the arrangement will reduce Adduction deformity

Roger Anderson’s well leg traction

Sliding Traction• Principle:• The traction force is applied by weight attached to

adhesive strapping or skeletal traction by a cord acting over a pulley

• Counter traction is applied by raising one end of bed so that body tends to slide in opposite direction to that of traction force

• Initial traction weight is more than required to reduce the fracture than the weight required to maintain the reduction

Sliding Traction• In Lower limb :Buck’s extension skin tractionPerkin’s tractionHamilton Russel Traction90 -90 tractionGallow’s TractionBohler Braun frame

• In Upper Limb :Modified Dunlop’s TractionOlecranon Pin tractionMetacarpal pin traction

• Spinal Traction:Cervical tractionHalo Pelvic traction

Buck’s Traction• Indication:

•Temporary management of femur neck fracture

•Management of fracture of femoral shaft in older and young children

•Undisplaced fracture of acetabulum

•After reduction of dislocated hip

•To correct minor fixed flexion deformity of hip or knee

•In case of pelvic traction for low back pain

Buck’s Traction•Application:•Apply above knee skin traction and support

limb on a soft pillow•Pass the cord over a pulley and attach weight•Attach 2.5 to 3 kg weight•Elevate foot end of bed

•Disadvantage:•Lateral rotation of limb is not controlled by

this method

Perkin’s Traction• Indication :•Treatment of tibia fracture•Treatment of femur fracture from subtrochanteric

region and distally in all age groups•Trochanteric fracture in patients under 45-50yr

•Application:•Apply a regular skeletal traction without using any

splint and pillows below knee•Attach the pillow to weight and raise foot end of

bed•Start active movements of injured limb as soon as

possible

Perkin’s Traction•Advantage:•Preventing knee

stiffness by early mobilisation

•Disadvantage:•Needs special split

bed•Gives less support for

the fracture

Hamilton Russell Traction•Indication:

•Management of fracture shaft femur•After arthroplasty of hip

•Application:

•Apply skin traction below knee

•Place a soft broad sling under the knee, the cord attach to it passes over a system of pulleys

•No splint is attached

•Weight in adults 3.6 kg (8lb)

•Infants and Children 0.28 to 1.8 kg (1/2 – 4 lb)

Hamilton Russell Traction

•Advantage :

•Based on law of parallelogram – The two over head pulleys double the pull on the limb and resultant traction is in axis 30 degree to horizontal i.e. in line of shaft of femur

•Disadvantage:

•This method doesn’t prevents backward sagging or lateral angulation

90-90 Traction• Indication:• Subtrochanteric fracture• Fracture of proximal 1/3rd

shaft of femur

• Application:• Skeletal traction is applied

either through lower end of femur or upper end tibia

• The hip and knee are flexed at 90 degree

• Leg can be supported by Tulloch Brow U loop or second low tibial Steinmann pin or Below knee POP cast

90-90 Traction

Application:•The traction weight is attached with hip

and knee flexed at 90 degree•The traction weight mustn’t lift buttocks

on that side •Angulation is prevented by applying

weight along the width of the leg•Rotation is controlled by knee being

flexed and keeping foot, leg and thigh in same line

Disadvantages of 90-90 traction•Stiffness and loss of extension of knee•Flexion contractures of the hip•Injury to the lower femoral or upper tibial

epiphyseal growth plates in children•Neurovascular damage

Bryant’s traction

•In treatment of fracture shaft of femur in children up to the age of 2 years who weighs less than 18 kgs.

Bryant’s Traction• Application:• Apply adhesive strapping to

both the lower limbs and tie the traction cords to an overhead beam

• Tighten the traction cords sufficiently to raise the child’s buttock just clear of the mattress

• Counter traction is obtained by the weight of the pelvis and the lower trunk.

Bryant’s Traction

•Vascular complications•Ischaemic fibrosis of calf muscles

•Frank gangrene of distal limbs

•Contraindications :It is absolutely contraindicated above the

age of 4 years.

Modified bryant’s traction

•Sometimes used in the intial management of congenital dislocation of hip

•Bryant’s traction is set up as explained•After 5 days abduction of both hips is

begun, abduction being increased by about 10 degrees on alternate days

•By 3 weeks hip should be fully abducted.

Sliding traction with a Bohler- Braun frame•It is a Bohler’s modification of Braun

splint

•Braun splint had three pulley where as there are four pulley s in BB splint.

Indications

•Comminuted trochanteric fracture of femur

•Treatment of fracture shaft femur•Supracondylar fracture femur•For fracture shaft of tibia and fibula.

Function of pulleys• First pulley acts as a

dynamic splint for the patient foot drop

• Second pulley to apply traction in the line of femur

• Third pulley to apply traction in the line of supracondylar area and for high tibial traction

• Fourth pulley to apply traction in the line of legs as in low tibial or calcaneal traction

Sliding traction with a Bohler- Braun frame

•Application: •Both skin and skeletal traction can be

used•Steinmann pin is connected to Bohler

Stirrup•Attach a cord to stirrup and pass over

required pulley•Attach a 3.2 – 4.5 kg weight to cord•Elevate the foot end and tie BB splint to

the cot

Disadvantages of BB Splint

•Nursing care is difficult

•It is heavy and cumbersome frame

•May cause deformity at the fracture site

Lateral Femoral Traction• Indications:• Management of central

fracture dilocation• If superior rim of

acetabulum is fracture it is combined with Buck’s or Russel traction

• If posterior rim of acetabulum and if reduction of dislocated hip is unstable then combined with skeletal traction of lower end femur or upper end tibia

Maximum weight 4.5 – 9kgContinue traction for 4-6 weeksEncourage active hip and knee movements

Dunlop’s Traction• Indications:

• Management of supracondylar and intercondylar humerus fractures when further flexion of elbow causes circulatory compromise

Dunlop’s Traction

• Application:

• Apply skin traction over forearm• Abduct the shoulder to 45 degree• Pass traction cord over the pulley so that elbow is

flexed to 45 degree• Place padded sling over distal humerus• Attach weight of not more than 0.5 – 1 kg• Check radial pulse hourly for 12hrs and then twice

daily• Remove traction if any signs of ischaemia are

present

Olecranon Pin Traction

• Indication:

• Supracondylar fracture of humerus in patients with poor operative risk or or with external wound

• Comminuted fracture of lower end humerus with poor operative risk

• Unstable fracture shaft of humerus

Olecranon Pin Traction

• Advantages :• With skeletal traction a greater force can be

applied and rotation at fracture site can be controlled

• Moving the puuley towards the patient causes medial rotation at fracture site

• Moving the pulley away causes lateral rotation

• Angulation can be corrected by varying the direction of pull of the fracture site

Metacarpal Pin Traction• Indication:

• Management of comminuted fracture of distal end radius

• In combination with olecranon pin traction in cases with humerus and forearm fractures

• Maximum attachable weight 1.3 – 1.8 kg

• Complication:• Fibrosis of interosseus

muscles causing stiffness of fingers

Finger traps

• Used for distal forearm reductions

• Changing fingers imparts radial/ulnar angulation

• Can get skin loss/necrosis

• Recommend for no more than 20 minutes

Halter Non Skeletal Traction

•Indications:•Management of Cervical spondylosis as an out patient

•Device hooks over door

•Face door to add flexion

•Use about 30 min per day

•Weight 10-20 lbs

Skull or Skeletal Traction

•Indications:•To reduce a dislocation or fracture

dislocation of cervical spine•To mintain position of Cervical spine

before and after operative fusion•Management of Cervical Spondylosis with

severe nerve root compression

•Maximum weight 9-18 kg

Skull Traction with Gardner Tongs

• Place directly cephalad to external auditory meatus

• In line with mastoid process

• Just clear top of ears• Screws applied with

30 lbs pressure

Skull Traction with Gardner Tongs• Pin site care important• Weight ranges from 5

lbs for cervical spine to about 20 lbs for lumbar spine

• Excessive manipulation with placement must be avoided

• Poor placement can cause flexion/extension forces

Skull Traction with Crutchfield Tongs

• Must incise skin and drill cortex to place

• Rotate metal traction loop so touches skull in midsagittal plane

• Place directly above external 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 patient out of bed while traction maintained

• Used for cervical spine or thoracic spine fractures

Halo Ring Traction

• Application:• Ring with threaded

holes• Allow 1-1.5 cm

clearance around head• Infilterate four pin sites

with local anaesthia• Pins should be at 90

degree angle to the skull

• No incision neede • Don’t allow puckering

of skin

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 patient out of bed

•Can use plaster jacket or plastic jacket

Halo Vest

•Disadvantages:•Pin site infection a risk•Can remove pins and place in different

hole•Pin penetration can produce CSF leak•Scars over eyebrows•Can get sores beneath vest

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