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doi 10.

1308/003588405X50976
The Royal College of Surgeons of England

Bruce Campbell, Section Editor

Technical Section
Technical Tutorial
Surgical tracheostomy how I do it
JP PRACY, JC WATKINSON

TECHNICAL TUTORIAL, NOTES, AND TIPS

Head & Neck Office, The Queen Elizabeth Hospital, Birmingham, UK


CORRESPONDENCE TO:

Mr JC Watkinson, Consultant Otolaryngologist, Head & Neck Office, The Queen Elizabeth Hospital, East Ward 5, Edgbaston, Birmingham B15 2TH, UK T/F: +44 (0)121 697 8371; E: john.watkinson@uhb.nhs.uk

There is no clear evidence in the literature of an advantage of either surgical or percutaneous tracheostomy in this setting. Those who are for percutaneous tracheostomy argue that there is a lower complication rate for percutaneous techniques. This assertion is not borne out by the literature. For all tracheostomies, the complication rates are low and the complications tend to be minor (bleeding, wound infection), for percutaneous tracheostomies the complications tend to be peri-operative and for surgical tracheostomies they tend to be postoperative.5 Unfortunately, the literature on tracheostomy over the past 1015 years has been dominated by discussions concerning the percutaneous tracheostomy and the complication rates quoted for surgical tracheostomy are usually taken from publications which are 20 or even 40 years old.810 Part of another procedure A permanent tracheostomy, where the upper trachea is divided from the larynx and brought to the surface of the skin as an end tracheostome, is an integral part of laryngectomy and pharyngolaryngectomy. However, a temporary tracheostomy is an essential part of procedures which may result in a significant degree of postoperative swelling with a consequent risk of upper airway obstruction. The tracheostomy not only provides protection against airway obstruction secondary to swelling, but also against aspiration of blood in the event of a postoperative haemorrhage. Removal of secretions Accumulating secretions in the lower airways can cause a deterioration in gas exchange in the alveoli and result in respiratory failure. Secretions are more easily aspirated via a tracheostomy and the reduction in dead space reduces the work of breathing. These aims can be achieved by the use of a minitracheostomy via a cricothyroidotomy. However, this has little advantage over a percutaneous tracheostomy or surgical tracheostomy and may result in more problems as a result of a smaller luminal diameter and the proximity of the tube to the subglottic area which may predispose to the development of subglottic stenosis if the mini-tracheostomy tube is left in situ for even a slightly prolonged period. Upper airway obstruction Upper airway obstruction is no longer the commonest reason for a tracheostomy. The development of such techniques as fibre-optic intubation and the use of oesophageal airways mean that a tracheostomy is rarely the first option for a patient with upper airway obstruction. However, it should always be remembered

INTRODUCTION

Tracheostomy is one of the oldest surgical procedures1 and is included in many of the ancient medical texts.2 Before the end of the 19th century with the improvements in anaesthesia and antisepsis, it was an extremely hazardous procedure and was performed only in extremis. Chevalier Jackson described the principles of the operation at the beginning of the 20th century and these have remained to the present day.3 While improvements in endotracheal tube technology have increased the number of airway problems that can be managed by nasotracheal and orotracheal intubation, tracheostomy remains the gold standard in the surgical management of upper airway obstruction.4 Tracheotomy is the term used to describe the surgical opening of the trachea while tracheostomy refers to the creation of a stoma at the surface of the skin which leads into the trachea.
INDICATIONS

Prolonged ventilation For those patients who require prolonged, continuous or intermittent positive pressure ventilation, tracheostomy provides the safest means of assisting ventilation. A tracheostomy tube is more secure than either an orotracheal or nasotracheal tube. The majority of tracheostomies carried out for this indication are now done using a percutaneous technique. There are a number of different techniques, the safest of which is the dilatation technique under bronchoscopic control.57 Percutaneous tracheostomy should only be carried out by someone well trained in the technique and is not suitable for patients with bleeding disorders, patients who have had a previous tracheostomy or in patients who have unfavourable neck anatomy due to obesity, cervical spine problems, thyroid goitre or prior major neck surgery.

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that other forms of intervention may precipitate a sudden deterioration in the airway with the need for an emergency tracheostomy. Percutaneous tracheostomy is contra-indicated in cases of upper airway obstruction. A cricothyroidotomy is an effective means of gaining rapid control of the airway in case of complete obstruction. The airway can then be maintained for a short period of time using a wide-bore intravenous cannula or a mini-tracheostomy tube. The patient should be taken to theatre immediately for a formal surgical tracheostomy.
SURGICAL TECHNIQUE

The procedure should, whenever possible, be carried out under sterile conditions in an operating theatre. There will, however, be times when compromises need to be made. The procedure can be carried out at the bedside although the width of the bed means that access to the patient is usually not as good as when the patient is on an operating table. If intubation is not possible or is deemed too hazardous, then the procedure can be carried out under local anaesthetic. The patient should be positioned supine on the operating table with a sandbag under the shoulders to aid neck extension. It is very important at this stage to ensure that the patients shoulders are square on the operating table so that the position of the midline structures of the neck is maintained throughout the procedure. If neck extension provokes a worsening of the airway obstruction, then a compromise position may have to be adopted. It is useful to mark the surface anatomy on the skin to highlight the position of the lower border of the cricoid cartilage and the suprasternal notch (Fig. 1). The horizontal incision is sited midway between these landmarks. It is useful to infiltrate the incision with adrenaline to aid haemostasis. In an emergency case, a vertical midline incision may be employed to gain rapid control of the airway by cutting straight down onto the tracheal wall. The skin and subcutaneous tissues are divided horizontally to the depth of the strap muscles. The strap muscles are separated in the

Figure 2 The tracheal wall is visible following division and ligation of the thyroid isthmus.

Figure 1 The skin incision is sited midway between the sternal notch and the lower border of the cricoid cartilage.

midline and retracted laterally. At this point, it should be possible to identify the thyroid isthmus which should be divided between clamps and the ends over-sewn. Retraction of the isthmus should be discouraged as it may interfere with replacement of an accidentally dislodged tube. Once the thyroid isthmus has been divided, the tracheal wall should be visible (Fig. 2). It is useful to palpate the cricoid cartilage and count the tracheal rings to determine the best place to make a tracheotomy. Before opening the trachea, it is the responsibility of the surgeon to select an appropriate tracheostomy tube, to check that the cuff will inflate, and that all of the supplied connectors are compatible with the anaesthetic equipment. Once the surgeon is satisfied, the anaesthetist should be informed that the trachea is about to be opened. In general, the tracheotomy should be made through the 2nd to 4th tracheal rings. A higher incision, particularly if it involves trauma to the cricoid cartilage, may predispose to subglottic stenosis. The incision should cause as little disruption to the tracheal cartilages as possible. A midline vertical incision between silk-stay sutures is ideal. The stay sutures allow the trachea to be held open if the tube needs to be resited prior to the formation of

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a good track and the tracheal wall can be pulled up close to the skin surface to facilitate a tube change. When a window of cartilage is removed, there is a risk of inducing either tracheal stenosis or tracheomalacia. Superiorly or inferiorly based flaps such as the Bjork flap designed to aid tube changes should also be avoided as they may flick back into the stoma and cause obstruction during a tube change. Prior to the trachea being opened, the anaesthetist should remove any tapes used to secure the endotracheal tube so that the tube can be withdrawn smoothly under instruction from the surgeon. It is vital that the anaesthetist and surgeon work together to ensure that the tracheostomy tube is correctly sited before the endotracheal tube has been fully withdrawn. If there are problems in inserting the tracheostomy tube, the endotracheal tube can be pushed down the trachea past the site of the tracheotomy and ventilation continued without any upset to the patient. Once the tracheostomy tube has been correctly placed, the endotracheal tube is removed and the ventilator is connected to the tracheostomy tube. The incision should be closed loosely, to prevent the formation of surgical emphysema and the tracheostomy tube should be sutured in position.
POSTOPERATIVE MANAGEMENT

References
1. Frost EAM. Tracing the tracheostomy. Ann Otolaryngol 1976; 85: 61824. 2. Porter R. Medicine and faith. In: The Greatest Benefit to Mankind. London: Fontana, 1997; 83105. 3. Jackson C. Tracheostomy. Laryngoscope 1909; 19: 28590. 4. Weymuller E. Acute airway management. In: Cummings CW et al. (eds) Otolaryngology Head and Neck Surgery. St Louis, MO: Mosby, 1998; 236881. 5. Gysin C, Dulguerov P, Guyot J-P, Perneger TV, Abajo B, Chevrolet J-C. Percutaneous versus surgical tracheostomy. Ann Surg 1999; 230: 70814. 6. Winkler WB, Karnik R, Seelmann O, Havlicek J, Slany J. Bedside percutaneous dilatational tracheostomy with endoscopic guidance: experience with 71 ICU patients. Intensive Care Med 1994; 20: 4769. 7. Nates JL, Cooper J, Myles PS, Scheinkestel CD, Tuxen DV. Percutaneous tracheostomy in critically ill patients: a prospective, randomized comparison of two techniques. Crit Care Med 2000; 28: 37349. 8. Friedman Y, Mayer AD. Bedside percutaneous tracheostomy in critically ill patients. Chest 1993; 104: 5325. 9. Friedman Y, Fides J, Mizock B et al. Comparison of percutaneous and surgical tracheostomies. Chest 1996; 110: 4805. 10. Gaukroger MC, Allt-Graham J. Percutaneous dilatational tracheostomy. Br J Oral Maxillofac Surg 1994; 32: 3759.

When a patient returns to the ward following a tracheostomy, they will require specialist nursing from a nurse who is familiar with the problems encountered by the tracheostomy patient. The patient should have been told about their inability to talk in the immediate postoperative period and writing materials should be available. Under normal circumstances, the nose and pharynx are responsible for warming and humidifying inspired air before it reaches the trachea. Following tracheostomy, the trachea is directly exposed to environmental air which is cold and contains particulate matter; this results in irritation of the tracheal mucosa and consequent increased production and viscosity of secretions. The use of warm water-bath humidification or nebulisers helps to prevent crust formation. In the early postoperative period, the patient will require frequent suction to clear secretions. However, as the trachea becomes acclimatised to the presence of a tracheostomy tube and the patient learns to cough secretions out through the tube, this need will diminish. It should be noted that, even when the patient appears to be coping well with the secretions, there is still a need for suction equipment to be available and for vigilance by the nursing staff to ensure scrupulous cleanliness of the tube to prevent the formation of crusts which may obstruct the tube resulting in airway obstruction. The cuff on the tube should remain inflated for as long as there is a risk of aspiration; in practice, most uncomplicated patients will only need the cuff inflated for the first 12 h to prevent blood from running down into the lungs. The tracheostomy tube should be secured with sutures until the first tube change has taken place. At the first tube change the wound sutures can be removed and the tube should be secured with tapes.

Technical Notes
A model for training in grommet insertion
PRANAY KUMAR SINGH, MRIGANKA DE, RICHARD VAUGHAN-JONES

Worcestershire Royal Hospital, Worcester, UK


CORRESPONDENCE TO

Mr PK Singh, Worcestershire Royal Hospital, Charles Hastings Way, Worcester WR5 1BD, UK T: +44 (0)1634 817823; M: +44 (0)7866 473224; F: +44 (0)1634 316841; E: pranay_singh@hotmail.com

BACKGROUND

Aural ventilation tubes, such as grommets and t-tubes, are frequently inserted for the treatment of chronic otitis media with effusion. It is a relatively safe and simple procedure and so is frequently performed by junior trainees. However, it can be technically challenging for the inexperienced junior. We describe a simple model to practice grommet insertion using equipment available in theatre.
TECHNIQUE

The key material required is the container of the grommet. Universal Shah Grommets come in a container comprising two cylindrical tubes with different diameter lumens (Fig. 1). This can be used to represent the middle ear. Clear adhesive tape is applied over the end of the tube, replicating the tympanic membrane. Further adhesive tape is then applied around the

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References

1. Baer S, Williams H, McCombe A. A model for instruction in myringotomy and grommet insertion. Clin Otolaryngol 1990; 15: 282384. 2. Owa AO, Farrell RWR. Simple model for teaching myringotomy and aural ventilation tube insertion. J Laryngol Otol 1998; 112: 6423.

Intra-operative femoral nerve stimulation as an aid in tibial tuberosity transfer


M LOGAN, A WILLIAMS

Chelsea & Westminster Hospital, London, UK


CORRESPONDENCE TO:

Mr A Williams, Chelsea & Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK E: andywilliamsortho@hotmail.com

BACKGROUND

Successful re-alignment surgery for patellofemoral instability requires precise transfer of the extensor mechanism.1 Recurrent instability is common.25 A cause for this is inadequate medialisation of the tibial tuberosity. Another is excessive medialisation, which can lead to medial patellar instability, which is often disastrous. A technique is described to aid optimal tibial tuberosity placement.
TECHNIQUE

3
Figures 13

circumference, replicating the external auditory canal. Having two tubes of differing diameter allows the trainee to initially practice with the larger diameter tube, followed by the narrow one (Figs 2 and 3). These diameters resemble adult and paediatric ear canals. This model ear can be mounted in plasticine to secure it to a work surface. Once it has been assembled, grommet or ttube insertion can be practiced in theatre using standard myringotomy equipment and operating microscope.
DISCUSSION

Under general anaesthetic without muscle relaxation, a 22-G electrode needle is inserted into the appropriate groin, under aseptic conditions, to stimulate the femoral nerve via a nerve stimulator. The circuit is completed by attaching an electrode plate to the lateral side of the thigh (Fig. 1). Beware excess hip flexion, which may later displace the needle. When the tibial tuberosity has been mobilised, it is transferred medially according to pre-operative planning. It is temporarily fixed in this position with a stout Kirschner wire. Whilst the knee is flexed 30, to engage the patella in the trochlea groove, and the tibia is in neutral rotation, the femoral nerve is stimulated (0.5 mA). (Note: excessive quadriceps stimulation risks pulling off the tibial tuberosity

Myringotomy and grommet insertion is technically challenging for inexperienced surgeons but there are no simple commercially available teaching models. Whilst other models have been described in the literature,1,2 the authors believe this to be the simplest and most versatile, and makes use of equipment already in use for grommet insertion.

Figure 1 Nerve stimulator inserted in the appropriate groin (arrow) with electrode plate on the same thigh completing the circuit.

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despite K-wire fixation). The consequent quadriceps activation pulls on the patella and its resultant mediolateral displacement as it moves proximally can be assessed. Apart from visual observation, holding the medial and lateral sides of the patella lightly between forefinger and thumb gives a good assessment of net tracking. Accordingly, the tibial tuberosity transfer position can be adjusted. The needle in the groin may be used to instil local anaesthetic to provide postoperative analgesia.

References
1. Kettelkamp DB. Management of patellar malalignment. J Bone Joint Surg Br 1981; 63: 13448. 2. Aglietti P, Buzzi R, Insall JN. Disorders of the patellofemoral joint. In: Insall JN, Windsor RE, Scott WN, Kelly MA, Aglietti P. (eds) Surgery of the Knee. New York: Churchill Livingstone, 1993; 241386 3. Kumar A, Jones S, Bickerstaff DR, Smith TW. Functional evaluation of the modified ElmslieTrillat procedure for patello-femoral dysfunction. Knee 2001; 8: 28792. 4. Morshuis WJ, Pavlov PW, de Rooy KP. Anteromedialisation of the tibial tuberosity in the treatment of patellofemoral pain and malalignment. Clin Orthop 1990; 255: 24250. 5. Shelboume KD, Porter DA, Rozzi W. Use of a modified ElmslieTrillat procedure to improve abnormal patellar congruence angle. Am J Sports Med 1994; 22: 31823.

Figure 1 Hold the pin in the Yankeur sucker to get an unobstructed and safe X-ray to create the centre punch.

centre punch. This is passed through a Yankeur sucker to reduce radiation exposure2 of the surgeons hands (Fig. 1). The tip of the pin is centred in the nail hole, tapped into bone, then carefully brought parallel to the X-ray beam. The pin is screened, and then tapped more forcibly to make a cortical depression. The tip of the drill is placed in the depression, screened, then brought up parallel with the X-ray beam. One cortex is partially drilled, the drill is removed from the chuck; screening confirms drill position. The drill is re-attached and drilling completed. The hole is measured and a screw inserted.

A user-friendly technique for distal locking of intramedullary nails


A ROCHE, M MANNING

Discussion This technique gives the operator an unobstructed view of the distal holes to allow safe and accurate placement of the Steinmann pin to create the centre punch for drill guidance.

Department of Orthopaedics and Trauma, St Helens and Knowsley NHS Trust, Whiston, Merseyside, UK
CORRESPONDENCE TO

Mr A Roche, Orthopaedic Department, Royal Liverpool Childrens NHS Trust, Eaton Road, Liverpool L12 2AP, UK T: +44 (0)151 228 4811; M: +44 (0)7769 678855; E: andyroche@hotmail.com

References
1. Keenan J, Stitson D, Charnley GJ. McIndoes scissors a simple technique to aid distal locking of an intramedullary nail. Ann R Coll Surg Engl 2000; 82: 1434. 2. Madan S, Blakeway C. Radiation exposure to patient in intramedullary nailing of the lower limb. Injury 2002; 33: 7237.

BACKGROUND

A simple, safe and effective method of image intensifier-assisted distal locking using the centre punch principle is described.
TECHNIQUE

The Multi-functional Surgical Device


R RAGOOWANSI, J MANUSHAKIAN

This technique can be used for distal locking of any long bone. Just as in the standard technique employing radiolucent drivers, the C-arm is positioned to show the distal nail hole as a perfect circle. The long-looped handle of a bone lever or scissors1 is placed over the hole in the nail, and screened to centre the hole in the loop. An accurate skin incision is made. Blunt dissection proceeds to bone. A cruciate incision in the fascia lata allows passage of the pin and drill. When drilling metal, an engineer will first make a small depression with a centre punch. The drill then sits in the small depression, and does not wander as it bites. We employ a Steinmann pin as a

Department of Plastic & Reconstructive Surgery, University College London, London, UK


CORRESPONDENCE TO

Mr R Ragoowansi, 70 St Johns Wood Court, St Johns Wood Road, London NW8 8QS, UK M: +44 (0)7775 712739; E: pragoowans@aol.com

BACKGROUND

The design of the Multi-functional Surgical Device (MFSD) incorporates three (scalpel, biploar diathermy and sucker) well-

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Technical Tips
Innovative suction apparatus: two low-cost techniques for non-industrialised countries
PJ SHANKAR, A SAKLANI

Department of Surgery, Trafford General Hospital, Manchester, UK


CORRESPONDENCE TO

Mr PJ Shankar E: jothi65@hotmail.com

Figure 1 A prototype of the Multi-functional Surgical Device.

tested and familiar instruments into a single device. The instrument has been tested successfully on fresh specimens from scar-revisions and excision of full-thickness burns.
TECHNIQUE

Suction drains are used to drain small collections of fluid and blood and they usually stay in for about 2448 h. Commercially available drains may be sterile but expensive to use in this setting.
TECHNIQUE 1

The basis of the MFSD (Fig. 1) is a pair of Teflon-insulated stainless steel forceps. The copper connectors at their proximal ends provide the connection to a bipolar electrical power supply. At their tips, the forceps arms are uninsulated such that the passage of a current between the two arms allows bipolar cautery. One of the forceps arms has a recessed area in which is mounted a blade-holder. The other forceps arm has a suction tube implanted within it. On the inner aspect of each forceps arm is a locking device. When both the arms of the MFSD are firmly pressed together, the locking mechanism engages. This brings the tips of the forceps in contact with each other and, therefore, no current can pass through the tissues. This allows the forceps arms to act as a scalpel handle and a sucker. In order for the device to be used as cautery, it is necessary to rotate the MFSD through 180. This brings the sharp end of the scalpel pointing upwards and away from the tissues to be cauterised. The arms of the forceps are pressed together firmly and this disengages the locking mechanism. The forceps tips are apart and the instrument can be used for bipolar coagulation.
FOOTNOTE

Requirements: infant feeding tube (drain); 20-cc syringe; a needle cap/piston of an insulin syringe. A vacuum drain is fashioned using a 20-cc syringe. The syringe is connected using luer-lock/three-way to an infant feeding tube in the wound. The piston is withdrawn to the maximum limit thereby creating a negative pressure equivalent to its volume. The needle cover/piston of an insulin syringe is placed between the flange of the syringe and the end of the withdrawn piston. This helps to maintain the position of the piston and a negative pressure equivalent to 1520 cmH2O. This procedure can be repeated after emptying the syringe through a three-way tap. This is cheap and convenient as it is small enough to be carried in a pocket.

The device is available in the UK from M&W International Instrument Manufacturers, London, UK

Figure 1 Illustration of Technique 1.

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TECHNIQUE 2

ACKNOWLEDGEMENT

Requirements: an empty 30-ml vial with the rubber bung and seal intact; a butterfly set (drain); a 10-cc syringe and needle. Vacuum is created in the vial by aspirating air out of it using the 10-cc syringe and needle. The tube end of the butterfly set acts as the drainage tube and it sits in the cavity to be suctioned; a few tiny holes can be fashioned on the tube to aid better drainage. The needle tip is introduced into the vial and maintained in position using adhesive tape. This acts as an excellent suction drain. Further suction can be maintained as and when required by aspirating air out of the vial. We have used these type of suction devices to aid drainage in postoperative cavities such as following subcutaneous lipoma excision, parotid/submandibular salivary gland excision and in hernia repairs.

We thank Vital Signs Inc. UK (314 Eldon Way, Lineside Industrial Estate, Littlehampton, West Sussex BN17 7HE, UK) for authorising the illustration of their infusor bag.

A simple technique to maintain fracture reduction and facilitate application of longarm plaster in fractures of forearm bones
PRASHANT KANABAR

Department of Trauma and Orthopaedics, Luton and Dunstable Hospital, Luton, UK


CORRESPONDENCE TO

An alternative use of pressure infusor in thyroid surgery


ALTAF K AWAN, CHARANJEIT S UBHI

Mr P Kanabar, 125 Fordwich Rise, Hertford SG14 2DF, UK T: +44 (0)1582 498512; F: +44 (0)1582 497403; E: prashantkanabar @hotmail.com

Department of General and Endocrine Surgery, Nottingham City Hospital, Nottingham, UK


CORRESPONDENCE TO

Mr AK Awan, Department of General Surgery, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB; UK M: +44 (0)7759 292479; F: +44 (0)115 9627764; E: akawan@doctors.org.uk

Extension of the neck in thyroid/parathyroid surgery is traditionally accomplished by placing a sandbag beneath the shoulders. We describe use of a pressure infusor (Vital Signs Inc., West Sussex, UK), which is technically easier, safe and convenient. The pressure infusor (Fig. 1) is checked for any leakage and is placed under the patient's shoulders. After inflation, the valve is moved to the locked position to prevent decompression. Prior to closure of the deep cervical fascia, the bag is deflated to help apposition of platysma and skin. Neck extension is achieved without unnecessary movement and the degree of inflation can be adjusted.

Closed reduction and long-arm plaster application are the treatment of choice for the majority of fractures of shaft of radius and ulna in children. Maintaining the reduction of unstable fractures while applying the plaster can be difficult even with the help of two assistants. This is particularly so out-of-hours, when the surgeon is short of assistants and is inexperienced. Applying a cotton bandage around distal part of the upper arm and tying it to the leg of a footstool will negate the need for a second assistant. The assistant applies the traction by pulling vertically on the fingers and thumb with patient's shoulder abducted and elbow flexed to 90. The counter traction is applied by the bandage applied around the upper arm and tied to the leg of the stool, which is held in place by the assistant standing on the stool (Fig. 1). This technique also allows easy access for image intensifier to check the reduction. The plaster is applied while the assistant maintains the fracture reduction by applying traction. Once the plaster is set, the bandage is cut on one side and is pulled out. Application of the bandage for a short period, while plaster is applied, does not cause any ill effects to the soft tissue structures. This simple technique helps maintain the reduction of fracture and application of plaster.

Figure 1 Vital Signs Inc. pressure infusor.

Figure 1 Assistant maintaining fracture reduction by applying traction.

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