Department of Orthopaedics

K.M.C., Manipal and Mangalore

(Under the aegis of Manipal Academy of Higher
Education &
Canara Orthopaedic Society)
August 2, 2020 on Microsoft Teams

TRACTION IN ORTHOPAEDICS
Dr. Rajendra A
Dr. Sharath K. Rao Dr. Anil K. Bhat
Dean, KMC Assoc. Dean, KMC
Manipal Manipal
Dr. Shyamasunder Bhat N Dr. Surendra U Kamath
Prof. & Head, Orthopaedics Prof. & Head, Orthopaedics
KMC, Manipal KMC Mangalore
 Definition

•The act of drawing or exerting a

pulling force along the long axis of
the structure
 Objectives of traction

• Fractures (reduction and alignment)

• Contractures of muscles (deformities)
• Muscle spasms
• Rest a diseased joint
 Objectives
• Reduce a dislocated joint

• Immobilize a fracture and maintain alignment until callus formation

and calcification begin

• Prevent further soft tissue damage

• Hold a bone or bones in place for joint healing

Many Important
Some Historical
Few Obsolete
 Mechanical components
• Angles
• Weights
• Pulleys
• Counter traction
• Bed and balkan bar
• Stirrup
• Splints
• Slings and padding
• Cords.
 Axis
• Axis is defined as line that passes through the centre or a part of the
body .

• Determined by placement of the pulleys on the bed frame and angle

of the involved joints
Weights
• The amount of the weight applied determines the pulling force
(traction)
• Excess weight
• Distracts the bone fragments too far – no callus formation
• damage the surrounding soft tissues , blood vessels and nerves may
increase the pain
Less weight
• allow the overriding of the bone fragments – malunion at the # site
• will increase the pain from muscle spasm
• will allow motion of the fragments
FACTORS THAT INFLUENCE THE
AMOUNT OF WEIGHT TO BE
APPLIED
• Fracture site – # femur will require more weight than # humerus
• Patient s age n wt.
• Strength of the muscle mass surrounding the # -e.g. athlete s muscle
will require more wt.
• Patient s medical condition – poor bone stock – less wt.
PULLEYS

• The number of pulleys in traction assembly affects the pull exerted .

• With one pulley the traction force = amount of wt. applied

• With 2 pulleys the traction exerted = twice the amount of wt. applied
 COUNTER TRACTION
• Effective traction requires counter traction .

• It is the pull in the direction opposite to the pulling force of a traction.

• 10 pounds of pulling force exerted on an object that weighs 5 pounds

without counter traction it moves towards the pulling force.

• If the same force is applied with counter traction, there is an added 5

pounds of pull in the opposite direction and the object is stabilized
 CORDS
• Red and green cords-
traction cords
• White cords –
suspension cords

• TYPE OF KNOTS
• Clove hitch
• Half hitch
• Two half hitch
• Barrel hitch
• Reef knot
METHOD OF TRACTION
• TWO TYPES
•
• SKIN TRACTION

• SKELETAL TRACTION
Skin traction
• Definitive/first aid/temporary treatment
• Mechanism: the traction force is applied over a large area. This
spreads the load & is more comfortable & efficient. Force applied is
transmited from skin to the bones,via the superficial fascia, deep
fascia & intermuscular septa.
• For better efficiency the traction
force is applied only distal to the #.
• Max weight: 6.7kg
TWO METHODS
• 1.ADHESIVE SKIN TRACTION
• 2. NON ADHESIVE SKIN TRACTION
• SKIN ADHESIVE TRACTION
• Application:
• prepare the part.
• Use adhesive strapping
• avoid over bony prominences.
• avoid wrinkles & creases.
• traction 4-6 weeks.
NON ADHESIVE SKIN TRACTION
• Indicated in thin , atrophic & sensitised to adhesive
straps.
• Temporary management of femur & IT #.
• Femoral # in older and hefty children.
• Undisplaced # of acetabulum.
• After Reduction of a dislocation of hip.
• To correct the minor FFD of hip & knee.
• After guillotine amputation to approximate the
tissues.
• Max wt-4.5 kg
CONTRAINDICATION
• Abrasion & laceration
• Impairment of circulation- varicose ulcers, impending gangrene.
• Dermatitis
• Marked shortening of bony fragments.
COMPLICATIONS
• Allergic reactions
• Skin excoriations
• Pressure sores
• Nerve injuries
• Compartment syndrome
• Mechanical failure/excessive rotation/excessive abduction
SKELETAL TRACTION
• A metal pin or wire through the
bone.
• MATERIAL: Steinmann pin,
Denham pin, Kirschner wire, cord,
pulley, stirrup, weight & optional
splint.
• COMMON SITES: olecranon,
metacarpal, femur(upper & lower
end), tibia & calcaneum.
OLECRANON TRACTION
• INDICATION:To immobilize supracondylar#,
Dislocation of elbow, humerus and shoulder

• Application: Just deep to subcutaneous

border of the upper end of the ulna,3cm
distal to the tip of the olecranon. This avoids
the elbow joint.
• keep perpendicular to ulna
• Avoid ulnar nerve injury.
2.Metacarpal traction
• The point of insertion of the k-wire is 2-
2.5 cm proximal to the distal end of
2nd metacarpal.

• Wire traverses 2nd & 3rd MC

transversely to lie at right angles to the
longitudinal axis of radius.
3.Upper end of femur traction
• The lateral surface of femur is 2.5 cm below
the most prominent part of the greater
trochanter, mid way between anterior and
posterior surface of femur
• coarse threaded cancellous screw or screw
eye is used.
4.Lower end of femur traction
• Point of insertion is the line from upper pole of
patella horizontally intersecting another vertical
line from the head of the fibula.
• OR
• Just proximal to upper part of lateral femoral
condyle, i.e, 3cm proximal to the articulation
between the lateral femoral condyle and lateral
tibial plateu.
• Dont enter the knee joint.
• Prolonged traction predisposes to knee stiffness
5.UPPER END OF TIBIA
• The point of insertion is 2cm
behind the crest just below the
level of tibial tubercle

• Pin should be driven from lateral

to medial to avoid common
peroneal nerve.

• In young pts. avoid the epiphysis

6.Lower end tibial traction
• Point of insertion is 5 cm above
the level of ankle joint midway
between
• ant. and post. borders of tibia
Calcaneal traction
• Point of insertion is 2cm below and
behind the lateral malleolus or 3 cm
below and behind the medial malleolus
• Avoid subtalar joint
• Advantage – traction force is applied in
the line of calf muscle , thereby reducing
deforming action on the # fragment
• Disadvantage – frequent loosening ,
infection ,subtalar joint stiffness
Complications of skeletal traction
• Infection
• Incorrect placement of the pin
• Distraction at the # site
• Ligamentous damage
• Damage to epiphyseal plate
• Depressed scars
Types of counter traction
• Fixed traction

• Sliding traction

• Combination of the above

FIXED TRACTION
• Counter traction is achieved by applying a force against a fixed point
on the body

• METHODS OF FIXED TRACTION

• Thomas splint
• Charnley s traction unit
• Roger Anderson s well leg traction
Thomas Splint
• Angle of the ring 120 degrees
• Two side bars
• Outer bar bent to
accommodate the greater
trochanter
• Leg supported on slings tied to
the side bars
TRACTION IN THOMAS SPLINT
• Mechanism- traction is exerted from the fixed points of the pts pelvis.
• The extension tapes pull the limb down to the splint , which is
prevented from moving in the opposite direction by the resistance of
the ring of the splint against the ischial tuberosity .
• It is used to maintain but not to obtain the reduction of the #
• A reduced transverse # is most suitable but the reduced oblique or
spiral # can be maintained.
• The significant features of fixed traction is that the traction force
balances the pull of the muscles and as the muscular pull and
hematoma decrease , the traction also decreases .
How to apply Thomas splint
• Measure the oblique circumference of the
thigh immediately below the gluteal fold of the
buttock and ischial tuberosity.
• Unaffected leg + 5-6cm for swelling
• Corresponds to inner circumference of ring
• Distance from groin to heel --15-20cm for
plantar flexion
Advantages
• Distraction at the # is less likely to occur
• counter traction is not dependent upon gravity
• It is self contained
• Pt. may be lifted and moved without the risk of displacement of #
CHARNLEY S TRACTION UNIT

• Modification in Thomas splint used for management of # shaft femur.

• It consists of upper tibial steinmann pin in corporated in a light B/K
p.o.p cast
• Advantage –
• - compression of the tissues doesn’t occur
• - equinus deformity doesn’t occur
• - tendo calcalneus is protected
• - rotation of the foot and distal fragment is controlled
• -ipsilateral tibial # can be treated conservatively
Traction unit
FIXED TRACTION IN A ROGER
ANDERSON WELL LEG TRACTION

• Principle - with an abduction deformity

at the hip the affected limb appears to
be longer, when traction is applied to
the well limb and the affected limb is
simultaneously pushed up , the
abduction deformity is reduced .
• Reversing the arrangement will reduce
an adduction deformity
• Used in correcting abductor and
adductor deformity of the hip and
before an extra-articular
arthrodesis is carried out
Sliding traction
• Weight of body with gravity-counter traction
• Principle –
• The traction force is applied by wt. attached to adhesive strapping or
steinmann pin by a cord acting over a pulley .
• Counter traction-rising one end of the bed by means of wooden
block or bed elevator
• opposite direction to that of the traction force .
Instructions
• Initial wt. required to obtain reduction is > wt. required to maintain
the reduction
• The exact wt. required is determined by a trial -observing a behaviour
of the #
• For # shaft femur the initial wt is 10% of the body wt.
• Heavier the traction wt. used higher the end of the bed must be
raised e.g. for each 0.5 kg 2.5 cm should be raised
Types of sliding traction-Lower limb

a. Buck s extension skin traction

b. Perkin s traction
c. Russel traction
d. 90-90 traction
e. Gallow’s traction
f. Bowler Braun splint
g. lateral upper femoral traction
h. pelvic traction
II upper limb
• Modified Dunlop traction
• Olecranon pin traction
• Metacarpal pin traction
III Spine
• Head halter or non skeletal traction
• canvas or chamois leather head halter traction
• Crile head halter traction
•
• skull traction
• halo pelvic traction
Buck s extension traction
• Temporary management of # neck femur
• # shaft femur in older and larger children
• Undisplaced # acetabulum
• After reduction of dislocation of the hip
• To correct minor FFD of hip and knee
• In place of pelvic traction in management of low back ache
Buck s extension traction
• Application – skin traction
supported by soft pillow ,pass
the cord from spreader over a
pulley , attach 3.5 kg wt. and
elevate the foot of the bed

• Disadvantage – lateral rotation

of limb is not controlled
PERKINS TRACTION
• # tibia , femur (sub trochanteric) and distal femur #,
trochanteric #

• Application – apply regular skeletal traction without

using splint , keep pillow below the knee attach wt.
through the pulley , rise the foot end . Commence
active movts. of injured limb as soon as possible .
• Advantage – by active muscular activity knee
stiffness can be prevented
• Disadvantage – needs a special split bed or a std.
hospital bed and gives less support for the #
HAMILTON RUSSEL TRACTION
• Indication
• - management of # shaft
femur and after arthroplasty
operations on the hip
• Application – apply skin
traction B/K , place a soft
broad sling under the knee
where cord and pulley are
attached , suggested wt is 3.5
kg
Hamilton-Russell (balanced) skin traction
• Advantage – based on law of parralellogram of forces .
• The 2 pulley blocks at the foot of the bed theoretically double the
pull on the limb , the resultant traction is in axis of 30 * to the
horizontal i.e in the line of shaft of femur
• Disadvantage – this method does not protect backward sagging or
lateral angulation
90 – 90 TRACTION
• Indication

• operative and early post operative management of compound #

femur with wound over the post. aspect of the thigh , sub-
trochanteric # , proximal 1/3rd # shaft femur
90-90 traction
• Application- under GA traction is
applied to lower end of femur or upper
end of tibia
• Hip and knee flexed to 90*
• Attach sufficient wt
• keep the leg suspended with knee
flexed to 90
• Angulation is prevented by moving the
pulley across the width of the leg
90-90 traction
• Advantage – hip and knee exercises encourages union , rotation is
controlled
• Danger
• stiffness and loss of extension of knee
• flexion contracture of the hip
• injury to lower femoral and upper tibial epiphyseal growth plate
• Neurovascular damage
Gallow s or Bryant s traction
• Indication - # shaft femur in children of 2 yrs
who weigh < 18 kgs

• adhesive strapping to both bones lower limbs

• tighten the traction cord to raise the child s

buttock just clear of the mattress .

• Counter traction is obtained by wt. of pelvis and

lower trunk
• Advantage – children tolerate well , good alignment of # , rapid union
within 4 weeks
• Complication – ischaemic fibrosis of calf muscle and frank gangrene of
distal limb
• TO CHECK – state of circulation , color and temp. of feet , dorsiflexion
• Contraindication - > 4yrs
BOHLER BRAUN FRAME
• Indication – comminuted
trochanteric # of femur
• # shaft femur
• supracondylar # femur
• occasionally # shaft tibia and fibula
Function of Pulleys
• 1st pulley – dynamic splint for foot drop
• 2nd pulley – traction in line of femur
• 3rd pulley –to apply traction in line with
leg

• Disadvantage – nursing care difficult ,

heavy cumbersome frame, may cause
deformity at # sit
LATERAL UPPER FEMORAL TRACTION
• Indication – management of central # dislocation of hip with
acetabular # ,
• If sup. rim of acetabulum # ,with Buck traction and Russel traction.
• if post rim of acetabulum # combine with vertical sketetal traction
• max wt 4.5kg-9kg
• period 4-6 wks
• Complication-septicaemia
PELVIC TRACTION
• INDICATION:
• Treatment of displaced #
pelvis esp; post ring
instability
• Treatment of unstable
pelvic disruption
• Conservative management
of I V D P
Pelvic traction
• PRINCIPLE : special canvas harness is buckled to pts pelvis , the cords
which are crossed to produce compression and internal rotation
• ADVANTAGE – reduction by traction in pelvic suspension by
decreasing movt. at traction site
• CONTRAINDICATION – comminuted # acetabulum , hemipelvic #
dislocation
Dunlop traction
• Apply skin traction to the forearm
• place the child supine on the bed
• abduct the shoulder abt. 45*
• elbow is flexed to 45*
• place a padded sling over the distal humerus .
• Attach wt to both the traction and padded sling .
• Wt. required is 0.5-1 kg .
• Elevate the same side of the bed as the affected limb and under x ray view
increase the traction wt until the satisfactory reduction of # is obtained.
DUNLOP TRACTION
• Indication – management of supra and
intra condylar # humerus when flexion of
elbow causes further circulatory
embarrassment and loss of radial pulse

• CHECK the circulation of limb

• Do not just check the radial pulse ,
• check for full active and passive flexion of
fingers . If you suspect ischaemia
discontinue the traction
OLECRANON TRACTION
• Indication –
• Supracondylar # humerus in pts with poor operative condition ,
debilatated and with external wound ,
• Comminuted # lower end of humerus who are medically unfit ,
• Unstable # of shaft of humerus
METACARPAL PIN TRACTION
• Indication – comminuted # of bones of forearm ,
• combination with olecranon pin traction can be used in # humerus
• Max wt = 1.3-1.8 kg
• Complication – fibrosis in interosseous muscle causing stiffness of
fingers
SPINAL TRACTION
• CERVICAL TRACTION
• HEAD HALTER or NON SKELETAL TRACTION
• Indication – treatment of cervical spondylosis as an
out patient
• 2 types of head halter traction
- a canvas or chamois leather
- crile head halter
• Max wt-3-5 lb
• Head end must be raised to provide counter traction.
SKULL TRACTION
• Applied by gaining purchase on the outer table of the skull with metal
pins under local anaesthesia
• For cervical traction we can use –
• crutch field tongs
• cone or barton tongs
• halo splint
• Max wt – 20 to 40 lb
Indication

• To reduce a dislocation or # dislocation of c.spine

• To maintain the position of c. spine before and after operative fusion
• In the treatment of cervical spondylosis with severe nerve root
compression
Crutchfield traction
• draw a line on the scalp bisecting the
skull from front to back
• Draw a second line joining the tips of
the mastoid process which crosses the
first line at rt. angles.
• Apply tongs fully open with a min
distance of 10 cm, making the
bisecting point as central.
BARTON TONGS

• Application- a drill is not

required for insertion , the
threaded steel points are
screwed into the parietal bones
behind the ears , rest as same
as crutchfield tongs application
HALO SPLINT
• It is an oval metal band
which arches up
posteriorly to clear the
occiput, to enable the pt.
to rest his head more
comfortably. it has a no.
of threaded holes at 2,4,8,
and 10 o clock positions
through which fixing pins
are screwed into the
outer table of the skull .
Halo splint
• Application – identify the pin sites
• 1 cm above the lateral third of eyebrows on each side and 1 cm above the
ears in line with the mastoid on each side
• position the pt in supine ,
• Head supported by 4 inch wide board placed under his head and neck ,
• select a halo ring that allow 1.5cm clearance from head in its perimeter ,
position the halo ring – ask the attender to hold it.
• Use positioning pins and plates to place the ring in proper attitude and to
equal use the clearance around the head
• Skull pins should be at 90* to the skull and turned to finger tighten
Complications of skull traction
• Crutchfield tongs may pull out of the skull,may penetrate the inner
table of the skull if they are over tightened.
• Osteomyelitis of the skull,extradural haematoma,extradural
abscess,subdural abscess,cerebral abscess.
• These complications may be heralded by pyrexia & headache &
progress to fits,hemiplegia & coma
HALO PELVIC TRACTION
• Indication –
• to immobilize the spine
• to slowly correct or reduce deformities of spine such as scoliosis
and TB before surgery is carried out
Halo Pelvic traction
• Materials – 4 vertical spring loaded
distraction rods to a steel pelvic
hoop .
• The pelvic hoop in turn attached to
2 long threaded steel rods
• Pin through wing of the ilium which
is 5 cm superior and inferior to the
ASIS.
• There should be allowed gap of 2.5-
3.8 cm between pts skin and hoop.
Complications
• A.cranial screws
• 1.infection
• 2.cerebral abscess
• 3.loosening of screws
• 4.pain & penetration of inner table of skull
B Pelvic rods
• vague aches & pain around hips
• peritoneal penetration with or without bowel damage
• superficial infection
• loosening
• hip contracture from ilio-psoas fibrosis.
Complications contd
• C.neurological
• 1.abducent nerve palsy
• 2.glosso-pharyngeal nerve palsy
• 3.recurrent laryngeal nerve palsy
• 4.hypoglossal nerve palsy
• 5.brachial nerve palsy
• 6.spinal cord – paraplegia
 D.General
1.death from resp.insufficiency
2.osteoporosis of vertebra
3.cervial subluxation C1 over C2
4.avascular necrosis of proximal pole of odantoid
process
Traction table
• With
stienmann
pin/ shoe

• Femur and
trochanteric
fractures,
proximal tibia
fractures
In shoulder arthroscopy
THANK YOU