g09 crc traction casts jtg rev 2-4-10

8/13/2019 G09 CRC Traction Casts JTG Rev 2-4-10

1/63

Closed Reduction, Traction,and Casting Techniques

David Hak, MD

Original Author: Dan Horwitz, MD; March 2004

New Author: David Hak, MD; Revised January 2006, October 2008


2/63

Closed Reduction Principles

All displaced fractures should be reduced to

minimize soft tissue complications,

including those that require ORIF

Use splints initially

Allow for swelling

Adequately pad all bony prominences


3/63


Adequate analgesia and muscle relaxation

are critical for success

Reduction maneuver may be specific forfracture location and pattern

Correct/restore length, rotation, and

angulation Immobilize joint above and below


4/63


Reduction may require reversal of mechanism ofinjury, especially in children with intact periosteum

When the bone breaks because of bending, the softtissues disrupt on the convex side and remain intact

on the concave side

Figure from Chapmans Orthopaedic Surgery 3rdEd.

(Redrawn from Charnley J. The Closed Treatment of

Common Fractures, 3rd ed. Baltimore: Williams &

Wilkins, 1963.)


5/63


Longitudinal traction may not allow the fragments tobe disimpacted and brought out to length if there is anintact soft-tissue hinge (typically seen in children whohave strong perisoteum that is intact on one side)




Wilkins, 1963.)


6/63


Reproduction of the mechanism of fracture to hookon the ends of the fracture

Angulation beyond 90 is usually required




Wilkins, 1963.)


7/63


Three point contact (mold)

is necessary to maintain

closed reduction

Removal of any of the three

forces results in loss of reduction

Figure from: Rockwood and Green: Fractures

in Adults, 4thed, Lippincott, 1996.


8/63


Cast must be molded to resist deforming

forces

Straight casts lead to crooked bones

Crooked casts lead to straight bones


9/63

Anesthesia for Closed Reduction

Hematoma Block - aspirate hematoma and

place 10cc of Lidocaine at fracture site

Less reliable than other methods

Fast and easy

Theoretically converts closed fracture to open

fracture but no documented increase ininfection


10/63

Anesthesia for Closed Reduction

IV Sedation

Versed - 0.51 mg q 3 minutes up to 5mg

Morphine - 0.1 mg/kg Demerol - 1- 2 mg/kg up to 150 mg

Beware of pulmonary complications with deepconscious sedation - consider anesthesia service

assistance if there is concernPulse oximeter and careful monitoring are

recommended


11/63

Anesthesia for Closed Reductions

Bier Block- superior pain relief, greaterrelaxation, less premedication needed

Double tourniquet is inflated on proximal arm andvenous system is filled with local

Lidocaine preferred for fast onset

Volume = 40cc

Adults 2-3 mg/kg Children 1.5 mg/kg

If tourniquet is deflated after < 40 minutes then deflatefor 3 seconds and re-inflate for 3 minutes - repeat twice

Watch closely for cardiac and CNS side effects,especially in the elderly


12/63

Common Closed Reductions

Distal Radius

Longitudinal traction

Local or regional block

Exaggerate deformity

Push for length and reversal

of deformity

Apply splint or cast with

3-point mold

Figure from: Rockwood and Green: Fractures in

Adults, 4thed, Lippincott, 1996.


13/63

Common Joint Reductions

Elbow Dislocation - traction, flexion, and

direct manual push

Figures from Rockwood and Green, 5thed.


14/63


Shoulder Dislocation- relaxation, traction,gentle rotation if necessary

Figures from Rockwood and Green, 5thed.


15/63


Hip Dislocation

Relaxation, flexion,

traction, adduction

and internal rotation

Gentle and atraumatic

Relocation should be palpable and permit significantly

improved ROM. This often requires very deep sedation.Figures from Rockwood and Green, 5th ed.


16/63

Splinting

Non-cicumferentialallows for further

swelling

May use plaster or prefab fiberglass splints

(plaster molds better)


17/63

Common Splinting Techniques

Bulky Jones

Sugar-tong

Coaptation

Ulnar gutter

Volar / Dorsal hand

Thumb spica Posterior slab (ankle) +/- U splint

Posterior slab (thigh)


18/63

Sugar Tong Splint

Splint extends around the

distal humerus to provide

rotational control Padding should be at least

3 - 4 layers thick with

several extra layers at the

elbow


19/63

Medially splint ends in

the axilla and must bewell padded to avoid

skin breakdown

Lateral aspect of splintextends over the deltoid

Figure from Rockwood and Green, 4thed.

Humeral Shaft Fracture Coaptation Splint


20/63

Fracture Bracing

Allows for early functional ROM and

weight bearing

Relies on intact soft tissues and muscleenvelope to maintain alignment and length

Most commonly used for humeral shaft and

tibial shaft fractures


21/63

Convert to humeral fracture

brace 7-10 days after fracture(i.e. when fracture site is not

tender to compression).

Allows early active elbow ROM

Fracture reduction maintainedby hydrostatic column principle

Co-contraction of muscles

- Snug brace during the day

- Do not rest elbow on tablePatient must tolerate a

snug fit for brace to be

functionalFigure from Rockwood and Green, 4th ed.


22/63

Casting

Goal of semi-rigid immobilization while

avoiding pressure / skin complications

Often a poor choice in the treatment ofacute fractures due to swelling and soft

tissue complications

Good cast technique necessary to achievepredictable results


23/63

Casting Techniques

Stockinette - may require two different

diameters to avoid overtight or loose

material Caution not to lift leg by stockinette

stretching the stockinette too tight around

the heel may case high skin pressure


24/63

Casting Techniques

To avoid wrinkles in

the stockineete, cut

along the concavesurface and overlap to

produce a smooth

contour

Figure from Chapmans Orthopaedic

Surgery 3rdEd.


25/63

Casting Techniques

Cast padding

Roll distal to proximal

50 % overlap2 layers minimum

Extra padding at fibular

head, malleoli, patella,

and olecranonFigure from Chapmans Orthopaedic

Surgery 3rdEd.


26/63

Plaster vs. Fiberglass

Plaster

Use cold water to maximize molding time

Fiberglass

More difficult to mold but more durable and

resistant to breakdown

Generally 2 - 3 times stronger for any given

thickness


27/63

Width

Casting materials are available in various

widths

6 inch for thigh

3 - 4 inch for lower leg

3 - 4 inch for upper arm

2 - 4 inch for forearm


28/63


Surgery 3rdEd.

Avoid molding with

anything but the heels of

the palm in order to avoid

pressure points

Mold applied to produce

three point fixation

Cast Molding


29/63

Below Knee Cast

Support metatarsal heads

Ankle in neutralflex knee to relax gastroc

Ensure freedom of toes

Build up heel for walking casts - fiberglass

much preferred for durability


30/63

Padding for fibular head and plantar aspect of foot


31/63

Padded fibular

head

Flexed knee

Neutral ankleposition Toes free

Assistant or foot stand required to maintain ankle position

Figure from: Browner and Jupiter: Skeletal Trauma, 2nded, Saunders, 1998.


32/63

Short Leg Cast

When working alone,

the patient can help

maintain proper ankleposition by holding

onto a muslin

bandage placedbeneath the toes


Surgery 3rdEd.


33/63

Above Knee Cast

Apply below knee first (thin layer proximally)

Flex knee 5 - 20 degrees

Mold supracondylar femur for improved

rotational stability

Apply extra padding anterior to patella


34/63

Anterior padding

Support lower

leg / cast

Extend to

gluteal crease

Figure from: Browner and Jupiter: Skeletal Trauma, 2nded, Saunders, 1998.


35/63

Forearm Casts & Splints

MCP joints should be free

Do not go past proximal palmar crease

Thumb should be free to base of MC

Opposition of thumb to little finger should be

unobstructed


36/63

x

x


37/63

Examples - Position of Function

Ankle - Neutral dorsiflexionNo Equinus

Hand - MCPs flexed 7090, IPs in extension

70-90 degrees

Figure from Rockwood and Green, 5thed.


38/63

Cast Wedging

Early follow-up x-rays are required

to ensure reduction is not lost

Cast may be wedged to correctreduction

Deformity is drawn out on cast

Cast is cut circumferentially

Cast is wedged to correct

deformity and the over-wrappedExample of cast wedging to correct

loss of reduction of a pediatric

distal both bone forearm fracture.

From Halanski M, Noonan KJ. JAm Acad Orthop Surg. 2008.


39/63

Complications of Casts & Splints

Loss of reduction

Pressure necrosismay occur as early as 2

hours Tight castcompartment syndrome

Univalving = 30% pressure drop

Bivalving = 60% pressure dropAlso need to cut cast padding


40/63


Thermal Injury - avoid plaster > 10 ply, water>24C, unusual with fiberglass

Cuts and burns during removal

Keloid formation as a result of an injury

during cast removal. From Halanski M,

Noonan KJ. J Am Acad Orthop Surg. 2008.


41/63


DVT/PE - increased in lower extremity fracture

Ask about prior history and family history

Birth Control Pills are a risk factor

Indications for prophylaxis controversial in patientswithout risk factors

Joint stiffness

Leave joints free when possible (ie. thumb MCP for

below elbow cast)

Place joint in position of function


42/63

Traction

Allows constant controlled force for initial

stabilization of long bone fractures and aids

in reduction during operative procedure

Option for skeletal vs. skin traction is case

dependent


43/63

Skin Traction

Limited force can be applied - generally notto exceed 5 lbs

More commonly used in pediatric patients

Can cause soft tissue problems especially inelderly or rheumatoid patients

Not as powerful when used during operative

procedure for both length or rotationalcontrol


44/63

Skin Traction - Bucks

An option to provide temporary comfort in

hip fractures

Maximal weight - 10 pounds

Watch closely for skin problems, especially

in elderly or rheumatoid patients


45/63

Skeletal Traction

More powerful than skin traction

May pull up to 20% of body weight for thelower extremity

Requires local anesthesia for pin insertion ifpatient is awake

Preferred method of temporizing long bone,

pelvic, and acetabular fractures until operativetreatment can be performed


46/63

Traction Pin Types

Choice of thin wire vs. Steinman pin Thin wire is more difficult to insert with hand

drill and requires a tension traction bow

Tension BowStandard Bow


47/63

Traction Pin Types

Steinmann pin may be either smooth or

threaded

Smooth is stronger but can slide if angledThreaded pin is weaker, bends easier with

higher weight, but will not slide and will

advance easily during insertion

In general a 5 or 6 mm diameter pin is

chosen for adults


48/63

Traction Pin Placement Sterile field with limb exposed

Local anesthesia + sedation

Insert pin from known area of neurovascular

structureDistal femur: MedialLateral

Proximal Tibial: LateralMedial

Calcaneus: MedialLateral Place sterile dressing around pin site

Place protective caps over sharp pin ends


49/63

Distal Femoral Traction

Method of choice for acetabular and proximalfemur fractures

If there is a knee ligament injury usually use distal

femur instead of proximal tibial traction


50/63

Distal Femoral Traction

Place pin from medial

to lateral at the

adductor tubercle -slightly proximal to

epicondyle

Figures from Althausen PL, Hak DJ. Am J Orthop. 2002.


51/63

Balanced Skeletal Traction

Allows for suspension of leg withlongitudinal traction

Requires trapeze bar, traction cord, andpulleys

Provides greater comfort and ease ofmovement

Allows multiple adjustments for optimalfracture alignment


52/63

One of many options for setting up balanced suspension

In general the thigh support only requires 5-10 lbs of weight

Note the use of double pulleys at the foot to decrease the total

weight suspended off the bottom of the bed

Figure from: Rockwood and Green: Fractures in Adults, 4thed, Lippincott, 1996.


53/63

Proximal Tibial Traction

Place pin 2 cm posterior

and 1 cm distal to tubercle

Place pin from lateral to

medial

Cut skin and try to stay

out of anterior

compartment - pushmuscle posteriorly with

pin or hemostat

Figures from Althausen PL, Hak DJ. Am J Orthop. 2002.


54/63

Calcaneal Traction

Most commonly used with a

spanning ex fix for travelling

traction or may be used with

a Bohler-Braun frame

Place pin medial to lateral

2 - 2.5 cm posterior and

inferior to medial malleolus

Medial Structures

Lateral StructuresFigures from Althausen PL, Hak DJ. Am J Orthop. 2002.


55/63

Olecranon Traction

Rarely used today

Small to medium sized pinplaced from medial to lateral in

proximal olecranon - enter bone1.5 cm from tip of olecranonand walk pin up and down toconfirm midsubstance location.

Support forearm and wrist withskin traction - elbow at 90degrees


Surgery 3rdEd.


56/63

Gardner Wells Tongs

Used for C-spine reduction / traction

Pins are placed one finger breadth above

pinna, slightly posterior to external auditorymeatus

Apply traction beginning at 5 lbs. and

increasing in 5 lb. increments with serialradiographs and clinical exam


57/63

Halo

Indicated for certain cervical fractures as

definitive treatment or supplementary

protection to internal fixation Disadvantages

Pin problems

Respiratory compromise


58/63

Left: Safe zone for halo pins. Place anterior pins about 1 cm above orbital rim,

over lateral two thirds of the orbit, and below skull equator (widest circumference).

Right: Safe zone avoids temporalis muscle and fossa laterally, and supraorbital andsupatrochlear nerves and frontal sinus medially.

Posterior pin placement is much less critical because the lack of neuromuscular

structures and uniform thickness of the posterior skull.

Figure from: Botte MJ, et al. J Amer Acad Orthop Surg. 4(1): 4453, 1996.


59/63

Halo Application

Position patient maintaining spineprecautions

Fit Halo ring

Prep pin sites

Anterior - outer half above eyebrow avoidingsupraorbital artery, nerve, and sinus

Posterior - superior and posterior to ear

Tighten pins to 6 - 8ft-lbs.

Retighten if loose Pins only once at 24 hours

Frame prn

Figure from: Rockwood and Green:Fractures in Adults, 4th ed, Lippincott, 1996.


60/63

References

Freeland AE. Closed reduction of hand fractures.Clin Plast Surg. 2005 Oct;32(4):549-61.

Fernandez DL. Closed manipulation and casting

of distal radius fractures. Hand Clin. 2005Aug;21(3):307-16.

Halanski M, Noonan KJ. Cast and splintimmobilization: complications. J Am AcadOrthop Surg. 2008 Jan;16(1):30-40.

Bebbington A, Lewis P, Savage R. Cast wedgingfor orthopaedic surgeons. Injury. 2005;36:71-72.


61/63

References

Halanski MA, Halanski AD, Oza A, et al. Thermal injurywith contemporary cast-application techniques andmethods to circumvent morbidity. J Bone Joint Surg Am.2007 Nov;89(11):2369-77.

Althausen PL, Hak DJ. Lower extremity traction pins:indications, technique, and complications. Am J Orthop.2002 Jan;31(1):43-7.

Alemdaroglu KB, Iltar S, imen O, et al.Risk Factors inRedisplacement of Distal Radial Fractures in Children. J

Bone Joint Surg Am. 2008; 90: 1224 - 1230. Sarmiento A, Latta LL. Functional fracture bracing. J Am

Acad Orthop Surg. 1999 Jan;7(1):66-75.


62/63

Classical References

Sarmiento A, Kinman PB, Galvin EG, Schmitt RH,Phillips JG. Functional bracing of fractures of the shaft ofthe humerus. J Bone Joint Surg Am. 1977 Jul;59(5):596-601.

Sarmiento A, Sobol PA, Sew Hoy AL, et al. PrefabricatedFunctional Braces for the Treatment of Fractures of theTibial Diaphysis. JBone and Joint Surg. 1984. 66-A: 1328-1339.

Sarmiento A, Latta LL. 450 closed fractures of the distal

third of the tibia treated with a functional brace. ClinOrthop Relat Res. 2004 Nov;(428):261-71.

Sarmiento A. Fracture bracing. Clin Orthop Relat Res.1974 Jul-Aug;(102):152-8.


63/63

Questions

Return toE-mail OTA

If you would like to volunteer as an author for theResident Slide Project or recommend updates toany of the following slides please send an e mail
http://localhost/var/www/apps/conversion/tmp/scratch_1//FileShares/specialty$/Ota%20web/res_slide%20III/index_general.htmlmailto:[email protected]?subject=Resident%20Slide%20Presentation%20G09mailto:[email protected]?subject=Resident%20Slide%20Presentation%20G09http://localhost/var/www/apps/conversion/tmp/scratch_1//FileShares/specialty$/Ota%20web/res_slide/index.htmlhttp://localhost/var/www/apps/conversion/tmp/scratch_1//FileShares/specialty$/Ota%20web/res_slide%20III/index_general.html

g09 crc traction casts jtg rev 2-4-10

Documents