DEPARTMENT OF ORTHOPAEDICS .

SUBJECT SEMINAR ON :

TRACTION IN ORTHOPAEDICS

Moderator: Prof Dr. Veeranna.H.D

Presented by: Dr. Yashavardhan.T.M

WHAT IS TRACTION ?

Traction - the application of a

force to stretch certain parts of

the body in a specific direction

WHY DO WE NEED TRACTION ?

Inflammation of a joint

Pain and muscle spasm

Deformity

fracture of bone

Pain

THE PURPOSE OF TRACTION IS TO:

• To regain normal length and alignment of involved bone.

• To reduce and immobilize a fractured bone.

• To relieve or eliminate muscle spasms.

• To relieve pressure on nerve roots.

• To prevent or reduce skeletal deformities or muscle contractures

• Control pain.

• Reduce fracture.

• Maintain reduction.

• Prevent & correct deformity

BALKEN BEAM FRAME

• Commonly Used to suspends splints.

• one or two Balken Frames are used

• Today balken frames are made up of

Metal tubes

• Two uprights are on each side of bed and

are joined by two long horizontal bars.

• Other short horizontal bar may be there

joined to two uprights on same side or to

long horizontal bar.

TRACTION CORDS

• Used to suspend weights to give traction

• Cords perform two functions – traction and

suspension

• For this colour code system is available –

• red or green for traction cords

• white for suspension cords.

PULLEYS

• Function of pulley is to control the

direction of weight attached to end of the

cord over pulley.

• Large pulley wheels of 6cm in diameter

and 6mm in diameter of axles are

preferable

• Majority of pulleys are prepared from

Tuflon

WEIGHTS

• The amount of weight required to

suspend an appliance depends

upon -

• weight of appliance

• weight of part of body suspended in

appliance

• the amount of friction present in

system.

CLASSIFICATION

•Based on principle

1. Fixed traction

2. Sliding traction

FIXED TRACTION

• Traction is applied to the leg against a fixed point of counter pressure.

1. Fixed traction in Thomas’s splint

2. Roger Anderson well-leg traction

3. Halo-Pelvic Traction

THOMAS SPLINT

• Hugh Owen Thomas introduced his splint which he

called "The Knee Appliance" in 1875

• The method of Hugh Owen Thomas uses fixed traction

with the counter traction being applied against the

perineum by the ring of the splint.

• The Thomas splint is well up in groin and fits snugly

around the root of the limb.

• This is in contrast to other methods using weight

traction which is countered by the weight of the body.

• Indication

• The use of supports enables correction of angulation caused by muscle tension

• Placement of a large pad behind the lower fragment acts as a fulcrum over which

backward angulation is then corrected by the traction force

• Used for fracture shaft of femur

• Counter traction provided by ischial Tuberosity

• Measure from Crotch to Heal and it should be 15-23 cm beyond heal.

• Ring should be angled at 120° to inner side bar.

• Complication: excoriation of skin, pressure sore around malleolus

• Thomas splint was threaded over the cast and the skin traction tied to the lower end

of the splint. The plaster cast was then split and the splint secured to cast by

banding. This assembly popularly known as TOBRAK SPLINT.(Bristow, 1943)

ROGER ANDERSON WELL-LEG TRACTION

• Well leg traction ( Anderson ,1932) was originally used in management

of fractures of pelvis, femur and tibia , skeletal traction being applied to

the injured leg ,while the well leg was employed for counter traction.

• Indications Method is used to correct either an adduction or abduction

deformity at hip, for instance before an extra-articular arthrodesis is

carried out

HALO- PELVIC TRACTION

• The ‘Halo’, a metal ring secured with four screws into the

outer dipole of the skull, was popularised by Perry and

Nickel in the 1970s for prolonged cervical traction in place

of the old-fashioned, two-screw skull tongs used in cervical

fractures.

APPLICATION OF HALO SPLINT:

• For application of halo splint, choose a halo splint which will allows a clearance of

half inch i.e 1.25 cm to the circumference of head. The splint is positioned with its

lower margin laying just above the ears and 6mm above the eyebrows.

• For four fixation points anterior 2 pins are inserted about 1 cm above the lateral one

third of the eye brows that is in between the superior orbital ridges and the frontal

prominence. Posterior 2 pins are inserted about 1 cm above the top of ears in line

with the mastoid processes.

• The pelvic rods are fixed with make a stab wound

at point 2 inches superior and posterior to ASIS

(iliac tubercle), in fat patients it’s difficult to

palpate make a incision at summit of the iliac crest

large enough to pass the finger.

• Position of drilling jig , place posterior part of jig

over PSIS and anterior end of jig over the tubercle

of Iliac crest, continue the drilling around 6 inches

projects posteriorly.

• Indications Halo-pelvic traction was ideal for the treatment of severe and

rigid spinal deformities such as healed tuberculosis kyphosis and various

types of severe scoliosis such as that due to neurofibromatosis and

poliomyelitis.

• Complication was discovered in the odontoid process of the second

cervical vertebra. The blood supply to this process is essentially derived

from ligaments attached to this bone. With tension in the ligaments from

distraction, blood supply to the odontoid process is jeopardised leading to

avascular necrosis. This was a rather common complication in HPT. The

necrosis itself recovered, but stiffness and early degeneration of the

cervical spine.

COMPLICATIONS OF HALO-PELVIC TRACTION

• 1.Cranial screws – superficial infection around the cranial screws, cerebral abscess,

pain when the screw are tight, penetration to inner table; diagnosed by tangential

views x rays.

• 2.Pelvic rods – vague ache and pains , peritoneal penetration , superficial infection

hip contracture from ilio-psoas fibrosis and loosening

• 3.Neurological includes traction lesion abducent nerve palsy –moving of affected

eye to outward direction , glosso pharyngeal nerve palsy – difficulty in swallowing,

recurrent laryngeal nerve palsy- hoarseness, spinal cord – paraplegia

SLIDING TRACTION

• It was describe by John Haddy James on 1839

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

influence of gravity, is utilized to provide counter-traction.

• Exact weight required is determined by trial.

• For the fracture of femoral shaft an initial weight of 10% of

body weight

• Foot end is elevated so that the body slides in opposite

direction.

• 1 inch (2.5 cm) for each 1 lb (0.46 kg) of traction weight.

TYPES OF TRACTION ON APPLICATION

1. Skin traction

Adhesive and Non – adhesive

2. Manual traction

3. Skeletal traction

SKIN TRACTION

• Traction force is applied over a large area of skin

• Applied over limb distal to fracture site

• Antero-medial and postero-lateral part should be covered with cotton and malleoli

should be covered with cotton.

• Adhesive skin traction: Maximum weight 6.7 kg

• Non-adhesive skin traction Maximum weight should not exceed 4.5 kg

Used in thin and atrophic skin, skin sensitive to adhesive strapping,

COMMON SKIN TRACTIONS

• Buck’s Traction

• Hamilton Russel Traction

• Tulloch Brown Traction

• Gallow’s or Brayant’s Traction

• Modified Brayan’s Traction

• Pelvic Traction

• Dunlop Traction

BUCK’S TRACTION:

• Bucks traction , popularised in America civil war (bucks

,1861)

•

Indication temporary management of fracture of femoral

neck, un displaced fracture of acetabulum to correct minor

displacements of hip and knee

• Also in place of pelvic traction in lower back ache.

• But lateral rotation of limb is not corrected by this method

of traction.

HAMILTON RUSSEL TRACTION

• Described by Russell 1924

• Indication : management in fracture shaft of femur and after arthroplasty

operations in hip.

• Below knee skin traction is applied

• A broad soft sling is placed under the knee

The two pulley blocks B at the foot of bed nominally double

the pull on the limb.

The resultant of the two forces acting along the cord

providing a pull in line of the shaft of femur.

TULLOCH BROWN TRACTION

•

Tulloch brown, or U loop tibial pin , traction and suspension

(nagle, 1951) with a nissen foot plate and stirrup ( nissen

1971)

• Indication for management of patients who have had a cup

arthroplasty or pseudoarthrosis operation on the hip , or

who have sustained a fracture of the shaft of femur.

• Not used in children

BRYANT’S (GALLOW’S ) TRACTION

• Discovered by Brayant in 1880

• The treatment of fracture shaft femur in children up to age of 2 yrs.

• Weight of child should be less than 15- 18 kg

• Above knee skin traction is applied bilaterally

• Tie the traction to the overhead beam.

• Vascular complication should be checked by observing the colour and temperature of

feet and dorsiflex of both ankle passively especially during first 24-72 hours after

application of traction, dorsiflexion should be full and painless; if its present remove the

banding and adhesive plaster Immediately

MODIFIED BRYANT’S TRACTION

• Sometimes used as initial management of developmental dysplasia of

hip (1 YR)

• After 5 days of Bryant’s traction, abduction of both hips is begun

increased by about 10 degree alternate days. By three weeks hips

should be fully abducted. Check for the circulation and while gradually

increasing the abduction child may cry and scream do to stretching of

capsule by impingement of femoral head on superior lip of acetabulum

so decrease the degree of abduction will relieve the pain.

PELVIC TRACTION

• The amount by which foot end should be elevated depends upon

patient’s weight, more heavy the patient, more should be

elevation.

• In pelvic traction a special canvas harness is buckled around the

patient pelvis. The long cords or straps attach the harness to the

foot of the bed. When foot side of the bed is raised, gravity causes

the patient to slide towards the head of bed.

• Used for conservative management of PIVD. The function of

traction is to ensure that the patient lies quietly on bed, rather

than to attempt to distract the vertebral bodies.

DUNLOP TRACTION

• Discovered by Dunlop in 1939

Supracondylar & trans condylar fracture of humerus.

• The weight depends on weight of child but often 0.5 -1 kg is sufficient initially.

Under radiographic control increase the traction weight daily until the satisfactory

reduction of fracture obtain.

• Useful when flexion of elbow causes circulatory embarrassment with loss of radial

pulse

• Apply skin traction to forearm. Abduct shoulder about 45 degree the elbow is flexed

45 degree.

COMPLICATIONS

• Of Adhesive Skin Traction :

• Allergic reactions to adhesives.

• Excoriation of skin.

• Pressure sores over bony prominences and tendoachillis.

• Common peroneal nerve palsy.(neuro-prexia)

SKELETAL TRACTION

• Using pin or wire

• more frequently used in lower limb fractures

• Should be reserved for those cases in which

skin traction is insufficient.

• Generally used when more weight is needed to

give traction.

• To treat fractures conservatively.

TRACTION PIN TYPES

• Steinmann pin may be either smooth or threaded Smooth is stronger but can slide if

angled

• Threaded pin is weaker, bends easier with higher weight, but will not slide and will

advance easily during insertion

• In general a 5 or 6 mm diameter pin is chosen for adults SKELETAL TRACTION

• Denham pin . introduced by denham in 1972 to reduce risk of pin sliding. This

type of pins are used in cancellous bone, such as calcaneus, or in osteoporotic bone.

SITES

• Lower limb• Upper tibial

• Lower femoral

• Lower tibial

• Calcaneus

• Upper limb • Olecrenon

• Metacarpel

PIN PLACEMENT

• Sterile field with limb exposed

• Local anesthesia + sedation

• Insert pin from known area of

neurovascular structure

• Distal femur: Medial toLateral

• Proximal Tibial: Lateral to Medial

• Calcaneus: Medial to Lateral

• Place sterile dressing around pin site

• Place protective caps over sharp pin

DISTAL FEMORAL TRACTION

• Place pin from medial to lateral at the adductor tubercle - slightly proximal to

epicondyle.

• Method of choice for acetabular and proximal femur fractures

• If there is a knee ligament injury usually use distal femur instead of proximal tibial

traction

PROXIMAL TIBIAL TRACTION

• Used for distal 2/3rd femoral shaft fracture.

• Easy to avoid joint and growth plate

• 2 cm distal and posterior to tibial tubercle.

• Place pin 2 cm posterior and 1 cm distal to

tubercle

• Place pin from lateral to medial

• Cut skin and try to stay out of anterior

compartment - push muscle posteriorly with

pin.

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DISTAL TIBIAL TRACTION

Useful in certain tibial plateau fracture

• Pin inserted 5 cm proximal to tip medial malleolus , midway between ant and post

border of tibia.

• Avoid saphenous vein

• Place through fibula to avoid peroneal nerve

• Maintain partial hip and knee flexion

CALCANEAL TRACTION

• Temporary traction for tibial shaft fracture or calcaneal fracture

• Do not skewer subtalar joint or NV bundle

• Maintain slight elevation legMost commonly used with a spanning ex fix for

“travelling traction” or may be used with a Bohler-Braun frame

• Place pin medial to lateral 2 - 2.5 cm posterior and inferior to medial malleolus.

COMPLICATIONS OF SKELETAL

• Introduction of infection to bone

• Incorrect placement of pin or wire may lead

• pin to cut out of bone

• result in un even pulling being applied to ends of the pin or wire and thus causes the pin

or wire to move inside bone

• Ligamentous damage when large force been applied

• Damage to growth plates when applied to children , genu recurvatum can occur

• Depressed scars.

SOME OTHER SKELETAL TRACTIONS

• Lateral or Upper Femoral Traction

• Nintey / Nintey traction

• Olecranon traction

LATERAL UPPER FEMORAL TRACTION

• For the management of central fracture dislocation of the hip

• about 2.5 cm from most prominent part of greater

• trochanter mid way between ant. And post. surface of femur

• threaded screw eye

• Attach weight upto 9 kgs

• Traction to continued for about 4-6 wks

NINETY / NINETY TRACTION

1. Using a Tulloch Brown-U loop

2. Using a second Steinman pin (second pin inserted through lower end of tibia and

attached to a Bohler stirrup)

3. Using a below knee Plaster cast

• Used for sub trochanteric fractures and those in the proximal third of the shaft of

the femur

• Management of fractures with posterior wound is easier

• Traction is given through lower femoral pin, which is more efficient, or by upper

tibial pin.

COMPLICATIONS OF 90/90 TRACTION:

• Those related with skeletal traction.

• Stiffness and loss of extension of knee.

• Flexion contracture of hip.

• Injury to epiphyseal plate in children.

• Neurovascular damage

OLECRANON TRACTION

• Rarely used today

• Small to medium sized pin placed from medial to lateral

in proximal olecranon - enter bone 3 cm from tip of

olecranon and walk pin up and down to confirm mid

substance location.

• Support forearm and wrist with skin traction - elbow at

90 degrees

PRE-OP

• X-rays are done pre-op and may be repeated during treatment to assure a stable

alignment

• Blood and urine tests are done

• Patient may meet with an anaesthesiologist to discuss health conditions (if skeletal

traction is being done)

POST –OP SKIN TRACTION

• Make sure the limb stays aligned.

• Make sure skin does not become sore or irritated.

• Be sure patient is alert to any swelling or tingling due to the limb being wrapped too

tightly.

POST –OP SKELETAL TRACTION

• Traction may be continued for several months until healing is complete.

• Deep breathing exercises are taught.

• Range-of-motion done to unaffected parts of the body.

• Patient teaching is done on how to use a trapeze bar

RISKS

• Two main risks are: traction is applied incorrectly or the skin becomes irritated.

1. Bone inflammation may occur.

2. Infection may occur at the pin sites.

• Because of long periods of immobility, the patient may develop bed sores, reduced respiratory function,

urinary or circulatory problems.

• Traction can take an emotional toll on the patient.

Cut out

Distraction at fracture site

Physial damage

Nerve Injury

SLIDING TRACTION WITH BOHLER BROWN SPLINT:

• Used for the fracture of tibia or femur.

• Skeletal traction is usually applied, but

skin traction can be given b/k.

SPINAL TRACTIONS & CERVICAL TRACTIONS

• SKIN TRACTION Head Halter traction

• SKELETAL TRACTION

Crutchfield tongs

Cone or Barton tongs

HEAD HALTER TRACTION• Non skeletal traction ( A CAVAS OR CHAMOIS LETHER HEAD HALTER)

• One part is placed under the chin and other under the occiput

• Simple type cervical traction

• Management of neck pain

• Weight should not exceed 1.4-2.3 kgs

• Simple type cervical traction

• Management of neck pain

• Weight should not exceed 3 kg initially

• Can only be used a few hours at a time

• Head end should be elevated to give counter traction

CRUTCHFIELD TONGS• Must incise skin and drill cortex to place

• Rotate metal traction loop so touches skull in mid-sagittal plane

• Place at the line connecting tips of mastoid processes on both side

• Shave the scalp locally and sedate patient fully open the tongs with

fully opened tongs laying equally on each side of antero-posterior

line , press the points into scalp making dimple infiltrate the tip

down so that it includes the periosteum with local anaesthetic

solution.

• Make a stab wounds over dimples

• Using special drill point ,drill through the outer table of skull in direction parallel to

the point of tongs. Drill point is inserted to depth of 3mm in children and 4mm in

adults

• Fit the point of tongs in to drill holes

• Tighten the adjustment screw until a firm grip is obtained repeated daily for first 3

to 4 days

• Attach the cords to two lugs ansd attach weight

CHARNLEY’S TRACTION UNIT

• POP incorporating the Steinmann or Denham pin

• Common peroneal nerve and calf muscles protected

• External rotation of the foot and distal fragments is controlled

• The tendo achilles is protected from pressure sores

• Ipsilateral tibia # can be managed

• References :

• Stewart Hallett 2nd edition Traction and orthopaedic application .

• Zimmer traction handbook.