The misuse of skeletal traction

The misuse of skeletal traction rather than the application of the method itself leads to most of the difficulties associated with it.The greatest danger of the method is infection, which may result from improper surgical technique at the time of application or from subsequent motion of the metal agent used for traction. A method of preventing longitudinal axis motion of skeletal pins is described.The complications of infection are most severe when a hematoma, joint or linear fracture communicating with a major fracture are traversed by a traction pin.Improperly placed pins may result in inefficient traction, pressure necrosis of soft tissues or severe damage to the bone or neighboring epiphyseal areas and joints.The use of metal tongs is condemned, except for traction on the skull.The problem of distraction resulting in delayed union and nonunion is discussed.The hazards associated with the use of multiple points of skeletal fixation and distraction types of apparatus are emphasized. The ambulatory management of patients treated by the incorporation of skeletal pins in plaster is considered dangerous, particularly when weight bearing on the skeletal pins is allowed.     

Skeletal traction for fractures of the femoral shaft in children. A long-term study

Fifty-four children who had been treated with 90-90 skeletal traction for a fracture of the femoral shaft were examined after an average follow-up of 4.3 years. All of the patients were functioning normally and had a symmetrical range of motion of both hips and knees. A limb-length discrepancy of more than thirteen millimeters was found in three of thirty-nine children who were less than eleven years old and in eight of fifteen who were more than eleven years old. Traction pins that were placed obliquely were associated with a statistically significant (p less than 0.01) and predictable difference in the intercondylar angle (axis of the knee joint) as compared with pins that were placed horizontally. The study showed that pins for skeletal traction should be placed parallel to the axis of the knee joint and that fractures in children who are more than eleven years old should be reduced without overriding.     

Percalcar Steinmann's pins fixation of intratrochaner fixation fracture. Clinical observation]

80 cases of intratrochaner fractures were treated by fixation of 4 Steinmann's pins which were 3.5 mm in diameter and inserted percutaneously through the calcar and compression trabeculae and distension trabeculae respectively. They were compared with the cases treated by skeletal traction or fixed by Nail-plate or angle plate. The rate of bony union in fixed position in the percalcar Steinmann's pins group was 83.7%. Normal neck-shaft angle accounted to 53.1% in the traction group. Varus deformity occurred in 16.3% cases of the Steinmann's pins group, and 35.9% cases of the traction group. The deformity was most frequently seen in cases of type IIIa and IV. No fixation failure occurred in the Steinmann's pins group. The Steinmann's pins passing through the outer cortex, calcar and compression trabeculae produced strong fixation and it's direction was in parallel to the weight-bearing line of the hip, with less shearing force and much compression force distributed on the fracture line. The operation was done under local anesthesia. No blood transfusion and early mobilization were the advantages of this method.     

Lower extremity traction pins: indications, technique, and complications

The placement of pins in the lower extremity for the purpose of skeletal traction is a basic skill required by an orthopedic surgeon. These pins are primarily used for the management of fractures and dislocations. Although simple, the insertion and care of these pins can be accompanied by severe complications including damage to neurovascular structures, physeal injury, ligamentous insult, fracture, and infection. We review the techniques of pin insertion at the distal femur, proximal tibia, and calcaneus to provide a foundation for residents and attendings alike so that unnecessary complications may be avoided and proper placement ensured.     

The value of external fixation for unstable pelvic ring injuries

Unstable pelvic ring injuries are severe injuries, with high morbidity and mortality rates. Since 1994, the authors have been using external fixation to treat these injuries. They present the results achieved in a series of 22 cases of unstable pelvic ring injuries admitted to their institution between 1994 and 2001. External fixation was performed in all cases with pins inserted between the anterior superior and the anterior inferior iliac spine. Posterior injuries were treated operatively in four cases and non-operatively in others. The average age of the patients was 32 years (range: 22 to 56 years). According to Tile's classification, there were 10 type B and 12 type C injuries. Functional evaluation using Majeed's score at the time of review showed a mean score of 75.6 (range: 12-100). The pain score was 22.7/30. Radiological results were good in horizontal injuries, with satisfactory reduction of the symphyseal disruption. In vertical shear injuries however, skeletal traction alone did not achieve accurate posterior reduction in four cases, in which internal fixation was required. Anteroinferior placement of external fixation pins appears as a safe technique with a potential for increased stability of fixation. Associated posterior injuries must be treated with direct internal fixation in cases with vertical instability in which heavy skeletal traction has failed to achieve reduction.     

刻槽针内固定治疗股骨颈骨折生物力学研究与临床应用

目的：验证刻槽针治疗股骨颈骨折较普通斯氏针更具有锚固性，方法：通过生物力学试验，采用均质木块与牛股骨按骨折固定方式钉入直径4mm斯氏针与刻槽针，置弹簧拉力试验机上进行拔出力对比，并将刻槽针临床应用于50例股骨颈骨折的治疗，结果：斯氏针在木块上平均拔出力为10．2kg，刻槽针为21．00kg，为斯氏针的2倍，斯氏针在牛股骨上的平均拔出力为5．7kg,刻槽针为14．5kg，为斯氏针的2．45倍，刻槽针临床应用效果良好，结论：刻槽针治疗股骨颈骨折较斯氏针固定牢固，临床应用证实无脱针，折针发生。     

Displaced supracondylar humeral fractures in children. A comparison of results and costs in patients treated by skeletal traction versus percutaneous pinning.

Clinical outcome and treatment cost were compared in 65 children treated by either percutaneous pinning or skeletal traction for displaced supracondylar humeral fractures. Clinical outcome was evaluated by loss of elbow motion and change in carrying angle. Results of treatment were basically equivalent in the two groups and were satisfactory in 90% or more. To determine treatment cost, the authors analyzed factors that vary according to the type of therapy. Cost of treatment was lowest in those who had percutaneous pinning and subsequent pin removal in the office. Compared to this group, the cost of treatment increased by 23% in those who had percutaneous pinning and removal of the pins as a surgical procedure, by 117% in those treated by traction with the olecranon pin inserted in the emergency room, and by 142% in those treated by traction with the olecranon pin inserted in the operating room.     

Osteomyelitis in burn patients requiring skeletal fixation

Deep and severe burns often present with the exposure of musculoskeletal structures and severe deformities. Skeletal fixation, suspension and/or traction are part of their comprehensive treatment. Several factors put burn patients at risk for osteomyelitis, osteosynthesis material being one of them. In order to determine the safety of skeletal fixation, we reviewed all pediatric patients treated with pin insertion during the past 10 years. Forty-one severely burned children (61+/-3% TBSA full thickness burns), had a total of 357 skeletal fixation procedures. Pins were maintained an average of 25.3+/-1.7 days. Thirteen pins (3. 6%) were loose before the expected time of removal, two patients (4. 8%) presented with cellulitis of the pin site and two patients (4. 8%) presented with osteomyelitis. Loose pins, pin site cellulitis, burn wound infection and sepsis were not associated with osteomyelitis. Skeletal fixation in severely burned patients presents with a low incidence of infectious complications. Its use should be considered in patients affected by severe burns that present with exposed deep structures and for positioning purposes. The exact timing for pin removal in burned patients is still to be defined.     

The Effect of Axial Tension on the Load Bearing Capacity of Traction Pins

Skeletal traction is often used in the conservative treatment of fractures. Although a small diameter traction pin causes less trauma, its use is limited by the strength of the pin and the holding power of the bone. Both theoretical analysis and in vitro experiments were conducted to investigate the bending resistance of traction pins subjected to an applied traction force. the results of this study indicate that thin K-wires could be used successfully as traction pins. Excessive bending of these wires could be prevented by applying tension. the possibility of a pin cutting through bone is minimal if the cortical bone structure of the patient is normal. However, further in vivo study is necessary to ascertain whether necrosis might occur due to excessive contact stress between the pin and the bone.     

Chronic osteomyelitis in pin tracks

We reviewed the cases of fourteen patients with chronic osteomyelitis involving a pin track (twelve tibial, one ulnar, and one radial) after either external fixation (thirteen patients) or skeletal traction (one patient). In general, the involved pins had been inserted into cortical bone; in no patient was the pintrack infection in cancellous bone. Treatment consisting of débridement, curettage, open packing, and administration of antibiotics successfully eradicated seven of the eight Staphylococcus aureus infections but failed to cure four of the six gram-negative-rod infections. Repeat curettage with delayed fresh autogenous cancellous bone-grafting was successful in treating the more resistant infections.     

The Effect of Axial Tension on the Load Bearing Capacity of Traction Pins

Skeletal traction is often used in the conservative treatment of fractures. Although a small diameter traction pin causes less trauma, its use is limited by the strength of the pin and the holding power of the bone. Both theoretical analysis and in vitro experiments were conducted to investigate the bending resistance of traction pins subjected to an applied traction force. the results of this study indicate that thin K-wires could be used successfully as traction pins. Excessive bending of these wires could be prevented by applying tension. the possibility of a pin cutting through bone is minimal if the cortical bone structure of the patient is normal. However, further in vivo study is necessary to ascertain whether necrosis might occur due to excessive contact stress between the pin and the bone.     

Technique for achievement and maintenance of reduction for severe spondylolisthesis using spinous process traction wiring and external fixation of the pelvis

A technique is described for achievement and maintenance of reduction for severe spondylolisthesis in conjunction with reconstructive surgery. Spinous-process traction wires exert a posterior and cephalad force on the lumbar spine, while Hoffman pins anchored to the ilium rotate the sacrum in an anterior and caudad direction. Once maximum reduction is achieved, the patient is kept supine for 3 months with pins and traction wires incorporated in a plaster cast. At follow-up, two patients demonstrated excellent correction of slip angle and a solid fusion.     

Comminutive fracture of the trapezium treated by ligamentotaxis. A case report

We report a case of trapezium fracture treated by continuous traction. The fracture involved the trapezium alone and was associated with scapho-trapezium subluxation. Three percutaneously inserted pins were used for traction, one scapho-capitate pin and two pins in the first and second metacarpal bones. This allowed distraction of the entire first row. Good anatomic reconstruction of the trapezium was evidenced radiographically. The functional outcome was quite satisfactory with mobility strictly the same as the healthy side and complete pain relief.     

The mechanics of skull traction calipers

The relationship between the torque applied to the loading screw and the load required to pull off Cone's type of skull traction caliper was established on cadavers. It was found that at a torque of 0.7 Newton metres (Nm), which corresponds to a compressive force of 13 lb (58 N) on the skull, the caliper became detached at the maximum traction load of 60 lb, but still held during this traction load at compressive forces above 18 lb (80 N). Clinically, an instrumented load cell was incorporated into one of the fixing pins on a skull traction caliper and it was found that the compressive load fell on average by 15 per cent over a period of 21 days of traction. Taking into account this fall in load with time and the limiting torque for pull-out with a traction force of 60 lb (265 N) it is suggested, for complete clinical safety, that a compressive load of 20 lb (88 N) obtained at a torque of 0.85 Nm should be applied to the loading screw of a Cone's type of caliper. Using these values in a loading analysis of the securing pins, suggestions are made as to the ideal design of skull traction calipers and the shortcomings of various designs of existing calipers are discussed, in particular the pins' lengths, compressive load and the pins' placement.     

The effect of intra-operative skeletal (skull femoral) traction on apical vertebral rotation

The study design is a retrospective review of consecutive case series. Our goal was to identify and quantify the effect of skeletal traction on the apical vertebral rotation (AVR). Intra-operative skeletal traction has been used for the correction of large magnitude idiopathic and neuromuscular scoliosis. The ability of skeletal traction to correct the rotational deformity of the spine has not been characterized. Following REB approval, retrospective analysis of 22 (AIS = 14, neuromuscular = 8) consecutive pediatric patients having surgical posterior instrumented correction and fusion for their scoliosis was performed. Intra-operative skeletal traction with approximately 50% body weight was achieved with smooth distal femoral pins. Counter-traction up to 25% was used through Gardner–Wells tongs. The AVR of the major curve was assessed using the Nash–Moe grading system by a radiologist and a senior spine surgeon not involved in the treatment of these cases. Statistical analysis was performed to determine the significance. The overall mean AVR of the major structural curve was 3.1 ± 0.8 and reduced to 2.4 ± 0.6 (p = 0.0001) following traction. The AVR decreased by one or more Nash–Moe grades with traction in 14/22 (64%) patients. The Cobb angle corrected from a mean of 88.2° to 49.1° (44.3%, p = 0.00001) with traction. The decrease in AVR correlated with the higher magnitude Cobb angles (correlation 0.53, p = 0.014). Patients with pre-traction AVR ≥ 3 showed the largest change with traction (3.4–2.5, p = 0.000004). There was very good association between the radiologist and the spine surgeon, 0.72(standing films) and 0.63(traction films). The minor structural curve corrected from a mean Cobb of 53.5° to 33.8° (37.8%) with AVR decreasing from a mean of 1.9 to 1.4 (p = 0.014). Significant apical derotation occurs with the use of intra-operative skull-skeletal traction in the correction of high magnitude scoliotic curves. This derotation can facilitate spinal exposure, placement of pedicles screws and final correction in these patients.     

Halo Skeletal Fixation: Techniques of Application and Prevention of Complications

The halo skeletal fixator provides the most rigid cervical immobilization of all orthoses. However, complications such as pin loosening and infection are common. Appreciation of local anatomy and adherence to established application guidelines should minimize pin-related problems. A relatively safe zone for anterior pin placement is located 1 cm above the orbital rim and superior to the lateral two thirds of the orbit. Posterior pin-site locations are less critical; positioning on the posterolateral aspect of the skull, diagonal to the contralateral anterior pins, is generally desirable. Pins should enter the skull perpendicular to the cortex, with the ring or crown sitting below the widest portion of the skull and passing about 1 cm above the helix of the ear. Pins are inserted at a torque of 8 in-lb and retightened once to 8 in-lb at 48 hours. A loose pin can be retightened to 8 in-lb if resistance is met; otherwise, a loose pin should be replaced at a nearby site. Superficially infected pins are managed with local pin care and oral antibiotics. Persistent or severe infections require pin replacement to a nearby site, parenteral antibiotic therapy, and incision and drainage as needed. In-ability to maintain acceptable cervical reduction with a halo fixator is an indication for alternative treatment, such as internal fixation or traction.     

The double pin method in the treatment of fractures of the tibia and fibula

In fractures of the tibia and fibula with displacement, and those that have a tendency toward displacement, the double pin method is indicated. The advantages of this method are: (1) uniformity of procedure; (2) no operative team is necessary. Elaborate technic for reduction of fracture is done away with. (3) In our series, there has been no case of infection at the site of the Steinman pins. (4) Inasmuch as this method produces firm fixation, it has a particular advantage in the treatment of compound fractures. (5) The time and cost of hospitalization have been drastically reduced as compared with previous methods employed. (6) With the use of the double pin method we obtain firm immobilization of the fractured fragments as compared to the previous method of skeletal traction—suspension with one pin through the os calcis.     

Fracture of the tibia complicated by acute compartment syndrome

A consecutive series of 32 patients with tibia fractures complicated by compartment syndrome was treated with fasciotomy. One group was also treated with closed reduction of the fracture and cast immobilization and compared with a comparable group treated with internal fixation without case immobilization after fasciotomy. All other patients were treated with fasciotomy and reduction followed with either external skeletal fixation, pins and plaster, or skeletal traction. Care of the open fasciotomy incisions, observation of the neurovascular status of the limb, and rehabilitation of the extremity were facilitated by internal fixation operations without subsequent external cast immobilization. The anatomic and functional results in this group were better than those treated with fasciotomy and cast immobilization. All fractures were united by 20 weeks. Complications in both groups were similar, although one deep infection, which was resolved with appropriate treatment, occurred in the group treated with internal fixation. Six open tibia fractures were treated with external skeletal fixation after fasciotomy; the results were less satisfactory, but the initial injuries were also more severe in this group. Patients with closed tibial fractures complicated by compartment syndromes should be treated expeditiously with fasciotomy, followed by stable internal fixation.     

Use of a stockinette in closed reduction of distal extra-articular tibia fractures

Tibia fractures are common orthopaedic injuries. One of the most difficult tibia fractures that physicians encounter is the extra-articular distal third fracture. Operative fixation has certain risks depending on the procedure. Intramedullary nails fail to obtain adequate distal locking, and plate fixation increases the risk of soft tissue complications. Therefore, when indicated, closed reduction should be attempted. We have devised a method of applying in-line traction while performing closed reduction and casting with the use of a stockinette. This method avoids many of the problems encountered with other techniques such as calcaneal traction pins and hair splints. With the use of in-line traction through the stockinette, we are able to apply traction throughout casting without assistance, and the procedure is noninvasive.     

持续质量改进在降低下肢骨折患者骨牵引无效率中的应用

目的：下肢骨牵引是骨科常用的治疗手段,骨牵引治疗情况是骨科评价骨科专科护理质量指标之一。本研究通过对持续质量改进,为降低下肢骨折患者骨牵引无效率和提升专科护理品质提供依据。方法将下肢骨折骨牵引患者42例（304人次）按照入院时间分为：对照组[20例（146人次）,2014年6~7月收治]和研究组[22例（158人次）,2014年10~11月收治]。利用自制下肢骨牵引查检表对对照组患者下肢骨牵引情况进行调查,通过柏拉图分析法确定下肢骨牵引无效的主要类型,利用鱼骨图对其原因进行分析。针对分析结果进行持续护理质量改进并对实施持续质量改进的研究组患者进行效果评价。结果对照组的下肢骨牵引无效率为24.66%,研究组为8.86%,差异有统计学意义（P＜0.05）。结论对下肢骨折骨牵引患者进行持续质量改进,可有效地降低骨牵引无效率。