Skeletal traction

Although the use of traction has decreased over the years, an increasing number of orthopaedic
practitioners are using traction in conjunction with bracing (see Milwaukee brace). The section
below provides some details on traction and its use.

Bryant's Traction
Bryant's traction is mainly used in young children who have fractures of the femur or congenital
abnormalities of the hip.[1] Both the patient's limbs are suspended in the air vertically at a ninety
degree angle from the hips and knees slightly flexed. Over a period of days, the legs hips are
gradually moved outward from the body using a pulley system. The patient's body provides the
countertraction.

Purpose
The purpose of traction is to:

• To regain normal length and alignment of involved bone.

• To reduce and immobilize a fractured bone.
• To lessen or eliminate muscle spasms.
• To relieve pressure on nerves, especially spinal.
• To prevent or reduce skeletal deformities or muscle contractures.

In most cases traction is only one part of the treatment plan of a patient needing such therapy.
The physician’s order will contain:

• Type of traction
• Amount of weight to be applied
• Frequency of neurovascular checks if more frequent than every four (4) hours.
• Site care of inserted pins, wires, or tongs
• The site and care of straps, harnesses and halters
• The inclusion of any other physical restraints / straps or appliances (eg. mouth guard)
• the discontinuation of traction

Responsibility of initial application

The physician is typically responsible for initial application of traction and weights while the
adjustment or removal (to perform ablution functions / physiotherapy) of skeletal traction
weights will be based on the doctors charted plan.

In most cases cervical traction may be adjusted or temporarily removed, per physician order, by
an orthopedic nurse who has documented competency to do so.
The alignment and moving of the patient will only be changed on physician's directive and the
affected extremity will need to be maintained in proper alignment at all times with the ropes and
traction straps - making sure the mentioned is unobstructed and weights hanging freely.

If it is necessary to move the patient while skeletal traction is in place, the patient should be
moved in the bed with weights hanging freely.

In most cases traction will be applied for a number of weeks to months and Neurovascular
checks will need to be performed by a nurse as ordered by the physician or as dictated per
traction unit policy.

Traction is an appropriate treatment for a number of medical problems including spinal

deformities such as scoliosis.

Thomas Splint Traction

• Hugh Owen Thomas introduced his splint which he called "The Knee
Appliance" in 1875
• The method of Hugh Owen Thomas uses fixed traction with the counter
traction being applied against the perineum by the ring of the splint
• This is in contrast to other methods using weight traction which is countered
by the weight of the body
• Backward angulation of the distal fragment can never be corrected by
traction in the axis of the femur which only results in elongation with
persistence of the deformity
• A Thomas splint and fixed traction is only capable of maintaining a reduction
previously achieved by manipulation
• The use of supports enables correction of angulation caused by muscle
tension
• Placement of a large pad behind the lower fragment acts as a fulcrum over
which backward angulation is then corrected by the traction force
• The pad should be 6" in width, 9" long and 2" thick, applied transversely
across the splint under the distal fragment and popliteal fossa
• It is the splint which controls alignment and not the traction
• The tension in the apparatus should only be that sufficient to balance resting
muscle tone
• Suspension of the splint using an overhead beam enables the splint to move
easily with the patient when they move in bed
• Its use in combination with a Pearson Knee-flexion piece enables mobilisation
of the knee, while maintaining traction, alignment and splinting of the
fracture

Hamilton Russell Traction

• Robert Hamilton Russell wrote "Fracture of the femur: A clinical study" in

which he described his traction in 1924
 • Sling under the distal 1/3 of the thigh provides upward lift, as well as
longitudinal traction in the line of the tibia
• The sling under the distal fragment controls posterior angulation and the
lifting force is related to the main traction force through the medium of
pullies
• No rigid splinting is used in this method
• Combines a means of suspending the lower extremity and a means of
applying traction in the axis of the femur
• Many other varieties of both skeletal and skin traction result in a similar
effect

Buck Traction

• Buck introduced simple horizontal traction in 1861

• Traction is analogous to Pugh's traction only the inclination of the bed is
replaced by the application of weights over a pulley

Bryant's traction

• Vertical extension traction was described by Bryant in 1873 and applied to

the management of femoral fractures
• The development of ischemia of the lower leg through reduced perfusion
resulted in limitation of its application to the short term management of a
fractured femur
• A modification of his traction has been shown to reduce the risk of limb
ischemia and may be applicable where prolonged traction is required in an
infant

Braun Frame

• This is merely a cradle for the limb

• Disadvantage is that the position of the pulleys cannot be altered and the
size of the splint often does not fit the limb as might be wished
• Lateral bowing is common as the splint and the distal fragment are fixed to
the frame, while the patient and the proximal fragment can move sideways
leaving the frame behind

Perkins Traction

• Here no splinting is used at all

• The posterior angulation of the thigh is controlled by a pillow
• The alignment and fixation depend entirely on the action of continuous
traction

Fisk Traction

• Hinged version of a Thomas splint is arranged to allow 90o of knee movement

• It is particularly attractive as it allows active extension of the knee joint
 • Fixation and alignment is dependent entirely on the weight traction and the
splint merely applies the motive power for assisted knee movement

90 - 90 Traction

• The thigh is suspended in the vertical plane by weight traction pulling

vertically upwards
• The ill effect of gravity as the cause of backward angulation of the fragments
is thus eliminated

Charnley

• Strongly recommends the use of a BK POP incorporating the Steinmann or

Denham pin in the upper end, in order to reduce pressure on the soft
structures around the knee
• Benefits of POP/Traction unit (Charnley) :
o Foot supported at right angles to the tibia
o Common peroneal nerve and calf muscles protected from pressure
against the slings of the splint and the splint itself
o The tibia is suspended from the skeletal pin inside the POP, so that an
air space develops under the tibia as the calf muscles loose their bulk
o External rotation of the foot and distal fragments is controlled
o The tendo achilles is protected from pressure sores
o Comfort; The patient is unaware of the traction when applied through
the medium of a nail

Upper Limb

• A number of skin traction methods have been described and a number more
utilised without documentation in the literature
• Ingerbrightsen's overhead skin traction (A); Dunlop's side arm skin traction
(B); and Graham's extension skin traction (C) are but a few
• Skeletal pin traction can also be utilised :
o Overhead (A)
o Overhead with secondary distal forearm traction directed cephalad (B)
o Side arm pin traction (C)

INTRODUCTION OF TRACTION

• Traction produces a reduction through the surrounding soft parts, which align
the fragments by their tension
• When the shaft of a long bone is fractured the elastic retraction of muscles
surrounding the bone tends to produce over-riding of the fragments
• This tendency is greater when
o The muscles are powerful and long bellied as in the thigh
o When the fracture is imperfectly immobilised, so that there is pain and
therefore muscle spam
 o When the fracture is mechanically unstable, because the fragments
are not in apposition or because the fracture line is oblique
• Continuous traction generated by weights and pulleys, in addition to causing
reduction of a deformity, will also produce a relative fixation of the fragments
by the rigidity conferred by the surrounding soft tissue structures when under
tension
• It also enables maintenance of alignment, while at the same time it is
possible to devise apparatus, which permit joint movement
• Traction may be applied through traction tapes attached to skin by adhesives
or by direct pull by transfixing pins through or onto the skeleton
• Traction must always be apposed by counter traction or the pull exerted
against a fixed object, otherwise it merely pulls the patient down or off the
bed
• Traction requires constant care and vigilance and is costly in terms of the
length of hospital stay and all the hazards of prolonged bed rest must be
considered when traction is used :
o Thromboembolism
o Decubiti
o Pneumonia
o Atelectasis
• Excessive traction which leads to distraction of the fracture is undesirable
• Once the fracture is reduced a decreasing amount of weight is required to
maintain a reduction once the muscle stretch reflex has been overcome and
the fracture immobilised
• For a femoral fracture no more than 10 lbs should be used and for fractures
of the tibia and upper limb less weight is required

Traction modalities

Skin Traction

• Traction is applied to the skeleton through its attached soft tissue and in the
adult should be used only as a temporary measure
• Skin is designed to bear compression forces and not shear
• If much more than 8 lbs is applied for any length of time, it results in
superficial layers of skin pulled off
• Other difficulties such as migration of the bandage may occur with lower
weights

Types of skin traction

Skull Tongs Traction

• Skull tongs are used to immobilize the cervical spine in the treatment of unstable
fractures or dislocation of the cervical spine. Although Crutchfield tongs were used
almost exclusively in the past, Gardner-Wells skull tongs are in wide use. Some think
these are less likely to pull out than the Crutchfield tongs. The patient is prepared for
either type with a local anesthetic to the scalp. The tongs are surgically inserted into the
 bony cranium, and a connector half-halo bar is attached to a hook from which traction
can be applied.
• The patient is supine and is usually on a special frame instead of the regular hospital bed.
If a hospital bed is used, two or more people are required to assist the patient with any
turning movements. The head of the bed may be elevated to provide counter traction.
• Because patients remain in this type of traction for an extended period, observe the
precautions taken for the patient in other types of skeletal traction. Difficulties with the
performance of activities of daily living, infection at the tong sites, and restlessness and
boredom are common. It is useful to teach the patient range-of-motion exercises, provide
good nutrition and suggest recreational or occupational activities.
• Halo Traction
• Halo traction provides stabilization and support for fractured cervical vertebrae. The
surgeon inserts pins into the skull. A half circle of metal frame connects the pins around
the front of the head. Vertical frame pieces extend from a halo section to a frame brace
that rests on the patient’s shoulders. The halo traction allows the patient to be out of bed
and mobile while stabilizing the cervical vertebrae could injure the spinal cord.
•

Skeletal Traction

• First achieved by the use of tongs

• The application of traction applied by a pin transfixing bone was introduced
by Fritz Steinmann
• Now a threaded Denham pin is preferred to prevent early loosening of the
device
• The threaded portion of the Denham pin is offset, closer to the end of the pin
held in the drill chuck and should engage only the proximal cortex of the
recipient long bone

Traction by Gravity

• Only applies to fractures of the upper limb (hanging cast)

Traction categories

Traction on a limb demands either a fixed point from which the traction may be exerted (fixed
traction) or an equal counter-traction in the opposite direction (balanced traction)

Fixed Traction

• The length of the limb remains constant

• There is continuous diminution of traction force, as the tone in the muscles
diminishes and no further stimuli results in activation of the muscle stretch
reflex
 • Pull is exerted against a fixed point, e.g. tapes are tied to the cross piece of a
Thomas splint and the leg pulled down until the root of the limb abuts against
the ring of the splint
• Pins in plaster is a form of fixed traction

Balanced Traction

• In weight traction, it is the tension in the apparatus which remains constant

and the length depends on the amount of tearing of the intermuscular
septum and fibrous tissue of the limb
• The pull is exerted against an opposing force, provided by the weight of the
body when the foot of the bed is raised

Combined Traction

• May be used in conjunction with fixed traction, where the weight takes up
any slack in the tapes or cords, while the splint maintains a reduction
• This combination facilitates less frequent checks and adjustment of the
apparatus

Sliding Traction

• First introduced by Pugh by applying traction tapes to the limb and fastening
them to the raised foot of the bed which was then inclined head down
• He utilised this traction in the treatment of conditions such as Perthes, where
only one limb was fastened to the end of the bed enabling the pelvis on the
opposite side to slide down the bed more; thus creating traction and
abduction
• The extent to which the patient slides down on the bed is limited by the
friction of the body against the mattress
• The traction was subsequently modified by Hendry using a mattress on a
sliding frame, which resulted in the same amount of traction with an
inclination of 10o, as on a normal mattress at 30 - 40o inclination
• This is also really a form of balance traction, where the amount of weight is
determined by the inclination of the bed