TRACTION IN ORTHOPAEDICS

Sunilsanthosh.G
Moderator : Dr. Sivaprasad
Definition:
Traction is defined as an act of drawing or
exerting a pulling force applied to limbs,
bones, or other tissues along the longitudinal
axis of the structure to pull the tissues apart,
often for realignment.
 History :
• Hippocrates (460-360BC) treated fracture shaft of femur
and of leg with the leg straight in extension.
• Percival Pott (1714-1788) - He taught that the fractured
limb should be placed in the position in which the muscles
are most relaxed.
• Josiah Crosby - First to demonstrate and effectively
promote the use of skin traction for the treatment of shaft
of femur
• Thomas Bryant introduced Bryant's traction for treatment
of fracture shaft femur in children.
• Malgaigne in 1847 introduced the 1st effective
traction which grasped the bone itself. He used
Malgaigne's hooks.
• Steinmann (1872-1932) in 1907 introduced a
method of applying skeletal traction to the femur
by means of two pins driven into the femoral
condyles.
• Lorenz Bohler - "the father of traumatology"
popularized skeletal traction worldwide by means
of Steinmann pin after he devised Bohler's stirrup.
He modified Braun's splint and developed the
multipurpose Bohler Braun splint.
 Traction is Applied to
• Reduce a fracture
• Reduce dislocation of a joint
• Relieve pain
• Rest the limb in functional position
• Aid in healing of bone.
• overcome muscle spasm and deforming forces.
• Correction of soft tissue contractures by pulling
them gradually.
Principles of traction Care:
1. Maintain the established line of pull.
2. Maintain continuous traction.
3. Maintain counter traction.
4. Maintain traction equipment .
5. Maintain correct body alignment .
6. Prevent friction to the skin.
METHODS OF APPLYING TRACTION

• Skin traction
1)Adhesive
2)Non-adhesive
• Skeletal traction
Skin traction:
Used as a definitive method of treatment as well as a first aid
or temporary measure.
Mechanism:
• Traction force is applied over a large area. Load is spread and
is more comfortable and efficient.
• Force applied is transmitted from skin to the bones, via the
superficial fascia, deep fascia and intermuscular septa.
• For better efficiency, the traction force is applied only to the
limb distal to the fracture.
Maximum weight:
Recommended is 6.7kg (depending on size and age of patient
) (1/10th the body weight).
 Adhesive skin traction
• Use adhesive strapping which can be stretched only
transversely
• Avoid placing adhesive strapping over bony prominences
• Leave a loop of 2 inches ( 5cm) projecting beyond the
distal end of limb to allow the movement of finger / foot
Non-Adhesive skin traction
• This consists of lengths of soft, ventilated latex
foam rubber, laminated into a strong cloth backing.
• These are useful in thin and atrophic skin or when
there is sensitivity to adhesive strapping. It is
applied in similar fashion as adhesive skin traction
• As the grip is less secure, frequent reapplication
may be necessary
• Attached traction weight should not be more than
4.5kg (10 lbs)
Indication of skin traction :
• Temporary management of femoral neck fractures and
intertrochanteric fractures.
• Management of femoral shaft fractures in older and hefty
children.
• Undisplaced fracture of acetabulum.
• After reduction of a dislocation of the hip.
• Prevent minor fixed flexion deformities of the hip or knee.
• Management of low back ache.
• Post Gullitone amputation to approximate the tissues.
 Contraindication of skin traction
1. Abrasion & Laceration to skin.
2. Dermatitis.
3. Any fragile condition of skin.
4. Impairment of circulation-varicose ulcers,
Impending gangrene.
5. Marked shortening of bony fragments where more
traction weight has to be applied.
Complications of skin traction
• Allergic reaction to adhesive.

• Excoriation of skin on slipping.

• Pressure sores around malleoli & tendoachilles.

• Common peroneal nerve palsy.

Skeletal Traction
• Traction force is applied directly to the bone by
means of pins or wire driven through the bone
• it is used more frequently in the management of
lower 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
Most commonly used pin are
• Steinman pin:
Are rigid stainless steel, pins of varying
length, 4 to 6 mm diameter.
After insertion a special, stirrup (Bohler
1929) is attached to the pin.
The Bohler stirrup allows the direction of
the traction to be changed without turning the pin
in the bone.
Steinmann's pin&
bohler sturrup
• Denham Pin:
Similar to Steinmanns pin except for a short
threaded length situated in the center and held in
the introducer.
It engages the bony cortex and reduces the
risk of pin sliding.
Used in a) cancellous bones & b) osteporotic
bones
Kirschner wire:
Is of small diameter and is insufficiently rigid
until pulled taut in a special stirrup, rotation of the
stirrup is imparted to the wire.
Though they are thin but if proper special stirrup
is used they can withstand a
large traction force because the
stirrup provides a longitudinal
tension force which increases
the rigidity of the K-wire
Common sites for application of skeletal traction:
a) Olecranon:
• k- wire passed 3cms distal to
tip of the olecranon
• passed medial to lateral
at right angle to longitutinal axis
of ulna deep to subcutaneous border to
avoid injury to ulnar nerve
• For supra condylar and trans condylar
# humerus
• Unstable # shaft of humerus
• A screw eye can also be used
B) Second and Third Metacarpals:
• Proximal to distal end of 2nd metcarpal
• It trasverses 2nd and 3rd metacarpal right angle to
longitudinal axis of radius.
• USED IN COMMINUTED #s OF BONES OF FOREARM-
PARTICULARLY THAT OF LOWER END OF RADIUS.
C) Upper end of femur:
• Used in central fracture dislocation of hip
• Cancellous screw or screw eye is used
D) Lower end of Femur:
E) Upper end of Tibia:
Pin is passed lat to medial to avoid injury to
Common peroneal nerve
E) Lower end of Tibia:
5cms above the ankle joint mid-way b/n ant & pos
diameter
F) Calcaneus:
Advantages:
Traction force directly in line
of the calf muscles and cou
teract their pull
Disadvantages:
Subtalar joint stiffness
 COMPLICATIONS OF SKELETAL TRACTION
•Introduction of infection into a bone.

•Incorrect placement of pin

-Allows pin to cut out of bone.
-Makes control of rotation of limb difficult.
-Makes application of splint difficult.
-Unequal pull causes pin to move in the bone causing ischemic
necrosis

•Large traction force.

-Distraction at fracture site.
-Ligament damage.

•Damage to epiphyseal growth plate in children.

•Depressed scar and stiffness of joints.

Counter- Traction
• Reason for applying Traction is to counteract
deforming effect of muscle spasm this tends draw
body in direction of traction
• To prevent this force is to be used in opposite
direction called Counter-traction
• It can be done in two methods
A) Fixed Traction
B) Sliding Traction
 FIXED TRACTION
• When counter traction acts through an appliance
which obtains purchase on a part of the body, its
called a fixed traction.
Fixed traction in Thomas` splint:
• Maintain but not obtain reduction
• Counter thrust passes up the side
bars to padded ring around the
root of the limb.
• The malleoli are well padded to
avoid pressure sores.
• The outer traction cord passes above
and the inner cord passes below its
respective side bar, to hold the limb in
medial rotation.
• The traction cords are tied over the
end of the Thomas spint.

• A traction wt of 5lb(2.3kg)attached
to the Thomas`splint is sufficient
Traction unit
• Introduced by Charnley.
• For the treatment of # Shaft Of Femur.
• Consists of upper tibial steinman pin incorporated in a
below knee cast which is then fit in to a Thomas`
splint
• Advantages
• 1. Compression of the tissue of the upper calf
including common peroneal nerve does not occur
• 2. Equinus deformity at the ankle can't occur
because the foot is supported by plaster cast
• 3. The tendo-calcaneus is protected by the padded
cast
• 4. Rotation of the foot and the distal fragment is
controlled
• 5. A fracture of the ipsilateral tibia can be treated
conservatively time.
ROGER ANDERSON WELL-LEG TRACTION

• Originally used in management of #s of pelvis,

femur, tibia.
• Skeletal traction being applied to injured leg, while
the well leg was employed for counter traction.
• But this method is valuable in correcting either
abduction and adduction deformity at the hip.
PRINCIPLE:
With abduction deformity at the hip,
The affected limb appears to be longer. When Traction is applied to
the well limb and Affected limb is simultaneously pushed Up
(counter traction), the abduction deformity is reduced.

REVERSING THE
ARRANGEMENT
WILL REDUCE
AN ADDUCTION
DEFORMITY.
A/K PLASTER CAST
LIMB WHICH WILL
BE PUSHED UP

STEINMENN PIN
LARGE STIRRUP IN THROUGH LOWER
PLASTER END OF THE TIBIA OF
THE LIMB WHICH IS
TO BE PULLED DOWN.
BY ALTERING THE
POSITION OF SCREW
THE RELATIVE
POSITIONS OF TWO
STIRRUP CAN BE ALTERED.
Sliding traction:
• Definition:
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.

• Principle:
The traction force is applied by weight attached to
adhesive strapping or a steel pin by a cord acting over a
pulley. Counter traction is obtained by raising one end of
the bed by means of wooden blocks so that the body tends
to slide in the opposite direction.
 BUCK`S TRACTION

USED IN THE TEMPORARY MANAGEMENT OF

• Femoral neck fractures,

• Femoral shaft fractures in older and larger children,
• Undisplaced #s of acetabulum,
• In place of pelvic traction,
• Correction of minor fixed flexion deformites of hip
• After reduction of dislocation of hip.
APPLICATION:

• APPLY ADHESIVE STRAPPING TO ABOVE KNEE OR IN ELDERLY VENTOFOAM

SKIN TRACTION

• SUPPORT THE LEG WITH PILLOW.

• PASS THE CORD FROM SPREADER OVER PULLEY.

• ATTACH 2.3-3.2kgs (5 – 7 lbs) TO THE CORD.

• ELEVATE THE FOOT END OF BED.

Lateral rotation of
limb is not controlled
 PERKIN`S TRACTION (1970)
USE IN TREATMENT OF
• Fracture tibia
• # femur from subtrochanteric region distally in all ages
• fracture Trochanter in <50 yrs
• Principle-
is use of Skeletal traction without any externalsplintage
coupled with active movements of injured limb
• Perkins showed that by encouraging early muscular activity
stiffness of joint was prevented by extensibility of muscles
by reciprocal innervation.
 Application
 Under GA and aseptic
precautions,
 Insert Denham pin through
upper Tibia
 Attach Simonis swivel to each
end of pin
 Connect 2 traction cords to
each swivel
 Pass each cord over separate
pulleys
• Attach wt (4.6kgs) to each traction cord making
total traction wt of 9.2kgs.
 Elevate foot of bed by 1 inch for every 0.46 kg.
 Place pillows under thigh to maintain normal bowing
of thigh.
 CHECK LIMB LENGTH WITH TAPE & INCREASE OR
DECREASE THE TRACTION WEIGHT
 Start active quadriceps exercises immediately.
Hamilton –Russel Traction
Indications:
• Management of the fracture shaft of femur
• After arthroplasty operations on the hip
Application:
• Belo knee skin traction
• Pulley attached to spreader
• Soft sling placed under knee
Weight
adults – 3.6 kg
chidren – 0.28- 1.8 kg
• Advantage:
Based on law of parallelogram of forces that - the
2 pulley blocks at the foot of the bed theoretically
doubles the pull on the limb and the resultant
traction is in axis of 30° to the horizontal i.e. in line
of shaft of femur
TULLOCK BROWN TRACTION.
used in
• Management of patients who under went
cup arthoplasty or pseudoartrosis of hip
• # shaft of femur
Application:
Steinman pin through the proximal tibia.
•Support legs on slings suspended from light duralumin U-loop which is
slipped over the ends of Steinman pin.
•Attach the Nissen stirrup to the steinman pin it enables leg to be
suspended and rotation of movements controlled.
•Foot supported in Perspex foot plate & foot end elevated.
 NINETY/NINETY TRACTION
• Devised by Obletz (1946)
• Used in # femur with wounds over post aspect of
thigh (operative & post op management)
• Subtrochanteric and proximal third # femur
• Used in both children and adults
• Here both hip and knee are flexed to 90*
• Skeletal traction is applied through lower femur or
upper tibia
• 3 methods of supporting leg in 90/90 traction
USING B/K CAST
• USING A SECOND
STEINMAN PIN
• USING TULLOCH
BROWN U LOOP
• Varus /valgus angulation at fraction site is controlled by
moving the pully,over which the traction cord passes,in
a plane across the width of the bed.

• Rotation is controlled by the knee being flexed.

• As the union of fracture occurs, encourage active hip and

knee exercise-extension , gradually lower the limb into a
more horizontal position.
 DANGERS OF 90/90 TRACTION

1. Those of skeletal traction.

2.Stiffness and loss of extension of the knee.

3.Flexion contracture of hip.

4.Injury to the lower femoral or upper tibial

epiphyseal growth plates in children.

5. Neuro vascular damage.

BRYANT`S TRACTION(GALLOWS)(1880)

• # Shaft of femur in children <2 yrs

• Apply adhesive strapping to both lower limbs
• Tie traction cords to an over head beam
• Tighten the traction cord to raise the buttocks
just clear the mattress
• Counter traction obtained by weight of pelvis
• Vascular complication of Bryants traction may occur in either the
injured or normal limb.

• A careful check must be done in both limbs during first 24-72 hrs.
-By checking color and temp of limbs.
-Dorsiflexion of both ankle passively.

• Bryants traction in children

under 2yrs - safe
2-4yrs - vascular complications more(can be
prevented by using posterior splint).
Over 4yrs - absolutely contraindicated.
 Modified Bryant`s traction

• In the initial management of CDH when

diagnosed over the age of 1 year.
• After 5 days abduction of hip is started
• Abduction is increased by 10* on alternate
days
• By 3wks hips should be fully abducted
 COMPLICATION:

• The child will become restless and scream

repeatedly with pain.

• The pain is due to stretching of capsule and

impingement of femoral head on superior lip of
acetabulam.
SLIDING TRACTION IN BOHLER-BRAUNFRAME
• In management of tibia and femoral fractures.
 DISADVANTAGES:

1.Bohler Braun frame rests on pts bed and cannot move

with the patient.

2.Nursing care is more difficult.

3.Movement of proximal #fragments in relation with distal

fragment which is cradled in the splint.

4. This predisposes to deformity.

Lateral upper femoral traction
• Used alone or along with traction in long axis of
femur in management of central fracture-
dislocation of Hip.
• If only superior rim of acetabulum is fractured -
combined with Buck's Russell traction
• If posterior rim of acetabulum is fractured and if
reduction of dislocated femoral head is unstable,
combined with vertical skeletal traction in lower
end of femur or upper end of tibia.
• Maximum attachable weight - 4.5-9kg
 PELVIC TRACTION
•In pelvic traction special canvas harness is
buckled around the patients pelvis.
•Long cords attach the harness to the foot of the bed.
•Foot end of the bed raised-provides sliding traction.
•Used in conservative management of IVDP. To
ensure that the pt lies quietly in bed rather than to
distract the vertebral bodies.
•Buck`s traction may also be employed
Dunlop's traction:
• Used in management of Supracondylar and
transcondylar fractures of Humerus in
children.
• This method is useful if flexion of the elbow
causes circulatory embarrassment with loss of
radial pulse
• Apply skin traction to fore arm
• Place the pt supine
• Abduct the shoulder to 45*
• Pass the traction cord over a
pulley so that elbow flexed to 45*
• Place padded sling over distal
humerus
• Attach 1-2 lb wt to traction
cord and padded sling
• Elevate same side of bed
• Check circulation
OLECRANON TRACTION:
• Indications:
• Supracondylar fracture of humerus
• Comminuted fracture of lower end of the humerus
• Unstable fracture of the shaft of the humerus
• Weigt – 1.3- 1.8 kg
METACARPAL PIN TRACTION:
• Comminuted fracture of forearm bones - especially
for a comminuted # of lower end of the radius
• Maximum attachable weight is - 1.3-1.8kg
Complications:
• Fibrosis in the interosseous muscles causing
stiffness of fingers.
• General complications of skeletal traction.
 SPINAL TRACTION
• Cervical spine
-skeletal traction(skull traction)
-non skeletal traction(halter traction)
Halters Traction
Indications:
• Treatment of Cervical Spondylosis as an out patient
• Maximum weight is 1.4 to 2.3 kgs
• Two types – Canvas & Crile head halter
• Head end of bed should raised to provide counter-traction
Skull Traction
Applied by gaining purchase on the outer table of
the skull with metal pins
Used in the serious injuries of cervical spine like
• To reduce a dislocation or fracture dislocation - in both
case with traction the dislocation is under control and
injury to spine does not occur
• To maintain the position of c- Spine before and after
operative fusion
• For the treatment of cervical spondylosis with severe
nerve root compression
• Maximum applicable weight is 9.1 to 18.2kg
• For skull traction use
a) Crutch field tongs
b) Cone or Barton tongs
Crutch field tongs:
• Fits in to parietal bone
• A special drill with a shoulder is used to enable an
accurate depth of hole to be drilled
CONE OR BARTON TONGS
• A drill is not required for their insertion. The
threaded steel points are screwed into the parietal
bones behind the ears
 Complications
• Tongs may pull out of skull
• Tongs may penetrate inner table
• Osteomyelitis
• Extradural hematoma
• Extradural abscess
• Subdural abscess
• Cerebral abscess
 Goals of cervical traction in cervical spine
injury
• To realign spine
• To prevent loss of function of undamaged
neurological tissue
• To improve neurological recovery
• To obtain and maintain spinal instability
• To obtain early functional recovery
 Recommended traction wts
LEVEL MINIMUM WT MAXIMUM WT
C1 2.3 kg 4.5 kg
C2 2.7 kg 4.5-5.5 kg
C3 3.6 kg 4.5 -6.7 kg
C4 4.5 kg 6.7-9.0 kg
C5 5.4 kg 9.0-11.3 kg
C6 6.7 kg 9.0-13.5 kg
C7 8.2 kg 11.3-15.8 kg
 Removal of traction
 Continue traction untill # is stable and then change to
another method of supporting the # until union is
achieved
 Traction is continued for
-elbow # with olecranon pin-3wks
-tibial # with calcaneal pin-3 to 6 wks
-trochanteric # - 6wks
-# SOF –6 to 12 wks
Thank u