Application of traction in orthopaedics

1. Application of Traction in
Orthopaedics
By- Prabhnoor Singh Hayer
Moderated by- Dr. Rajesh Maheshwari

2. Definition
Traction is the application of a pulling
force to a part of the body

3. History
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

4. 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

5. Indications
To reduce the fracture or dislocation
To maintain the reduction
To correct the deformity
To reduce the muscle spasm

6. 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)

7. 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

8. Advantages of Traction
Decrease pain
Minimize muscle spasms
Reduces, aligns, and immobilizes fractures
Reduce deformity
Increase space between opposing surfaces

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

10. 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

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

12. Knots
A slip knot tightens
under tension
Up and over, down
and over, up and
through

13. Knots - types
Clover hitch
Barrel hitch
Reef knot
Half hitch
Two half hitches

14. Skin traction
Skin traction

15. 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 boot
Not more than 4.5 kgs
Not used to obtain or
hold reduction

16. Hamilton Russell Traction
Buck’s with sling
May be used in more
distal femur fracture in
children
Can be modified to hip
and knee exerciser

17. 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

18. 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

19. 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

20. 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

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

22. 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

23. Contraindications
Abrasions and lacerations of skin in the area to which
traction is to be applied
Impairment of circulation - Varicose veins, impending
gangrene
Dermatitis
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

24. Complications
Allergic reactions to adhesive
Excortication of skin
Pressure sores around the malleoli and over the tendo
calcaneus
Common peroneal nerve palsy

25. Skeletal Traction

26. Indications
It should be reserved for those cases in which skin traction
is contraindicated
In patients with lacerated wounds
In patients with external fixator in situ
When the weight required for traction is more then 6.5 kgs-
Obese patients

27. Proximal Tibial Traction
•Used for distal 2/3
rd
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.

28. Upper Femoral Traction
Lateral traction for
fractures with medial or
anterior force
Stretched capsule and
ligamentum teres may
reduce acetabular
fragments

29. 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

30. 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

31. Distal Femoral Traction
•Draw 1
st
line from before
backwards at the level of the
upper pole of patella,2
nd
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

32. Ninety-Ninety Traction
Useful for
subtrochantric and
proximal 3
rd
femur
fracture
Especially in young
children
Matches flexion of
proximal fragment
Can cause flexion
contracture in adult

33. Perkin’s traction
Treatment 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

34. 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

35. Perkin’s traction:

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

37. Pearson Attachment
•Middle 3
rd
fracture has
mild flexion proximal
fragment
•30 degrees elevation with
traction in line with femur
•Distal 3
rd
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

38. Distal Tibial Traction
Useful 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 vein
Place through fibula to avoid
peroneal nerve
Maintain partial hip and knee
flexion

39. 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

40. 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

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

42. 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.

43. 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 2
nd
/3
rd
MC
Stiffness of intrinsics is
common

44. 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.

45. Gardner Tongs
U shaped tongs, used
for spinal traction
In patients having
cervical injury
Easy to apply
Place directly above
external auditory
meatus
In line with mastoid
process
Just clear top of ears

46. Gardner Tongs
Pin site care important
Weight ranges from2.3
kg to 15.8 kg for c-spine
Excessive manipulation
with placement must be
avoided
Poor placement can
cause flexion/extension
forces
Patient can get occipital
decubitus

47. 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

48. Application of Crutchfield
Tongs
Sedate the patient
Shave the scalp locally
Draw 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

49. 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

50. Recommended Weights in Cervical Traction
(Crutchfield)
Level Minimum
Weight
Maximum
Weight
C1 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

51. 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

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

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

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

55. Removal Of Traction
Elbow fracture with olecranon pin - 3 weeks
Tibial fracture with calcaneal pin - 3-6 weeks
Trochanteric fracture of femur- 6 weeks
Femoral shaft fracture
with application of cast brace and
partial weight bearing - 6 weeks
without external support and
partial weight bearing - 12 weeks

56. Thank You