ORTHOPAEDIC TRACTION

Bodla
PG(PIMS)

Dr. Srinivas
Ortho

Definition

Traction is the application of a

pulling force to a part of the body

History

Skin traction used extensively in Civil

War for fractured femurs
Skeletal traction by a pin through bone
introduced by Steinmann and Kirschner
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

History
Percival pott- fractured limb should be
placed in the position in which muscles are
most relaxed
Josiah crosby isotonic skin traction for
treatment of shaft of femur
Thomas Bryant- Braynts traction for
treatment of fracture shaft of femur in
children
Thomas Thomas splint, used for applying
fixed traction

History
Malgaigne introduced the 1st effective
traction which grasped the bone itself. He
used malgaignes hooks
Fritz-Steinmann introduced a method of
applying skeletal traction to the femur by
means of two pins driven into the femoral
condyles.
Lorenz-Bohler The Father of Traumatology
popularised skeletal traction by means of
steinmann pins after he devised Bohler
stirrup.

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

Types

Skin traction

The traction force applied over a large area of skin

- Adhesive and 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, kirschner wire)

Advantages

decrease pain
minimize muscle spasms
reduce, align, and immobilize fractures
reduce deformity
increase space between opposing
surfaces

Disadvantages

Costly in terms of hospital stay

Hazards of prolonged bed rest

Thromboembolism
Decubiti
Pneumonia

Requires meticulous nursing care

Can develop contractures

Understanding traction

Principles Of Effective Traction

Countertraction must be used to achieve

effective traction.
Countertraction is the force acting the
opposite direction.
Usually, the patient's body weight and
bed position adjustments supply the
needed countertraction.

Counter traction
Fixed traction- by applying force against
a fixed point of body.
Ex:
fixed traction by thomas splint
Roger Anderson well leg traction

Counter traction
Sliding traction- by tilting bed so that patient
tends to slide in opposite direction to traction
force
Ex:
Hamilton russell traction
Tulloch Brown traction
Agnes Hunt traction
Perkins traction

APPLIANCES

Beds And Frames

Standard bed has 4post traction frame

Ideal bed for traction
with multiple injuries
is adjustable height
with Bradford frame
Mattress moves
separate from frame

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

Knots

Ideal knots can be

tied with one
hand while
holding weight
Easy to tie and
untie
Overhand loop
knot will not slip

Knots

A slip knot
tightens under
tension
Up and over,
down and over,
up and through

Knots - types

Clover hitch
Barrel hitch
Reef knot
Half hitch
Two half
hitches

Pulleys

To control the direction of weight

By altering site and by using more than 1
pulley the force exerted by a given weight can
be increased
Pulleys of 5-6.25cm diameter with 6cm
diameter axles are preferrable

Weights
Amount of weight required depends upon
Wt of the appliance
Wt of part of body suspended
Amount of friction present in the system
Mechanical advantage of the system
employed for suspension

SKIN TRACTION

Skin traction

The traction force is applied over a large area,

this spreads the load and is more comfortable
and efficient.
Force applied is transmitted from skin to the
bones via superficial fascia, deep fascia and
intermuscular septa
For better efficiency the traction force is applied
only to the limb distal to the fracture

Weight
Skin

damage can result from too much of

traction force.
Maximum weight recommended for skin
traction is 6.7 kgs
depending on size and weight of the patient

Application

Adhesive skin traction:

Prepare the skin by shaving as well as washing
& applying tincture benzoin which protects the
skin and acts as an additional adhesive.
Avoid placing adhesive strapping over bony
prominences, if not, cover them with cotton
padding and do the strapping.
Leave a loop of 5 cm projecting beyond the
distal end of limb to allow movement of fingers
and foot.

Application

Non adhesive skin traction

Useful in thin and atrophic skin
Frequent reapplication may be necessary
Attached traction wt. must not be more
than 4.5 kgs.

Indications

Temporary management of # of NOF and

IT #
Management of # - Femoral shaft of older
and hefty children
Undisplaced # of acetabulum
After reduction of dislocation of Hip
To correct minor fixed flexion deformities
of hip and knee

Contraindications

Abrasions and lacerations of skin in the

area to which traction is to be applied
Varicose veins, impending gangrene
Dermatitis
When there is marked shortening of the
bony fragments as the traction weight
required is greater than which can be
applied through the skin

Complications

Allergic reactions to adhesive

Excortication of skin
Pressure sores
Common peroneal nerve palsy

SKELETAL TRACTION

Skeletal traction

It may be used as a means of reducing

or maintaining the reduction of a
fracture
It should be reserved for those cases in
which skin traction is contraindicated

Steinmann Pin

Rigid stainless steel pins of varying lengths

4 6 mm in diameter. Bohler stirrup is
attached to steinmann pin which allows the
direction of the traction to be varied
without turning the pin in the bone

Denham Pin

Identical to stienmann pin except for a

short threaded length in the center . This
threaded portion engages the bony
cortex and reduce the risk of the pin
sliding
Used in cancellous bone like calcaneum
and osteoporitic bones

Kirschner wire

They are easy to insert and minimize the

chance of soft tissue damage and infections
It easily cuts out of the bone if a heavy
traction weight is applied
Most commonly used in upper limb eg.
Olecranon traction

Application
Follow

regular OT procedures
Use GA or LA
Paint the skin with iodine and spirit
Mount the pin/wire on the hand drill
Hold the limb in same degree of lateral rotation
as the normal limb and with ankle at right
angles.
Identify the site of insertion and make a stab
wound
Hold the pin horizontally at right angles to the
long axis of the limb.

Application
Apply

small cotton woolen pads soaked in

tincture around the pins to seal the wound
The pin should pass only through skin, SC
tissue and bone avoiding muscles and
tendons

Complications

Introduction of infection into bone

Distraction at fracture site
Ligamentous damage
Damage to epiphyseal growth plates
Depressed scars

VARIOUS TRACTIONS

SPINAL TRACTION

Used to treat the unstable spine

Pull along axis of spine
Preserves alignment and volume of canal

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

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

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

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 tspine fx

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

Halo Ring Traction

Two anterior pins

Two posterior pins

Placed in frontal bone

groove
Sup and lat to
supraorbital ridge
Placed posterior and
superior to external ear

Tighten pins to 5-6

inch-pounds with
screwdriver

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 pt out of
bed
Can use plaster
jacket or plastic,
sheepskin lined
jacket

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

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

Halo pelvic traction

To immobilize the spine.

To slowly correct or
reduce the deformities of
the spine such as
scoliosis.

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

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

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

Dunlops 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

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

Lateral Olecranon Traction

Used for humeral

fractures
Arm held in
moderate abduction
Forearm in skin
traction
Excessive weight will
distract fracture

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.

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

Metacarpal pin traction

Point of Insertion: 2-2.5 cms

proximal to the distal end of
2nd metacarpal
Technique: push the 1st
dorsal interosseius muscle
volarly 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 transversly.

Finger traps

Used for distal

forearm reductions
Changing fingers
imparts radial/ulnar
angulation
Can get skin
loss/necrosis
Recommend no more
than 20 minutes

LOWER EXTREMITY TRACTION

Can 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

Bucks Traction

Often used
preoperatively for
femoral fractures
Can use tape or premade boot
No more than 10 lbs
Not used to obtain or
hold reduction

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

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 suprapatellar
pouch, NV structures, and
growth plate in children

Split Russells Traction

Bucks with sling

May be used in more
distal femur fx in
children
Can be modified to
hip and knee
exerciser

Bryants Traction

Useful for treatment

femoral shaft fx in
infant or small child
Combines gallows
traction and Bucks
traction
Raise mattress for
countertraction
Rarely, if ever used
currently

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

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

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

Proximal Tibial Traction

Used for distal 2/3rd femoral

shaft fx

Femoral 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.

Perkins traction:

Treatment of # tibia.
Treatment of # of femur
from the subtrochanter
region and distally.
Trochanteric # of femur
in pts under 45-50yrs
age.
Denham pin is inserted
through upper end of
tibia for # of femur, the
mid tibia for #of
condyles of tibia.

Balanced Suspension with

Pearson Attachment

Enables elevation of
limb to correct
angular
malalignment
Counterweighted
support system
Four suspension
points allow angular
and rotational control

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

Distal Tibial Traction

Useful in certain tibial

plateau fx
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

Calcaneal Traction

Temporary traction for

tibial shaft fx or
calcaneal fx
Insert about 1.5 inches
(4cms) inferior and
posterior to medial
malleolus
Do not skewer subtalar
joint or NV bundle
Maintain slight
elevation leg

MANAGEMENT

Management of patients in
traction

Care of the patient

Care of the traction suspension system
Radiographic examination
Physiotherapy
Removal of traction

The patient

Blood loss
# Tibia
-500-1000ml
#Shaft of Femur-1500-2000ml
#Pelvis
-2000ml
#Humerus
-500-2000ml

Chest complications
Urinary tract
Bowels

The patient
Care of the injured limb Pain
Parasthesia or Numbness
Skin irritation
Swelling
Weakness of ankle, toe, wrist or finger
movement

The traction suspension

system

Bed and Balkan beam

Splints
Slings and padding
Skin traction
Skeletal traction
Stirrups
Cord
Pulleys
Weights

Radiographic examination

2-3 times in first week

Weekly for next 3 weeks
Monthly until union occurs
After each manipulation
After each weight change

Removal of traction

Elbow # with olecranon pin

wks
Tibial # with calcaneal pin
6wks
Trochanteric # of femur
Femoral shaft #
with cast brace
without external support
-12wks

-3
- 3- 6wks
- 6 wks

THANK YOU