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Orthopaedic and Traumatology Departement

Textbook Reading July 2013

UPPER AND LOWER EXTREMITY TRACTION IN ORTHOPAEDIC

Presented By Ahmad Ramdhani Amir Mahafendy S. Tukan Nur Afeeza Emil Kardani Henry Liemer Wijaya Advisor Dr. Hendrian Chaniago Dr. Harianto Simbolon Dr. Luthfi Muammar SUpervisor
MEDICAL FACULTY OF HASANUDDIN UNIVERSITY MAKASSAR 2013

Introduction
Inflamation of the joint or fractured bone can

cause painful limb thus can result muscle spasm Purpose of traction is
To relive pain and allow the limb to be rested To immobilize a joint or part of the body
To prevent or reduce muscle spasm

Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

Methods of Applying Traction

Skin Traction

Skeletal Traction

SKIN TRACTION

Skin Traction
The force is applied over the large area of skin

Load spreading, more comfortable and efficient


The traction force must be applied to the limb

distal to the fracture site, otherwise the efficiency of the traction force is reduced

Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

Skin Traction
Adhesive
Strapping can only stretched transversely Limited force max.15 lb (6.7kg) Elastoplast Skin Traction Kit, Tractac, Seton Skin Traction Kit, Orthotrac, and Skin-Trac

Non adhesive
The grip is less secure Frequent reapplications may be necessary Limited force max.10 lb (4.5kg) Ventfoam Skin Traction Bandage, Specialist Foam Traction, and Notac Trantion

Skin Traction
Adhesive Non adhesive

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
Brooker AF, Schmeisser G. Orthopaedic Traction Manual. 1980. London: Williams & Wilkins

Contraindications
Impairment of circulation

Dermatitis
Abrasions of the skin Laceration of the skin in the area to which the

traction to be applied

Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

Complications
Excoriating of the skin from slipping of the

adhesive strapping Common peroneal nerve palsy Pressure sores around the malleoli and over the tendocalcaneus Allergic reaction to adhesive

Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

SKELETAL TRACTION

Skeletal Traction
A metal pin or wire is driven through the bone in

skeletal traction Freaquently used in the management of lower limb fractures

Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

Types of pin used


Types of pin Steinmann pin Discription Rigid stainless pins of varying lenghts, 4-6mm in diameter Bohler stirrup is applied so that the direction of the traction to be varied without turning the pin in the bone Identical to a Steinmann pin except for a short raised threaded length situated toward the end held in the introducer The threaded length engage the bony cortex and reduces the risk of the pin sliding Suitable for use in cancellous bone (eg. Calcaneus , osteoporotic bone) Small diameter Insufficiently rigid until pulled taut in a special stirrup Rotation of the stirrup is impared to the wire The wire easily cuts Hallet, out of the if the heavy traction Stewart, JDM. JP. bone Traction and Orthopaedic weight Appliances. is applied 2nd ed. London : Churchill Livingstone

Denham pin

Kirschner wire

Bohler stirrup with Steinmann pin

Kirschner wire strainer

Denham pin

Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

Common sites for application of skeletal traction


OLECRANON Just deep to the subcutaneous border of the upper end of the ulna, 1 inches (3,0 cm) distal to the tip of the olecranon Avoid elbow joint Drive the Kirschner wire from medial to lateral at right angles to the Position for K-wire in olecranon longitudinal axis of the ulna Brooker AF, Schmeisser G. Orthopaedic Traction Avoid the ulnar nerve.
Manual. 1980. London: Williams & Wilkins

Common sites for application of skeletal traction


SECOND AND THRID METACARPALS
The point of insertion

of the Kirschner wire is s -1 inch (2,0 2,5cm) proximal to the distal end of the second metacarpal The wire traverses the second and the third metacarpal Position for K-wire in second and third metacarpal transversely to lie at right angles to the Brooker AF, Schmeisser G. Orthopaedic Traction Manual. 1980. London: Williams & Wilkins longitudinal axis of

Common sites for application of skeletal traction


Upper end of femur greater trochenter
The lateral surface of

the femur, 1 inch (2,5 cm) below the most prominent part of the greater trochanter, mid-way between the anterior and posterior surface of the femur.

Position for screw eye in upper end of femur for lateral femoral traction

Brooker AF, Schmeisser G. Orthopaedic Traction Manual. 1980. London: Williams & Wilkins

Common sites for application of skeletal traction


LOWER END OF FEMUR Predisposes to knee stiffness from fibrosis in the extensor mechanism of the knee Steinmann pin through the lower end of the femur must be removed after two to three weeks and be replaced by one through the upper end of tibia UPPER END OF TIBIA The point insertion is inch (2,0 cm) behind the crest, just below the level of tubercle of the tibia The pin should be driven from the lateral to the medial side of the limb to avoid damage to the common peroneal nerve
Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

Position for Steinmann pin in lower end of femur and upper end of tibia

Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

Common sites for application of skeletal traction


LOWER END OF TIBIA The point of insertion is 2 inches (5,0 cm) above the level of the ankle joint, midway between the posterior and anterior borders of the tibia

CALCANEUS The point insertion is inch (2,0 cm) below and behind th lateral malleolus. (as the lateral malleolus lies inch more posterior and distal than the medial malleolus, the above point correspondens with that 1 inches below and behind the malleolus. Care must be taken to avoid entering the subtalar join Stewart, JDM. Hallet, JP. Traction and Orthopaedic
Appliances. 2nd ed. London : Churchill Livingstone

Position for Steinmann pin in lower end of tibia and calcaneus Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

The limb must be held in the same degree of lateral rotation as the normal limb; the Steinmann pin lies horizontally

The steinmann pin is inserted at right angles to the longitudinal axis of the limb

Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

Complications
Introduction of infection into bone 2. Incorrect placement of the pin or wire may - Allow the pin or wire to cut out of the bone causing pain and the failure of the traction system - Make control of rotation of the limb difficult - Make the application of splint difficult
1.

Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

Complications
Distraction at the fracture site as very large traction force can be applied through skeletal traction 4. Ligamentous damage if a large traction force is applied through a joint for a prolonged period of time 5. Damage to epiphyseal growth plate when use in children 6. Depressed scar
3.
Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

UPPER EXTREMITY TRACTION

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

Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

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
Brooker AF, Schmeisser G. Orthopaedic Traction Manual. 1980. London: Williams & Wilkins

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 Brooker AF, Schmeisser G. Orthopaedic Traction antecubital fossa
Manual. 1980. London: Williams & Wilkins

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 Brooker AF, Schmeisser G. Orthopaedic Traction
Manual. 1980. London: Williams & Wilkins

LOWER EXTREMITY 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

Stewart, JDM. Hallet, JP. Traction and Orthopaedic Appliances. 2nd ed. London : Churchill Livingstone

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
Brooker AF, Schmeisser G. Orthopaedic Traction Manual. 1980. London: Williams & Wilkins

Split Russells Traction


Bucks with sling May be used in more

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

Brooker AF, Schmeisser G. Orthopaedic Traction Manual. 1980. London: Williams & Wilkins

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 Brooker AF, Schmeisser G. Orthopaedic Traction currently
Manual. 1980. London: Williams & Wilkins

90-90 Traction
Useful for subtroch and

proximal 3rd femur fracture Especially in young children Matches flexion of proximal fragment Can cause flexion contracture in adult
Brooker AF, Schmeisser G. Orthopaedic Traction Manual. 1980. London: Williams & Wilkins

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
Brooker AF, Schmeisser G. Orthopaedic Traction Manual. 1980. London: Williams & Wilkins

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
Brooker AF, Schmeisser G. Orthopaedic Traction Manual. 1980. London: Williams & Wilkins

THANK YOU

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