Ovid: Manual of Orthopaedics

Editors: Swiontkowski, Marc F.; Stovitz, Steven D.
Title: Manual of Orthopaedics, 6th Edition
> Table of Contents > 9 – Traction

I. Objectives
Although traction is being used with decreasing
frequency for fracture care in the Western world, a knowledge of these
effective principles is necessary for special indications or situations
in which equipment or expertise is not available or patient
comorbidities do not permit operative intervention.
  • Traction maintains the length of a limb as well as alignment and stability at the fracture site. Treating femoral fractures with fixed skeletal traction is an example.
  • Traction can allow joint motion
    while maintaining alignment of the fracture. For example, the Pearson
    attachment on a Thomas splint allows knee movement during traction
    treatment of a femoral fracture; overbody or lateral skeletal traction
    allows elbow motion while maintaining alignment of a humeral fracture.
  • Traction can overcome muscle spasm
    associated with bone or joint disease. An example is Buck traction,
    which is sometimes recommended for patients with hip injuries.
  • Edema is reduced in an extremity by a traction unit that elevates the affected part above the heart.
II. Essential Materials
The bed must have a firm mattress or a bed board.
Elevate the head or the foot of the bed by using either shock blocks or
the bed’s intrinsic elevation system. Attach an overhead frame,
trapeze, and side rails to the bed so the patient can shift position.
Traction equipment includes bars, pulleys, ropes, weight hangers,
skeletal traction apparatus, and, in some instances, plaster cast
materials. Various figures in this chapter show the type and placement
of equipment about the bed.
III. Skin Traction
  • Skin traction may be used as a definitive method of treatment as well as a first aid or temporary measure. The traction force
    applied to the skin is transmitted to bone via the superficial fascia,
    deep fascia, and intermuscular septa. Skin damage can result from too
    much traction force. The maximum weight recommended for skin traction
    is 10 lb or less, depending on the size and age of the patient. If this
    much weight is used, then discontinue the skin traction after 1 week.
    If less weight is used and if the skin is inspected biweekly, then skin
    traction may be safely used for 4 to 6 weeks. Pediatric patients need
    skin inspection on a more frequent basis.
  • Application
    • Carefully prepare the skin by removing the hair as well as washing and drying the area.
    • Avoid placing adhesive straps over bony prominences.
      If bony prominences are in the area of strap application, cover them
      well with cast padding before the adhesive straps are applied. Always
      use a spreader bar to avoid pressure from the traction rope on bony
    • Make the adhesive straps
      from adhesive tape, moleskin adhesive, or a commercial skin traction
      unit consisting of foam boots with Velcro straps. Place the straps
      longitudinally on opposite sides of the extremity, with free skin left
      between the straps to prevent any tourniquet effect. Attach the free
      ends of these straps to the spreader bar. Hold the straps in place by
      encircling the extremity with an adhesive or elastic wrap. Then apply
      the traction rope to the spreader bar.
    • Support the leg in traction with pillows or folded bath blankets to prevent edema and irritation of the heel.


IV. Skeletal traction
  • Definition. Skeletal traction is applied through direct fixation to bone.
  • Equipment
    • Kirschner wire
      is a thin, smooth wire that is 0.0360 to 0.0625 in. in diameter. The
      advantages of Kirschner wire are that it is easy to insert and that it
      minimizes the chance of soft-tissue damage or infection. The
      disadvantage is that it rotates within an improper bow and can cut
      through osteoporotic bone. These complications are minimized by using
      the proper traction bow. Even though Kirschner wire is small in
      diameter and flexible, it can withstand a large traction force when the
      proper traction bow is used. This special bow (Kirschner bow) provides
      the wire with rigidity by applying a longitudinal tension force (Fig. 9-1).
      If properly placed and not improperly stressed, the wire does not break
      and causes less bone damage than the larger Steinmann pins.
    • Steinmann pins
      vary from 0.078 to 0.19 in. in diameter and come in smooth and threaded
      forms. Because they are large enough to have inherent stability, the
      Steinmann pin bow (Böhler bow), which attaches to these pins, does not
      exert tension along the pin as does the Kirschner traction bow. The two
      types of pins should be readily recognized and used with the
      appropriate bow (Fig. 9-1).
    • Factors to be considered
      • A nonthreaded wire or pin
        is smaller, more uniform, less easily broken, more easily inserted, and
        removed with less twisting than the threaded type. A disadvantage is
        that it can slide laterally through the skin and bone. Even with
        careful attention, it can move enough to disturb the traction or
        predispose to a pin tract infection.
      • The threaded wire or pin
        has stress risers at each thread, breaks more easily, must be larger in
        diameter to gain the same strength, and takes a longer time to insert.
        In inserting a threaded pin, one is tempted to go rapidly with the hand
        drill, which creates an undue amount of heat. On the other hand,
        because the threads prevent lateral slippage of the pin, this type is
        preferable to the nonthreaded variety for long-term (longer than 1–2
        weeks) traction.
    • The wires and pins are available with two types of points. One is a trocar, a blunted point that tends to grind through the bone with relatively little cutting ability. The other is a diamond-shaped point,
      a modified type of drill that passes through bone more easily and with
      less heating. Wires and pins that are dull, sharpened off-center, or
      bent should not be used. These wander during insertion and create a
      hole that is too large.
    • Note that pins and wires are frequently used as internal fixation devices for fractures; such use is discussed in Chap. 10 and the chapter on hand fractures.
  • Pin and wire insertion guidelines
    • Pin or wire insertion is a surgical procedure, so some form of consent
      is needed, at least with a witness in attendance who signs a note in
      the chart attesting that informed consent was obtained. A signed,
      witnessed surgical consent is preferred.
    • Establish the status of neurovascular structures
      before inserting the pins. Placement of the pins requires knowledge of
      the specific anatomy and the location of vital structures. Rule:
      Always start the pin on the side where the vital structures are
      located. This gives better control and better avoidance of these
      structures. For instance, start an olecranon pin on the medial side to
      avoid the ulnar nerve.
    • Skin preparation.
      The skin should be free of signs of infection. Follow aseptic
      procedures, using a topical germicidal antiseptic, drapes, mask, and
    • It is difficult to obtain enough anesthesia
      to block the periosteum completely. Anesthetize the skin and
      subcutaneous tissue with 1% lidocaine on the starting side of the bone.
      Go down to the periosteum with the needle tip and insert enough
      lidocaine around this area to produce some anesthesia. If there is pain
      as the pin is inserted and approaches bone, then inject more


      the pin approximately halfway through the bone, get an idea where it
      will come out, and then anesthetize the opposite side. In a case in
      which the wire penetrates two bones, such as the tibia and fibula, it
      is impossible to anesthetize the area between the two bones. Tell the
      patient ahead of time that this may be painful for a few seconds but
      that as soon as the drilling stops, the pain will cease. If done in the
      emergency department, conscious sedation should be utilized.

      Figure 9-1. Traction bows. When using skeletal traction to treat femoral fractures, the knee is kept in slight flexion (A).
      Proximal tibial traction is reserved for adults. To avoid physeal
      injury in children with resultant recurvation deformity, distal femoral
      traction proximal to the distal femoral physis is used. For larger
      Steinmann pins, a Böhler bow is used (B). The tensioning capabilities of the Kirschner bow allows the use of smaller Kirschner wires (C).
    • Skin incision.
      When starting the procedure, pass the wire or pin through a stab wound
      made with a no. 11 blade. If only a puncture wound is made by


      the pin, then tight
      skin adherence to the pin predisposes to an infection. If an infection
      with abscess does occur, then drain it by extending the stab wound.
      Dress the pin site with sterile 4 × 4s on each side with Betadine
      solution applied.

    • Pins and wires should be inserted using a hand drill
      rather than a power tool. The time saved by using power equipment is
      expended in preparation time. There is also a tendency to use too high
      a speed with power drills and generate too much heat, thereby promoting
      development of bone necrosis around the pin insertion, resulting in a
      ring sequestrum. The smaller the pin and the slower the rotation of the
      hand drill, the faster the pin is inserted. Adequate support of the
      limb from adequate help must be available so that, as the pin is being
      inserted, the limb does not shift and cause the patient further pain.
    • Traction wires or pins are best placed in the metaphysics,
      not in dense cortical bone. Use caution to avoid epiphyseal plate
      damage, which can result in a growth disturbance. In skeletally
      immature patients, the pin should be inserted under fluoroscopic
      control to avoid the physis. In the area of the tibial tubercle, assume
      in female patients younger than 14 years old and in male patients
      younger than 16 years old that the epiphyseal plate is open. Because of
      the risk of physeal injury in the proximal tibia, choose the distal
      femur for skeletal traction in younger patients if possible. Ideally,
      pass the pin through only skin, subcutaneous tissue, and bone. Avoid
      muscles and tendons.
    • Do not violate a fracture hematoma by skeletal wires or pins for traction or else the equivalent of an open fracture will result.
    • Do not penetrate joints
      with traction wires or pins as pyarthrosis can occur. Do not enter the
      suprapatellar pouch with distal femoral wires or pins. Here again,
      inserting the pin under fluoroscopic control can avoid these
    • Points to remember about wire or pin insertion:
      • Chuck the wire or pin so that just 2 to 4 in. are exposed to prevent wandering and bending.
      • Tighten chuck sufficiently to prevent score marks that are sources of metal corrosion and fracture.
      • Be certain the wire does not bend as it is inserted.
      • Use the proper traction bow (Fig. 9-1).
  • Specific areas of insertion
    • Metacarpals.
      Place the wire through the metaphyseal diaphysed junction of the index
      and middle metacarpals. To facilitate insertion, push the first dorsal
      interosseous muscle in a volar direction and palpate the subcutaneous
      portion of the bone. Angle the wire to pass through the index and
      middle metacarpals and to come out the dorsum of the hand, so as to
      preserve the natural arch.
    • Distal radius and ulna. Usually place the wire or pin through both the radius and the ulna. This site is rarely used.
    • Olecranon.
      Take care to avoid an open epiphysis. Do not place the pin too far
      distally because this causes elbow extension, and it is more
      comfortable to pull through a flexed elbow than an extended elbow. Use
      a moderate-sized wire or pin and insert from the medial side to avoid
      the ulnar nerve. Use a very small traction bow.
    • Distal femur.
      Start on the medial side, anterior enough to avoid the neurovascular
      structures. This insertion is best accomplished by placing the pin 1
      in. inferior to the abductor tubercle. If the pin will be used for
      traction on a fracture table for delayed intramedullary nailing, make
      sure it is placed far anterior, off the coronal midline to avoid
      incarceration by the intramedullary nail. Fluoroscopy should be used to
      help the surgeon avoid an open physis.
    • Proximal tibia.
      Place the wire or pin 1 in. inferior and 1/2 in. posterior to the
      tibial tubercle, starting on the lateral side to avoid the peroneal
      nerve. Take extreme care to avoid an open epiphysis; if the anterior
      portion of the proximal tibial epiphyseal plate is violated, genu
      recurvatum can occur.
    • Distal tibia and fibula.
      Start the pin 1 to 1 1/2 fingerbreadths above the most prominent
      portion of the lateral malleolus to avoid the ankle mortise. Insert it


      to the ankle joint and angulate it slightly anteriorly. The surgeon
      should feel the pin pass through the two fibular cortices and then the
      two tibial cortices. Pass the pin through both bones to avoid the
      tendons and neurovascular structures. If the pin is placed too far
      proximally, the foot rests on the bow, and a pressure sore may occur.

    • Calcaneus.
      Generally select a large diamond-point pin. The preferred insertion
      site is 1 in. inferior and posterior from the lateral malleolus or 1
      3/4 in. inferior and 1 1/2 in. posterior from the medial malleolus.
      Because of the position of the tibial nerve, the medial starting site
      is preferred. If the pin is placed too far posteriorly, it causes a
      calcaneal position of the foot. If the pin is placed too far
      inferiorly, it may cut out of the bone. If the pin is placed too far
      superiorly, it can enter the subtalar joint and also spear the flexor
      tendons or tibial nerve and/or artery. Infections that are difficult to
      treat often occur when the calcaneus is used for long-term traction.
V. Cervical Spine Traction
  • Neck halter traction
    is the simplest of the different types of cervical spine traction but
    usually is not used in the treatment of acute cervical spine fractures
    or dislocations, being reserved for chronic conditions such as a
    cervical radiculopathy. Apply the traction to the mandible and occiput
    with a soft, commercially made halter.
    • When continuous traction
      is used with the patient in the supine position, do not exceed 10 lb (5
      lb is usually sufficient). With the patient sitting, approximately 8 lb
      may be added to the attached weight to account for the weight of the
      head. The total attached weight should not exceed 15 lb with the
      patient in the sitting position. The traction should not be strictly
      continuous but used for 1 to 3 hours followed by rest intervals to
      allow jaw motion and to relieve pressure on the skin.
    • If intermittent traction for short periods of time is used three times daily, then up to 30 lb may be used.
    • Problems
      associated with head halter traction are related to the weight used and
      the position of the neck. The optimum position is usually neutral or in
      slight flexion. Temporomandibular joint discomfort can ordinarily be
      relieved by changing the direction of traction force or decreasing the
      attached weight. Symptoms from local skin pressure may be relieved by
      the above methods or by appropriate padding.
  • Skull tong traction is a form of cervical spine traction and is applied by one of the many types of skull calipers (tongs) (Fig. 9-2). The most satisfactory caliper is


    screwed into the skull without the need for previous trephining and
    does not penetrate more than a preset depth. The Gardner-Wells tongs
    are recommended (Fig. 9-3) (1).
    With this type of apparatus, heavy traction can be applied to the skull
    for as long as required. It is especially useful for cervical spine
    fractures and dislocations. Perform the following procedures after the
    scalp is cleaned and draped; local shaving is sufficient but is not
    absolutely mandatory.

    Figure 9-2.
    Tong traction. This treatment is used for most cervical fractures and
    dislocations. The points are positioned just above the ear pinnae.
    Padding can be used to generate more flexion or extension of the
    cervical spine as is indicated for reduction based on lateral cervical
    Figure 9-3. Gardner-Wells tongs.
    • The Gardner-Wells skull traction tongs
      are easy to insert. After preparing the skull, position the tongs below
      the temporal crest and tighten. A spring device within the tong points
      automatically sets the correct depth and tension. Then the indicator
      protrudes 1 mm from the knob of the tong, at which time the correct
      pressure (equivalent to 6–8 in./lb) is exerted. Retighten these pins in
      a sequential manner to the same value the next day, and then do not
      tighten them again unless loosening occurs.
    • Keep the head end of the frame slightly elevated so the patient’s body acts as countertraction.
    • Initiate cervical traction at 10 to 15 lb
      and incrementally increase only after checking the appropriate
      roentgenograms. Initiating traction at higher weights can occasionally
      result in marked distraction of ligamentous injuries. For definitive
      traction, Crutchfield’s rule of 5 lb/level starting with 10 lb for the head allows for a maximum range of 30 to 40 lb for a C5–C6 injury.
  • Fixed halo skull traction. The halo device, originally introduced by Nickel and Perry (2,3), can be used alone for traction or combined with a vest or cast.
    • Materials
      • Halo ring
        (five standard sizes available). Carbon fiber rings are preferred
        because radiographs and magnetic resonance imaging (MRI) scans can be
        obtained without distortion.
      • Five skull pins (one spare included)
      • P.143

      • Two torque screwdrivers
      • Four positioning pins
      • A wooden board (4 × 15 × 1/4 in.)
    • Application procedures are modified from those described by Young and Thomassen (4) and Botte et al (2).
      • Shave and trim hair
        around the pin sites (optional). The pin sites should be 1 cm above the
        lateral third of the eyebrow and the same distance above the tops of
        the ears in the parietal and occipital areas. Place the halo just
        inferior to the greatest circumference of the head (Fig. 9-4).
        Figure 9-4. Principles of a halo ring application. The correct ring size allows for 1.5 cm of clearance (A). Positioning pins are used to stabilize the ring while the skull pins are inserted (B). The proper position of the ring is 1 cm above eyebrows and ear pinnae (C, D).
      • P.144

      • Position the patient supine on a bed with the head extended beyond the edge. Have the head supported by an assistant’s hands or by a 4-in. wide board placed under the head and neck.
      • Place a sterile towel under the patient’s head. This step is not necessary if an attendant is holding the head.
      • Select a halo ring that allows for 1.5 cm clearance. If MRI studies are anticipated, then an MRI-compatible ring and pins must be used (carbon fiber material).
      • The halo ring, skull pins, and positioning pins should be autoclaved or gas sterilized.
      • The assistant, wearing gloves, positions
        the halo ring around the head with the raised portion of the ring over
        the posterior part of the skull. Use positioning pins and plates to
        place the ring in the proper attitude and to equalize the clearance
        around the head.
      • Infiltrate the skin with an anesthetic at the four pin sites.
      • The skull pins
        should be at a 90-degree angle to the skull and turned to finger
        tightness. The skull pins are designed so that no scalp incisions or
        drill holes are needed. The shape of the point draws the skin under it
        and does not cause bleeding. Try to avoid puckering of the skin at the
        pin site. If puckering does occur, then remove the pins, flatten the
        skin, and repenetrate.
      • Both operators use the torque screwdrivers
        simultaneously, turning opposing skull pins. Gain increments of 2
        in./lb evenly up to the maximum desired by the physician. A suggested
        maximum is 4 1/2 in./lb for children and 6 to 8 in/lb for adults.
      • Remove the positioning pins.
      • Incorporate the support rods of the halo apparatus into the plaster body jacket, as shown in Fig. 7-5, or use a sheepskin-lined molded plastic body jacket that is commercially available or custom made by an orthotist (Fig. 7-6).
      • Tangential roentgenographic views
        of the skull or a computed tomography (CT) scan can be ordered to check
        the depth of the skull pins but are not routinely necessary.
    • Care of pin sites
      • Clean around the pins with peroxide solution using a cotton swab twice daily.
      • Check the torque of the pins for the first few days. Note:
        If the patient complains of repeated looseness or if the proper torque
        cannot be gained, then move the pin to another place on the ring by the
        aforementioned method. Do not remove a loose pin until the fifth
        replacement pin is inserted.
VI. Upper Extremity Traction
  • Dunlop or modified Dunlop skin traction. This type of traction is occasionally useful for the management of supracondylar humeral fractures (5).
    Place the patient supine and suspend the arm in skin traction with the
    shoulder abducted and slightly flexed. In addition, slightly flex the
    elbow. Modification of this type of traction provides counteraction on
    the humerus, which can be achieved with the arm over the edge of the
    bed and counterweight suspended from a felt cuff over the humerus, or
    with a felt cuff over the forearm pulling laterally with the elbow
    flexed (Fig. 9-5).
    Two disadvantages of Dunlop traction are that it cannot be applied over
    skin injuries and that elevation of the humeral fracture above the
    level of the heart is not possible with this method.
  • Overbody or lateral skeletal traction
    • In the management of extraarticular
      humeral shaft and metaphyseal fractures, it is occasionally desirable
      to maintain the shoulder in flexion without abduction but with the
      elbow at a right angle by placing the arm over the body. Maintain this
      position through olecranon skeletal traction, which allows some flexion
      and extension of the elbow if the traction pin is properly inserted.
      Because the


      and wrist usually tire in this position, support the wrist with a
      plaster splint. Skeletal traction through the olecranon may also be
      used in the lateral position (Fig. 9-6).

      Figure 9-5.
      Modified Dunlop traction. A weight of 1 to 5 lb is usually required.
      Associated circulatory embarrassment might be aggravated by increasing
      elbow flexion.
    • A special, rarely used adaptation of upper extremity olecranon traction may be made by placing the patient in a shoulder spica cast
      that incorporates an olecranon pin into the plaster to apply fixed
      skeletal traction. This adaptation allows the patient to be ambulatory.
VII. Lower extremity traction
  • Apply Buck extension skin traction (Fig. 9-7)
    to the lower extremity to reduce muscle spasms about the knee or hip.
    However, do not use this form of traction for back conditions. Control
    rotation to some extent by placing the leg on a pillow with sandbags on
    the lateral side of the ankle. Although Buck traction is commonly
    recommended for hip fractures, its use should be limited in duration.
    For intracapsular fractures, keep the hip flexed to increase hip
    capsule volume and thereby limit pain. The effectiveness of this type
    of traction in decreasing pain has not been demonstrated (6,7).
  • Hamilton-Russell traction (Fig. 9-8)
    may be used for hip or femoral fractures, especially in children
    weighing 40 to 60 lb. Accomplish the traction with either skin traction
    or distal tibial skeletal traction plus a sling placed beneath the
    posterior distal thigh (avoid pressure in the popliteal fossa). A rope
    is attached to the sling and goes first to an overhead pulley, then to
    a pulley at the foot of the bed, next to a pulley on the foot plate
    attached to the spreader bar, then to a fourth pulley at the end of the
    bed, and finally to the attached weight. Analysis of the vector forces
    shows that the traction applied to the leg is increased considerably by
    moving the overhead pulley toward the foot of the bed. If this type of
    traction is used on a child, one usually attaches 3 lb to the traction
    apparatus. Produce a countertraction with the patient’s body weight by
    elevating the foot of the bed.
    Figure 9-6. Olecranon pin traction. A:
    Overbody traction. Note that the elbow joint can move without
    disturbing the fracture. The hand and wrist rest in a plaster splint. B: Lateral traction.
    Figure 9-7.
    Buck extension skin traction. Note elevation of the foot of the bed and
    support under the calf. Protect the fibular head and malleoli. A weight
    of 5 to 7 lb of traction is sufficient.
    Figure 9-8.
    Hamilton-Russell traction. Note that the resultant force on the femur
    is a summation of vector analysis and depends on the position of the
    overhead pulley. Change the angulation of the distal fragment by moving
    the single overhead pulley.
  • P.146



  • Split Russell traction
    has the same indications and vector forces as Hamilton-Russell
    traction. The difference is that split Russell’s traction uses two
    separate ropes and weights, as shown in Fig. 9-9.
  • Charnley traction unit (boot) is useful for applying skeletal traction to a lower limb and is recommended for routine use (Fig. 9-10).
    This limits rotational forces on the limb controlling alignment,
    maintains the ankle in neutral position, and limits the stress on the
    traction bow. The unit is assembled by inserting a wire or pin through
    the proximal end of the tibia and then incorporating the wire or pin in
    a short-leg cast. The advantages are as follows:
    • The foot and ankle are maintained in a neutral functional position.
    • The limb is suspended in a cast, and there is no pressure on the calf muscles or peroneal nerve.
    • Movement of the skeletal pin or wire is reduced to a minimum.
  • Balanced suspension skeletal traction
    provides a direct pull on either the tibia or the femur through a wire
    pin. Rest the lower extremity on a stockinet or a cloth towel stretched
    over a Thomas splint. The splint, with or without a Pearson attachment,
    is balanced with counterweights to suspend the leg in a freely floating
    system. Attach separate suspension ropes to both sides of the proximal
    full ring


    splint, run the ropes through overhead pulleys, and fasten weights to
    ropes at either end of the bed but not over the patient. Control
    rotation of the ring by individually adjusting the amount of attached
    weight. Suspend the distal end of the splint from a single rope to an
    overhead pulley, with the weight attached to the rope at one end of the
    bed. For safety reasons, place no weights over the patient. Control
    rotation of the extremity by a light counterweight attached to the side
    of the splint or by a crossbar attached to the plaster cast. The
    Charnley traction unit (boot) is ideally suited for both balanced
    suspension and fixed skeletal traction (which is discussed next) (Fig. 9-11). A Pearson attachment
    allows for flexion motion of the knee joint, which is an advantage,
    especially for those in traction for a long period of time or for those
    who have a comminuted tibial plateau fracture.

    Figure 9-9.
    Split Russell traction is the same as Hamilton-Russell traction except
    that two separate ropes and weights are used instead of one.
    Figure 9-10.
    Charnley traction unit consisting of a skeletal wire or pin
    incorporated into a short-leg cast, which has a crossbar fixed to the
    sole. The unit is commonly employed for femoral fractures treated with
    skeletal traction.
    Figure 9-11.
    With balanced suspension traction, the various weights are adjusted
    until satisfactory alignment and suspension of the femoral fracture are
    achieved within the Thomas splint. Note the Charnley traction unit,
    firm mattress, bed board, and master pad. Wrap an elastic bandage about
    the thigh and splint to minimize the acute swelling.
  • P.150

  • Use fixed skeletal traction
    in the initial treatment of femoral fractures in patients who will go
    on to intramedullary nailing or who need to be transported either in
    the hospital or to another facility.
    • In the rare situation in which the fracture must be reduced, the apprehensive patient or the patient with a transverse fracture usually requires general or regional anesthesia.
    • Apply the Charnley traction unit to the lower leg.
    • Select a full or half ring Thomas splint that is 2 in. greater than the proximal thigh (8).
      This leeway is critical because a ring that is too tight causes distal
      edema and one that is too loose is ineffective. The ring must fit
      against the fibrofatty tissue in the perineum and the medial arch of
      the buttocks. The half ring is placed against the ischium and the strap
      tightened loosely against the anterior thigh.
    • While the leg is supported in traction, place the ring on the limb. Attach a single master sling
      of nonextensible cloth (a double-thickness cloth towel is ideal)
      measuring 6 to 9 in. long to the splint beneath the fracture. Adjust
      tension to support the limb. If the sling is too tight, then it causes
      excessive flexing of the proximal fragment; if it is too loose, then it
      does not control the fracture. Attach this sling to the splint with
      several clamps.
    • Make a supporting or master pad that is 1
      to 1 1/2 in. thick and 6 to 9 in. long from an abdominal dressing or a
      folded towel. Insert a safety pin into the pad to assist localization
      of the pad on roentgenograms. Place this pad beneath the fracture and
      adjust it to maintain the normal anterior bow of the femur. A single
      sling is placed on the Thomas splint distally to support the short-leg
    • Check the reduction.
      End-on reduction for transverse fractures is ideal in the adult; take
      care to avoid distraction of the fracture. If the patient will have
      delayed intramedullary nailing, maintain some distraction, which will
      aid in intraoperative reduction. In the child, bayonet apposition is
      preferred. With the oblique fracture, it is important to feel
      bone-on-bone contact to be certain there is no soft-tissue
      interposition. If there is interposition, then it can usually be
      dislodged by manipulation. Then assess length, alignment, and
      rotational positions and attach traction to the end of the splint.
      Extend two ropes from the Steinmann pin around the sides of the splint
      and attach them to the splint end. Tape two tongue blades together to
      form a Spanish windlass to adjust tension. After the first day or two,
      when muscle spasm subsides, only slight traction is necessary to
      maintain the appropriate alignment. It might not be possible to gain
      full length initially because of unusual tense swelling of the thigh.
      Attach a second pad or C-clamp to add cross-traction if needed for
      better alignment, particularly in the more transverse fracture patterns.
    • Suspend the splint to allow patient mobility in bed and to reduce edema. Figure 9-12 depicts the completed setup.
    • Follow-up care,
      particularly in the first few weeks, is important. Wash the skin
      beneath the ring daily with alcohol, dry thoroughly, and powder with
      talc every 2 hours. The conscious patient may perform this care each
      hour and massage the skin to improve blood supply. If it is necessary
      to relieve skin pressure under the ring, then apply traction directly
      from the end of the splint; slight distraction is preferred when
      intramedullary nailing is to be delayed for more than 24 hours. Be
      careful, however, not to cause distraction at the fracture site when
      using fixed skeletal traction as the definitive treatment. Start
      quadriceps exercises within the first few days and continue on an
      around-the-clock basis. All the elements outlined earlier are essential
      for effective utilization of fixed skeletal traction.
VIII. Complications of Skeletal Traction
  • An infection
    of the pin tract is a common complication, but its incidence is reduced
    when the previously stated guidelines for pin and wire insertion are
    carefully followed. If an infection with a small sequestrum occurs, it
    is wise to


    the pin, curette the pin tract, and replace the pin in the operating
    room under adequate anesthesia. The infection usually subsides
    satisfactorily with antibiotic therapy.

    Figure 9-12.
    Fixed skeletal traction. Note the Charnley traction unit, the method of
    adjusting traction force via the windlass, the position of the master
    pad, and the traction on the end of the Thomas splint to relieve skin
    pressure on the proximal thigh. Place an elastic bandage around the
    thigh and splint to help control edema.
  • Distraction
    of bone fragments at the fracture site is avoided by frequently
    measuring extremity length, by using roentgenograms to check the
    position of fragments, and by keeping traction to a minimum.
    Distraction is best assessed by lateral roentgenograms because
    anteroposterior roentgenograms may not be perpendicular to the fracture
    and may underestimate the distraction. Distraction can predispose to a
    delayed union or nonunion of the fracture.
  • Use heavy traction with care and close observation to avoid nerve palsy. If paralysis does occur, adjust and possibly abandon the traction.
  • Pin breakage
    is unusual but can occur if very heavy traction is used for long
    periods, especially in a restless patient. To protect the pin,
    incorporate it into plaster in the manner of the Charnley traction
    unit. Decrease the potential of metal corrosion and fracture by using a
    wire or pin that is not scored.
1. Gardner W. The principle of spring-loaded points for cervical traction. J Neurosurg 1973;39:543–544.
2. Botte
MJ, Byrne TP, Garfin SR. Application of the halo device for
immobilization of the cervical spine utilizing an increased torque
pressure. J Bone Joint Surg 1987;69A:750.
3. Garfin SR, Botte MJ, Enteno RS, et al. Osteology of the skull as it effects halo pin placement. Spine 1985;10:696–698.
4. Young R, Thomassen EH. Step-by-step procedure for applying a halo ring. Orthop Rev 1974;3:62.
5. Prietto CA. Supracondylar fractures of the humerus. A comparative study of Dunlop’s traction versus percutaneus pinning. J Bone Joint Surg 1979;61:425–428.
6. Finsen V, Borset M, Buvik GE, et al. Preoperative traction in patients with hip fractures. Injury 1992;23:242–244.


7. Jerre R, Doshé A, Karlsson F, et al. Preoperative skin traction was not useful for hip fractures. J Bone Joint Surg 2001;83:303.
8. Henry BJ, Vrahas MS. The Thomas splint: questionable boast of an indispensable tool. Am J Orthop 1996;25:602–604.
Selected Historical Readings
Charnley J. The closed treatment of common fractures, 3rd ed. Baltimore, MD: Williams & Wilkins, 1972.

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