Application of Traction in Orthopaedics

By- Prabhnoor Singh Hayer

Moderated by- Dr. Rajesh Maheshwari

Definition

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

HistoryHippocrates- treated fracture shaft of femur and of

leg with the leg straight in extensionGuy de chauliac- introduced continuous isotonic

traction in the fracture of femur

General ConsiderationsSafe and dependable way of treating fractures for

more than 100 yearsBone reduced and held by soft tissueLess risk of infection at fracture siteNo devascularizationAllows more joint mobility than plaster

IndicationsTo reduce the fracture or

dislocationTo maintain the reductionTo correct the deformityTo reduce the muscle spasm

Types Based On Method Of Application

Skin traction

The traction force is applied over a large area of skin• Adhesive• Non-adhesive skin tractions

Skeletal traction

Applied directly to the bone either by a pin or wire through the bone. (eg- Steinmann pin, Denham pin or Kirschner wire)

Types Based On Mechanism

Fixed Traction

By applying force against a fixed point of body.

Sliding Traction

By tilting bed so that patient tends to slide in opposite direction to traction force

Advantages of TractionDecrease painMinimize muscle spasmsReduces, aligns, and immobilizes fractures Reduce deformityIncrease space between opposing surfaces

Disadvantages of TractionCostly in terms of hospital stayHazards of prolonged bed rest

ThromboembolismDecubitiPneumonia

Requires meticulous nursing careCan develop contractures

The Traction Suspension System

• Bed and Balkan beam

• Splints- Thomas splint, Bohler-Braun frame, Fisk Splint

• Slings and padding

• Skin traction

• Skeletal traction- Steinmann pin, Denham pin or Kirschner wire

• Bohler Stirrup

• Cord

• Pulleys

• Weights

Knots

Ideal knots can be tied with one hand while holding weight

Easy to tie and untie

Overhand loop knot will not slip

KnotsA slip knot

tightens under tension

Up and over, down and over, up and through

Knots - typesClover hitchBarrel hitchReef knotHalf hitchTwo half hitches

Skin traction

Skin traction

Buck’s Traction or Extension

Used in temporary management of fractures of Femoral neck Femoral shaft in older children Undisplaced fractures of the acetabulum After reduction of a hip dislocation To correct minor flexed deformities of the hip or knee In place of pelvic traction in management of low back pain

Can use tape or pre-made bootNot more than 4.5 kgsNot used to obtain or hold reduction

Hamilton Russell TractionBuck’s with slingMay be used in more

distal femur fracture in children

Can be modified to hip and knee exerciser

Bryant’s Traction

Useful for treatment of femoral shaft fracture in infant or small child

Combines gallows traction and Buck’s traction

Raise mattress for counter traction

Rarely used currently

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 proximal humeral shaft fracture

Arm abducted 30 degrees

Elbow flexed 90 degrees

Risk of ischemia at antecubital fossa a

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 at 45 degrees

Finger traps

Used for distal forearm reductions

Changing fingers imparts radial/ulnar angulation

Can get skin loss/necrosis

Recommend no more than 20 minutes

Head Halter traction

Simple type cervical traction

Management of neck pain

Weight should not exceed 2.3 kg

Can only be used a few hours at a time

Contraindications Abrasions and lacerations of skin in the area to

which traction is to be appliedImpairment of circulation - Varicose veins,

impending gangreneDermatitis When there is marked shortening of the bony

fragments, the traction weight required will be more then 6.7 kg which cannot be applied through the skin

ComplicationsAllergic reactions to adhesiveExcortication of skinPressure sores around the malleoli and over the

tendo calcaneus Common peroneal nerve palsy

Skeletal Traction

IndicationsIt should be reserved for those cases in which skin

traction is contraindicatedIn patients with lacerated woundsIn patients with external fixator in situWhen the weight required for traction is more then

6.5 kgs- Obese patients

Proximal Tibial Traction• Used for distal 2/3rd

femoral shaft fractures• Tibial 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.

Upper Femoral TractionLateral traction for

fractures with medial or anterior force

Stretched capsule and ligamentum teres 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 NV structures and growth plate in children

Distal Femoral Traction

Alignment of traction along axis of femur

Used for superior force acetabular fracture and femoral shaft fracture

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

Ninety-Ninety Traction

Useful for subtrochantric and proximal 3rd femur fracture

Especially in young children

Matches flexion of proximal fragment

Can cause flexion contracture in adult

Perkin’s tractionTreatment of fractures of tibia and of

the femur from the subtrochantric region distally.Basis of management is the use of skeletal

traction coupled with active movements of the injured limb

By encouraging early muscular activity, the development of stiff joint is frequently prevented by both maintaining extensibility of muscles by reciprocal innervation, and preventing stagnation of tissue fluid

Application of Perkin’s traction

A Hadfield split bed is required

Under General anaesthesia and full aseptic conditions, a Denham pin is inserted through the upper end of tibia

A Simonis swivel is attached to end of each Denham pin

Two traction cords are connected to each of swivel

4.6 kg weight is attached to each traction cord making a total traction weight of 9.2 kg

Foot end of the bed is elevated by one inch for each 0.46 kg of traction weight

One or more pillow is placed under the thigh to maintain the anterior bowing of the femoral shaft

Length of the limb is checked with a tape measure and total traction weight is increased or decreased as necessary

Active Quadriceps exercises are started immediately and continued

Knee flexion is started after a week of admission, under supervision

Perkin’s traction:

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 fracture has mild flexion proximal fragment• 30 degrees elevation with

traction in line with femur

• Distal 3rd fracture has distal fragment flexed posterior• Knee should be flexed more

sharply• Fulcrum at level of fracture• Traction at downward angle• Reduces pull of

gastrocnemius

Distal Tibial TractionUseful in certain tibial

plateau fracture Pin inserted 5 cm above

the level of the ankle joint, midway between the anterior and posterior borders of the tibia

Avoid saphenous veinPlace through fibula to

avoid peroneal nerveMaintain partial hip and

knee flexion

Calcaneal Traction

Temporary traction for tibial shaft fracture or calcaneal fracture

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

Do not skewer subtalar joint or NV bundle

Maintain slight elevation leg

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 fracture

Once reduction obtained, pins can be incorporated in cast

Pin placed radial to ulnar through base 2nd/3rd MC

Stiffness of intrinsics is 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 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 transversely.

Gardner TongsU shaped tongs, used for

spinal tractionIn patients having cervical

injuryEasy to applyPlace directly above

external auditory meatusIn line with mastoid

processJust clear top of ears

Gardner TongsPin site care importantWeight ranges from2.3 kg

to 15.8 kg for c-spineExcessive manipulation

with placement must be avoided

Poor placement can cause flexion/extension forces

Patient can get occipital decubitus

Crutchfield Tongs

Crutchfield tongs fit into the parietal bones

A special drill point with a shoulder is used to enable an accurate depth of hole to be drilled

Application of Crutchfield Tongs

Sedate the patientShave the scalp locallyDraw a line on the

scalp, bisecting the skull from front to back

Draw a second line joining the tips of the mastoid processes which crosses the first line at right angles

Fully open out the tongs

Application of Crutchfield Tongs

With the fully open tongs lying equally on each side of the antero-posterior line, press the points into the scalp making dimples on the second line.

Infiltrate the area of the dimples down to and including the periosteum, with local anaesthetic solution.

Make small stab wounds in the scalp at the dimples. Using the special drill point, drill through the outer table of

the skull in a direction parallel to the points of the tongs. Fit the points of the tongs into the drill holes. Tighten the adjustment screw until a firm grip is obtained,

and repeat daily for the first 3 to 4 days, and then tighten when necessary

Attach a traction cord to the two lugs. Attach a weight to the traction cord. Raise the head end of the bed to provide counter traction

Recommended Weights in Cervical Traction

(Crutchfield)Level Minimum

WeightMaximum

WeightC1 2.3 KG 4.5 KG

C2 2.7 KG 4.5 – 5.4 KG

C3 3.6 KG 4.5 – 6.7 KG

C4 4.5 KG 6.7 – 9.0 KG

C5 5.4 KG 9.0 – 11.3 KG

C6 6.7 KG 9.0 – 13.5 KG

C7 8.2 KG 11.3 – 15.8 KG

Complications of Skeletal Traction

Introduction of infection into the bone Incorrect placement of the pin or wire may-

Allow the pin or wire to cut out of the bone causing pain and the failure of the traction system

Make control of rotation of the limb difficult Make the application of splints difficult Result in uneven pull being applied to the ends of the pin

or wire and thus cause the pin or wire to move in the bone Distraction at the fracture site Ligamentous damage if a large traction force is applied

through a joint for a prolonged period of time Damage to epiphyseal growth plates when used in children Depressed Scars

Management of patients in traction

Care of the patientCare of the traction suspension systemRadiographic examinationPhysiotherapyRemoval of traction

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

Radiographic Examination2-3 times in first weekWeekly for next 3 weeksMonthly until union occursAfter each manipulationAfter each weight change

Removal Of TractionElbow fracture with olecranon pin - 3 weeksTibial fracture with calcaneal pin - 3-6

weeksTrochanteric fracture of femur - 6 weeksFemoral shaft fracture

with application of cast brace and partial weight bearing - 6 weekswithout external support and partial weight bearing - 12 weeks

Thank You