kin Traction - Lower Extremity

Buck's skin traction is widely used in the lower limb for femoral
fractures, lower backache, acetabular and hip fractures. Skin traction
rarely reduces a fracture, but reduces pain and maintains length in
fractures.
Method
The skin is prepared and shaved -it must be dry. Friar's balsam may be
used to improve adhesion. The commercially available strapping is
applied to the skin and wound on with an overlapping layer of bandage.
The bandage should not extend above the level of the fracture.

Dangers of Skin Traction

 Distal Oedema
 Vascular obstruction
 Peroneal nerve palsy
 Skin Necrosis over bony prominence's

Avoid complications resist the temptation of

trying to improve adhesion by wrapping the
bandages more tightly. If the tapes slip rather use
skeletal traction if possible (not a child)

Gallows Traction
This is used in infants and children with femoral fractures.
Indications Gallows Traction
 Child must weigh less than 12 kg
 Femoral fractures
 Skin must be intact

Both the fractured and the well femur are placed in skin
traction and the infant is suspended by these from a
special frame. Vascular compromise is the biggest
danger. Check the circulation twice daily. The buttocks
should be just off the bed.

Femur Fractures in older children

Older children with femur fractures can be treated with skin traction in
 a Thomas splint. Unlike the adult the knee must be kept straight in the
Thomas Splint.
The ring of the Thomas splint must allow two
Skin
traction
finger clearance on all sides- try it on the well
in a leg for fit before applying. The skin strapping
Thomas
Splint. is applied and the Thomas Splint fitted. The
ropes from the strapping are tied to the end of
the Thomas splint. The outer one is
passedunder the Thomas splint bar and the inner one Over. This rotates
the foot internally. The limb is rested on three flannel strips secured by
safety pins. The Master sling is the flannel strip directly distal to the
fracture.
These slings can be adjusted so that he fracture
ends align in the vertical plane. The longitudinal
traction needs adjustmentevery day in the first
week. The knot at the end of the Thomas splint is
loosened and the slack taken up. The quality of
reduction is confirmed by regular X rays.
Slings of flannel 150mm wide are The Thomas splint is suspended from
positioned down the length of the
Thomas splint. The Master sling aBalkan Frame. This is a frame attached to
should be just distal to the fracture, the bed. To allow the patient to move about
allowing the proximal fragment to
reduce under gravity. in the bed e.g. to use a bed pan. The limb
with the Thomas splint is suspended from the top of the Thomas "Inner Under 
Outer Over"
Splint by means of a counter weight. The longitudinal traction for counter-torque
exerts pressure on the groin and a further weight is placed over a
pulley on the balkan frame. It is in line with the long axis of the
limb at the foot of the bed. This counter acts the reactive force on
the groin generated by the skin traction.
Overgrowth Slight overlapping (up to 2 cm) of the bones is acceptable,
as the fracture stimulates overgrowth in the local growth plates. End-on-
end reduction, as with plating and other internal fixations, sometimes
results in the injured limb growing more then the uninjured. Most of the
overgrowth takes place in the first year after fracture.

Femur Fractures in Adults

This requires a skeletal pin.
At Tygerberg hospital the Denham pin is commonly used. This has a
threaded middle portion that keeps it in the tibia. For femoral fractures
the Denham Pin through the proximal tibia. Always insert from lateral
to medial in the proximal tibia, as the peroneal nerve needs to be missed
and the site of exit is unpredictable. On some occasions a distal femoral
site, or even the calcaneus may be used.
Site for prox. tibial Denham pin 2.5 cm inferior and distal to tibial tubercle

A Thomas splint, (check it fits, by trying on the well leg) is applied.

Three flannel slings are secured by safety pins under the thigh. The
"Master splint" is the one under the fracture. The correct tension on this
sling will align the fracture in the lateral plane. The knee can be flexed
by using a Pearson flexion splint attached to the
Thomas splint at the knee. The desired knee
flexion can be maintained by a rope at its end
leading from the Thomas splint to the Pearson
attachment. Ropes from the Denham pin can
either be tied distally to the Thomas splint Thomas Traction -Adult 
(static traction) or they can be led over a pulley Click to see annotated larger image
on the end of theBalkan frame (dynamic
Traction) In either case start with 7 kg ( or 10% body weight) in the long
axis of the femur. This opposes the pull of the thigh muscles. As with the
child, the traction is made balanced by a system of pulleys on the
horizontal limb of the Balkan frame to allow the patient to move his
limb. A "monkey chain" hung above the arms also allows the patient to
transfer himself onto a bedpan. as he moves in the bed.

Alignment of Thomas Splint

The Thomas splint must be aligned by pointing the Balkan frame in the
direction of the proximal fragment.

Displacement of a
femur fracture
 Muscles causing
the displacement

How to align the

Thomas Splint.
Also raise foot-
end to provide
flexion

Balkan Frame Adjustment: For flexion, raise pulley (a).

For abduction, swing foot-end of balkan wide of bed (b)

Displacement - Proximal femur fracture

 Prox. Femur - Flexion
 Prox. Femur - Abduction
 Align frame - Flexion & Abduction
Mid-shaft fractures remain relatively un displaced as the proximal and
distal muscles balance.
Distal femur fracture displacement
 Posterior angulation - pull of gastrocnemius
 Solution - flex the knee as far as possible

Bed Blocks
Bed Blocks must be placed under the foot end of the bed with all the
above types of traction. Raising the foot of the bed a few centimeters
 provides a counter force to prevent the patient being pulled distally
down the bed by the longitudinal traction.

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Halter Traction
Halter traction is used for short term cervical traction. Uses include minor neck
injuries without obvious fractures e.g. Whiplash injury, neck muscle spasm,
conservative treatment of cervical disk lesions.
Children with cervical fractures can also be treated without skeletal pins as their
skull is too fragile to withstand pins.

Problems with Halter Traction

 Uncomfortable
 Tempero-mandibular pain
 Contraindicated in mandible fractures
 Difficult to control flexion - extension

Flexion Extension cervical X-rays

If a patient has normal cervical X-rays, but has neck muscle spasm Flexion
Extension views may be needed to exclude serious instability of the cervical spine.
Halter traction is a good way to relieve the spasm before these X Rays can be done.
The patient is admitted and placed in Halter traction until the neck is free of
muscular spasm. Under direct supervision of the attending doctor the flexion
extension views are taken in the X ray department. The patient must have no pain
when the neck is flexed and extended. If neurological symptoms such as parasthesia
develop the X rays are abandoned.

Skull Traction
 In more serious cervical injuries skull tongs such as Cones calipers are indicated.
Indications include the conservative treatment of cervical fractures and dislocations.

Application of Cones Calipers

 Shave the hair above the ear region

 Local anaesthetic
 Avoid masseter
 Avoid Temporal artery
 Small incision above ear in line with auditory meatus
 Screw in pin until it just perforates outer table skull
 Tie on rope
 Attach weights
 
Direction and Weights

 Force - 2.5 kg for

head and 1/2 kg for
Crutchfield tongs:
each vertebra* Allow the patient to be
Position to apply the Cone's Caliper pins - in line with auditory meatus  Direction easily turned, as the
caliper sits high on the
skull. Consider these in
Neutral In line with a paralized patient.
Auditory meatus
 Flexion needed - raise pulley
 Extension needed - use double mattress ending @ shoulders
*(Each uninvolved vertebra cephalad)

Complications of Cervical Traction

 Bleeding - temporal artery

 Pressure sore on skull - avoid downwards vector to rope
 Sepsis - from skin to subural abscess
 Worsening neurological status
 Squint from 6th craneal nerve fallout

Contraindications Skull Tongs

 Children
 Local sepsis
 Skull fracture
 The double mattress method is an effective way to extend the neck. Never place the
head pulley too low as a pressure sore can result on the occiput, especially in the
unconscious or neurologically compromised patient.
At Tygerberg Hospital the Cone's calipers are commonly used. The Crutchfield
tongs are another caliper that fit higher on the skull vault and allow easier turning of
the paralised patient.

Reduction of Facet dislocations

Skeletal traction to the skull can be used to reduce cervical facet dislocations

Weights are serially

added while the neck is positioned in flexion After each 2.5kg weight is added a
lateral X ray is taken to determine reduction. The attending doctor checks for
neurological signs. If neurology deteriorates the weights are removed. Up to 20 kg.
traction may be used in this way for a few hours only. After reduction the neck is
placed in extension and the lighter maintenance weights are used.

Dunlop Traction
The main use of Dunlop's traction is in the maintenance of reduction in
supracondyar fractures of the humerus in children.
Dunlop Traction
 Supracondyar fractures in children
 Allows swollen elbow to settle
 Contraindicated in open fractures and skin defects

Skin traction is placed on the

forearm and A special frame used
on the side of the bed. 
Traction is placed along the axis of
the forearm as well as at right
angles to the humerus by means of
a broad sling placed around the
upper arm. Bed blocks are required
on the lateral side (fracture side up)
of the bed.

If a supracondyar fracture cannot be

reduced to over 90 degrees elbow
flexion, this method of traction is an
alternative to invasive methods such as
a percutaneous K-wires. It allows
swelling to subside. Do not rely on this
method to reduce a supra condylar
fracture, a manipulation will still be required!

Pelvic traction for Backache

In sciatica and other backaches relief from pain can be obtained by means of pelvic
traction. Traction is applied to a pelvic harness with weights over the end of the bed.

An alternative in Sciatica is the 90-90 position. By

means of cushions under the knees, the hips are
flexed near 90 degrees, as well as the knees. This shortens the sciatic nerve and
relieves pain.

Acetabular Traction
In conservative treatment of acetabular fractures longitudinal traction in the long
axis of the limb is often used. In addition the head of the femur can be disimpacted
from the acetetabulum ( central fracture dislocations) by means of manipulation
under anesthesia. The reduction is maintained by means of lateral traction from pins
paced in intertrochanteric region.

Lateral Traction for an acetabular fracture

 
 Posterior Hip Dislocations
Posterior hip dislocations are the most common. The usual cause is a motor vehicle
accident with the passenger's knee hitting the dashboard and forcing the femoral head out
of the acetabulum posteriorly. The limb is shortened, and the hip flexed, the foot is in
internal rotation.
Check for other fractures especially femur neck or shaft fractures and tibial fractures.
Remember that associated fractures of the ipsilateral femoral shaft are not uncommon.
Obtain a pelvic x ray when managing any femur or tibia fracture, especially
in the unconscious victim.
Associated femur head and acetabular rim fractures of ten complicate these
injuries. Sciatic nerve damage is common - check that there is good
X-ray signs
posterior dorsiflexion of the foot.
dislocation Reduction - posterior dislocation
 Broken Reduction is an emergency - do not delay this. Closed reduction and should
Shenton's line
be performed at the original hospital if it is any significant distance from the
 Shortenin
g regional institution as delay significantly increases the incidence of vascular
 Adductio necrosis.
n femur Use general anaesthetic with muscle relaxants. An assistant
 Lesser steadies the pelvis while the surgeon applies longitudinal
trochanter not
visible (internal
traction to get the femoral head under the acetabulum. The
rotation) hip is now flexed and pulled upwards. The internal rotation
is corrected at this stage and a click should be felt as the hip reduces.
Once reduced check the hip for stability. It should have a full range of
motion and be in neutral rotation.  Obtain a postoperative x ray to confirm the hip is
concentrically reduced. Widening of the joint space may mean that there are bony
fragments in the joint cavity (later arthrotomy and repair may be needed) or that the
acetabulum is deficient due to a fracture.
The patient is placed in skin traction or a Denham pin may be inserted into the proximal tibia for 3
to 6 weeks traction.

Any femur head and acetabular fractures are operated on electively, once computer
tomogrammes are done to define the lesion.
Complications Posterior hip dislocation

 Sciatic nerve damage (10%)

 Associated fractures (acetabulum, femur head or
neck)
 Avascular necrosis (up to 5%)
 Osteoarthritis (up to 40%)
 
Anterior Hip Dislocations
With an anterior dislocation the lower limb is lengthened, the hip abducted and the foot is
in external rotation.
As the femur head is either anterior in the groin or in the obturator fossa it
can obstruct the femoral vein causing thrombosis and possible pulmonary
embolism.
X ray signs of an anterior hip dislocation are the lesser trochanter being
more visible (due to external rotation. The hip is abducted and the femur
head is usually inferior to the acetabulum. Shenton's line is also broken.
Anterior
dislocation. Hip is
in abduction.

Reduction - anterior hip dislocation

You will need at least one assistant and an anesthetist to reduce an anterior hip dislocation.
Under general anaesthetic the assistant disimpacts the femur from the obturator fossa by
applying a lateral force to the hip.
The surgeon then pulls on the partially flexed hip. As
with a posterior dislocation correction of the
rotation is done last. Once the femur head is over
the acetabular opening the external rotation is
corrected by internally rotating the femur. Once
reduction is achieved the femur should be able to
move in all directions and return to neutral position.
Take a post reduction X ray to confirm your
successful reduction. Postoperative longitudinal
traction is given for 2 to 6 weeks.