orthopedic tractions
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Transcript of orthopedic tractions
ORTHOPAEDIC TRACTION
Dr. Srinivas Bodla Ortho PG(PIMS)
Definition
Traction is the application of a pulling force to a part of the body
History Skin traction used extensively in Civil
War for fractured femurs Skeletal traction by a pin through bone
introduced by Steinmann and Kirschner 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
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
Thomas – Thomas splint, used for applying fixed traction
History Malgaigne introduced the 1st 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.
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
Types Skin tractionThe traction force applied over a large area of skin- Adhesive and Non-adhesive skin tractions
Skeletal tractionApplied directly to the bone either by a pin or wire
through the bone. (eg- Steinmann pin, denham pin, kirschner wire)
Advantages decrease pain minimize muscle spasms reduce, align, and immobilize fractures reduce deformity increase space between opposing
surfaces
Disadvantages Costly in terms of hospital stay Hazards of prolonged bed rest
Thromboembolism Decubiti Pneumonia
Requires meticulous nursing care Can develop contractures
Understanding traction
Principles Of Effective Traction Countertraction must be used to achieve
effective traction. Countertraction is the force acting the
opposite direction. Usually, the patient's body weight and
bed position adjustments supply the needed countertraction.
Counter traction Fixed traction- by applying force against
a fixed point of body. Ex: fixed traction by thomas splint Roger Anderson well leg traction
Counter traction Sliding traction- by tilting bed so that patient
tends to slide in opposite direction to traction force
Ex: Hamilton russell traction Tulloch Brown traction Agnes Hunt traction Perkins traction
APPLIANCES
Beds 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
Beds and Frames
Bradford frame enables bedpan and linen changes without moving pt
Alternatively bed can be flexible to allow bending at hip or knee
Knots
Ideal knots can be tied with one hand while holding weight
Easy to tie and untie
Overhand loop knot will not slip
Knots
A slip knot tightens under tension
Up and over, down and over, up and through
Knots - types
Clover hitch Barrel hitch Reef knot Half hitch Two half
hitches
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
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
SKIN TRACTION
Skin traction The traction force is applied over a large area,
this spreads the load and is more comfortable and efficient.
Force applied is transmitted from skin to the bones via superficial fascia, deep fascia and intermuscular septa
For better efficiency the traction force is applied only to the limb distal to the fracture
Weight Skin damage can result from too much of
traction force.Maximum weight recommended for skin
traction is 6.7 kgsdepending on size and weight of the patient
Application Adhesive 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.
Application Non adhesive skin traction
Useful in thin and atrophic skin Frequent reapplication may be necessary Attached traction wt. must not be more
than 4.5 kgs.
Indications Temporary management of # of NOF and
IT # Management of # - Femoral shaft of older
and hefty children Undisplaced # of acetabulum After reduction of dislocation of Hip To correct minor fixed flexion deformities
of hip and knee
Contraindications 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
Complications Allergic reactions to adhesive Excortication of skin Pressure sores Common peroneal nerve palsy
SKELETAL TRACTION
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
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
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
Kirschner wire 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
ApplicationFollow regular OT proceduresUse GA or LAPaint the skin with iodine and spiritMount the pin/wire on the hand drillHold 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 Apply small cotton woolen pads soaked in
tincture around the pins to seal the woundThe pin should pass only through skin, SC
tissue and bone avoiding muscles and tendons
Complications Introduction of infection into bone Distraction at fracture site Ligamentous damage Damage to epiphyseal growth plates Depressed scars
VARIOUS TRACTIONS
SPINAL TRACTION Used to treat the unstable spine Pull along axis of spine Preserves alignment and volume of canal
Gardner Tongs
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
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
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
Halo Ring 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
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
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
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 pt out of bed
Can use plaster jacket or plastic, sheepskin lined jacket
Head Halter traction
Simple type cervical traction
Management of neck pain
Weight should not exceed 5 lbs initially
Can only be used a few hours at a time
Outpatient head halter traction
Used to train neck pain and radicular symptoms from cervical disc disease
Device hooks over door Face door to add
flexion Use about 30 min per
day Weight 10-20 lbs
Halo pelvic traction To immobilize the spine. To slowly correct or
reduce the deformities of the spine such as scoliosis.
UPPER EXTREMITY TRACTION Can treat most fractures Requires bed rest Usually reserved for comatose or
multiply injured patient or settings where surgery can not be done
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
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 5-7 lbs on arm Risk of ischemia at
antecubital fossa
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
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
Lateral Olecranon Traction
Used for humeral fractures
Arm held in moderate abduction
Forearm in skin traction
Excessive weight will distract fracture
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.
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
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.
Finger traps
Used for distal forearm reductions
Changing fingers imparts radial/ulnar angulation
Can get skin loss/necrosis
Recommend no more than 20 minutes
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
Buck’s 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
Upper Femoral Traction Several traction
options for acetabular fractures
Lateral traction for fractures with medial or anterior force
Stretched capsule and ligamentum may reduce acetabular fragments
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 suprapatellar pouch, NV structures, and growth plate in children
Split Russell’s Traction
Buck’s with sling May be used in more
distal femur fx in children
Can be modified to hip and knee exerciser
Bryant’s 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
90-90 Traction
Useful for subtroch and proximal 3rd femur fx
Especially in young children
Matches flexion of proximal fragment
Can cause flexion contracture in adult
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
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
Proximal Tibial 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.
Perkin’s traction: Treatment of # tibia. Treatment of # of femur
from the subtrochanter region and distally.
Trochanteric # of femur in pts under 45-50yrs age.
Denham pin is inserted through upper end of tibia for # of femur, the mid tibia for #of condyles of tibia.
Balanced Suspension with Pearson Attachment
Enables elevation of limb to correct angular malalignment
Counterweighted support system
Four suspension points allow angular and rotational control
Pearson Attachment
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
Distal Tibial 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
Calcaneal 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 or NV bundle
Maintain slight elevation leg
MANAGEMENT
Management of patients in traction Care of the patient Care of the traction suspension system Radiographic examination Physiotherapy Removal of traction
The patient Blood loss
# Tibia -500-1000ml#Shaft of Femur-1500-2000ml#Pelvis -2000ml#Humerus -500-2000ml
Chest complications Urinary tract Bowels
The patientCare of the injured limb- • Pain• Parasthesia or Numbness• Skin irritation• Swelling• Weakness of ankle, toe, wrist or finger
movement
The traction suspension system Bed and Balkan beam Splints Slings and padding Skin traction Skeletal traction Stirrups Cord Pulleys Weights
Radiographic examination 2-3 times in first week Weekly for next 3 weeks Monthly until union occurs After each manipulation After each weight change
Removal of traction Elbow # with olecranon pin - 3
wks Tibial # with calcaneal pin - 3-
6wks Trochanteric # of femur - 6wks Femoral shaft # with cast brace - 6 wks without external support -
12wks
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