application of traction in orthopaedic practice

1. TRACTION IN ORTHOPAEDIC
GEDE MADE OKA RAHADITYA
Orthopaedic and Traumatology Department – Saiful Anwar Hospital, Malang

2. OUTLINES
DEFINITION AND PRINCIPLES
HISTORY
PURPOSE, ADVANTAGES AND DISADVANTAGES
APPLIANCES
TYPE OF TRACTION
SKIN TRACTION
SKELETAL TRACTION
SPECIFIC TRACTION

3. DEFINITION AND PRINCIPLES
raction is the application of a pulling force to a part of the body
“Traction is the application of a pulling
force for medical purposes, to treat muscle or
skeletal disorder - for example, to reduce fracture, maintain
bone alignment, relieve pain, or prevent spinal injury”
“Traction is the application of a force to stretch certain
parts of the body in a specific direction”

4. DEFINITION AND PRINCIPLES
PRINCIPLES
• Provide Counter traction, using the patient’s body or
pull of weights in the opposite direction
.
• Maintain continuous traction in a correct line of pull.
• Prevent friction
• Provide daily traction care

5. HISTORY
• The use of traction dates as far
back as 3000 years (Aztecs and
the ancient Egyptians)
• Hippocrates (350 BC) wrote
about manual traction and the
forces of extension and
counterextension
• Guy de Chauliac (1300 - 1368) :
introduction of continuous
traction

6. HISTORY
Pott’s doctrine
• Most Fracture deformities result
from the contraction of the
surrounding muscles
• Fractured limb should be placed
in the positions in which its
muscles are most relaxed
• Shaft of the femur : flexion of the
hip and the knee

7. PURPOSE, ADVANTAGES AND DISADVANTAGES
• CONTROLS PAIN
• REDUCES FRACTURE
• MAINTAIN REDUCTION
• PREVENTS AND CORRECT DEFORMITY
PURPOSE

8. PURPOSE, ADVANTAGES AND DISADVANTAGES
ADVANTAGES
• Reduce pain
• Minimize muscle spasm
• bone reduce and held by soft tissue
• increase space between opposing surfaces
• allows more joint mobility than plaster

9. PURPOSE, ADVANTAGES AND DISADVANTAGES
DISADVANTAGES
1. Costly in terms of hospital stay
2. Hazards of prolonged bed rest :
• DVT, PE
• Pressure wounds/ulcers
• Pneumonia
3. Requires meticulous nursing care
4. Can develop contractures

10. APPLIANCES
BED AND FRAMES
KNOTS
PULLEYS WEIGHTS

11. APPLIANCES
BED 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

12. APPLIANCES
BED AND FRAMES
• Bradford frame enables bedpan and linen changes
without moving pt
• Alternatively bed can be flexible to allow bending at hip
or knee

13. APPLIANCES
KNOTS
• Ideal knots can be tied with
one hand while holding
weight
• Easy to tie and untie
• Overhand loop knot will not
slip

14. APPLIANCES
KNOTS
• A slip knot tightens under
tension
• Up and over, down and
over, up and through

15. APPLIANCES
KNOTS
• Clover hitch
• Barrel hitch
• Reef knot
• Half hitch
• Two half hitches

16. APPLIANCES
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

17. APPLIANCES
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

18. APPLIANCES
ATTENTION!!!
1. POSITION
2. COUNTERTRACTION
3. FRICTION
4. CONTINOUS
5. LINE OF PULL
6. PROTECTION OF CARDIOVASCULAR SYSTEM
7. MAINTENANCE OF NEUROVASCULAR STATUS
8. SKIN CARE
9. MAINTENANCE OF THE MUSCULOSKELETAL SYSTEM
10.NEVER IGNORE A PATIENT’S COMPLAINT

19. TYPE OF TRACTION
BASED ON PRINCIPLE
1. Fixed Traction
2. Sliding Traction
BASED ON APPLICATION
1. Skin Traction
2. Skeletal Traction

20. TYPE OF TRACTION
BASED ON PRINCIPLE
1. Fixed Traction
Traction is applied to the leg against a fixed point of
counter pressure.
• Fixed traction in Thomas’s splint
• Roger Anderson well-leg traction
• Halo-Pelvic Traction

21. TYPE OF TRACTION
BASED ON PRINCIPLE
Thomas Splint
• Used for fracture shaft of
femur
• Counter traction provided
by ischeal Tuberosity

22. TYPE OF TRACTION
BASED ON PRINCIPLE
When the weight of all or part of the body, acting
under the influence of gravity, is utilized to provide
counter-traction.
2. Sliding Traction

23. SKIN TRACTION
• Traction force is applied over a large area of skin
• Applied over limb distal to fracture site
• Anteromedial and posterolateral part should be
covered with cotton

24. SKIN TRACTION
• Skin damage can result from too much of traction force.
• Maximum weight recommended for skin traction is 6.7 kg
• depending on size and weight of the patient
Weight

25. 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.
Adhesive skin traction

26. SKIN TRACTION
• Useful in thin and atrophic skin
• Frequent reapplication may be necessary
• Attached traction wt. must not be more than 4.5 kgs.
Non adhesive skin traction

27. SKIN TRACTION
• Temporary management of fracture of NOF and IT #
• Management of fracture - Femoral shaft of older and
hefty children
• Undisplaced fracture of acetabulum
• After reduction of dislocation of Hip
• To correct minor fixed flexion deformities of hip and
knee
Indication

28. SKIN TRACTION
• 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
Contraindication

29. SKIN TRACTION
Complication
• Allergic reactions to adhesive
• Excortication of skin
• Pressure sores
• Common peroneal nerve palsy

30. 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

31. SKELETAL TRACTION
• 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
Steinmann Pin

32. SKELETAL TRACTION
• 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

33. SKELETAL TRACTION
• 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
Kirschner wire

34. SKELETAL TRACTION
• 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

35. SKELETAL TRACTION
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

36. SKELETAL TRACTION
• Introduction of infection into bone
• Distraction at fracture site
• Ligamentous damage
• Damage to epiphyseal growth plates
• Depressed scars
Complications

37. • Used to treat the unstable spine
• Pull along axis of spine
• Preserves alignment and volume of canal
SPECIFIC TRACTION
SPINAL TRACTION

38. SPECIFIC TRACTION
SPINAL TRACTION
• 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

39. SPECIFIC TRACTION
SPINAL TRACTION
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

40. SPECIFIC TRACTION
SPINAL TRACTION
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

41. SPECIFIC TRACTION
SPINAL TRACTION
Recommended Weights in Cervical Traction
(Crutchfield)

42. SPECIFIC TRACTION
SPINAL 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
Halo Ring Traction

43. SPECIFIC TRACTION
SPINAL TRACTION
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

44. SPECIFIC TRACTION
SPINAL TRACTION
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

45. SPECIFIC TRACTION
SPINAL TRACTION
• To immobilize the spine.
• To slowly correct or reduce
the deformities of the spine
such as scoliosis.
Halo pelvic traction

46. SPECIFIC TRACTION
• Can treat most fractures
• Requires bed rest
• Usually reserved for comatose or multiply injured
patient or settings where surgery can not be done
UPPER EXTREMITY TRACTION

47. SPECIFIC TRACTION
UPPER EXTREMITY TRACTION
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

48. SPECIFIC TRACTION
UPPER EXTREMITY 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
Double Skin Traction

49. SPECIFIC TRACTION
UPPER EXTREMITY TRACTION
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

50. SPECIFIC TRACTION
UPPER EXTREMITY TRACTION
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

51. SPECIFIC TRACTION
UPPER EXTREMITY TRACTION
• Used for humeral
fractures
• Arm held in moderate
abduction
• Forearm in skin
traction
• Excessive weight will
distract fracture
Lateral Olecranon Traction

52. SPECIFIC TRACTION
UPPER EXTREMITY 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
Olecranon traction

53. SPECIFIC TRACTION
UPPER EXTREMITY TRACTION
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

54. SPECIFIC TRACTION
UPPER EXTREMITY TRACTION
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.

55. SPECIFIC TRACTION
UPPER EXTREMITY TRACTION
Finger traps
• Used for distal forearm
reductions
• Changing fingers imparts
radial/ulnar angulation
• Can get skin loss/necrosis
• Recommend no more than 20
minutes

56. SPECIFIC TRACTION
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

57. SPECIFIC TRACTION
LOWER EXTREMITY 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
Buck’s Traction

58. SPECIFIC TRACTION
LOWER EXTREMITY TRACTION
• Several traction options for
acetabular fractures
• Lateral traction for fractures
with medial or anterior force
• Stretched capsule and
ligamentum may reduce
acetabular fragments
Upper Femoral Traction

59. SPECIFIC TRACTION
LOWER EXTREMITY TRACTION
• 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
Femoral Traction Pin

60. SPECIFIC TRACTION
LOWER EXTREMITY TRACTION
• Buck’s with sling
• May be used in more distal
femur fx in children
• Can be modified to hip and
knee exerciser
Split Russell’s Traction

61. SPECIFIC TRACTION
LOWER EXTREMITY 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
Bryant’s Traction

62. SPECIFIC TRACTION
LOWER EXTREMITY TRACTION
• Useful for subtroch and proximal
3rd femur fx
• Especially in young children
• Matches flexion of proximal
fragment
• Can cause flexion contracture in
adult
90-90 Traction

63. SPECIFIC TRACTION
LOWER EXTREMITY TRACTION
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

64. SPECIFIC TRACTION
LOWER EXTREMITY TRACTION
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

65. SPECIFIC TRACTION
LOWER EXTREMITY 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.
Proximal Tibial Traction

66. SPECIFIC TRACTION
LOWER EXTREMITY TRACTION
• Treatment of Fr tibia.
• Treatment of Fr of femur
from the subtrochanter
region and distally.
• Trochanteric Fr of femur
in pts under 45-50yrs age.
• Denham pin is inserted
through upper end of tibia
for fr of femur, the mid tibia
for fr of condyles of tibia.
Perkin’s traction:

67. SPECIFIC TRACTION
LOWER EXTREMITY TRACTION
Balanced Suspension with Pearson Attachment
• Enables elevation of limb to
correct angular
malalignment
• Counterweighted support
system
• Four suspension points
allow angular and rotational
control

68. SPECIFIC TRACTION
LOWER EXTREMITY TRACTION
• 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
Pearson Attachment

69. SPECIFIC TRACTION
LOWER EXTREMITY 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
Distal Tibial Traction

70. SPECIFIC TRACTION
LOWER EXTREMITY 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
• Maintain slight elevation leg
Calcaneal Traction

71. THANK YOU