Application of traction in orthopaedics


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Application of traction in orthopaedics

  1. 1. Application of Traction in Orthopaedics By- Prabhnoor Singh Hayer Moderated by- Dr. Rajesh Maheshwari
  2. 2. Definition Traction is the application of a pulling force to a part of the body
  3. 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. 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. 5. Indications To reduce the fracture or dislocation To maintain the reduction To correct the deformity To reduce the muscle spasm
  6. 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. 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. 8. Advantages of Traction  Decrease pain  Minimize muscle spasms  Reduces, aligns, and immobilizes fractures  Reduce deformity  Increase space between opposing surfaces
  9. 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. 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. 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. 12. Knots A slip knot tightens under tension Up and over, down and over, up and through
  13. 13. Knots - types  Clover hitch  Barrel hitch  Reef knot  Half hitch  Two half hitches
  14. 14. Skin traction Skin traction
  15. 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. 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. 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. 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. 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. 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. 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. 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. 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. 24. Complications  Allergic reactions to adhesive  Excortication of skin  Pressure sores around the malleoli and over the tendo calcaneus  Common peroneal nerve palsy
  25. 25. Skeletal Traction
  26. 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 kgsObese patients
  27. 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. 28. Upper Femoral Traction  Lateral traction for fractures with medial or anterior force  Stretched capsule and ligamentum teres may reduce acetabular fragments
  29. 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. 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. 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. 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. 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. 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
  35. 35. Perkin’s traction:
  36. 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. 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. 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. 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. 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. 41. Lateral Olecranon Traction  Used for humeral fractures  Arm held in moderate abduction  Forearm in skin traction  Excessive weight will distract fracture
  42. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 52. Management of patients in traction  Care of the patient  Care of the traction suspension system  Radiographic examination  Physiotherapy  Removal of traction
  53. 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. 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. 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  without external support and partial weight bearing - 6 weeks - 12 weeks
  56. 56. Thank You