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Definition
Traction and suspension setups are arrangements of bars, pulleys, ropes, and weights which exert a pulling force on a part or parts of the body, or serve to suspend or float a part of the body-most frequently a limb
Introduction
When a limb is painful as a result of inflammation of a joint or fracture of a bone the controlling muscles go into spasm The antagonistic muscles in a limb are not all equally powerful hence the action of more powerful muscle produces deformity which may seriously impair the future function of the limb
Introduction
Traction when applied to a limb can over come the deforming force and thus can be used to reduce a fracture or dislocation of a joint In addition by overcoming muscle spasm traction can relieve pain andallows the limb to be rested in best functional position
Purpose
The purpose of any traction setup is one or more of the following :
To achieve these purposes, the traction setup must: 1. Align the distal fragment to the proximal fragment 2. Remain constant 3. Allow for adequate exercise and diversion 4. Allow for optimum nursing care
Anatomical Considerations
Figure illustrates a fracture femur. The muscle groups have pulled the broken parts out of alignment. The pull of the muscle group is overcome by a new force (traction) created with weights and pulleys. Weights provide a constant (isotonic) force; pulleys help establish and maintain constant direction. The forces thus applied must remain constant in amount and direction until the fracture fragments unite.
Anatomical Considerations
Figure illustrates the same femur after traction has been applied to realign (approximate) the broken parts
Anatomical Considerations
During an extensive period of healing, the limb must be supported to assist in maintaining fragment alignment, but the patient should still be able to move about as much as possible until union is achieved
This is why a second system of weights and pulleys called balanced suspension is often used Balanced suspension permits the limb to float over the bed, and facilitates bed pan use and changing of bed linen with minimal disturbance of the fracture
Anatomical Considerations
Countertraction, which is the resistance of the body to move in the direction of the forces exerted by a traction device, is a factor which is built into each setup by utilizing the patients body weight When necessary, the countertraction of the patients body weight may be increased by elevation of the foot of the bed or using blanket rolls, sand bags, etc
Manual Traction
In manual traction, the hands are used to exert a pulling force on the bone which is to be realigned.
Generally, this type of traction is reserved only for very stable fractures or dislocations prior to splinting or immobilization in a cast. It also may be used prior to the application of skin or skeletal traction or surgical reduction.
Skin Traction
Mechanism : The traction force is applied to large area of skin
This spreads the load and is more comfortable and efficient Force applied is transmitted from skin to bone via the superficial facia, deep fascia and intermuscular septa
Skin Traction
In treatment of fractures the traction force must be applied to limb distal to fracture site otherwise the efficiency of traction force is reduced The maximum traction weight that can be applied is 15 lb (6.7kg) depending on the size and age of the patient Methods : Adhesive Skin Traction Non Adhesive Skin Traction
The extension tapes are then bandaged to limb with help of crape bandages which must not be too loose or too tight Suport the limb to prevent edema and heel should be leave free
Skin traction can be safely used for 4-6 weeks
Skeletal Traction
Here the traction is applied directly to the bone by the means of pins and wires driven through the bone It is rarely used to manage upper limb fractures
Equipments
Steinmann Pin : They are rigid stainless pins of varying lengths and 4-6mm in diameter They are attached to Bohler Stirrup which allows the direction of traction to be varied without turning the pin in bone
Equipments
Denhamm Pin : It is identical to steinmann pin except short threaded part situated in center This threaded part engages the bony cortex and prevents pin sliding It is used in : 1) Cancellous bone like calcaneum 2) Osteoporotic bones
Equipments
Kirschner wire: Advantages : They are easy to insert Minimize the chance of soft tissue damage Disadvantages : If improper stirrup is used then they can cut through osteoporotic bones Although they are thin if special stirrup is used they can withstand large traction force because stirrup provides longitudnal tension forces which increases the rigidity of the K wire Uses : Most often in upper limb traction like olecranon traction
Equipments
Bohler Stirup
K Wire Tractor
Olecranon : Point of insertion : It is just 3cm from subcutaneous border of upper end of ulna This avoids the joint and epiphysis Technique : Pass K wire from medial to lateral side and avoiding ulnar nerve injury
Do not place the pin too distal as it may cause extension of elbow joint
Upper end Femur (Greater trochanter) : Lateral Femoral traction Point of insertion : Lateral Surface of femur 2.5cm below tip of GT and midway between anterior and posterior surface of femur
Lower end of femur: Point of insertion : 2 ways to determine At the intersection of two lines one passing transversly at upper pole of patella and other vertically above anterior to head of fibula 3cm proximal to lateral knee joint line Technique : Pass as anteriorly as possible to avoid neurovascular structures Disadvantages: Prolonged immobilzation can cause knee stiffness due to fibrosis of extensor mechanism of knee
Counter Traction
Goal of Counter traction is to relieve muscle spasm and hence correcting the deformity Types of counter traction: Fixed Traction: Here counter traction is applied by force against a fixed point in the body proximal to the attachment of muscles in spasm Sliding or Balanced traction: Here counter traction is applied by weight of all or part of body acting under influence of gravity
Thomas Splint
Described by Hugh Owen Thomas in 1876 Selection of Thomas splint Measure the oblique circumference of thigh immediately below the gluteal fold and ischial tuberosity
Measure the distance between crotch and heel and add 6-9 inches
Thomas Splint
Preparing a Thomas splint: Attach sling to the side bars on which the limb can rest - Pass the length of bandage around inner bar and then both end above the outer side bar
- The poximal sling leaves a unsupported triangular area which can be obliterated with passing the bandage around the ring and around side bar
Thomas Splint
- The distal sling must end 2.5 inches above the heel to avoid pressure sore over tendo- achillis Line the sling with gamgee tissue Put a large pad under lower part of thigh to maintain normal anterior bowing of femur
Thomas Splint
If the leg is to be supported in a knee flexion piece the hinge must coincide with axis of movement of knee that is at level of adductor tubercle of femur
After the splint has been fitted bandage the limb to splint
The extension tapes pull the limb down to the splint which is prevented from moving in opposite direction by resistance of the splint against ischial tuberosity
It is use to maintain reduction not to obtain the reduction of fracture
The outer traction cord passes above and the inner traction cord passes below its respective side bar
The traction cord are tied at the end of Thomass splint The counter traction force thus passes along the side bars to the root of limb
Advantages: Compression of tissue of upper calf and peroneal nerve doesnt occur Equinus deformity at ankle is prevented Tendo achillis is protected with padded cast Rotation of foot and distal fragment is controlled
Sliding Traction
Principle: The traction force is applied by weight attached to adhesive strapping or skeletal traction by a cord acting over a pulley Counter traction is applied by raising one end of bed so that body tends to slide in opposite direction to that of traction force Initial traction weight is more than required to reduce the fracture than the weight required to maintain the reduction
Sliding Traction
In Lower limb : Bucks extension skin traction Perkins traction Hamilton Russel Traction 90 -90 traction Gallows Traction Bohler Braun frame In Upper Limb : Modified Dunlops Traction Olecranon Pin traction Metacarpal pin traction Spinal Traction: Cervical traction Halo Pelvic traction
Bucks Traction
Indication:
Temporary management of femur neck fracture Management of fracture of femoral shaft in older and young children Undisplaced fracture of acetabulum After reduction of dislocated hip
Bucks Traction
Application: Apply above knee skin traction and support limb on a soft pillow Pass the cord over a pulley and attach weight Attach 2.5 to 3 kg weight Elevate foot end of bed Disadvantage: Lateral rotation of limb is not controlled by this method
Perkins Traction
Indication : Treatment of tibia fracture Treatment of femur fracture from subtrochanteric region and distally in all age groups Trochanteric fracture in patients under 45-50yr Application: Apply a regular skeletal traction without using any splint and pillows below knee Attach the pillow to weight and raise foot end of bed Start active movements of injured limb as soon as possible
Perkins Traction
Advantage: Preventing knee stiffness by early mobilisation
Disadvantage: Needs special split bed Gives less support for the fracture
No splint is attached
Weight in adults 3.6 kg (8lb) Infants and Children 0.28 to 1.8 kg (1/2 4 lb)
90-90 Traction
Indication: Subtrochanteric fracture Fracture of proximal 1/3rd shaft of femur Application: Skeletal traction is applied either through lower end of femur or upper end tibia The hip and knee are flexed at 90 degree Leg can be supported by Tulloch Brow U loop or second low tibial Steinmann pin or Below knee POP cast
90-90 Traction
Application: The traction weight is attached with hip and knee flexed at 90 degree The traction weight mustnt lift buttocks on that side Angulation is prevented by applying weight along the width of the leg Rotation is controlled by knee being flexed and keeping foot, leg and thigh in same line
Bryants traction
In treatment of fracture shaft of femur in children up to the age of 2 years who weighs less than 18 kgs.
Application: Apply adhesive strapping to both the lower limbs and tie the traction cords to an overhead beam
Bryants Traction
Tighten the traction cords sufficiently to raise the childs buttock just clear of the mattress
Counter traction is obtained by the weight of the pelvis and the lower trunk.
Bryants Traction
Vascular complications Ischaemic fibrosis of calf muscles Frank gangrene of distal limbs Contraindications : It is absolutely contraindicated above the age of 4 years.
Indications
Comminuted trochanteric fracture of femur Treatment of fracture shaft femur Supracondylar fracture femur For fracture shaft of tibia and fibula.
Function of pulleys
First pulley acts as a dynamic splint for the patient foot drop Second pulley to apply traction in the line of femur Third pulley to apply traction in the line of supracondylar area and for high tibial traction Fourth pulley to apply traction in the line of legs as in low tibial or calcaneal traction
Disadvantages of BB Splint
Nursing care is difficult It is heavy and cumbersome frame May cause deformity at the fracture site
Maximum weight 4.5 9kg Continue traction for 4-6 weeks Encourage active hip and knee movements
Dunlops Traction
Indications: Management of supracondylar and intercondylar humerus fractures when further flexion of elbow causes circulatory compromise
Dunlops Traction
Application:
Apply skin traction over forearm Abduct the shoulder to 45 degree Pass traction cord over the pulley so that elbow is flexed to 45 degree Place padded sling over distal humerus Attach weight of not more than 0.5 1 kg Check radial pulse hourly for 12hrs and then twice daily Remove traction if any signs of ischaemia are present
Finger traps
Used for distal forearm reductions Changing fingers imparts radial/ulnar angulation Can get skin loss/necrosis Recommend for no more than 20 minutes
Halo Traction
Traction pull more anterior for extension More posterior for flexion Use same weight as with tong traction
Halo Vest
Major use of halo traction is combine with body jacket Allows patient out of bed Can use plaster jacket or plastic jacket
Halo Vest
Disadvantages: 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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