Lower Limb traction

Ppt on lower linb traction. Ppt frm traction and orthopedic appliances from Stewart.

1. TRACTION (SKELETAL AND SKIN) UPPER LIMB AND LOWER LIMB BY DR VIPIN DEV M GUIDE DR DARSHAN SONAWANE

2. TRACTION When inflammation or fracture , controlling muscles in to spasm Antagonist not powerful Leads to deformity For overcoming the deforming force

3. Uses Against deforming force Relieve pain Allow limb to be rested in best functional position Controls movement of affected part- helps in healing

4. SKIN TRACTION Over a large area of skin Max weight can b applied – 6.7 kg

5. Contraindications Abrasions of skin Laceration of skin where it to be applied Impairment of circulation – varicose u lcers and impending gangrene Dermatitis Marked shortening of bony fragments – when weight needed more than that can be applied through

6. Complications Allergic reaction Excoriation due to slipping Pressure sores Nerve palsy

7. METHODS OF APPLYING SKIN TRACTION ADHESIVE SKIN TRACTION NON ADHESIVE SKIN TRACTION

8. Adhesive skin traction Prepare the skin by shaving washing and drying Use adhesive strapping which can be stretched only transversely Avoid placing adhesive strapping over bony prominences Leave a loop of 2 inches ( 5cm) projecting beyond the distal end of limb to allow the movement of finger / foot

9. Always leave a free skin between the straps Must not be too tight or too loose Leave the heels free Can be safely used for 4-6 weeks It may be pulled down day by day

10. Non-Adhesive skin traction This consists of lengths of soft, ventilated latex foam rubber, laminated into a strong cloth backing . In thin and atrophic skin and allergic to adhesive It is applied like adhesive skin traction As the grip is less secure, frequent reapplication may be necessary Max weight – 4.5 kg

11. Skeletal Traction Metal pain or wire is driven through bone Force applied through bone Frequent for lower limb where skin traction contraindicated Series Complication - osteomyelitis

12. Skeletal Traction Steinmann pin Rigid stainless steel pins 4-6 mm in diameter Attached to bohler stirrup

13. Denham pin Same as Steinman Short raised threaded length towards end Engages the bony cortex and reduces pin sliding K wire Wire easily cuts through if heavy weight applied More in upperlimb

14. Sites- Olecranon Just deep to subcutaneous border of upper end of ulna 3cm distal to tip of olecranon To avoid elbow joint K wire from medial to lateral at right angle to long axis of ulna

15. Second and third metacarpals 2-2.5 cm proximal to distal end of 2 nd metacarpal Wire transvers 2 nd and 3 rd metacarpal Lie at right angle to long axis of radius

16. Upper end of femur – greater trochanter Lateral surface of femur 2.5 cm below prominent part of GT Mid way between anterior and posterior surface Screw eye or CC screw used

17. Lower end of femur Prolonged traction leads to fibrosis and knee stiffness To be removed in 2 weeks

18. Point of insertion – 2 way determination Proximal to upper limit of lateral femoral condyle 3cm proximal to joint line Care to avoid knee joint Lateral fold of knee capsule up to 2 cm above joint 2 nd one –intersecting point line form upper pole of patella transversely and line anterior to head of fibula

19. Upper end of tibia 2 cm behind and below the crest, just below the level of tubercle of tibia. Pin to be driven from lateral to medial to avoid CPN

20. Lower end of tibia 5 cm above level of ankle joint Mid way between anterior and posterior border of tibia Calcaneum 2 cm below and behind lateral malleolus Ie 3 cm below and behind medial malleolus Can result in subtalar stiffness

21. Complications Can introduce infection to bone. Incorrect placement can cause Cut out of bone – pain and failure of traction Make control of rotation of limb difficult Make the application of splint difficult Result in uneven pull thus cause movement of pin Can cause infection or ischemic necrosis

22. Distraction at fracture site Ligamentous damage if applied for a long time Damage to epiphyseal growth plates if in children Depressed scars – can be prevented if pin track pinched at time of remova l Due to fibrous tissue with skin and periosteum

23. COUNTER TRACTION Tractional force applied will overcome muscle spasm only if another force in opposite way as tractional force If no counter body will get pulled towards traction TYPES FIXED TRACTION SLIDING TRACTION

24. Fixed traction When counter traction acts through an appliance which obtains a purchase on a part of body. By applying force to a point in the body proximal to the attachment of muscle in spasm The length of the limb remains constant Continous dimunition of traction force as the tone in the muscles diminish and further no activation of muscle stretch reflex Pull is exerted against a fixed point.

25. Fixed traction Balances the pull of muscles Muscular pull and hematoma decreases Distraction and non union less likely to occur Not dependent on gravity Self contained Patient may be lifted and moved with out risk of displacement.

26. METHODS OF FIXED COUNTER TRACTION

27. Fixed traction in Thomas` splint Maintain but not obtain reduction Counter thrust passes up the side bars to padded ring around the root of the limb . The malleoli are well padded to avoid pressure sores .

28. The outer traction cord passes above and the inner cord passes below its respective side bar, to hold the limb in medial rotation. The traction cords are tied over the end of the Thomas spint . A traction wt of 2.3kg attached to the Thomas`splint is sufficient to prevent getting pressure sore at root of leg.

29. Advantages of Thomas splint: Distraction at the # site less likely to occur No need to tighten the traction cords repeatedly Apparatus is self contained and can be moved without risk of displacement of #

30. Traction unit Introduced by Charnley . For the treatment of # Shaft Of Femur. Consists of upper tibial steinman pin incorporated in a below knee cast which is then fit in to a Thomas` splint 15cm wodden bar transversely in the sole of the plaster midway between toes and heel to control rotation

31. Advantages: Compression of the tissue of the upper calf including common peroneal nerve does not occur Equinus deformity at the ankle can't occur because the foot is supported by plaster cast The tendo -calcaneus is protected by the padded cast Rotation of the foot and the distal fragment is controlled A fracture of the ipsilateral tibia can be treated conservatively at the same time.

32. ROGER ANDERSON WELL-LEG TRACTION used in management of #s of pelvis, femur , tibia. Skeletal traction being applied to injured leg, while the well leg was employed for counter traction . But this method is valuable in correcting either abduction and adduction deformity at the hip.

33. A/K PLASTER CAST LIMB WHICH WILL BE PUSHED UP LARGE STIRRUP IN PLASTER BY ALTERING THE POSITION OF SCREW THE RELATIVE POSITIONS OF TWO STIRRUP CAN BE ALTERED. STEINMENN PIN THROUGH LOWER END OF THE TIBIA OF THE LIMB WHICH IS TO BE PULLED DOWN.

34. PRINCIPLE: With abduction deformity at the hip,the affected limb appears to be longer. When Traction is applied to the well limb and Affected limb is simultaneously pushed Up ( counter traction ), the abduction deformity is reduced. Reversing the arrangement will reduce an adductiondeformity .

35. Sliding Traction Described by Haddy James In his rib bandge attached to head of bed acted as a counter traction When weight of whole body or part of body acted as counter traction – its sliding traction Gravity utilized to provide counter traction by tilting the bed Obtained by raising bed over a wodden block

36. Initiall traction weight to reduce a fracture is more than traction weight required to maintain traction Traction weight depends on Site Age and weight of patient Power and damage of muscles Degree of friction By trail and error method

37. For femoral shaft 10% of BW The higher the traction weight higher the bed must be elevated 2.5 cm for every .5 kg of weight

38. BUCK’S TRACTION OR EXTENSION Used in Femoral neck fracture Shaft fracture in children Undisplaced acetabular fracture Post reduction of dislocated hip To correct minor ffd of hip and knee

39. Rarely reduce fracture For pain relief Lateral rotation of limb cannot be controlled

40. Application: Apply adhesive strapping to above knee or in elderly ventofoam skin traction Support the leg with pillow. Pass the cord from spreader over pulley. Attach 2.3-3.2kgs TO THE CORD. Elevate the foot end of bed.

41. PERKIN`S TRACTION Principle: It is the use of skeletal traction without any external splintage coupled with active movements of injured limb Perkins showed that by encouraging early muscular activity stiffness of joint was prevented by extensibility of muscles by reciprocal innervation

42. USE IN TREATMENT OF Fracture tibia Subtrochanteric and shaft femur #

43. Application Under GA and aseptic precautions Insert Denham pin through upper Tibia Attach Simonis swivel to each end of pin Connect 2 traction cords to each swivel Pass each cord over separate pulley For femur 4.6kg over each pulley For tibia 2.3 kg over each pulley

44. Hamilton – Russel Traction Indications : Management of the fracture shaft of femur After arthroplasty operations on the hip Application: Below knee skin traction Pulley attached to spreader Soft sling placed under knee and attach a cord Weight adults – 3.6 kg chidren – 0.28- 1.8 kg

45. Advantage : Based on law of parallelogram of forces that -the 2 pulley blocks at the foot of the bed theoretically doubles the pull on the limb and the resultant traction is in axis of 30° to the horizontal i.e. in line of shaft of femur

46. TULLOCH BROWN TRACTION Application: Steinman pin through the proximal tibia. Support legs on slings suspended from light duralumin u loop which is slipped over the ends of steinman pin.

47. Attach the nissen stirrup to the steinman pin it enables leg to be suspended and rotation of movements controlled. Foot supported in perspex foot plate & foot end elevated.

48. NINETY/NINETY TRACTION Devised by Obletz (1946) Used # femur with wounds over post aspect of thigh (operative & post op management) Subtrochanteric and proximal third # femur Used in both children and adults Here both hip and knee are flexed to 90 degree.

49. Skeletal traction is applied through lower femur or upper tibia 3 methods of supporting leg in 90/90 traction

50. USING B/K CAST

51. USING A SECOND STEINMAN PIN

52. USING TULLOCH BROWN U LOOP

53. As the union of fracture occurs, encourage active hip and knee exercise-extension , gradually lower the limb into a more horizontal position.

54. DANGERS OF 90/90 TRACTION Those of skeletal traction. Stiffness and loss of extension of the knee. Flexion contracture of hip. Injury to the lower femoral or upper tibial epiphyseal growth plates in children. Neuro vascular damage

55. Sliding Traction in a Fisk Splint It is a modification of Thomas splint where in a knee flexion piece is attached to Thomas splint. Active flexion and extension of the knee is possible , but little movement occurs at the hip The patient as soon as possible begins assisted movement of the lower limb which is moved as one unit as though the patient were walking. Uses : In femoral shaft fractures and tibial condyle fracture .

56. BRYANT`S TRACTION(GALLOWS) Used in # Shaft of femur in children <2 yrs Apply adhesive strapping to both lower limbs Tie traction cords to an over head beam Tighten the traction cord to raise the buttocks just clear the mattress Counter traction obtained by weight of pelvis

57. Vascular complication of Bryants traction may occur in either the injured or normal limb. A careful check must be done in both limbs during first 24-72 hrs. By checking color and temp of limbs. Dorsiflexion of both ankle passively. Bryants traction in children : under 2yrs - safe 2-4yrs - vascular complications more(can be prevented by using posterior splint). Over 4yrs - absolutely contraindicated.

58. Modified Bryant`s traction In the initial management of CDH when diagnosed over the age of 1 year. After 5 days abduction of hip is started Abduction is increased by 10* on alternate days By 3wks hips should be fully abducted

59. COMPLICATIONS: The child will become restless and scream repeatedly with pain. The pain is due to stretching of capsule and impingement of femoral head on superior lip of acetabulam .

60. SLIDING TRACTION IN BOHLERBRAUNFRAME In management of tibia and femoral fractures Most proximal pulley-to prevent foot drop. 2 nd pulley-to apply traction in line of Femur. 3 rd pulley-to apply traction in line of supracondylar area of femur and high tibial traction . 4 th pulley-to apply traction in line of leg as in low tibial or calcaneal traction . 3.2 -4.5kg can be arrched

61. DISADVANTAGES: Bohler Braun frame rests on pts bed and cannot move with the patient. Nursing care is more difficult. Movement of proximal #fragments in relation with distal fragment which is cradled in the splint. This predisposes to deformity.

62. Lateral upper femoral traction Used alone or along with traction in long axis of femur in management of central fracturedislocation of Hip. If only superior rim of acetabulum is fractured combined with Buck's OR Russell traction If posterior rim of acetabulum is fractured and if reduction of dislocated femoral head is unstable , combined with vertical skeletal traction in lower end of femur or upper end of tibia . Maximum attachable weight - 4.5-9kg

63. PELVIC TRACTION In pelvic traction special canvas harness is buckled around the patients pelvis. Long cords attach the harness to the foot of the bed. Foot end of the bed raised-provides sliding traction. Used in conservative management of IVDP. To ensure that the patient lies quietly in bed Buck`s traction may also be employed

64. Dunlop's traction Indication - Supracondylar transcondylar fractures of Humerus in children . This method is useful if flexion of the elbow causes circulatory embarrassment with loss of radial pulse

65. Apply skin traction to fore arm Place the pt supine Abduct the shoulder to 45* Pass the traction cord over a pulley so that elbow flexed to 45* Place padded sling over distal humerus Attach 0.5-1 kg wt to traction cord and padded sling so that it elbow is just above the bed Elevate same side of bed Check circulation

66. OLECRANON TRACTION Indications: Supracondylar fracture of humerus Comminuted fracture of lower end of the humerus Unstable fracture of the shaft of the humerus Weight – 1.3- 1.8 kg

67. METACARPAL PIN TRACTION Indications Comminuted fracture of forearm bones - especially for a comminuted # of lower end of the radius Maximum attachable weight is - 1.3-1.8kg Complications: Fibrosis in the interosseous muscles causing stiffness of fingers. General complications of skeletal traction.

68. THANK YOU.