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orthopedic tractions

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  • 1. ORTHOPAEDIC TRACTION Dr. Srinivas Bodla Ortho PG(PIMS)
  • 2. Definition
    • Traction is the application of a pulling force to a part of the body
  • 3. 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
  • 4. 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
  • 5. History
      • Malgaigne introduced the 1 st 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.
  • 6. 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
  • 7. Types
    • Skin traction
    • The traction force applied over a large area of skin
    • Adhesive and 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, kirschner wire)
  • 8. Advantages
    • decrease pain
    • minimize muscle spasms
    • reduce, align, and immobilize fractures
    • reduce deformity
    • increase space between opposing surfaces
  • 9. Disadvantages
    • Costly in terms of hospital stay
    • Hazards of prolonged bed rest
      • Thromboembolism
      • Decubiti
      • Pneumonia
    • Requires meticulous nursing care
    • Can develop contractures
  • 10. Understanding traction
  • 11. 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.
  • 12. Counter traction
    • Fixed traction- by applying force against a fixed point of body.
    • Ex:
    • fixed traction by thomas splint
    • Roger Anderson well leg traction
  • 13. 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
  • 14. APPLIANCES
  • 15. 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
  • 16. 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
  • 17. Knots
    • Ideal knots can be tied with one hand while holding weight
    • Easy to tie and untie
    • Overhand loop knot will not slip
  • 18. Knots
    • A slip knot tightens under tension
    • Up and over, down and over, up and through
  • 19. Knots - types
    • Clover hitch
    • Barrel hitch
    • Reef knot
    • Half hitch
    • Two half hitches
  • 20. 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
  • 21. 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
  • 22. SKIN TRACTION
  • 23. 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
  • 24. Weight
        • 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
  • 25. 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.
  • 26. 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.
  • 27. 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
  • 28. 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
  • 29. Complications
    • Allergic reactions to adhesive
    • Excortication of skin
    • Pressure sores
    • Common peroneal nerve palsy
  • 30. SKELETAL TRACTION
  • 31. 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
  • 32. 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
  • 33. 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
  • 34. 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
  • 35. Application
      • 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.
  • 36. 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
  • 37. Complications
    • Introduction of infection into bone
    • Distraction at fracture site
    • Ligamentous damage
    • Damage to epiphyseal growth plates
    • Depressed scars
  • 38. VARIOUS TRACTIONS
  • 39. SPINAL TRACTION
    • Used to treat the unstable spine
    • Pull along axis of spine
    • Preserves alignment and volume of canal
  • 40. 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
  • 41. 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
  • 42. 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
  • 43. 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
  • 44. 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
  • 45. 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
  • 46. Halo Traction
    • Traction pull
    • more anterior for extension
    • more posterior for flexion
    • Use same weight as with tong traction
  • 47. 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
  • 48. 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
  • 49. 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
  • 50. Halo pelvic traction
    • To immobilize the spine.
    • To slowly correct or reduce the deformities of the spine such as scoliosis.
  • 51. 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
  • 52. 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
  • 53. 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
  • 54. 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
  • 55. 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
  • 56. Lateral Olecranon Traction
    • Used for humeral fractures
    • Arm held in moderate abduction
    • Forearm in skin traction
    • Excessive weight will distract fracture
  • 57. 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.
  • 58. 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 2 nd /3 rd MC
    • Stiffness intrinsics common
  • 59. Metacarpal pin traction
      • Point of Insertion: 2-2.5 cms proximal to the distal end of 2 nd metacarpal
      • Technique: push the 1 st 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 2 nd and 3 rd metacarpal diaphysis transversly.
  • 60. Finger traps
    • Used for distal forearm reductions
    • Changing fingers imparts radial/ulnar angulation
    • Can get skin loss/necrosis
    • Recommend no more than 20 minutes
  • 61. 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
  • 62. 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
  • 63. 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
  • 64. 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
  • 65. 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
  • 66. 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
  • 67. 90-90 Traction
    • Useful for subtroch and proximal 3 rd femur fx
    • Especially in young children
    • Matches flexion of proximal fragment
    • Can cause flexion contracture in adult
  • 68. 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
  • 69. Distal femoral traction
        • Draw 1 st line from before backwards at the level of the upper pole of patella,2 nd 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
  • 70. Proximal Tibial Traction
    • Used for distal 2/3 rd 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.
  • 71. 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.
  • 72. Balanced Suspension with Pearson Attachment
    • Enables elevation of limb to correct angular malalignment
    • Counterweighted support system
    • Four suspension points allow angular and rotational control
  • 73. Pearson Attachment
    • Middle 3 rd fx had mild flexion prox fragment
      • 30 degrees elevation with traction in line with femur
    • Distal 3 rd fx has distal fragment flexed post
      • Knee should be flexed more sharply
      • Fulcrum at level fracture
      • Traction at downward angle
      • Reduces pull gastroc
  • 74. 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
  • 75. 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
  • 76. MANAGEMENT
  • 77. Management of patients in traction
    • Care of the patient
    • Care of the traction suspension system
    • Radiographic examination
    • Physiotherapy
    • Removal of traction
  • 78. The patient
    • Blood loss
      • # Tibia -500-1000ml
      • #Shaft of Femur-1500-2000ml
      • #Pelvis -2000ml
      • #Humerus -500-2000ml
    • Chest complications
    • Urinary tract
    • Bowels
  • 79. The patient
    • Care of the injured limb-
    • Pain
    • Parasthesia or Numbness
    • Skin irritation
    • Swelling
    • Weakness of ankle, toe, wrist or finger movement
  • 80. The traction suspension system
    • Bed and Balkan beam
    • Splints
    • Slings and padding
    • Skin traction
    • Skeletal traction
    • Stirrups
    • Cord
    • Pulleys
    • Weights
  • 81. Radiographic examination
    • 2-3 times in first week
    • Weekly for next 3 weeks
    • Monthly until union occurs
    • After each manipulation
    • After each weight change
  • 82. 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
  • 83. THANK YOU