tractions in orthopaedics
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Tractions In Orthopaedics
Dr. Parth Chaudhary
Definition
•Traction and suspension setups are arrangements of bars, pulleys, ropes, and weights which exert a pulling force on a part or parts of the body, or serve to suspend or “float” a part of the body-most frequently a limb
Introduction
•When a limb is painful as a result of inflammation of a joint or fracture of a bone the controlling muscles go into spasm
•The antagonistic muscles in a limb are not all equally powerful hence the action of more powerful muscle produces deformity which may seriously impair the future function of the limb
Introduction
•Traction when applied to a limb can over come the deforming force and thus can be used to reduce a fracture or dislocation of a joint
•In addition by overcoming muscle spasm traction can relieve pain andallows the limb to be rested in best functional position
Purpose•The purpose of any traction setup is one or
more of the following :
1. To prevent or reduce muscle spasm
2. To immobilize a joint or part of the body
3. To reduce a fracture or dislocation
4. To correct soft tissue contractres
•To achieve these purposes, the traction setup must:
1. Align the distal fragment to the proximal fragment
2. Remain constant
3. Allow for adequate exercise and diversion
4. Allow for optimum nursing care
Anatomical Considerations
• Figure illustrates a fracture femur. The muscle groups have pulled the broken parts out of alignment.
• The pull of the muscle group is overcome by a new force (traction) created with weights and pulleys.
• Weights provide a constant (isotonic) force; pulleys help establish and maintain constant direction.
• The forces thus applied must remain constant in amount and direction until the fracture fragments unite.
Anatomical Considerations
•Figure illustrates the same femur after traction has been applied to realign (approximate) the broken parts
Anatomical Considerations•During an extensive period of healing, the limb must
be supported to assist in maintaining fragment alignment, but the patient should still be able to move about as much as possible until union is achieved
•This is why a second system of weights and pulleys called “balanced suspension” is often used
•Balanced suspension permits the limb to “float” over the bed, and facilitates bed pan use and changing of bed linen with minimal disturbance of the fracture
Anatomical Considerations
•Countertraction, which is the resistance of the body to move in the direction of the forces exerted by a traction device, is a factor which is built into each setup by utilizing the patient’s body weight
•When necessary, the countertraction of the patient’s body weight may be increased by elevation of the foot of the bed or using blanket rolls, sand bags, etc
•THREE BASIC TYPES:
1. Manual Traction
2. Skin Traction
3. Skeletal Traction
Manual Traction
• In manual traction, the hands are used to exert a pulling force on the bone which is to be realigned.
• Generally, this type of traction is reserved only for very stable fractures or dislocations prior to splinting or immobilization in a cast.
• It also may be used prior to the application of skin or skeletal traction or surgical reduction.
Skin Traction•Mechanism : •The traction force is applied to large area
of skin
•This spreads the load and is more comfortable and efficient
•Force applied is transmitted from skin to bone via the superficial facia, deep fascia and intermuscular septa
Skin Traction
• In treatment of fractures the traction force must be applied to limb distal to fracture site otherwise the efficiency of traction force is reduced
• The maximum traction weight that can be applied is 15 lb (6.7kg) depending on the size and age of the patient
• Methods :• Adhesive Skin Traction • Non Adhesive Skin Traction
Adhesive Skin Traction• Application :• The limb is prepared, shaved and tincture
benzoin can be applied which protects the skin and acts as an adhesive
• Adhesive strapping is applied on each side of the limb with cotton padding over the bony prominence
• A loop of two inches kept beyond the distal end of limb to allow movement of fingers / foot
Adhesive Skin Traction•In lower limb the strapping is applied to
lateral aspect must lie slightly behind and parallel to a line in between greater trochanter and lateral malleoli on the medial aspect it should lie in front of the above line to encourage medial rotation of the limb
Adhesive Skin Traction• Always leave free skin between the straps to
prevent any tourniquet effect
• The extension tapes are then bandaged to limb with help of crape bandages which must not be too loose or too tight
• Suport the limb to prevent edema and heel should be leave free
• Skin traction can be safely used for 4-6 weeks
Adhesive Skin Traction
Non Adhesive Skin Traction• These are used in thin and atrophic skin or
when there is sensitivity to adhesive
• It is applied in Similar fashion as Adhesive skin traction
• As the grip is less secure frequent reapplication is required
• Attached traction weight shouldn’t be more than 4.5 kg
Indications of Skin traction • Temporary management of femoral neck # and
Intertrochanteric #
• Management of femoral shaft # in older patients and in children
• Undisplaced fracture of acetabulum
• After reduction of a dislocated hip
• To correct minor fixed flexion deformities of hip and knee
• In place of pelvic traction in management of low back ache
• After Gulliton amputation to approximate the tissues
Contraindication to Skin Traction• Pre-existing health problem which predisposes the skin to
damage and poor healing (DM, varicose ulcers and use steroid drug)
• Any wounds or sores in the area where traction to be applied
• Marked swelling in the area
• A history of hypersensitive skin
• Impairment of the circulation – varicose vein or impending gangrene
• Dermatitis
• When there is marked shortening and required traction weight is more than what can be applied through skin
Complication of Skin Traction•Allergic reaction to adhesive – Most common
agent causing allergy is Zinc oxide
•Excoriation of the skin from slipping of adhesive Strapping
•Pressure sores around malleoli and over tendo achillis
•Common Peroneal nerve palsy
Skeletal Traction
•Here the traction is applied directly to the bone by the means of pins and wires driven through the bone
•It is rarely used to manage upper limb fractures
•It should be reserved for those cases in which skin traction is contraindicated
Equipments•Steinmann Pin : They are rigid stainless pins of
varying lengths and 4-6mm in diameter•They are attached to Bohler Stirrup which
allows the direction of traction to be varied without turning the pin in bone
Equipments
•Denhamm Pin : It is identical to steinmann pin except short threaded part situated in center
•This threaded part engages the bony cortex and prevents pin sliding
•It is used in : 1) Cancellous bone like calcaneum
2) Osteoporotic bones
Equipments• Kirschner wire:• Advantages : They are easy to insert• Minimize the chance of soft tissue damage
• Disadvantages : If improper stirrup is used then they can cut through osteoporotic bones
• Although they are thin if special stirrup is used they can withstand large traction force because stirrup provides longitudnal tension forces which increases the rigidity of the K wire
• Uses : Most often in upper limb traction like olecranon traction
Equipments
Bohler Stirup K Wire Tractor
Common Sites for Application of Skeletal Traction
• Metacarpals : Placed through diaphysis of 2nd and 3rd metacarpals
• Point of insertion : 2-2.5 cm proximal to distal end of 2nd metacarpal
• Technique :• Push the 1st dorsal interosseus muscle
volarly and palpate subcutaneous portion of bone
• Pass the K wire at right angle to longitudinal axis of the radius traversing diaphysis of 2nd and 3rd metacarpals transversly
Common Sites for Application of Skeletal Traction
• Olecranon :• Point of insertion :• It is just 3cm from
subcutaneous border of upper end of ulna
• This avoids the joint and epiphysis
• Technique : Pass K wire from medial to lateral side and avoiding ulnar nerve injury
• Do not place the pin too distal as it may cause extension of elbow joint
Common Sites for Application of Skeletal Traction
• Upper end Femur (Greater trochanter) :
• Lateral Femoral traction
• Point of insertion : • Lateral Surface of femur
2.5cm below tip of GT and midway between anterior and posterior surface of femur
• Course threaded Cancellous screw or Screw eye is used
Common Sites for Application of Skeletal Traction
• Lower end of femur:• Point of insertion : 2 ways to determine• At the intersection of two lines one passing transversly
at upper pole of patella and other vertically above anterior to head of fibula
• 3cm proximal to lateral knee joint line
• Technique : • Pass as anteriorly as possible to avoid neurovascular
structures
• Disadvantages:• Prolonged immobilzation can cause knee stiffness due
to fibrosis of extensor mechanism of knee
Common Sites for Application of Skeletal Traction
•Lower end of femur:
Common Sites for Application of Skeletal Traction
• Upper end of Tibia:• Point of inseertion• 2cm below and lateral to tubercle of tibia
• Technique :• Pin should be inserted from lateral to medial side to
avoid injury to common peroneal nerve
• Lower end of Tibia :• Point of insertion:• 5cm above the level of ankle joint and midway
between anterior and posterior border of tibia
Common Sites for Application of Skeletal Traction
•Upper end of Tibia:
Common Sites for Application of Skeletal Traction
• Calcaneus:• Point of insertion:• 2cm below and behind
lateral malleolus• Or 3cm below and behind
medial malleolus
• Disadvantages:• Subtalar joint stiffness• Infection• Frequent loosening
Complications of Skeletal Traction• Pin tract infection
• Incorrect placement of pin/wire may:
Allow pin/wire to cut out
Make control of rotation difficult
Make application of splint difficult
Result in uneven pull leading to movement of pin in bone and hence causing infection and ischaemic necrosis of surrounding skin due to pressure by Bohler stirrup
Complications of Skeletal Traction• Distraction at the fracture site
• Ligamentous damage if kept through a joint for long time
• Damage to epiphyseal growth plate
Counter Traction•Goal of Counter traction is to relieve muscle
spasm and hence correcting the deformity
•Types of counter traction:
•Fixed Traction: Here counter traction is applied by force against a fixed point in the body proximal to the attachment of muscles in spasm
•Sliding or Balanced traction: Here counter traction is applied by weight of all or part of body acting under influence of gravity
Thomas Splint•Described by Hugh Owen Thomas in
1876
•Selection of Thomas splint
Measure the oblique circumference of thigh immediately below the gluteal fold and ischial tuberosity
Measure the distance between crotch and heel and add 6-9 inches
Thomas Splint•Preparing a Thomas splint:Attach sling to the side bars on which the limb can
rest - Pass the length of bandage around inner bar and then both end above the outer side bar
- The poximal sling leaves a unsupported triangular area which can be obliterated with passing the bandage around the ring and around side bar
Thomas Splint
- The distal sling must end 2.5 inches above the heel to avoid pressure sore over tendo- achillis
Line the sling with gamgee tissuePut a large pad under lower part of thigh to
maintain normal anterior bowing of femur
Thomas SplintIf the leg is to be supported in a knee
flexion piece the hinge must coincide with axis of movement of knee that is at level of adductor tubercle of femur
After the splint has been fitted bandage the limb to splint
Fixed Traction in Thomas Splint
•Here the traction is exerted from fixed points of patient’s pelvis
•The extension tapes pull the limb down to the splint which is prevented from moving in opposite direction by resistance of the splint against ischial tuberosity
• It is use to maintain reduction not to obtain the reduction of fracture
Fixed Traction in Thomas Splint• The ring of thomas splint is well upto the groin and snugly fits around the root of the limb
•The malleoli are well padded to avoid pressure
•The outer traction cord passes above and the inner traction cord passes below its respective side bar
•The traction cord are tied at the end of Thomas’s splint
•The counter traction force thus passes along the side bars to the root of limb
Fixed Traction in Thomas SplintAdvantages :• It balances the pull of muscle and as the
muscle pull and heamatoma decreases the traction also decreases
• Distraction at the fracture site less likely to occur
• As traction doesn’t depend on gravity patient can be lifted and moved without the risk of displacement of fracture
Fixed Traction in Charnley’s Traction Unit
•It is modification of Thomas Splint•It consist of Upper tibial steinmann pin
incorporated in a light Below knee POP cast
•Advantages:•Compression of tissue of upper calf and
peroneal nerve doesn’t occur•Equinus deformity at ankle is prevented•Tendo achillis is protected with padded cast•Rotation of foot and distal fragment is
controlled
Fixed Traction in Charnley’s Traction Unit•Charnley’s traction unit consist of skeletal wire incorporated into short leg cast with cross bar fixed at the sole
•The traction force is adjusted using the windlass
•The extra padding under thigh and traction at the end of Thomas splint relieves skin pressure on the proximal thigh
Roger Anderson’s well leg traction
• Uses : • In correcting either abductor or adductor deformity at the
hip• Applied before an Extra articular arthrodesis is carried out
• Principle : With an abduction deformity at hip, the affected limb
appears to be long so the traction is applied to normal limb and affected limb is simultaneously pushed up by counter traction hence reducing the deformity
Reversing the arrangement will reduce Adduction deformity
Roger Anderson’s well leg traction
Sliding Traction• Principle:• The traction force is applied by weight attached to
adhesive strapping or skeletal traction by a cord acting over a pulley
• Counter traction is applied by raising one end of bed so that body tends to slide in opposite direction to that of traction force
• Initial traction weight is more than required to reduce the fracture than the weight required to maintain the reduction
Sliding Traction• In Lower limb :Buck’s extension skin tractionPerkin’s tractionHamilton Russel Traction90 -90 tractionGallow’s TractionBohler Braun frame
• In Upper Limb :Modified Dunlop’s TractionOlecranon Pin tractionMetacarpal pin traction
• Spinal Traction:Cervical tractionHalo Pelvic traction
Buck’s Traction• Indication:
•Temporary management of femur neck fracture
•Management of fracture of femoral shaft in older and young children
•Undisplaced fracture of acetabulum
•After reduction of dislocated hip
•To correct minor fixed flexion deformity of hip or knee
•In case of pelvic traction for low back pain
Buck’s Traction•Application:•Apply above knee skin traction and support
limb on a soft pillow•Pass the cord over a pulley and attach weight•Attach 2.5 to 3 kg weight•Elevate foot end of bed
•Disadvantage:•Lateral rotation of limb is not controlled by
this method
Perkin’s Traction• Indication :•Treatment of tibia fracture•Treatment of femur fracture from subtrochanteric
region and distally in all age groups•Trochanteric fracture in patients under 45-50yr
•Application:•Apply a regular skeletal traction without using any
splint and pillows below knee•Attach the pillow to weight and raise foot end of
bed•Start active movements of injured limb as soon as
possible
Perkin’s Traction•Advantage:•Preventing knee
stiffness by early mobilisation
•Disadvantage:•Needs special split
bed•Gives less support for
the fracture
Hamilton Russell Traction•Indication:
•Management of fracture shaft femur•After arthroplasty of hip
•Application:
•Apply skin traction below knee
•Place a soft broad sling under the knee, the cord attach to it passes over a system of pulleys
•No splint is attached
•Weight in adults 3.6 kg (8lb)
•Infants and Children 0.28 to 1.8 kg (1/2 – 4 lb)
Hamilton Russell Traction
•Advantage :
•Based on law of parallelogram – The two over head pulleys double the pull on the limb and resultant traction is in axis 30 degree to horizontal i.e. in line of shaft of femur
•Disadvantage:
•This method doesn’t prevents backward sagging or lateral angulation
90-90 Traction• Indication:• Subtrochanteric fracture• Fracture of proximal 1/3rd
shaft of femur
• Application:• Skeletal traction is applied
either through lower end of femur or upper end tibia
• The hip and knee are flexed at 90 degree
• Leg can be supported by Tulloch Brow U loop or second low tibial Steinmann pin or Below knee POP cast
90-90 Traction
Application:•The traction weight is attached with hip
and knee flexed at 90 degree•The traction weight mustn’t lift buttocks
on that side •Angulation is prevented by applying
weight along the width of the leg•Rotation is controlled by knee being
flexed and keeping foot, leg and thigh in same line
Disadvantages of 90-90 traction•Stiffness and loss of extension of knee•Flexion contractures of the hip•Injury to the lower femoral or upper tibial
epiphyseal growth plates in children•Neurovascular damage
Bryant’s traction
•In treatment of fracture shaft of femur in children up to the age of 2 years who weighs less than 18 kgs.
Bryant’s Traction• Application:• Apply adhesive strapping to
both the lower limbs and tie the traction cords to an overhead beam
• Tighten the traction cords sufficiently to raise the child’s buttock just clear of the mattress
• Counter traction is obtained by the weight of the pelvis and the lower trunk.
Bryant’s Traction
•Vascular complications•Ischaemic fibrosis of calf muscles
•Frank gangrene of distal limbs
•Contraindications :It is absolutely contraindicated above the
age of 4 years.
Modified bryant’s traction
•Sometimes used in the intial management of congenital dislocation of hip
•Bryant’s traction is set up as explained•After 5 days abduction of both hips is
begun, abduction being increased by about 10 degrees on alternate days
•By 3 weeks hip should be fully abducted.
Sliding traction with a Bohler- Braun frame•It is a Bohler’s modification of Braun
splint
•Braun splint had three pulley where as there are four pulley s in BB splint.
Indications
•Comminuted trochanteric fracture of femur
•Treatment of fracture shaft femur•Supracondylar fracture femur•For fracture shaft of tibia and fibula.
Function of pulleys• First pulley acts as a
dynamic splint for the patient foot drop
• Second pulley to apply traction in the line of femur
• Third pulley to apply traction in the line of supracondylar area and for high tibial traction
• Fourth pulley to apply traction in the line of legs as in low tibial or calcaneal traction
Sliding traction with a Bohler- Braun frame
•Application: •Both skin and skeletal traction can be
used•Steinmann pin is connected to Bohler
Stirrup•Attach a cord to stirrup and pass over
required pulley•Attach a 3.2 – 4.5 kg weight to cord•Elevate the foot end and tie BB splint to
the cot
Disadvantages of BB Splint
•Nursing care is difficult
•It is heavy and cumbersome frame
•May cause deformity at the fracture site
Lateral Femoral Traction• Indications:• Management of central
fracture dilocation• If superior rim of
acetabulum is fracture it is combined with Buck’s or Russel traction
• If posterior rim of acetabulum and if reduction of dislocated hip is unstable then combined with skeletal traction of lower end femur or upper end tibia
Maximum weight 4.5 – 9kgContinue traction for 4-6 weeksEncourage active hip and knee movements
Dunlop’s Traction• Indications:
• Management of supracondylar and intercondylar humerus fractures when further flexion of elbow causes circulatory compromise
Dunlop’s Traction
• Application:
• Apply skin traction over forearm• Abduct the shoulder to 45 degree• Pass traction cord over the pulley so that elbow is
flexed to 45 degree• Place padded sling over distal humerus• Attach weight of not more than 0.5 – 1 kg• Check radial pulse hourly for 12hrs and then twice
daily• Remove traction if any signs of ischaemia are
present
Olecranon Pin Traction
• Indication:
• Supracondylar fracture of humerus in patients with poor operative risk or or with external wound
• Comminuted fracture of lower end humerus with poor operative risk
• Unstable fracture shaft of humerus
Olecranon Pin Traction
• Advantages :• With skeletal traction a greater force can be
applied and rotation at fracture site can be controlled
• Moving the puuley towards the patient causes medial rotation at fracture site
• Moving the pulley away causes lateral rotation
• Angulation can be corrected by varying the direction of pull of the fracture site
Metacarpal Pin Traction• Indication:
• Management of comminuted fracture of distal end radius
• In combination with olecranon pin traction in cases with humerus and forearm fractures
• Maximum attachable weight 1.3 – 1.8 kg
• Complication:• Fibrosis of interosseus
muscles causing stiffness of fingers
Finger traps
• Used for distal forearm reductions
• Changing fingers imparts radial/ulnar angulation
• Can get skin loss/necrosis
• Recommend for no more than 20 minutes
Halter Non Skeletal Traction
•Indications:•Management of Cervical spondylosis as an out patient
•Device hooks over door
•Face door to add flexion
•Use about 30 min per day
•Weight 10-20 lbs
Skull or Skeletal Traction
•Indications:•To reduce a dislocation or fracture
dislocation of cervical spine•To mintain position of Cervical spine
before and after operative fusion•Management of Cervical Spondylosis with
severe nerve root compression
•Maximum weight 9-18 kg
Skull Traction with Gardner Tongs
• Place directly cephalad to external auditory meatus
• In line with mastoid process
• Just clear top of ears• Screws applied with
30 lbs pressure
Skull Traction with Gardner Tongs• Pin site care important• Weight ranges from 5
lbs for cervical spine to about 20 lbs for lumbar spine
• Excessive manipulation with placement must be avoided
• Poor placement can cause flexion/extension forces
Skull Traction with Crutchfield Tongs
• Must incise skin and drill cortex to place
• Rotate metal traction loop so touches skull in midsagittal plane
• Place directly above external auditory meatus
• Risks similar to Gardner tongs
Halo Ring Traction
• Direction of traction force can be controlled
• No movement between skull and fixation pins
• Allows the patient out of bed while traction maintained
• Used for cervical spine or thoracic spine fractures
Halo Ring Traction
• Application:• Ring with threaded
holes• Allow 1-1.5 cm
clearance around head• Infilterate four pin sites
with local anaesthia• Pins should be at 90
degree angle to the skull
• No incision neede • Don’t allow puckering
of skin
Halo Traction
• Traction pull more anterior for extension
• More posterior for flexion
• Use same weight as with tong traction
Halo Vest
•Major use of halo traction is combine with body jacket
•Allows patient out of bed
•Can use plaster jacket or plastic jacket
Halo Vest
•Disadvantages:•Pin site infection a risk•Can remove pins and place in different
hole•Pin penetration can produce CSF leak•Scars over eyebrows•Can get sores beneath vest
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