Skeletal Traction (Fig. 1.3)
- This is more powerful, with greater fragment control, than skin traction.
- It permits pull up to 15% to 20% of body weight for the lower extremity.
- It requires local anesthesia for pin insertion if the patient is awake.
- Local anesthetic should be infiltrated down to the sensitive periosteum.
- It is the preferred method of temporizing long bone, pelvic, and acetabular fractures until operative treatment can be performed.
- Choice of thin Kirschner wire (K-wire) versus Steinmann pin
- K-wire requires a tension traction bow (Kirschner).
- The Steinmann pin may be either smooth or threaded.
- A smooth pin is stronger but can slide through bone.
- A threaded pin is weaker and bends more easily with increasing weights, but it will not slide and will advance more easily during insertion.
- In general, the largest pin available (5 to 6 mm) is chosen, especially if a threaded pin is selected.
Tibial Skeletal Traction
- The pin is placed 2 cm posterior and 1 cm distal to the tibial tubercle.
- It may go more distal in osteopenic bone.
- The pin is placed from lateral to medial to direct the pin away from the common peroneal nerve.
- The skin is released at the pin’s entrance and exit points.
- Optimally, avoid penetrating the anterior compartment.
- A sterile dressing is applied next to the skin. Sharp ends should be protected.
Femoral Skeletal Traction (Fig. 1.4)
- This is the method of choice for pelvic, acetabular, and many femoral shaft fractures (especially in knees with ligamentous injuries).
- The pin is placed from medial to lateral (directed away from the neurovascular bundle) at the adductor tubercle, slightly proximal to the femoral epicondyle.
- The location of this pin can be determined from the anteroposterior (AP) knee radiograph using the patella as a landmark.
- One should spread through the soft tissue to bone to avoid injury to the superficial femoral artery.
Calcaneal Skeletal Traction
- This is most commonly used with a spanning external fixation for “traveling traction,” or it may be used with a “Böhler-Braun” frame.
- It is used for irreducible rotational ankle fractures, some pilon fractures, and extremities with multiple ipsilateral long bone fractures or compromised soft tissues.
- The pin is placed from medial to lateral, directed away from the neurovascular bundle, 2 to 2.5 cm posterior and inferior to the medial malleolus.
Olecranon Traction
- Rarely used today
- A small- to medium-sized pin is placed from medial to lateral in the proximal olecranon; the bone is entered 1.5 cm from the tip of the olecranon.
- The forearm and wrist are supported with skin traction with the elbow at 90 degrees of flexion.
Gardner-Wells Tongs
- Used for cervical spine reduction and traction
- Unicortical screws are placed into the skull one fingerbreadth above the pinna of the ear, slightly posterior to the external auditory meatus.
- Traction is applied starting with 5 lb and increasing in 5-lb increments with serial radiographs and clinical examination.
Halo
- Indicated for certain cervical spine fractures as definitive treatment or supplementary protection to internal fixation
- Disadvantages
- Pin problems
- Respiratory compromise
- Technique
- Positioning of patient to maintain spine precautions
- Fitting of halo ring
- Preparation of screw sites
- Anterior: above the eyebrow, avoiding the supraorbital artery, nerve, and sinus
- Posterior: superior and posterior to the ear
- Tightening of pins to 6 to 8 ft-lb of torque
- Retightening pins if loose
- Only once at 24 hours after insertion
- Frame as needed
Spanning External Fixation
- Concept of “Damage Control Orthopaedics” (DCO)
- Allows for temporary stabilization of long bones
- Allows for transfer of patient in and out of bed
- Does not foster elevated compartment pressures in affected extremities
- Usually performed in the operating room with fluoroscopy present but can be done at the bedside in emergency settings or the field if necessary
- Half pins can be placed into the ilium, femur, tibia, calcaneus, talus, and forefoot.
- Connected by various clamps and bars
- Traction applied across affected long bones and joints
- Allows for delayed definitive fixation