Traction and orthopedic appliances

321 Pages·2018·27.25 MB·English

'•
Traction and
Orthopaedic Appli?nces
JOHN D.l\1.. STE\\' ART
!>.ti\ (CantJb}, FRCS (EngbnJ}
Cousull2111 01 thop•cdic Surgeon,
Chid;cs1cr, a!'ld \Vunhinc Dis1ric1
Group~ of llospiub.
JEFFREY P. HALLETT
MA (Oxon), FRCS (England)
Consult3nt OnJ1opacdic Surgeon,
·rhe lpswii.:h flospiuls
SECOND EDITION
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CHlJRClllLL LIVINGSTONE
EDINBURGH LONDON i\1.ELBOURNE AND NE\V YORK 1983
CHURCHILL LIVINGSTONE
Medical Divhion or Longman Group Limi1cd
Dimibu1cd in 1he United States of America by
Churchill Livincstone Inc., 1560 Broadway, New Yor~,
N.Y. 10036, and by auociatcd companies,
branches and aprcsentalivcs 1hroughout the world.
~ Lon~m1n Group UmiicJ 1975, 19!1)
All richu reserved. No pm of 1his publication m2y be
reproduced, Slored in a retrieval sysiem, or transmiued in any
form or by any means, electronic, mechanical, phoiocopying,
recording or oiherwise, without the prior permission of 1he
publishers (Churchill Livini;>1onc, Rober! Stevenson llouse,
1·3 Burcr's Place, Lcilh 'l'allt, Edinburgh EH I JAF).
First edition 1975
Second cc.Jilion 1983
\
Reprinted 1985
ISBN 0 443 0200-I 3
Brirish Library Cataloguing in Publirnion Dara
Srewan, John D.M.
Traction and orthopaedic applianccs.- 2nd ed
l. Orthopedic appar>1us
I. Title II. .. hlle11, Jdfay P.
617'}07 R075,S
Library of Congress Caulo,ing in Publica1ion o .. u
Sicwan, John D.M.
Traction and onhopaedie appliances.
Includes bibliographics a.nd index.
I. Orthopedic trac1ion. 2. Onhopcdic
appuatus. I. Hallett, Jerrrcy P.
11. Title. (ONLM: I. Onhopcdic equipment.
2. Traction. WE 26 S849t)
RDH6.T7S7l 198) 617'.) 82-9632
Produced by Longman Group (Fl!) Ltd
Printed in Hong Kong
Contents
I Tr:ic1ion I
2 The Thomas's and Fisk splints 13
3 l'ixcd lr:iction 18
4 Sliding tr:iction 26
5 Suspension of :ippli:inccs 56
6 Spin:il tr;iction 71
7 Spliming for congcni1:.1l disloc:u ion oft he hip 92
8 M:in:igcmcnt ofp:iticnrs in tr:iction 105
9 Prescription ofo n hoses 11!!
10 Spinal orthoscs 129
11 Lower limb orthoscs 151
12 Footwear 171
13 Splinting and casting m:ucrials 195
J.1 l'laster-of·l'aris cas1:; 205
15 Functional bracing 215
16 External skclc:tal fixation 235
17 Wallcing aids 246
18 Crutch walking 259
19 Tourniquets 269
Appcndi': I 287
Appendix 2 293
Index 303
.
.,. . ·. . . ..
~ :
Preface to
the Second Edition
This book is still intended for 1he use of junior doclors and the 01hi:r staff of
orthopaedic and traun1a wards and clinics, who are conc~rned in the d:iy lo day
fflar;agement of p:nients.
1'hc new techniques which have becon1c popular in the treatment of fractures,
trac1ion in the n1anage1nent of fractures of the upper lintb, the prescription of
on hoses and the new 1crminology used in l}l(:ir description, a!i well as the n1any
new casting materials which have been developed, have be-en described. In
addition the previous clt:3ptcrs on ltfa11agen1e11r of JJarienls in 'fn1c1ivn and
1'ourniquets have ln:cn completely rewritccn.
~ wish to thank the n1my people who have assisted us in 1he prcpar:.uion of
1hls edition, in particular 1'1.r G. L. \V. Bonney for his help with the: ch:Jptc:r on
Tourniquets; /viiss J. Thonu.s and A1.rs A. Stickland for their instruccivc criticisn1
of the chapter on Af.a11agem~11l of Patie11ts in Trac1it111; A1r J. Florence for his
assistance with the .unravelling of the tangled v,,•cb of Orthoric lerminology ;i:nd
the prescription of orthosc:s; A1.r P. Sh;iw for shOwi.ng us how surgical fool \Year is
n1ade; and fin;dly the n1any n1anufacturer ~d distributors of the splinting and
casting matt:rialS discussed in Chapter
Bognor Rcgis,_ 1983 J.D.M.S.,
J.P.H.
-
-
Preface to
the First Edition
This book is written primarily for the use of orthopaedic house surgeons and
junior registrars, and of the ,nursing and physiotherapy. staff of accidenr and
orthopaedic wards.
Many of the procedures and appliances described here are in common us:ige.
The details, however, of hoW to carry out these procedures, 1heir contra·
indications and complications, and how to check the various applicances, are nor
available in the standard textbooks. This book is intended to rectify thb: ontlssion
and co be a practical source of instruction in these matters.
I wish to ihank chc many people who h<ive assi-:>tcd me in the preparation of
1his book, in particular Mr W. H. Tuck,. without whose considerable guidance
the chapters on Spinal Supporu, Lower Li1nb Bracing and Footwear would h:ive
been incomplete; Dr J. D.- G. Troup for his help with the section on the
biomechanics of the spine; Mr F. G. St C. Strange and Mr G. R. Fisk who have
kindly helped me in rhc description of their methods of applying traction to the
lower 1irnb; a.nd to the staff of the Physiotherapy Department of che Royal
National Orthopaedic Hospi1al for rheir assistance with the chapters on \~'alking
r\ids .and Crutch \Valking. I also wish to e>cprcss n1y gratitude co Professor R. G.
Burwell who advised me on the original scrip!, to 1\1.r J. Cr;nvford Adan1s \Vho
read the final drafl, and to Dr R. R. Mason for his careful re.a<ling of che proofs.
Bognor Regis, I 974 JD.M.S.
1
•
Traction
\Vhen a limb is pair.ful as a result ofinnan1n1a!ion ofa i0int or a fr::ic1ure ofo11e
of the bones, the con1rolling nlusclcs go into spas1n. 1'hc antagonistic 1nusi:lcs in
a Jin1b are not all equ:illy pov.1erful, vri1h 1he resulc 1h:it \'lhcn muscle spasn1 is
present, the action of the 1nore pow·crful n1usch::s CJll produce a defonni1y \vhich
inay seriously irnpair the future func1ion of the liu1b.
Jnf1ammation of the hip joint conunonly results in a flcx:ion:. adduction :and
lateral rotation deforr11ity tile presence of which causes apparent 1hortt11iug of the
1
affected lower limb.
When the shaft of the femur is fractured at the junction of the upper and
middle thirds, the proximal fragn1ent is flexed and abducted by the pull of the
ilio-psoas and hip abducror muscles respectively, and the dis1al frag1nent !s
adducted by the adductor n1uscles of the thigh. In addition, if apposition of the
fragments is lost, marke<l shonening of the femur occurs.
Traction, when applied to an injured n1t1b, can ovcrcon1e 1he eITect of 1he '
original deforming force, and thus can be use~ 10 reduce a fracture or a
dislocation of a joint (sliding lraction - sec Ch. 4). In addition by overco1ning
1nuscle spasm and, in ccnain traction sy$lems, the effect of gravity, 1raction can
relieve pain and allow the lin1b 10 be rc:sted in the best functiOnal posidon.
Traction also controls mov(:n1c1)t of an injured part of the body and thus aids in
the healing of bone and soft tissues.
METHODS OF APPLY ING TRACTION
To apply traction, a satisfactory grip must~ obtained on a pare of the body. Jn
the case of a limb, the traction force n1ay be app!icd through the skin - skin
tractio,l - or via the bones - skeletal cracrion.
A traction force 1n;iy be ~pplicd cilso to other parts of the body. Pelvic traction
is described in Chapter 4, ;ind spinal lratlion in Chapter 6.
SKIN TRACTION
The traction force is applied over a large area of skin. This spreads the load, and
is inorc comfonable and cfficicnc. In the 1rea1mcnt of fractures, the traction force
I. TIV\CJ JUN ANU UK 1 llUl't\tUH. • 1\1'1'' .IAN\-1:.'>
mus1 be applied only 10 rhe limb di$1:il to the froct1ir.: ~ilc, otherwise the
cClicicncy of the traction force is reduced.
The m:>ximum tracrion weight which can be :applied with skin traction is I Sib
(6. 7kg).. .
Two methods of applying skin trac1ion arc commonly used.
Adhesive skin tractio11
Adhesive s1r:1pping which can be strelched only 1r:insvcrscly is usc<l. The
ncccss:iry apparatus can be assembled. individually, but prep:m:d skin traction
kits for use in at.lulls or children can be obtained commercially.
Elastoplas1 Skin Traction Ki1s• arc available from Smith :ind Nephew Ltd.
Some patients arc allergic to adhesive strapping. For these p;iticnts 01her
prcparatibns which do not utilize :in adhesive containing zinc oxide can be used,
for example Tractac• Uohnson & Johnson Ltd) which uses an acrylic adhesive
and Scion Skin Traction Kit• (Seton Produc1s Ltd). Two other prepar:itions to
which allergic rc?ctions have not bc:cn reported :ire Orthotr;ic• (OEC
Orthopaedic Ltd) and Skin-Trac* (Zimmer, US:\).
APPLICATION OF ADHESIVE STRAPPING
. '• " .
' ' ·:-··:. • t ~ • • ··.':.. , .... • •••••
- Shave the limb (shavin'g is not required.with Tractac. ·.
• Orthotrac and Skin-Trac)• . -. __ ', . . . -:.
-- Prote.ct the malleoll/ulnar h~ad and. radi~(styloid process from.~
fri~tion with a strip-of felt,. foam rubber_9~.=~_few turns of a
· ere.pa or elasticated bandage under the. strapping. ·
- Starting at the ankle/wrist, but leaving a'loop projecting 2
inches {5.0 cm} beyond the distal end of t'he limb to allow
free movement of the foot/fingers, apply the widest possible
~-::~~\s~r-~~Ring to ea~~ ...~ _id~~of; th.e limb ...... ·.i;~~\;_.~ . . . , . _,.,--.:·
~~1.i'(:Lo~e~: limb .. The,st.rappi~9. is .. applied ;to'1.t_t!~~!~te/al and.medial~·!~:
.u~i.1·-' ~spects of. the .li_mb~ On,.the-latera·1 aspect:th~ ·strapping must)::::
IJ ·.~ : • ... _. •• - • .,_ • ' ,. ••••• ~· •• \. ••• , ••; .">. •,·:.• • • .. •{', •
.. : -~~ _li_e) Jigtitly behino, a11cf.i:faralfel to a line' betwe..' en: the lateral ' .~ ~;
: .. malleoius ~nd the greater trocha~ter.~ C?i!h~ rii~'dial aspect ..~ ·~ ..; ..
." the strapping must fie slightly in front of. the_a bove line to · :.
'o(
i)_.',.. encourage medial rotation_ the limb. (f:ig. ·~ 1. 1). . . : .-.·
... ,.,_r_ .:,, .... v· _ ...... ;.. ... ; · ·. . ·;;~ .:.1.,·: • .;.":!,.•• .:--:".- ,.,1,1.;~..._d' ..; v.~•~ ..; ~. . :.~ ... -\.~ ......• ""''"'·..1 ' •..1
. Ag.1.1 Skin tractioo: no1c that on the IJteral side, the str3pping lies slightly behind JmJ
)'lr~lcl lo 2 line bcawccn the 13tcral m31lcolus and the grt31cr troch3ntcr.
'!cc Arpcndiit
~CTION 3
,'. ·::i :u~~W~Ji~itilh:h~t1r~·~i~),~~~~a~1'r1:intdRi &1h~·~n11~~
'•..-!·.:•r••.y' t'•o ~*"~'n ,s,~u:-r~e ,' t h. a, t,,·: ,1 t I. h• e• s! . fla•,t,: ~~.·.:- ;._.. ·!~_ -·1~.•·' ~'O>:<·{ :ii!:-/0. ~: .f.. .•J • v. ' ,. : . -:-1')r.·..: :; ..; :• .-f ~.~ <-t ~7~'
_.-, ~!:'.'.Av6ici boriv ·prom.inences ~"::~-l-ri~1ia61U!tibia1 crest.~iJai~1a:'Ji1na'ifu
.... : . " t!'•:... •• .. ,. • ., . ,. . rl. . .J , . • • • ..1;1
: ·} \. h.~.~-d~;· radial ~et_ylold: proces·s~ •humerel ,_ep1condyles:,:!!l.'·~r,:6) ~ 7'~~f,
- Apply a r::repe or elasticated bandage firmly over the.~.,, ...... •!,.· --~
.
-::_L~ str13pping -starting at the\ankle/wri.~t,!_.8nd continuing.up.:t~+-;;:-/1
'..;;-.,,llffib.(Flg. 1.2). The bandage mu~t not be applied tightly:;:~J:::·,,::::
i
• _.,~' ~•:• ~' :a.'~ 9,,. u'··n d the ~imb. A tight.ba~d• agf:?l n:iay cause skin and . ._.~,~~!_.•~ i "~t[ •=·J• !
\f?••;•.~_Y..~•· -~~:~" ;'.~1.: .'..•: A. .•cv l.at'!.. i¢..•e. a•~- •c•hu hl .a_.~ tr t.n hcaeot.i,. mr. a ep·q sulipic·rr.ae etdaio d;ntersra:i..c.· ~ t.ni o8· n!.:t ·r waee·\.:i 1i.g ;6' :h h· t .f: c :..s:o-:r d«s • :·a ::r ~e:~ ·rpriri·. e"rs; e;·;~, ;<:t:. .. .~;..._ ~, ;~').-%,~.~;~··1:·:•, S~:•- .•;\;.•.: .:.:.-·';:.;.t _.!'... •1 J~!
~~i:. . ..;~v'...:~~'-"···"': .... ._, .. -!. . J.."-··• .,;...Jo1.:_1..L.;6~:;.~:,:,.~ ... • .. .':. -·..:.-... ,~\.,; .; ....L ; ..." _.t-•-.. ;:. ..~ ,:
, .• -,-•• =·"-~j.;,..:!:;","~tY.
_;
Fig. 1.2 Skin 1r2ciion.
No11..adhtsi~ skin traction
Vent foam Skin Traction Bandage• (The Scholl Manufac1uring Co. LtJ) consists
of lengths of soft, ventilated latex foam rubber lamina1ed to a strong clo1h
b:icking. Other non-:idhcsivc skin tr:iction systems arc: Spc:ci:ilist Foam Tr:ic1ion •
Uohnson & Johnson Ltd) and Notac Traction• (Seton Products Ltd). These are
useful on 1hin and atrophic skin, or when there: is sensitivity to adhesive
strapping. They arc applied in 1he same \vay as adhesive s1r:ipping, but as rheir
grip is less secure than that of adhesive scrapping, frcquem reapplic:itions may be
necessary. The traction weight used should not exceed IOlb (4.5kg).
CONTRAINDICATIONS TO SKIN TRACTION
1. Abrasions of the skin
2. Lacerations of tho skin in the area to which the traction is to
be applied
3. Impairment of circulation - varicose ulcers, Impending
gangrene
4. Dermatitis
5. Marked shortening. of the bony fragments, when the traction
weight required will be greater-·than can be applied through
the skin.
•Sec Appendix
4 TRACTION AND ORTHOPAEDIC APPLl/\NCF.S
COMPLICATIONS OF SKIN TRACTION
1. Allergic reactions to the adhesive.
2. Excoriation of the skin from slipping of the adhesive
strapping.
3. Pressure sores around the malleoli and ov~r the tendo
calcaneus.
4. Common peroneal nerve pal.sy. This may result from two
causes.
Rotation ~I the limb is difficult to control with skin traction:
There is a tendency for the limb to rotate laterally and for the
comrnon peroneal nerve to be compressed by the slings on
which the limb rests. Adhesive strapping tends to slide
slowly down the limb .. carrying the encircling bandage with it.,
The circumference of the limb around the knee is greater than
that around the head of the fibula. The downward slide of the
adhesive strapping and bandage is halted at the head of the
fibula. This can cause pressure on the common peroneal
nerve.
SKELETAL TRACTION
For skeletal traction, a metal pin or wire is dri':ltn through the bone. By this
means the traction force is applied directly to the skelc[on (for spinal 1rac1ion~ see
Ch. 6).
Skeletal traction is seldom necessary in the management of upper limb
fracrurcs. It is used frequently in the managcn1ent of lower limb fractures. h may
be employed as a means of reducing orof1naint3ining the reduction of:i fraccurc.
It should be reserved for those cases in which skin traction is contraindic:i:ed. 1\
serious complication of skeletal traction is osteo1nyclitis.
Steinmann pin
Steinmann pins (Steinmann, 1916) 3re rigid stainless sreel pins of varying
lengths, 4 to 6 millimetres in diameter. Afte{ Insertion, a special sti~rup (Bohler,
1929), illustrated in Figure 1.3, is auached to rhe pin. The BOh!er stirrup allO\\'S
the direction of the tracrion to be_ varied without turning the pin in the bone.
Denhc.1tn pin
The Denham pin (Denham, 1972) illustrated in Figure 1.4 is idemical a
10
Stelnrnann pin except for a. short•raiscd thread~d Jcnglh siruated towards the end
held in the introducer. 1'his rhrcadcd portion engages rhe bony cortex and
reduces the risk of the pin sliding. This 1ype of pin is particulorly suilable for use
in canccllous bone, such as rhc c3lcaneus, or in ostcopororic: bone.
TRACTION 5
Fig; l.l BOhlcr stirrup with St<innnnn pin.
Fig. 1.4 Denham pin.
Fag. 1.5 Kirschner wire strainer.