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Traction

- Method of applying sustained force to a part of the body with an external device
- Indications:
o Reduction of fracture or dislocation
o Retention of fracture post-reduction
o Overcoming and relieving muscle spasm
o Immobilizing affected part and prevent further soft tissue damage and promoting rest
- Types:
o Skin
o Skeletal
o Pelvic
o Spinal

Skin traction
- Traction placed over a large area of skin; 2 types: adhesive and non-adhesive
o Adhesive material used for strapping; applied anteromedial and posterolateral on either side of the
lower limb
o Non-adhesive skin traction is used in thin and atrophic skin, or in patients sensitive to the adhesive
strap.
o Non-adhesive skin traction
- Contraindications:
o Skin compromise (with or without infection), impaired circulation/sensation, hypersensitivity to
adhesive straps
- Traction weight is given by 1/10-1/7 of body weight. Maximum weight for skin traction: 15lbs/6.7kg. Generally
accepted and practiced rule is below 5kg
- Complications:
o Blister/excoriations from strap slipping
o Pressure sores over malleoli
o Common peroneal nerve injury
o
- Most commonly used skin tractions:
o Bucks extension
o Dunlops
o Bryants

Skeletal traction
- Traction with force applied onto bone rather than skin
- Two types of pins: Kirschner wires or Steinmann pins (others include Denham pins; Steinmann pins with
threaded body to reduce slipping )
- K-wires come in 3 diameters (0.9, 1.2 and 1.6mm) and are usually 9 inches long.
o Used for smaller bones
o When traction placed, K-wire traction bows are required
o
o When tightened, the bow stretches the wire to make it tight and less bendable
- Steinmann pins
o
o Come in various diameters, but generally thicker than K-wires
o 9 inch length
o Relatively unbendable therefore only simple traction bow needed
o
o May have 1 end point or both end points
-
o Applied under local anesthesia (infiltrated down to bone) (E)
o Stab incision made on skin (F)
o Introduce pin through incision horizontally and at right angles to the long axis of limb (G)
o Best inserted with T-handle or hand drill (H). Mallet used only at the start in the cortex
o Advance until skin stretches at the other end, and make a release incision (I)
o Dress pin site with sterile gauze (J), attach stirrups (K)
- Types of skeletal traction
o Femoral traction
o
o Must avoid suprapatellar pouch, neurovascular structures, and growth plate in children
o Place just proximal to adductor tubercle along midcoronal plane
o At level proximal pole patella in extended position
o Distal femoral traction used for superior acetabular and femoral shaft fractures when strong force
needed or knee pathology present
- Proximal tibial traction
o
o Used for distal two-thirds femoral shaft fractures
o Allows rotational movements
o Easy to avoid joint and growth plate
o Apply 1in distal and posterior to tibial tubercle
- Distal Tibial traction
o
o Useful in tibial plateau fractures
o Inserted 1.25in proximal to tip of medial malleolus,be careful to avoid saphenous vein
o Inserted through fibula to avoid peroneal nerve
o Maintain partial hip and knee flexion
- Calcaneal traction
o
o Used for temporary traction in tibial shaft or calcaneal fractures
o Inserted 1.5in inferior and posterior to medial malleolus
o Maintain slight elevation of leg
-

- Halter traction
o Cervical spine skin traction
o
o
o
o Occasionally used for cervical radiculopathy
o Weight should not exceed 5lbs/2.25kg
- Skull traction
o Used to treat unstable spine by pulling along the axis of the spine to preserve the alignment and volume
of canal
o Gardner Tongs most commonly used
o
o
o Placed directly cephalad to external auditory meatus, in line with mastoid process
o Weight ranges from 5lbs for cervical spine to 20lbs for lumbar spine
o Other examples include Crutchfield Tongs

o Must incise skin and drill cortex to place
o Rotate metal traction loop so touches skull in midsagittal plane
o Place directly above ext auditory meatus
o Halo Ring Traction
o
o Direction of traction force can be controlled
o Used for cervical or thoracic spine fixation
o Two anterior pins Placed in frontal bone groove Sup and lat to supraorbital ridge
o Two posterior pins Placed posterior and superior to external ear
o
o Traction pull anteriorly for more extension, and posteriorly for flexion
o Same weight as tong traction

Dunlops Traction
-
- A form of skin traction
- Used for supracondylar and intercondylar fractures of humerus where elbow flexion causes circulatory
compromise
- Used when closed reduction difficult or traumatic
- Applies skin traction over forearm and weight on upper arm
- Elbow flexed at 45 degrees

90-90 Traction
-
- Useful for subtrochanteric and proximal third femur fractures, especially in young children
- Matches flexion of proximal fragment

Pelvic traction
-
-
- May be used for herniated lumbar discs, or in some cases for spinal fractures
- For lumbar spondylosis, traction applied at 30-45 degs angle, to eliminate lumbar lordotic curve and opening the
posterior part of the intervertebral disc space

Bohler-Braun Frame
-
- For supracondylar or intercondylar fractures where skeletal traction and elevation of limb is required

Thomas splint

- A form of traction splint where the loop end is to be inserted up to the proximal thigh and traction bandange is
placed on the ankle tied to the other end of the splint

- Indications are similar to skin traction; for temporary traction in fractures of the femur and tibia, to reduce
muscle spasm and for immobilization

Bracing/Splinting
Plaster of Paris
- Also known as Gypsum plaster (calcium sulfate dihydrate)
- Moderately water soluble, and exhibits retrograde solubility (less soluble at higher temperatures)
- 2 (CaSO
4
H
2
O) + 3 H
2
O 2 (CaSO
4
.2H
2
O) + Heat
- When water is added to the hemihydrate form, it becomes soluble and heat is released; and returns to its
relatively insoluble form
- Setting starts about 10 mins and is complete in 45 mins, but fully dries in 72 hours
- Other synthetic materials are used for plaster cast, eg. Fiberglass impregnated with polyurethane. Lighter and
dries faster.

Upper limb casts
- Collar and cuff slings
o Wrist sling with weight of arms provide gravitational traction to humerus
o Indicated in minimally displaced humerus fractures or connective tissue injury requiring support and
partial immobilization
- U-slab
o
o Cast from shoulder up to forearm
o For more stability and comfort following conservative treatment of humerus fractures
- Hanging cast
o
o Similar principle to brace and apply gravitational traction to a humerus fracture, with the weight of the
cast providing extra traction.
o Used for comminuted humeral fractures
- Figure of 8 bandaging
o
o Used to partially immobilize shoulder protraction/retraction following clavicular fractures
- Above elbow cast
o Also known as long arm cast
o To immobilize a radial/ulna fracture following adequate reduction and to prevent forearm rotation
- Below elbow cast
o Also known as short arm cast
o To immobilize a wrist/distal forearm fracture
- Scaphoid cast
o
o Also known as thumb spica cast
o To immobilize the scaphoid for undisplaced scaphoid fractures
- Volar/back slab
o Temporary splinting while awaiting swelling improvement following fractures and soft-tissue injuries of
the distal forearm, wrist and hand, prior to application of a long term circular enclosing cast.
- Dynamic Splints
o
o Applies low passive load to a joint with low range of motion to stretch and resolve joint stiffness
o Indicated in any conditions with immobilization and results in loss of ROM and joint stiffness (post-ACL
reconstruction, TKR, contractures, radial nerve injury etc)
Lower limb casts
- Boot cast
o Indicated in lateral malleolar fractures with dislocation less than 2mm, post-operative casting of
malleolar fractures, post-operative casting for ankle ligament injuries and for midfoot injuries
- Below knee cast
o Also known as short leg cast
o
o Indicated in lower leg fractures, severe ankle ligamentous injuries/fractures, post-operative casting for
immobilization of muscles and tendons
- Above knee cast
o Also known as long leg cast
o Indicated in lower leg midshaft fractures
- Cylinder cast
o Indicated in knee fractures and dislocations
- Back slab
o Similar to back slab of the upper limb
- Patellar tendon bearing cast
o Also known as Sarmiento cast
o
o Primary cast for minimally displaced stable distal tibial shaft fractures
o Conservational follow-up casting in stable fractures of lower tibial shaft following initial long leg cast.
o
- Hip Spica
o Divided to unilateral,one and a half, and bilateral long leg hip spica cast
o
o Indicated in femur fractures and post-operative casting for thigh muscle/tendon surgery
o Bilateral hip spica is indicated in pelvic and proximal femur fractures
- Total contact cast
o
o
o Indicated in for supporting the healing of plantar neuropathic ulcers, including diabetic foot ulcers.
o Principles of this cast is plantar pressure unloading

Cervical collars
- Divided to 3 types:
o Hard collars
o
Indicated in temporary immobilization of the neck (unstable cervical fractures)
o Semi-rigid
Eg. Philadelphia collar

Semirigid cervical orthosis made from plastazote foam
Motion restriction moderate (60-70% flexion/extension/rotation, and 30-40% lateral bend)
Indicated in post-operative cervical bracing, as well as for cervical fractures (stable)
o Soft

Motion restriction very limited
Indicated for head support in neck soft tissue injuries/muscle spasms/cervical strain

Pelvic Sling
-
- For temporary bracing in unstable pelvic fractures, prevent further displacement in pubic rami fractures, and
may compress hemorrhage sites.

External Fixator
- Indications:
o Stabilizing open fractures
o Stabilizing infected non-union fractures
o Correction of extremity malalignments and length discrepancies
o Damage control frame for initial stabilization in polytrauma (due to rapid application of frame)
o Closed fractures with severe soft tissue injuries
o Severely comminuted diaphyseal and periarticular fractures
o Temporary transarticular stabilization of severe soft tissue and ligamentous damage
o Pelvic ring disruption
o Arthrodesis
- Types: Standard and ring ex fix

Balkan frame
- For suspension of the Thomas splint (to increase countertraction) on traction for femur fractures. Adjustable
height
Monkey pulley/chain
-
- For patients to mobilize self (transfer from position to another, for example from bed to bedpan etc) if lower
limbs are immobilized (on traction, paraplegic etc)

Functional brace/knee brace
-
- Indicated in ACL,PCL,MCL,LCL or combined instabilities, or post-operative bracing after reconstruction
- Prophylactic Braces: Intended to prevent or reduce the severity of knee injuries in contact sports;
- Functional Braces: Designed to provide stability for unstable knees;
- Rehabilitative Braces: Designed to allow protected and controlled motion during the rehabilitation of injured
knees;
- Patellofemoral Braces: Designed to improve patellar tracking and relieve anterior knee pain.


Bibliography
- Traction in orthopedics, chap 19, Practical Orthopedics; Ebnezar J. IK International Pvt Ltd, 2009
- Mechanical properties of orthopedic plaster bandages, Schimdt VE et al. Jour Biomech 6(2):173-176 1973.
http://dx.doi.org/10.1016/0021-9290(73)90086-9
- Knee braces: current evidence and Clinical Recommendations for their use. Palluska, McKeag. Am Fam Physician.
2000 15;61:411-418. Retrived from: http://www.aafp.org/afp/2000/0115/p411.html