Jo n . M.

S ewart
e ery . Hallet
 I ~;1
~:; ~ ~-
Traction and Orth~paedic
Appliances ~~g
-s-e .;-,
by

J OHN D. M . STEWART
M.A. (Cantab.), F.R.C.S. (England)

Consultant Orthopaedic Surgeon

Chichester & Graylingwell, and Worthing,
Southlands & District Groups of Hospitals

(formerly Lecturer in Orthopaedics,

Institute of Orthopaedics, Royal National
Orthopaedic Hospital, London)

CHURCHILL LIVINGSTONE
Edinburgh London and Ne\v York 1975
CHl:RCHILL LJVI~GSTO~E
Preface
.\1edical DJ\·ision of Longman Gro_up Limited
Disrributed in the L:nited States o1 Am~nca by
Longman Inc., ~ew York and by ass?c1ated
compame~. br3nches and representan,·es throughout
This book is written primarily for the use of orthopaedic house
the world.
surgeons and junior registrars, and of the nursing and physiotherapy
~ Longman Group Limited staff of accident and orthopaedic wards.
All rights resen·cd. ~o part of this Jim blication Many of the procedures and appliances described here are in
mav be reproduced, stored in a rerne,·al system, or common usage. The details, however, of how to carry out these
transmitted in any form or by any means, electromc, procedures, their contraindica tions and complications, and how to
mechanical, photocopying, recording or ?then,·1se,
without the prior permission of the pubhshers . check the various appliances, are not available in the standard text-
(Churchill Livingstone, 23 Ra,·elston Terrace, Ed1nburgh.). books. This book is intended to rectify this omission and to be a
practical source of instruction in these matters.
First published 1975 I wish to thank the many people who have assisted me in the
! SB~ 0 443 01196 6 preparation of this book, in particular Mr W. H. Tuck \Nithout whose
considerable guidance, the chapters on Spinal Supports, Lower
Library of Congress Catalog Card ~umber 74-80738
Limb Bracing and Footwear would have been incomplete;
Filmset on 'M onophota' 600 by Dr J. D. G. Troup for his help with the section on the bio-
f yldetype Limited, Kirkham, PR4 3BJ, England mechanics of the spine; Mr F. G. St. C. Strange and Mr G. R. Fisk
who have kindly helped me in the description of their methods of
applying traction to the lower limb; and to the staff of the
Physiotherapy Department of the Royal National Orthopaedic
Hospital for their assistance with the chapters on Walking Aids and
Crutch Walking. I also wish to express my gratitude to Professor
R. G. Burwell who advised me on the original script, to Mr. J.
Crawford Adams who read the final draft, and to Dr. R. R. Mason
for his careful reading of the proofs.

-·.·:i!: ~ .;;. .:::: ' ~· · . ' " .· · ::.1't.··

}OHN D. M. STEWART.
Bognar R egis, 1974.
:.. .... :._.

~:.
'
... . . .
...
; ~

~
-
' .
(..

~
... ......\,
;;
,.. ,
..-
~

lr ! -
-..;

• ~ • • : ~:
.•• "' ; -~ ·il . {"'f ' 'f ·) ·
• ';

Printed m Great Britain.

 C ontents

To
D.M.S. Chapter 1 TRACTION
General principles and methods of application
2 THE THOMAS'S AN"D FISK SPLINTS 9
3 FIXED TRACTION 15
4 SLIDING TRACTION 23
5 SUSPENSION OF APPLIANCES 37
6 THE MANAGEMENT OF PATIENTS IN
TRACTION 53
7 SPINAL TRACTION 59
8 SPINAL SUPPORTS (thoraco-lumbar and cervical) 75
9 SPLINTING FOR CONGENITAL
DISLOCATION OF THE HIP 97
10 LOWER LIMB BRACING 109
11 FOOTWEAR 131
12 \'<'ALKING AIDS 149
13 CRUTCH WALKING 161
14 PLASTER-OF-PARIS CASTS 171
15 TOURNIQUETS 181
16 PLASTAZOTE 191
APPENDIX 197
INDEX 199
1. Traction
General Principles and Methods of Application

When a limb is painful as a result of inflammation of a joint or a

fracture of one of the bones, the controlling muscles contract simul-
taneously. This is called muscle spasm. The antagonistic muscles
in a limb are not all equally powerful, with the result that when
muscle spasm is present, the action of the more powerful muscles
can produce a deformity which may seriously impair the future
function of the limb.
Inflammation of the hip joint commonly results in a flexion,
adduction and lateral rotation deformity, the presence of which
causes apparent shortening of the affected lower limb.
When the shaft of the femur is fractur.ed at the junction of the
upper and middle thirds, the proximal fragment is flexed and ab-
ducted by the pull of the ilio-psoas and hip abductor muscles
respectively, and the distal fragment is adducted by the adductor
muscles of the thigh. In addition, if apposition of the fragments is
lost, marked shortening of the femur occurs.
Traction, by overcoming muscle spasm, relieves pain and thus
allows a limb to be rested in the best functional position. In addition,
traction reduces the movement of an injured part of the body and
thus aids in the healing of bone and soft tissues. When bony injury
is present, the injured part is usually splinted.

METHODS OF APPLYING TRACTION

To apply traction, a satisfactory grip must be obtained on a part of

the body. In the case of a limb, the traction force may be applied
through the skin-skin traction-or via the bones-skeletal traction.
A traction force may be applied also to other parts of the body.
Pelvic traction is described in Chapter 4, and spinal traction in
Chapter 7.

Skin traction
The traction force is applied over a large area of skin. This spreads
the load, and is more comfortable and efficient. In the treatment
of fractures, the traction force must be applied only to the limb
 1. TRACTION 3
distal ro rhe fracture site, otherwise the efficiency of the traction
force is reduced. APPLI CATION OF VENTFOAM SKIN TRACTION
The maximum traction weight which can be applied v;ith skin BANDAGE
traction is l5lb (6·7kg). Shaving of the limb is not required.
Two methods of appl~;ng skin traction are commonly used. • Lie the Ventfoam Skin Traction Bandage (foam surface to the skin) on
Ad hesive strapp i n g each side of the limb.
This can only be stretched trans,·ersely. The necessary apparatus can e Leave a loop projecting 4 to 6 inches ( 10 to 15 em) beyond the sole of the
be assembled indi,·idually, but prepared Elastoplast Skin Traction foot.
e Apply a crepe bandage, beginning with 2 to 3 turns around the ankle
Khs (Smith and Nephew Ltd.)* for use in adults or children can be
under the Ventfoam Bandage before catching in each length. Continue
obtained. bandaging up the limb over the Ventfoam Bandage.
Some patients are allergic to adhesi,·e strapping. For these • Place the metal spreader provided, in the loop formed.
patients other preparations which do not utilize an adhesive contain- • Attach a cord and the required traction weight to the metal spreader.
ing zinc oxide can be used, for example Seton Skin Traction Kit The traction weight should not exceed 10 lb (4·5 kg).
(Seton Products Ltd .).* Two other preparations to which allergic
reactions have not been reported are Orthotrac (Zimmer Ortho- Contraindications to skin trac tion
paedic Ltd.)* and Skin-Trac (Zimmer, U.S.A.).* 1. Abrasions of the skin.
2. Lacerations of the skin in the area to which the traction is to be
APPLICATION OF ADHESIVE STRAPPING applied.
• Shave limb (shaving is not required with Orthotrac and Skin-Trac). 3. Impairment of circulation-varicose ulcers, impending gangrene,
• Protect the malleoli from friction with a strip of felt, foam rubber or a stasis dermatitis.
few turns of bandage under the strapping. 4. Marked shortening of the bony fragments, when the traction
• Starting at the ankle but leaYing a loop projecting 4 to 6 inches (I 0 to weight required will be greater than can be applied through the
15 em) beyond the sole of the foot, apply the ,,;dest possible srrapping skin.
to both sides of the limb, parallel to a line between the lateral malleolus
and the greater trochanter. On the lateral aspect the strapping must lie
slightly behind, and on the medial aspect, slightly in front of this line to Comp lications of skin t rac tion
encourage medial rotation of the limb. 1. Allergic reactions to the adhesive.
• A,·oid wrinkles and creases. If necessary, nick the strapping to ensure 2. Excoriation of the skin from slipping of the adhesive strapping.
that it lies flat. 3. Pressure sores around the malleoli and over the tendo calcaneus.
• A,·oid the malleoli, tibial crest and patella. 4. Common peroneal nerve palsy. This may result from two causes.
• Apply a crepe or elasticated bandage O\'er the strapping, again starting Rotation of the limb is difficult to control with skin traction. There
at the ankle. A 6 inch (15 em) bandage is used for adults, and a 4 inch is a tendency for •he limb to rotate laterally and for the common
(I 0 em) bandage for children. peroneal nerve to be compressed by the slings on which the limb
• Artach a spreader bar or cords to the distal end of the strapping. rests. Adhesive strapping tends to slide slowly down the limb,
• Attach the required traction weight.
carrying the encircling bandage with it. The circumference of the
limb around the knee is greater than that around the head of the
N on-a dhesive strapping fibula. The downward slide of the adhesive strapping and bandage
Ventfoam Skin Traction Bandage (The Scholl Manufacturing Co. is halted at the head of the fibula. This can cause pressure on the
Ltd. )* consists of lengths of soft, ventilated latex foam rubber common peroneal nerve.
laminated to a strong cloth backing. It is useful particularly on thin
and atrophic skin, or when there is sensitivity to adhesive strapping. Skeletal traction
Its grip is less secure than that of adhesi"e strapping and therefore For skeletal traction, a metal pin or wire is driven through the bone.
frequent reapplications may be necessary. By this means the traction force is applied directly to the skeleton.
(For spinal traction, see Chapter 7.)
~See Appendix. Skeletal traction is seldom necessary in the management of upper
limb fractures. It is used frequently in the management of lower
4 TRACTION AKD ORTHOPAEDIC APPLIA~CES
1. TRACTION 5

limb fractures . It may be employed as a means of reducing or of

maintaining the reduction of a fracture. It should be reserved for
those cases in which skin traction is contraindicated. A serious com-
plication of skeletal traction is bony infection.
Steinmann pin
Steinmann pins ( Steinmann, 1916) are rigid stainless steel pins of
,·arying lengths, 4 to 6 millimetres in diameter. After insertion, a
special stirrup (Bohler, 1929), illustrated in Figure 1.1, is attached
to the pin. The Bohler stirrup allows the direction of the traction
to be \'aried without turning the pin in the bone.

Figure 1.3 Kirschner wire strainer.

Common sites for application of skeletal traction

LOWER END OF FEMUR

Prolonged ttaction through the lower end of the femur predisposes to
Figu re 1.1 Bohler stirrup wirh Steinmann pin. knee stiffness from fibrosis in the extensor mechanism of the knee. For
this reason, a Steinmann pin through the lower end of the femur must
be removed after two to three weeks and be replaced by one through the
Denham pin
upper end of the tibia.
The Denham pin (Denham, 1972) illustrated in Figure 1.2, is The point of insertion for skeletal traction through the lower end of
identical to a Steinmann pin except for a short threaded length situ- the femur can be determined in two ways.
ated towards the end held in the introducer. This threaded portion 1. Draw a line from before backwards at the level of the upper pole of
engages the bony cortex and reduces the risk of the pin sliding. This the patella. Draw a second line from below upwards anterior to the head
type of pin is particularly suitable for use in cancellous bone, such of the fibula. Where these two lines intersect is the point of insertion of
as the calcaneus, or in osteoporotic bone. a Steinmann pin ( Fig. 1.4).
2. Just proximal to the upper limit of the lateral ~emoral condyle. In ~he
<=======~~M&m~==========~ average adult this point is 1i inches (3·0 em) prox1mal to the aruculanon
Figure 1.2 Denham pin. between the lateral femoral condyle and the lateral tibial plateau.
Care must be taken to avoid entering the knee joint. The lateral fold
of the capsule of the knee joint reaches t tot inch (1·25 co 2·0 em) above
Kirschner wire the le\·el of the joint ( Fig. L.4) .
A Kirschner wire ( Kirschner, 1909) is of small diameter, and is UPPER END OF TIBIA
insufficiently rigid until pulled taut in a special stirrup (Fig. 1.3) The point of insertion is i inch ( 2·0 em) behind the crest, jusr below the
(Kirschner, 1927). Rotation of the stirrup is imparted to the wire. level of the tubercle of the tibia (Fig. 1.4) .
The ''ire easily cuts out of bone if a heavy traction v>eight is applied. LOWER END OF TIBIA
Although Kirschner wires can be used in the lower limb, they are The poinr of insertion is 2 inches (5·0cm) above the level of the ankle
more often used in the upper limb. joint, mid-way between the anterior and posterior borders of the tibia
(Fig. 1.5).
 CALCANEUS 1. TRACTION 7
The point of insertion is i inch (2·0 em) below and behind the lateral
malleolus. (As the lateral malleolus lies-! inch ( 1·25 em) more posterior
and distal than the medial malleolus, the abo,•e point corresponds with The insertion of a Steinmann pin through the calcaneus may
that lt inches (3·0cm) below and behind the medial malleolus). Care result in stiffness of the subtalar joint, or more seriously, in infection '
must be taken to a,·oid entering the subtalar joint (Fig. I .5). in the bone. However, with a pin in this site, the traction force is
applied in the line of the calf muscles, counteracts their pull, and
thereby reduces the deforming action of these muscles on the
fracture. When possible the lower tibial site for insertion of a
Steinmann pin should be used.

APPLICATIO~ OF SKELETAL TRACTIO~, USI NG

A STEINMANN PIN
• Use general or local anaesthesia. If local anaesthesia is used, the skin and
Capsule of the knee joint the periosteum must be infiltrated.
11' k"" • Shave the skin.
j _- -- - • Use full aseptic precautions-mask, cap, gown, gloves and drapes.
• Paint the skin with iodine.
• Drape skin towels under and around the limb.
• Mount the Steinmann pin on the introducer.
• Ask an assistant to hold the ankle at a right angle, with the toes pointing
straight upwards.
• Identify the site of insertion (see above).
I • Hold the pin horizontally and at right angles to the long axis of the limb.
I I • Drive the pin from lateral to medial, through the skin and the bone with
t' i " ., a gentle twisting motion of the forearm, while keeping the flexed elbow
Figure 1.4 Position for Steinmann pm in lower end of femur and upper end of tibia. against the side of your body.
• Apply on each side a small cotton wool pad, soaked in Benzomastic,
around the pin to seal the wounds. Always use two separate pads. One
strip of gauze wound back and forth across the shin and around the
Steinmann (>in may cause a pressure sore. Benzomasric is the best sealing
compound as it will stick to skin and metal.
I
I • Fit the Bohler stirrup.
• Apply guards over the ends of the pin.

By not incising the skin with a scalpel prior to inserting the

Steinmann pin, a much tighter fit around the pin is obtained, thus
Medial ------r - reducing the chances of infection and puckering of the skin on one
malleolus
r Lateral
side of the pin. If the skin does pucker, it should be incised and one
L _ malleolus or two sutures inserted if necessary.
A Steinmann pin may also be gently hammered in. It is in-
advisable to use this method when inserting a pin into the lower end
of the femur or tibia, as splintering of the cortex may occur.
If- r _.J Lateral malleolus
I " I
r- 1:lr" ~ Medial malleolus
COUNTER-TRACTION
Figure 1.5 Position for Steinmann pin in lower end of tibia and calcaneus. One of the reasons for applying a traction force to a part of the body
is to counteract the deforming effects of muscle spasm. The muscles
in spasm tend to draw the distal part of the body in a proximal
 2. The Thomas's and Fisk splints
direction. A traction force applied to the affected part of the body
will o,·ercome muscle spasm only if another force acting in the
opposite direction-counter-traction-is applied at the same time as
the traction force. If counter-traction is not applied, the whole body THOMAS'S SPLINT
will be pulled in the direction of the traction force, and muscle
spasm will not be overcome. The splint which today is called the Thomas's splint was described
originally by Hugh Owen Thomas (Thomas, 1876) as a knee
Fixed tractio11 appliance which he used in the ambulant management of chronic
One method of obtaining counter-traction is by applying a force or subacute inflammation of the knee joint. The present splint
against a fixed point on the body, proximal to the attachments of consists of a padded oval metal ring covered with soft leather,
the muscles in spasm. A similar ·situation exists when an attempt is to which are attached inner and outer side bars. These side bars
made to extract a cork from a bottle. The neck of the bottle is which exactly bisect the oval ring, are of unequal length so that
gripped in one hand and the corkscrew in the other. When a the padded ring is set at an angle of 120 degrees to the inner
traction force is initially applied to the corkscrew, another force, side bar. At the distal end the two side bars are joined together
acting in the opposite direction (counter-traction), is applied at the in the form of a 'W'. The outer side bar is often angled out 2 inches
same time to the bottle, the counter-traction force passing along the (5.0 em) below the padded ring, to clear a prominent greater
arm to the neck of the bottle. This mechanical arrangement is trochanter (Fig. 3.1).
called fixed traction. The padded ring is made in different sizes and the side bars in
To apply a force against a fixed point on the body, an ap- varying lengths.
pliance, for example a Thomas's splint (see Chapter 2) is used. The
ring of the splint snugly encircles the root of the limb. The traction CHOOSING A THO.\IiAS'S SPLINT
cords are tied to the distal end of the splint, and the counter- 1. Measure the oblique circumference of the thigh immediately
traction force passes along the side bars of the splint to the ring below the gluteal fold and ischial tuberosity. The line of measure-
and hence to the body proximal to the attachment of the muscles ment is oblique and must correspond with the inclination of the ring of
the splint ( Fig. 2.1). This measurement equals the internal circumference
in spasm (Fig. 3.1 ).
of the padded ring. If the above measurement cannot be taken without
Fixed traction is discussed in Chapter 3. causing the patient pain, measure the oblique circumference of the
normal thigh. Add 2 inches (S·Ocm) to this measurement if there is much
Sliding traction swelling of the injured thigh. Accuracy is required if fixed traction is
Gravity may be utilized to provide counter-traction by tilting the intended. With sliding traction, accuracy is not so important because
the function of the splint is merely to support the limb.
bed so that the patient tends to slide in the opposite direction to
2. Measure the distance from the crotch to the heel and add 6 to
that of the traction force. This is called sliding traction and is
9 inches ( I 5 to 23 em) . This distance equals the length of the inner side bar
discussed in Chapter 4. A splint is often used when sliding traction (Fig. 2. 1).
is employed, but the function of the splint in this instance is merely
to cradle the limb.
PREPARING A THOMAS'S SPLINT
1. Fashion slings, between the side bars, on which the limb can
REFERENCES
rest.
BOHLER, L. (1929) The Trca11nrnr of Fracrme.<. English Translation by Steinberg, M. E. • Cut an adequate length of 6 inch (15·0cm) wide domette bandage or
p. 38 and p. 39, Fig. 56. Vienna: \\". Maudrich. calico. It is bener to cut off excess length later, than to have to change
D~HA.\1, R. :\. l9i2' Personal communication. a sling which is too short, after the limb has been placed in the splint.
KlRScH:-;ER, .\1. ,·o:-; 1909) : t.:eber !\'agelextension. Beirr6ge ::ur Klinischen Chirurgie,
• Pass the length of domene bandage or calico around the inner side bar.
64,266.
KJRSCH:-;ER, .\\. \"0!" 1927' \'erbesserungen Der Drahtextension. Archit: Fiir Klinischc Then pass both ends above the outer side bar ( Fig. 2.2).
Chirurgie. 148, 651.
STEr.-;~vs:-;, F. \"0!" 1916) Die Nagelextension. Ergebnisse Der Chirurgie und Or!ha- 9
piidie, 9, 520.
 0 TRACTION A~D ORTHOPAEDIC ;\PPLIANCES 2. THE THOMAS'S AND FISK SPLINTS 11

Thigh girth of the limb, and to avoid excess pressure in the region of the neck of the
fibula and the tendo calcaneus.
The proximal sling leaves a triangular area of thigh unsupported
Crotch because of the obliquity of the ring of the splint with the side bars. This
triangular area can be supported by passing the length of domette
bandage around the ring of the splint as well as the side bars ( Fig. 2.3),
(Strange, 1965).

Heel

Figure 2.3 t\t\ethod of arranging the proximal sling to obliterate the triangular gap
which results from the obliquity of the ring of a Thomas's splint.
Add s·-s·

Figure 2.1 H ow w measure for a Thomas's splint.

The dis cal sling must end 2t inches (6·0 em) above the heel ro avoid
pressure sores developing over the tendo calcaneus ( Fig. 2.4).
• Fasten the two ends to the sling so formed with two large safety pins
or toothed clips.
In this way the tension of the sling can be adjusted easily after the
~plim has been fined to the limb (Fig. 2.2), to ensure uniform support

Figure 2.2 D('tail offixmg of sling to inner and outer side bars of a Thomas's spli nt. Figure 2.4 Arrangement of pad, slings and gamgee lining for a Thomas's splint.
12 TRACTION Al'D ORTHOPAEDIC i\PPLIANCES

2. THE THOMAS'S AND FISK SPLINTS 13

The slings tend to slip distally on the side bars of the Thomas's splint.
This can be prevented by pinning each sling to the one abo,·e or by FISK SPLINT
binding the side bars with zinc oxide strapping before applying the
slings.
A safe and comfortable substitute for domette slings is an elastic rube The splint described by Fisk ( 1944) consists of a modified Thomas's
bandage (Tubigrip-Seton Products Ltd.*). A Tubigrip bandage is spline to which a knee-flexion piece is attached. The Thomas's splint
slipped o,·er the splint, the ends are folded back, and the position held is modified by removing the side bars beyond the level of the
with safety pins. When an exceptionally hea,·y limb has to be supported. knee joint, and turning the cut ends of the side bars horizontally
the thickness of the Tubigrip can be doubled (Board, 1967). outwards ro form small rings. A knee-flexion piece is fixed firmly to
2. Line the slings with Gam gee tissue. the side bars just proximal to these rings, level with the axis of
3. Fashion one large pad f ro m Gamgee tissue or cotto n wool. movement of the knee joint.
This pad should measure roughly 6 by 9 inches ( 15 by 23 em) and be about The splint is now purpose-designed* ( Fig. 2.6). The padded
2 inches (5·0 em) thick when compressed. Place this pad transversely groin ring, the front half of which is replaced by a padded strap
under the lower part of the thigh to maintain the normal anterior bowing
of the femoral shaft ( Fig. 2.4).
-1. If t he leg is to be supported in a knee- flexion p iece, t he hinge
m u st coincide with the axis of movement of the knee joint . The
mon!ment of flexion and extension at a normal knee joint is not one of
simple hinge mo,·ement, but is complex, following a polycentric pathway
(the instant centres determ ined for each increment of flexion mo,·ing
posteriorly in a spiral pattern (Gunston, 1971 ), as shown in Fig. 2.5).

T ---T - --
Telescopically Adjustable

F igu r e 2.6 Fisk splint, side-view. Insert shows method used to attach traction cords
(Polycentric pathway of movement
ro a Steinmann pin with locking collars and U-stirrups.
in the normal knee)
and buckle, is attached by swivel joints to the side bars, so that
the same splint can be used for either limb. The distal ends of
the side bars are connected just beyond the knee by a squared-off
Figure 2.5 Hinge of knee-flexion piece is sited le,·el with the adductor 1ubercle of frame which has two small eyelets at each upper corner. The knee-
the femur. flexion piece is fixed to the side bars, just proximal to the squared-
off frame, through off-set double-cog hinges. These hinges m ust lie
Howe,·er, from the point of view of the siting of the hinge of a knee- at the level of the axis of movement of the knee joint when the
flexion piece, the axis of movement is taken to lie level with the adductor splint is applied to the limb. The side bars of the thigh and knee-
tubercle of the femur ( Fig. 2.5). flexion parts of the splint are adjustable telescopically, thus enabling
5. After the splint has been fitted, bandage the limb into the all lengths of lower limb ro be accommodated.
splint . Application of sliding traction with the Fisk splint is described
in Chapter 4, and suspension of the splint in Chapter 5.

• Set Appendix.

*
14 TRACTION AND ORTHOPAEDIC APPLIANCES 3. Fixed traction

REFERE"l"CES

Bo ARD, C. P. (1967) Sling for Thomas' s splint. La11cec, ii, 757. If traction is applied to a limb, counter-traction acting in the opposite
FtSK, G. R. (1944) The fractured femoral shaft: new approach to rhe problem. direction must be applied also, to prevent the body from being pulled
Lanccc, i, 659. in the direction of the traction force. When counter-traction acts
Gt.~STO~, F. H. ( 1971) Polycentric knee arthroplasty. J oumal of Bon~ and J oim
Surgery , 53-B, 272. through an appliance which obtains a purchase on a part of the body,
STRANGE, F. G. Sr. C. ( 1965) The Hip, p. 99, Fig. iv. 6 and p. 269, Fig. x. 7. the arrangement is called fixed traction.
London: Heinemann.
THOMAS, H. 0. (1876) Diseases of rhe Hip, Knee and Ankle J oines, o;.:·irh Their
Deformiries, Treaced by a l\"ew ami Efficiem Mahod, 2nd ed., p. 98 and Plate 13,
Fig. 4. Lh·erpool: T . Dobb & Co.
FIXED TRACTION IN A THOMAS' S SPLINT

Fixed traction in a Thomas's splint can ' maintain', but not ·obtain'
the reduction of a frac ture. It is therefore indicated when the femoral
fracture can be reduced by manipulation. A reduced transverse
fracture is most suitable, but the reduction of an oblique or spiral
fracture can be maintained also .
When the cords attached to the adhesive strapping or a tibial
Steinmann pin are pulled tight, the counter-thrust passes up the side
bars of the splint to the padded ring around the root of the limb
(Fig. 3.1 ). The ring, which must be a snug fit, may cause pressure
sores unless daily attention is paid to the skin (see Chapter 6). The
pressure of the padded ring around the root of the limb can be
reduced partly by pulling on the end of the splint. A traction weight
of 5lb (2·3 kg) attached to the Thomas's splinr usually is sufficient
for this purpose.
The significant feature of fixed traction is that the traction force
balances the pull of the muscles and, as the muscular pull and
haematoma decrease, the traction force decreases. Distraction at the
fracture site and the accompanying danger of delayed union or non-
union of the fracture is less likely to occur. It is not necessary in
this system repeatedly to tighten the traction cords with a windlass,
except co compensate for any stretching of the cords or sliding
downwards of the adhesive strapping if skin traction is employed.
As counter-traction is not dependant upon gravity the apparatus
is self-contained, and the patient may be lifted and moved without
risk of displacement of the fracture. This method is valuable in the
treatment of civilian casualties. During the Second World War a
modification of this method was employed. The whole limb and the
Thomas's splint was encased in plaster-of-Paris; this assembly was
known as the Tobruk splint (Bristow, 1943).
15
16 TRACTION AND ORTHOPAEDIC APPLIA1\CES 3. FIXED TRACTION 17

For comfort and ease of movement of the patient, the Thomas's Transverse fracture. An assistant standing at the foot of the splint
splint can be suspended (see Chapter 5). holds the Bohler stirrup, exerts a traction force in the long axis of the ,
limb, and simulraneoulsy forces the ring of the splint against the ischial
tuberosity.
• Stand at the side of the limb and grip the limb above and below the
fracture sire. Move the proximal and distal fragments in the directions
determined from the study of the pre-reduction radiographs, to reduce
the fracture. For example, in a fracture at the junction of the middle and
Figure 3.1
lower thirds of the shaft of the femur, the distal fragment usually is
displaced posteriorly. Therefore place one hand under the distal fragment
Fixed traction in a Thomas's
splint. The grip on the leg is and the ocher on top of the proximal fragment, and push anteriorly with
obtained by adhesive strapping. the hand under the distal fragment. The general rule is that the distal
Note :-the ring of the Thomas's fragment is reduced ro the proximal fragment and not vice versa, as the
splint is well up in the groin and
fits snugly around the root of the
manipulator has control only of the distal fragment, the proximal
limb. fragment being under control of the muscles attached to it.
-the malleoli are well padded to • Check that apposition of the fragments has been obtained by tempor-
avoid pressure. arily reducing the traction force. The absence of telescoping of the limb
-the outer traction cord passes
above and the inner cord passes indicates that apposition has been achieved.
below its respective side bar. to e When apposition has been obtained, carefully lower the limb, while
hold the limb in medial rotation. maintaining traction, onto the prepared Thomas's splint, with the large
- the traction cords are tied over
the end of the Thomas's splint. pad under the lower part of the thigh.
- a windlass is omitted. This • Maintain traction.
avoids the temptation to re- • Arrange the tension in the other slings to allow 15 to 20 degrees of
peatedly tighten the traction
cords and thereby either distract knee flexion.
the fracture or pull the adhesive • Attach traction cords to each end of the Steinmann pin and tie them to
strapping off the limb. the lower end of the Thomas's splint.
-the counter thrust (traction)
passes up the side bars. as • Release the pull on the Bohler stirrup.
indicated by the arrows. to the • Take antero-posterior and lateral radiographs to check the reduction of
root of the limb. the fracture. If the reduction is not satisfactory, re-manipulate.
• Palpate the dorsalis pedis and posterior tibial pulses. If the pulses are
absent, reduce the traction force. If the pulses do not return, very gemly
re-manipulate the fracture. If the peripheral pulses are still absent, notify
more senior colleagues immediare/y.
• If the peripheral pulses are present and the reduction is satisfactory,
remove the Bohler stirrup.
• Suspend the Thomas's splint (see Chapter 5).
Oblique, spir al or comminuted fractures. A formal manipulation
REDUCTION OF A FEMORAL SHAFT FRACTURE of these fractures is not required. The traction force is applied in the
For children skin traction is adequate, but for adults skeletal traction long axis of the limb as described above, until the fractured femur is
with an upper tibial Steinmann pin (Denham pin for the elderly) is used restored to its correct length. Traction is maintained until the traction
more frequently. cords are tied to the foot of the T homas's splint.
• Insert an upper tibial Steinmann pin under general anaesthesia and attach The instructions about the large pad, radiographs, peripheral pulses
a Bohler stirrup. and suspension of the Thomas's splint also apply.
• Thread the prepared Thomas's splint over the limb.
• Palpate the dorsalis pedis and posterior tibial pulses. Traction unit
• Study the radiographs. Determine the type of fracture, in which direction
For many years, Charnley (1970), has employed what he terms a
the fragments are displaced and in which direction they need to be
mo,•ed to obtain apposition of the bone ends. The next step depends
traction unit (Fig. 3.2), in conjunction with fixed traction in a
upon the type of fracture. Thomas's splint, for the management of fractures of the femoral
 3. FIXED TRACTIO>< 19
shaft. Basically a traction unit consists of an upper tibial Steinmann
pin incorporated in a light below-knee plaster cast. pressed between the Steinmann pin and the upper edge of the
sling supporting the calf. Even when a sling is used to support
the traction unit, compression of the calf does not occur because
it is protected by the plaster cast. .
2. Equinus deformity at the ankle cannot occur because the foot IS
supported by the plaster cast.
3. The tendo calcaneus is protected from pressure by the padded
Figure 3.2 Traction unit. The broken line shows the position of the side bars of the cast.
Thomas's splint in relation to the cross-bar fixed to the sole of the plaster cast. 4. Rotation of the foot and the distal fragment is controlled.
5. A fracture of the ipsilateral tibia can be treated conservatively at
the same time as the femoral fracture.
APPLICATION OF A TRACTION UNIT WITH
FIXED TRACTION
• Choose the correct size of Thomas's splint.
• Fashion one sling and a large pad to support the thigh.
ROGER ANDERSON WELL-LEG TRACTION
• Under general anaesthesia, thread the prepared Thomas's splint over the Well-leg traction ( Anderson, 1932) was originally used in the m~n­
limb, inserr an upper tibial Steinmann pin and attach a Bohler stirrup.
agement of fractures of the pelvis, femur and tibia, skeletal tracuon
• While the leg is supported by an assistant holding the stirrup and keep-
being applied to the injured leg, while the 'well' leg was employe~
ing the foot at a right angle, apply a padded below-knee plaster cast
incorporating the Steinmann pin. The cast must be well padded around for counter-traction. It is rarely used for these purposes today. Th1s
the heel to prevent pressure sores from developing. method however is valuable in correcting either an abduction or
• l ncorporate a 6 inch ( I 5·0 em) long wooden bar transversely in the sole adduction deformity at the hip, for instance before an extra-
of the plaster cast about mid-way between the heel and the toes. This articular arthrodesis is carried out.
bar controls rotation of the limb. The principle is as follows:
• When the plaster cast has hardened, reduce the fracture and lower the With an abduction deformity at the hip, the affected limb appears
limb onto the prepared splint. to be longer. When traction is applied to the 'well' limb _and the
• Check that the thigh sling and the large pad correctly support the thigh, affected limb is simultaneously pushed up (counter-tracnon), ~e
maintaining the normal anterior bowing of the femoral shaft. abduction deformity is reduced. Reversing the arrangement Will
• Allow the trans\·erse bar to rest on the side bars of the Thomas' s splint.
reduce an adduction deformity ( Fig. 3.3).
If the thigh sling is correctly tensioned, and the trans\'erse bar is
positioned correctly, the knee should be in 15 to 20 degrees of flexion, ABDUCTION
ADDUCTION
and the limb in neutral rotation. DEFORMITY DEFORMITY
• Attach a cord to each end of the Steinmann pin, loop them once around
the side bars of the splint and tie them over the end of the splint.
• Check that the pressure of the thigh sling against the thigh is not
excessive. If it is, reduce the pressure by placing a sling under the upper
end of the traction unit. The tighter the calf sling is pulled, the more
the pressure on the thigh is relieved.
• Suspend the Thomas's splint (Charnley uses .~1ethod 2, Chapter 5).
• Attach a 5lb (2·3 kg) weight to the end of the Thomas's splint to reduce
partly the pressure of the padded ring of the splint around the root of
the limb.

Advantages of t h e tracti on unit

1. Compression of the tissues of the upper calf, in particular the
common peroneal nen·e, does not occur. \X' hen fixed traction
without a traction unit is employed, the upper calf may be com-
t 1
Diagramatic illustration of the principle of Roger Anderson well-leg
Figure 3.3
traction.
 3. FIXED TRACTION 21
APPLICATION OF ROGER ANDERSON WELL-LEG
TRACTION • Apply an above-knee plaster cast to the limb which is to be pushed
The simultaneous pulling do~n of one leg and the pushing up of the . upwards. This plaster cast must extend to the top of the thigh; it must
other is achieved by using the apparatus illustrated in Figure 3.4. be well padded and moulded over the medial aspect of the upper thigh,

- .-·-
to prevent the cast pressing on the tissues and obstructing the circulation;
and it must be well padded around the ankle and heel as these will be
the sites of continuous pressure from the direction of the heel.
line of iliac spines - • e Incorporate the larger stirrup in this plaster.
e Insert a Steinmann pin through the lower end of the tibia of the limb
which is to be pulled down, and incorporate the Steinmann pin in a
light padded below-knee plaster cast.
e Pass the ends of the Steinmann pin through the lowest possible holes in
the side arms of the smaller stirrup.
By altering the position of the screw (on the left in Figure 3.4), the
relative positions of the two stirrups can be altered.
The arrangement illustrated in Figure 3.4 can be used to correct an
abduction deformity at the right hip, or an adduction deformity at the
left hip.

REFERENCES

R. ( 1932) A new method of treating fractures, utilizing the well leg for
A:-.L>ERSON,
counter traction. Surgery, Gynaecology and Obstetrics, 54, 207.
BRISTOW, W. R. ( 1943) Some surgical lessons of the war. Journal of Bone and Joint
Surgery, 25, 524.
CHARNLEY, J. ( 1970) The Closed Treatment of Common Fraccures, 3rd ed., p. 179.
Edinburgh and London: Churchill Li\·ingstone.

tl
II
II
It
,,
'J
I ,

II
It
I,
II
II
II
II
,,
IJ

It
tl 'r
,,
11
II
:I
tl
II II
II II

Figure 3.4 Roger Anderson well-leg traction (modified). The padded below-knee
plaster cast is not illustrated.
4. Sliding traction

In 1839, John Haddy James of Exeter described a method, which

he had employed for several years, of treating fractures of the lov.:er
limb with 'continuous yet tolerable traction ... by weight and
pulley' (Jones, 1953). The patient' s trunk was fi.xed co the head of
the bed by a rib bandage. The leg was bandaged into a padded
hollow splint fitted with a foot piece. A castor on the hollow spline
rested upon a wooden plank. A cord from the footpiece passed over
a pulley at the foot of the bed co a weight. The head of the bed
was raised. James did not utilize the weight of the body, acting
under the influence of gravity, to provide counter-traction. In his
system, counter-traction was represented by the tension in the rib
bandage.
When the weight of all or part of the body, acting under the
influence of gravity, is utilized to provide counter-traction, the
arrangement is called sliding traction. The traction force is applied
by a weight, attached to adhesive strapping or a steel pin by a cord
acting over a pulley (Fig. 4.1). The traction force continues to act
as long as the weight remains clear of the floor. Counter-traction is
obtained by raising one end of the bed by means of wooden blocks
or a bed elevator, so that the body tends to slide in the opposite
direction to that of the traction force.
\'V'hen sliding traction is used to reduce a fracture, the initial
traction weight required to obtain the reduction is greater than the
traction weight required to maintain the reduction. Great care muse
be caken co ensure that distraction of the fracture does not occur. For

Figure 4.1 The principle of sliding traction.

23
 correct length has been obtained. \Xlhen this has been achieved, the
traction weight must be reduced to that sufficient to maintain the 4. SLIDING TRACTION 25
reduction. Daily radiographic examination may be employed, bur do
1101 ignore the use of a tape measure.
The traction weight needed to reduce or to maintain the re-
duction of a ;>articular fracture depends upon the site of the fracture,
the age and weight of the patient, the power of his muscles, the
amount of muscle damage present and the degree of friction present
in the system. The exact weight required is determined by trial, and
observing the beha\;our of the fracture. For a fracture of the
femoral shaft an initial weight of 10 to 20lb (4·5 to 9·0kg) is usually
sufficient for an average adult, and 2 to 10 lb (1·0 to 4·5 kg) for an
average child. The heavier the traction weight used, the higher the
end of the bed must be raised to provide adequate counter-traction.

BUCK'S TRACTION OR EXTENSION Figure 4.2 Sliding traction-skeletal. The lower limb resrs in a Thomas's splint.:U:d
knee-flexion piece. A Steinmann pin is inserted through the upper end of the ub1a.
A rraction cord passes from the pin over a pulley to the traction weight. The foot of
Buck's traction, popularised during the American Civil War (Buck,
the bed is raised to provide counter-traction.
1861 ), is used in the temporary management of fractures of the
femoral neck and in the management of fractures of the femoral cruciate ligament of the knee, which might cause hyperexten.si~n
shaft in older and larger children. instability, and allows variation in the direction of pull when a ttbtal
Steinmann pin is used.
APPLICATION OF BUCK'S TRACTION
• Apply adhesive strapping to aboYe the knee or, in elderly patients, with
APPLICATION OF SLIDING TRACTION WITH
atrophic skin, Vemfoam Skin Traction Bandage.
A THOMAS'S SPLINT AND KNEE-FLEXION PIECE
• Support the leg on a soft pillow to keep the heel clear of the bed.
• Choose the correct size of Thomas's splint (see Chapter 2) .
• Pass the cord from the spreader O\·er a pulley attached to the end of e Fashion slings on the knee-flexion piece and the proximal part of the
the bed.
Thomas's splint, and line the slings with Gamgee tissue.
• Attach 5 to 71b (2·3 ro 3·2kg) to the cord.
• ElcYate the foot of the bed.
e Insert an upper tibial Steinmann pin. .
e Pass the prepared Thomas's splint over the limb, and rest the hmb on
Lateral rotation of the limb is not controlled by this method of the padded slings. Remember the large pad under the lower part of the
traction.
thigh.
e Check that the !-tinge of the knee-flexion piece lies at the level of the
adductor tubercle of the femur.
SLIDING TRACTION WITH A THOMAS'S SPLINT e Suspend the distal end of the knee-flexion pie~e by .two cords, one on
AND A KNEE-FLEXION PIECE each side, from the distal end of the Thomas s sphnt. The length of
cord is such that the knee is flexed 20 to 30 degrees. (The extende.d
Sliding traction in a Thomas's splint with a knee-flexion piece position is regarded as zero degrees and flexion is ~easured from t~IS
(Fig. 4.2) is often employed to obtain the reduction of an oblique or starting position-American Academy of Orthopaedic Surgeons, 196,).
spiral fracture of the shaft of the femur, and then to retain that With a supracondylar fracture of the femur, the distal fragment IS
reduction until union occurs. The use of a knee-flexion piece allows usually tilted anteriorly upon the shaft. To correct anterior tilting, ~nee
easier mobilisation of the knee. In addition knee flexion controls flexion is increased, the amount of knee flexion required being determmed
rotation, prevents stretching of the posterior capsule and posterior radiographically. The end of the knee-flexion piece may be suspende~
independently by a cord attached to a weight (see Chapter 5) . Thts
arrangement allows greater freedom of knee movement.
e Suspend the Thomas's splint (see Chapter 5). . . .
• Adjust the position of the thigh pad and the tensiOn m the shng sup-
porting the pad to obtain the normal anterior bowing of the femoral
shaft.
 4. SLIDING TRACTION 27
• Bandage the thigh into the Thomas's splint.
• Attach a Bohler stirrup and cord to the Steinmann pin.
• Pass the cord OYer a pulley at the foot of the bed so that the cord is • Push the Thomas's splint into the groin as far as possible and at the same
in line with the shaft of the femur. dme apply gentle steady traction to the cords. This achieves the optimal
• Attach a weight to' the cord. position.
• Ele,·are the foot of the bed. • Tie the cords over the distal end of the Thomas's splint using a reef knot.
• Loop two pieces of tape around each side bar of the Thomas's splint,
one at the padded ring, and the other level with the foot.
SLIDI~G TRACTION WITH A 'FIXED' THOMAS'S • Fashion slings of domene (see Chapter 2) and adjust the tension in the
SPLINT slings w maintain the normal anterior bowing of the shaft of the femur
and uniform support of the limb. A thigh pad may be used to maintain
the anterior bowing of the shaft of the femur, but its use is not essential.
When sliding traction with a Thomas's splint is employed in the • Tie a traction cord co the end of the Thomas's splint using a clove hitch,
treatment of a fracture of the shaft of the femur, there is a tendencv then pass the cord over a pulley at the foot of the bed and attach it to
for the splint to slip down the limb. This can be avoided by th~ a spring clip.
careful arrangement ~f the suspension cords (see Chapter 5) or by • Clip a weight to the traction cord. A weight of 18 lb (8·2 kg) is adequate
fixing the traction cords from the patient to the splint, and then for most adults.
pulling on the splint. By this means the traction force passes \'ia the • Suspend the Thomas's splint (see Chapter 5, Method 4) so that the heel
splint to the lower limb (Strange, 1972). A knee-flexion piece is not is just off the bed, and the traction cord is in line with the splint.
used. • Elevate the foot of the bed.

APPLICATION OF SLIDING TRACTION WITH A 'FIXED'

TH0~1AS'S SPLIKT (Strange, 1972)
SLIDING TRACTION IN A FISK SPLINT
See Figure 4.3.
• Choose the correCt size of Thomas's splint (see Chapter 2).
• Pass the Thomas's splint o\·er the limb while maintaining gentle manual The treatment of fractures of the femoral shaft and tibial condyles
traction. with sliding traction in a Fisk splint (Fig. 2.6) differs from other
• Vnder local or general anaesthesia, insert a Kirschner ''ire or Steinmann conservative methods (Fisk, 1944). With fixed traction in a Thomas's
pin through the upper end of the tibia. \'\'hen a Kirschner wire is used splint the knee is held in almost full extension, and little movement is
it must be tensioned with the special Kirschner wire strainer (Fig. 1.3) possible. With sliding traction in a Thomas's splint with a knee-
using right-angled washers. The Kirschner wire strainer must be kept flexion piece, some active flexion and extension of the knee is possible,
,·enical. If it is allowed to lie on the crest of the tibia e,·en for onh· a but little movement occurs at the hip, which is in flexion. \Xfhen a
short time, a pressure sore will de,·elop. · Fisk splint is used, the patient, as soon as possible, begins assisted
• Insert 'S' hooks with cords attached into the holes in the right-angled movement of the lowc:r limb, which is moved as one unit as though
washers.
the patient were walking. Passive movements are not encouraged
• Twist the cords twice around the side bars of the Thomas's splint.
(see Chapter 5).
Inhibition of muscular contraction is usually present for the first
few days, but within two to three weeks powerful contractions are
established. While the li mb is exercised, variations in the line of the
traction cord relative to the long axis of the femur, and angulation
at the fracture site occur, but neither appear to adversely influence
the result. Clinical union is present at four to six weeks and sound
bony union occurs commonly by twelve weeks at which time a wide
range of movement at the knee is present.

Figure 4.3 Sliding traction with a 'fixed ' Thomas's 5plint. :-:ote that the Kirschner
APPLICATION OF SLIDING TRACTION WITH
wire strainer must be kept ,·ertical {Strange, 1972). A FISK SPLINT
• Adjust the splint to accommodate the limb (see Chapter 2).
• Fashion slings to support the thigh and calf.
 4. SLIDING TRACTION 29
• Insert an upper tibial Steinmann pin under general anaesthesia for
fractures of the femur. Use skin traction for fractures of the tibial
condyles.
• Attach a traction cord to each end of the Steinmann pin (Fig. 5.10) and
tie these cords, which must be long enough to clear the foot, to a
trans,·erse wooden rod about 6 inches ( 15·0cm) long.
• Pass the prepared splint o,·er the limb.
• ~1anipulate the fracture (see Chapter 3).
• Adjust the position of the thigh pad to maintain the normal anterior
bowing of the femoral shaft.
• Tie a single cord to the centre of the wooden rod, pass the cord O\'er
a pulley at the foot of the bed and attach a weight. After six weeks
the initial traction weight is reduced to 6 to Sib (2· 7 to 3·6 kg).
• Suspend the F isk splint (see Chapter 5).
• Check that the traction cord is in line with the shaft of the femur (when
a Steinmann pin is used) when the splint is suspended and the hip is
flexed 45 degrees.
• Elevate the foot of the bed.

HAMILTON RUSSELL TRACTION Figure 4.4 Hamilton Russell traction.

Hamilton Russell traction (Russell, 1924) is used in the management

of fractures of the femoral shaft and after arthroplastv operations on
the hip. -
APPLICATION OF HAMILTO~ Rt:SSELL TRACTIO~
See Figure 4.4.
• Apply skin traction to the limb below the knee.
• Attach a pulley to the spreader.
• Place a soft broad sling under the knee.
• Support the limb, with the knee slightly flexed, on two soft pillows, one
abo,·e and the other below the knee, with the heel clear of the bed.
• Attach a length of cord to the knee-sling.
• Pass the cord over pulley A which is pl~ced well distal to, 1101 proximal
to the knee, round one of the pulleys B, round pulley C and then
around the other pulley B before attaching it to a weight. The pulleys B
must be at the same level as the foot of the patient when the leg is lying
horizontally on a pillow (Fig. 4.4). Figure 4.5 Theory of Hamilton Russell tractio n. The construction of a parallelogram
• EJe,·ate the foot of the bed. of forces shows that the resultant force: acts in the line of the femoral shaft.
SuggeSTed u•eighrs:
Adults-8 lb (3·6 kg).
Infants and older child ren- t to 4 lb (0·28 to 1·8 kg).
TULLOCH BROWN TRACTION
Theory of Hamilton Ru ssell traction ( Fig. 4.5)
The two pulley blocks B at the foot of the bed nominallv double Tulloch Brown, or U-loop tibial pin, traction and suspension
the pull on the limb. In practice the pull is modified by th~ friction (Nangle, 1951 ) with a Nissen foot plate and stirrup (Nissen, 1971),
present in the system. The resultant of the two forces acting along is used for the management of patients who have had a cup arthro-
the cords pro\'ides a pull in the line of the shaft of the femur. plasty or pseudarthrosis operation on the hip, or who have sustained
n f ............... nf rht> <;h:~ft of the femur. It is not used in children.
30 TRACTION AND ORTHOPAEDIC APPLIA.~CES
4. SLIDING TRACTION 31

APPLICATIO~ OF TULLOCH BRO\'\;N TRACTJON

See Figure 4.6.
e Insert a Steinmann pin through the upper end of the tibia.
e Support the leg on slings suspended from the light duralumin U-loop
which is slipped OYer the ends of the Steinmann pin.
/\'ore: The proximal ends of the U-loop ha\·e two staggered lines of
holes (Figs. 4.6 and 4.8). This arrangement giYes a wide choice in the
mode of attachment of the U-loop to the Steinmann pin. By \·arying the
holes used, it is possible to ensure that the U-loop lies evenly on each
side of the leg.

Figure 4.8 Detail of l':issen foot plate and U -loop.

BRYANT'S (OR GALLOWS) TRACTION (Fig. 4.9)

Figure 4.6 Tulloch Brown U-loop tibial pin traction. Alternatively the traction cords
Bryant's traction (Bryant, 1880) is convenient and satisfactory for
can be arranged as for Hamilton Russell traction (Fig. 4.4). A ~issen foot plate can be the treatment of fractures of the shaft of the femur in children up to
attached to the U-loop to maintain dorsiflexion at the ankle. the age of two years. Over this age, vascular complications, which
are discussed later, may occur.
Care must be taken that the slings supporting the calf are not tight,
otherwise compression of the tissues of the leg will occur between the APPLICATION OF BRYA!"T'S TRACTION
proximal edge of the sling nearest the knee, and the Steinmann pin. • Apply adhesive strapping to both lower limbs (shaving is not necessary).
• Attach the Nisson stirrup {Fig. 4.7) to the Steinmann pin. This stirrup • (See below about the use of posterior gutter splints.)
enables the leg to be suspended and rotation of the limb to be controlled. • Tie the traction cords to an overhead beam.
• Mount the detachable Perspex foot plate on the U-loop to support the • Tighten the traction cords sufficiently to raise the child's bunocks just
foot (Fig. 4.8). The foot plate prevents equinus of the ankle. In addition, clear of the mattress. Coumer-traction is obtained by the weight of the
as the attachment of the foot plate to the U-Joop is not rigid, the leg pel vis and lower trunk.
muscles can be exercised.
• Usc a simple pulley (Fig. 4.6) or Hamilton Russell system (Fig . 4.4) for Children tolerate this position very well, and good alignment of
suspension.
the fracture is obtained. When treating a fracture of the shaft of the
• Elevate the foot of the bed .
femur in a young child, it is preferable to allow the fragments ro
overlap about.; inch (1·25 em), as subsequent overgrowth in length
of the femur occurs due to hyperaemia of the limb consequent upon
the fracture.
Fractures in children unite rapidly. It is therefore seldom
necessary to maintain traction for more than four weeks.
Figure 4.i ~issen stirrup.
Important: check the state of the cirwlacion in the limbs frequently,
'"'"''""''"""' ,..{ thn An .... nat- ,..( ttlnf'rulnr rrn•1nl·i rntinnt (~pp hPlou.r)
32 TRACTION AND ORTHOPAEDIC APPLIANCES
4. SLIDING TRACTION 33

Nicholson ec a/. (1955) recorded the blood pressure at the ankles

nf children aged 1 to 8 years whose lower limbs were in the position
ts for Bryant's traction. They found a permanent reduction in the
blood pressure at the ankles, which was in almost direct proportion
lO the hydrostatic pressure necessary to maintain a column of water
u the height of the ankles above the heart. This reduction in the
blood pressure was particularly proportional in children over the age
of two years.
These authors also investigated the influence of hyperextension
at the knees on the blood pressure at the ankles. They found, in
children under the age of two years, that hyperextension at the knees
with or without traction and irrespective of the position of the lower
limbs, did not have any appreciable effect upon the blood pressure.
In children over the age of 4 years however, the blood pressure at the
ankles was reduced to zero when traction was applied with the knees
hyperextended and when the lower limbs, without traction but with
the knees hyperextended, were raised to the vertical.
Nicholson era/. (1955) concluded that in Bryant's traction the
blood pressure at the ankles in children under the age of 2 years is
insignificantly affected even with hyperextension at the knees; that
Figure 4.9 Bryant's (gallows) tracrion. Note: Child's bunocks are lifted just off the
between the ages of 2 and 4 years the circulation is precarious; and
bed. Knees can be kept slightly flexed by applying posterior gutter splints (not over the age of 4 years the circulation is definitely impaired.
illustrated). Lidge ( 1959) stated that the use of Bryant's traction should be
limited to children under 4 years old and to those weighing less
than 35 to 40 lb ( 15·9 to 18·2 kg). .
The use of Bryant's traction is reasonably safe in children under
Vascular compZt:carion.s of Bryam's tracrion the age of 2 years. Between the ages of 2 to 4 years vascular
complications are more likely to occur, but their occurrence is less
A careful check must be kept upon the state of the circulation in likely if posterior gutter splints are applied to keep the knees in slight
both limbs, especially during the first 24 to 72 hours after the flexion. Over the age:: of 4 years the use of Bryant's traction is
application of the traction, because vascular complications may absolutely contraindicated.
occur in either the injured or the normal limb. In older children fractures of the shaft of the femur may be
adequately treated in Buck's traction or in still older and larger
HOW TO CHECK THE STATE OF THE CIRCULATION children by fixed traction in a suspended Thomas's splint.
• Obsen·e the colour and 1empera1ure of both jeer.
• Dorsiflex bozh ankles passively. Dorsijlexio11 should be full a11d painless.
If dorsiflexion is limited or painful, muscle ischaemia may be present,
therefore lower the limbs and remove all bandaging and adhesive 51rappi11g MODIFIED BRYANT'S TRACTION
immediazely.
Modified Bryant's traction is sometimes used in the initial manage-
A number of authors (Thompson and Mahoney, 1951; Miller
ment of congenital dislocation of the hip when diagnosed over the
er a/., 1952; Nicholson et a/., 1955; and Lidge, 1959) have reported
age of one year. Bryant's traction is set up as described above. After
vascular complications, Yarying from ischaemk fibrosis of the calf
five days abduction of both hips is begun, abduction being increased
muscles to frank gangrene, following the use of Bryant's traction in
by about 10 degrees on alternate days. By three weeks the hips should
children aged 3 to 8 years.
h ... f'.,tl., <>hrlnrtNi .
 4. SLIDING TRACTION 35
I MPORTA~T
1. Check the state of the circulation as described aboYe.
2. Occasionally, after an increase in the degree of abduction of the fracture, or through the lower end of the tibia or the calcaneus for a
hi~s, the child will become restless and scream repeatedly with pain. The tibial fracture.
pam results from stretching of the capsule of the hip joim by impinge- • Attach a Bohler stirrup to the Steinmann pin.
ment of the femoral head on the superior lip of the acetabulum. This • P lace the limb on the slings.
occurs when abduction is commenced before the femoral head has been • Attach a cord to the stirrup and pass the cord over the required pulley
pulled _down_ to li_e opposite the acetabulum. Decreasing the degree of as shown in Figure 4.10.
abducnon Will reheve the pain . • Attach a 7 to 10 l b (3·2 to 4·5 kg) weight to the cord.
• Elevate the foot of the bed.
This method of traction has certain disadvantages. The BQ.hler-
SLIDING TRACTION WITH A BOHLER-BRAUN Braun frame rests on the patient's bed, and cannot move with the
FRAME • patient. Nursing care is more difficult because the patient is not as
mobile as he would be for example in a Thomas's splint. The
Sliding traction with a Bohler-Braun frame (Bohler, 1929) can be patient's body and the proximal fragment of the fracture can move
used for the management of fractures of the tibia or femur. It is relative to the distal fragment which is cradled in the splint and is
mor~ commonly used on the continent of Europe. Although skjn therefore relatively immobile. This may predispose to the occurrence
tracn on can be employed, skeletal traction is usually used. of a deformity at the fracture site.
The Bohler-Braun frame is illustrated in Fig. 4.1 0. Also indicated
are the pulleys over which the cords pass when a femoral or tibial
fracture is treated.
PELVIC TRACTION
In pelvic traction a special canvas harness is buckled around the
patient's pelvis. Long cords or straps attach the harness to the foot
of the bed . When the foo t of the bed is raised, gravity causes the
patient to slide towards the head of the bed. The amount by which
the foot of the bed must b e elevated depends upon the patient's
weight: the heavier the patient, the more the foot of the bed m ust
be raised.
This type of traction is used often in the conservative manage-
ment of a prolapsed lumbar intervertebral disc. T h e function of the
traction is to ensure that the patient lies quietly in bed, rather than
to attempt to distract the vertebral bodies. The vertebral bodies can
be distracted b y traction, but the pull required is very much greater
than that which can be exerted by this arrangement.
Buck's traction, applied to both lower limbs, with the cords
attached either to the foot of the bed, or to traction weights, may
be employed also in the conservative managemen t of a prolapsed
lumbar intervertebral disc. Pelvic traction is superior, however,
Figure 4.10_ . Bohler· Braun frame, showi ng the pulleys whi ch are used when treating
femoral or n b1al fracrures.
because it leaves the patient's legs unencumbered and therefore able
to move freely.
A PP~ICATIO~ OF SLIDI~G TRACTION WITH
REFE RENCES
A BOHLER-BRA U~ FRAME
• S~spend slings between the hori zontal sides of the frame to support the (1965) Joim Afotion: Method of
rt.\IERICI\t' ACI\OEMY OF ORTHOPAEDIC SURGEONS
thigh and leg. Cover the slings with G amgee tissue. Measuri11g and Recordirtg p. 66. Reprinted 1966 by The Orthopaedic Association.
• Insert a Steinmann pin through the upper end of the tibia for a femoral
Edinburgh and London: Churchill Livingstone .
-l&ll&ll&ll&l. .. _ . __ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ __ _ __jL_~-~B~o~H~l~ER~,L
:~-~( 1929) Tit~ Trearmmc of Fracwus. English Translarion by Steinberg, 1\L E.,
• n Vi. Fill. 48. \"ic:nna: W . .Maudrich.
36 TRACTION A~D ORTHOPAEDIC APPLIANCES

5. Su sp ension of appliances
REFERE)\CES •comimu;d J

BRB:-:T, T. ( 18801 On the ,·aJue of 11 r

treatmem of hi.p disease and hip . ~ar~ e IS~hof the lower extremities in the
Lcmcer, i, 159. IOJUnes, " 11 the best means of obtaining it. One initial difficulty in understanding traction is the presence of the
Bl:CK, G. (1861 ) An impro,·ed method of treat' fi many cords attached to both the patient and the appliance. The
ca~es and a drawing.
TramaCiiom the • mg ractures of the thigh i!lustrated by
0 problem is simplified if it is recognised that the cords perform two
riSK. G. R. ( 19-14' The f f .\r.c York Academy of /llcdiCin<. 2. 232.
Lancer. i , 659. ractured femoral shaft: new approach tO the problem. distinct and separate functions: traction, described in Chapters l, 3
]o:-:ES. :\. R. ( 1953) John Haddv James . Jo~ml a1 OJ,, Bonearld]oim Surgcrl' 35-B 661
and 4, and suspension of the appliance. (In the illustrations, black
LlOG£ R T ( 19"9) Co I' ·.
' · · ~ mp 1cauons followmg Bn·an , · 1· •. ' ' · is used for suspension cords, and red for traction cords.)
Association, section on Orthopaedic Sur er~ ; s tractiOn ~ Ame~1can .\1edicaJ By suspending appliances the mobility of the patient is increased;
\ Bo11eand]ohu Surgcry,41 -A, 1540. g ·' nnual Meenng 19::>9. ]emma/ of
. 1JU£R, D. S., MARKJ~, L. and GROSSMA:-: E (19 5 2) I . . .
nursing is easier and the dangers of immobility-thrombosis and
extremitv in children America" ]all lal ·.;S · schaem1c fibrOSIS m lower embolism, pressure sores, muscle wasting, joint stiffness and con-
~ · E · - · n OJ urgery, 8 4, 3 J 7
. Al'GLE, . j. (19::>1) lnsrrumcms and Apparal/1<· iu Orrhopacd'rc.Surgcry, p. 9. Oxford:
Blackwell. tractures, pneumonia, decalcification, renal stones and urinary in-
~JCHOLSON, J. T., FOSTER, R . ."vi. and HEATH R - , fection -are decreased.
a pro,·ocative cause of circulaton• com r .' · D. (195::>) Bryan~ s
traction, The appliance is suspended from an overhead frame by a
Associarion, 157,415. • p lcauons. Journal of rhc Amcncan ,,1cdical
series of counter-weights attached to it by cords which run over
NISSEN, K. ( 1971 ) Personal communication
pulleys. A Thomas's splint can also be suspended by springs.
RusSELL, R. H. (1924) Fractures of the f~mu . r . ..
Surgery, 11, 491. r · a c mlcal Study. Bnmh Joumal of The overhead frame is generally referred to as a Balkan beam,
STRA!\G£, F. G. St. C. ( 1972) Personal communication although each manufacturer uses a different name for his own
THOMSO:-:, S. A. and .'v1.'\HONEY, L J (1951 ) V . . , . .
its relationship 10 fractures of. the ~ oJlkmann s 1 ~chaem1c contracture and overhead frame.
33-B, 336. emur. oumal of Bont and Joim Surgery,

THE BALKAN BEAM

Overhead wooden beams were introduced during the Balkan Wars
by a Dutch ambulance unit in 1903 ( Bick, 1948). Today the Balkan
beam is made from metal tubing which may be of round, square or
octagonal cross section, depending upon the manufacturer. The
methods of fixing the tubing to the bed differ, but the basic principle
is the same.
Two uprights, one attached to each end of the bed, are joined by
a longitudinal horizontal bar. Other shorter transverse horizontal
bars may be attached to the uprights and to the longitudinal
horizontal bar.
When a single Thomas's splint is tO be suspended, only a single
Balkan beam is required. One upright is attached to the centre
of the top of the bed, and the other upright is attached to the
same side of the foot of the bed as that on which the injured limb
lies. If two splints or a plaster bed are to be suspended, two
Balkan beams are required. The Balkan beams are attached to each
side of the ends of the bed, and are joined together by the transverse
horizontal bars.
37
 38 TRACTION AKD ORTHOPAEDIC APPLIAJ\:CES 5. SUSPENSION OF APPLIAI"CES 39

SUSPENSION CORDS Ltft over

Barrel hnch
Sash cord generally is used to suspend appliances. Easier recognition
of the function of each cord in a traction-suspension system is
possible if cords of two different colours are used, for example, red
or green for traction cords, and \\'hite for suspension cords.
=$=
II
The cords must be attached firmly to the appliance. If they slip,
the efficiency of the system is reduced and the patient may be Hold
injured. Many of the remarks made below apply also to the attach-
ment of traction cords.

KNOTS
CLOVE HITCH (Fig. 5.1 ) . A clove hitch is the best knot to use to
attach a cord to an appliance, as it is self tightening and therefore is
less likely to slip. It can be reinforced if necessary with a half hitch.

BARREL HITCH (Fig. 5.1). A barrel hitch is used to attach a single

Pull Reef knot
cord to a loop of cord. The position of the knot on the cord can
be altered easily, by sliding the knot along the loop. When the Figure 5.2 How to com·ert a barrel hitch imo a reef knot.
correct position is obtained, the barrel hitch is convened to a reef
knot as shown in Figure 5.2. . . 5 1) The cords attached to spring clips
of a barrel h1tch (Fig. · · ? d ·nto the tape loops
.1 . dog's lead are c1tppe 1
s m1lar to those on ~ . '. b ed ro attach the cords to
REEF I<KOT (Fig. 5.1). The cords used in traction-suspension systems ( Strange, 1972) . Spnng chps may e us
should not be joined, as the knots may jam in the pulleys. If it the weights.
should be necessary to join two lengths of cord, a reef knot is used.

PULLEYS
. I the direction of action of the
The function of a pulley IS to contro . e the pulley. Bv
h d of the cord passmg ov r .
weight attach~d to t e en f he cord and the pulley, or by
altering the Site of attachme~ ~e \ stem, the force exerced by a
usmg more than one_ pulley dl Th's ~s termed the mechanical ad-
Clove hnch Barrel hnch Reef knot
Figure 5.1 Clo,·e hitch, barrel hitch and reef knot.
given weight can be Increase . I
vanr.age of the system. . 2t inches (5·0 m 6·25 em) diameter
After a knot is tied, the cord is cut about 2 inches (5· 0 em) away Large p_ulley wheels o~ 2 to r axles are preferable. Small rough
from the knot. The free end is bound to the main cord with a short and with t mch ( 6 mm) dlamete ~ l thes lines are less efficient.
length of zinc oxide strapping. T his further reinforces the attach- cast pulley wheels, such ashusel d orpcll'oed by the' manufacturers of
ment of the cord to the appliance. · · of pulley w ee s sup . .
The ma)Ortty f T ffnil nylon or a s1m1lar
Even a clo\'e hitch may slip on the side bars of a Thomas's splint. orthopaedic supplies are made ro~ k~pt ciean and oiled where
This can be prevented by wrapping a short length of zinc oxide synthetic material. All pulleys must e
strapping around the side bars OYer which the knot is tied.
necessary. k (F - 3) consists offour small wheels
The attachment of the cord to a Thomas's splint can be simpli- A compound pulley bloc tg. :>. . ·I all enclosed
fied and time sa,·ed by using short loops of linen rape. These d l ge wheel on tts own axe,
on a common axle an one ar b opened at one side to allow
loops are ried to the side bars of the Thomas's snlinr in rh~> "'"nn .... in a common frame. The frame can e
 5. SUSPENSIO~ OF APPLIANCES 41

Figure 5.3 A compound pulley block, used in suspension ofThom as's splint (Fig. 5. 7)
and plaster bed (Fig. 5.1 1).

the cords to be slipped on and off the wheels. The cords attached
to the appliance usually are looped over the smaller wheels, but if a
pulley system with an increased mechanical advantage is required,
the compound pulley block can be inverted. This arrangement is
used in suspending a plaster bed (see page 50).
When suspending a Thomas's splint, the pulleys must be
positioned correctly as the directions in which the cords run from
the splint to the pulleys are important. The cords by their direction
of pull keep the ring of the splint around the root of the limb
raise the splint off the mattress and thus enable the patient to mov;
freely, and at the same time maintain the splint and thus the distal
fragment of the fracture in correct alignment with the proximal
fragment (Fig. 5.4).
Figure 5.4 The distal fragment must be reduced to the proximal fragment. Wi_th a
fracture at the juncrion '> f the middle and upper thirds of the femur, the prox1mal
fragment is abducted as well as flexed, while the distal fragment is ad~ucted. T~e
CONTROL OF ROTATION splint, carryi ng rhe distal fragment, muse therefore be abducted, otherw1se there w11l
be a varus deformity at rhe fracture sire.
Rotation of the Thomas's splint around its long axis must be con-
trolled, to prevent the limb from slipping off the splint and to
prevent union of the fracture occurring in mal-rotation. Rotation is
most likely to occur in a lateral direction. body suspended in the appliance, the mechanical advantage of the
The methods employed to control rotation are described below. system employed for suspension, and the amount of friction present
in the system.
The actual amount of weight required is determined by observ-
SUSPENSION WEIGHTS ing the behaviour of the suspension_ syste~. When the_ co_rrect
amount of weight is obtained, the appltance wtll move readily m all
The amount of weight required to suspend an appliance depends directions with little effort on the part of ~he patient, •vill return
upon the weight of the appliance, the weight of the pan of the quickly to the position of rest, and will maintain the appliance in its
correct relationship ro the patient.
42 TRACTI0:-1 A:-.10 ORTHOPAEDIC APPLIA~CES 5. SUSPE).;SION OF APPLIANCES 43

.\1.ETHODS OF SCSPENDING A TH0~1.AS'S SPLINT rasses close to the patient's face, the ring of the splint is not
oldequately retained in the groin, and the patient's mobility is limited.
Fracture boards are placed under the mattress to ensure a firm
base.
A suspended Thomas's splint is entirely free from the bed,
except at its upper end where the back of the padded r ing rests on
the mattress. The patient can raise his pelvis off the bed by pulling
up with his arms on a patient's helper, aided by downward pressure
on the bed with his other foot. The whole of the injured limb, from
the ischial tuberosity to the foot, mo,·es in one piece v.:ith the
patient's trunk, and therefore the position of the fracture is un-
changed.

Using cords) pulleys and 'U.!eights

A Thomas's splint may be suspended in a number of different ways
using cords, pulleys and weights. The details differ but the principles
are the same. ~---- ------ ------- w
l. The cords must be attached firmly to the splint. Different methods Fi~re 5.5 Method I. Suspension of Thomas's splint. Separate suspension cords and
of attaching the cords to the splint haYe been described abo,·e. we1ghts are attached to each end of the Thomas's splint.
2. The Thomas's splint must not mo,·e independently of the Jo,,·er
limb. In fixed traction the counter-traction force is directed up the Method two (Fig. 5.6)
side bars of the splint (Fig. 3.1 ), and therefore the ring of the Two lengths of cord, one on each side, are attached to each end of
splint remains around the root of the limb. In sliding traction, the splint. Each cord passes over two pulleys. A suspension weight is
counter-traction is obtained by raising the foot of the bed to attached firmly to both cords at a point nearer the pelvis.
utilize body weight. The splint only supports the limb. If a Rotation is controlled by adjusting the length of each cord. By
cranially-directed force is not applied to the splint, the splint may shortening the outer cord slightly, medial rotation of the splint is
be pulled down the limb with serious consequences for the obtained.
position of the fracture. The disadvantages of this system are that the suspension weight
3. The pulleys must be positioned correctly and run smoothlv. is directly over the patient's thigh and, unless it is attached firmly
4. Rotation of the Thomas's splint must be controlled. • to the cords, it may fall injuring the patient, and the mobility of the
5. The suspension weights must be adjusted carefully. patient is limited.
This system of suspension is satisfactory for the suspension of
Method one (Fig. 5.5) a Thomas's splint when fixed traction is used.
Small loops of cord are formed between the side bars of the splint
at each end. The suspension cords are attached to the centre of each Method three (Fig. 5.7)
loop using a barrel hitch, and are then passed upwards and craniallY Dommisse and Nangle ( 1947) described a method of suspending a
to pulleys. From these pulleys the cords pass to other pulle::s Thomas's splint using a compound pulley block.
situated at the head or foot of the bed, before runnin~ 0 ,·enicallv• Two lengths of cord, one on each side, are attached to each end
down to "·eights. of the splint. These cords must not be too long. Both cords pass
Rotation of the splint is adjusted by moYing the position of the over the smaller wheels of a compound pulley block, situated over
knots on the proximal and distal loops, until the correct position is the patient's thigh. A cord passes up from the ring above the larger
obtained, when the barrel hitches are con,·erted to reef knots. wheel, over a pulley attached to the overhead frame, down and
The disad\'antages of this system are that the proximal cord round the larger wheel of the compound pulley block and then up
 7. SPIKAL TRACTION 63

• Draw a second line joining the rips of the mastoid processes (the plane
of the cen;cal articularions) which crosses the first line at right angles
(Fig. 7.4).
• Fully open out the tongs.
• \X'ith the fully open tongs J~;ng equally on each side of the antero-
posterior line, press the poims into the scalp making dimples on the
second line.
• Infiltrate the area of the dimples d0\\11 to and including the periosteum,
~ith local anaesthetic solution.
• .\1ake 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 parallelro rhe poims of rhe tongs. The drill point is inserted
to a depth of 3 millimerres in children, care being taken because of the
scanty diploic space, and 4 millimetres in adults.
• Fit the points of the tongs inro 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 (see page 64).
• Raise the head of the bed to pro,·ide counter-traction. Ele,·arion must
be increased as the traction weight is increased.

Failu re of the procedure _ ) · ·

No separate dnlhng · requtr~
· ~d · The special
Figure 7.:> ~ne (Ba~ton tongs.. I ds of the tongs and tightened alternately.
IS
Crutchfield (1954) stated that failure may be due to se,·eral factors. steel points are mserted mto the comca en
1. The use of a faulty instrument. \X!hen opened out fully, the
distance between the points should be 11 em and certainJy not
less than IOcm.
2. The pins must be long enough to prevent the arms of the tongs
from crushing the scalp, and they must be set obliquely enough
to ensure that they penetrate the diploe almost at right angles to
the line of traction.
3. Placing the drill holes too close together in the skull.
4. Insufficient penetration of the skull.
5. Failure to keep the tongs tight.
__!/
Cone (Barton) tongs
The tongs were designed by Barton (Cone and Turner, 1937).
A drill is not required for their insertion (Fig. 7.5). The threaded I .
Figure 7.6 Skull. mharkmg~ess
C ne ton s A vertical line through the mastoid
!o:eco~d line ~i;ecting the skull from front to back.
steel points are screwed into the parietal bones behind the ears. process crosses at ng t an

APPLICATION OF CONE (BARTON) TO:t--:GS

• Sedate the patient. :
•
~e:lptrp~~\~i~oa~;: :i: ~:a!o~~:~~~~sc;;~~s~~nfirmly ~gainst
. .
Insert both steel pomts mco e
the
th conical ends and ughten eac on
bl f the skull
~calp~
• Draw a line up from the tip of the mastoid process to cross the sagittal
plane at right angles (Fig. 7.6). alternately, driving the points through the outer ta eo .
• Sha,·e the skull abo,·e and behind the ears. • Attach a traction cord to the cwo lugs.
• Open out the tongs sufficiently, and determine where the conical ends • Attach a weight to the traction cord. (see page 6-l). . Elevation must
lie on the line dra\m abO\·e. • Elevate the head of the bed to ~rov~d~ councer-rracoon.
be increased as the traction wetght ts mcreased.
 7. SPIN AL TRACTION 65
Management of skull traction
Disloca tion or fracture-di slocation of the cervical spine These traction weigh ts are approximately correct for the various
The majority of serious injuries to the cenical spine result from levels of the cervical spine when the head of the patient's bed is •
forward flexion "·ith or without an element of lateral flexion, and are raised not more than 20 degrees for the purpose of counter traction.
therefore relatively stable in extension. Occasionallv extension in- Im portant : check daily tha t :
juries occur, in which cases the spine is stable in· flexion. In all 1. There has not been a change in the neurological examination
injuries, rotation of the spine is dangerous. of the patient.
It is not advisable to attempt a rapid reduction of a dislocation 2. The tongs are firmly applied to the skull. Tighten as necessary.
or fracture-dislocation of the cenical spine, as the spinal cord may 3. The scalp wounds are not infected.
be damaged if the initial pull is excessive. 4. The traction cord runs freely in the pulley and is not frayed.
Aims of t rea tm~n t 5. The traction weight is hanging free.
1. To avoid damage to the cervical cord.
2. To restore the antero-posterior diameter of the spinal canal. Complica tions of skull tr action
3. To obtain complete reduction of the dislocation or fracture- Skeletal traction applied to the skull may give rise to complications
dislocation. Although thi s is desirable it is not always possible. which may be fatal-osteomyeli tis of the skull, extradural haema-
A decrease in the antero-posterior diameter of the spinal canal of toma, extradural abscess, subdural abscess, cerebral abscess (Weisl,
less than 3 mm m ay be accepted (Rogers, 1957). 1971 ).
These complications may be heralded by pyrexia and headaches,
PROCEDURE and progress to fits, hemiplegia and coma. Examination of the
• Apply tongs as described abo\'e. cerebrospinal fluid and cerebral angiograph y may be normal. In the
• Apply minimum traction weight (see below). presence of osteomyelitis of the skull, radiographic examination may
• Take radiographs the foiiO\\ing day.
show radiolucent areas at the site of insertion of the pins.
• If reduction has not been obtained, gradually increase the traction weight.
It is rarely necessary ro more than double the minimum traction weight.
If infection is suspected, the scalp wounds must be swabbed to
• When sufficient distraction has been obtained- discover the infecting organism and its antibiotic sensitivity, and the
!. D o nor increase the traction weight further. tongs removed, another method of controlling the cervical spine
2. Extend the cenical spine by placing a small rolled towel or sand-bag being substituted.
under rhe neck (nor under the head as this \\ill flex the cenical spine,.
• \'\'hen satisfactory alignment has been obtained, reduce the traction
weight to 5 to 7lb (2·3 to 3·2 kg) to maintain the corrected position, Halo traction
until the spine is stable. This takes 6 ro 10 weeks.
• If a heavy traction weight is used initially, rake radiographs at 15 minute The halo traction apparatus ( Fig. 7 .7) consists of a jointed adjustable
inter\'als for at least one hour, or until it can be seen that the traction skull frame incorporated in a plaster jacket which extends from the
force is not too strong, and reduce the traction weight as soon as shoulders to the iliac crests, the neck being free from plaster (Perry
sufficient distraction has been obtained. and Nickel, 1959). This is a method of applying fixed skeletal
traction to the cervical spine, purchase on the body being obtained
R ecommende d traction weights, by the close moulding of the p laster jacket aroun d the iliac crests.
for correction of deformi ty only (Crutchfield, 1954). Patients in halo traction are ambulant.
Halo traction comprises:
Let.·cl ,\1inimum z::eighr Maximum weight 1. A U-shaped metal bracket fixed to the shoulder straps of the
Cl Sib (2·3 kg) 10lb (4·5kg)
C2 6lb (2·7 kg) plaster jacket.
10 to l2lb (4·5 to 5·4 kg)
C3 Sib (3·6 kg) 10 ro 15lb (4·5 to 6·7 kg) 2. Two angled vertical steel rods fitted into vertical sockets in the
C4 10lb (4·5kg) 15 tO 20lb (6·7 tO 9·0kg) U-bracket.
C5 l2lb (5·-!kg) 20 ro 25lb (9·0 to 11·3 kg) 3. An adjustable rectangular frame with three transverse bars (the
C6 l5lb (6·/ kg) 20 to 30 lb (9·0 to 13·5 kg) anterior and middle bars carry the three supporting arms of the
C7 l8lb (8·2kg) 25 to 35lb (11·3 ro 15·8 kg) halo; the posterior bar gives rigidity) attached to the upper ends
of the vertical rods.
 7. SPINAL TRACTION 67

• Lie me patient over the end of an operating table 'vith the shoulder
pieces of the jacket projecting over the end of the table.
• Maintain control of me cervical spine by manual traction.
• Shave the patient's head for a distance of about 2 inches (5·0 em) around
each screw sire, and prepare the partly shaven scalp.
• Scrub up.
• Advance one screw in each quadrant about! inch ( l·25cm) through a
selected screw hole-use the middle holes initially.
• Slip the halo splint over the skull and position it so that the lower
margin of the splint lies just above the ears and about t inch (6·0 mm)
above the eyebrows.
• Mark the point of penetration of the skull on the scalp with Bonney's
Blue, by sighting along the previously advanced screws. The anterior
screws are inserted in the shallow grooves on the forehead between the
supra-orbital ridges and the frontal protuberances.
• Remove the halo splint.
• Infiltrate each of the above marks with 2 to 3 ml of 2 per cent local
Figure 7. 7 Halo traction.
anaesthetic solution.
• Slip the halo splint on again and advance all the screws until they touch
4. The halo splin~--:-an oval steel band arched upwards posteriorly
the scalp at the previously marked points.
to clear the occ1pnal area, with four sets of three threaded holes
• Adjust the screws so that the halo splint lies symmetrically around the
at 2, 4, 8, ~d 10 o'clock. Four screws, one for each set of holes,
skull.
are passed mto the outer table of the skull. The screws ha,·e • Advance the screws using a torque-limiting screwdriver preset ro
small. sharp points which rapidly flare our onto broad shoulders, 5·51b inches (6·3~ kg cm) until slip occurs. The screws must be advanced
creaong a large area of contact against the skull ,,;th the mini- in diametrically oppoud pairs at the same time, to avoid side-to-side drifting
mum of penetration. of the halo splint. Incision of the scalp is not required. Tighten the
5. Three supporting arms fix the halo splint ro the rectangular locking nut on each screw.
frame .. All .the ~upporting arms can be adjusted in an antero- • Assemble the steel superstructure.
p~stenor d1recoon by aJtering the position of the anterior and e Fix the U-bracket to the plaster jacket v.ith plaster.
• Adjust the position of the halo splint to the desired position of the
m1~d.Je transverse bars. Lateral adjustment is b\' altering the
posJnon of the supporting arms on the transverse bars. cervical spine.
• Lock all movable pans of the apparatus by tightening all the nuts.
• Sit the patient up. It may be necessary to re-adjust the apparatus before
APPLICATION OF HALO TRACTION allowing the patient to walk, as some sinking of the plaster jacket may
The application of halo traction is carried our in rwo stages (Thompso
occur when the patient stands up.
1962; Nickel, et al., 1968). n,
Do not remove the Crutchfield tongs until the final adjustments
Application of the plaster jacket
have been made.
• F!t Crutch.field tongs to control an unstable spine.
• Sn the paoent on_: stool w.ith vertical traction on the Crutchfield tongs.
Management of halo traction
• Place 11 mch (3· f:J em) th1ck sorbo-rubber or orthopaedic felt 0\'er the
shoulders. l. Examine the scalp wounds DAILY for the presence of infection.
• ~pply a plaster jacket from the shoulders do'm to the iliac crests, where
If a cranial screw site becomes infected, swab the wound to
lt must be moulded accurately. discover the infecting organism and its antibiotic sensitivity, then
• Return the patient to his bed. insert a new sterile screw through an adjacent hole. Tighten the
Fitting of the traction apparatus-48 hours later new screw with a torque-limiting screwdriver before removing the
• ~oose a halo splint which is about i inch (1·25 em) larger than the infected screw.
Clrc~mference of the patient's head. Autoclave the splint, screws and 2. DAILY for the first week check the tightness of the cra11ial screws.
locking nuts. Each cranial screw is checked as follows. Hold the cranial screw
steady with an ordinary screwdriver while loosening the locking
 68 TRACTION AND ORTHOPAEDIC APPLIA>'CES 7. SPINAL TRACTION 69

nut with a spanner. Tighten the cranial screw with a torque- 'halo traction', except that posteriorly the band does not arch
limiting screwdriYer preset to 5·51b inches (6·3-1 kg em) until slip upwards to clear the occipital area, and it is drilled and tapped
occurs. Hold the cranial screw steady, again using an ordinary around its perimeter to accept screws for the attachment of the four
screwdrh·er, while re-tightening the locking nut. By holding the extension bars.
cranial screw steady while the locking nut is being loosened and Each threaded rod transfi..xes one wing of the ilium, follO\\ing
tightened, rotation of the locking nut will not be imparted to the the ilio-pectineal line beneath the iliacus muscle and passing through
cranial screw. four cortices of bone in the thickest portion of the pelvis (Fig. 7.9).
3. U'lash the patient's hair once or zwice each v.:eek.
P.S.I.S.
4. Check that pressure sores are not de-veloping under the plaster jacket,
especially around the pelvis.
5. Check that all the locki11g nuts on the superstmcwre are tight.
P.S.I.S.
H ala-pelvic traction lf//1/1//
Halo-pelvic traction (Fig. 7.8) consists of a halo splint connected by
four vertical extension bars to a steel pelvic hoop. The pelvic hoop
in turn is attached to two long threaded steel rods each of which
passes through one wing of the ilium (Dewald and Ray, 1970;
O'Brien et al., 1971 ).

Hemi pelv•s seen from above Lateral aspect of pelvis

Figure 7.9 Halo-pelvic t.r action. Each threaded rod transfixes one wing of the iliu~,
passing through four cortices of bone from just above and lateral to the amenor
superior iliac spine (.'\.$.!.$.) to the posterior superior iliac spine (P.S.I.S.) on the

~I
same side.

e The pelvic hoop, which must be of large enough diameter to allow

; , <l> a gap of 1 tO It inches (2·5 to 3·8 em) between the patienr'.s skin
and the hoop, is attached to the threaded rods by four unl\:e~sal
/ \ ....__
clamps. Superiorly the extension bars are attached ro the halo splint.
Inferiorly they pass through four universal clamps, different from
those which clamp rhe pelvic hoop to the threaded rods, on the
pelvic hoop. Locking nuts are placed on each extension b.a:, one
above and the other below the clamp. By adjusting the poswon of
these locking nuts, the effective length of the extension bars ~an
Figure 7.8 Halo-pelvic traction. be increased, thus increasing the distance between the halo sphnt
and the pelvic hoop and thereby exerting a distraction force upon
This form of skeletal traction may be used to immobilize the the spine.
spine or to slowly correct or reduce deformities of the spine, such
as occur in scoliosis and tuberculosis, before spinal fusion is carried APPLICATION OF HALO-PELVIC TRACTION
Halo-pelvic traction may be applied under endotracheal anaesthesia or
out. The halo-pelvic apparatus remains in place during the operation after the administration of Ketamine Hydrochloride ( Ketalar, Parke-
and for a \'ariable period of time afterwards. Patients in halo-pehic
Davis).1r
traction may remain ambulant.
_...,_______:T:...:h:.:..e:...:.:h.::.a:.:lo:....::!::::..:n~t is basically similar to that described abo\·e under " See Appendix.
 7. SPINAL TRACTIO~ 71

Halo spli nt, pelvic rods and hoop

Under full aseptic conditions, apply the halo splint as described under 10 o'clock, and attach the upper end of each extension bar to the halo
'Halo Traction'. splint. .
• Mount a threaded rod in a hand brace. • Carefully adjust the position of the universal clamps o~ the pelnc h~op
• .\1ake a small stab wound just abO\·e and lateral to the anterior superior so that the extension bars lie evenly disposed on each stde of the paoenr
iliac spine on each side, in order that the threaded rod \\ill enter and do not interfere with movement of the upper limbs. The extension
bone ar the v.idest pan of the ilium. bars may have to be contoured, when there is a large rib hump or
• Position the drilling jig (Cass and Dwyer, 1969). Place the posterior end pel~ic obliquity, to avoid pressure on the skin. . .
of the jig o,·er the posterior superior iliac spine, and then insert the • Screw the upper locking nuts down onto the clamps to mamtam ~e
anterior end of the jig through the stab wound 0 11 rhe .~ame side until it correct length of the extension bars before screwing up the lower locking
impinges upon the pehis jusr abo,·e and lateral ro the anterior superior nuts.
iliac spine. Tighten the jig. The use of the jig ensures the correct • Release the traction on the halo splint.
positioning of the threaded rods. • If the position of the extension bars is satisfactory, tig~ten all s~rews
• Check the position of the jig by pushing a Steinmann pin through the and nuts on the halo splint, extension bars and pelvtc hoop wnh a
anterior parr of the jig imo the ilium. spanner, Allan key or screwdriver. Remember that the cr::ni~l. screws on
• Insert the mounted threaded rod into the jig and drill it through the the halo splint must be tightened only with a torque-brruong screw-
wing of the ilium in an anrero-posrerior direction, removing the jig when driver.
the point of the rod emerges posteriorly from the bony pelvis. • Return the patient to the ward.
• Insert the second rod through the opposite wing of the ilium in the
same manner.
• Apply small dry dressings around the entry and exit wounds. Mana gement of halo-pelvic traction .
• Clamp the pelvic hoop ro the threaded rods, arranging the hoop ro lie 1. Every patient in halo-pelvic traction must be exarmned DAILY,
evenly around the pelvis in a horizontal plane. The pelvic hoop if especially while distraction is being carried out, for the presence
possible should lie abo,·e the threaded rods as this allows the patient ro of any neurological complications (see below). . .
sir more comfortably v.ithour the threaded rods impinging on the thighs. 2. Examine the scalp wounds DAILY for the presence of mfectlon (see
Howe\'er, to ensure the horizontal positioning of the peh·ic hoop, the
under Halo traction).
hoop may lie either abO\·e or below the threaded rods on one or both
sides. 3. DAILY for the first week check the tightness of the cranial screws
• Remo,·e the lengths of the threaded rods projecting beyond the pelvic (see under Halo traction). .
hoop by cutting them with hea,·y-dury bolt cutters. 4. Examine the wounds around the pelvic rods at regular mtervals for
• Rerum the patient ro the ward. the presence of infection. If infection is p~esent,. s~va~ the ~v~~d
Extension bars. Fit the extension bars the follO\\ing day, after the to determine the infecting organism and tts anobtooc sensiOvtty.
patient has recO\·ered fully from the anaesthetic. This reduces the in- Infection at these sites usually responds rapidly to regular
cidence of respiratory complications. If the spine is unstable because of cleansing with an antibacterial solution and systemic antibiotics.
the presence of a fracture or fracture-dislocation, apply traction ro the 5. Ask the patient if he feels pain around the pelvic rods. Pain may
halo splint ro immobilise the spine unril the extension ba.r s are fitted. be caused by infection or loosening of the rods.
• Sir the patient comfortably on a stool. 6. Check that all the screws and nuts on the pelvic hoop and
• Apply traction to the halo splint so that the patient sits erect \\ith his
extension bars are tight. This must be carried out twice each
buttocks almost raised from the stool.
• Ensure that the cen·i cal spine is neither flexed nor extended. week until the apparatus is removed.
• Select four extension bars of adequate length. 7. Wash the patient's hair once or twice each week. .
• Position the second set of four universal clamps on the pelvic hoop so 8. Distraction. Lengthen the distraction bars each day by loosenmg
that they lie at the comers of a square, rwo antero-laterally and two the lower locking nuts and then screwing do'Wn each of the upper
posrero-laterally. locking nuts by two complete turns. Two complete turns equals
• Check that one locking nut is screwed well up on the lower threaded 0·1 inch (2·5 mm). Retighten the lower locking n uts.
portion of each extension bar.
• Insert the lo\\'er threaded end of each extension bar through one of the
It has been found that by delaying distraction for one week
uni\·ersal clamps. after the extension bars have been fitted, the incidence of neuro-
• Select suitable holes on the halo splint at approximately 2, 4, 8 and logical complications is decreased (Mannin.g, 1972). .
Distraction is continued until the destred correcoon has been
72 TRACTION A!-."D ORTHOPAEDIC APPLIA>;CES 7. SPI~AL TRACTIOK 73

achie,·ed, the patient suffers painful spasm of the neck muscles, or DEWALD, R. L. and R.w, R. D. (19i0) Skeletal traction for the treatment of severe
neurological complications (see below) occur. scoliosis. Journal of Bone and Joim Surgery, 5~-A! 233.
Complications of halo- pelvic traction \.1A:-<Nt:-\G, C. W. S. F. ( 1972) : Personal commumcanon. .. .
~10RTON, J. and 1•vt~LI:-\S, P. ( 1971) The correction of spinal deformmes by h~lo-pelvtc
(See also Complications of skull traction, page 65.) traction. Physiocherapy, 57, 576.
1. Superficial infection around the pelvic rods and cranial screws. NICKEL, V. L., PERRY, J., GARRETT, A. and HEI'I'ENSTALL, M . (1968} The _halo;
2. Loosening of the cranial screws and pelvic rods. a spinal skeletal traction fixation device. Joumal of Bone and Jomc Sw-g<ry, :)0-A,
3. Psoas spasm which causes difficulty in walking without assistance. O'B~;~~·, J. P., YAll, A. C. M. C., SMITH, T. K. and HoooSO:-\, A. R. ( 19!1)
It is relieved by removing the pelvic rods (O'Brien ez al., 1971). Halo pelvic traction. A preliminar~ re~~t on a ~ethod of exte_rnal skeletal fixanon
4. Neurological complications may result from traction lesions of for correcting deformities and mamtammg fixatton of the spme. Joumal of BaM
and Joim Surglry, 53-B, 217. . .
peripheral or cranial nerves or the spinal cord. They may be PERRY, J. and NICKEL, V. L. (1959) Total cervical spine fuston for neck paralySIS.
temporary or permanent. Journal of Bone and Joinr Surgery, 41-A, ~7. . .
Abducem nerve palsy- the patient is unable to move the affected ROGERS, w. A. ( 1957) Fracture and dislocanon of the cervtcal spme. An end-result
srudy. Journal of Bone and Joint Surgery, 39- A, 3~ l. .
eye in an outward direction. Contraction of the internal rectus THOMPSON, H. ( 1962) The halo traction apparatus. Journal of Bone and Jomr Surgery,
muscle eventually leads to internal strabismus and diplopia. 44-B, 655. . . B d
Glosso-phary11geal nerve palsy-the patient complains of difficulty WEISL, H. (19i l ) Unusual complications of skull cahper tracnon. Journal of on• an
Joim Surgery, 54-B, 1~3.
in swallowing anct· may choke. There is loss of sensation to touch
and taste over the posterior third of the tongue (Manning, 1972).
Recurrent laryngeal nerve palsy-hoarseness.
Hypoglossal nerve palsy- on protrusion, the tongue de,iates to the
affected side.
Brachial plexus palsy-either the upper or lower or all of the
components of the brachial plexus (C5, C6, C7, C8 and T1 ) may
be im·olved.
Spi11al cord-paraplegia. This is more likely to occur when
congenital scoliosis is being treated.
When any of the above neurological complications occur, dis-
traction must be discontinued immediately.
Paraeszhesiae in the discriburion of rhe !aural curaueous nen•e of zhe
thigh-may occur follov..ing insertion of the peh·ic rods. It settles
in one to two weeks without any specific measures being taken.
5. Death from respiratory insufficiency.
6. Cen·ical subluxation Cl on C2. This results from the incorrect
application of the appliance ,,;th the cervical spine in flexion
(Morton and Malins, 1971 ).
7. Osteoporosis of the vertebrae.

REFERENCES

C...ss, C. A. and DwYER, A. F. ( 1969) A drilling jig for arthrodesis of the hip.
Joumal of Bone and Joim Surgery, 51-B, 135.
and Tt:R..._ER, \\'. G. (I93i) The treatment of fracture-dislocation of the
Co:-\£, \'\'.
cen·ical \'enebrae by skeletal traction and fusion. Joumal of Bone and Joint
Surgery, 19, 58-t.
CRl..'TCHFIELD, \\'. G. 1933) Skeletal traction for dislocation of the cen·ical spine.
Repon of a case. Southern Surgeon, 2, 156.
CRt.:TCHFIELD, \X.'. G. (1954) Skeletal traction in treatment of injuries to the cen·ical
spine. Joumal of the American .'Wedical Association, 155, 29.
 r the years many spinal supports have been designed and later
1rtted. This development has occurred largely in the absence of
1• led knowledge of the biomechanics of the spine, \\;th the result
· the value, in mechanical terms, of many supports is doubtful.
h work is being done on the biomechanics of the normal spine,
' as yet little on the effect of spinal supports on function in
t \C'r the normal or diseased spine. This work must be increased
that supports which limit the different movements occurring in
h different regions of the spine can be designed, manufactured
' I prescribed with precision. Before spinal supports can be
, cribed, knowledge of the functional anatomy of the spine is
~·ntial. It must be remembered, however, that the movemen ts
l11ch occur in a particular region of the normal spine may differ
(rom those wh ich may be possible in the presence of disease.

I UNCTIONAL ANATOMY OF THE SP INE

\ fovements occurring in the different regions of the spine

I he spinal column is basically a segmented cylindrical structure
'hich subserves three main functions: protection of the spinal cord,
upport of the trunk, and transmission of the weight of the head,
upper limbs and trunk to the peh·is and lower limbs. The segmental
nature of the vertebral column confers considerable mobility upon
he spine by the summation of the small amounts of mo\·ement
that can occur between the indi\·idual segments.
The movements that occur in the spine are forward flexion,
l'Xtension, lateral flexion and rotation. The range of movement and
the directions in which it can occur differ in each region of the
,pine, depending upon the anawmical structure of that region.
Cervical spine
In the cervical region the range of forward flexion, extension and
lateral flexion is considerable. Rotation mainly occurs bet\\'een the
atlas and axis. Below the le\·el of the axis, the upper articular facets
of the pos terior articulations face posteriorly and slightly upwards,
and the lo.ver facets anteriorly and slightly do>vnwards. This con-
figuration ?f the articular facets prevents rotation occurring between
the individual cervical vertebrae ( C2 to C7) without concomitant
lateral flexion.
75
76 TRACTfO).: .o\).:D ORTHOP.o\EDIC APPLB~CES 8. SPINAL SUPPORTS (THORACO-LUt\1BAR AXD CERVICAL) 77

Thoracic spine the hamstring muscles and the mobility of the lumbar spi?e. For .
In the thoracic region, the ribs limit rotation less than they limit this reason, the range of lumbar flexion should be .rested m ~oth
mon.!menrs in the other directions. The articular facets of the the standing and sitting positions. The lumbar spine 1s substanually
posterior articulations lie in a nearly ,·ertical plane, the upper flexed when sitting erect, and the flexion is increased markedly 'vhen
pair facing posteriorly and Yery slighrly laterally, and the lower pair sitting slumped, the degree of forward flexion betv:een the fourth ~d
facing in the opposite direction. This configuration allows up to fifth lumbar vertebrae actually exceeding that observed dunng
6 degrees of rotation between adjacent Yertebrae (Gregersen and ma.ximal forward bending (Norton and Brov..n, 1957). As mo,·ement
Lucas, 1967). The centre of a.xial ro~ation in the thoracic region of the lumbar spine largely occurs secondary to mo,·em~nts of_~e
lies within or anterior to the inten·enebral disc. Lateral flexion in lower limbs on the trunk (Troup et al., 1968), absolute tmmoblhs-
this region is accompanied by some degree of rotation. ation of the lumbar spine cannot be achieved by extern~! support
Lumbar spine without severely restricting the movements of the lower hmbs.
In the lumbar region, forwa.rd flexion, extension and lateral flexion
are free, bur rotation is limited nor so much by the configuration
Vertebral stability and control of spinal movenzents
of the articular facets of the posterior articulations which on trans-
verse sections are curYed, as by the annulus fibrosus which restricts The vertebral column depends for its stability upon the structure
lateral displacement of adjacent vertebral bodies. The superior and integrity of the individual vertebrae and the soft tissues which
~nicular facets, situated further apart than the lower pair, face control and bind them together.
mediaJJy and slightly posteriorly, while the lower pair face laterally The movement of the vertebral column as a whole is comrolled
and slightly anteriorly. The centre of axial rotation in the lumbar by muscles which bridge many segments, the sacrospinalis muscles,
region lies posterior to r.he articular processes. Up to 10 degrees of the psoas, the diaphragm, the abdominal muscles a~d other muscles
rotation can occur at r.he thoraco-lumbar junction. A further 10 of the trunk. Movement of individual segments IS controlled by
degrees of rotation can occur ben,·een the first and fifth lumbar muscles which bridge only one or two segments. ·
Yertebrae in the sitting position, this being increased to 16 degrees The paravertebral muscles can be di,ided into three groups. ~he
in the standing position (Gregersen and Lucas, 1967). Approxi- longitudinal group, the sacrospinalis muscles, are most superfic~al.
mately 6 degrees of rotation, which is always associated with flexion They bridge many segments and form a large muscular ~ass wh1ch
of the fifth lumbar vertebra on the sacrum, can occur at the lumbo- is thickest in the lumbar region. The muscles of the o~hque gro_up
sacral junction (Lumsden and Morris, 1968). lie deep to the sacrospinalis muscles and includ~ multifidus wh1ch
Durir.g walking, the pehis and shoulders rotate in opposite is thickest in the lumbar region, and rotatores "'·h1ch are confined to
directions, the amount of rotation depending upon the length of the thoracic region of the spine. The muscles of the oblique group
each step. Gregersen and Lucas (1967) found that during walking and the still deeper situated intersegmental group, interspinales and
5 degrees of rotation of the pectoral girdle occurred in one direction imertransversarii, bridge only one or two segments. .
measured at the le\·el of the first thoracic ''ertebra and, at the peh·is, Electromyography of the paravertebral, psoas and abdor:un~l
6 degrees in the opposite direction, the transition point lying ber,,·een muscles give some indication of their function. The ~acrospmahs
the sixth and eighth thoracic ,·errebrae. Lumsden and Morris (1968) muscles exhibit some activity when sitting and standmg ( ~1orns
calculated that approximately 1·5 degrees of rotation occurred at the et al., 1962; Nachemson, 1966), this activity being greater m the
lumbo-sacral junction during normal walking. lower thoracic and upper lumbar regions of the spine (Joseph and
The range of lateral flexion is greater in the upper region of the McColl, 1961 ). They and the oblique group of muscle~ are. nlsn
lumbar spine than in the lower, being maximal at the L3 4 level active during forward flexion, this acti,·ity being increased 1f wetghts
(Tanz, 1953), \\'hereas the range of forward flexion is greater in the are held in the hands (N achemson, 1966). Activity decreases w~cn
low~:r region of the lumbar spine than in the upper, being ma.'i:imal the fully flexed spine is at rest, multifidus and rotatores then bctng
at the L4 5 and L5 Sl le,·els (Tanz, 1953; Allbrook, 1957). In inactive. During the early stages of extension of the flexed trllnk,
forward flexion from the standing position, mo,·emem occurs both there is little electromyographic activity in the paraverteb:al mu~c~:s,
in the lumbar spine and at the hip joints. The distance, therefore, extension occurring mainly at the hip joints ( Floyd and Stl,·er, IQ,,).
between the finger tips and the floor, on carr~ing out this manoeune Later this activity increases, but decreases again as the erect po~lttOn
\'aries from one indi,idual to another depending upon the length of is regained. \Vhen extension from the erect position is forced, th
 78 TR.-\CTIO:-\ :\~D ORTHOPAEDIC APPL!A:-\CES
8. SPII'AL SUPPORTS ( THORACO-LuMBAR Al"D CERVICAL) 79
sacrospinalis muscles, but not multifidus, are active (.\iorris ec al
1962\ ., THORACO-LUMBAR SPINAL APPLIANCES
. ~are~al flexi?n ~rom the erect position is accompanied by definite
aco,·ny m the 1psllateral, bur only slight acth·itv in the contra- Function of spinal appliances
lateral, sacrospinalis muscles, suggesting that the;e muscles assist
gra\·ity. ~~ti\·ity is not greatly increased during assumption of the The many differen t spinal appliances which have been designed
erect posmon. can be divided into two groups, supportive and corrective. They are
. In the_ ere~t ?osition, the sacrospinalis muscles are generallv used co relieve pain, to support weakened or paralysed muscles and
aco,·e dunng lpsllateral, and the mukifidus and rotatores durin~ unstable joints, to immobilise me vertebral column in the best
contralateral rotation (Morri s cr a/. , 1962). "' functional position while healing occurs, to prevent the occurrence
. Ps~a~ i~. activ~ w~e~ sitting or standing erect, this actidty of deformity, and to correct an existing deformity. The supportive
mcrea~m, '' 1th any de~v1auon of the trunk from the vertical, especiallv group includes supports made from various fabrics (belts and
extensiOn ~d lateral flexion (Keagy eta/., 1966; }:achemson, 1966), corsets), rigid spinal braces, and those moulded from leather, plastic,
but decreasmg as the erect spine is flexed forward (>Jachemson plaster-of-Paris and Plastazote. Those appliances in the correcti\·e
1966). . > group produce an active corrective force in one or more directions.
During forward flexion and the early stages of extension of the The various functional advantages that have been claimed for these
.~exed trunk, especially if this action is associated wirh lifting, con- differenr appliances are difficult to evaluate.
Siderable forces are generated within the spine, particularly in the Investigations have been carried out in an attempt to determine
lumbo-sacral region. Comraction of the thoracic and abdominal the effect of various spinal supports upon the mobility of the spine
muscles an~ t?ose of the diaphragm and pelvic floor, raises the and the electrical activity of its controlling muscles. However, the
pressures_w1thm the tl1oracic and abdominal cavities and converts results of these investigations may not be applicable to patients
these ~a,:aies into rigid-walled structures, which are capable of suffering from disorders of the spine as the observations were made
trans~nmg forces produced during bending and lifting, and thereb\· upon people with normal spines.
reducmg the for~es ."·ithin the spine (Da,·is, 1956; Banelink, 195 7). Fabric supports restrict only the extremes of forward flexion and
The pressures w1tl1m the thoracic and abdominal cadties increase extension (VanLeuven and Troup, 1969), and have a variable and
as the \\"eight lifted increases (Da,·is and Troup, 1964). It is calculated unpredictable effect upon rotation at the lumbo-sacral junction
that these pressures decrease the force on the Jumbo-sacral disc bv (Lumsden and Morris, 1968). They decrease the activity of the
30 per cent and on the lower thoracic spine by 50 per cent (_r.,1orri.s paravertebral and abdominal muscles during standing but do not
r:t al., 1961 ). The mechanical ad,·amage of the pressure increases is have any significant effect during slow or fast walking (\'Caters and
greatest when the lumbar spine is flexed. These pressure increases Morris, 1970). However, when an (inflatable) corset produces
thus ha,·e the!r greatest effect during the acceleration phase of lifting sufficient abdominal compression to be uncomfortable, the acti\ity
before the spme begms to extend (DaYis and Troup, 1965). of the abdominal muscles on lifting decreases, indicating that the
The re_ctus a~domi~is is inacti,·e in standing and sitting (\Xlaters activity of the thoracic and abdominal muscles can be reduced by
and_ :\ 1orns, 19 t0). \\hen the trunk is raised from the supine external abdominal pressure (Morris et al., 1961).
po:mon, ~e rec~us abdominis and the external oblique muscles are The presence of an inflated corset also reduces the pressure
a:m·e, th1s acnvny being greater fro m 0 to 45 degrees, than from within ilie lumbar discs when standing (Nachemson and Morris,
4::> -~o 90 degrees,_the later mm·ement being primarily one of hip 1964). These findings may not be applicable to the fabric supportS
flexiOn. On lowenng the trunk, acti,ity is again greater from 45 to prescribed for patients.
0 degrees (Flint, 1965). Long spinal braces, for example the Taylor brace (see below),
The .load on the_ ~ntervenebral discs in the lumbar region and the plaster-of-Paris moulded spinal support, increase movement
depends ~pon the position of the trunk and the weight of the bodY at the lumbo-sacral junction, but decrease movement at the upper
above ~~t largely upon the tension denloped by the muscles of rh~ levels (Norton and Brown, 1957). Rotation at the lumbo-sacral
rru~~- I he pressures \\·ithin these discs are greatest in the sitting junction is restricted by short spinal braces when standing, but
posmon an~ ~re reduced by 30 per cent on standing and by 50 per increased when \va1king (Lumsden and Morris, 1968). They decrease
cent on reclmmg (Nachemson and Morris, 1964). the activity of the abdominal and paravertebral muscles during
standing, but do not have any effect during slow walking. During
80 TRACTION AND ORTHOPAEDIC APPLIAKCES
8. SPINAL SUPPORTS ( THORACO-LUMBAR A;ID CERVICAL) 81

fast walking the activity of the abdominal muscles is again un-

affected, but that of the paravertebral muscles is increased (Waters which encircles the pelvis, passing between the greater trochanters
and ~1orris, 1970). and the iliac crests on each side. It is fastened anterior!~ by straps
In spite of the apparent mechanical deficiencies of spinal sup- and buckles or hooks. Perineal straps may be added to prevent the
pons many patients obtain symptomatic relief from their use. This support from riding upv.:ards.
relief may be psychological, or may result from abdominal com- A l umbo-sa cr a l support (Figs. 8.1 and 8.2) is 8 to 16 inches
pression, from support of a pendulous abdomen and a concomitant (20 to 40 em) deep posteriorly. It extends up to the thoraco-lumbar
decrease in lumbar lordosis, from a change in the amount of junction posteriorly and coYers the entire abdomen anteriorly. It has
mo,·ement occurring in different regions of the spine, from a a closely fitting fulcrum strap, attached posteriorly, which passes
decrease in activity of the Yarious associated muscle groups, from around the pelvis between the greater trochanters and the iliac crests
local support of the sacro-iliac joints and ilio-lumbar ligaments, or and buckles firmly in the region of the symphysis pubis, thus
from a combination of all these factors. It is interesting that sub- obtaining a grip on the pel vis and giving a stable foundation to
jective support can be obtained by the application of non-elastic the support. Flexible or rigid vertical metal strips are incorporated
adhesive strapping to the lumbar and gluteal regions of the back. posteriorly on each side of the spinous processes to reinforce the
support and to provide a wide stable area posteriorly from which
the support can act on the abdomen. Further vertical metal strips
SUPPORTIVE SPINAL APPLIANCES can be added to increase rigidity. To ease pressure on the costal
Elastic gusset
Fabric spinal supports (Spinal belts and corsets) Flap intercostal
Spinal belts and corsets are the most commonly prescribed spinal
supports (Perry, 1970). The majority of these supports are made
from jean (twilled weaYe Egyptian cotton), coutil (herring-bone
wea\'e Egyptian cotton) or canvas (plain weave American cotton).
They can be made also from duck (light can,·as), rayon, nylon or
airtex (open weaYe cotton). They are reinforced as necessary with
bone or metal strips. Corsets e."Xtend further dO\\TI O\'er the buttocks
and upper thighs than do belts to giYe a smoother contour, and
therefore are prescribed for women. Belts are prescribed for men. Fulcrum band Keeper Fulcrum strap
Elastic gusset gluteal
These supports encircle the sacral region and extend a Yariable Figure 8.1 Lumbo-sacral support. T ypical minimum depth at the centre back is
distance upwards, the term applied to them (sacro-iliac, lumbo- chat from the tho raco-lumbar junction to the middle of the sacrum.
sacral, thoraco-lumbar) depending upon their depth posteriorly (see
below). In front they are fastened with straps and buckles, eyelets
and laces or hooks and eyes. In addition a fulcrum strap (Figs. 8.1
and 8.2), broad posteriorly where it is attached to the mid-line, and
narrowing towards the from , fastens in the front with a buckle.
Elastic insets may be let into the upper and lower margins to ease
the fitting over the costal margin and around the buttocks re-
spectively.
Fabric supports, even when reinforced with metal strips, do not
immobilise the spine; they only restrict the extremes of forward
and lateral flexion, and extension. They probably function by
supplying subjecti,·e support and by reminding the patient to avoid
moYements which may bring on or exacerbate his symptoms.
A sacro-iliac support is 2 to 6 inches (5 to 15 em) deep pos-
teriorly and basically consists of a wide belt of leather or fabric
F igure 8.2 Lumbo-sacral support can be fitted with suspenders or groin straps.
 8. SPINAL SUPPORTS (THORACO - LUMBAR AND CERVICAL) 83
margin, elastic gussets can be let into the upper edge. Perineal
~ s~r~ps or suspenders may be fitted to pre\"ent the support from Rigid spinal braces
ndmg upwards. The support is adjusted by straps and buckles or All spinal braces, except the anterior hyperextension brace described •
~yelets and laces. A 'quick release' panel of hooks and eves is often later, are constructed on the basis of a metal frame which takes firm
mcorporared. · support from the pelvis. Metal uprights, joined together by various
A tho~aco-Iurnbar support is more than 16 inches (40 em) deep cross bars, are attached to the pelvic support. Devices ro apply
postenorly, and extends upwards O\"er the scapulae. Padded shoulder pressure over the abdomen and over the front of the shoulders are
str~ps wh1ch ~~us~ ?e kept fairly tight are fitted. Otherwise the provided. The metal frame is padded with felt and covered with
bas1c c~nstrucn~n lS 1dentical \\·ith that of the lumbo-sacral support. leather.
It prondes cons1derable support. The metal frame must have a firm foundation on the pelvis to
. Wllen a support is worn by an obese, heavy-breasted woman, hold the appliance in contact with the body, and ro distribute the
a ndge of skin and subcutan eous fat can be trapped between the body weight, transmitted by the uprights, over a large area. This
u~per edge of the support and the lower edge of her brassiere. This can be obtained by using a pelvic band or a moulded pelvic corset.
d1fficuJry can be o~·~rcome by the addition of brassiere cups to the A pelvic band is made from flat metal bars which encircle the
support, or by adnsmg the woman to v•ear a 'long-line' brassiere. posterior and lateral aspects of the pelvis and press upon the
sacrum. These metal bars extend for a variable distance tovvards the
FITTJ::-.JG OF FABRIC SPJ}:AL St..:PPORTS midline anteriorly in different types of braces. A moulded pelvic
Check the support
corset ( Fig. 8.8) gives a firm grip around the peh·is. The corset may
• The support must be adequate for its intended function. be made of leather or plastic. A negative cast of the pelvis and
• II musr extend well down to the symphysis pubis.
abdomen is taken with plaster-of-Paris or Plastazote, from which a
• It must fit firmly and smoothly over the greater trochanters iliac crests
and buttocks. ' positive plaster model is made. The leather or plastic is moulded
• The ~sterior steel strips must follow closely the curves of the sacrum
over the plaster model.
and spme. The metal uprights attached to the pelvic support extend up-
• It must not interfere with hip flexion and sitting. wards for varying distances depending upon the length of spine tO
• It must not ride upwards. be supported. There are tw"O uprights posteriorly lying on each side
• Irmust be_ comfortable. Some patients who ha,·e not worn a support before of the spinous processes-the back lever. To obtain more rigidity,
may find It un_comfortable at first. They should be advised to graduallv further uprights can be attached laterally or anteriorly. The uprights
lengthen the ume they wear it, as they would do with new shoes. · are joined together by horizontal cross bars. When lateral or anterior
Instruct the patient uprights are present, the cross bar in the thoracic region extends
The fulcrum strap must always be firmly buckled. anteriorly around the trunk belo"". the axillae ( Fig. 8.4).
The other abdominal straps or laces must be tightened firmlY also Abdominal support is obtained by an abdominal plate (Figs. 8.3
although to ease pressure 0\·er the costal margin and thighs the. uppe; and 8.5) attached by straps and buckles to the metal frame, or by
and lowermost fastenings may be left slightly loose. a fabric corset (Fig. 8.4). Pressure over the front of the shoulders to
Immediate lumbar supports hold them back into the brace can be obtained by using padded
shoulder straps or clavicular pads which curve upwards and press
A fabric support m_ade to fit an individual patient takes time to on the chest wall in the infra-clavicular region.
manufactu:e. An eas~~y made and cheap 'instant' lumbar support has There are many spinal braces with the same basic construction
been descnb~d by ~1chols ez a/. (1966). A length of Tubigrip bod\" but called by different names. Some braces have withstood the test
b~dage of e1ther smgle or double thickness, extending from th~ of time, while the existence of others is perpetuated by the written
n1p_ples ro_ the upper thighs, is rolled onto the patient. With the word (Perry, 1970). Described below are some of the more commonly
patJent lymg prone, s.itting or standing, whichever is the most used spinal braces. The descriptions used are those found in the
comfortable, ~ ro 12 th1cknesses of 6 to 8 inches (15 to 20 em) "ide Surgicai Appliances Contract 1972 of the Department of Health and
plaster-of-Pans bandage are applied O\"er the spine from the th Social Security.
Ju b · · h oraco-
m ar )Uncuon tot e sacrum. The top and bottom of the Tubigrip Taylor spinal brace ( Fig. 8.3)
bandage are turned back and fi:-..:ed do,~-.n. In 1863, C. F. Taylor described a spinal brace, for use in the
treatment of tuberculosis of the spine, which can be considered as
 TRACTION AND ORTHOPAEDIC APPLlAKCES 8. SPINAL SUPPORTS (THORACO-LUMBAR AND CERVICAL) 85

Figure 8.3 Taylor spinal brace. -~

the prototype of all spinal braces designed to support the thoraco- Figure 8.4 Fisher spinal brace.
lumbar spine. It consists of a wide straight spring-steel peh·ic band
which ext_ends for~ard in front of the anterior superior iliac spines. Abdominal support is provided by a fabric corset which extends
The pelv1c band IS completed anteriorly with leather straps and forward from the lateral uprights and fastens in the mid-line
buckles. There are two parallel posterior uprights connected at the anteriorly. Well padded shoulder straps pass up from the tips of the
level of the scapulae by a cross bar made from a thin plate of a.xillary crutches, over the shoulders, cross posteriorly, and then
moulded steel . Above this le\·el the uprights gently angle outwards swing forwards again to buckle on the front of the corset on each
towards the shoulders. The steel frame is padded with a thin la,·er side level with the iliac crests.
of felt and cO\·ered with leather. · The axillary crutches are not designed to bear weight. If they
Shoulder straps, covered by upward extensions of the leather press into the axillae, nerve palsies will result. . .
covering the posterior uprights, pass from the uprights over the The Fisher spinal brace limits forward flex10n and extensiOn of
shoulders and back under the axillae ro be anached ro the cross bar. the lower thoracic and upper lumbar regions of the spine. Lateral
Abdominal support is prO\·ided by a rigid, padded, leather abdominal flexion is limited more than with the Taylor spinal brace. Rotation
pla:e, e~tending between the umbilicus and the symphysis pubis, of the thoracic spine is limited also.
wh1ch IS attached below to the peh·ic band and above to the Thomas or Jones spina l brace (Fig. 8.5)
posterior uprights by two straps which pass backwards around the This type of spinal brace was designed originally by H. 0. Thomas.
loins. Groin straps are fitted also.
The Taylor brace limits forward flexion extension and lateral
flexion of the thoraco-lumbar region of th~ spine and to some
exr_ent, rotation of the lumbar and lower thoracic regions of the spine.
It mcreases moYement at the lumbo-sacral junction (Norton and
Brown, 1957).
Fisher spinal brace ( Fig. 8.4)
The Fisher spinal brace was described originally in 1886. It consists
of a ~eta! pelvic band to \vhich two metal pelvic hoops, one on
each s1de, are attached . These peh·ic hoops arch over the iliac crests.
There are two posterior uprights and two adjustable lateral uprights.
A !ransv~rs_e metal bar, at the le,·el of the inferior angles of the
~cap~lae, )Oms the posterior and lateral uprights and ends anteriorly
m ax11lary cr~t_ches: ~~~ the metal pans except the lateral uprights
86 TRACTIO~ A~D ORTHOPAEDIC APPLIM\CES
8. SPINAL SUPPORTS (THORACO-LUNIBAR AKD CERVICAL) 87

It was used extensively by Sir Robert Jones instead of a plaster-

of-Paris moulded support, for the ambulant treatment of spinal of the thorax and abdomen, in the pectoral and inguinal regions
tuberculosis (Jones and LO\·etr, 1923). respectively, while the longer sides lie in the mid-a."illary lihe. Pads,
It consists of a large padded pelvic strap which is attached hinged on the metal frame, lie over the pubis and upper sternum.
posteriorly to a padded, leather-covered metal frame. Abdominal An elastic strap passes posteriorly from the side arms over the
support is pro,·ided by an abdominal pad to which are buckled thoracic spine and is kept sufficiently tight to hold the brace against
waist, peh·ic and groin straps. Shoulder straps pass from the metal the patient's body. Addltional pelvic and thoracic straps may be
frame o,·er the shoulders and under the a'l:illae to be reattached to added to keep the brace in position.
the metal frame at the le,·el of the inferior angles of the scapulae.
Moulded spinal supports
FITTING OF LONG SPINAL BRACES Moulded spinal supports fie the contours of the trunk and distribute
• Tighten the peh·ic band and ensure that the peh·ic band or peh·ic corset the body weight over a very large area. They can be made from
fits snugly around the peh·is. leather, plastic, plaster-of-Paris or Plastazoce. Their rigidity will
• Check that the posterior metal uprights follow closely the contour of depend upon the material used in their construction. A leather
the spine.
support can be reinforced by attaching metal bands. A Plastazote
• After checking the posterior uprights, tighten the shoulder straps if fitted.
support is less rigid than a plaster-of-Paris or plastic support, but
• Fasten the groin and waist straps, abdominal plate or fabric corset if
fitted. it is light and comfortable to wear, and can be moulded directly
• Check that the axillary crutches, if fitted, do not press into the axillae. onto the patient (see Chapter 16), as can plaster-of-Paris. Leather
• (\X'ith a Jones spinal brace, when the patient stands \\"ith a good posture, and plastic supports require to be moulded over a positive model of
it should be possible to slip two fingers between the back lever and the the patient and therefore are more expensive and take longer to make
upper pan of the spine.) than do those made from plaster-of-Paris or Plastazote.
These supports must extend from the symphysis pubis co the
Anterior hyperextension spi nal brace (Fig. 8.6) upper sternum anteriorly and be accurately fitted around the pelvis.
This type of brace utilises a completely different method of con- They are cut low posteriorly (Fig. 8.7).
struction from the above spinal braces. It was described originally
by Hoadley in 1896, who used it tO provide mechanical support
'of the spinal column ben,·een the middle of the lumbar and the
m1ddle of the thoracic regions'. It employs the principle of three-
point action of a bendlng force. Kumerous modlfications to this
brace have been made, but that of Baker (1942) is described here.
The anterior hyperextension spinal brace consists basically of a
rectangular metal frame, the short sides of which fit oYer the front

Figure 8.7 Moulded spinal jacket, extends from the upper sternum ro the symphysis
pubis anteriorly and is cut lower posteriorly.

PRESCRIBING A SUPPORTIVE SPINAL APPLIANCE

It is impossible here to give deta1led indications for the prescription

of the various spinal supports, as they depend upon the underlying
Figure 8.6 Amerior hyperextension brace.
spinal disability and its site and extent, the incensiry of the patient's
 88 TRACTIO]'.; Al'\D ORTHOPAEDIC APPLIANCES ,. AND CERVICAL) 89
8. SPINAL SUPPORTS ( THORACO-LUMBAR

symptoms and their response to other forms of treatment, the Rigid spinal braces • . th
patient's age and sex, whether the appliance is to be worn per- ffi tive in reducing movement m e
manently or only for a limited time, and the function required of Rigid spinal braces are more e ec . f the spine than fabric
the appliance (Berger, 1969). . d per lumbar reg1ons o . th
lower thoraciC an up d h . e that movement m e
b emembere ' owev r' .
Before a spinal support is prescribed, it is imperative that an supports. It must e r . . II the lumbo-sacral juncnon,
accurate history is taken, a detailed physical and radiological examin- adjacent regions of the spme, esp~c; y 1957) and this increase
ation is performed, and other special investigations are carried out in tends to be increased .<No~ton an . roW::;ticulariy if degenerative
in movement may give nse to pam, p
an attempt to diagnose accurately the cause and site of the patient's
symptoms. Treatment in all cases must be directed towards the changes are present. . b es All these spinal braces
1
underlying cause of the symptoms which often may be relieved by Fisher, Taylor and J:nes s:~~ion r:~te~sion, lateral flexion ~d
means other than a spinal support. \Xlhen symptoms persist or limit, to some degree, orwar . ' f the spine the Fisher spmal
. . th th o-lumbar regwn o ' Th
change, in spite of apparent adequate treatment, the patient must rotan on m e orac . e and the Jones the least. e~e
be reassessed carefully, as the symptoms may be due to a patho- brace being the most. effecov bulant management of tuberculosis
logical condition, for example tuberculosis or neoplasia, which could spinal braces are used m the am I mbar reo-ions of the spine, the
not be detected initially. of the lower thoracic and uppe~ u f actur:S vertebral osteochon~
Spinal appliances are prescribed commonly under a proper more severe vertebra.! compressl~nd :ealmes~ of the trunk muscu-
dritis and osteoporOSIS, and mar e
name, which name may be that of the original designer or someone
who has modified the appliance. In addition many appliances, lature. . . al brace. This brace is uncom-
although called by the same proper name, may differ considerably in Anterior hyperextension spm the thoracic spine is too great.
construction from place to place, and appliances of the same design fortable if the pressure .exerted o~er b t is more comfortable when
and construction may be called by different names in different places. It was designed to provtde ext~ns~~~a~d flexion. Conditions which
It is important therefore to describe accurately the appliance re- used merely to prevent ~xcesslve o ompression fractures of the
can be treated with thiS brace are c ..
quired, the movements which the appliance is intended to control,
verte b r al bodies and ankylosing spondyhus.
and to ensure that the appliance supplied to the patient fits correctly
and fulfils its intended function.
Moulded spinal supports all for
. . a!orcs are reserved usu y
Moulded leather or plasuc spt ~~PP of the spine from any cause
Fabric spinal supports the management of severe de ~rnunes uf ture and fit a fabric
for which it would be impossible to man ac
Sacro-iliac support. This support may be prescribed for the rare
cases of sacro-iliac strain. support or a rigid soinal brace. f laster-of~ Paris or Plastazote are
Moulded spinal supportS 0 ~
Lumbo-sacral support. These supports are prescribed commonly use d wh en the need for a support IS temporary.
in the management of chronic low back pain which may be due to
a variety of causes, such as generalised degenerative changes affecting
the intervertebral discs and posterior articulations, prolapsed inter- CORRECTIVE SPINAL APPLIANCES
vertebral disc in the later stages after the acute symptoms ha\'e
subsided, spondylolysis, spondylolisthesis, spinal instability, osteo- Milwaukee spinal brace (Fig. 8 ·8) l ) is an active cor-
porosis, minor compression fractures, and following some spinal
operations such as spinal fusion.
i' 1958
The Milwaukee spinal brace (Bloun~ e~ a in the ambulant treat-
recti ve spinal brace used almost ~xcbu~lve tyo postpone temporarily
Thoraco-lumbar support. These are prescribed instead of r . the aim emg
ment of structural sco IOSIS, .
)
It is used also in the
rigid spinal braces ,,·hen the patient's symptoms arise from the or permanently, the need for op.eratto~.occasionally in the man-
thoracic or upper lumbar regions of the spine, from conditions . ·od This brace IS use
post-operaove pen . d r . and tuberculosis of the upper
such as generalised degenerati\'e changes, senile kyphosis, osteo- agemen t of. ankylosing ~pon I Y~~:se later two instances, a pressure
porosis, minor compression fractures, and spinal infections in the thoracic region of the spme. n
elderly. pad (see below) is not necessary.
 8. SPINAL SUPPORTS (T HORACO-L UMB AR AND CERVICAL) 91

e When the patient stands erect and the pressure pads are fine.d, he must ,
be able to raise his chin and occiput from the head support at the
same time.
• With the head resting upon its supports, the patient must be able to
move the chest away from the lateral pressure pad.

If the brace is fitted as outlined above, pressure sores over the

chin and occiput, hypoplasia of the mandible and adverse effects
upon the incisor teeth will be avoided. Meralgia paraesthetica can
occur during the wearing of a Milwaukee spinal brace (Moe and
Kettleson, 1970).

CERVICAL SPINAL APPLIANCES

The head is balanced upon the cervical spine by the action of the
neck muscles. The cervical spine exhibits a considerable range of
Figure 8.8 .111ilwaukee brace. movement in all directions. Inflammatory conditions or mechanical
derangements of the cervical spine are associated commonly with
It consists of a moulded leather or Ortholene pelvic corset which spasm of the neck muscles and pain. This spasm and pain may be
fits snugly 0\·er the iliac crests, around the waist, and curves relieved by heat, massage and exercises, but occasionally immobiliz-
upward in front to support the abdomen. It is cut lower at the ation of the cervical spine combined with support of the head to
sides to avoid pressure on the costal margin. Metal side bars are relieve pressure upon the cervical vertebrae, intervertebral discs and
attached to the leather pelvic corset to form a base from which one joints, and the cervical nerves is required. This can be achie,·ed by
anterior and two posterior metal uprights pass upwards to a padded spinal traction (see Chapter 7 ) or by external splintage of the neck.
ring around the neck. These uprights are adjustable to allow for To immobilize and relieve pressure upon the cervical spine, an
growth. Anterior and posterior bars with padded submental and external support must be shaped to fit the contours of the lower jaw
occipital pieces are attached to the ring around the neck. and occiput, the shoulders, clavicles and sternum and the upper
Rib rotation is corrected by a pressure pad located over the rib thoracic spine. In the presence of a lesion of the uppermost part of
prominences. The pressure pad is fixed to a single, heavy, broad the cervical spine, the forehead also must be included in the support.
leather strap which is attached to the uprights at the desired level The inclusion of the thoracic spine and trunk depends upon the level,
by srud fastenings. The leather strap is passed over the posterior extent and severity of the lesion of the cervical spine.
bar on the convex side so that the pressure is applied directly from For adequate immobilization of a lesion above the level of the
the lateral side. To avoid pressure on a breast, the leather strap can sixth thoracic vertebrae, the cervical spine must be immobilized.
be attached to an outrigger on the anterior bar. This is achieved by attaching a cervical support to a long spinal
Because of the close moulding of the pelvic corset, the brace brace, or by prescribing a M ilwaukee spinal brace.
has to be remade as growth occurs. Felt or foam r ubber collar
FITTING OF A MIL\X1AUKEE SPINAL BRACE This type of collar consists of a length of orthopaedic felt or foam
The correct prescribing, manufacture and fitting of a Milwaukee spinal rubber covered with stockinette. It is useful in an emergency or
brace is highly speciali~ed, and should be carried out only by experienced when a temporary support is required, for example follo\ving muscle
surgeons and appliance makers (Orthotists). Outlined below are some strain. It is prepared as follows:
important points about the correct fitting of a Milwaukee spinal brace.
• The peh·ic corset must fit snugly about the waist abo\'e the iliac crests. • Cue a strip of orthopaedic felt or foam rubber measuring 18 inches by
• It must be possible at all times to pass a finger between the chin and 8 inches (45·75 em by 20·0 em) and fold it in half lengthways.
the submental piece. • Cover the felt or foam rubber with stockinette, leaving th~ ends long,
to act as ties.
92 TRACTlO:N Al\:D ORTHOPAEDIC APPLIA~CES 8. SPI:-.;AL SUPPORTS (THORACO-LUMBAR AND CERVICAL) 93

Thomas's collar
Many different cen'ical supports are called 'Thomas's Collars'. The
original cervical support described by Hugh Owen Thomas was
made from sheet metal covered with felt and sheepskin. The sheet
metal, the edges of ,,·hich were flared out, reached from the chin to
the sternum anteriorly, from the base of the neck to the occiput
posteriorly, and was long enough to encircle the neck. The support
was fastened securely around the neck, rested upon the chest and
shoulders and supported the chin, jaw and occiput.
Thick plastic sheet is used commonly today instead of metal.
These collars (Fig. 8. 9) are 'ready-made' and are supplied in differ em

Figure 8.10 Moulded polythene cervical collar.

Cervical braces
There are many different types of cervical brace; one such is illus-
trated in Figure 8.11. It consists of padded chin and occiput supports
attached by adjustable uprights to padded chest. and bac~ pla~es_.
It is easy to apply and adjust. It can be applied pnor to radiologtcal
examination when bony injury to the cervical spine is suspected.

Figure 8.9 Thomas cervical collar.

sizes or are adjustable. Great care must be taken to ensure that they
are fastened securely around the neck, rest upon the chest and
shoulders and support the chin, jaw and occiput. Often they are
fitted incorrectly and do not support the cervical spine at all.
Mould ed cervical su ppor t s
1. Plastazore
Plastazote, a foamed polyethylene, is easily moulded after being
heated at 140· C. for 5 minutes in a hot-air oven. After heating it
is moulded around the patient's neck, and in this way accurately
fining cervical supports, holding the patient's head in the most
comfortable position, can be made rapidly (see Chapter 16).
2. Polyzhene
Supports made from polythene (Fig. 8.10) are used usunllv for
tmmobllll.mon nf the <.:1 \11..<~1 pine alt~l opt"ralt• n llo\\C\'er,
\lnhke Pin 111 tc J')l I f m d I \CI \\)l!dl \hr J I 11 1 I
 94 TRACTION AND ORTHOPAEDIC APPLIANCES
8. SPINAL SUPPORTS ( THORACO-LUl'ABAR AND C ERVICAL) 95
M i nerva jacket
FLI!\T, 1\IL M. ( 1965) Abdominal muscle in•·olvement during the performance of
In. the presence of a lesion of the uppermost part of the cen·ical various forms of sic-up exercises. AmmcanJoumal of Physical Medici1rl!, ~. 224. ,
spme, ~e fore.head also must be included in any external support FLOYD, W. F. and SILVER, P. H. S. ( 1955) The functions of the erectores spina.:
The Miner~a Jacket made from plaster-of-Paris.(Fig. 8.12) is used muscles in certain movements and postures in man. Journal of Physiology, 129, 184.
GREGERSEN, G. G. and Lt:CAS, D. B. ( 1967) An in vivo study of the axial rotation of
common~· m such situations. The halo traction arrangement (see the human thoraco-lumbar spine. Journal of Bone and Joint Surgery, 49-A, 247.
Chapter t) may be used also. HOADLEY, A. E. ( 1896) Spine-brace. Transactiom of the American Orthopaedic
Association, 8, 164.
Jo~ES, R. and LovETT, R. W. ( 1923) Orthopa~dic Surgery, p. 236. London: Henry
Frowde and Hodder & Stoughton.
JOSEPH, J. and McCOLL, [. ( 1961) Electromyography of muscles of posture: posterior
vertebral muscles in males. Journal of Physiology, 157, 33.
KEAGY, R. D., BRUMLICK, J. and BERGA~, J. J. ( 1966) Direct electromyography of
the psoas major muscle in man. Joumal of Bon~ and Joim Surgery, 48-A, 1377.
LU."'SOEN, R. M. and MORRIS, J. M. ( 1968) An in vivo study of axial rotation and
immobilisation at the lumbo-sacral joint. Journal of Bone and Joint Surg~ry, 50-A,
1591.
Moe, J. H . and KETTLESON, D. N. ( 1970) Idiopathic scoliosis. Journal of Bone and
Joim Surgery, 52-A, 1509.
MORRIS, J. M., LUCAS, D. B. and BRESLER, B. ( 1961 ) Role of the trunk in stability
of the spine. Joumal of Bone and Joim Surgery, 43-A, 327.
MORRIS, J. M., BENNER, G. and LUCAS, D. B. ( 1962) A n e\ectromyographic study
of the intrinsic muscles of the back in man. Joumal of Anatomy, 96, 509.
NACHEMSON, A. ( 1966) Electromyographic studies on the verteb ral portion of the
psoas muscle. Acca Orthopaedica Scandinat·ica, 37, 177.
NACHEMSON, A. and MORRIS, J. .'vL ( 196-l) In vivo measurements of incra-discal
pressure: discometry, a method for the determination of pressure in the lower
lumbar discs. Journal of Bone and Joim Surgery, 46-A, 1077.
NICHOLS, P. J. R., MCCAY, G. and BR.\DfORD, A. ( 1966) Immediate lumbar supports.
Bruish Medical Journal, ii, 707.
KORTON, P. L. and BRO\If:'.l, T. ( 1957) Immobilising efficiency of back braces: their
Figure 8.12 .\1inen·a plaster-of-Paris jacket. effect on the posture and motion of the lumbo-sacral spine. Joumal of Bom; a11d
Joi111 Surgery, 39- A, 111.
PERRY, J. ( 1970) The use of external support in the treatment of low-back pain.
Journal of Bone and Joint Surgery, 52-A, 1440.
REFERENCES St:RGICAL APPLIA.'<CES CoNTRACT 1972 ( .\IH.\150), Department of Health and Social
Services ( D.S.B.4A), Government Buildings, Block !, Warbreck Hill Road,
ALI..BROOK, D. ( I 957) .\10\·ements of the lumbar s . Blackpool.
Joint Surgery, 39- B. 339. pmal column. Joumal of Bo11c a11d
T A~Z, S. S. ( 1953) Motion of the lumbar spine: a roentgenologic study. American
BAKER, L. D. (1942) Rhizomelic s
24, 827.
d ·1 ·
pon ~ OSJS.
J ournal of Bone and Joim Surgery, Journal of Roemg:nology, 69, 399.
TAYLOR, C. F. ( 1863) On the mechanical treatment of Pott's disease of the spine.
BARTELI!\K, D. L. (1957) The role of abd · J · • . Transactions of the New York Scare t'vfedical Society, 6, 67.
the lumbar intervertebral disc omma pressure 1.n rehe,•mg the pressure on
TROUP, J. D. G., Hooo, C. A. and CH.\P-"tA!\, A. E. ( 1968) Measurements of the
BERGER N ( 1969) T . 1 s. J.ouma/ of Bone alld Jomt Surgen·, 39-B ilS
n~s, P· 4 · pmal Onhorics:
' · ermmo ogv m Spinal Onho · ~ s· · ' · sagittal mobility of the lumbar spine and hips. Amuds of Physical l'v[edicine, 9, 308.
A Report Sponsored by the Committ VAN LEUVEN, R. M. and TROUP, J. D. G. ( 1969) The 'instant' lumbar corset.
of the Division of Engin eering Nat" ee lo; Prosthetic Re~.earch and De"elopmem
Sciences, Washington D C Ch- . lona H eEsearch Council, National Academy of Physio therapy, 55, 499.
Bto . w p S ' · ., arrman, . lftman. WATERS, R. L. and MoRRIS, J. M. ( 1970) Effect of spinal supports on the electrical
l.il'T, · ., CHMIDT, A. C. and Bidwell R G - . . activity of muscles of the trunk. Jownal of Bone and Joint Surgery, 52-A, 51.
brace. Journal of Bo 11e and Joint Surgery _A -2 <19,8) .'\1akmg the M 1lwaukee
DA\'JS, P. R. ( 1956) Variations ofrhe hum '.
lifting in different postures J
40
':d ·.6
,;An mtra-a ommal pressures during weight-
DAVIS p R d T . ourna1 OJ narom:y, 90, 601.
' · · an ROUP, J. D G (1964) p .
pulling, pushing and lifting. E.rg . . 7 4r6e5ssures m the trunk ca,·iries when
ononucs, ,
DA\"IS, P. R. and TROt;P J D G 096 - ) E ·
loads in different pos~r~s P. i p ' d~ecrs ~n the trunk o!
handling hea'"Y
3 3
Association Congress. Donm.und i9:.cee mgs o 2nd Jnternauonal Ergonomics
FISHER, F. R. (1886) 0rthopaedic sureen.. th fd ..
Encycloptudia of Surgery edited b . ~A,.' h e tr~~em o eformllles. In lmcrnational
p. 1082, Fig. 1510. !'\ew York. w.\x,~:.rst, ., nr. Vol. 6, p. 1080, Fig. 1509 and
9. Splin ting for congen ital dislocation
of the hip
..

The detection of the unstable hip as soon as possible after birth,

and its prompt treatment, are vital. There is no direct evidence that
every unstable hip at birth will, if untreated, become a dislocated
hip, but if every hip that is found to be unstable at birth is treated,
established dislocation of the hip virtually disappears (Rosen, 1962).
Unstable hips at birth are diagnosed clinically. All doctors who
work with the new-born must know how to detect an unstable hip.
Barlow ( 1962) found only 159 unstable hips in 9000 births, an
incidence of 18 per 1000 (as opposed to 1·5 per 1000 for the
incidence of established dislocation of the hip in Western Europe).
This means that many normal hips will be examined before an
unstable hip is found.

CLINICAL TESTS FOR UNSTABLE HIPS

Barlow's test ( 1962)

This test must be carried out within two to three days of birth, in a
warm room and preferably after the child has been fed, when he
will be relaxed and contented. The examiner's hands must be warm.
The test is carried out in two stages.

STAGE ONE
• Remove the child's nappy.
• Place the child supine on a warm firm surface with its legs pointing
towards you.
• Hold the knees fully flexed, with the flexed legs in the palms of your
hands, and with the middle finger of each hand on the greater trochanter
and the thumb on the inner aspect of the thigh opposite the lesser
trochanter (Fig. 9 .l ).
• Flex the hips to a right angle and abduct them to 45 degrees.
• Press forwards in turn with the middle finger of each hand on the
greater trochanter and attempt co lift the femoral head into the
acetabulum.

The test is positive when the joint is dislocated and the femoral
head returns to the acetabulum with a palpable and often audible
clunk or jerk. The clunk or jerk is due to the femoral head snapping
97
 98 TRACTIO::-\ Al':D ORTHOPAEDIC APPLIA~CES
9. SPLINTING FOR CONGENITAL DISLOCATIO~ OF THE HIP

the thumb over the inner side of the knee, and with the other fingers ove
the greater trochanter), exerr gende pressure in a latero-medial directiot'
with the fingers and at the same rime slowly abduct the hip througl •
90 degrees, until the outer side of the knee touches the couch. When th•
rest is positive, somewhere in the 90 degree arc of abduction reduction o
the dislocation will occur and the head of the femur will slip inco th•
acetabulum with a visible and palpable movement-a clunk or jerk.

The tests described above are generally reliable, but they rna~
be misleading in certain situations. When limited abduction of a hii
is present due to contraction of its adductor muscles, a clunk rna~
not be elicited. H owever the presence of limitation of abduction it.sel
may indicate dislocation of that hip. 'Clinks' as opposed to clunks o:
Figure 9.1 Barlow's rest.
jerks can often be elicited on manipulation of the normal hips o
the new-born.
back over the posterior rim of the acetabul . The incidence of unstable hips decreases in the first few week:
must not be confused with Jig ~m .mto the socket. This after birth. Nelson (1966) found, on the examination of 866 livt
. .
b e e1!Cited amentous chcking wh· h f
from a baby's normal hip. ' IC can o ten births, an incidence of 15·9 per cent soon after birth which fell t<
7 per cent seven to ten days after birth, and to 0·35 per cent a
STAGE T\X'O three weeks. The decrease in the incidence of unstable hips in the
• Co .
• p nonbue .r~ hold .the lower limbs as described abo\'e. weeks immediately after birth gives rise to some controversy as t<
ress ack\\ards m rum \\ith each th b . . whether an unstable hip at birth should be treated immediately o:
If the femoral head slips back . udm on the mner Side of the thigh.
\\ ar s onto the po · · whether only those which are still unstable some weeks after bird
acetabulum or acruall di 1 . . srenor 1lp of the
Y s ocates, the hlp IS unstable should be treated. It is not within the scope of this book to discus:
• In doubtful cases, firmly hold the I . . .
on the pubis and the fing d pe VIS WJth one hand, with the thumb the indications for treatment. Generally, however, it is better to er:
ers un er the sacrum wh 1'1 " on the side of over-treatment, as long as the treatment is carried ou
above rest on one hip with th . ' e per1orming the
• E. · e o pposne hand. correctly, and as long as the treatment does not give rise to an~
:xarrune the second hip in the same way.
complications.
This rest is reliable and can be u
months, by which time the ~ h sed up ro the age of six
difficult to reach the greater t em~ra ave ?ecome so long that it is X-RAY EXAMINATION
fingers. roc anters \l'vlth the tips of the middle
Ossification in the capital epiphysis of the femur is not present a
Orzolam·'s zest birth and therefore the capital epiphysis cannot be demonstrate<
radiologically. This makes the radiological identification of a dis·
This test was described b 0 I . . located hip in the young child difficult. However, the ossific nucleu:
between three and nine m~ thrto ~;~ m. 1948 for. use in children
of the femoral head can be seen radiologically in 78 per cent o:
in the new-born (Barlow, 19~2).s o . It IS not ennrely satisfactory
normal hips at six months of age and in 99 per cent at one yea:
(Wynne-Davies, 1970).
PROCEDCRE:
• Lay the child supine on a warm tirm . . Under six months of age
towards you . surface With Its legs pointing
• Flex the hips and knees to . h .· Andren and von Rosen ( 1958) described a technique for use in thi:
hips in slight internal rotati~~~g t angle \\ Hh the knees to uching and the age group in which an antero-posterior X-ray is taken with tht
• Hold one leg steady. \X'ith the other knee in the palm of . h . child supine and with both lower limbs in full medial rotation anc
:our and (\\'lth 45 degrees of abduction.
 9. SPLINTING FOR CONGE~ITAL DISLOCATION OF THE HIP 101
When the head of the femur is dislocated, the upward pro-
longation of the long axis of the shaft of the femur points towards Perkin's line
the anterior superior iliac spine and crosses the midline in the lower
lumbar region of the spine (Fig. 9.2). \X/hen the hip is nor dislocated,

Normal hip Dislocated hip

Normal hip Dislocated h1p · h 1ower I"tm bs together and in neut.ral
· X-ray wtt
Figu re 9.3 Standard antero-postenor
Fig ure 9.2 Anrero-posrerior X- ray with lower limbs in full medial rotation and rotation in child over six months.
45· abduction in child under six momhs.
APPLIANCES AND PLASTER CASTS USED TO
the upward prolongation of the lon g axis of the shaft of the femur MAINTAIN THE REDUCTION OF A DISLOCATED
points towards the lateral m ar gin of the acetabulum and crosses the H IP
posterior part of the pelvis in the region of the sacro-iliac joint
(Fig. 9.2). Four of the many different appliances wh.ich can be used to m ain tain
As a dislocated hip may reduce owith abduction, it is possible to the reductionofa dislocated hip are descnbed bel~w. The von Rosen
obtain a false negative result with this technique. and Barlow splints and the Frejka pillow are used m the ma?agement
of the dislocated hip diagnosed soon after birth. The Den~s Browne
Over six momhs of age h . splint may be used when the diagnosis has been made either early
ortplate. Plaster casts are used o nl y m
· t h e 1ater sta<>es
"' of management.
Once the ossific nucleus of the femoral head is present, standard
antero-posterior X-rays of the pehis and hips, with the legs together Splines
and in neutraf rotation, can be used.
In a normal hip, the ossific nucleus of the femoral head lies below v on R osen splint ( Rosen, 1956)
the horizontal line (of Hilgenreiner) passing through the rri-radiate The von Rosen splint (Fig. 9.4) isH-shaped, the crossbar of~: H
cartilages of the acetabula, and medial to the vertical line (of Perkins) being extended on each side. It is cut from malleable alurrumum
passing through the outer lip of the acetabulum, perpendicular to the
above horizontal line (Fig. 9.3). ·
\X/hen the head of the femur is dislocated, the ossific nucleus of
the head t ends to lie lateral to the vertical line and above the
horizontal line (Fig. 9.3).
Furthe r radiological findings in congenital di sl ocation
of th e hip ( Fig. 9.3)
The ossific nucleus of the dislocated hip is smaller, or its appearance
is delayed, compared with the normal side.
The angle between the horizontal line of Hilgenreiner and the line
of the acetabular roof (acetabular angle or index) is greater than
35 degrees.
Shenton 's line is broken.
Fivure 9.-l Von Rosen splint.
 102 TRACTION AND ORTHOPAE DIC APPLIANCES
9. SPLINTING FOR CONGE~IT.-l.L DISLOCATION OF THE HIP 103

sheetinQ
,, padded d 1arex bb
b . . . an co,·ered ' ,.·th .
el~g Jess lrntating I
to the skin of ru .er or plasnc, the latter together by a single rivet 9 inches (22·5 em) below the top end. The
splmt are a,·ailable. some children. Three sizes of aluminium strips are padded on one side with felt, are covered with
soft leather and are provided with a canvas strap which can be
APPLICATIO~ OF THE \·o~ passed through slots in the top ends of the splinr.
: Choose a sp~inr of adequate size. • ROSE:-\ SPLJ::-.=T ( Fig. 9.4) The Barlow splint is applied in a similar way to that described
Place the child supine on the li for the von Rosen splint. The upper ends are moulded over the
• .\1ould the upper limbs of thes;pl~~~ ,. shoulders where they are held together with the canvas strap which
• th\1ey do not press on the sides of the ~h ;rd~e shoulders, taking care that passes around the child's chest ( Fig. 9.5). The lower ends of the
1
.
· ould the shon cem ra 111mbs of the r s neck. splint are moulded around the thighs after reduction of the hip, with
• Reduce the hip and . sp Jnt around the child's tr k
.. mamtam the red . un . the hips in a position of 90 degrees of abduction flexion and lateral
posJtJon of 90 degrees of abdu . ft ~coon by holding the hip in
be possible to obtain this
abd ·
c.u~n exJon, and lateral rotation It
pos1oon easilv \\'.th · must
a rotation.
One complication of the Barlow splint is that as the two
ucoon cannot be obtained easil\' . I out using force. If full
subcutaneous tenotomy of the add~; the adducrors are too ngh t and a
aluminium strips are joined by only a single rivet, the upper ends
performed under general anaesth . tor muscles at their origin must be of the splint may press against the sides of the child's neck as the
• Ca:efully mould the lO\\'er hmbs es;a befor~ the splint is applied. child moves.
\\'hJle keeping the hlp reduced o the splmt around the child's thighs
• Check that th e h'1ps are nor flexed· MAJ.~AGEMENT OF A CHILD IN A SPLINT
~d th.at there is not excessive t~nsio~ri~bducred more than 90 degrees, • Insuuct the mother not to take the child out of the splint. The child
e;ces.sJve pressure on the head of th f the adductor muscles, to a\·oid is tended and washed in the splint.
o ~plphysitis of the femoral ca ita e e.mur ~nd the consequent dan er
bel~ ! _e~JphysJs. ~ot
• Examine the child at weekly intervals, adjusting the splint as necessary.
eve that there is a risk of e .Ph Barlow ( J 968) does • Replace the splint with a larger one when necessary. When a larger splint
behe\'eS that a large ossificati~;; c~~JOS ~ccurring in the new-born. He is being applied the hips must be kept in abduction, flexion and lateral
present befQre epiph,·sitis can tre m the femoral head must be rotation. This can be accomplished by lying the child on irs abdomen
• Check that the child .and occur. while the splint is being changed.
the splint \\'hen the child espeCially the lower limbs do not come f
...,. h~uttho
splint is beneficial mo,·es. Some mo,·ement of the hips ..
e Discard the splint after twelve weeks.
m e • Examine the child at weekly intervals for the first six weeks after dis-
carding the splint, then at decreasing intervals until six months have
Barlow splint (Barlow, 1962) elapsed.
The Barlow splint (Fi 9 - . • X·ray the child's hips when he is six months old. If the X-ray is
aluminium 1 inch v.id/~nd-:>]2 ~~:srsl of two_ strips of malleable normal, see the child at one-yearly intervals. If the X-ray shows a
es ong (2·:> em by 55 em) held difference in the acetabular angle on the affected side compared with the
normal side, take further X-rays at yearly intervals until normal develop-
ment of the acetabulum has occurred.

Frejka pillow (Frejka, 1954)

The Frejka pillow (Fig. 9.6) consists of a firm rectangular pad filled
with feathers or kapok which may be divided transversely into three
sections. Attached to the upper end of the pad are two long straps,
joined in the region of the scapulae, which pass over the shoulders to
be reattached by buckles to the lower end of the pad. There are two
shorter straps which pass around the sides of the trunk.

APPLICATION OF THE FREJKA PILLO\X' (Fig. 9.6)

• Choose a suitable Frejka pillow. The \\idth of the pad should be just
less than the distance between the popliteal fossae when the hips are in
Figure 9.5 Barlow splint.
a position of 90 degrees of abduction and flexion.
 9. SPLI:-.iTING FOR co:-;GENITAL DISLOCATION OF TH E HIP 105

F igure 9.7 Denis Browne hip splint seen from bc:hind.

This splint is applied in basically the same way as that described

for the von Rosen and Barlow splints (Fig. 9.8).

Figu re 9.6 Frejka pillow.

• Lie the Frejka pillow flat on a firm surface.

• Place the child's sacrum on the upper part of the pad and then fold the
pad forwards between the abducted and flexed lower limbs and up over
the front of the abdomen.
• Pass the long straps o\·er the shoulders and buckle them to the pad O\'er
the abdomen. '
• Pass the short straps around the trunk and o\·er the thighs and buckle
them to the pad o\·er the abdomen.
• Check that the pad is held fi.rrnly against the perineum.

Frejka originally introdu ced this appliance in 1938, an d since

1946 has used it regularly as t he method of choice in the treatment Figure 9.8 Denis Browne hip spline.
of children in the fir st year of life. He claims that the d islocated
femoral head slips spontaneously and without any manipulation into In this splint the child's hips are held in abductionfftex~on ~d
the acetabulum. The disad,·amage of the Frejka pillow is that it lateral rotation, the range of movement possible in each dtrecoon
must be removed frequently to clean and bathe the child. being about 30 degrees. The spline does not h~ve to be re~ov:d
to keep the child clean. Crawling and later walking a~e posstble m
D eni s Brown e hip splint this splint. As the child grows, the position of the thtgh ban~s on
The Denis Browne hip splint (Brov-.rne, 1948) can be used in the the metal bar is adjusted. One important advantage of the sphnt as
management of congenital dislocation of the hip when the condition opposed to immobilization in a plaster cast (L~oyd- Roberts,. 1971)
has been diagnosed soon after birth, or later after the child has is that it will not retain an unstable reducnon as th~. htp re-
started to walk. d islocaces, thus enabling the surgeon to recognise thts condltlon early
T he splint (Fig. 9.7) con sists of a strong metal bar to which two rather than lace. . .
thigh bands are attached. The position of the thigh bands on the When used in the m anagement of a dislocated h tp dtagnosed
metal bar can be altered. The thigh bands are fasten ed over the soon after birth, the splint is retained for about twelve weeks .. W~en
child's thighs either by straps and buckles or, to pre,·ent the mother used on the older child, it is retained until radiological exarrunauon
from remo,ing the splint, by stitching. A waterproof pad, on which shows that the acetabulum is developing satisfaccoril~ and ~a: there
the child's sacrum rests, is attached to the centre of the bar between is congruity of the ossifying femoral ~apical e?tphysts m the
the thigh bands. Straps pass upwards from the bar OYer the shoulders acetabulum. This rime varies between stx and etghteen months.
and back to the bar, crossing each other over the back and chest After the splint is removed, the legs slowly adduct to the neutral
wh ere they are stitched together. The knees are left free. position during the subsequent four co si~ weeks. \'<'hen the legs
attain the neutral position a further X-ray ts taken .
 106 TRACTION AND ORTHOPAEDI C APPLIANCES

9. S PLINTING FOR COI\GENITAL DISLOCATIO:--: OF THE HIP 107

Plaster casts
F r og or Loren z plaster ca st
This cast (Fig. 9.9) holds the hips in a posltJOn of 90 degrees of
abduction flexion and lateral rotation as in the YOn Rosen, Barlow

Fig u re 9. 10 Batc'.1elor plasters.

Figure 9. 9 Frog or Loren z plaster cast.

REFEREXCES

. 9-8) The diagnosis of dislocatio n of the hip in

and Denis Browne splints. Unlike the splints, however, 1t 1s n o t AI'DRE:-;, L. and RosE:-:, ~· voN (I ~ f ·mmediate treatment. Acca Radiologica,
newborns and the pnmary resu ts o t
generall y used in the managem ent of the dislocated hip in the new-
born. The cast extends from the nipple line down to the ankles on . T G ( 1962) Early diagnosis and treatment o f congemt
49, 89. · at dislocation of hip.
SARLO\\, · · . -14 B 29?
both sides, Jea,ing the ankles and feet free. P articular care must b e J ournal of Bone and Jomr S~trger?'t c;ti;n of.the hip Hospical }vfedicinl!. 2, 5i I.
taken to ensure that the cast is strong enough over the groins and BARLOW, T. G. ( 1968) Congemtal dt} o
BROW~E, D . ( 19-48) The trea~~enr o conge
nita! disloca.tion of the hip. Proco<dings of
buttocks. If it is not, the cast easily cracks due to the stresses
the Royal Sociuy of McdiCIIII!, ~; c · .. ·,. Tr•arm.mt o' COI"'etzital Dislocatic>t
4 388
imposed upon it by the strong mo\'ements of the child's limbs. An \{ B ( 19--4) Tho Danger o1 onur.attwl! • 1 ~ C . .
FREJKA,
of thl. Hip,
. . p. ::>73.
- ::> Stxth
• I nternatt~
. Ml Congress Societe International<: de hlrurgu!
adequate opening must be allowed around the perineum to enable
the child to be kept clean. Orthopedique et de Traumatologte. . 'l dh d ~IS London:
LLOYD-ROBERTS, G · C · ( 1971) Orrlwpaedics mlnfancy and Clu oo • p.- .

lmpor rant :
Butterworth.
~ELSO~, .\LA. ( 1966) . .· o f congenital dislocation of the hip. JoumJI
Early dtagnoSlS 4
• Check that the adductor muscles of the hips are not right and that Bon< and Joint Surgcl)', 48-B~ 38SC . D ·1/'anca \'uot.·t Criuri Diagt~ostrd •
ORTOLA.--:1, y{. ( 19-48) ~~ Lussa::roF•~e o;t,g;nua 20• Figs .. 5. and 6 and p. 21, Ftg. 7.
t.he hips can be placed easily in the desired position before appl~ing the Pro.filauico-Corretltt;r. P· 19, tgs. - ' p. '
cast. If the adductor muscles are tight, subcutaneous tenotomy of them
R Bo_loSgn~~~·(~;f~e~~rtr diagnosis and treatment of congenital dislocation of the
at their origin must be carried out. OSE:-;, · · ' S d' · ~6 136
• ~ever abduct or flex the hips beyond 90 degrees as this may obstruct hip joint. Acta Ortlto~<~<dt<·a. .:mdt mat·r.:a, - ~f c~ngeniral dislocation of the: hip
ROSE'-' S VON ( 1962) Dtagnosts an treatment . I I B '8-t,
the blood supply to the femoral head causing ischaemia and epiphysitis ·• · · b J 1 .r Bo 1111 and Jot>ll Suroery, .,.,- • - ·
joint in the new- orn. o~mrafo, . h ·t'olog~· of congenital dislocation of
e\·en in a normal hip. WtLKt:-;so:-: J. A. ( 1963) Pnme actors tn t e ~- 1 •
• .r 8 d J 111
. I Surge•-:>· .J,-B, 268. .
the hip. Journal o, ow an ° d .' d f milia! joint taxi tv · two aetiologtcal
Ba tchelor plasters WY:-<~E-DW!ES, R. ( 1970) ~cerabular rs~1as~~panJo~mal of Bon; (1;,;; Joillt Surg•r·y,
factors in congemtal d tslocatton o t e 1 •
Batchelor plasters hold the hips in abduction and medial rotation. 52-B, 704.
They encircle the lower limbs <;>nly and extend from the groins to
the ankles being joined by a crossbar (Fig. 9. 10). The knees must
be held in 15 to 20 degrees of flexion to prevent rotation of the
limbs within the plaster casts.
A possible complication of the use of Batchelor plasters is an
increase in the degree of anteYersion of the femoral necks (\Xlilkinson,
1963), which may ha\·e to be corrected subsequently by derotation
osteotomies of the upper ends of the femora.
10. Lower limb bracing

A caliper is an external supporting device for the lower limb \Yhich

may be used permanenrly or for a shorr time only. The functions
of a caliper are :
To provide stability for a weakened, paralysed or unstable limb.
To relieve weight bearing.
To relieve pain.
To control deformity aggravated by postural forces.
T o restrict movement of the joints of the lower limb.
Two or more of these functions may be combined. The ultimate
aim is to enable the patient to walk. To achieve this a caliper must
be strong, light and easy to apply and manipulate. In general the
more simple an appliance is, the better.
There are two main types of caliper:

WEIGHT -RELIEVING CAL IPER

The body weight is transmitted from the ischial tuberosity to a
padded ring or moulded leather (bucket) top, through metal side bars
to the shoe and hence the ground. In practice a weight- relie\·ing
caliper provides only parcial weight relief. Its use is indicated when
control of rotation of the lower limb is lost or when it is advisable
to decrease the amount of body weight taken through the bones of the
lower limb.

CHECKING A \'<'EIGHT-RELIEVING CALIPER

This may be carried out in two ways.
8 With the patient supine, lift the splinted leg at right angles to the body.
Place the finger between the bearing point of the caliper and the ischial
tuberosity. Lower the leg. If the finger is trap ped, the length of the
caliper is correct. If the finger can easily be removed, the caliper is too
short ; if the ring sli ps past the finger, the cali per is too long.
• With the patient standing and sitting back on the caliper cop, it should
just be possible to slip a finger under the patient's heel.

Advise the patient to sit back on the top of the caliper and ro a,·oid
leaning forward with the hip flexed, because as the hip is flexed,
the point of contact is transferred forwards progressi\·ely from the
ischial tuberosity to the ischial ramus and finally the pubic ramus
(Young, 1929).
 10. LOWER LIMB BRACI~G lll
):;ON WEIGHT-RELIEVING CALIPER
1. Long leg brace similar in design to a weight-relieving caliper bur
the body weight is not supported on a ring. The ring merely
locates the upper end of the side bars. This type of caliper is
used mainly to control deformity or to restrict the moYement of
the joints of the lower limb.
2. Below-knee appliance, used when the ankle or foot alone requires
ro be controlled.
The basic design of a caliper-two metal side bars connected
superiorly by a band encircling the upper thigh, and inferiorly to a
shoe-may be modified, depending upon the function required of the
caliper. The common ' 'ariations of each part of a caliper and their
functions are described below.

UPPER END OF A Cf2.LIPER

The upper end of a caliper may be fitted with a ring, cuff or
- Anterior knee cap
block leather bucket top.
Posterior g utter p1ece -

Ring top
A ring top ( Fig. 10.1 ) consists of a metal ring padded with felt
and covered with leather. It may or may not be weight-relieving.
If the ring top is to transmit body weight, it must be a snug fit,
otherwise the ischial tuberosity will slide through the ring, weight
relief will be lost and the ring will press into the perin eum where
it may cause a pressure sore.
Adjustabl e s1de bars _ __..
This type of top is often used on calipers for children, or for
temporary calipers for adults. It is simple and cheap to construct.

Cuff top
A cuff top (Fig. 10.2) consists of a broad posterior metal thigh
band padded with felt and covered with leather. Anteriorly there is
a broad soft leather band adjustable by means of a strap and buckle
Figure 10.1 Ring top caliper with unjointed adjustable side bars, round spur pieces,
or a Velcro fastening. A cuff top cannot be weight-relie..,ing.
anterior knee cap, posterior gutter piece and ankle strap.
It is simple and cheap to construct, is less bulky than a ring top,
and is easy to apply. A cuff top is particularly indicated when, in ischial tuberosity rests. It is reinforced posteriorly by a transverse
the presence of marked wasting of the thigh, it would be impossible metal band connected to the side bars. A metal strip •vith a flange
to pass a ring top of the correct size over the foot or the knee. projects upwards to support the bucket under the ischial tuberosity.
Straps and buckles or lace eyelets are fitted anteriorly ( Fig. 10.3):
Block leather bucket top As this type of top must be made carefully, it is more expenSt\'e
This type of top is made by moulding leather over a plaster cast to manufacture than the other two types. Its use is reserved usually
of the thigh. The leather bucket fits accurately around the upper for permanent adult weight-relieving calipers. When the knee is
third of the thigh, and has a posterior curved lip on which the unstable, support can be provided by extending the bucket top down-
wards to enclose almost the whole thigh.
 10. LOWER LIMB BRACING 113

Buckettop -

Joint release strap

Anterior thigh pad

- - - Ring-locking joants - --1 - -- - - Barlock joints - - - -

Anteraor and posterior -

calf band - Antenor and posterior - -
calf band

Figure 10.2 Cuff top caliper with non-adjustable side bars, ring-locking knee joints,
round spur pieces, anterior thigh pad, anterior and posterior calf bands and ankle Figure 10.3 t\lloulded leather bucket top caliper with non-adjustable side bars,
~tr:lp.
barlock knee joints, round spur pieces, anterior thigh pad, anterior and posterior
calf bands and ankle scrap.
PELVIC BAND AND HIP JOINTS upward extensions of the lateral side bars of long leg calipers at the
level of the hips (Fig. 10.4). It is better to use two long leg calipers
A pelvic band is a padded rigid metal band covered with leather with a pelvic band. If only one caliper is used, the pelvic band can
which encircles the pelvis posteriorly (extending between the anterior rotate on the pelvis.
superior iliac spines)> and presses on the sacrum. It is fastened The hinge or hip joint may allow either free flexion or extension,
anteriorly with a broad padded leather strap and buckle. Lateral or be fitted \\'ith a lock ro limit these movements either separately
metal bands extending dov.nwards from the peh·ic band hinge v.ith or in combination. It is important that the hip joints of the ap-
pliance are positioned on the axis of hip flexion-parallel and J
 114 TRACTION A:-\D ORTHOPAEDIC APPLJ.Au'\CES
10. LOWER LIMB BRACING 115

present, and for permanent calipers. Du~alurnin is s.ui.table for the

side bars of light appliances. The movmg parts, JOlOts and the
attachments of the caliper to the shoe, are always made of steel.
The side bars are shaped to the contour of the limb and must
not rub the skin. In children they must be adjustable for length to
allow for growth ( Fig. 10.1 ).
The side bars are attached proximally to the ring, cuff or block
leather bucket top, and distally are slotted into the heel of the shoe
or boot. Knee joints may be incorporated.

KNEE JOINTS
Figure 10.4 Pel de band and hip joim. Kote that the peh·ic band encircles the peh·i~
below the anterior superior iliac spines, and the hip joint is positioned slightly m The normal knee is a combination of a hinge and a. sliding joint.
front of the greater trochanrer. It is not practicable to make an artificial j oi~lt whtch accurately
follows normal knee movement. The nearest pomt correspondmg to
adjacent to the greater trochanters of the femora -otherwise dis- the natural axis of movement is situated t inch (1·25 em) above the
comfort is experienced by the patient, and unnecessary stress is joint line, and a little posterior to its centre.
thrown upon the appliance. A limited abduction joint may be needed
also for the older, heavier child or adult to prevent the rapid wearing
out of the flexion-extension joint. Ring lock knee joint
If support to decrease lumbar lordosis is required upward
The ring lock knee joint is the safest and most dur~ble. !t is
extensions from the pelvic band to a lumbo-sacral support may be
added. illustrated in Figures 10.2 and 10.5. The a:xis of rotanon ot ~he
joint is eccentric to prevent the anterior edge ~f rh:e male secuon
The function of a peh-lc band with hip joints is to pre\·enr the
from projecting when the joint is flexed. The nng IS pulled up ~o
development of a flexion deformity and to control adduction and
allow the knee to flex and is pushed downwards when the knee IS
medial rotation at the hip, in the presence of muscle imbalance
extended, to lock the hinge. A spring-loaded ball contro~s the
around the hip, following anterior poliomyelitis, spina bifida or
position of the ring. A p~tient must hav~ s~cient ~o:ver m, the
cerebral palsy. In addition these appliances increase the stability of
the spine. fingers to manipulate the nng lock. In hemtplegta~ the nno lock knee
joint must be fitted to the same side of the caliper as the normal
These appliances are always very cumbersome, even although
they can be made with only a lateral side bar tO the long leg
calipers \>.·hen the pelvic band is well fitting. They should be
recommended only after very careful consideration, as the patients
who require such appliances are seldom able to walk more than a
few yards, even although their stability and mobility may be im-
proved. Light appliances which simply brace the lower limbs may
be better, the patient using crutches and a swinging gait.

SIDE BARS
Stability is pro\·ided by metal side bars which must be both strong
and light. Steel is used for calipers for the lower limbs in heavv
patients, the active child, and when Se\'ere spasticity or athetosis i~
Figure 10.5 .\\anual ring-lock knee joim.
116 TRACTION AKD ORTHOPAEDIC APPLIA."'CES 10. LOWER LHv1B BRACI:-<G 117

upper. limb, and a simple non-locking joint to the other side bar. only on permanent appliances for patients who will always have to
. . Ring lock knee joints with springs which automaticaJlv Jock the walk with an extended knee, as this joint cannot be left unlocked.
)Omt when the knee is extended, may be fitted . An automal7c · · rmg
· The barlock knee joint must never be used when spasticity is
lock must. n.ot . be fitt~d to all four hinges when two calipers are present, as failure is very likely to occur.
wo~n, ~s It lS 1mposs1bl~ for a patient to manipulate all four ring It is important that this type of knee joint is manufactured
lock~ Simultaneously wh1le attempting to sit down. A further modi-
correctly. The tips of the pawls move through an arc of a circle.
fica.uon of.the auron:atic ring lock is caJled the rod-spring ring lock. To ensure accurate locking, the lugs on the distal side of the knee
T~1s cons1st~ of a :mg lock to the ring of which a length of rod joint must lie on the same arc, and must therefore point upwards
w1th .a co-ax1al spnng is fitted. An upward pull on the rod raises
and backwards ( Fig. 10.6).
the nng and frees the joint. \Xlhen the knee is extended, release of
the ~o.d allow.s the co-axial spring to push the ring dO\~n and lock Posterior off-set knee joint ( Fig. 10.7)
the JOmt. Th1s type of locking knee joint is used when a patient is
unab~e .to lean forward far enough to operate an ordinary ring Jock The posterior off-set knee joint is a non-locking type of joint.
knee JOmt, or when he cannot regain the erect position after bending When incorporated into a long leg caliper, the axis of movement of
forward . the joint is situated posterior to the axis of flexion /extension of the
knee. This means that when the knee is in at least 10 degrees of
Bar lock (Swiss lock ) knee joint hyperextension, the posterior off-set knee joint is stable as the bodf
weight passes down a line anterior to the axis of movement of the
Th~ barlock type of knee joint ( Figs. 10.3 and 10.6) Jocks auto-
joint.
mancally on extension of the knee. By pulling on a strap attached

e
e

Figure 10.7 Posterior off-set knee joint.

Figure 10.6 Bar lock knee joint. Note the arc of moYemenr of tbe pa\\'1. .
These types of knee joints are used instead of locking knee joints
t? a curved posterior bar connecting the pawls, the pawls on both in the 'cosmetic' appliances, which have been introduced recently,
s1des are released simultaneously, thus allowing knee flexion. The for patients with a flail lower limb who exhibit at least 10 degrees
release strap from the cun·ed bar is attached to the top, outer edge of hyperextension at the knee (see later). Hyperextension can be
of ~e block leather bucket or ring top. A broad elastic band con- aided if necessary by lowering the heel of the shoe slightly and
nec~ng the cun·e~ bar to the calf band pro,·ides the necessarv
adding a small raise to the sole.
tensiOn for the locking de,·ice ( Fig. 10.3). · Knee joints usually are not fitted to children's calipers. Locking
. The main disad,·antage of this type of locking knee joint is that knee joints may be essential for a spastic child or to aid in sitting
w1th lateral malalignment, the pawls may not fit into their notches at school. They are reserved for permanent adult calipers, cHher
accurately, and therfore malfunction may occur. This joint is used weight relieving or non-weight relieving, to ease sitting.
 10. LOWER LIMB BRAC1:-.:G 119
HEEL ATTACHMENT OF SIDE BARS

The distal ends of a caliper may be attached to the shoe or boot

by means of heel sockets or ,·ia a stirrup.
......,
Heel sockets \
-'""--- ...... \
: ___ _J-------~?
The distal ends of the side bars of a caliper are bent inwards ar
a right angle and slotted into metal sockets fitted into the heel of Figure 10.8 Sandal or insert type of stirrup.
the shoe. The caliper ends (spur pieces) and the heel sockets mav
be round or flat (rectangular). · size when there is a discrepancy in the size of the feet, as may
Roun~ soc~ets are employed when muscle control is adequate and occur in patients who have had poliomyelitis. The disadvantages of
rhe panenr IS able to dorsiflex and plantar-flex his ankle. The dis- the sandal type of stirrup are that pressure sores may develop, and
advantages of the round socket are that movement at the anatomical control of movemenr between the foot and the foot plate is difficult.
ankle joint does not correspond with the le\'el of the ankle join r of the The sandal type of stirrup must never be used for patients with
appliance, with the result that the appliance rides up and down with paraplegia or sensory disturbance in the foot.
dorsiflexion and plantar-flexion; compression of the calf by the calf
band occurs on dorsiflexion; and the heel tends to slip out of the Toe-out
shoe. The ad,·anrages of round sockets are that they are easier to When arranging the attachment of the side bars of a caliper to a
~ake and adjust, the apparatus is lighter, and different shoes are shoe by any of the above methods, it is necessary to provide toe-out,
mrerchangeable easily. to prevent the patient from tripping over his toes. The amount of
Round so~kets are used usually for children's calipers, and for toe-out required is determined individually. It depends upon the
temporary calipers for adults. relationship between the axes of movement of the knee and ankle
Flat .<or rectangular) sockets. This type of heel socket allows joints, which in tum depends upon the degree of tibial torsion
easy mterchangeability of shoes but does not allow the heel of the present. The amount of toe-out usually provided is 10 to 15 degr:es.
sh?e to ph·or. It i_s therefore usually employed with an ankle hinge To achieve this the attachment of the inner side bar of the caliper
(Fig. 10.12). A fla1l ankle could be controlled by flat sockets without is positioned slightly posterior to that of the outer side bar ( Fig. 10.9).
a1~ ankle hinge, but fi..xation is roo rigid and the shoe would not
Withstand the strain unless it was reinforced. Flat sockets are
expensi,·e and are reserved usually for permanent calipers.

Stirrups
There are two types of stirrup attachment, the ordinary stirrup and
the sandal or insert stirrup.
~rdinary stirrup . An ordinary stirrup consists of a U-shaped
p1ece of metal which is rigidly fixed to the anterior part of the
u~d erside of the heel of the shoe. The arms of the U pass up and
shghtly backwards (about 5 to 6 degrees) on each side of the shoe
to ankle joints positioned on the axis of movement of the anatomical
ankle joint.
Figure 10.9 Toe-out.
Sandal or insert type of stirrup. In this type a footplate is
attached to the stirrup, both of which are placed inside the shoe ANKLE JOINTS
( Fig. 10.8). The main adnntage of this method is that shoes can
be cha_nged easily. ~1oreover, as the foot plate and stirrup take up A joint at the level of the ankle follows the natural ankle movement.
room m the shoe, Jt may be possible to wear shoes of the same It can be constructed to allow free mo,·ement, or to limit plantar-
flexion or dorsiflexion or both.
 10. LOWER LIMB BRACING 121

It is essential that the a-xes of movement of the mechanical and

anatomical ankle joints are identical. The axis of anatomical mon: passively control a drop foot. There are however a number of active
ment lies on a line which passes from just below the tip of the methods employed which utilise a spring device of some sort.
medial malleolus and which bisects the lateral malleolus one half inch
above its tip. Double below-knee iron) round heel sockets and roe-raising
When ankle joints are incorporated in a caliper, flat heel sockets spring
(Fig. I 0.12) or a stirrup are necessary. As these fittings are difficult The simplest type of toe-raising spring is illustrated in Figure 10.11.
and expensive to make, thev are reserved usuallv for permanem The spring is attached to the double below-knee iron which fits
adult calipers or when a toe ;aising de~·ice is requi;ed. into round heel sockets, by a Y -shaped strap. The lower end of
the spring is attached to the middle of the dorsum of the shoe, at

CONTROL OF ANKLE JOINT MOVEMENT

Movement at the anatomical ankle joint can be controlled bv

specially constructed mechanical ankle joints, or, when round he~l
sockets are used, by heel stops.
A heel stop is a metal lug attached to the anterior or posterior
aspects of a round heel socket (Fig. 10.10), ro limit dorsiflexion or

Figure 10.10 Back heel stop fined ro a round heel socket ro control plantar-
flexion at the ankle joint.

plantar-flexion respectively. If plantar-flexion is weak, excessive

dorsiflexion can be controlled with a front or calcaneus stop. Con- Figure 10.11 Double below-knee iro n, round spur pieces, tOe-raising spring and
versely if dorsifle.xion is weak, foot control can be improYed by ankle srrap.
adding a back or equinus stop. In the presence of a flail ankle,
front and back stops can be fitted so that only a few degrees of the level of the metata.-so-phalangeal joints, by a small leather lug
dorsiflexion and plantar-flexion are possible. The main disadYantage stitched to the shoe. This is a cheap and effective mechanism but
of this method of controlling ankle mo\·ement is that the axis of it is obvious, especially when worn by women, and considerable
mo\·ement of the appliance does not correspond with that of the stress is imposed upon the heel sockets and the shoe.
ankle joint, with the result that considerable stress is imposed upon
the heel sockets and the shoe itself. Double below-knee iron) ankle joints) fiat heel sockets and
we-raising spring
TOE-RAISING DEVICES A less obvious toe-raising spring is that employed with an ankle
joint and fiat spur pieces and heel sockets as illustrated in Figure
\'Vnen weakness of dorsiflexion is present, the fitting of a device to 10.12. The spring is attached to the outer side bar (or both side
aid dorsiflexion will improYe greatly the patient's function. Tripping bars) of a caliper or double below-knee iron by an adjustable strap
0\·er uneven ground and the characteristic high stepping gait will and buckle or wire rod, and to a lug projecting forward from the
be abolished. As stated abo\'e, the fitting of a back stop or a centre of the ankle joint. This apparatus is heavy and expensive.
mechanical ankle joint constructed to control plantar-flexion will Considerable stress is still imposed upon the shoe and heel sockets,
and with time the flat spur pieces become worn and loose.
 10. LOWER LIMB BRACING 123

tj

Figure 10.12 Double below-knee iron with ankle joints, flat spur pieces, toe-raising Figure 10.13 Exeter double coil-spring toe-raising appliance.
spring and ankle strap.

Double below-knee iron w£th rubber torsion socket

Ortholene* drop foot splint (Fig. 10.14)
When the force required to o,·ercome the drop foot is not great~
a toe-raising de,·ice concealed in the heel can be used. Originally When the ankle joint can be dorsifl.exed passively to at least a right
this device consisted of a number of turns of spring piano wire angle, and when spasticity is absent, an Ortholen_e* or Perplas*
wound round a rod (Tuck, 1957). Square sockets were sunk in each ( both are high-density polyethylenes) drop foot sphnt can be pre-
end of the rod to take the spur pieces. A similar toe-raising scribed. .
mechanism with a rubber bush ,·ulcanised to the rod is now avail- From a plaster-of-Paris cast of the leg, taken wtth the ankle h~ld
able (Tuck, 1962). The spring action results from torsional stresses above a right angle if possible, a positive cast is ma?e, o.ver whtch
in the rubber which can be varied by a screw thread. The dis- a strip of high-density polyethylene is moulded. Thts stnp extends
advantages of the rubber bush are that it may rapidly wear out and downwards from behind the upper calf, around the heel ~d forwa~ds
it can be fitted only to a broad-heeled shoe. Both these de,·ices under the sole to the base of the toes. When the h1gh-d~n~1ty
are light and cheap, the later type being mass produced. polyethylene has cooled, it is trimmed to ensure a snug fit ms1de
the shoe, and the edges are chamfered, especially un~er the toes.
If necessary a calf pad of Plastazote can be added to 1mprove the
Exete1' coil spring toe-raising appliance cosmetic appearance of the leg.
The splint is worn next to the skin. A Velcro strap may be
For children under the age of five years, a belov..·- knee appliance fitted to the upper end to keep it closely applied to the back of the
fitted with a toe-raising spring, e\·en if made of Duralumin, would calf, or an elastic stocking may be worn. . .
be too hea,·y. In such cases an Exeter coil spring toe-raising This splint overcomes the cosmetic and mec~::ruc~l disadvan-
appliance ( Fig. 10.13) which combines the functions of supporting tages of the previously described appliances. In add1 tiOn ~t overco_mes
side bars and a toe-raising spring in a simple light appliance, can the disadvantage of some of the present-day commer~1al foot\\ ear,
be used. This appliance, howe,·er, is very restrictive, with the result the heels of which are hollow plastic mouldings unsUitable for the
that the attachment of the spring steel to the heel of the shoe may insertion of heel sockets.
become loose, or the steel itself may break.
*See Appendix.
 TRACTION AND ORTHOPAEDIC APPLJAJ\CES
10. LOWER LI1\1B BRACING 125

buckle on the other side of the leg, and the end of the strap
pointing backwards.
A T -strap may be attached to either the inside or the outside
of the shoe, to provide stability and to substitute for paralysed or
partially paralysed invertor or evertor muscles. A single below-knee
appliance (side bar) is used in conjunction -w;th a T -strap (Fig.
10.15).
Examples:
1. When the tibialis anterior and tibialis posterior muscles are weak,
but the peroneal muscles are strong, the foot will assume a
position of valgus. This deformity can be controlled by an outside
iron and an inside T -strap.
2 . A varus deformity from weakness of the peroneal muscles can be
controlled with an inside iron and an outside T -strap.

RETAINING STRAPS AND BANDS

Figure 10.14 Onholene drop foot splint.

T-STRAPS In addition to the above modifications which may be made to a

caliper, it must be remembered that the limb must be retained
A Tth-strhap is cut fr~m le~ther. The vertical limb of the T is anached within the caliper. This is achieved by using various leather straps
to e s oe at the Juncnon of th . and bands. These are described below.
well forward. The stra . : upper Wlth the sole. It is placed
P lS cut 'W1th long tongues so that the A~I<LE STRAP. The spur pieces of an appliance must be retained in
end of the strap encircles both the ankle and the side bar wi~p:; the heel sockets. A T -strap will perform this function as well as
correcting a varus or valgus deformity. In the absence of a T -strap,
an ankle strap must be present. An ankle strap is attached to the
outer side bar, passes around the inner side bar and lower part of
the leg, and back to the outer side bar where it is buckled firmly.
(Figs. 10.1, 10.2, 10.3, 10.11, 10.12, and 10.17.)
CALF BAND and ANTERIOR THIGH PAD. When a knee joint is used
a calf band and an anterior thigh pad are fitted. The calf band, lined
with felt and covered with leather, is attached to the side bars just
below the knee joint. A padded anterior thigh pad is fitted above the
knee joint (Figs. 10.2 and 10.3). It is not required when a long
leather bucket top is used. The calf band and the anterior thigh pad
are fastened with a strap and buckle or a Velcro fastening. Eyelets
and a lace can also be used for the latrer.
Kl\'EE PAD. A knee pad is not always fitted to hinged calipers as it
limits knee flexion. Its function is to stabilise the knee in a non-
hinged caliper. In addition to the anterior knee pad, a leather gutter
piece is attached to the side bars to lie across the popliteal fossa
(Fig. 10.1 ).
A knee pad can also be used to control or to prevent the
Figure 10.15 Single inside below-knee iron with round .
T -strap. spur p1ece and outside de\·elopment of a valgus or varus deformity of the knee in the
presence of ligamentous la.xity. To control a \·algus deformity of the
 10. LOWER LIMB BRACING -;l~~:~· .
.--... .

Postenor thtgh band .- -

Figu r e 10.16 Knock-knee pad.

knee, the pad is attached ro the outer side bar and passes around
the knee (between the knee and the inner side bar) to be. attached
again to the outer side bar. In addition there are two narrow straps - - Anterior knee cap
which attach the top and bottom of the knee pad loosely to the
inner side bar, to control knee flexion ( Fig. 10.1 6). To control a
varus deformity of the knee, the attachments of the knee pad are
reversed.

PATTEN-ENDED CALIPER

When it is essential for a limb to be relie,·ed of all weight bearing,

a patten-ended caliper ( Fig. 10.17) is required. This type of caliper
was commonly used in the ambulant treatment of Perthes' disease
of the hip. It is used less often for this purpose today. Ankle strap
A patten-ended caliper has a snugly fining ring top. The steel
side bars, without knee joints, are adjustable for length and are Strap from heel of shoe
prolonged about 3 inches (7 ·6 em) below the heel. The distal ends to patten to stabil tze foot
of the side bars are welded to a steel ring, the patten, from which and shoe tn the caltper - --.+-
a strap passes to the back of the shoe, to control plantar-flexion of
the ankle. The foot of the affected leg is thus kept sufficiently clear
of the ground to preYent the child from taking weight on his toes.
In addition posterior thigh and calf bands, a knee pad and an ankle
strap are provided.
F"
----
10.17 Patten ended caliper with ischial bearing ring top, adjustabk side
b~~s~r;osrerior thigh band, anterior knee cap, posterior calf band, ankle strap and
Normal footwear is worn on the affected side, but a compen- strap from heel of shoe to patten.
sating patten must be added to the opposite shoe to accommodate the
increase in length of the affected lower limb (Fig. 10.18).
The length of the caliper must be adjusted repeatedly to allow
for growth, otherwise the child will soon bear weight on its toes.
Whether or not this is occurring can be determined by examining
the toe of the shoe worn on the affected side, for the presence of wear.
 10. LOW'ER LIMB BRACING !29
THE 'COSMETIC' LONG LEG CALIPER (Fig. 10.19)
allow, the bucket top is riveted, forming a rigid cylinder which is
The long leg calipers illustrated in Figures 10.1, 10.2, and 10.3 have threaded over the limb when the caliper is applied. .'
a number of disadvantages. They are cumbersom e, heavy, rigid and T he side bars t erminate just below the knee where the~· are
often uncomfortable. They frequently break, are not cosmetically riveted to a modified Ortholene drop foot splint. This results in the
acceptable especially to women, and take many hours to make. In caliper being lighter, and more resilient and cosmetically accept.aole
addition all the patient's shoes haYe to be fitted with heel sockets, to the patient. The cosmetic appearance can be improve~ furt)ler
an d as the foot of t:J'le affected limb is often smaller, the patient by adcling a false calf of Plastazote. The side bars are fim~hed by
may have to buy two pairs of sho·es each time. sand blasting and then heat- coated with nylon.
To o\·ercome these inherent disadvantages and the additional Ring-lock knee joints ( Fig. 10.5) are used commonly, b~rl~k
problem of the unsuitable present-day commercial footv.:ear, a new joints only rarely. When at least 10 degrees of hyper.extensiOn ts
type of long leg ca1iper for use in cases of flaccid paralysis of th e present at the knee, posterior off-set knee join ts (Fig. 10.7) can .be
lower limb has been developed by Mr W. H. Tuck at T he Royal fitted instead of locking knee joints, providing that the patient's ot)ler
:::\ational Orthopaedic Hospital. This development has resulted from limb is normal, as the patient's stability depends upon his being
the introduction of plastics and has received adclitional impetus from able to maintain hyperextension at the knee.
the previous developm ent of the O r tholene drop foot splint. The caliper, with the addition of a knee or anterior ~ig~ pad
This new appliance is fitted with a bucket top made from high- and possibly an anterior calf band, is worn next to the skm m che
density polyethylene moulded around a posiri\·e cast of the upper same way as the Ortholene drop-foot splint.
thigh and ischial region. Where the shape and size of the foot will The choice of suitable footwear is wide. The heel must be broa~
and it is advisable that it should not exceed 1 to 1·5 inches (2·:>
to 3·75 em) in height. As the caliper fits inside the shoe, com-
pensation can be made easily for any discrepancy in size of the fe~t.
These new types of calipers have a number of advantages o'er
the older types. They are much lighter, weighing about half that of
the older calipers; they are cosmetically acceptable; they aJIOW
movement of the foot and caliper within the shoe which results 10
the patient being better able to adapt to uneven surfaces; they are
more hygienic; they are quicker to make, the time being reduced b.Y
about one-third; and they are no more expensive.
Appliances of similar design (Hartshill lower limb appliances,
Yates, 1968) but using polypropylene instead of Ortholene* or
Perplas* are made by Salt & Son Ltd.*
CARE OF CALIPERS . . . . and
Every patient who wears a caltper must be tnstructed tn ItS care,
must be advised to-
• Always handle the caliper with care, and to avoid dropping it.
e Examine his skin every night for evidence of undue pressure from the
caliper.
e Each week open all locks and remo,·e any accumulated dirt or fluff.
e Oil each joint weekly.
e Inspect all moving parts for wear, and ensure that all bolts and screws
are present and not loose.
e Inspect all leather pares regularly, keep them .tn good cond'ICIOn,
.
an
d get
Figure 10.19 'Cosmetic' long leg caliper. ~ote that the ~ide bars end ju~t below any necessary repairs carried out immediately.
the knee where they are riveted to an Onholene drop foot splint. Posterior off-set e Keep che heels and che soles of the footwear in good condition.
knee joints are ill ustrated.
* See Appendix.
PRESCRIBING A LOWER LIMB APPLI_A NCE 11. Footwear
The main functions of the _lower limbs are support of the uunk and
.propulsion. The aim of prescribing appliances for the lo"·er limbs
is to improv~ t~1es~ functions by providing stability, overcoming The manufacture of special footwear, or alterations or additions to
weakness, rehevmg pam and controlling deformities. To achieve this existing footwear, may be necessary to accommodate deformed feet,
the ~ppliance must be as strong, light, simple and easy to apply and to relieve pain, or to compensate for shortening of a lower limb.
manipulate as possible, and in addition it should be cosmeticallY
acceptable to the patient. •
B_efore an appliance is prescribed, careful e\·aluation of existing SURGICAL FOOTWEAR
funcnon and examination of the affected limb or limbs must be
carried out. The problem and its possible solution must be discussed Any attempt to accommodate severely deformed feet within normal
with U:e patient and the appliance maker (Orthotist). Occasionally footwear will result in pain, callosity and bursa formation, and
operanons are necessary to correct deformities, in order to simplifv occasionally skin ulceration, from ·localised areas of excessive
the manufacture and fitting of an appliance. • pressure. These complications can be avoided by wearing surgical
When an appliance is prescribed, all the relevant personal detai ls footwear made on a last consuucted from accurate measurements or
of ~e pati~nt? the diagnosis, the part to be braced, the type of from a plaster cast of the deformed feet.
appliance, as mtended function and the details of its composition \Vhen a foot is deformed, for example by hammer toes or hallux
must be entered on the prescription. valgus, but is still plantigrade, careful measurements of the foot are
Sample prescrip tion adequate for the construction of the last. When the abnormality of
A child contracted poliomyelitis which affected one of his lower the foot is such that the plantar surface of the foot cannot be
limbs, leaving v.-eakness particularly of extension of the knee and accommodated on a leather sole, for example severe untreated talipes
dorsiflexion of the ankle. Contracrures of the joints haYe not equino-varus, a preliminary plaster cast of the foot is essentiaL An
developed. inside cork sole shaped to the contour of the base of the foot is
} ..'ame: JOHN $,\11TH. made. This ensures that the body weight is transmitted evenly over
Age: 13 years. a large surface area, thus avoiding localised areas of excessive
Diagnosis: Poliomyelitis right lower limb \\'ith weakness of the quadriceps pressure.
and dorsiftexors of the ankle. Shoes are usually prescribed when the deformity is limited to the
Caliper required to stabilise the knee and compensate for weak- forefoot, and boots if the foot is grossly deformed, if the hind foot
ness of dorsiflexion of the ankle. is involved, if scars are present around the ankle which would be
Rx.: Right long leg caliper \\'ith cuff top, adjustable side bars, double rubbed by the top of the shoe, or if a large raise is required.
automatic ring lock knee joints, round spur pieces and heel The toe of the shoes or boots supplied is commonly plain because
sockets with posterior heel srops, anterior thigh pad, calf band
and ankle strap.
it has a smooth inner surface.
When surgical footwear is prescribed, consideration must also be
given to the size of the opening through which the foot is to be
REFEREl'CES inserted, and the method of fastening to be employed. For example
Tuc;.:,_ \'i/. H. ( 1957) Drop-foot appliance with concealed spring. Joumal of Bone and a rigid or flail foot requires a large opening such as is provided
] 01111 Surgc1:\', 39-B. 335. with the Canadian open pattern footwear, or with lacing extended
Tuc;.:, \'\'. _H. (1962' D;op-foot appliance with rubber torsion socket. Journal of Bone
and ]01111 Surgery, 4-l-B, 896.
distally to the toe.
YATES, G. ( 1968) A method for the pro,·ision of lightweight aesthetic orthopaedic Patients who have limited finger function, such as may occur in
appliances. Orrhopacdrcs. Oxford. 1. 153. rheumatoid arthritis, may be unable to manage laces and may
YOt;~G, C. ~- ( 1929)_A study in fini~g the ring of the Thomas splint. Joumal of therefore require footwear of the slip-on variety. This may also apply
rh~ Amencan ,\ledzca/ Asscciazion, 93, 602.
to patients with poor hip flexion who are unable to reach shoe
131
 ll. FOOTWEAR 133

laces. The replacement of ordinary shoe laces with elastic laces can
• Excessive pressure must not be exerted on the foot by the upper or
be of great help in the latter situation.
inner sole.
Most surgical footwear is still made of leather, but the hand-
• There must be adequate room over the dorsum of the roes and over the
sewn welted leather sble is gradually being replaced by the micro- sides of the heads of the first and fifth metatarsals.
cellular (rubber) sole which is cemented to the upper. A microcellular • There must be a gap between the ends of all the toes and the toe of
sole and heel is lighter, more flexible and harder wearing than leather. the shoe or boot.
Q,·er the last few years many new synthetic materials have been • The patient must be able to move all his toes freely.
developed. These are now beginning to be used in the manufacture • The metatarso-phalangeal joint of the big toe must be level with the
of surgical footwear. From materials such as Plastazote* (a high- inner curve of the sole, where the sole starts to curve laterally under
density polyethylene) covered '~ith Yampi* (a plastic), ,·acuum- the arch.
formed shoes and bootees can be made. e The upper must fit snugly around the ankle and the back of the heel.
• The waist of the shoe or boot must grip the foot firmly enough to
prevent the foot from slipping forward or backward.
Vacuum-fonned Plastazote and Y ampi
foorwear (Tuck, 1971)
This type of footwear may be used in the conservative management MODIFICATION TO EXISTING FOOTWEAR
of any severely deformed foot, such as may occur in rheumatoid
arthritis, after partial amputation or leprosy, or when trophic ulcer- Although surgical footwear as discussed above may be required for
ation or gross swelling is present. Shoes or bootees can be made, the managemenr of painful feet, particularly in cases of severe
the latter being prescribed when the foot is severely deformed. deformity, much foot pain can be alleviated by prescribing various
A preliminary plaster-of-Paris cast of the foot is taken, from additions or modifications to existing footwear. For convenience of
which a positive plaster cast is made. A Plastazote inner sole is discussion, pain in the foot is considered to arise from one or more
initially formed, and is then added to and trimmed as necessarv to of the following four sites: medial longitudinal arch, metatarsal arch,
obtain a flat surface. The upper is then formed, and after trim~ing heel and toes. An accurate diagnosis must be made before these
it is attached to the inner sole with an adhesive. A rnicrocellular additions or modifications are prescribed and it must be remembered
sole and heel and a Velcro fixing are added finally. that foot symptoms often can be relieved by physiotherapy.
This type of footwear has a number of advantages over the
presently accepted surgical shoes and boots. It fits snugly around Mediallongirudinal arch
the heel and mid-foot; it provides total surface contact with the sole Pain arising from the medial longitudinal arch of the foot may be
of the foot, thus ensuring that the body-weight is spread eYenly o,·er due to foot strain (from prolonged unaccustomed standing, rapid
a large area and that localised areas of excessive pressure are increase in body weight, resumption of weight-bearing after a long
avoided; it is about one-third the weight of similar leather footwear; period of bed rest), or degenerative changes in the tarsal and tarso-
it can be washed and is therefore more hygienic; the Velcro fixing metatarsal joints. It is usually associated with flattening of the medial
is managed easily e'•en by severely deformed hands; and it \\ill longitudinal arch and can be relieved by supporting that arch. This
last for up to tweh·e months. The main disadvantages are that support can be obtained in a number of different ways.
some patients experience excessive swearing of their feet and the Insoles
appearance is not so smart as that of leather footwear. Valgus insoles. These are constructed commonly from felt or sponge
rubber covered with leather and mounted on a firm leather insole
HOW TO CHECK THAT FOOT\v"EAR FITS CORRECTLY (Fig. ll.l). Occasionally rigid arch supports made from metal or
The fit of any footwear is of the greatest importance during weight plastic are prescribed.
bearing and walking because there is a tendency for the foot to lengthen The support extends from the middle of the heel forward under
and broaden, due to the stretching of the ligaments of the foot, under the medial longitudinal arch to half an inch ( 1·25 em) behind the
the influence of body weight. Therefore the patient must be asked to
metatarsal heads. The height of the arch support must be correct.
stand and walk when footwear is checked.
It must not be too high for the rigid fiat foot, or too low for a
~See Appendix.
mobile fiat foot. Even if the condition is unilateral it is advisable
to prescribe a pair of insoles.
 134 TRACTION AND ORTHOPAEDIC APPLIAl-:CES
11 . FOOTWEAR 135

,-----~' ....
. d. h of the shoe on the medial
I
\
I';'
,,_ --.. the under surface of the longttu t~a1;rc the medial breastline of

~ sthideh.Aimtoedthia~ ~~:ko:~: ;;stte::tatra~:.l where it i~ feathe)red to

----J ------ e ee k f th e shoe. (F.1o·
a 11 . 3 .
I d .th the sole level with the brea 0
ben WI d Th. ombmaoon of wedges
( 3) Nfedial heel and lateral sole we ges. . IS c th h I and to evert
. d tendency to mvert e ee
(cross wedgmg) pro uces a . . of the medial longitudinal
the forefoot, which results m e1evaoon
arch.
Figure 11.1 Valgus insole-full length. The support extends from the middle of
the heel forwards under the medial longitudinal arch to the metatarsal heads.

When marked flattening of the medial longitudinal arch is

present attention must be paid to the metatarsal arch because support
for both arches may be necessary. A combined valgus and metatarsal
arch support may be prescribed also for pes cavus, so that the body
weight is evenly distributed and pressure on the metatarsal heads
is relieved.
Figure 1 t.3 Medial shank filler.
Insoles may be either of full or three-quar.ter length. A full length
insole is less likely to shift within the shoe with movement of the
foot. It does, however, decrease the amount of space in which the Metatarsal arch .
toes can move, and therefore should not be prescribed if there is h · of the foot 1s usua11Y
any tendency to hammer roe or claw toe deformity. Pain arising from the metatarsal arc regftothn e central three meta-
. of one or more o
As an insole takes up space ~ithin a shoe it may be necessary due to the prommence ciated with dorsal sublu."<ation
to ad,·ise the patient to buy footwear half a size larger than he tarsal heads in the sole of th~ foot, ~:~~rso phalanaeal joints. A ham-
usually wears. Patients who have been prescribed insoles should be or dislocation of the resp.ecn.ve me r~sent al;o. The latter may
adYised to wear them initially for only a short period during the mer or claw toe deforrruty IS usOuathlly pcauses of metatarsalgia are
· d ·th pes cavus. er
day, gradually increasing the length of time until they are wearing be assoctate
. , d. wt of a metatarsa1 h ead ' an interdiaital "' neuroma,
them continuously. Fretberg s tsease . h heumatoid arthritis. Symptoms
Shoe alterations March fracture or dtse~se .sue as r the plantar aspect of the
can be alleviated by rehevmg pressure on
(1 ) Thomas heel. The front surface (breasrline) of a normal heel is metatarsal heads.
slightly concave and runs transYersely across the sole. In a Thomas
heel (Fig. 11.2), the medial parr of the breastline is extended forward Insoles, etc. etatarsal arch support consists of
( 1) Metatarsal arch support. A m fi leather insole and
at least 1 inch (2·5 em), at which point the front of the heel lies under bber mounted on a rm .
the na\·icular bone. This gives support to the medial longitudinal a pad of sponge ru . d t (Fio. 11.4) will provide
arch. covered with leather. A smg le dome supp0 r "'
(2) Medial shank filler. Heavy patients sometimes depress the longi- ,... ____ -';,
I /).._
tudinal arch of their shoes. This can be prevented and support for I 1"----- ....
1
the medial longitudinal arch of the foot can be obtained by adding ~ ~
il - - - -;-- - ~
, ___ _
a medial shank filler, which fills in the gap between the ground and

·~
. pressure on on.: or two of the
Figure 11.~ Do med metatarsal support, to rehve
Figure 11.2 Thomas heel.
middle metatarsal heads.
 136 TRACTION AND ORTHOPAEDIC APPLIANCES
11. FOOTWEAR 137

Shoe alteration s · d 1
,,r
1v1etatarsa l ba r. Pressure on the metatarsal. heads can be reheve
bb a so
.
by placmg . d bar of leather or mlcrocellular ru. er across
a ra1se
the sole of the shoe directly behind and parallel ro the !me ~etween
the first and fifth metatarsal heads (Fig. 11.7) .. The antenor ~d
osterior extensions of the bar are feathered mto the sole. . e
~ar takes the body weight behind the metatarsal heads and pro•ad~s
a roc ker movement· The average heioht ::. of the bar. for adults
d · th IS
Figure 11.5 Full width, three quarter length metatarsal arch support. The support 5 8ths of an inch (1·6 em). The disadvantage of thts meth.o IS at
must lie behind the metatarsal heads.
the useful life of the bar is short due to wear, but It can be
support for one or two of the middle metatarsal heads. \Xlhen support renewed easily without damage ro the shoe.
for more than one or two metatarsal heads is indicated, a full width
arch support is prescribed (Fig. 11.5).
A valgus and metatarsal arch support can be combined on one
insole. As metatarsalgia is often associated with hammer or claw toe
deformities, care must be taken before prescribing a metatarsal arch
support on a fu ll length insole. In such a situation a three-quarter
length insole is preferable.
(2) Metatarsal pad and garter. This consists of a pad of sponge
\
rubber mounted on a broad elastic band, which is slipped over the
foot (Fig. 11.6). It is useful in relieving mild metatarsalgia and has
the additional advantage of allov.ing the patient to change his foot-
wear without having to transfer any insoles. \
F' 11.7Metatarsal bar for metatarsalgia. :;..;ote that the apex of the b: l~es
=:d~ately behind and parallel to the hne joining the first and fifth metatarsal ea s.

Painful heels
P am. d h heel for example from plantar f ascuus, .. · mav... be
un er t e , b h 1 d ms1de
relieved by fitting a horse-shoe shaped sponge ~ub er. ee paff. ..
Figure 11.6 ,\·ietatarsal pad and garter. the shoe on a leather insole (Fig. 11.8). If the msole IS norde ;cuve,
It IS pOSSI'ble to excavate the heel of a welted shoe an en to
Jv1etatarsal arch supports must be of adequate thickness and must fill the cavity with sorbo rubber. .
be positioned correctly. This is very important. They musr lie behind P . OV"r the back of the heel from an exostOSIS of the calcaneus
(not under) rhe metatarsal heads. Pressure on the metatarsal heads can beaJn "' by removing the suffener
relieved . from th e b ac k of the shoe
is reduced by the body weight being transferred through the necks
of the metatarsals. ,------,.-;
I
......
'/-;. _ _ _
A new metatarsal arch support must be checked after it has been \ '
worn for one or two weeks. Prominent metatarsal heads tend to
wear a depression in, or leave a clearer mark upon the insole. If the
F=>.-- :::-::-- ~
- - - -I .J - - - - -
I

arch support is in the correct position neither of these two signs

~
will be present. If these changes are present upon the insole, then
the support is placed too far posteriorly, or is not high enough, and
if present upon the arch support, then the support is placed too
far forwards.
~
Figure 11.8 Heel pad. Kote the horse-shoe shape ro the sponge rubber pad.
 In the absence of radiological evidence of increased talar tilt
. 1ther with or without general anaesthesia, or if the patient should
decline operative repair of the ligament, inversion injuries can be
and inserting two small thick sponge rubber pads coYered with
chamois leather, one on each side of the exostosis. prevented by floating out the lateral side of the heel of the shoe
Fig. 11.1 0).
Painful toes
Deformed toes may giYe rise to pain due to pressure upon them
by the shoe. This pressure may be relie,·ed by stretching the shoe
OYer the roes, but it may be necessary to prescribe surgical footwear
to accommodate the deformities. figure 11.10 Outside heel fioat. In addition an outside heel wedge can be added
when weakness of the peroneal muscles is present.
Hallux rigidus. The pain from hallux rigidus may be relie,·ed by
modifying the footwear so that dorsiflexion at the metatarso- Normally the first part of the heel of the shoe to strike the
phalangeal joint of the hallux is reduced or eliminated. This can be ground is situated about one-quarter to one-half inch (0·6 to 1·25 em)
achieved in two ways. to the lateral side of the centre of the heel. By floating out the
(1) Rocker bar. A rocker bar (Fig. 11.9) is added to the sole of lateral side of the heel, the part of the heel which first strikes the .
the shoe or boot. Its apex lies just behind and parallel to the line ground is brought medially towards the mid-point of the now
joining the first and fifth metatarsal heads. It differs from a meta- widened heel. This discourages the tendency to varus movemenr at
tarsal bar in that its anterior extension is longer, its OYerall length the ankle and subtalar joints.
being up to 2t inches (5·6 em). In muscle imbalance, when the peroneal muscles are weak, an
outside heel float with possibly the addition of an outside heel
wedge, or an inside below knee iron with an outside T strap, can
be used to correct the varus deformity which occurs.

Toe blocks
Occasionally for multiple deformities, gangrene or infection, all the
roes ha\·e to be amputated. Following this procedure a toe block is
prescribed. It is made of sorbo rubber or Plastazore. In addition,
a light steel or high density polyethylene (Ortholene) shank ex-
Figure 11.9 Rocker bar for h2llux rigidus. ~ote that the apex of the bar lies
immed iately behind and parallel to the line joining the first and fifth metatarsal tending from the heel ro the toe of the shoe must be fitted, to
heads. bm rhar irs amerior exrwsion is longer rhan rhar of a merararsal bar. (Fig. 1I. 7'. prevent the tip of the shoe from curling upwards.

(2) Snff ening rhe medial side of the sole of zhe shoe. In a shoe of
TRUE AND APPAREi\T DISCREPANCY IN LE~GTH
welted construction, this can be achieved by inserting a steel plate
OF THE LOWER LIMBS
(shank) 1 inch (2·5 em) wide between the layers of the sole. The
steel shank must extend well back into the waist of the shoe. In clinical practice, the exact length of each lower rimb is relatively
An alternative method, in a shoe of non-welted construction, is unimportant. What is importanr is the difference in length which
to add an extra layer of leather (not microcellular rubber) to the may exist between the two limbs. This difference in length may be
sole of the shoe. The additional stiffness these procedures confer, true or apparent, or a combination of both.
prevents dorsiflexion at the metatarso-phalangeal joint of the hallux.
True discrepancy in Lengch
Outside heel float True shortening of one lower limb is present when there is a
decrease in the distance between the upper surface of the head of
The lateral ligament of the ankle may be partially or completely
the femur and the lower surface of the calcaneus, compared with
ruptured following a seYere inversion injury. This may result in the
ankle being unstable and repeatedly suffering further inversion
injuries.
 141
the other limb. This distance cannot be measured accurately
clinical means because of the deeply placed positions of the ,.,.,,.,.,,..
Longitudinal axis of the body
bony points. Accurate measurement is possible only by taking
special radiograph-a scanograph-on which both lower limbs f
the hips to the feet are sho\~n alongside a scale. Suprasternal notch
For clinical purposes, the fixed bony points between wh1cb
measurements are taken are the anterior superior iliac spine and th
tip of the medial malleolus. It is accepted that the anterior super1o XiphiSternum
iliac spine lies at a level proximal and lateral to the upper surfac
of the head of the femur~ and that a part of the talus and calcaneu
F1xed deformity
lies distal to the tip of the medial malleolus. This means that
destruction of the superior lip of the acetabulum, or upward sub- ABDUCTION ADDUCTION
luxation or dislocation of the head of the femur, will show as trut
shortening when in fact the distances between the upper surface of
the head of the femur and the under surface of the calcaneu s of
both limbs are identical. In addition loss of limb length fro m 1
compression fracture of the calcaneus will not be identified.

Apparent discrepancy in length

Apparent discrepancy in length of the lower limbs is due to the
Med1al malleoli
presence of a fixed adduction or abduction deformity at one hip.
In normal walking or standing, the lower limbs are parallel. T o
bring the lower limbs into a parallel position when a fixed ad-
duction or abduction deformity is present at one hip, the peh.is is
tilted in one direction or the other (Fig. 11.11 ). In the presence Figure 11.11 Apparem discrepancy in length of one lower limb may be due to a
fixed abduction or adduction deformity being present at one or the ocher hip joint.
of a fixed adduction deformity, the anterior superior iliac spine on
the same side is raised abo\·e the horizontal, causing apparent
The anterior superior iliac spine lies proximal and lateral to the upper
shortening of the ipsilateral limb. When a fixed abduction deformity surface of the head of the femur. This is of no significance if the
is present, the anterior superior iliac spine on the opposite side is long axis of each limb subtends the same angle with the line joining
raised above the horizontal, causing apparent shortening of the both anterior superior iliac spines. If, however, the angle is different on
contralateral limb (or apparent lengthening of the ipsilateral limb). each side, the measurements will be misleading. Abduction of a limb
The accurate measurement of apparent discrepancy in the length approximates the anterior superior iliac spine and the medial malleolus,
of the lower limb is unimportant clinically. What is important is whereas adduction increases the distance between these two points
that the detection of an apparent discrepancy in length indicates the (Fig. 11.12).
presence of a fixed deformity at one hip. • Prior to measuring the true lengths, place the normal limb in a similar
position to that of the affected limb. When a fixed adduction deformity
is present at one hip, the affected limb will lie across the distally
MEASUREMENT OF T HE TRUE LENGTH OF projected line (Fig. 11.13), and when a fi.xed abduction deformity is
THE LOWER LIMBS present, the affected limb will tie some distance away from this line
With the p atien t supin e
(Fig. 11.14).
• Stand on the right-hand side of the patient.
• Grip one end of a tape measure between the tips of the lefc inde.-..;
• Identify both anterior superior iliac spines and draw an imaginary line
finger and thumb, so that the thumb nail is at right angles to the upper
joining these two points.
surface of the tape measure.
• Project a second line distally from the centre and at right angles to the
• Slip the left thumb and tape measure in an upward direction until the
line joining the anterior superior iliac spines.
pulp of the thumb, CO\'ered by the end of the tape measure, impinges
upon the lower surface of the anterior superior iliac spine.
 TRACTION AND ORTH OP AED IC APPLIAN CES

Longitudinal ax1s
of the body
A.S.I.S.

Segment of arc drawn

through A.S.I.S

''
' ..... ..._

M.M .

Abduction Adduction
Figure . 11.12 AS IS Ante· · · . .
·: · · 10 1
• r supenor 1 1ac spine; .\i.M . .".1edial mall 1
Abducuon. of the hlp approximates the medial malleolus and the A S I S :o
u~
adducr,on mcreases the distance between the medial malleolus and th~ ~.s.i'.;~· erea~

Figure 11.1~ The position in which the lower limbs must be placed when measuring
for crue lengch in the presence of a fixed abduceion d<formiry at one (here the left) hip.

Identify the anterior superior iliac spine in this manner, as the

presence of overlying mobile subcutaneous fatty tissue will make the
accurate identification of the anterior superior iliac spine impossible by
any other means.
• Maintain the left thumb in contact with the anterior superior iliac spine
and lay the tape measure evenly along the medial border of the patella,
and then slide the right thumb do\m the cape measure until it slips
over the lower margin of the medial malleolus.
• Note the reading on the cape measure.
• Maintain the same grip on the cape measure with the left hand, and
repeat the manouevre for the opposite limb.
• Any difference between the two measurements indicates the amount of
true shortening present.
With the patie nt s tanding
• Stand the patient erect with both knees fully extended.
• Identify both anterior superior iliac spines. T he anterior superior iliac
spine on the side of the shorter limb will lie at a lower le\·el.
• Place wooden blocks of varying thickness under the foot of the shorcer
Figure 11.13 The position in which the lower limb limb until the anterior superior iliac spines lie on a horizontal plane.
measuring for 1rue lmgrh in the re<e . ~ must b: placed when e The total height of the wooden blocks used equals the difference in
the left) hip. p - nee of a fixed addumon defonmry at one (here
limb length.
144 TRACTION AND ORTHOPAEDIC APPLIANCES

6. Is dorsiflexion at the metatarso-phalangeal joint of the hallux

.\1E:\S'CRE~i.E)\T
OF THE APPARENT LE};"GTH OF limited? Limi cation of movement at this joint influences the
THE LO\\'ER LL\1BS
amount of equinus of the ankle and forefoot which can be
The apparen t lengths of the lower limbs are measured from a fixed
allowed. If too great a degree of equinus is allowed, the
median point, such as the xiphisternum or suprasternal notch ro the
tips of the medial malleoli. ' metatarso-phalangeal joint of the hallux will be forced into dorsi-
• Lay the patient supine. flexion. This may give rise co pain.
• Ignoring the position of the pel \"is, arrange the lower limbs evenly about CALCULATION OF THE AMOUNT OF RAISE REQUIRED
the longitudinal axis of the trunk, with only 3 to 4 inches (7·5 tn It is rarely necessary tO compensate for the first half an inch (1 ·25 em)
10 em) between the medial malleoli (Fig. 11.11 ). of shortening, as this amount can be accommodated easily by tilting the
• .\1easure the distance from the xiphisternum or suprasternal notch to
pelvis.
the lower margin of each malleolus, handling the tape measure a• Although the theoretical height of the heel raise required to com-
described above. pensate for any shortening can be calculated by subtracting half an inch
• A difference between the measurements for each lower limb indicates ( 1·25 em) from the difference in length of the lower limbs measured
the prese_nce of a fixed adduction or abduction deformity at one hip, with the patient supine, this method is unlikely to be satisfactory. All
but only lf true shortening or lengthening is absent. patients who require compensation for shortening must be measured in
the standing position. In this position the height of the heel raise, and
Compensarim~ for a shm·t lower limb the degree of allowable equinus of the ankle and forefoot neces~ary
A short leg gait can be ungainly and tiring. In addition it can to compensate for any true or apparent shortening, which is comfortable
increase the stresses imposed upon the hip joints and Jumbo- sacral co the patient, can be determined. The comfort of the patient is much
spine and therefore contribute to the occurrence of pain at these more important than any theoretical calculation.
sites. Compensation for inequality in length of the lower limbs, e Stand the patient erect with both knees fully extended.
• Insert wooden blocks under the foot of the shorter limb. Blocks equal
whether true or apparent, can improve function. to the theoretical height of the required raise can be used initially.
Before determining the height of raise required to compensate
• Tell the patient co mark time.
for shortening of a lower limb, a number of facts must be taken • Vary the thickness of the wooden blocks under the heel and tread unril
into consideration. the patient is comfortable. Remind the patient to mark time between
1. Does the patient have a fixed lateral curvature of the spine or each variation in thickness of the wooden blocks.
fixed pel\'ic obliquity? The presence of either of these deformi,ties • The ultimate thickness of the wooden blocks under the heel and tread
will influence the degree of pelvic tilt ,..,·bich can occur. equals the height of the raise required at these sites.
2. \X! hat is the range of flexion present at each hip? \Xi hen one hip is
~nhrodesed, the patient can bring that limb forward during walk-
Note: The height of the heel raise is measured anterior to the centre
mg only by swinging the pelvis forward on the opposite hip. Unless of the heel of the shoe, that is, in line with the medial malleolus
sufficient clearance is allowed between the foot on the affected side (Fig. 11.15). This meai1S that when a raise is added co the heel of
and the ground, this will be impossible. Any raise supplied must
be such that the affected limb is effectively one-hal finch (1·25 em)
shorter than the other limb to give sufficient clearance.
3. \X'_hat is th~ range of fte.xion present at each knee? Again any
ra1se supphed must allow sufficient clearance-half an inch
(1 ·25 cm)-to bring the affected limb forward.
4. \Vnat degree of fixed equinus (plantar flexion ) of the ankle or
forefoot is present? The degree of these deformities will determine
the heights of the raises under the heel, the tread (metatarsal
heads) and the toes.
5. \Xlhat degree of mobility exists at the ankle and in the forefoot?
Figure 11.15 The height of a heel raise is measured in front of the centre of the
As much equinus of the ankle and forefoot (pitch) as possible is heel, in line with the medial malleolus. Note that the heel raise must be higher
allowed. This improves the appearance and decreases the weight
posteriorly than anteriorly.
of the footwear.
 146 TRACTION AND ORTHOPAEDIC APPLIANCES

a shoe, the thickness of the posterior border of the heel must be When a heel raise of more than three-quarters of ~ inch
greater than that of the anterior border, otherwise the under surface (2·0 em) IS . ed' the existing sole and heel
. requlr . are. removed
Th andk
of the sole and heel will not make simultaneous contact with the layers of cork are added to obtain the requtr~d . height. e t~~
ground when standing, and all the stress \\ill be taken by the la ers are shaped and covered with leather Sl~ar ~o that ~ e
anterior border of the heel. s:Oe. The original sole and heel are reattached If possible, or If not,
As it is necessary to pro,·ide a rocker action for walking, the a new sole and heel are made ( Figs. 11'.16 and 11.17).
height of the raise must decrease towards the toe (Fig. 11.16). The
height of the raise at the roe will depend upon that at the tread.
If this is large, the tapering must be more.
Occasionally after giving a patient a raise determined in the aboye
way, the gait pattern may still be poor. Do not 0\·er-compensate
for shortening to try to improve a gait pattern in the presence of
adequate compensation for shortening, as the poor gait pattern may Figure 11.17 Outside raise-arched.
be due to weakness of the spinal or abdominal muscles.
IWn~~~ear:~~: is deformed or of an odd size, surgical footwear mulsdt
be made. In these cases, all or part o f the. raise
. may
. be . concea e
. . h This is known as an mside raise (Fig. 11.18).
w1thm t e upper. · · 11 3.1. ·nches
. height for an inside raise IS usua y -z I
The max1mum - ) the tread and
(8·0 em) at the heel, with 2 inches (::>·0 em at . th ' th's
. 1 1 . h (2·5 em) at the toe. If a larger raise an 1
~pprox~meadtethy
1s reqwr , e a~~~itional height is obtained by adding an outside
He1ght of ra1se at. raise.
Figure 11.16 Outside raise. ~ore that the raise rapers towards the toe 10 aid walking.

TYPES OF RAISES EMPLOYED

Outside raise Figure 11.l8 Inside raise in a surgical shoe.
If the foot is normal, the raise can be added to ordinary footwear.
Sensible footwear is essential. Certain types of footwear are un- When the required raise is more than 3t inches (~·0 em), ~he
suitable for the addition of a raise, for example: . be arched and bridge waisted. The bndge, which
Shoes with heels exceeding 2 inches (5·0 em) in height. cork rbruse cang and perhaps reinforced with a steel plate, prevents
must e stron · ( F 0' 11 19)
Court shoes. The addition of a raise to a court shoe causes loss the heel and tread raises from splaying out on walkmg lo· . .
of flexibility of the shoes with the result that the patient's heel
tends to come out of the shoe.
Shoes with welded rubber soles and heels, as it is difficult to
remove the original sole.
Veltshorn shoes are not suitable for a raise in excess of It inches
(3·75 em).
\Vhen the required raise is one-quarter to three-quarters of an
inch (0·6 t6 2·0cm), the heel and if necessary the sole can be raised
by adding to the surface of the existing heel and sole. Micro-
cellular rubber is used for the raise in preference to leather, as it is
lighter, more flexible and wears better. Figure 11.19 Outside raise arched and bridge waisted.
 TRACTION AND ORTHOPAEDIC APPLIANCES

As has already been mentioned as m h .

and forefoot as possible is allowed. Howev~~ i:~~~nhuas ~f th~ ankhlco 12. Walking aids
heel platform b fi ' SJtuanon t ~
down the slop~:~ ~ at t~ pr~vent t~e p~tie.nt's foot from slidina
the shoe. e pauent s toes lmpmgmg against the tip or
Walking aids are used to increase the mobility of a patient, as they
enable some of the body weight to be supported by the upper limbs.
REFEREJ'-:CES There are many different walking aids-parallel bars, walking
Tt:CK, \'\1. H. (1 971 ) Personal commun ication. frames, crutches and sticks-and many different types within each
broad group. The correct selection of a walking aid for a particular
patient is very important and depends upon:
1. Stability of the patient.
2. Strength of the patient's upper and lower limbs.
3. Degree of co-ordination of movement of the upper and lower
limbs.
4. Degree of relief from weight-bearing required.

These aids may be sufficient in themselves or they may have

to be used in conjunction with calipers or other orthopaedic
appliances.
As the condition of the patient improves he may progress through
the different types of walking aids. Whether or not the ultimate aim
of walking unaided is achieved will depend upon the degree of any
permanent residual disability.
After a prolonged illness, many patients are generally weak. This
can be minimised by good nutrition and a well planned progressive
course of exercises. When a walking aid is used, part of the body
weight is taken by the muscles of the shoulder girdles and upper
limbs. Attention may have to be paid to the strength of these
muscles when planning the rehabilitation of the patient. The par-
ticular muscles used are:

l. Flexors of the fingers and thumb to hold the handgrips firmly.

2. Dorsiflexors of the wrist to stabilise the wrist in dorsiflexion,
thereby obtaining the best functional position for powerful finger
flexion.
3. Extensors of the elbow to stabilise the elbow in slight flexion when
the body weight is taken through the upper limb.
4. Flexors of the shoulder to move the walking aid forward.
5. Depressors of the shoulder girdle to support the body weight.
To regain confidence in walking takes time. When walking is
commenced it is therefore important to eliminate the fear of falling
and to avoid too rapid progression.
149
 151
150 TRACTION A~D ORTHOPAEDIC APPLJAl'CES

PARALLEL BARS

Parallel bars are rigid and do not have to be moved by the pati ent
This enables the patient to concentrate entirely on mo\'ing his lower
limbs correctly. For this reason parallel bars are often used when
the patient is not stable, or initially to develop a particular pattern
of gait, the patient being taught the correct sequence of arm and
lower limb movement.
A full-length mirror should be placed at one end of the parallel
bars. In it the patient can observe his mo,·ements and thus avoid
looking at his feet, a common mistake made when any type of
walking aid is used initially. A mirror is particularly helpful if the
patient has lost proprioception. Figure 12.1 \X'alking frame.
Adjustment: Some parallel bars are not adjustable. If they are,
adjust the distance between the bars and the height of d1e bars so
that when they are held by the patient his elbows are in 30 degrees Adjustment: If the frame is adjustable, alter the height of all the
of flexion. vertical rubes, and ensure that mey are all of equal length, so that
when me handgrips are held by the patient, the patient's elbows
are in 30 degrees of flexion. Patients wiili incoordination of me lower
WALI<ING-FRAMES
I limbs mav find walking easier if me handgrips are higher. '
How to u;e: The patient stands in the walking-frame, lifts and places
A patient is not usually given a walking-frame unless he will never
me frame forward a short distance and th~ walks into the frame
be able to walk with walking-sticks, tripods or crutches, as the pattern
of gait acquired in a walking-frame is difficult to change. More- still holding me handgrips.
over, a patient who uses a walking-frame is usually confined to his
home, and is unable ro manage stairs. If parallel bars are not
Reciprocal walking-frame
available, however, a walking-frame is very useful initially when a A reciprocal walking-frame is basically identical with a standard
patient is unstable and fearful of falling. frame, except that each side of me frame can be moved forward
There are three main types of walking-frame: the standard alternately. There are swivel joints between me front horizontal and
walking-frame, the reciprocal walking-frame and the rollator. The vertical tubes. As me frame does not have to be lifted clear of the
first two are usually used for elderly patients who lack confidence ground with each step, me patient's stability is increased.
in walking and are unsteady. Walking with full or partial weight Adjustment: Adjust as for the standard walking-frame. .
bearing is possible. The rollator is usually reserved for patients How to use: A four-point gait is used (see Chapter 13). One stde
suffering from a neurological conditions, such as disseminated of dJe frame is lifted and moved forward, ilie tWO legs of the oilier
sclerosis, with incoordination of the lower limbs. side remaining in contact with the ground.

Standard walking-frame Rolla tor

The standard walking-frame (.Fig. 12.1 ) is light, rigid, stable and A rollator ( Fig. 12.2) has two small wheels at me front and two
easy to use. It consists of four almost vertical aluminium alloy tubes short legs at the back, protected by rubber tips. The rear legs are
arranged in a rectangle, and joined together on three sides by upper almost vertically under the handgrips. Care must be taken when
and lower horizontal rubes. One long side of the rectangle is left recommending a rollarot: for elderly patients as it may roll too far
open. The lower ends of the vertical rubes, which may be adjustable forward so mat iliey lose their balance.
by means of spring-loaded double ball catches, are fined wiili rubber Adjustment: Adjust as for the standard 1.valking-frame.
tips. Hand-grips are fitted to the short, upper, horizontal rubes on How co use: The patient holds the handgrips, lifts them to raise
each side.
152 TRACTION Al'D ORTHOPAEDIC APPLIANCES

and use that hand to open a door or adjust his clothing, while
continuing to support himself. This is important when the patient's
balance is poor.
Method s of initial measurement of length for
axillary crutch es
It is necessarv to be able to obtain some initial indication of the
overall length. of the crutches required by a particular patient. This
measurement should be as accurate as possible. Final adjustment of
the crutches for overall length and position of the handgrip, however,
must be carried out with the patient standing and wearing shoes.
There are many methods of obtaining such a measurement.
Beckwith (1965) states that the follov.:ing two methods of measuring
patients for axillary crutches are the most accurate.
Figu re 12.2 Rollator. 1. Subtract 16 inches (41·0 em) from the height of the patient, or
2. With the patient iying supine, measure the distance from the
anterior axillary fo ld to the bottom edge of the heel of the shoe.
the rear legs just off the ground, wheels the rolla tor forward a short
distance, Jowers the rear legs onto the ground and then walks forward The measurement obtained with these two methods equals the
into the rollator still holding the handgrips. overall length of the crutch from the top of the axillary pad to the
bottom of the rubber tip.

CRUTCHES ADJUSTME).;T OF AXILLARY CRUTCHES

The overall length and the position of the handgrip must be correct for
There are three main types of crutches, axillary or underarm each patient.
\'\'hen walking with crutches, patients wear shoes and the height of
crutches, elbow crutches and gutter crutches. the heel will vary from patient to patient. \X'ith the patient standing up
straight, the axillary crutches extend from a point 2 inches ( 5·0 em) or
Axillary crutches three finger breadths below the anterior axillary fold, to a point on the
The common axillary crutches (Fig. 12.3) are made of wood. The\' ground 6 inches ( 15·0 em) in front of and lateral to the tips of the toes.
The shoulders are depressed and the palms of the hands rest on top
consist of a double upright joined at the top by a padded axillary
of the handgrips with the elbows in 30 degrees of flexion. (See Crutch
portion, a handgrip, and a non-slip rubber tip covering the lower
stance, Chapter 13.)
end. The overall length of the crutch and the position of the hand- Adjustment must be carried out with the patient standing and wearing
grip should be adjustable. By using adjustable crutches, it is easier shoes.
to fit each individual patient correctly, and the possible waste of e Place a crutch under each arm.
cutting nonadjustable crutches to the correct size, is avoided. e Check that the palms of the hands are on top of the handgrips.
When triceps weakness is present, support can be provided by e Place the tips of the crutches on the groLmd 6 inches ( 15·0 em) in front
attaching to the outer side of the crutch, above the level of the of and lateral to the tips of the toes.
handgrip, a half-loop band benveen the double upright through e Ask the patient to st:md up straight and to relax his shoulders.
which the upper arm is placed, or a short metal gutter piece to the
posterior upright against which the upper arm is pressed backwards. Checking overall length
All degrees of weight relief are possible with axillary crutches. • Attempt to insert three fingers between the axillary pad and the ant.:rior
Usually they are used when crutch walking is commenced initialh· axillarv fold.
and when non-weight bearing on one lower limb is indicated, fo~ Too lo;1g-Less than three fingers can be inserted between the axillary
example after a fracture. Although more cumbersome than elbo"· pad and the anterior axillary fold. The crutches are forced into the
a.xilla, the shoulders are hunched and the patient is unable to lift his
crutches, they are more stable. The patient can release a handgrip
 154 TRACTION AND ORTHOPAEDIC APPLIANCES

body off the ground. Pressure on the nerves in the axilla m.l\
paralysis.
Too short-,\1ore than duee fingers can be inserted between the
pa~ an~ the anterior axi!Jary fold. The patient leans forward from
wa1st, h1s bur~ocks project ?ackwards a11d the line of his centre of gr \
passes do,,n m front of h1s feet. This position is potentiallY un t 1 1 ~
It could be corre~ted and the pehis brought forward by ~:unt.unl
s~~e degree of h1p and knee flexion. This must not be done J~ 11
onng and may hinder crutch walking.
l
I
To adjust the length of the crutch
• Take off the bottom two \\ing nuts and remove the bolts.
• Slide the crutch extension to the correct length.
• R~place rl1e bolts and wing n uts, but do not tighten the wing nut~ II
th1s stage, otherwise it will be impossible to mo,·e the handgrip.
• Check the o,·erall Jengm of the crutch again.

Checking the position of the handgrip

\X'irh rh e shoulder depressed and the palm of the hand on top of the
handgrip, the elbow should be in 30 degrees of flexion.
Too high- The elbows are flexed more than 30 degrees, the shoulder\
are hunched and rhe ability to grip the axillary pad between the upper Figure 12.3 .4\xillary, elbow and gutter crutches.
arm and the Side wall of the chesr is lost.
Too lo.t::- The palms of ilie hands do not rest on top of me handgrips.
the axillary pad presses inro the axilla, the elbows are flexed Jess than to the upper end of the crutch. Armbands which are not made
30 degrees and the ability to rake weight on ilie hands is lost. from spring steel and are rigidly fi.."ed to the upper end of the
To adjust the position of the handgrip crutch can be obtained also. Occasionally for young children the
• RemoYe the uppermost \\ing nut and bolt. armband is replaced by a padded ring.
• Mo\•e the handgrip to the correcr position. Adjustment of the length of the crutch between the lo\ver end
• Replace the bolr and \\ing nut. and the handgrip is by means of a spring-loaded double-ball catch,
• Check thar the elbo"· is in 30 degrees of flexion. and this mechanism is also used in some crutches to vary the
• Tighten allrhe •;;.:i11g mas. distance between the handgrip and the armband.
-~·ore: The axillary pad must be gripped between the upper arm and the H eavy duty elbcw crutches, made from s tainless sted tubing,
Side w~ll of the ~hcsr. The patient must nor Jean on the axillary pad are available.
orhennse paralySIS may occur from pressure of the axillary pad on the Elbow crutches are less cumbersome, and confer less stability
ncn·es in the axilla. ·
than axillary crutches, but are more stable than walking-sticks. They
are prescribed for patients who can take some weight on both feet
Elbow crutches ( Loftsrrand crutches)
but require an aid for balance and confidence, fo~ example wh.en
Most. e.lbow crutches are made from a single adjustable tube of partial weight bearing with the three-poinc crutch gan, the four-pomt
alumm JUm alloy to \.vhich are attached a U-shaped metal cuff crutch gait or the two-point crutch gait (see Chapter 13). Some
(armband), to accommodate the forearm just below the elbow and a patients with paraplegia, who h ave unusual skill, strength, ~o­
rubber or plastic coYered handgrip. The lower end is protedted bv orclination and balance, may be able to use elbo"v crutches w1th
a rubber tip ( Fig. 12.3). · the swing-through gait.
The armband is made usually from spring steel. It grips the
forearm, thus enabling the crutch to be controlled when freedom of ADJUSTME~T OF ELBOW CRUTCHES . .
hand. moYement is required. The armband may ha\·e a front or side Elbow crutches must be accurately adjusted for each pan em. AdJustment
openmg and may be fi..xed rigidly or be attached by a hinge joint must be carried out with the patient standing and wearing shoes.
 156 TRACTION AN'"D ORTH OP ..~EDIC APPLI A:-\CES

deformity of the elbow joint, weakness of the muscles controlling

\\'hen elbow crmches are ad'usted the elbow joint or hand, a deformity of the hand causing difficulty
are on the ground 6 inche~ (15·b em . correctly the rips of the crutdl in gripping, or when the patient experiences pain in the hand or
of the toes and th . • . ? m front of and lateral to the 0"
e patient IS standmo up ·gh . . ,. wrist on taking weight through the upper limb.
depressed and his elbows in 30 d "' f s~ai t, with his shoulder
• A k th · egrres o ftex1on
. s e patient to put his arms throu h th . ADJUST.\.iE;:-.:T OF GUTTER CRUTCHES
handgrips. g e armbands and to grasp th
• Strap the forearm into the gutter so that the point of the elbow lies
• Check that the palms f th h at or just behind the posterior edge of the gutter.
• Place the tips of theoc echands are on top of the handgrips.
rut es on the g 0 d 6 . • Adjust the distance: between the front of the gutter and the: handgrip,
front of and lateral to ·'-e n' p f th
u• so e toes
r Wl ' mches (15·0 em m so that the handgrip can be grasped firmly. If rotatory adjustment of
• Ask the patient to stand up straight and ;o relax his shoulders. the handgrip in relation to the gutter is possible, adjust.
• Ask the patient to stand up as straight as possible.
Checkin g over a ll length • Place the tip of the crutch on the ground 6 inches ( l5·0cm) in front
Toodegrees.
30 /,mg- The shoulder I·S 11Unched and the elbow is flexed more than of and lateral to the rips of the toes.
• Adjust the height of the crutch by means of the spring- loaded double-
Too .lhorr-The patient is lea . f ball catch so that the elbow is in 90 degrees of flexion. If the patient
than 30 degrees. nmg orwards and the elbow is flexed lc::~~
is unable to flex his elbow to 90 degrees, then a crutch in which the
angle between the gutter and the crutch can be adjusted is required.
T~ adjus t the len g th of the crutch
• Disengage
buttons. the spring-loaded double-ball catch by pressing in both

• Slightly twist the lower part of th WALKI NG-ST ICKS

button is \isible. e crutch so that about half of each
• Sli~e the lower parr of the crutch to the desired .. The commonly used walking-stick is made of wood, ,,·ith a C-curved
• T'-'1St back the lo positiOn.
ball catch to jump:~:. parr of the crutch to allow both buttons of the handle; a right-angled or pistol-grip handle is also available and
may be preferred by the patient. A rubber rip protects the lower
• ~s~~~n~at the lower pan of the crutch is firmly locked in the new end. Adjustable sticks made from aluminium alloy tubing with
rubber or moulded plastic handgrips can be obtained.
• Check the O\·erall length of the crutch again.
\X' alking- sricks are not as stable as elbow crutches, but are lighter
and more easily stored. They assist balance and provide moderate
Checki ~ ~ t h e posi tion of the a rmband
The posmon of the armband is co support for a lower limb, and thus can improve gait and help to
of the armband and the fl . rrect when the gap between the top relieve pain, for example from a painful 'hip. Walking-sticks are not
Adjust the position of ~~racreabse odfthf e ~!bow is~ inches (5·0 em). used unless the disabled lower limb can bear weight.
rm an I thiS IS pOSSible.

Gutter crutches Choosing the correc t walking-stick

A patient when using a walking-stick should ha,·e his elbow in 30 degrees
A gutter crutch (Fig p 3 ) . .
aluminium alloy. An.acl~~d t~o~~s~ of a smgl_e adjustable tube of of flexion.
metal gutter Or trough in wh ich th e
90 degrees of tl .· p . .
r:r:r
_en~ IS a :hort horizontal
. ai m tests w1th the elbow in
Too lo11g- The shoulder is elevated, the elbow is flexed more than
30 degrees, ulnar deviation of the wrist is increased unless the grip on
. exlon. rOJectmg forward from th . the handle is changed and support is dec reased.
adJUStable bar carrvincr a ver tic I h d . e gutter IS an Too sho1·c-The patient leans forward and the elbow is flexed less than
be padded is secur~d ~o th f a an gnp. The gutter, which may
crutches the angl b . e orearm by Velcro fastenings. On some 30 degrees.
e et\\ een the ouner d th 11
position of rotation of the handcrri' . an . e a oy tube and the ADJUSTME~T OF WALKING-STICKS
adjusted Th l . "' P m relauon to the gutter mav be • Place the handle of the walking-stick on the ground beside the heel of
· e 0 '' er end of the crutch is ' ·
Adjustment of length is bv me f protected by a rubber tip. the patient's shoe.
catch. · ans 0 a spnng-loaded double-ball
• Remove the rubber tip.
Gutter crutches are indicated \\'hen there is a fixed flexion
 • Adjust the length of the walking-stick so that its (lower) end 1s le\
with the most prominent part of the greater trochanter or radial ~t\ J, ADJ USTMENT OF TRIPOD OR QUADRUPED
process.
WALKING AIDS . h" to take hold
• Replace the rubber rip. • Place the walking aid beside the paoent, and ask Im
• Re,·erse the walking- stick and check that the patient's elbow 15 lr
30 degrees of flexion. • ~~c~::~~p~id is correctly orientated. The handgrip muse lie _..·er~ic;ll~
above the ru:o l.tgs which ar: ;uares~ ro and p~rallei :oti:~: ~~~~~:::: o~:r
( Fi . 12.5). If the aid is posltloned mcorrectly, the_ p . .
TRIPOD AND QUADRUPED WALKING AIDS theglegs of the aid which lie, or will come to he wtth use, m front
of the patient's foot.
These walking aids are similar. They are made from aluminium allo\
or steel tubing.
The TRIPOD WALKING AID (Fig. 12.4) has three rubber-tipped
legs which touch the ground at the corners of an equilateral triangle.
The looped or righ t-angled han dgrip lies in the same plane as a line
joining two of the legs. T he h eight of the handgrip can be adjusted.

. . d lk" aid Note that the handgrip must

Figure 12.5 Correct orientatton of tn~ lk~a mJ whlch are nearest to and parallel
lie ,·ertically above the two legs of the "a mg at
to the patient's foot.

• Check that the palm of the hand lies on top _of the handgrip.
• Check that the handgrip is at the correct hetght.
Too high-the patient's elbow is ftexed more than 30 degrees.
Too low-the patient's elbow is ftexed ~ess than 30 degrees.
F igur e 12.4 Tripod walking aid. T o a djust the hei ght of the h a_ndgnp th ·ng-loaded double-ball
• Loosen the adjusting screw or disengage e spn
The QUADRUPED WALKI!'\G AID has four rubber-tipped legs. The catch.
handgrip lies vertically above the two inner legs, which are more • Raise or lower the handgrip to the corre~t le~l. . buttons of the ball
• T ighten the adjusting screw or ensure at e two
widely spaced than the two outer legs. The height of the handgrip
is adjustable. catch are engaged. . · · · th, t wo inner
• Check that the handgrip lies parallel to the' hne JOtnmg e
The tripod and quadruped walking aids, which may be used
singly or in pairs, confer more stability than walking-sticks or elbow e legs.
Push down yourself on th e h an d g n. p to ensure that the aid will not
crutches. They cann ot pivot for wards and must be lifted and placed collapse. h · ht
in a forward position. This requires more strength in the upper • Check again that the handgrip is at the correct elg .
limbs than would be required fo r walking-sticks or crutches. Usually
they are reserved for patients suffering from neurological conditions,
but they may be used in the rehabilitation of elderly patients who HAND GRIPS
have sustained injury to their lower limbs. These walking aids have
one particular ad,·anrage o,·er walking-sticks and crutches; they will The handgrips of all walking aids can be modifi~d to a~co~moda:~
. formed hand. The girth of a handgnp can e mcreas.
~;t~~:;p~~g
stand upright beside a bed or a chair, ready for use.
lengths of orthopaedic felt or sponge rubber around tt.
 160 TRACTION AND ORTHOPAEDIC APPLIANCES

For a deformed hand, such as may occur in rheumatoid arthritis, a 13. Crutch walking
mould of the grip of that hand can be taken in Plastazote* and
later be transferred to the handgrip of the appliance.

The majority of patients approach crutch walking \Vith some ap-

RUBBER TIPS prehension, and the older and the more disabled the patient, the
greater the apprehension. Sometimes crutches are needed . onl.y
The suction-type tip is best (Fig. 12.6). It is flexible and the sides temporarily; at other times their need is permanent. The panent s
of the tip flare out slightly. There are concentric rubber rings on abilitv to use crutches efficiently and perhaps eventually to walk
unaided depends upon a number of factors.

1. The strength of the muscles required in the use of crutches (see

·chapter 12).
2 . The correct selection and adjustment of the crutches (see
Chapter 12).
3. A good sense of balance.
4. Familiarity with the crutches and their maintenance.
5. The correct crutch stance.
6. Instruction in how to stand and balance with crutches before
taking any steps.
Figure 12.6 Cross-section of a rubber suction tip. 7. The pattern of gait employed.
8. The initial development of the gait pattern between parallel bars
if necessary.
the undersurface, with the outermost ring projecting slightly beyond 9. Instruction and practice in walking and the performance of
the other rings. On a wet surface these concentric rings exert a various manoeuvres essential for daily living, with the crutches.
suction-cup effect. The flexibility of the tip and the suction-cup
effect ensure that the undersurface of the tip comes into uniform
contact with the ground e,·en when the walking-stick or crutch is
CRUTCH MAINTENANCE
inclined at a slight angle from the verticaL
Hard small rubber tips, or worn suction tips are dangerous.
1. The wood or meta\ must not be cracked.
They are likely to slip. They must be replaced. 2. All the adjusting nuts must be tight, and all the spring-loaded
double-ball catches must be working.
3. The rubber tips must be in good condition. If the tip is badly
. REFERENCES
worn it must be replaced.
BECKWITH, 1. .\1. ( 1965) Analysis of methods of teaching axillary crutch measurement. 4. The handgrips and axillary pads if presem, must be in good
Joumal of the A111er·ican Physical Therapy Association, 45, I 060. condition.

CRUTCH STANCE-AXILLARY CRUTCHES

Before taking any steps with the crutches, the pati~n_t mu~t be
instructed in how to stand and balance with them. Th1s IS ach1e\·ed
by standing the patient against a wall and placing a crutch under
• See Appendix. 161
162 TRACTION AND ORTHOPAED IC APPLIANCES

each arm. The correct stance with crutches is in a position ~·ith r,.coanised that the length of step vvill vary with the height of the
the head up, the back straight with the pelvis over the feet as much pati;nt. It is important that any patient who is learning to use
as possible, the shoulders depressed not hunched, the axillary pads autches should gain confidence as quickly as possible. Confidence
of the crutches gripped between the upper arms and rhe side walls will be aained more quickly if the initial steps are small. As
of the chest 2 inches (5·0 em) below the anterior axillary fold, the confiden~e increases, the length of step can be increased. When the
crutch tips 6 inches (15-0cm) forward and 6 inches (15·0 cm) out ~round is wet or slippery, short steps are advisable as slipping will
from the tips of the roes: the palms of the hands on top of the be less likely to occur.
handgrips, the body weight taken mainly on the hands, and the
elbows in a position of 30 degrees of flexion. Swinging crutch gaits
The correct crutch stance with elbow or gutter crutches is
basically the same. There are two types of swinging crutch gait, the swing-to crutch gait
and the swing-through crutch gait. These gaits are used when the
body weight can be taken through both lower limbs together but
CRUTCH WALKING-PATTERNS OF GAIT the patient is incapable of moving his lower l in:~s individuall~ due
to paralysis. Calipers are frequently worn to s tabtl!se the l~wer llmbs.
There are four different patterns of gait. The lower limbs are moved by the trunk muscles acung on the
pelvis.
1. Swinging crutch gaits. The stable position is that of a tripod, with a large triangular
2. Four-point crutch gait. base and the apex at the shoulders. The two anterior legs of the
3. Two-point crutch gait. tripod are formed by the backward and inward slanting crutches .
4. Three-point crutch gait. The posterior leg of the tripod is formed by the trunk and l~wer
limbs of the patient as he leans forward on the crutches. A pauent,
The patterns of gait employed with crutches differ in the com- paralysed below the waist, is stable in this position provided that
bination of crutch and foot or crutches and feet movements used flexion contractures of the hip, knee, or ankle joints are not present,
in taking steps, and in the sequence of such combinations. the knees are braced in extension and the centre of gravity falls
To select the pattern of gait ro be employed by a particular in front of the hip joincs, to maintain them passi\·ely in extension.
patient, the ability of the patient to step forward with either one or If the centre of gravity falls behind the hip joints, passive hip
both feet, to bear weight and keep his balance on one or both lower extension will be lost, the hips will flex and the patient will
limbs, to push his body off the ground by pressing down on both collapse. Before attempting to progress the patient must practise
crutches, to maintain his body erect, and to control the crutches standing in this position until he has acquired a sufficiently good
must be evaluated. sense of balance to give him confidence.
The pattern of gait which is selected should be as near normal In the swing-to crutch gait, the patient advances the crutches
as possible, consistent with the patient's condition. It is important to and then swings his body to the crutches. In the swing-through
remember that walking aids are u sed to increase the patient's crutch gait the body is swung through beyond the crutches.
mobility. Each patient must be encouraged to walk even if he does
not use a recognised pattern of gait. Any mobility is better than Swing-to crutch gait
immobility. Crutch- foot sequence: Both crutches; lift and swing the body to the
I~ is impossible to teach any d efinite pattern of crutch walking crutches.
to ch1ldren under the age of five years. Children over the age of
The patient is in the stable posicion.
five can be taught but when they are alone they may not practise
what they have been taught. e Place both crutches forward together a short distance.
A distance of 12 inches (30·0 em) is advocated as the length of e Take all the body weight on the hands and at the same time straighten
step and of forward movement of the crutches when the sequence of the elbows co lift the body.
e Swing both lower limbs forward together co b.:cw.!.m ch.! crwclus, arching
movem:nt in the different types of gait is described, in order to
the spine as the heels touch the ground firl>t.
emphas1se that these forward movements are small and equal. It is
 13. CRUTCH WALKING 165

• Keep_ the spine arched and the hips well forward. This \I 111
the h1ps and knees in extension and stabilise the lower limbs. • Place the left crmch forward a distance of 12 inches (30·0 em).
• Take the body weight on both feet. • Step forward 12 inches (30·0 em) with the riglu foot, taking parr of the
• ~mmediauly place both crutches forward a distance of 12 inche~ body weight on the left hand.
m from of the feeT, to regain the stable position. • Place the right crutch forward a distance of 12 inches (30·0cm) in front
• Repeat the ab01·e. of the 14t crutch.
• Step forward with the left foot, placing it 12 inches (30·0cm) in from
of clze right foot, taking pare of the body weight on the right hand.
lni_tially, patients may not ha,·e either the confidence or
• Repeat the above.
power 1~ the upper limbs or trunk to perform the swing-to crutch
as descnbed aboYe. \Xlhen this occurs, the patient is taught to h
Two-point crutch gait
the crutches forward and then to slide, jerk or drag the feet
to?ether by a _body movement, while bearing down on the Crutch-foot sequence: Right crutch and left foot simultaneously;
gnps and keepmg the body inclined forward sufficientlv to ma 1 left crutch and right foot simultaneously.
the centr~ of gravity in front of the hip joints. As co~fidencc 1 When the two-point crutch gait is used the amount of body
strength Improve, the swing- to crutch gait will deYelop. weight taken on both feet is reduced. This type of gait is used when
the patient's balance is good, some body weight can be taken through
Swin g- through crutch gait both lower limbs but both lower limbs are painful or weak.
Crutch-foot sequence: Both crutches; lift and swing the body bevond
the crutches. · The patient is standing on BOTH feet with a crutch under each ann.
The swi~g-through crutch gait, although quicker than the swina • Place the right crwch and the left foot forward together a distance of
~o crutch gan, must be attempted only when the patient's balance 12 inches (30·0 cm), taking part of the body weight on the left foot.
IS excellent.
• Place the left crucch and the right foot forward together a distance of
12 inches (30·0 em) in front of the left foot, taking part of the body
The patiem is in the stable position.
weight on the right foot.
• Repeat the above.
• Place both crutches forward together a short distance.
• Take all the body weight on the hands and at the same time straighten
the elbows to lift the bodv. Three-point crutch gait
• Swing_ both lower limbs forward together through the crutche.t, archina
the spme as the heels touch the ground first, 12 inches (30·0 em) ;11 front Crutch-foot sequence: Both crutches and the weaker lower limb
of the crutches. together; the stronger lower limb.
• Keep the spine arched and the hips well forward. By using the three-point crutch gait, the amount of body weight
• Take the body weight on both feet. The forward momentum brings the taken by a foot can vary from none to partial or full. The three-
trunk and the crutches to the erect position. point crutch gait is commonly taught to orthopaedic patients who
• ~mmediately place both crutches forward a distance of 12 inches (30·0 em) may have one painful or weak lower limb which cannot support the
m front of the feet, to regain the stable position.
• Repeat the aboYe.
whole body weight, and one lower limb which can. Both crutches
support the weaker lower limb, while the stronger lower limb takes
the whole body weight without any support from the crutches.
Fow·-poinr crutch gait The sequence of movement of the crutches and the lower limbs
Crurch-foor sequ~nce: Right c:u~ch; left foot; left crutch; right foot. in performing different functions is described below .
. The four-pomt crutch galt IS used when all or part of the body
weJghr can be tak~n on each foot, but the patient is unsteadv and Walking, non-weight bearing
The patient is standing on his RIGHT foot with a crutch under
~herefore requires a wide base of support. As the patient's b~lance
Improves, he may progress to the two-point crutch gait. each arm: che LEFT fooc is off the ground.

• Take all the body weight on the right foot.

The patiem is standing on BOTH feet with a crutch under each arm.
• Place both crutches forward together a distance of 12 inches (30·0 em).
 13. CRUTCH WALKI~G
166 TRACTION AND ORTHOPAEDIC APPLIANCES

Sittin g down in a chair

• Carry the lefr lower limb forward to a position between the crutch<
Crutches; weak LEFT lower limb.
with the left foot off the ground. As confidence increases both crutchc'
and the left lower limb can be ad\'anced together. e After reaching the chair, check that the chair is stable. This particularly
• Take the body weight on the hands and at the; same time carry till' applies to wheelchairs.
peh·is forward to between the crutches. By this means the cemre ol e Turn round so that the back of the right leg touches the from of the
gra,·ity passes downwards through a line between the two crutches. chair. This aids balance.
• Carry the l'ighr foot forward and place it on the ground 12 inches e Take the crutches from under the arms.
(30·0 em) in from of the crutches. Do not fall forwards. e Transfer the right crutch to the left hand.
• Take all the body weight on the righr foot. • Hold both crutches in the left hand.
• Repeat the abO\·e. e Place the right ha11d on the arm of the chair.
e Bend forward slightly.
By carrying the pel vis forward to a position between the crutches e Gently lower the body onto the chair.
before the right foot leaYes the ground, a more stable position is
obtained as the pendular mo,·ement of the peh·is and lower limb is Stepping up a kerb or step . . .
reduced and excess forward swing is avoided. The method described here is used also when gomg up sta1rs usmg
When non-weight bearing in an above-knee plaster cast, it may two crutches.
be necessary to add a raise to the opposite shoe, especially if the knee Always step up with the stronger lower limb first.
is held extended, to ensure that the injured limb will clear the ground Crutches; weak LEFT lower limb.
as it is brought forward. If a raise is not added, the injured limb • Approach the kerb.
will have to be carried in front of the body with the hip in slight e Place the ends of both crutches in the angle formed by the kerb and the
flexion. To ensure non-weight bearing in young children it is road.
essential to add a raise to the opposite shoe. e Take the body weight on the hands, straighten the elbows and carry the
\Xlhen a lower limb is strong enough to take part of the body pelvis forward to between the crutches.
weight, that limb is placed on the ground ax the same zime as zhe e Lift the right foot off the ground and carry it upwards and forwards
two autches. By this means part of the body weight is taken on the onco the kerb.
hands, and part through the lower limb. This is termed partial e Straighten the right knee, thereby transferring the body weight on to the
weight bearing. right foot.
e Lift both crutches up and carry them and the left lower limb forwards
Getting u p f r om a chair in preparation for the next step.
Crucches; weak LEFT lou.:er limb.
Steppi ng down a kerb or step . .
• Bring the heel of the right foot backwards to lie under the edge of the The following merh0d is used also when gomg down sta1rs using
chair. two crutches.
• Slide forwards on the chair so that the buttocks are resting on the edge Always sup dowrt with che crutches arzd the weaker lower limb
of the chair. together first.
• With the right hand, grip the arm of the chair as far forward as Crutches; weak LEFT lower limb.
possible.
• Take hold of the handgrips of both crutches with the lefr hand. e Approach the edge of the kerb.
• Place both crutches vertically on the ftoor near the front edge of the • Take all the body weight on the right foot.
chair. e Place both crutches downwards and 12 inches (30·0cm) forward on the
• Stand up by pushing upwards with the right leg and both arms, keeping road, bending the right knee and carrying the left lower li":b forward
the left foot off the ground. at the same time. The higher the kerb, the greater the diStance the
• Transfer one crutch ro the right hand. crutches must be placed away from the kerb.
• Place the crutches under the arms. e Take the body weight on both hands and carry the pelvis forward to
• Pause before walking to ensure that balance has been obtained. between the crutches.
e Lift the right foot off the ground and place it downwards and forwards
\Xlhen getting up from a wheelchair, check that the wheels are on the road in from of che crucches, thus proceeding to the next step.
locked.
Ascending stai rs ,,·ith a h an d r ail
Crwches; v:eak LEFT lower limb; ha11drail on The RIGHT. Once a lower limb is strong enough to be able to take nearly all
the body weight, two sticks can be substituted for crutches. The
• Approach the bottom of the stairs.
• Transfer the right crutch to the left hand. It is more convenient if the technique of walking with two sticks is the same as that described
rramfcrred crutch is carried horizontally in the left hand. above for partial weight bearing with crutches. It is preferable to use
• Take a forward grip on the handrail with the right hand. two walking-sticks initially. If only one walking-stick is used, t he
• \\.'irhout mo\'ing the left crutch, lift the body upwards and forwards wnh patient will rend to lean towards the stick, to cake a shorter stride
both hands and at the same time lift the righT foot upwards and forward~ on t hat side and to carry the opposite lower limb in abduction.
onro the first step. This abnormal gait tends to persist after the walking-stick is
e Lift the left crutch up on to the same step. abandoned. When a good technique using two walking-sticks has
• Repeat the procedure umil the top of the stairs is reached. been achieved, one stick can be discarded. The single z.::alking-scick
• Transfer the second crutch back under the right arm before proceeding. is carried in the opposite hand co che affr!cted lower limb. (Some
If the handrail is on the left, the procedure is identical except patients, however, with a lesion of the knee or ankle, may gain
that the left crutch is transferred to the right hand. Always step up more relief by holding the walking-stick in the ipsilateral hand.) For
with the stronger lower limb first. example, to obtain partial relief from weight bearing on the lefc foot,
hold the walking-stick in t he right hand, and place the left foot
D escen din g stairs wi th a h an d r ail and the walking-stick forward s together at the same time.
Crutches; weak LEFT lower limb; handrail on the RIG H T. Increased stability and further relief from weight bearing can be
• Approach the top of the stairs. obtained by bringing the hand inward to rest against the body in the
• Transfer the righT cruTch to the left hand, holding the transferred crutch region of the greater trochanter of the femur.
horizontally.
• Place the riglu hand slightly forward on the handrail.
• Place the left crutch on the step below, bringing the left lower limb
forward at the same time.
• Bend the righT k11ce to bring the pelvis forward between the crutch and
the right hand.
• Take the body weight on the hands.
• Lift the right foot off the ground and place it forwards and downwards
on the same step as the left crutch.
• Repeat the procedure until the bottom of the stairs is reached.
• Transfer the second crutch back under the right arm before proceeding.
If the handrail is on the left, the procedure is identical except that
the left crutch is transferred to the right hand. Always step down
with the crutch and the weaker lower limb first.
Before a patient can be considered to be really efficient with
crutches, he must be able to step backwards, forwards and sideways,
and to walk on uneven surfaces and up and down inclines. ·

WALKING-STICKS

Walking-sticks can be used to decrease the amount of body weight

taken through a lower limb during walking and therefore can com-
pensate for muscle weakness and relie,·e pain. In addition the use of
a walking-stick or sticks can increase the stability and the confidence
of a patient.
14. Plaster-of-Paris casts

Plaster-of-Paris casts can be responsible for the development of

serious complications.

IMPAIRMENT OF CIRCULATION
A limb which has been fractured, or upon which an operation has
been performed, will always swell to a greater or lesser degree
because of haemorrhage from the bone and surrounding traumatised
soft tissue, and because of reactionary tissue o-edema. If such a limb
has been encased in a plaster cast the swelling can r_s:sult in an
appreciable increase in pressure within the cast, and cause a reduction
in or the obliteration of the blood supply of the muscles and nerves.
An increase in the pressure within a fascial compartment of the limb
in the absence of a plaster cast can have the same result. This
impairment of the circulation can occur in the presense of distal
peripheral pulses. Ischaemia causes tissue death and subsequent
fibrosis. Joint contracture, muscle paralysis and altered cutaneous
sensibility may develop and cause considerable permanent impair-
ment of the future function of that limb.
Patients who have sustained a fracture or undergone an operation
commonly suffer pain. This pain rapidly and progressively decreases
over the following two to three days. The persistence, the increase,
or the recurrence of pain in an injured limb may herald the onset
of circulatory impairment, or the development of a pressure sore.
Circulatory embarrassment or the development of a pressure sore is
accompanied by severe pain. It is important to remember that patients
do not always complain of pain to the attending doctor for varying
reasons. Therefore, every patieru who has a plaster cast applied must
be directly questioned as to the presence of pain. Do not wait for
the patient to complain of pain-it may then be too late.

TO PREVENT VASCULAR C0.\1PLICATIONS

• Do not apply an unpadded plaster cast to a recently fractured limb.
t'vtany fracrures can be adequately immobilised initially by the application
over padding of a partly encircling plaster slab, the slab being retained
by an encircling bandage. If a complete plaster cast must be used to
maintain position, the plaster must be applied O\'er padding. Preferably
the plaster cast then should be split thro ughout its length.
172 PLASTER-OF-PARIS CASTS

e After an operation, always apply a well padded plaster cast, or split a bony prominences, the presence of foreign bodies such as coins or
lightly padded cast throughout its length.
matchsticks between the cast and the skin, or from the chafing of the
• Elevate the encased limb so that gravity can assist the venous return
from the limb. skin by the rough edges of a crack in the cast. The development
• Encourage active finger and toe movements, again to assist the venous of pressure sores can be prevented by the careful application of
return. adequate padding, by the avoidance of varying tension in a roll of
e Keep a frequent and careful check upon the state of the padding or plaster as it is being applied, and by the avoidance of
cir culation in t he affected limb . localised areas of pressure by fingers or thumb while the plaster is
1. Enquire abour the presence and site of any pain. Xever ignore rhe wet. With regard to the latter, a wet cast must be held only in
complaim of pain, as even a fussy patient can de\·elop circulatory the palm of the hand, so that pressure is spread over a wide area.
embarrassment or a pressure sore. In addition a wet cast must be supported throughout its length on
2. Examine the fingers or toes for swelling. Swelling may be due to a pillow until it is dry, to avoid direct pressure on an underlying
\'enous obstruction, dependancy of the injured limb, insufficient active
bony prominence, such as the heel or the point of the elbow.
exercise or a combination of all three.
3. Compare the state of the capillary circulation, especially in the nail
beds, in the injured limb with that in the uninjured limb. Blanching
on pressure should be followed by a quick return of colour on release
of the pressure. The colour should be pink. Blueness of the extremities
suggests \'enous obstruction. It should disappear on elevation of the Diagrwsis of the presence of a pressure sore
limb. White and cold fingers or toes suggest arterial obstruction.
4. The peripheral pulses may be obscured by the cast, but where l. Pain. Pressure sores are painful initially. The pain will decrease
possible palpate them and compare with the uninjured limb. Remember when full thickness skin ulceration occurs. If a patient complains
that circulatory embarrassment can be present even when the distal of pain under a plaster cast, which is not referable to the
pulses are palpable. fracture or operation, the presence of a pressure sore must be
5. Examine the extremities for the presence of altered skin sensibility- suspected.
hypoaesthesia. 2. Fretfulness especially in children. Children may be too youn g to
6. Test the ease and range of active and passive movement of the
complain of localised pain.
fingers and toes. Pain on passi\·e extension of the fingers or toes is
strongly indicative of ischaemia of the flexor muscle groups.
3. Disturbed sleep. This again particularly applies to children.
4. Rise in temperawre.
If rhere is evidence of impairmem of the circulazion in a limb, the 5. Recurrence of swelling of the fingers and toes once the initial
plaster case must be split throughout ics length, or removed completely swelling has subsided.
at once. If impairment is due to a rise of pressure within a fascial 6. The presence of an offensive smell.
compartment, then the limb must be decompressed immediately. 7. Discharge. A discharge may present either from under the edge of
Remember that the splitting or removal of a plaster cast may not the cast or by the appearance of a stain on a previously clean
be sufficient ; the limb may also need to be decompressed. The area of the cast.
delay of a few hours may have disastrous consequences. A good
rule is if in doubt split the plaster cast: it is better to split a cast By the time the patient exhibits a rise in temperature, or there
unnecessarily and possibly lose the position, than !0 run the risk of is a recurrence of swelling of the fingers or toes, or an offensive
ischaenuc changes occurring in a limb. smell or discharge is noted, full thickness skin ulceration with
In general a lower limb cast is split along the front, and an possibly necrosis of the underlying fat and muscle will have occurred.
upper limb cast along the ulnar or flexor surface. How to split a The presence of a pressure sore must be diagnosed before this state
plaster cast is described later. is reached.
If the preseuce of a pressure sore is suspected, the skin in rhat
PRESSURE SORES area muse be examined immediately either by curcing a windor.:.•, or by
remo·•.:iug the cast altogether (these procedures are described in detail
Pressure sores can develop under a plaster cast due to irregularity later). It is better to lose position rather than allow a pressure
of the inner surface of the cast, insufficient padding especially over sore to develop.
 INSTRUCTIONS TO AN OUT-PATIENT WEARJ~( 1

Q
A PLASTER CAST Along

Only a small number of patients who have had a plaster cast apph 1
are admitted to hospital. The ,·ast majority are treated as out Down Up Down
patients. I I
' -y
Before any patient is allowed to leave hospital, the circulathll\
in the encased limb must be checked and found to be satisfactot,
/' -"" \
In addition the patient must be given the following instructions both
verbally and in writing.
Figure 14. 1 The correct way to use an electric plaster saw.
1. The time and place of his next out-patient attendance which
must be within the fo llowing twenty-four hours.
2. The patient must reattend immediately at any time of the da\'
or night if he experiences severe pain or if his fingers or toe~ The plaster cast can be cut with plaster shears or with an
become blue, white or badly swollen. electric plaster saw (e.g. Zimmer). Generally shears are used f~r
3. The encased limb must be kept well elevated. child ren small casts, and· casts on the upper limbs. The elecc:zc
4. Active movements of his fingers or toes as well as all the joints plaster s~w must not be used on unp~dded casts. It may be used wtth
not immobilised by the plaster cast must be carried out at great care when there is only stockinette under the cast.
regular frequent intervals.
5. Excessive local pressure on the plaster cast must be a,·oided. HOW TO USE AN ELECTRIC PLASTER SAW (Fig. 14.~ )
6. The plaster cast must be kept dry. The cutting blade of an electric plaster saw does not rotate. It osct~lates,
7. The patient must reattend if the plaster cast shows e,·idence of and will damage the skin only if it is drav:n along the limb. or tf the
cracking or softening. skin is adherent to the underl:ying bone and therefore not mobtle.
8. If any ~bject such as a coin or pencil is dropped under the cast, • Switch on the saw. .
the panent must reattend immediately. • \Xiith light pressure apply the cutting blade to the plaster cast, keepmg
a finger under the neck of the saw to control the depth of the cut. In
The application of the different plaster casts used in the treat- this way it is easy to feel when the saw has cut through the cast.
ment of fractures and other conditions is not described. This is well e Remove the blade from the cut formed in the cast.
described in other books (Plaster-of-Paris Technique: Gypsona e Reapply the cutting blade at a slightly higher or lower level.
Technique: Orthopaedic Xursing ) . • Repeat these separate and distinct movements unul the cast has been
The following procedures are described. divided along its length. .
Removing a plaster cast. Do noc draw the cutting blade of an eleccric plaster saw along_ ch~ lzmb,
otherwise che skin tvi/l b~ cUI. Take particular care when there ts a blood-
Pre-operative preparation of a limb immobilised in a p laster cast.
Cutting a window in a plaster cast. soaked dressing under the case.
Do 110 , hold che electric sat:; with wee hauds, or allow the lead co the saw
Splitting a plaster cast.
Wedging a plaster cast. co get wee.

HOW TO REMOVE A PLASTER CAST (Fig. 14.2)

REMOVING A PLASTER CAST • Determine if the cast is padded. .
• Choose a line along which to cut the cast, avoiding any bony pron:unences,
A p laster cast used for the ex ternal immobilisation of a fracture will
to reduce the risk of skin damage. For a lower limb cast, the lme must
be removed after a certain number of weeks, to determine the pass in front of the lateral malleolus and behind ct:e medtal malleolus.
state of union clinically and radiologically. When a plaster cast is e Cut the cast on both sides of the limb (bi·ualv<), wtth ~are. .
remoYed, it is important that the skin of the limb is not damaged, • RemO\'C the front half of the cast, dh·ide the underl~1ng padding, then
the patient is not subjected to pain, and control of the fracture is carefully lift the limb out of the back half of the c~st.
maintained until it is decided that the cast can be discarded. • Reapply the bivalved cast for transport to the Radiology Department.
176 TRACTION A~D ORTHOPAEDIC APPLIA~CES 14. PL.<\STER-OF-PARIS CASTS 177

When it is known that a window will be cut later in a cast, for

c-:!J example fo r the removal of sutures, the site of the window can be
indicated by applying additional dressings or a pad of wool over the
woW1d, so that an elevation in the cast is produced.

PROCEDURE (Fig. 14.3)

R emoving the window
L1ft off front / divide padding

/
Gently lift limb free
e Identify and mark out on the cast the area of skin to be exposed,
allowing a reasonable margin for error.
• Cut along the marks with an electric plaster saw.
e Gently lever the window our.
e Remove the underl~ing padding to expose the skin.

~
Cut cast along line
- beh1nd medial malleolus
- in front of lateral malleolus
Remove padding Cut and apply felt

\
F igure 14.2 Bi,·al\'ing a plaster cast. Lift off Replace

PRE-OPERATIVE PREPARATI ON OF A L IMB

IMMOBIL ISED IN A PLASTER CAST

It may be necessary to operate upon a limb which has been im-

mobilised for some weeks in a plaster cast. Before operation, the
skin should be prepared to remove the dead superficial epidermis
and hair. After a few weeks a fractured limb can be moved painlessly F igure 14.3 Cutting a window in a plaster cast.
with gentleness and care.
R eplacin g th e window
PROCEDURE The window must be replaced after examination, other••ise, if the limb
e Bi,·ah·e the cast as described above. swells, the skin \\<ill impinge against the cut edges of the cast and
• Gently remove the limb from the cast and place it on a sheer of pressure sores v.-ill result. In addition the cast will be weakened.
polythene CO\'ered ,,;th a rowel. • Remove any padding from the undersurface of the \¥indow.
• Gently wash the limb with soap and water, if necessary using a soft • Cut a piece of orthopaedic felt to the exact size of the ~indow, and
nail brush, to remove the scaly skin. stick it onto the undersurface of the window.
• Shave the limb as necessary. • Replace the window.
e Wrap the limb in a sterile towel and replace it in the bh·alved cast. • Firmly apply zinc oxide strapping or plaster bandage around the cast to
• Apply a crepe bandage or lengths of zinc oxide strapping to hold the retain the window in position.
cast together.
SPLITTING A PLASTER CAST
CUTTING A WINDOW IN A PLASTER CAST HO\'<' TO SPLIT A PLASTER CAST
e i'vfake a longiwdinal cut through che cast from one end to the otlur, using
It is sometimes necessary to expose a limited area of skin surface plaster shears or an electric plaster saw.
for examination, when it is inadvisable to remove or bi,·ah·e the whole Noc~ that it is useless and dangerous to nibble at the free edge of the
cast. This can be achie,·ed by cutting a \\indow in the cast. cast under the misunderstanding that the swelling of the fingers or toes
 14. PLASTER-OF-PARIS CASTS 179
178 TRACTIO::-x Al'\0 ORTHOPAEDIC APPLJA:-:CES

is due to constriction by the free edge of the cast. The swellint: 11f 1
fingers or roes is indicath·e of increased pressure within the "holr
• Ease open the cur in the casr about t w! inch (0·6 to 1·25 em).
• Dit·ide all paddiug including any wound dressings to expose 1he 1111ci.!lw
skin. \'\'ound dressings must be cut as a blood-soaked gauze drc:u 1
dries rock hard and may itself form a constricting ring.
• Check 1ha1 bare skin is exposed 1hroughow the ~~hole leng1h of the cu1 1
1he caSI. This is particularly important o\·er the front of the ankle.
• Cut and place a srrip of orthopaedic felt along the whole length ol th
opening in the casr. This will pre,·ent herniation of the skin.
• Apply: crepe bandage around the casr.
e Ele.:ale the limb and encourage aClive movemem of the toes or fingers.

\X' hen impairment of circulation is due to an increase in pressure:

within a fascial compartment, the treatment is operatiYe decom 2
pression of that compartment.
Study X- Rays. ldenufy !eve! and
Check direction site of hinge.
of angulation. Mark cast.

WEDGING A PLASTER CAST

The aim when reducing a fracture is to reduce overlap and to obtain

correct apposition and alignment of the fragments without rotation at
the fracture site. It is difficult to maintain reduction during the
application of a plaster cast. Post-reduction radiographs may show
that although length and apposition have been satisfactorily obtained
and rotation corrected, angulation at the fracture site is present. This
can be corrected by wedging the plaster cast.
Charnley ( 1970) states that wedging of plaster casts should be
regarded as an unfortunate necessity rather than a procedure of
choice.
A wedge may be of the opening or closing type. In practice an
opening wedge is preferable (Watson Jones, 1932). Charnley (1970)
states that he has the impression that there is a higher incidence of
delayed union when an opening wedge is used. He ad,·ises that
wedging should be completed within the first 2 to 3 days after
the application of the first plaster cast. If however wedging is 4
3
delayed until the fracture is 'sticky', distraction of the fracture and
delayed union are less likely to occur. Only wedge a padded plasTer Cut along mark. Check X-Ray.
Open wedge. Insert felt.
casT. Insert wood Replaster cast.
block.
HOW TO WEDGE A PLASTER CAST (Fig. 14.4)
• ·Study the antero-posterior and I ateral radiographs to determine in which Figure 14.4 Wedging a plaster cast. ~ote: In the abo\·e diagrams, angulation is shown
direction angulation has occurred. on the antero-posterior X-rayonly. If angulation is present on both the amero-postenor
• Identify the le,·el of the fracture. This can be done by comparing the and the lateral X-rays, the apex of the wedge will be antero-medial lateral or postero-
radiographs with the cast, or more accurately by taking a radiograph medial lateral, and the hinge must therefore be left at that site.
 180 TRACTION AND ORTHOPAEDIC APPLIANCES

• Make a .circumferential mark on the cast at the level of the fracture. 15. Tourniquets
• Deter~me .where on this mark the hinge of the wedge is to be located
The h1~ge IS Situated over the apex of the angulation when an open in(!
wedge 1S proposed.
• Cut round the mark with an electric plaster saw, lea,·ing 2 inche•
In many orthopaedic operations on the upper or lower limbs such
<:·5 em) or one quarter of the circumference uncut, the site of the:
hmge. as nerve or tendon repair, a bloodless field is important. The
• Slow~y apply a corre~th·.e force to reduce the angulation, thus opening recognition of tissues is easier, and trauma to tissues by repeated
the "edge, the cast hmgmg on the uncut portion. swabbing is eliminated.
• Insert a.woo.den block to keep the wedge open. Temporarily secure the A tourniquet has two functions, to arrest haemorrhage and to
block wuh zmc ox1de strapping. provide a bloodless field. Although only the provision of a bloodless
• Tak~ radiographs to determine whether adequate correction has been field is considered here, much of what follows is applicable to the
obtatned. If not, open or close the wedge as required. first function.
• If correc.tion has been obtained, cut and insert a strip of orthopaedic To provide a bloodless field, blood must be removed and
felt the s1ze of the wedge, leaving the wooden block in place. prevented from re-entering a limb. Elevation for 5 minutes decreases
• Apply plaster bandages around the cast. the volume of blood in a limb as gravity increases the venous
• Change the plasrer casr- drainage. Reflex arteriolar constriction also occurs. More complete
J. If pa~n persists for more than I to 2 hours after wedging.
exsanguination of a limb is obtained· by actively squeezing blood
2. Routmely rwo weeks after wedging. Any plaster cast can only be
out of the limb. This is commonly achieved by using an Esmarch
wed~ed once. If more correction is required, a new cast must be
apphed. bandage (see below). To maintain a bloodless field the arterial supply
must be obliterated. This is achieved by pressure from an encircling
tightly applied rubber band or pneumatic cuff.
Complications of wedging of plaster casiS

1. Embarrassment of the circulation in the limb. DANGERS OF A TOURNIQUET

2. Pressure sores.
3. Complete loss of the reduction. T ourniq uets are dangerous. The incorrect use of a tourniquet
may cause damage to skin, muscles, blood vessels, nerves and other
tissues. This damage may be caused by direct pressure on the
REFERE~CES tissues beneath the tourniquet itself, or by congestion or ischaemia
of the tissues distal to the tourniquet. It may be so severe that
CHARl\LEY, 1. (J 970' The Closed Trearmenz of Common Fracrure< 3rd ed p 231
Edinburgh and London: Churchill Li"ingstone. ., ., · · amputation of the limb has to be performed (Watson-Jones, 1952).
El\GLISH,
p M. ( 1957) Plasrer-of-Paris Technique · Edinburgh·· E · & S . L'J\'Jngstone
· The dangers from using a tourniquet result from-
OW~L~, M. (1968) Onhopaedic Nursing, 6th ed. Edinburgh and London: E.· & S
Ll\·mgstone. ·
SMITH AND NEPHEW LTD. (1965) Gypsona Technique, 14th ed. Wehv"n Garden c·1 . 1. Incorrect placing of the tourniquet. The tourniquet musr be
Herrs. J ~' placed where the nerves and blood vessels are protected by
WATSOI'·]OI\£S, R. (1932) The treatment of fractures of the shafts of the tibia and muscle bulk) and where these structures are not likely to be
fibula. Joumal of Bone and Joint Surgery, 14, 591.
compressed against bone. The correct site in the upper limb is
around the arm and in the lower limb, around the upper thigh.
The practice of placing a tourniquet around the calf should be
discontinued.
2. Failure to protect the skin. The skin must be protected by
wrapping a few layers of orthopaedic wool around the limb at
the site of application of the tourniquet. Failure ro do this may
result in pinching and subsequent blistering of the skin.
181
 15. TOliR:-\IQUETS 183
182 TRACTION Al'D ORTHOP:\EDIC APPLJA:-\CES

harmful physiological changes which may occur with the use of a

3. Excessive tourniquet pressure. To maintain a bloodless lidd tourniquet, the length of time during which a tourniquet is used
the pressure exerted by a tourniquet must exceed the systolic must be minimal. Time therefore must not be wasted. This can
blood pressure. The subcutaneous fatty tissue and the muscles be achieved by careful pre-operative planning of the operation to
resist compression. The pressure required therefore depend5 avoid wasteful movements and by delaying the application of the
upon the site of application of the tourniquet, the size of thl" tourniquet until all the necessary instruments are ready, the
limb and the level of the patient' s systolic blood pressure surgeon is scrubbed, gowned and ready to cleanse the skin, the
A higher pressure is required for adults, the lower limb and fat patient is on the operating table and the operating light h~s been
limbs, and a lower pressure for children·, the upper limb and adjusted.
thin limbs. The pressures generally used are indicated below. The time at which the tourniquet is applied is written down
They will have to be modified for the individual pariem. on a large board which is easily seen by all the operating room
staff. The ma.ximum length of time during which the limb may
ADt;LT CHILD be kept ischaemic varies. Children and young adults appear to
UPPER LIMB (mm of Hg) 250 150 tolerate ischaemia better chan the elderly. 011e hour is che nzaximum
LOWER LIMB (mm of Hg) 500 250 length of cime generally accepted with an additional 30 minutes
added if absolutely necessary. When an operation is likely co take
longer, the tourniquet must be released to allow re-oxygenation
4. Excessive tourniqu et time. When a tourniquet is used, the of the tissues. Before releasing the tourniquet, moist packs are
tissues beneath and distal to the tourniquet are rendered is- placed over the operative site and the limb is elevate~ to control
chaemic. Changes occur in the pH, p0 2 , and pC0 2 ,·alues of
bleeding. The longer the tourniquet has been in place, the longer
these tissues, the extent of these changes (see below) being
must be the time allo\ved to elapse before the tourniquet is re-
dependent upon the length of time the tourniquet is in place applied. After a tourniquet time of 1 hour allow 10 minutes,
(Wilgis, 1971).
and after 1t hours allow 15 minutes.
To reduce the period of ischaemia, some surgeons release the
TOURNIQUET .l'v1EAN p02 MEAK pC02 courniquet before suturing the skin. Others close the wound and
TIME ~1EA~ pH in mm in mm apply a firm, well-padded dressing before releasing the tourni-
Before inflation 7·-+0 45 38 quet. The method practised will depend upon a number of
t hour 7·31 24 50 factors which include the length of time the operative field may
I hour 7·19 20 62 have been ischaemic, the possibility that large blood vessels may
Jt hours 7·04 10 85 have been damaged and the ease with which any further
2 hours 6·90 4 104 procedures may be carried out ,.,.·ithouc a bloodless field. How-
ever, it is generally agreed that the tourniquet must be released
Wilgis also found that after removal of the tourniquet, the before the end of the operation when nerve suture or skin
venous and arterial p02 values at each interval are equal initially, grafting is to be carried out. This is to avoid the formation of
but return to normal, taking 3-5 minutes after a tourniquet time a haematoma between the nerve ends or under the skin graft.
of -! hour, 5-10 minutes after 1 hour, 10-15 minutes after 5. Failure to r ecognise injury to a m a jor blood vessel during
11- hours, and longer than 15 minutes after 2 hours, thus suggest- the operation. Patrick (1963) described four cases of injury to the
ing that during these inren·als, oxygen diffusion across the popliteal artery which occurred during operations for the removal
capillary bed is minimal or absent due to shunting. of menisci. Kone of the injuries was recognised at the time of
Striated muscle rendered ischaemic for two hours shows operation.
evidence of cell damage (Solonen and Hjelt, 1968). Below pH 7·2, 6. O mitting to remove the tourniquet at the en d of the
the clotting time (in dogs) is increased (Rutherford er a!., 1966), and operation.
at a venous p0 2 of 10 mm, capillary permeability to fluid and protein 7. Usi ng a tourniquet when there are defin ite contra-
increases (Webb, 1965). indicati ons to its use.
These observations show that to minimise the potentially
 15. TOUR~IQUETS

CONTRAINDICATION$ TO THE USE OF A 5. Objective evidence of weakness m the muscles of the forearm
TOURNIQUET without real paralysis. •

1. Peripheral arterial disease. He stated that these findings could be seen when the operative
2. Sickle-cell disease. Under anoxic conditions the red blood cor trauma and post-operative immobilisation of the hand were in-
puscles sickle, blood Yiscosity increases, Yessels become block~d adequate to explain these phenomena and where haematoma form-
and a seYere episode of thrombosis and haemolysis may occur. ation and infection were absent.
particularly on release of the tourniquet. T est all patiems wh(l Swelling and stiffness of the hand and fingers after operation
are at risk for the presence of Haemoglobin-$ prior to the usc must be prevented, as the stiffness can become permanent due to
of a tourniquet. fibrosis of the periarticular structures.
3. Severe infections. To avoid dissemination of the infection an
exsanguinating tourniquet must not be used. Reduction of the PREVENTION OF THE POST -TOURKIQUET SYNDROME
volume of blood in the limb is obtained by elevation of the limb To decrease the degree of congestion of the tissues and to minimise
for 5 minutes. haematoma formation at the operative site:
4. When proven or suspected deep vein th1·ombosis is present an ex- e Select the correct operation for each patient. As the tissues of
elderly patients are less tolerant of ischaemia, swelling and stiffness are
sanguinating tourniquet must not be used. Austin (1963) reported
more likely to occur after operation. To carry out a lengthy operation
two cases in which massive fatal pulmonary embolism was may result therefore in a decrease rather than an increase in function.
precipitated by exsanguination with an Esmarch bandage in the e Avoid wasting time. It is imperative that the duration of tissue
presence of silent deep vein thrombosis. Both patients had ischaemia is kept to a minimum. As already stated this is achieved by:
sustained fractures around the ankle, initially treated by manipu- Careful pre-operative planning of the operation tO avoid wasteful
lation and immobilisation in a plaster cast, which 7 to 9 days movements.
later required internal fixation. Delaying the application of the tourniquet until all necessary instruments
5. Severe crushing injuries. In these cases the circulation is often are ready, the surgeon is scrubbed, gowned and ready to cleanse the
precarious. skin, the patient is on the operating table and the operating lights are
adjusted.
e Do not extend the tourniquet time unnecessarily. It is better to
POST-TOURNIQUET SYNDROME suture tendons after the tourniquet has been released rather than to
prolong the duration of tissue ischaemia. )\erves must always be sutured
Following the release of a tourniquet there is reactive hyperaemia and skin grafts applied after release of the tourniquet to avoid the
and congestion of the previously ischaemic tissues. Bruner (1951 ) formation of a haematoma between the nerve ends or under the skin
stated that untoward tissue reactions were not noted when the graft. ,
duration of ischaemia was 20 to 30 minutes. Bunnell (1956) stated e Ensure good haemostasis. If the tourniquet is released before the
that one hour is safe but two hours gives some reaction. Certainly wound is closed, capillary haemorrhage is controlled by local pressure
the longer the period of ischaemia and the older the patient the with saline compresses for 5 tO 10 minutes, after which the larger vessels
are clamped and ligated. If the wound is closed, a bulky dressing under
more likely it is that untoward tissue reactions will occur. These
moderate compression by a crepe bandage must be applied before the
reactions are manifest in the hand (Bruner, 1951 ) by:
tourniquet is released.
• Elevate the limb after the operation.
1. Puffiness of the hand and fingers, evidenced by a smoothing out • Encourage the patient to perform active movements of the
of the normal skin creases. pertinent part.
2. Stiffness of the hand and finger joints to a degree not otherwise
explained.
3. Colour changes in the hand which is pale in the horizontal TOURNIQUET PARALYSIS SYNDROME
position, more so when elevated and congested in the dependent
position. Tourniquet paralysis may result from excessive pressure, passive
4. Subjecti,·e sensations of numbness in the affected hand without congestion of the part with haemorrhagic infiltration of the nerves
true anaesthesia. when tourniquet pressure is too IO'-'V, keeping the tourniquet on too
186 TRACTION A:-ID ORTHOPAEDIC APPLIAJ'\CES 15. TOUR~IQUETS 187

long, the application of the tourniquet without consideration of the: of the gas supply at any time during the use of the tourniquet.
local anatomy (Smith, 1963), or applying a tourniquet on a ,·en Rapid inflation of the cuff is possible. The pressure, regulated by
thin limb. a control knob which can be pre-set to the desired level, is
maintained constant until changed by the control knob or by
Characrerisrics of rhe courniquex paralysis syndrome moving the inflate/deflate switch. The pneumatic cuffs are avail-
(MoldaYer, 1954) able in various sizes for use on children and upper and lower
limbs.
Distal to the site of application of the tourniquet there are dis-
turbances in the function of one or all of the nen·es.
The advantages of this type of tourniquet are that the pressure in
1. Motor paralysis with hypotonia or atonia but without appreciable the cuff is known, a continuous supply of gas from the cylinder or
atrophy. reservoir automatically compensates for any leaks in the system and
2. Evidence of sensory dissociation. Touch, pressure, ,·ibration and as a gas reservoir is used, the patient is less likely to be moved from
position sense usually are absent. The appreciation of pain is ne\'er the operating table with the tourniquet in place.
lost and hyperalgesia is usually present. In se,·ere cases the fast
pain fibres may be affected, resulting in delay in the recognition
Non-automatic pneumatic tourniquet
of painful stimuli. The recognition of heat and cold is usually not
affected. The patients do not complain of paraesthesia. This consists of a pneumatic cuff, a hand-operated pump and a
3. The sympathetic fibres are not affected. pressure gauge. The pressure in the cuff is known but there is no
4. The colour and temperature of the skin are normal. automatic compensation for leaks in the system and a regular check
5. All peripheral pulses are present. must be kept on the pressure in the cuff. In addition the hand-
Electrical studies of nerYe conduction reYeal a block to con- pump is small and it is easy to return the patient to the ward
duction, well localised to the site of application of the tourniquet. without removing the tourniquet.
There is no response to stimulation of the motOr nerves aboYe the
block, but stimulation below the block gives a good response. These Esmarch bandage
studies show that tourniquet paralysis is caused by direct local
mechanical pressure and not by generalised ischaemia of the limb. The Esmarch bandage (Esmarch, 1873) is a 3 inch (7·6cm) wide
\Xlhen a tourniquet paralysis is complete, recoYery may take up to and 6 yard (5·5 m) long india-rubber band, often with two tapes
three months, or longer. attached at one end. Although mainly used to exsanguinate a limb,
it can be used as a tourniquet. Its use as a tourniquet is dangerous
ADVANTAGES AND DISADVANTAGES OF because the pressure exerted on the limb is unknown. Each turn
DIFFERENT TYPES OF TOUNIQUETS adds to the pressure and hence to the risk of tourniquet paralysis.
For this reason it must not be used on the upper limb. Its use on
the lower limb is confined to the upper third of the thigh where
Automatic pneumatic touniquet
the greater muscle bulk affords some protection to the underlying
1. An automatic pneumatic tourniquet can be fabricated from a blood vessels and nerves.
blood pressure cuff attached by rubber tubing to a gas cylinder
fitted with a pressure reducing vah·e and a manometer. The HOW TO APPLY AN ES.YI.ARCH BANDAGE FOR
pressure in the cuff is furnished and maintained by gas from the EXSANGUINATION
cylinder. It is difficult however to pre-set the pressure accurately An assistant is necessary.
to the desired leYel. • Elevate the limb.
2. The Kidde Automatic Tourniquet* which can be clamped to an • Wrap the Esmarch bandage around the limb, starting at the hand or
infusion stand, utilizes a non-toxic, non-inflammable gas con- foot and working proximally. The extreme tips of the fingers and toes
and the heel can be left free.
tained in a transparent gas reserYoir. This permits a visual check
• Fully stretch each tum of the bandage before applying it to the limb.
9
See Append:x. • Overlap each turn of the bandage by t inch (1·25 em).
 15. TOUR.'\OIQUETS 189
188 TRACTION A:-\D ORTHOPAEDIC APPLIANCES

e At the md of the operation remove che coumiquec. This is the responsibillly

HO\X' TO APPLY A~ ESMARCH TOUR~IQUET of the surgeort. Note the time at u:hich the coumiquec is remo'Ved.
• Apply an Esmarch bandage as abo,·e. e At che end of the operation check that the circulation in the limb is
• At the upper thigh wrap the Esmarch bandage o,·er padding -i tO 5 11m sacisfaccory-peripheral pulses and or capillary circulation.
all the turns except the fi rst one being applied without srretchin11 th
bandage.
• Slip the remaining roll of the bandage under the last turn so that 11 lit REFERENCES
in the line of the femoral artery.
• Tie the two end tapes to the table to guard against the patient lea\'ma At:STI:\, M. ( 1963) The Esmarch bandage and pulmonary embolism. Journal of Bone
the theatre with the tourniquet still applied. and Joint Surgery, 45-B, 384. . .
BRt."SER, J. ,\,1. ( 1951) Safety facrors in the use of the pneumauc tourmquet for
• Beginning at the toes remoYe the bandage. haemostasis in surgery of the hand. ] oumal of B om and Joint Surg~ry, 33-A, 221 .
Bt."S:\ELL, S. ( 1956) Surg-try of the Hand, 3rd ed., p. 90. Ph~ladelphi~: Lippincott.
ES.\L-\RCH, F. vo:-: ( 1873) Ueber Kunsdich~ Blutleere bet Op~rauonen . .sam~lung
HOW TO APPLY A PXEWviATIC TOUR}JIQUET Klinischer Vortrage in Verbindung mtt Deutschen Khrukern. Clururgte, 19,
An assistant is necessary. ~0- 58,373. . . . .
• Apply a few layers of orthopaedic wool, or a towel, around the limb at MoLOAVER, J. ( 1954) Tourniquet paralysis syndrome. Amencan Medtcal Assoetallon
the tourniq uet site. Archi'l:es of Surgery, 68, 136. .
PATRtCK, J. (1963) Aneurys m of rhe popliteal vessels after Memscectomy. Journal of
• Choose the correct size of pneumatic cuff (upper limb, lower limb or Bone andJoim Surgery, 45-B, 570.
paediatr ic). RUTHERFORD, R. B., WEST, R. L . and H.~RDAWAY, R. M. ( 1966) Coagulation changes
• Express all air from the pneumatic cuff. during experimental haemorrhagic shock. Annal> of Surgery, 164, 203. .
• Snugly wrap the pneumatic cuff around the limb on top of the padding. SMITH, H. ( 1963) Surgical Technique, Chapter 2, p. 22. Campbell's ?peracwe
Oclwpaedics, Volume Ij 4th ed. Edited by A. H. Crenshaw. St. Louts: C. V.
• Ensure that the connecting rube lies on the outer aspect of the limb, and
Mosby Co. . . .
points proximally. SoLO:\E', K. A. and HJELT, L. ( 1968} .Vlorphologtcal changes m stnated muscle
• Reinforce the Velcro, or other type of fastening of the pneumatic cuff, during ischaemia. Acta Orclwpaedica S.:and_inaf.;ic~, ~9, 13.
with zinc oxide strapping or a cotton bandage. WATSOX·]O:-<ES, R. ( 1952) Fractures and Jomc [nJtmes, Vol. I, 4th ed., p. 121.
• EJe,·ate the limb for 5 minutes, or- Edinburgh: E. & S. Livingstone. . .
Wess, W. R. ( 1965) Pulmonary physiology tn surgery. SymposiUm on biologic
• Exsanguinate the limb by applying an Esmarch bandage as described foundations of surgery. Surgical Cli~tics of ;Vorth America, 45, 267.
above, stopping the bandage 1 to 2 inches (2·5 to 5·0 em) below the W!LGIS, E. F. S. ( 1971) Observations on the effects of tourniq uet ischaemia. journal
pneumatic cuff. If the Esmarch bandage is applied up to the )eye) of the of Bo11e and Joim Surgery, 53-A, 1343.
cuff, the cuff may slip distally at the time of inflation, or the pressure
in the cuff may be so lowered on removal of the Esmarch bandage that
bleeding may occur during the operation.
• Raise the pressure in the cuff rapidly to the predetermined leYel (see
above) to pre,·ent filling of the superficial Yeins before the arterial blood
flow has been occluded.
• ~ote the time and write it down on a board.
• RemoYe the Esmarch bandage.

\X1 HEN A TOURNIQUET IS USED:

• Use a colourless skin preparation solution especially for the toes and
fingers. The state of the circulation in the roes or fingers will be
determined more easily after the operation.
• Do not allow the skin preparation solution to collect under the edge of
the tourniquet. Skin irritation or burning may result.
• If the pressure of the tourniquet should fall during the operation, remove
the tourniquet completely to relieYe 'congestion before reapplying it.
• Do not allow the tissues exposed at the operath·e site to become dry.
Regularly apply cold saline compresses.
• Avoid the use of hot spot-lights which will accelerate the drying of
the tissues.
16. Plas tazote

There are a number of plastic materials used for orthopaedic

appliances and splints. Plastazote (Smith & ~ephew Ltd.)* is a
foamed polyethylene of closed-cell construction, cross-linked to
ensure extreme lightness and to improve its resistance to the tem-
perature required for moulding. It is non-toxic, is unaffected by all
common acids, alkalis and solvents, and is resistant to hot water and
detergents. It is inflammab le, but does not burn as readily as lint
or cotton wool. Patients wearing Plastazote splints must avoid contact
with naked flames or electric hoc-plates as combustion can occur
under such circumstances. \'{·hen heated to 140' C, sheets of Plasta-
zoce will bond together and can be moulded. Due to its closed-
cell structure, Plastazoce is resilient, buoyant and will not absorb
water. This makes it an ideal medium for supports worn in hydro-
therapy pools.

APPLICATION OF PLASTAZOTE
Plastazote has a wide range of usage in the orthopaedic management
of many conditions, and it is particularly useful in the construction
of temporary supports, as the support can be made and finished
within a few minures. It has been used for the construction of
cervical collars, spinal jackets, temporary insoles or permanent
insoles where trophic ulceration is present, upper and lower limb
splints, sandals and cradles for children suffering from fragilitas
oss:um. Because of its non-chafing and resilient properties, it is also
used for the lining of plaster beds and amputation sockets. It is also
very useful for making negative casts prior to the manufacture of
block leather and plastic supports.
The method of making some of these appliances is described
below. First, however, a description of the requisite equipment and
some general points about the handling of Plastazote will be gi\'en.

EQUIPMENT REQUIRED
• A hot-air oven. The temperature must be chermoscarically concrollcd
ac 140-C (range 135 co 145 C).
• A sharp knife or scissors.
• A cape measure.

• Sec: Appendix
192 TRACTION AND ORTHOP AEDIC APPLIA::-\CES 16. PLASTAZOTE 19"

• Sheets ofPlastazote of ,·:nying thickness, and sheets of solid polyethylene. • Place the Plastazote in the oven and heat it for 5 minutes.
• French chalk. • Sit the patient beside the oven.
• A fine emery grinding wheel or ~o. 1 glasspaper for smoothing off the • Remove the Plastazote from the oven and check its surface temperature.
edges of the appliance. • Stand behind the patient, and place the Plastazote shape with the centre
• Retaining straps and fastenings. of the shaped edge ( Fig. 16.1 ) on the chin. Stretch it gendy but firmly
first on one side and then the other around the neck. Avoid excessive
General poims about using Plastazote pressure over the larynx especially in men.
• After 3 minutes remove the collar from the neck.
1. Plastazote requires to be heated for 5 minutes in a hot-air oven • When the Plastazote is cool, trim and smooth the edges.
at 140 C, after which rime it can be moulded easily, and is auto- e Reapply the collar, and check that it fits correctly before applying a
adhesive. As a result of this auto- adhesin property, sheets of retaining strap.
Plastazote can be reinforced by placing strips of solid low-density
polyethylene between them before heating. W hen this is done, A reinforced cervical collar may be made from two ± inch
6 minutes are required in the oven. The tem peratu re of the (0.·62 em ) sheets of Plastazote with a strip of solid polyethylene,
Plastazote after its r em oval from the o ven must be ch ecked care- 1t inches b y 2t inches (3·75 em by 6·25 em), inserted anter iorly
fu lly. This is very important wh en solid stri ps of polyethylen e to support the chin.
have been in serted for reinforcement because they retain heat
longer than Plastazote. In addition great care m ust be taken to SPI~AL SUPPORT
ensure that solid polyethylen e does not project beyond the Reinforcem ent with strips of solid polyethylene is generally required.
Plastazote sheets.
2. Plastazote can be moulded for 3 ro 4 m inutes after its removal • Measure the patient fro m the mid-point of the sternum to the symphysis
from the oven. When it is laminated with strips of solid poly- pubis and the circumference of the thorax and the buttocks. These
ethylene, this time is extended slightly. measurements give the overall size of the sheets of Plasrazote required.
• Cut two sheets oft inch (0·62 em thick Plastazote to the required size.
3. Trimming must not be done until the Plastazote is thoroughly
• Cut four or more strips of solid polyethylene It inches (3·75cm, wide
cool.
to the required length and lay them between the sheets of Plastazote
4. Plastazote expands "·hen heated. where reinforcement is required, taking care that they do not project
5. To aYoid the Plastazote sticking to the sheh·es in the o\·en, either beyond the edges of the Plastazote.
the easy release paper which is supplied with the Plastazote, • Place a third piece of t inch (0·62 CmJ thick Plastazote O\·er the area of
or French chalk must be used. the reinforcing strips (Fig. 16.2), on the side which is going next to the
6. As swearing occurs under Plastazote appliances, they should be patient's skin.
perforated.

HOW TO MAKE VARIOU S APPLIA).JCES

CERVICAL COLLAR
• Cut a sheet of! inch {1· 25 em) Plasrazore as shown in Figure 16.1.

I
5· 1
' 18--------
Figure 16.2 Plastazote spinJl :.upport. :-\ot<! th:u the reinfo rcing strips of solid
polyethylene are CO\'ered by a third piece of Pla;tazote sheet which is plactd on
Figu re 16.1 ShaJX ofPlastazote fer a cen·ical collar. the side next tO the patient's skin.
194 TRACTJO~ A!'D ORTHOPAEDIC APPLIA!'\CES 16. PLASTAZOTE 195

• Heat in the o,·,m for 5 minutes. • Place the third piece of Plastazote on the floor beside the patient's foot:
• Sit the patient beside the oven on a srool. as a cushion for the piece to be moulded.
• Remo,·e the Plastazote from the o,·en and check its surface temper e Remove one heated piece of Plasrazote from the ot·en and dust French
• Stretch the Plastazote pattern gently, firmly and quickly around chalk over its upper surface and then place it on top of the unheated
patient's trunk, from behind forwards, using the jacket clamp. A I piece previously placed on the floor.
clamp is a piece of wide, strong, elastica ted webbing, fined with webb • Stand the patient with one foot on the pad for 2 w 3 minutes. \\"hile
straps and wooden toggles. the patient is standing press the sides of the Plastazote up under the
• After ..J ro 5 minures remo,·e the jacket from the patient, and when 1 arches of the foot.
Plastazote is cool, trim and smooth the edges. • Make a second support.
• Reapply the jacket, check that it fits correctly and then appl\ thr, • After the Plastazote has cooled trim the insole down to fir inro the
retaining straps. patient's shoe, especially under the roes.

FOREAR.".1 SPLI~T Vacuum-formed Plastazote footwear

e In an II inches (27·5cm) square sheet oft inch (1·25cm) 1h1d< Vacuum-formed Plastazoce footwear is discussed in Chapter ll.
Plastazotc cut a hole for the rhumb. The diameter of this hole should
be slightly less than the diameter of the metacarpo- phalangeal joint or'
the thumb. If a reinforced splint is required, j inch (0·62 em) sheets ,,(
Plastazote are used between which a piece of solid polyethylene is placnl
as shown in Figure 16.3.

Figure 16.3 Laminadon for reinforced forearm splint.

• Hear in the o,·en for 5 minutes.

• Remove the Plastazote from the oven and check its surface temperature.
• Place the patient's thumb through the hole, with the palm of the hand
resting on the sheet of Plastazote, and mould the Plastazore round the
hand and forearm on to the dorsum.
• After 3 to 4 minutes remove the splint, trim and smooth the edges.
• Apply three retaining straps.

FOOT St:PPORTS
• Cut three pieces measuring 12 inches by 4 inches (30 em by 10 em) from
a sheer of 1 inch 12·5 em) thick Plastazote.
e Put t~·o of the above pieces in the o,·en to heat for 5 minutes.
Appendix

Messrs. •
George Salter Ltd. Suspension springs for a Thomas's
West Bromwich splint.
Staffordshire
England.

Hangers Ltd. Ortholene

Limb Fitting Centre
Roehampton
Surrey
England.

Parke, Davis & Co. Ketalar (Ketamine Hydrochloride).

Pontypool
Monmouthshire
Wales.

Performance Plastics Ltd. Perplas.

Melton Mowbray
Leicestershire
England.

Pryor & Howard Ltd. Fisk splint; brackets for attaching

Willow Lane Bohler stirrup to Thomas's splint
Mitcham for suspension by springs.
Surrey
England.

Salt & Son Ltd. Hartshill Lower Limb Appliances.

220 Corporation Street
Birmingham
England.

Seton Products Ltd. Seton Skin Traction Kits: Tubi-

Tubiton House grip.
Medlock Street
Oldham
Lancashire
England.
197
198 TRACTJON AND ORTHOPAEDIC Al'PLIA"l\'CES

Smith & Nephew Ltd. Elastoplast Skin Traction Kits.

Bessemer Road (Outside the British Common-
\XIelwyn Garden City wealth, all Elastoplasr products Index
Hertfordshire are known under the name
England. Tensoplast. ) Plastazote and
Technical Information !\1anual.
Abdominal plate, S3 Block leather bucket top, 11~111, 113
Abducent nerve palsy, 72 Bohler-Braun frame, 34
The Scholl ~1anufacturing Co. Ventfoam Skin Traction Bandage. disadvantages of, 35
Abscess
Ltd. cerebral, and skull traction, 65 sliding traction in, 34-35
extradural, and skull traction, 65 Bohler stirrup, 4, 54
182-204 St. John Street Brachial plexus palsy, i2
subdural, and skull traction, 65
London Acetabular angle, 100, 101 Bryant's traction, 31- 33
England. Aertex, SO application of, 31
Ankle joint contraindications to, 33
for calipers, 11S, 119-120 modified, 33-34, 53
Victor Baldwin Ltd. Yampi, supplied in various colours. application of, 33-34
prevention of
Vansitard Estate equinus at, 19, 30, 49-50 vascular complications of, 31, 32-33
Ankle strap, Ill, 112,113,12 1,122,125, Bucket top, 109, 110, 113
Windsor Buck's traction, 24, 33, 35
127
Berkshire Ankylosing spondylitis, bracing for, 89 application of, 24
England. Anterior hyperextension brace, S6-S7, S9
indications for, S9 Calcaneus, exostosis, 137
Anter ior thigh pad, 112, 113, 125, 129 Calfband, 112, 113, 12;, 129
\Xlalter Kidde & Co. Inc., Kidde Automatic Tourniquet. Apparent discrepancy in limb length, 140 Caliper
Belleville Appliances ankle joims, 118, 119-120
New Jersey 07109 cen·ical, 91-94 basic design of, 110
for drop-foot, 12~124 bucket top, 11~111
U.S.A. Hartshilllower limb, 129, 197 care of, 129
long leg, 109--120, 126-1 30 cosmetic long leg, 117, 128-129
Zimmer Orthopaedic Ltd. Orthouac (in the U.S.A. it is called spinal cufftop, 110, 112
corrective, 79, S9-91 functions of, 109
176-178 Brompton Road Orth-0-Trac) : Zimmer Electric supportive, 79, So-89 hip joims, 112- 11-l
London S.\X/.3 Plaster Saw. suspension of, 37-52 how to prescribe, 130
advantage of, 37 knee joints, 115- 117
England. Arched and bridge waisted raise, 147 Barlock, 116-117
Armband, 154-155 posterior off-set, 117
Zimmer, U.S.A. Skin-Trac. Axillary crutches, 152-154 ring-lock, types of, 115-116
727 North Detroit adjustment of, 153-154 Swiss lock, 11frll7
checking handgrip position of, \54 non weight-relieving, 110
\Y/arsaw checking overall length of, 153-154 patten-ended, 126-127
Indiana 46580 for spinal brace, S4 pelvic band, 112-114
initial measurement for, 153 retaining straps and bands, 125-:-126
U.S.A. ring top, 110, I l l
Back l<!ver, S3 side bars, 11-l:-11;
Balkan beam, 37 heel attachmem of, 118-1 19
Barlock knee joint, 113, 116-117 heel sockets, 11S
Barlow splint, 102-103 stirrups, 118-119
Barlow test, 97-9S to.:-out, 119
Barrel hitch, 3S me-raising devices, 12~124
Barton tongs, 60, 62-63 T -straps, 12-l:-125
application of, 62-63 upper end of, 11~112
Batchelor plasters, 106-107 weight-relie,·ing, 109
Below-knee iron, 121-122 checking of, 109
Belts, spinal, 80 indications for, 109
Benzomastic, 7 Cam·as, SO
Bi\·ah·e of plaster cast, 175, 176 Care of calipers, 129
 I NDEX
Cerebral abscess and skull traction, 65 three-point, 162, 165-168
Cer\'ical appliances, 91-94 two-point, 162, I 65
Cen·ical collar rising from chair, 166 Fisher spinal brace, 84-85, 89 Gutter piece
felt, 91 sitting down, 167 indications for, 89 crutch, 152
moulded, 92 stepping down, 167 Fisk splint, 13, 27-28, 48, 49, 197 posterior, crutch, I l l, 125
Plastazote, 92, 191-193 stepping up, 167 sliding traction in, 27-28
polythene, 92 Crutches suspension of, 48, 49 Hallux rigidus, shoe alterations for, 138
Thomas's, 92 axillary, 152-154 Fixed traction, 8, 15-21 Halo spline, 66
Cer\'ical brace. 93 elbow, 154-156 application of, 15-17, 18, 20-21 Halo traction, 59, 65-68
Cerdcal spine gutter, 156-157 with Thomas's splint, 15-17 application of, 66-67
dislocation of, 60, 64 Lofrsuand, 154- I 56 for cervical spine, 65-72 management of patients in, 67-68
fracrure-dislocation of, 60, 64 maintenance of, 161 in Thomas's splint, 15-19 Halo-pelvic traction, 59, 68-73
Cen·ical spondylosis, 59, 60 underarm, I 52 in traction unit, I 7-19 application of, 69-71
Checking footwear, 132-133 Crutchfield tOngs, 60, 61-62 significant feature of, 15 complications of, 72
CJa,·icular pads, 83 transfer of patient in, 15 management of patients in, 71
application of, 61-62
Clo,·e hitch, 38 failure of procedure, 62 Flail ankle, management of, 118, 120 Halter traction, 59-60
Common peroneal nen·e palsy, 3 Foot place, Nissen, 29, 30, 31, 50 Hamilton Russell trac tion, 28-29
Cuff top, II 0, 112
Compensatory patten for shoe, I 26, I 27 Foot strain, 133 application of, 28
Compound pulley block, 39-40, 43, 44, Foot supports, Plastazote, 194-195 theory of, 28-29
45, 50 D enham pin, 4 Foo twear, 131-148 Handgr ips, 159- 160
Cone tongs, 60, 62-63 D enis Browne hip splint, 104-105 checking correct fit of, 132-133 Hartshill lower limb appliances, 129, 197
application of, 62-63 Discrepancy in limb length modifications to, 133-148 H ead halter
Congenital dislocation of the hip apparent, I 40 Plastazote, 132 canvas, 59
application of splint, 102 cause of, 140 surgical, 131-133 chamois leather, 59
Bryam·s traction, modified, for, 33 measurement of, 144 Forear m splint, Plascazote, 194 Crile, 60
clinical tests for, 97-99 calculation ofraise required, 145-146 Four-po int crutch gait, 162, 164-165 Heel
Barlow, 97-98 compensation for, 144-148 Fracrure boards, 42 artachemem of side bars, 118-1 19
Onolani, 98-99 general considerations, 144-145 Fracrure outside float, 138-139
maintenance of reduction true, 139-140 delayed union, 15 painful, 137
appliances, 101-105 measurement of, 140-143 distractio n of, 15, 23 sockets, 118, 120, 121
plaster casts, I06- I07 types ofraises used, 14&-148 femoral shaft scops, 120
management in splint, I 03 Disseminated sclerosis, 150 fixed traction for, 15 Thomas, 13-l
radio logical examination in, 99-101 Domene bandage, 9, I0 in adults, 2-l, 26, 27, 28, 29, 34 Hilgenreiner's line, 100, 101
splinting for, 101-107 Drop-foot appliances, 120-124 in children, 24, 31, 33 Hip arthroplasty, traction for, 28, 29
Cords Duck, 80 late angulation of, 56, 57 H ip
suspension, 37, 38, 42, 45, 48, 50, 54 reduction of, l&-17 congenital dislocation, 33
traction. 54 refracrure of, 56, 57 clinical rests for, 97- 99
Elasropla st skin traction kits, 2, I 98 traction unit for, 17-19 incidence of, 97
Corsets, SO
Elbow crutches, 154-I 56 femur, supracondylar, 25 radiological examination of, 99-100
Cosmetic long leg caliper, I 17, 128-129
adjustment of, 155-156 March, 135 splinting for, 101- 107
Counter-traction, 7-8, 15, 16, 19
checking overall length, I 56 neck of femur, 24 correction of deformity ac, 19
ele,·ation of bed end for, 23, 54, 60, 62,
Elecuic plaster saw non-union, 15 mechanical joint for caliper, 112-11-l
63 how to use, 175
fixed, 8, 15 peh·is, 19 unstable, 97
Esmarch bandage, 181, 187 tibial condyles, 27 decrease in incidence of, 99
~liding, 8
application of, 187-188 tibial shaft, 19, 34 incidence of, 97, 99
u~e of gra,•ity, 8, 23, 3 I
as tourniquet, 188 vertebral compression, 88, 89 H ypoglossal nerve palsy, 72
using splint, 8
danger of, 187 Fracture-dislocation Hypoplasia of mandible and ,>.,iilwaukee
well-leg, use of, 19
for exsanguination, 187 cervical spine, 60, 64 brace, 91
Coutil, 80
E xeter coil spring, 122 Fragil itas ossium, 191
Cru tch stance, 153, 161-162
Extra dural abscess and skull tract ion, 65 Freiberg's disease, 135 lmmobil icy, dangers of, 37
Crutch walking, 161-168
Extradural haematoma and skull traction, Frej ka pillow, 103-104 Inside raise, 147-148
ascending stairs, I 68
65 F rog plaster cast, 106 Insole
descending stairs, I 68
general considerations, 161 Fulcr um strap, 80, 81, 82 mecacarsal, 135-136
non weight bearing, I 65- I 66 ,·algus, 133-13-1
Fabric spinal supports, 80-82
partial weight bearing, 165-166 Gallows traction, 31-33 Instant lumbar support, 82
Fascial compartment, decompression of,
patterns of gait, I 62- I68 application of, 31 Imerdigital neuroma, 135
172, 178
four-point, 162, 164-165 Gamgee tissue, 12 Ischaemia
Felt collar, 91 and painful limitation of passi,·e
selection of, 162 Femur, capital epiphysis Glossopharyngeal nen'e palS}', 72
sw ing-through, 164 Gravitv as counter-traction, 8, 23, 31 mo\'emem, 54
appearance of, 90 and tourniquets, 181, 18-l
sw ing-to, 16>-164 epiphysitis, 102, 106 Gussets, elastic, 82
Gutter crutches, 156-157 of femoral capital epiphysis, 106
adjuscmenc of, 157 results of, 53, 5-l, 171
 202 INDEX 1NDEX 203

jean, 80 ,\1ilwaukee spinal ·brace, 89-91 Pelvic band Polythene

Joint complications of, 91 for caliper, 112-114 cervical collar, 92
ankle, for caliper, 118, 119-120 fining of, 90-91 for spinal brace, 83 spinal support, 87, 89
hip, for caliper, I I2-1 14 indications for, 89 Pelvic hoop, 68, 69 Posterior off-set knee joint, 117
knee .\1inen·a plasrer jacket, 94 Pelvic sling Post-tourniquet syndrome, 184-185
axis of mo\'ement of, I 2 .\1oulded spinal suppons, 87, 89, 193-191 application of, 51-52 prevention of, 185
forcaliper, JJS-117 indications for, 89 suspension of, 51-52 recognition of, 184-185
polycentric pathway, I 2 .\1uscle spasm, I, 7, 8 Peh·ic traction, 35 Prescribing a spinal appliance, 87-88
Jones spinal brace, 85-86 application of, 35 Pressure sores, 3, 11, I 5, 60, 68, 91, 110,
~en·e palsy Peripheral pulses in presence of impaired 119, 131, 171, 177, 180
Ketelar, 69, 197 abducent, 72 circulation, 54, 171 and plaster casts, 172- 173
Kidde automatic pneumatic tourniquet, and axillary crutches, 154 Perkins line, 100, 101 diagnosis of, 173
186, 198 and Fisher spinal brace, 85 Perplas, 123, 129, 197 Prolapsed intervertebral disc, 88
Kirschner wire, 4 and halo-peh·ic traction, i2 Perthes' disease, 126 Pulleys, 39-40
strainer, 5 and tourniquets, 186 Pes ca,·us, 134, 135 compound pulley block, 39-40, 43, 44,
Knee cap, anterior, II I, 127 brachial plexus, 72, 85 Physiotherapy and patients in craccion, 45, 50
Knee flexion piece, 12, 13 common peroneal, 3 53, 55-56 Pulmonary embolism and tourniquets,
siting of, 12 glossopharyngeal, 72 Pin trace infection, 54 184
Knee joints for calipers, I 15-117 hypoglossal, 72 Plantar fasciicis, 137
Knee pad, 125 recurrent laryngeal, 72 Plastazoce, 160, 191-195, 198 Quadruped walking aid, 158-!59
Knots Nerve suture and tourniquets, 183, 185 and Yampi footwear, 132
barrel hitch, 38 application of, 191 Radiological examination
>lissen footplate, 29, 30, 31, 50
com·ersion to reef knot, 38, 39 Kissen stirrup, 29, 30 calf pad and cosmetic caliper, 123, 129 and congenital dislocation of hip,
cJo,·e hitch, 38 Non-weight bearing with crutches, cervical collar, 92, 192-193 99-101
prevention of sli pping, 38 165-166 equipment required, 191-192 frequency of, and fractures, 55
reef, 38 foot supports, 194--195 Von Rosen technique, 99-100
forearm splint, 194 Reciprocal walking frame, 151
Onholene, 90, 123, 128, 129, 197
Late angulation of femoral shaft fracture, general properties of, 191 Recurrent laryngeal nerve palsy, 72
drop-foot splint, 123-124, 128, 129
56,57 handling of, 192 Reef knot, 38
Orthotist, 90, 130
Leprosy, foorwear for, 132 Orthorrac, 2, 198 reinforcement with polyethylene, 192, Refracture of femoral shaft, 56, 57
Limb, pre-operati,·e preparation of and Ortolani's test, 98--99 193, 194 Rheumatoid arthritis, 131, 132, 135, 160
plaster cast, I 76 spinal support, 87, 89, 193-19~ Rigid spinal braces, 83-87, 89
Osteochondritis, vertebral, 89
Limb length Plaster bed indications for, 89
Osteomyelitis and skull traction, 65
measurement of Osteoporosis, 72, 88, 89 suspension of, 50-51 Ring lock knee joint, 112, llS-116
apparent, 144 Outside raise, 146-147 Plaster casts, 171-180 automatic, 116
true, 140-143 cutting a window in, 173, 176-17i rod spring, 116
Loftstrand crutches, I 54-156 Pad batchelor, 106-107 Ring tOp, 110, Ill
Lorenz plaster cast, I06 anterior thigh, 1 I2, I I 3, 125, 129 frog, 106 Rocker bar
Lower limb bracing, 109-130 calf, Plastazote, 123, 129 impairment of circulation and, I i 1-172 for hallux rigidus, 138
Lumbar support, instant, 82 cJa,·icular, 83 instructions to patients, 174 for metatarsalgia, 137
Lumbo-sacral supports, 81, 88 Lorenz, 106 Roger Anderson well -leg traction, 19-21
for fractured femoral shaft, 12, 17, 18,
indications for, 88 preoperative preparadon of 1imb in, 176 application of, 20-21
25, 27,28
pressure sores, 172-173 Rollator, 151-152
knee, 125
March fracture, 135 Paraesthesia diagnosis of, 173 Rotation of limb, control of, 16, 18, 2-1,,
Medial longitudinal arch supports, prevention of complications, 171-173 30, 40, 42, 43, 45, 47, 48, 49
and post-tourniquet syndrome, 184
133-135 removal of, 173, 174--176 Rubber tips, 160, 161
and tourniquet paralysis syndrome, 186
heel and sole wedges, I 35 and traction, 53 splitting of, 172, 177-178
medial shank filler, 134 wedging of, 178-180 Sacro-iliac strain, 88
lateral cutaneous nen·e of thigh
Thomas heel, I34 complications of, 180 Sacro-iliac support, 80, 88
and halo-pelvic traction, 72 indications for, 88
\'algus insole, 133-134 and Milwaukee spinal brace, 91 Plaster jacket, 87, 89
Medial shank filler, 134 Plaster saw, electric, 198 Sandal stirrup, 118-1 19
Parallel bars, 150
Meralgia paraesthetica how to use, 175 Scanograph, 140
Paralysis syndrome, rourniquet, 185-186 Scoliosis, 68, 89
and halo-pel\'ic traction, 72 Paraplegia Pneumatic tourniquet
application of, 188 Seton skin traction kit, 2, 197
and Milwaukee spinal brace, 91 and halo-peh·ic traction, 72
.\1etatarsalgia, I 35, 136 automatic, 186-187 Shank, steel; for hallux rigidus, 138
and sandal type of stirrup, 119 Shenton's line, 100, 101
.\1etatarsal arch supports, 135-137 non-automatic, 187
and swinging crutch gaits, 155, I 63 Shoe raise
checking of, 136 Polyethylene, 123, 128
Partial weight bearing with crutches, calculation of, 145-146
metatarsal bar, I 37 reinforcement of Plastazote, 192, 193,
165-166 general considerations, 1-l+-145
metatarsal insoles, 135-136 Panen-ended caliper, 126-127 194
Polypropylene, 129 tapering of, 146
metatarsal pad and garter, 136 Panerns of crutch gaits, 162-168
 204 bJDEX
INDEX 205

types employed, 1-16-148 prevention of slipping, I 2, 54 and knee-flexion piece, 12, 13, 25-26
stability of, 77- 78
arched and bridge waisted, 147 Socket description of, 9
Splint
inside raise, 147-148 Rat/rectangular heel, I 18 Barlow, 102-103 'fixed', application of, 26-27
outside raise, 1-16-147 round heel, 1 18 danger of discarding too early, and 'fixed', suspension of, 45-47
unsuitable footwear for, 146 rubber torsional, 122 fractures, 56 fixed traction in, 15-19
Shoes, types unsuitable for raise, 146 Spinal appliances, 75-94 Denis Browne hip, 104-105 measuring for, 9
Shoulder straps, 82, 83, 8-l, 85, 86 cen·ical, 91-9-l Fisk, 13, 27-28, 48, 49, 197 preparation of, 9-12
Sickle-cell disease and tourniquets, 184 corrective, 79, 89-91 forearm, Plastazote, 194 sliding traction and, 24-27
Side bars of calipers, 114-115 fabric, 80-82 halo, 66 slings for, 9-12
Skeletal traction, 3-i, 65-72 fitting of, 82 Thomas's, 9-12, 15-19, 24-27, 42-48 suspension of, 42-48
application of, 3-7, 66-67, 69-71 function of, 79- 80 Tobruk, 15 with cords, pulleys, weights, 42--17
bony infection and, 4, 54, 65 investigations ro determine effects of, Von Rosen, 101- 102 with springs, 47-48
complications of, 4, 5, 7 79-80 when to discard, and fractures, 56-57 Thoraco-lumbar supports, 82, 88
Denham pin, 4 lumbo-sacral support, 81, 88 Spliuing of plaster casts, I 72, 177-178 indications for, 88
halo, 65-68 indications for, 88 Spondylolisthesis, 88 Three-point crutch gait, 162, 165-168
halo-pelvic, 68-72 moulded, 87, 89, 193-194 Spondylolysis, 88 Tobruk splint, 15
Kirschner wire, 4 indications for, 89 Spring Toe blocks, 139
sires for application of, 5-i possible benefits of, 80 clips for cords, 39, 45 Toe-out and calipers, 119
calcaneus, 6 prescription of, 87-88 Exeter coil, 122 Toe-raising appliances, 120-124
lower end of femur, 5, 6 rigid braces, 83-87, 89 Thomas's splint, su spension by, 37, T ongs
lower end of tibia, 5, 6 indications for, 89 47-48, 197 Barton, 60, 62-63
upper end of tibia, 5, 6 sacro-iliac support, 80, 88 we-raising, 121 Cone, 60, 62-63
skull, 60-65 indications for, 88 Spur pieces, 118 Crutchfield, 60, 61-62
spinal, 60-72 supporti\'e, 79, 80-89 Steinmann pin, 4, 7, 54 Tourniquet paralysis syndrome, 185-186
Steinmann pin, 4 indications for, 87-89 insertion of, 7 characteristics of, 186
Skin blistering and tourniquets, 181 thoraco-lumbar support, 82, 88 Sticks, walking, 157- 158, 168-169 Tourniquets, 181-189
Skin grafting and tourniquets, 183, 185 indications for, 88 Stirrup and deep vein thrombosis, 18-l
Skin-trac, 2, l 98 Spinal belts, 80-82 auachmentof caliper side bars, 118-119 and failure to protect skin, 18 I
Skin traction, 1-3 Spinal braces, 83-87, 89 Bohler, 4, 54 and failure to recognise injury tO m.1jor
appl ication of anterior hyperextension, 86-87 N issen, 29, 30 vessels, 183
adhesive strapping, 2 indications for, 89 Straps application of, 187-188
non-adhesi,·e strapping, 3 basic construction of, 83 ankle, 111,112,113, 121, 122, 125, 127 application 11meof, 183
ventfoam bandage, 3 Fisher, 8-l-85 fulcrum, 80, 81, 82 contratndtcations to use of, 184
complications of, 3 · indications for, 89 groin or perineal, 81, 82, 84 dangers of, 181-183
contraindications to, 3 fitting of, 86 retaining, for calipers, 125-126 excessive lime, dangers of, 182-183
Skull traction, 60-72 Milwaukee, 89-91 shoulder, 82, 83, 84, 85, 86 functions of, 181
aims of treatment. 64 complications of, 91 T, 12-1-125 incorrect placing of, 181
complications of,65 fi tring of, 90-91 Subdural abscess and skull traction, 65 physiological changes with, 182
indications for, 60 indications for, 89 Surgical footwear, general considerations, post-tourniquet syndrome, 184-185
management of, 6~65 Taylor, 83-84, 89 131-132 precautions when using a, 188
recommended weights, 6~ indications for, 89 Suspension cords, 37, 38, 42, 45, 48, 50, pressures
Sliding traction, 8, 23-35 Thomas or Jones, 85-86 54 determining factors and, 182
application of indications for, 89 Suspension of appliances, 37-52 excessive, dangers of, 182
Bohler-Braun frame, using, 34-35 Spinal cord injury and skull traction, 60, advantages of, 37 suggested, 182
Bryant's traction, 31 64,72 Suspension weights, 40-41,42,45,47, 48, reducing time required for, 183, 185
Bryant's traction, modified, 33-34 Spinal corset, 80-82 51,54 tourniquet paralysis syndrome,
Buck's traction, 24 Spinal muscles Swinging gaits with crutches, 114, 185-186
Fisk splin t, 27-28 and control of verte.bral movement, 163-16-l types of, 186-187
'fixed' Thomas"s splint, 26-27 77-78 Swing-through crutch gait, 16-l automatic pneumatic, 186-187
gallows traction, 31 electromyography of, 77-78 Swing-to crutch gait, 163-16-l Esmarch bandage, 187
Hamilton Russell traction, 28 Spinal traction, 59-72 Swiss lock knee joint, 116-117 non-automatic pneumatic, lSi
peh·ic traction, 35 non-skeletal or halter, 59-60 Traction
Thomas's splint and knee flexion skeletal or skull, 60-72 Taylor spinal brace, 83-8-l Bohler-Braun frame, using, 3-1-35
piece, 25-26 Spine indications for, 89 Bryant's, 31-33
Tulloch Brown traction, 30 control of movement of, 77-78 Than~t beam, 45, 46 Bryant's, modified, 33-3-!
for cervical spine, 59-65 functional anatomy of, 75-78 Thomas spinal brace, 85-86, 89 Buck's, 24
methods of application, 24-31,34-35 regional movements of indications for, 89 cords, 5-l
principle of, 23-2-l cervical, 75 Thomas's collar, 92 counter, 7-8, 15, 16, 19
Slings thoracic, 76 Thomas's splint, 9- 12, 15-19, 24-27, Fisk splint, in, 27-28, 48, 49
for Thomas's splint, 9 lumbar, i6-77 -12-48 fixed, 8, 15-21
 'fixed· Thomas's splint. in, 26-27, T -srraps, I 24-I 25
-t~7 Tuberculosis of spine, splinting for, 68,
gallows, 31-33 83. 86, 88, 89
halo, 65--68 Tubigrip, 12, 82, 197
halo-peh·ic, 68--73 Tulloch Brown traction, 29-31
halter, 59-60 application of, 30
Hamilton Russell, 28-29 suspension of, 48-t9
management of parients in 53-57 Two-point crutch gait, 162, 165
pelvic, 35
physiotherapy and, 55-56
t:Jceration, trophic, 132, 191
radiological examination in, 55
Underarm crutches, 152
Roger Anderson well-leg, 19-21
skeletal, 3-7, 65--72
skin, 1-3 Vacuum-formed footwear, 132
skull, 60-73 Valgus insole, 133-134
sliding, 8, 23-35 Vascular complications
spinal, 59-73 Bryant's traction and, 31, 32-33
Thomas's splint, in, I 5-17, 24-26, femoral shaft fractures and, I 7
42-45, 47--t8 plaster casts and, 171-172
pre,·ention of, 1i 1- 172
traction-suspension system, care of, 54
Ventfoam skin traction bandage, 2-3, 198
traction unit, in, 17-19
Tulloch Brown, 29-3 1, 48-49 application of, 3
Von Rosen splint, 101-102
when to discard splint, 56
application of, 102
with U-loop tibial pin, 29-31, 48--49
Traction kits management in, 103
Elastoplast, 2, 198
Seton, 2, 197 Walking aids, 149-160
Traction unit crutches, l 52-157
ad\'antages of, 18-19 factors in selection of, 149
application of, I 8 frames, I 50-152
fixed traction in, I 7- I 9 handgrips, 159-160
suspension of, 43 muscles used with, 149
Traction weight, 2, 15, 18, 24, 27, 28, 35, parallel bars, 150
54, 55; 60, 64 rubber tips, 160
Bohler-Braun frame, 35 walking sricks, 157-158
Buck· s traction, 24 tripod and quadruped, 158-159
determining factors, 24 \X'alking frames, 150-152
femoral shaft, adults, 24 Walking sticks, 157-158, 168-169
femoral shaft, children, 24 adjustment of, 157-158
for 'fixed' Thomas's splint, 27 selection of, 157
Hamilton Russell traction, 28 \X'alking with crutches, 161- 168
head halter, 60 Wedging of plaster cast, 178-180
skin traction, 2 complications of, 180
skull traction, 60, 64 \'Vindlass, 15, I 6
ro reduce groin pressure, 15, IS \Vindow, cutting, in plaster cast, I 73,
Tripod walking aid, 158-159 li6-177
adjustment of, 159
True discrepancy in limb length, I 39-140 Yampi, 132, 198

\
Printed by T. & A. Constable Ltd. Edinburgh, Scotland