traction - alpha hand surgery centre – you are in · pdf fileskeletal traction by a pin...
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Orthopaedic Traction
Dr Terence Tay
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TractionAllows constant controlled force for initial stabilization of long bone fractures and
aids in reduction during operative procedure !Option for skeletal vs. skin traction is case dependent
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General Considerations
Safe and dependable way of treating fractures for more than 100 years
Bone reduced and held by soft tissue
Less risk infection at fracture site
No devascularization
Allows more joint mobility than plaster
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Disadvantages
Costly in terms of hospital stay
Hazards of prolonged bed rest ▪ Thromboembolism ▪ Decubiti ▪ Pneumonia Requires meticulous nursing care
Can develop contractures
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History
Skin traction used extensively in Civil War for fractured femurs
Known as the “American Method” Skeletal traction by a pin through bone introduced by Steinmann and Kirschner
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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
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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
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Knots
Ideal knots can be tied with one hand while holding weight Easy to tie and untie Overhand loop knot will not slip
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Knots
A slip knot tightens under tension Up and over, down and over, up and through
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Skin Traction
Limited force can be applied - generally not to exceed 5 lbs More commonly used in pediatric patients Can cause soft tissue problems especially in elderly or rheumatoid patients Not as powerful when used during operative procedure for both length or rotational
control
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Skin Traction - “Bucks”An option to provide temporary comfort in hip fractures Maximal weight - 10 pounds Watch closely for skin problems, especially in elderly or rheumatoid patients
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Skeletal Traction
More powerful than skin traction May pull up to 20% of body weight for the lower extremity Requires local anesthesia for pin insertion if patient is awake Preferred method of temporizing long bone, pelvic, and acetabular fractures until operative
treatment can be performed
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Traction Pin TypesChoice of thin wire vs. Steinman pin Thin wire is more difficult to insert with hand drill and requires a tension traction bow
Tension BowStandard Bow
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Traction Pin TypesSteinmann 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
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Traction Pin Placement
Sterile field with limb exposed Local anesthesia + sedation Insert pin from known area of neurovascular structure ▪ Distal femur: Medial → Lateral ▪ Proximal Tibial: Lateral → Medial ▪ Calcaneus: Medial → Lateral Place sterile dressing around pin site Place protective caps over sharp pin ends
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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
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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
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Cervical skeletal traction
Used to treat the unstable spine Pull along axis of spine Preserves alignment and volume of canal Gardner-Wells and Crutchfield tongs commonly
used
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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
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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
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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
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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
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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
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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
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Halo Traction
Traction pull more anterior for extension More posterior for flexion Use same weight as with tong traction
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Left: “Safe zone” for halo pins. Place anterior pins about 1 cm above orbital rim, over lateral two thirds of the orbit, and below skull equator (widest circumference).
Right: “Safe zone” avoids temporalis muscle and fossa laterally, and supraorbital and supatrochlear nerves and frontal sinus medially.
Posterior pin placement is much less critical because the lack of neuromuscular structures and uniform thickness of the posterior skull.
Figure from: Botte MJ, et al. J Amer Acad Orthop Surg. 4(1): 44 – 53, 1996.
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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
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Halo Vest
Pin site infection a risk
Can remove pins and place in different hole
Pin penetration can produce CSF leak
Scars over eyebrows
Can get sores beneath vest
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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
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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
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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
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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
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Olecranon Pin Traction
Difficult 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
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Lateral Olecranon Traction
Used for humeral fractures Arm held in moderate abduction Forearm in skin traction Excessive weight will distract fracture
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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
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Finger traps
Used for distal forearm reductions Changing fingers imparts radial/ulnar angulation Can get skin loss/necrosis Recommend no more than 20 minutes
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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
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LOWER EXTREMITY TRACTIONCan 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
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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
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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
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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
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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
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Femoral Traction Pin
Must avoid suprapatellar pouch, NV structures, and growth plate in children Place just proximal to adductor tubercle along midcoronal plane At level proximal pole patella in extended position
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Distal Femoral Traction
Place pin from medial to lateral at the adductor tubercle - slightly proximal to epicondyle
Figures from Althausen PL, Hak DJ. Am J Orthop. 2002.
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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
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Proximal Tibial Traction
Used for distal 2/3rd femoral shaft fx Femoral pin allows rotational moments Easy to avoid joint and growth plate 1 inch distal and posterior to tibial tubercle
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Balanced Suspension with Pearson Attachment
Enables elevation of limb to correct angular malalignment Counterweighted support system Four suspension points allow angular and rotational control
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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
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Distal Tibial Traction
Useful in certain tibial plateau fx Pin inserted 1.25 inches proximal to tip medial malleolus Avoid saphenous vein Place through fibula to avoid peroneal nerve Maintain partial hip and knee flexion
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Calcaneal Traction
Temporary traction for tibial shaft fx or calcaneal fx Insert about 1.5 inches inferior and posterior to medial malleolus Do not skewer subtalar joint or NV bundle Maintain slight elevation leg
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Thank You