traction in orthopaedic

TRACTION IN ORTHOPAEDIC

I GEDE MADE OKA RAHADITYA

Orthopaedic and Traumatology Department – Saiful Anwar Hospital, Malang

OUTLINES

DEFINITION AND PRINCIPLES

HISTORY

PURPOSE, ADVANTAGES AND DISADVANTAGES

APPLIANCES

TYPE OF TRACTION

SKIN TRACTION

SKELETAL TRACTION

SPECIFIC TRACTION


“Traction is the application of a pulling force to a part of the body”

“Traction is the application of a pulling

force for medical purposes, to treat muscle or

skeletal disorder - for example, to reduce fracture, maintain

bone alignment, relieve pain, or prevent spinal injury”

“Traction is the application of a force to stretch certain

parts of the body in a specific direction”


PRINCIPLES

• Provide Counter traction, using the patient’s body or

pull of weights in the opposite direction

.

• Maintain continuous traction in a correct line of pull.

• Prevent friction

• Provide daily traction care

HISTORY

• The use of traction dates as far

back as 3000 years (Aztecs and

the ancient Egyptians)

• Hippocrates (350 BC) wrote

about manual traction and the

forces of extension and

counterextension

• Guy de Chauliac (1300 - 1368) :

introduction of continuous

traction

HISTORY

Pott’s doctrine

• Most Fracture deformities result

from the contraction of the

surrounding muscles

• Fractured limb should be placed

in the positions in which its

muscles are most relaxed

• Shaft of the femur : flexion of the

hip and the knee


• CONTROLS PAIN

• REDUCES FRACTURE

• MAINTAIN REDUCTION

• PREVENTS AND CORRECT DEFORMITY

PURPOSE


ADVANTAGES

• Reduce pain

• Minimize muscle spasm

• bone reduce and held by soft tissue

• increase space between opposing surfaces

• allows more joint mobility than plaster


DISADVANTAGES

1. Costly in terms of hospital stay

2. Hazards of prolonged bed rest :

• DVT, PE

• Pressure wounds/ulcers

• Pneumonia

3. Requires meticulous nursing care

4. Can develop contractures

APPLIANCES

BED AND FRAMESKNOTS

PULLEYS WEIGHTS

APPLIANCES

BED AND FRAMES

• Standard bed has 4-post traction frame

• Ideal bed for traction with multiple injuries is adjustable

height with Bradford frame

• Mattress moves separate from frame

APPLIANCES

BED AND FRAMES

• Bradford frame enables bedpan and linen changes

without moving pt

• Alternatively bed can be flexible to allow bending at hip

or knee

APPLIANCES

KNOTS

• Ideal knots can be tied with

one hand while holding

weight

• Easy to tie and untie

• Overhand loop knot will not

slip

APPLIANCES

KNOTS

• A slip knot tightens under

tension

• Up and over, down and

over, up and through

APPLIANCES

KNOTS

• Clover hitch

• Barrel hitch

• Reef knot

• Half hitch

• Two half hitches

APPLIANCES

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

preferrable

APPLIANCES

WEIGHTS

• Amount of weight required depends

upon

• Wt of the appliance

• Wt of part of body suspended

• Amount of friction present in the

system

• Mechanical advantage of the system

employed for suspension

APPLIANCES

ATTENTION!!!

1. POSITION

2. COUNTERTRACTION

3. FRICTION

4. CONTINOUS

5. LINE OF PULL

6. PROTECTION OF CARDIOVASCULAR SYSTEM

7. MAINTENANCE OF NEUROVASCULAR STATUS

8. SKIN CARE

9. MAINTENANCE OF THE MUSCULOSKELETAL SYSTEM

10.NEVER IGNORE A PATIENT’S COMPLAINT

TYPE OF TRACTION

BASED ON PRINCIPLE

1. Fixed Traction

2. Sliding Traction

BASED ON APPLICATION

1. Skin Traction

2. Skeletal Traction

TYPE OF TRACTION

BASED ON PRINCIPLE

1. Fixed Traction

Traction is applied to the leg against a fixed point of

counter pressure.

• Fixed traction in Thomas’s splint

• Roger Anderson well-leg traction

• Halo-Pelvic Traction

TYPE OF TRACTION

BASED ON PRINCIPLE

Thomas Splint

• Used for fracture shaft of

femur

• Counter traction provided

by ischeal Tuberosity

TYPE OF TRACTION

BASED ON PRINCIPLE

When the weight of all or part of the body, acting

under the influence of gravity, is utilized to provide

counter-traction.

2. Sliding Traction

SKIN TRACTION

• Traction force is applied over a large area of skin

• Applied over limb distal to fracture site

• Anteromedial and posterolateral part should be

covered with cotton

SKIN TRACTION

• Skin damage can result from too much of traction force.

• Maximum weight recommended for skin traction is 6.7 kgs

• depending on size and weight of the patient

Weight

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.

Adhesive skin traction

SKIN TRACTION

• Useful in thin and atrophic skin

• Frequent reapplication may be necessary

• Attached traction wt. must not be more than 4.5 kgs.

Non adhesive skin traction

SKIN TRACTION

• Temporary management of fracture of NOF and IT #

• Management of fracture - Femoral shaft of older and

hefty children

• Undisplaced fracture of acetabulum

• After reduction of dislocation of Hip

• To correct minor fixed flexion deformities of hip and

knee

Indication

SKIN TRACTION

• Abrasions and lacerations of skin in the area to

which traction is to be applied

• Varicose veins, impending gangrene

• Dermatitis

• When there is marked shortening of the bony

fragments as the traction weight required is greater

than which can be applied through the skin

Contraindication

SKIN TRACTION

Complication

• Allergic reactions to adhesive

• Excortication of skin

• Pressure sores

• Common peroneal nerve palsy

SKELETAL TRACTION

• It may be used as a means of reducing or

maintaining the reduction of a fracture

• It should be reserved for those cases in which skin

traction is contraindicated

SKELETAL TRACTION

• 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

Steinmann Pin

SKELETAL TRACTION

• 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

SKELETAL 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

Kirschner wire

SKELETAL TRACTION

• Follow regular OT procedures

• 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.

Application

SKELETAL TRACTION

Application

• 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

SKELETAL TRACTION

• Introduction of infection into bone

• Distraction at fracture site

• Ligamentous damage

• Damage to epiphyseal growth plates

• Depressed scars

Complications

• Used to treat the unstable spine

• Pull along axis of spine

• Preserves alignment and volume of canal

SPECIFIC TRACTION

SPINAL TRACTION

SPECIFIC TRACTION

SPINAL TRACTION

• Easy to apply

• Place directly cephalad to

external auditory meatus

• In line with mastoid process

• Just clear top of ears

• Screws applied with 30 lbs

pressure

Gardner Tongs

SPECIFIC TRACTION

SPINAL TRACTION

Gardner Tongs• Pin site care important

• Weight ranges from 5 lbs for c-spine to

about 20 lbs for lumbar spine

• Excessive manipulation with placement

must be avoided

• Poor placement can cause flex/ext

forces

• Can get occipital decubitus

SPECIFIC TRACTION

SPINAL TRACTION

Crutchfield Tongs• Must incise skin and drill cortex to place

• Rotate metal traction loop so touches skull

in midsagittal plane

• Place directly above ext auditory meatus

• Risks similar to Gardner tongs

SPECIFIC TRACTION

SPINAL TRACTIONRecommended Weights in Cervical Traction

(Crutchfield)

SPECIFIC TRACTION

SPINAL TRACTION

• Direction of traction force can be controlled

• No movement between skull and fixation pins

• Allows the pt out of bed while traction maintained

• Used for c-spine or t-spine fx

Halo Ring Traction

SPECIFIC TRACTION

SPINAL TRACTION

Halo Ring Traction

• Ring with threaded holes

• Allow 1-1.5 cm clearance around head

• Place below equator

• Spacer discs used to position ring

• Central anterior and 2 most posterior

SPECIFIC TRACTION

SPINAL TRACTION

Halo Ring Traction

• Two anterior pins

• Placed in frontal bone groove

• Sup and lat to supraorbital ridge

• Two posterior pins

• Placed posterior and superior to external ear

• Tighten pins to 5-6 inch-pounds with screwdriver

SPECIFIC TRACTION

SPINAL TRACTION

• To immobilize the spine.

• To slowly correct or reduce

the deformities of the spine

such as scoliosis.

Halo pelvic traction

SPECIFIC TRACTION

• Can treat most fractures

• Requires bed rest

• Usually reserved for comatose or multiply injured

patient or settings where surgery can not be done

UPPER EXTREMITY TRACTION

SPECIFIC TRACTION


Forearm Skin Traction

• Adhesive strip with Ace wrap

• Useful for elevation in any injury

• Can treat difficult clavicle

fractures with excellent cosmetic

result

• Risk is skin loss

SPECIFIC TRACTION


• Used for greater tuberosity or prox

humeral shaft fx

• Arm abducted 30 degrees

• Elbow flexed 90 degrees

• 7-10 lbs on forearm

• 5-7 lbs on arm

• Risk of ischemia at antecubital

fossa

Double Skin Traction

SPECIFIC TRACTION


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

SPECIFIC TRACTION


Olecranon Pin 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

SPECIFIC TRACTION


• Used for humeral

fractures

• Arm held in moderate

abduction

• Forearm in skin

traction

• Excessive weight will

distract fracture

Lateral Olecranon Traction

SPECIFIC 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

Olecranon traction

SPECIFIC TRACTION


Metacarpal Pin Traction

• Used for obtaining difficult

reduction forearm/distal

radius fx

• Once reduction obtained, pins

can be incorporated in cast

• Pin placed radial to ulnar

through base 2nd/3rd MC

• Stiffness intrinsics common

SPECIFIC TRACTION


Metacarpal Pin Traction

• Point of Insertion: 2-2.5 cms proximal to the

distal end of 2nd metacarpal

• Technique: push the 1st dorsal interosseius

muscle volarly 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

transversly.

SPECIFIC TRACTION


Finger traps

• Used for distal forearm

reductions

• Changing fingers imparts

radial/ulnar angulation

• Can get skin loss/necrosis

• Recommend no more than 20

minutes

SPECIFIC TRACTION

LOWER EXTREMITY TRACTION

• Can be used to treat most lower extremity fractures

of the long bones

• Requires bed rest

• Used when surgery can not be done for one reason

or another

• Uses skin and skeletal traction

SPECIFIC TRACTION


• Often used preoperatively for

femoral fractures

• Can use tape or pre-made boot

• No more than 10 lbs

• Not used to obtain or hold

reduction

Buck’s Traction

SPECIFIC TRACTION


• Several traction options for

acetabular fractures

• Lateral traction for fractures

with medial or anterior force

• Stretched capsule and

ligamentum may reduce

acetabular fragments

Upper Femoral Traction

SPECIFIC TRACTION


• 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 suprapatellar pouch, NV

structures, and growth plate in children

Femoral Traction Pin

SPECIFIC TRACTION


• Buck’s with sling

• May be used in more distal

femur fx in children

• Can be modified to hip and

knee exerciser

Split Russell’s Traction

SPECIFIC TRACTION


• Useful for treatment femoral shaft fx in

infant or small child

• Combines gallows traction and Buck’s

traction

• Raise mattress for countertraction

• Rarely, if ever used currently

Bryant’s Traction

SPECIFIC TRACTION


• Useful for subtroch and proximal

3rd femur fx

• Especially in young children

• Matches flexion of proximal

fragment

• Can cause flexion contracture in

adult

90-90 Traction

SPECIFIC TRACTION


Distal Femoral Traction

• Alignment of traction along axis

of femur

• Used for superior force

acetabular fx and femoral shaft

fx

• Used when strong force needed

or knee pathology present

SPECIFIC TRACTION


Distal Femoral Traction• Draw 1st line from before backwards

at the level of the upper pole of

patella,2nd 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

SPECIFIC TRACTION


• Used for distal 2/3rd femoral shaft fx

• Femoral 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.

Proximal Tibial Traction

SPECIFIC TRACTION


• Treatment of Fr tibia.

• Treatment of Fr of femur

from the subtrochanter

region and distally.

• Trochanteric Fr of femur

in pts under 45-50yrs age.

• Denham pin is inserted

through upper end of tibia

for fr of femur, the mid tibia

for fr of condyles of tibia.

Perkin’s traction:

SPECIFIC TRACTION


Balanced Suspension with Pearson Attachment• Enables elevation of limb to

correct angular

malalignment

• Counterweighted support

system

• Four suspension points

allow angular and rotational

control

SPECIFIC TRACTION


• Middle 3rd fx had mild flexion prox fragment

• 30 degrees elevation with traction in line with

femur

• Distal 3rd fx has distal fragment flexed post

• Knee should be flexed more sharply

• Fulcrum at level fracture

• Traction at downward angle

• Reduces pull gastroc

Pearson Attachment

SPECIFIC TRACTION


• Useful in certain tibial plateau fx

• 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

Distal Tibial Traction

SPECIFIC TRACTION


• Temporary traction for tibial shaft

fx or calcaneal fx

• Insert about 1.5 inches (4cms)

inferior and posterior to medial

malleolus

• Do not skewer subtalar joint

• Maintain slight elevation leg

Calcaneal Traction

THANK YOU

traction in orthopaedic

Health & Medicine