applicationoftractioninorthopaedics-131015073303-phpapp02.pdf
- 1. Application of Traction in Orthopaedics By- Prabhnoor Singh Hayer Moderated by- Dr. Rajesh Maheshwari
- 2. Definition Traction is the application of a pulling force to a part of the body
- 3. History 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. General Considerations Safe and dependable way of treating fractures for more than 100 years Bone reduced and held by soft tissue Less risk of infection at fracture site No devascularization Allows more joint mobility than plaster
- 5. Indications To reduce the fracture or dislocation To maintain the reduction To correct the deformity To reduce the muscle spasm
- 6. Types Based On Method Of Application Skin traction The traction force is applied over a large area of skin • Adhesive • Non-adhesive skin tractions Skeletal traction Applied directly to the bone either by a pin or wire through the bone. (eg- Steinmann pin, Denham pin or Kirschner wire)
- 7. Types Based On Mechanism Fixed Traction By applying force against a fixed point of body. Sliding Traction By tilting bed so that patient tends to slide in opposite direction to traction force
- 8. Advantages of Traction Decrease pain Minimize muscle spasms Reduces, aligns, and immobilizes fractures Reduce deformity Increase space between opposing surfaces
- 9. Disadvantages of Traction Costly in terms of hospital stay Hazards of prolonged bed rest Thromboembolism Decubiti Pneumonia Requires meticulous nursing care Can develop contractures
- 10. The Traction Suspension System • Bed and Balkan beam • Splints- Thomas splint, Bohler-Braun frame, Fisk Splint • Slings and padding • Skin traction • Skeletal traction- Steinmann pin, Denham pin or Kirschner wire • Bohler Stirrup • Cord • Pulleys • Weights
- 11. Knots Ideal knots can be tied with one hand while holding weight Easy to tie and untie Overhand loop knot will not slip
- 12. Knots A slip knot tightens under tension Up and over, down and over, up and through
- 13. Knots - types Clover hitch Barrel hitch Reef knot Half hitch Two half hitches
- 15. Buck’s Traction or Extension Used in temporary management of fractures of Femoral neck 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
- 16. Hamilton Russell Traction Buck’s with sling May be used in more distal femur fracture in children Can be modified to hip and knee exerciser
- 17. Bryant’s Traction Useful for treatment of femoral shaft fracture in infant or small child Combines gallows traction and Buck’s traction Raise mattress for counter traction Rarely used currently
- 18. 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
- 19. Double Skin Traction Used for greater tuberosity or proximal humeral shaft fracture Arm abducted 30 degrees Elbow flexed 90 degrees Risk of ischemia at antecubital fossa a
- 20. 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 at 45 degrees
- 21. Finger traps Used for distal forearm reductions Changing fingers imparts radial/ulnar angulation Can get skin loss/necrosis Recommend no more than 20 minutes
- 22. 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
- 23. Contraindications Abrasions and lacerations of skin in the area to which traction is to be applied Impairment of circulation - Varicose veins, impending gangrene Dermatitis When there is marked shortening of the bony fragments, the traction weight required will be more then 6.7 kg which cannot be applied through the skin
- 24. Complications Allergic reactions to adhesive Excortication of skin Pressure sores around the malleoli and over the tendo calcaneus Common peroneal nerve palsy
- 26. Indications 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
- 27. Proximal Tibial Traction • Used for distal 2/3rd 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.
- 28. Upper Femoral Traction Lateral traction for fractures with medial or anterior force Stretched capsule and ligamentum teres may reduce acetabular fragments
- 29. Femoral Traction Pin • 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
- 30. 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
- 31. 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
- 32. Ninety-Ninety Traction Useful for subtrochantric and proximal 3rd femur fracture Especially in young children Matches flexion of proximal fragment Can cause flexion contracture in adult
- 33. 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
- 34. Application of 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
- 36. Balanced Suspension with Pearson Attachment Enables elevation of limb to correct angular malalignment Counterweighted support system Four suspension points allow angular and rotational control
- 37. Pearson Attachment • Middle 3rd fracture has mild flexion proximal fragment • 30 degrees elevation with traction in line with femur • Distal 3rd fracture has distal fragment flexed posterior • Knee should be flexed more sharply • Fulcrum at level of fracture • Traction at downward angle • Reduces pull of
- 38. 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
- 39. Calcaneal 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
- 40. 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
- 41. Lateral Olecranon Traction Used for humeral fractures Arm held in moderate abduction Forearm in skin traction Excessive weight will distract fracture
- 42. 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.
- 43. 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 2nd /3rd MC Stiffness of intrinsics is common
- 44. 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.
- 45. 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
- 46. 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
- 47. 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
- 48. Application of Crutchfield Tongs 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
- 49. Application of Crutchfield Tongs 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
- 50. 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
- 51. Complications of Skeletal Traction Introduction of infection into the bone 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
- 52. Management of patients in traction Care of the patient Care of the traction suspension system Radiographic examination Physiotherapy Removal of traction
- 53. In The Patient Care of the injured limb- • Pain • Parasthesia or Numbness • Skin irritation • Swelling • Weakness of ankle, toe, wrist or finger movement
- 54. Radiographic Examination 2-3 times in first week Weekly for next 3 weeks Monthly until union occurs After each manipulation After each weight change
- 55. 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
- 56. Thank You