TRACTION

IN
ORTHOPAEDICS
Dr. Muslihah Binti Zainon

OUTLINE
Principle of traction
Skin traction
Skeletal traction
Management

PRINCIPLE OF
TRACTION

DEFINITION
Traction is the application of a force
to stretch certain parts of the body
in a specific direction

GENERAL CONSIDERATIONS
Safe and dependable way of treating
fractures for more than 100 years
Bone reduced and held by soft tissue
Less risk infection at fracture site
No devascularization
Allows more joint mobility than
plaster

THE PURPOSE OF TRACTION

To regain normal length and
alignment of involved bone
To reduce and immobilize a fractured
bone
To relieve or eliminate muscle
spasms
To relieve pressure on nerves,
especially spinal
To prevent or reduce skeletal
deformities or muscle contractures
Controls pain

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

Requires meticulous nursing care

Can develop contractures

UNDERSTANDING TRACTION

PRINCIPLES OF EFFECTIVE
TRACTION
Countertraction must be used to
achieve effective traction.
Countertraction is the force acting
the opposite direction.
Usually, the patient's body weight
and bed position adjustments supply
the needed countertraction.

COUNTERTRACTION
Fixed traction - by applying force
against a fixed point of counter
pressure (body).
Ex:
fixed traction by Thomas splint
Roger Anderson well leg traction

COUNTERTRACTION
Balanced / Sliding traction - by
tilting bed so that patient tends to slide
in opposite direction to traction force
Ex:
Hamilton Russell traction
Tulloch Brown traction
Agnes Hunt traction
Perkins traction

TRACTION TO LIMBS

METHODS OF TRACTION1
TRACTION BY GRAVITY
SKIN TRACTION
SKELETAL TRACTION

TRACTION BY GRAVITY

TRACTION BY GRAVITY
applies only to upper limb injuries
with a wrist sling the weight of the
arm provides continuous traction to
the humerus

Skin traction

SKIN TRACTION

SKIN TRACTION
applied over a large area of skin
spreads the load and is more
comfortable and efficient
Force applied is transmitted from
skin to the bones via superficial
fascia, deep fascia and
intermuscular septa
For better efficiency : force applied
to the limb distal to the fracture site

Application
Measuring the limb
to determine length
of strapping
required (A);
above-knee traction :
from the greater
trochanter to the sole
of the foot

Below-knee traction :
from the tibial
condyles

Application
levels of tibial
condyles, malleoli,
and Achilles tendon
(B);

sandwiching the
spreader between
two strappings
(C);

Application
applying strapping to
the leg while protecting
the malleoli (D);
Protect the malleoli,
Achilles tendon insertion,
and the head and neck of
the fibula by placing strips
of felt or cotton-wool
padding under the
strapping at these sites
leave enough space (10 15 cm) between the sole
and the spreader to permit
movement at the ankle)

bandaging
over the
strapping (E);

Application
attaching traction (F, G )

Maximum weight recommended for skin

traction is 5 kg
Skin damage can result from too much of
traction force

Indications
Tempory traction :
preoperative
pain
Temporary management of # of NOF and IT #

Management of # - Femoral shaft of older

and hefty children
After reduction of dislocation of Hip
To correct minor fixed flexion deformities
of hip and knee

Contraindications
limb with abrasions, lacerations, ulcers of the
skin
limb with loss of sensation, impending gangrene,
atrophic skin
peripheral vascular disease
marked overriding of fracture fragments
Elderly patients are not typically recommended
for skin traction because their skin is fragile and
their circulation may already be damaged or
weakened.

Complications
allergic reaction to the adhesive material
(usually zinc oxide);
blister formation or excoriation of the skin
from the strapping slipping;
pressure sores over the malleoli;
common peroneal nerve palsy
most important cause : lateral rotation of the limb,
compression of the nerve at the upper end of
the fibula
Avoid this by keeping the patients knee joint
moderately flexed (up to 10)

Common Skin Tractions

Bucks Traction
Russel Traction
Gallows or Brayants Traction
Modified Brayants Traction
Pelvic Traction
Dunlop Traction

Bucks Traction
Often used
preoperatively for
femoral fractures
Can use tape
No more than 5
kgs
Not used to obtain
or hold reduction

Russel Traction
Below knee skin traction is applied
A broad soft sling is placed under
the knee

Bryants (Gallows ) Traction

Useful for treatment of fracture
femoral shaft in children up to age
of 2 yrs.
Weight of child should be less than
15- 18 kg
Above knee skin traction is applied
bilaterally
Tie the traction to the over head
beam

Modified Bryants Traction

Sometimes used as a initial
management of developmental
dysplasia of hip (1 yr)
After 5 days of Bryants traction,
abduction of both hips is begun
increased by about 10 degree
alternate days.
By three weeks hips should be
fully abducted.

Pelvic Traction
used to relieve low back pain, and hip
and leg pain associated with lower
back disorders
Applies traction to the lower spine
with a belt wrapped snugly around
the hips.
Wearing the belt too high, like around
the waist, will have no benefit and
may cause more pain; the force must
be directly applied to the pelvis.

Dunlop Traction
Commonly used for supracondylar &
transcondylar fracture of humerus
(preferable in children)
Apply skin traction to forearm
Abduct shoulder about 45
degree
the elbow is flexed 45 degree
(prevents poor circulation to
the elbow)

SKELETAL TRACTION

SKELETAL TRACTION
used as a means of reducing or
maintaining the reduction of a
fracture
It should be reserved for those cases
in which skin traction is
contraindicated
used when long-term, continuous
traction is needed
Invasive

Application

Steinmann Pin
Rigid stainless steel pins of varying lengths 4
6 mm in diameter.
Bohler stirrup is attached to Steinmann pin
which allows the direction of the traction to
be varied without turning the pin in the bone

Denham Pin
Identical to Steinmann pin except for
a short threaded length in the
center . This threaded portion
engages the bony cortex and
reduce the risk of the pin sliding
Used in cancellous bone like
calcaneum and osteoporitic bones

Kirschner wire
They are easy to insert and minimize the
chance of soft tissue damage and infections
It easily cuts out of the bone if a heavy
traction weight is applied
Most commonly used in upper limb eg.
Olecranon traction

Sites
Proximal femoral
about 2.5 cm from most
prominent part of greater
trochanter mid way between
ant. and post. surface of femur
threaded screw eye

Sites
Proximal tibia
insert the pin
approximately 2.5 cm
distal to the tibial
tuberosity and 2.5 cm
behind the anterior
border of the tibia
from the lateral side to
avoid the common
peroneal nerve

 The common peroneal nerve begins posteriorly in the thigh

and runs from the center of the popliteal fossa laterally and
anteriorly together and below the tendon of the biceps
femoris. It winds anteriorly around the neck of the fibula
and then ramifies in the anterior compartment into a
superficial sensory and deep motor and sensory branches.

Sites
Distal tibia
insert the pin from the lateral side
approximately 4 cm proximal to
the most prominent part of the
lateral malleolus
Place the pin proximal to the
ankle mortise, parallel to the
ankle joint, and midway
between the anterior and
posterior borders of the tibia
There will be resistance as the pin
passes through both cortices of
the tibia anterior to the fibula.

Sites
Calcaneum
insert the pin 2 cm inferior and 2 cm
posterior to the tip of the medial
malleolus
from the medial side to
avoid damaging the
posterior tibial artery
and nerve or entering
the subtalar joint

 Olecranon

K wire from medial to lateral

Right angles to logitudinal axis of ulna
3 cm distal to tip of olecranon
Avoid ulnar nerve

Complications
Introduction of infection into bone
Clinically the skin is inflamed; the wounds are moist; percussion over the
bone elicits tenderness; and the pin becomes loose.
If the infection is not controlled by repeated dressings and antibiotics,
remove the pin and employ an alternative method of traction.

If the bone is osteoporotic and the traction too heavy, the pin will
cut through the bone.
Distraction at fracture site
Accurate insertion of the pin avoids complications from damage
to the neighbouring neurovascular bundles and from penetration
into a neighbouring joint. Prevent possible stiffness in the joint or
contractures of tendons by repeated active and assisted
exercises.
Damage to epiphyseal growth plates
Depressed scars

Common Skeletal Tractions

Proximal Tibial Traction

Distal Tibial Traction
Upper Femoral Traction
90/90 Traction
Calcaneal Traction
Olecranon Traction

Upper Femoral Traction

Several traction options
for acetabular fractures
Lateral traction for
fractures with medial or
anterior force
Stretched capsule and
ligamentum may reduce
acetabular fragments
Attach weight up to 9 kgs
Traction to continued for
about 4-6 wks

Ninety / Ninety Traction

Used for sub trochanteric fractures
and those in the proximal third of the
shaft of the femur
Management of fractures with
posterior wound is easier
Traction is given through lower
femoral pin, which is more efficient,
or by upper tibial pin.

 Complications of 90/90
traction:
those related with skeletal traction.
Stiffness and loss of extension of knee.
Flexion contracture of hip.
Neurovascular damage

Proximal Tibial Traction

Used for distal
2/3rd femoral
shaft fracture
Contraindicated if
the knee
ligaments have
been injured.

Distal Tibial Traction

Useful in certain
tibial plateau
fracture
Maintain partial
hip and knee
flexion

Calcaneal Traction
Temporary
traction for tibial
shaft fx or
calcaneal fx
Do not skewer
subtalar joint or
NV bundle
Maintain slight
elevation leg

Olecranon Traction
Usually use in supracondylar
fracture
Rarely used today
Support forearm and wrist with skin
traction - elbow at 90 degrees
Indication :
if the fracture is severely displaced and
cannot be reduced by manipulation;
if, with the elbow flexed 100 degrees,
the pulse is obliterated and image
intensification is not available to allow
pinning and then straightening of the
elbow
for severe open injuries or multiple
injuries of the limb

Halo
Indicated for certain cervical
fractures as definitive treatment or
supplementary protection to internal
fixation
Disadvantages
Pin problems
Respiratory compromise

Left: Safe zone for halo pins. Place anterior pins about 1 cm
above orbital rim, over lateral two thirds of the orbit, and below
skull equator (widest circumference).
Right: Safe zone avoids temporalis muscle and fossa laterally,
and supraorbital and supatrochlear nerves and frontal sinus
medially.
Posterior pin placement is much less critical because the lack of
neuromuscular structures and uniform thickness of the posterior

Halo Ring Traction

Direction of traction
force can be controlled
No movement between
skull and fixation pins
Allows the pt out of
bed while traction
maintained
Used for c-spine or tspine fx

Halo Ring Traction

Ring with threaded
holes
Allow 1-1.5 cm
clearance around
head
Place below equator
Spacer discs used to
position ring
Central anterior

Halo Ring Traction

Two anterior pins
Placed in frontal bone
groove
Sup and lat to
supraorbital ridge

Two posterior pins

Placed posterior and
superior to external
ear

Tighten pins to 5-6

Halo Traction
Traction pull
more anterior
for extension
More posterior
for flexion
Use same
weight as with
tong traction

Halo Vest
Major use of halo
traction is
combine with
body jacket
Allows pt out of
bed
Can use plaster
jacket or plastic,
sheepskin lined
jacket

Halo Vest
Pin site infection a risk
Can remove pins and place in
different hole
Pin penetration can produce CSF leak
Scars over eyebrows
Can get sores beneath vest

MANAGEMENT

Management of patients in traction

Care of the patient
Care of the traction suspension
system
Radiographic examination
Physiotherapy
Removal of traction

The patient
Care of the injured limb Pain
Parasthesia or Numbness
Skin irritation
Swelling
Weakness of ankle, toe, wrist or
finger movement

The traction suspension

system

Splints
Slings and padding
Skin traction
Skeletal traction
Stirrups
Cord
Pulleys
Weights

Radiographic examination

2-3 times in first week

Weekly for next 3 weeks
Monthly until union occurs
After each manipulation
After each weight change

Removal of traction
Elbow # with olecranon pin
- 3 wks
Tibial # with calcaneal pin
- 3-6wks
Trochanteric # of femur
- 6wks
Femoral shaft #
with cast brace
- 6 wks
without external support

References :
1. Apleys System of Orthopaedics and
Fractures 9 ed. 2010
2. Campbell
3. Surgery
at the District Hospital: Obstetri
cs, Gynaecology, Orthopaedics and
Traumatology
(WHO; 1991; 207 pages)
4. http://www.primary-surgery.org/ps/vol2
/html/sect0346.html
5. http://

THANK YOU