Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Traumatology and orthopaedics
Acute Trauma Management
Trauma in perspective
Principles of Primary Trauma Care
Six phases of Primary Trauma Care
Procedures
Orthopaedic Techniques
Traction
Casts and Splints
Application of external fixation
Diagnostic imaging
Physical therapy
Crania burr holes
Orthopaedic Trauma
Upper extremity injuries
The hand
Fractures of the pelvis and hip
Injuries of the lower extremity
Spine injuries
Fractures in children
Amputations
Complications
War related trauma
General Orthopaedics
Congenital and developmental problems
Bone tumours
Infection
Degenerative conditions
Traction
 





SKIN TRACTION

Skin traction requires pressure on the skin to maintain the pulling force across the bone. A maximum of 5 kg of weight may be applied using this method. More than 5 kg of weight will result in the skin becoming excoriated with blister formation and pressure sores caused by slipping of the tightly wrapped strapping. Wrapping the straps more tightly to prevent slipping increases the risk of creating a compartment syndrome in the injured extremity.

If more than 5 kg of weight is needed to control the fracture, use skeletal traction instead.

Do not apply traction to skin with abrasions, lacerations, surgical wounds, ulcers, loss of sensation or peripheral vascular disease.

Technique

1 Clean the limb with soap and water and dry it. If available, use a commercial traction set, which will contain adhesive tapes, traction cords, spreader bar and foam protection for the malleoli. This is usually not available, so improvise the apparatus as described below.
2 Measure the appropriate length of adhesive strapping and place it on a level surface with the adhesive side up. Ask the patient about adhesive tape allergy before applying.
3 Place a square wooden spreader of about 7.5 cm (with a central hole) in the middle of the adhesive strapping (Figure 17.1).
Figure 17.1
Figure 17.1

4 Gently elevate the limb off the bed while applying longitudinal traction. Apply the strapping to the medial and lateral sides of the limb, allowing the spreader to project 15 cm below the sole of the foot (Figure 17.2).
Figure 17.2
Figure 17.2

5 Pad bony areas with felt or cotton-wool. Wrap crepe or ordinary gauze bandage firmly over the strapping (Figure 17.3).
Figure 17.3
Figure 17.3

6 Elevate the end of the bed, and attach a traction cord through the spreader with the required weight (Figure 17.4). The weight should not exceed 5 kg.
Figure 17.4
Figure 17.4


Complications

1 Allergic reactions from the adhesive material
2 Blister formation and pressure sores from slipping straps
3 Compartment syndrome from over-tight wrap
4 Peroneal nerve palsy from wraps about the knee.


SKELETAL TRACTION


Apply skeletal traction by placing a metal pin through the metaphyseal portion of the bone and apply weight to the pin. It is important to place the pin correctly to avoid injury to vessels, nerves, joints and growth plates. The amount of weight to be used depends on the fracture but, generally, between 1/10 and 1/7 of body weight is safe and adequate for most fractures.

Technique

1 Wash the skin with antiseptic solution and cover the surrounding area with sterile drapes. Infiltrate the skin and soft tissues down to the bone with 1% lidocaine on both the entrance and exit sides.
2 Make a small stab incision in the skin and introduce the pin through the incision horizontally and at right angles to the long axis of the limb. Proceed until the point of the pin strikes the underlying bone (Figure 17.5). Ideally, the pin should pass through the skin and subcutaneous tissue, but not through muscles.
Figure 17.5
Figure 17.5

3 Insert the pins with a T-handle or hand drill (Figure 17.6). Advance the pin until it stretches the skin of the opposite side and make a small release incision over its point (Figure 17.7).
Figure 17.6
Figure 17.6

Figure 17.7
Figure 17.7

4 Dress the skin wounds separately with sterile gauze. Attach a stirrup to the pin, cover the pin ends with guards and apply traction (Figure 17.8).
Figure 17.8
Figure 17.8

5 Apply counter-traction by elevating the appropriate end of the bed or by placing a splint against the root of the limb.

Sites of pin placement

Proximal tibia
Insert the pin 2 cm distal to the tibial tubercle and 2 cm behind the anterior border of the tibia (Figure 17.5). Begin on the lateral side to avoid the common peroneal nerve.

Calcaneus
Insert the pin 4.5 cm inferior and 4 cm posterior to the tip of the medial malleolus (Figure 17.9). Begin on the medial side to avoid damage to the posterior tibial artery and nerve and to avoid entering the subtalar joint.

Figure 17.9
Figure 17.9


Distal femur
Insert the pin from the medial side, in the mid-portion of the bone, at the level of the proximal pole of the patella. This should be just proximal to the flare of the femoral condyles and posterior to the synovial pouch of the knee joint.

Olecranon
Insert the pin from the medial side of the ulna 2 cm from the tip of the olecranon and 1 cm anterior to the posterior cortex. This should avoid the ulnar nerve which passes through the groove inferior to the medial epicondyle of the humerus (Figure 17.10).

Figure 17.10
Figure 17.10


Complications

:: Pin tract infection is common:
The skin will look inflamed with drainage about the pin; the pin will eventually loosen
Control the infection with wound cleansing, dressing changes and antibiotics
If this fails, place a new pin at a different site or discontinue traction
 
:: Joint stiffness is prevented by active and active-assisted exercise.


SKULL TRACTION

Use skull traction for traumatic and infectious conditions in the cervical spine. Apply it to the skin using head halter traction or to the skull bones using Gardner-Wells tongs or a halo device.

Technique: Gardner-Wells tongs

1 Place the pins below the brim of the skull in line with the external auditory meatus, 2–3 cm above the top of the pinna (Figures 17.11 and 17.12).
Figure 17.11
Figure 17.11

Figure 17.12
Figure 17.12

2 Prepare the patient’s scalp by shaving the hair and washing the skin with an antiseptic solution.
3 Position the tongs correctly and mark the pin entrance points.
4 Infiltrate the pin sites with 1% lidocaine and make stab wounds through the skin and down to the bone. Insert the pins by alternately tightening one side and then the other, until 3.6 kg of torque is applied. Determine the tightness with a special torque screwdriver or by tightening the pins, using two fingers only to grip the screwdriver.
5 Dress the wounds with sterile gauze and apply the appropriate traction weight. Tighten the pins again once on the following day, then leave them alone unless they are loose.


Technique: halo traction

1 Determine the ring size by measuring the head circumference or by trial. The clearance should be 1–2 cm at all points.
2 Carefully place the patient’s head off the end of the bed and hold it with a special headholder, or with an assistant. The halo should be just above the eyebrows and ears (Figure 17.13).
Figure 17.13
Figure 17.13

3 Use two pins posterior-laterally and two in the lateral third of the forehead. These may be placed as far back as the hairline for cosmetic reasons, but should be anterior to the temporal muscle (Figure 17.14).
Figure 17.14
Figure 17.14

4 Shave the hair under the selected sites for the pin holes, wash the skin with antiseptic solution and infiltrate with 1% lidocaine through the four holes selected.
5 Advance the pins to finger tightness while keeping the halo placement symmetrical. Ask the patient to keep his/her eyes closed during the procedure to avoid pulling the skin upward and preventing eye closure once the pins are tight.
6 Next, tighten the pins sequentially across the diagonals. If a torque screwdriver is available, tighten the screws to 34–45 cm/kg. If not, twist the screws tight while holding the screwdriver with two fingers.
7 Tighten the screws once after 1–2 days and thereafter only if loose. Traction can now be applied or the patient can be placed in a halo jacket.


EXTREMITY TRACTION

The following are examples of traction arrangements for the upper and lower extremities.

Figure 17.15: Dunlap’s traction
Figure 17.16: Olecranon traction
Figure 17.17: Perkin’s traction
Figure 17.18: Perkin’s traction
Figure 17.19: Russell’s traction
Figure 17.20: 90/90 balance suspension

Figure 17.15
Figure 17.15


Figure 17.16
Figure 17.16


Figure 17.17
Figure 17.17


Figure 17.18
Figure 17.18


Figure 17.19
Figure 17.19


Figure 17.20
Figure 17.20



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  Kep Points  
Use an appropriate method of traction to treat fractures of the extremities and cervical spine


Apply extremity traction to the skin or to the skeleton using a pin inserted through the bone distal to the fracture



 
Apply traction to the cervical spine using a head halter chin sling or skull tongs


 
The weight applied through the traction system counteracts the muscle force pulling across the fracture, keeping the bone in proper alignment and length.