Traction in orthopaedics

This ppt will give basic idea about traction.

1. Traction by Dr.Ramesh Charan under guidance of Dr.B.L.Khajotia sir

2. Definition : traction is defined as force applied to overcome the muscle spasm TYPES 1. Based on method of application Skin traction Skeletal traction 2. Based on mechanism of traction Fixed Traction By applying force against a fixed point of body. Sliding Traction When the weight of all or part of the body, acting under the influence of gravity , is utilized for counter traction

3. History Malgaigne introduced the 1 st 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 S teinmann pins after he devised Bohler stirrup.

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

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

6. Counter traction The resistance or back pull made  to traction or pulling on a limb ;  for  example;  in the case of traction made on the  leg,countertraction  may be effected by raising the foot of the bed so that the weight of the body pulls against the  weightattached  to the limb.

7. 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

8. Weights Amount of weight required depends upon Weight of the appliance Weight of part of body suspended Amount of friction present in the system Mechanical advantage of the system employed for suspension

9. Skin traction Applied over a large area of skin This spreads the load and is more comfortable and efficient Traction force must be applied distal to fracture site Maximum traction weight can be applied with skin traction is 15lb ( 6.7kg )

10. Two types 1. Adhesive skin traction Elastoplast skin traction kit Seton skin traction kit 2. Non-adhesive skin traction Useful in thin and atrophic skin Allergy to adhesive strapping Frequent reapplication may be necessary Attached traction wt. must not be more than 10lb ( 4.5kg ) Below knee traction

11. P recautions 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.

12. Contraindications Abrasions of the skin Lacerations of the skin in the area to which traction is applied Impairment of circulation – varicose ulcers, impending gangrene Dermatitis

13. Complications Allergic reaction to adhesive Excoriation of skin from stripping of the adhesive strapping Pressure sore around the malleoli and over the tendo -calcaneus Common peroneal nerve palsy Blistering of skin

14. USES It is used in temporary management of fractures of Femoral neck Femoral shaft in older children Un displaced 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 Used to obtain or hold reduction

15. Tractions in routine use Gallows traction Russels traction Bryants traction Agnes hunt traction 90-90 Traction Dunlops raction Head halters traction Pelvic traction

16. 1 . Gallows traction Legs of the child is tied to an overhead beam Hips are kept a little raised from the bed so that the weight of the body provides counter traction Used for #shaft of femar in childrens less then 3yr old 2. Hamiltons Russels traction Buck’s traction with sling under the knee Used in management of fractures of the femoral shaft After arthroplasty operations of hip 3. Bryant’s traction fractures of the shaft of femur in children upto age of two years who weight less than 35-40lb ( 15.9- 18.2kg)

17. Gallow’s Russel’s

18. Modified Bryant’s traction Sometimes used in initial management of congenital dislocation of hip After 5days of application of Bryant’s traction abduction of both hips begun being increased by 10 degrees on alternate days By three weeks hips should be fully abducted

19. 4. Agnes H unt traction To correct mild flexion deformity of hip eg ; poliomyelitis 5. 90-90 Traction Fracture of shaft femur in children subtrochanter and proximal third fracture Used in fixed flexion contracture of knee Using a Tulloch – Brown U- loop Using a second steinmann pin Using a below knee pop cast

20. Dunlop’s Traction Used for supracondylar and trans-condylar fractures of humerus in children Used when closed reduction difficult Forearm skin traction with weight on upper arm Elbow flexed 45 degrees

21. Double Skin Traction Used for # of greater tuberosity or proximal humeral shaft Arm abducted 30 degrees Elbow flexed 90 degrees 7-10 lbs on forearm 5-7 lbs on arm Risk of ischemia at antecubital fossa

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

23. Head halters 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

24. Pelvic traction Used in fractures of pubis rami,pelvic diastasis ,iliac blade ,acetabulum Can also be used in the conservative management of PIVD Halopelvic traction Used in scoliosis

25. Skeletal traction 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

26. Steinmann pin Rigid stainless steel pins of varying lengths 4 – 6 mm in diameter. Bohler’s stirrup is attached to S teinmann pin which allows the direction of the traction to be varied without turning the pin in the bone

27. Denham’s 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

28. Kirschner’s 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

29. How to Apply Use GA or LA Paint the skin with iodine and spirit Mount the pin/wire on the hand drill Hold 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.

30. Apply small cotton woolen pads soaked in tincture around the pins to seal the wound The pin should pass only through skin, SC tissue and bone avoiding muscles and tendons

31. 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 Distal tibial traction Pin is inserted 5cm above the level of the ankle joint mid way between the anterior and posterior border of the tibia Avoid saphenous vein Mantain partial hip and knee function

32. Distal femoral traction Alignment of traction along axis of femur Used for acetabular fracture and femoral shaft fracture Used when strong force needed or knee pathology present

33. Calcaneal traction Inserted from medial side Temporary traction for tibial shaft fracture or calcaneal fracture Insert about 3cms inferior and posterior to medial malleolus

34. Upper femoral traction(Trochanteric hook) Hook driven into the neck of femur Stretched capsule and ligamentum teres may reduce acetabular fragments upon application of suitable weight to the hook

35. Perkins traction Denham pin is inserted through the upper end of tibia Simoni’s swivel is attached to 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

36. Olecrenon tip 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

37. 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 .

38. 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

39. 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 Weight ranges from2.3 kg to 15.8 kg for c-spine Poor placement can cause flexion/extension forces Patient can get occipital decubitus

40. Gardens crutchfeilds

41. 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 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

42. Care of patients in traction Look for blisters or any skin changes Check distal neurosensory function Check distal pulse(NBC) Active toe/finger movement Elevation of limb Care of the traction suspension system Radiographic examination Physiotherapy

43. THANK YOU