Tractions

orthopaedic tractions

1. Tractions in orthopaedics Dr. harshwardhan Dawar r.s.o . orthopaedics M.Y.H. Indore

2. TRACTIONS TRACTION IS A FORCE APPLIED MANUALLY OR MECHANICALLY GENERATED BY WEIGHTS OR FORCE, USED TO REDUCE FRACTURES / DISLOCATIONS OR TO ACHIEVE RELATIVE IMMOBILIZATION. USES – TO REDUCE FRACTURE / DISLOCATION BY COUNTERACTING MUSCLE SPASM. TO RELIEVE PAIN BY RELATIVE IMMOBILISATION AND RELIEVING SPASM TO KEEP JOINT SURFACES APART IN INFLAMMATORY CONDITIONS LIKE SEPTIC / TUBERCULAR ARTHRITIS.

3. History : Skin traction used extensively in Civil War for fractured femurs Known as the “American Method” 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. History: Percival pott - fractured limb should be placed in the position in which muscles are most relaxed Josiah crosby – isotonic skin traction for treatment of shaft of femur Thomas Bryant- Braynt’s traction for treatment of fracture shaft of femur in children

5. 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 steinmann pins after he devised Bohler stirrup.

6. Indication : Lessen or eliminate muscle spasms Relieve pressure on nerves, especially spinal ToIncrease space between opposing surfaces Prevent or reduce skeletal deformities or muscle contractures To provide a fusiform tamponade around a bleeding vessel

7. Advantages : Decrease pain Minimize muscle spasms Reduces, aligns, and immobilizes fractures Reduce deformity

8. Disadvantages : Hazards of prolonged bed rest Thromboembolism Decubitus ulcers Pneumonia Requires meticulous nursing care Can develop contractures

9. Classification : CLASSIFICATION I – SKIN TRACTION SKELETAL TRACTION MANUAL TRACTION CLASSIFICATION II – BALANCED TRACTION FIXED TRACTION

10. SKIN TRACTION – TRACTION IS APPLIED THROUGH SKIN BY ADHESIVE BANDAGE/BANDAGE FOAM CONSTRUCT SKELETAL TRACTION – TRACTION IS APPLIED TO BONE USING STEINMANN PIN / K – WIRES BALANCED TRACTION – USES GRAVITY FOR COUNTER-TRACTION FIXED TRACTION – TRACTION IS GIVEN BETWEEN TWO FIXED POINTS

11. Sliding traction: Introduced by Pugh, treatment of perthes . One limb is tightened via skin traction and fastened to the end of bed, the bed is then raised head down, enabling the pelvis on the opposite side to slide down in traction and abduction. The amount of traction can thus be changed by friction of mattress. Hendry modified the traction by using a sliding fracme on the mattress.

12. Factors: Type of traction Amount of weight to be applied Frequency of neurovascular checks if more frequent than every four hours Site care of inserted pins, wires, or tongs The site and care of straps, harnesses and halters The inclusion of any other physical restraints / straps or appliances (e.g., mouth guard) The discontinuation of traction

13. components

14. Cord: Sash cord generally used, nylon cord can also be used Easier recognition of each cord is possible if cords of two different colours used

15. 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 Pulleys of 5-6.25cm diameter with 6cm diameter axles are preferred.

16. Knots

17. SKIN TRACTION:

18. 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 ) Two types Adhesive skin traction Nonadhesive skin traction

19. Do’s and don’t for skin traction: 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.

20. 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, skin infection. Marked shortening of bony fragments, when traction weight is required will be greater than can be applied through the skin

21. COMPLICATIONS OF SKIN TRACTION – PRESSURE SORE AROUND THE MALLEOLI AND OVER THE TENDOCALCANEUS COMMON PERONEAL NERVE PALSY BLISTERING OF UNDERLYING SKIN DISTAL ISCHAEMIA ALLERGIC REACTION TO ADHESIVES PEELING / SLOUGHING OF SKIN

22. Buck’s traction: Used in temporary management of fractures of Femoral neck Intertrochanteric fractures 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

23. Hamilton russel’s traction: Used in management of fractures of the femoral shaft After arthroplasty operations of hip Buck’s traction with sling under the knee Weight: Adults upto 3.6 kgs Children upto 1.8 kgs

24. GALLOW’S TRACTION: U seful for children younger than 2 years who weigh 10-12 kg for Fracture shaft of femur . Careful examination of the neurovascular status of the extremity is mandatory in the early period after application of traction . Older children have a risk of compartment syndrome , vascular insufficiency, peroneal nerve palsy, and skin breakdown  when treated with this method.

25. Bryant’s traction: Treatment of fractures of the shaft of femur in children upto age of two years who weight less than 35-40lb ( 15.9- 18.2kg ) Combines gallows traction and Buck ’ s traction Raise mattress for counter traction Rarely used currently

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

27. Forearm skin traction: Adhesive strip with wrap Useful for elevation in any injury Can treat difficult clavicle fractures Good cosmetic result Risk is skin loss

28. Double skin traction: Used for greater tuberosity or prox humeral shaft fx Arm abducted 30 degrees Elbow flexed 90 degrees 7-10 lbs on forearm (3-4 kgs ) 5-7 lbs on arm (2-3 kgs ) Risk of ischemia at cubital fossa

29. 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 45 degrees Max weight 2kgs each side

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

31. 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 Also used in physiotherapy for cervical spondylolysis

32. Agnes hunt traction: To correct mild flexion deformity of hip

33. Pelvic traction: Used in conservative management of prolapse of intervertebral disc, sciatica. Max amount of weight varies according to body weight, but 30-45kgs remains average.

34. SKELETAL TRACTION

35. 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 - Obese patients Max weight permitted is 11-18 kgs . (normally)

36. Steinmann pin: Rigid stainless steel pins of varying lengths 4 – 6 mm in diameter. Bohler stirrup is attached to steinmann pin which allows the direction of the traction to be varied without turning the pin in the bone

37. denham 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

38. K WIRE TRACTION: 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

39. COMPLICATIONS OF SKELETAL TRACTION – Pin tract infections, osteomyelitis Neurovascular injuries 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

40. PROXIMAL TIBIAL TRACTION: Used for distal 2/3 rd femoral shaft fractures and Intertrochanteric 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

41. Upper femoral traction Lateral traction for fractures with medial or anterior force. For acetabular fractures. Stretched capsule and ligamentum teres may reduce acetabular fragments

42. 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. 6.5mm or 12mm pins with a rounded external end available.

43. 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

44. 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

45. 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

46. 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

47. Calcaneum 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

48. Olecranon traction: Supracondylar/distal humerus fractures Greater traction forces allowed Can make angular and rotational corrections Place pin 1.25 inches distal to tip of olecranon Avoid ulnar nerve

49. Lateral olecranon traction: Used for humerus fractures Arm held in moderate abduction Forearm in skin traction Excessive weight will distract fracture

50. 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.

51. 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

52. 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.

53. 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

54. 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

55. Crutchfield tongs Crutchfield tongs fit into the parietal bones A special drill point with a sleeve used to enable an accurate depth of hole to be drilled

56. 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

57. Procedure: 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

58. 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

59. Perkin’s traction:

60. 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

61. 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

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

63. 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

64. 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

65. From- Traction and Orthopaedic appliances John D.m Stewart, Jeffrey P. hallet

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