Application of Traction in

Orthopaedics

By- Prabhnoor Singh Hayer

Moderated by- Dr. Rajesh Maheshwari

Definition

Traction is the application of a

pulling force to a part of the body

History
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

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

Indications
To reduce the fracture or dislocation
To maintain the reduction
To correct the deformity
To reduce the muscle spasm

Types Based On Method Of

Application
Skin traction
The traction force is applied over a large area of skin
Adhesive
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
or Kirschner wire)

Types Based On
Mechanism
Fixed Traction
By applying force against a fixed point of body.

Sliding Traction
By tilting bed so that patient tends to slide in
opposite direction to traction force

Advantages of Traction
Decrease pain
Minimize muscle spasms
Reduces, aligns, and immobilizes fractures
Reduce deformity
Increase space between opposing surfaces

Disadvantages of Traction
Costly in terms of hospital stay
Hazards of prolonged bed rest
Thromboembolism
Decubiti
Pneumonia

Requires meticulous nursing care

Can develop contractures

The Traction Suspension

System
Bed and Balkan beam
Splints- Thomas splint, Bohler-Braun frame, Fisk Splint
Slings and padding
Skin traction
Skeletal traction- Steinmann pin, Denham pin or Kirschner wire
Bohler Stirrup
Cord
Pulleys
Weights

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

Skin traction

Skin traction

Bucks Traction or Extension

Used in temporary
management of
fractures of

Femoral neck
Femoral shaft in older children
Undisplaced fractures of the
acetabulum
After reduction of a hip
dislocation
To correct minor flexed
deformities of the hip or knee
In place of pelvic traction in
management of low back pain

Can use tape or pre-

made boot
Not more than 4.5 kgs
Not used to obtain or
hold reduction

Hamilton Russell Traction

Bucks with sling
May be used in more
distal femur fracture
in children

Can be modified to
hip and knee
exerciser

Bryants Traction
Useful for treatment of
femoral shaft fracture
in infant or small child

Combines gallows
traction and Bucks
traction

Raise mattress for

counter traction

Rarely used currently

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 proximal
humeral shaft fracture

Arm abducted 30
degrees

Elbow flexed 90
degrees

Risk of ischemia at
antecubital fossa a

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 at 45
degrees

Finger traps
Used for distal
forearm reductions

Changing fingers
imparts radial/ulnar
angulation

Can get skin

loss/necrosis

Recommend no more
than 20 minutes

Head Halter traction

Simple type cervical
traction

Management of neck
pain

Weight should not

exceed 2.3 kg

Can only be used a

few hours at a time

Contraindications
Abrasions and lacerations of skin in the area to
which traction is to be applied

Impairment of circulation - Varicose veins,

impending gangrene

Dermatitis
When there is marked shortening of the bony
fragments, the traction weight required will be
more then 6.7 kg which cannot be applied through
the skin

Complications
Allergic reactions to adhesive
Excortication of skin
Pressure sores around the malleoli and over the
tendo calcaneus

Common peroneal nerve palsy

Skeletal Traction

Indications
It should be reserved for those cases in which skin
traction is contraindicated

In patients with lacerated wounds

In patients with external fixator in situ
When the weight required for traction is more then
6.5 kgs- Obese patients

Proximal Tibial Traction

Used for distal 2/3rd

femoral shaft fractures

Tibial 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.

Upper Femoral Traction

Lateral traction for
fractures with medial
or anterior force

Stretched capsule
and ligamentum
teres 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 NV structures
and growth plate in
children

Distal Femoral Traction

Alignment of traction
along axis of femur

Used for superior

force acetabular
fracture and femoral
shaft fracture

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

Ninety-Ninety Traction
Useful for

subtrochantric and
proximal 3rd femur
fracture

Especially in young
children

Matches flexion of

proximal fragment

Can cause flexion

contracture in adult

Perkins traction
Treatment of fractures of tibia and of
the femur from the subtrochantric
region distally.
Basis of management is the use of skeletal
traction coupled with active movements of the
injured limb
By encouraging early muscular activity, the
development of stiff joint is frequently
prevented by both maintaining extensibility of
muscles by reciprocal innervation, and
preventing stagnation of tissue fluid

Application of Perkins
traction
A Hadfield split bed is required
Under General anaesthesia and full aseptic conditions, a Denham pin is
inserted through the upper end of tibia

A Simonis swivel is attached to end of each Denham pin

Two traction cords are connected to each of swivel
4.6 kg weight is attached to each traction cord making a total traction
weight of 9.2 kg

Foot end of the bed is elevated by one inch for each 0.46 kg of traction
weight

One or more pillow is placed under the thigh to maintain the anterior
bowing of the femoral shaft

Length of the limb is checked with a tape measure and total traction weight
is increased or decreased as necessary

Active Quadriceps exercises are started immediately and continued

Knee flexion is started after a week of admission, under supervision

Perkins 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

Pearson Attachment
Middle 3rd fracture has
mild flexion proximal
fragment
30 degrees elevation with
traction in line with femur

Distal 3rd fracture has

distal fragment flexed
posterior
Knee should be flexed
more sharply

Fulcrum at level of fracture

Traction at downward angle
Reduces pull of
gastrocnemius

Distal Tibial Traction

Useful in certain tibial

plateau fracture
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 fracture or
calcaneal fracture

Insert about 1.5 inches

(4cms) inferior and
posterior to medial
malleolus

Do not skewer subtalar

joint or NV bundle

Maintain slight elevation

leg

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
fracture

Once reduction

obtained, pins can be

incorporated in cast

Pin placed radial to ulnar

through base 2nd/3rd MC

Stiffness of intrinsics is
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 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
transversely.

Gardner Tongs
U shaped tongs, used for
spinal traction

In patients having cervical

injury

Easy to apply
Place directly above
external auditory meatus

In line with mastoid

process

Just clear top of ears

Gardner Tongs
Pin site care important
Weight ranges from2.3 kg
to 15.8 kg for c-spine

Excessive manipulation

with placement must be

avoided

Poor placement can cause

flexion/extension forces

Patient can get occipital

decubitus

Crutchfield Tongs
Crutchfield tongs fit
into the parietal
bones

A special drill point

with a shoulder is
used to enable an
accurate depth of
hole to be drilled

Application of Crutchfield
Tongs
Sedate the patient
Shave the scalp locally
Draw a line on the

scalp, bisecting the

skull from front to back

Draw a second line

joining the tips of the

mastoid processes
which crosses the first
line at right angles

Fully open out the tongs

Application of Crutchfield
Tongs
With the fully open tongs lying equally on each side of the

antero-posterior line, press the points into the scalp making

dimples on the second line.

Infiltrate the area of the dimples down to and including the

periosteum, with local anaesthetic solution.

Make small stab wounds in the scalp at the dimples.

Using the special drill point, drill through the outer table of
the skull in a direction parallel to the points of the tongs.

Fit the points of the tongs into the drill holes.

Tighten the adjustment screw until a firm grip is obtained, and
repeat daily for the first 3 to 4 days, and then tighten when
necessary

Attach a traction cord to the two lugs.

Attach a weight to the traction cord.

Traction
(Crutchfield)
Level

Minimum
Weight

Maximum
Weight

C1

2.3 KG

4.5 KG

C2

2.7 KG

4.5 5.4 KG

C3

3.6 KG

4.5 6.7 KG

C4

4.5 KG

6.7 9.0 KG

C5

5.4 KG

9.0 11.3 KG

C6

6.7 KG

9.0 13.5 KG

C7

8.2 KG

11.3 15.8 KG

Complications of Skeletal
Traction
Introduction of infection into the bone
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 splints difficult
Result in uneven pull being applied to the ends of the pin
or wire and thus cause the pin or wire to move in the bone

Distraction at the fracture site

Ligamentous damage if a large traction force is applied
through a joint for a prolonged period of time

Damage to epiphyseal growth plates when used in children

Depressed Scars

Management of patients
in traction
Care of the patient
Care of the traction suspension system
Radiographic examination
Physiotherapy
Removal of traction

In The Patient
Care of the injured limb-

Pain
Parasthesia or Numbness
Skin irritation
Swelling
Weakness of ankle, toe, wrist or finger movement

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 fracture with olecranon pin

- 3 weeks

Tibial fracture with calcaneal pin

- 3-6 weeks

Trochanteric fracture of femur

- 6 weeks

Femoral shaft fracture

with application of cast brace and
partial weight bearing
without external support and
partial weight bearing

- 6 weeks
- 12 weeks

Thank You