G09 crc, traction, casts

Closed Reduction, Traction, and Casting Techniques

Dan Horwitz, MD

Principles of Closed Reduction

• All displaced fractures, including those which will undergo ORIF should be reduced to minimize soft tissue complications

• Splints must respect soft tissue condition – Pad all bony prominences– Allow for swelling

Principles of Closed Reduction

• Adequate analgesia and muscle relaxation are critical for success

• Axial traction and reversal of mechanism of injury• Attempt to correct/restore length, rotation, and

angulation• Reduction maneuvers - often specific for

particular location • Immobilize - joint above and joint below

Principles of closed reduction

Three point contactand stabilization isnecessary to maintainmost closed reductions

Removal of any of the threeforces results in loss of reduction

Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.

Common closed reductions

Distal Radius Longitudinal tractionLocal or regional blockExaggerate deformityPush for length and reversal

of deformityApply splint or cast

Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.

Common closed reductions• Elbow Dislocation - traction, flexion, and

direct manual push

Figures from Rockwood and Green, 5th ed.

Common closed reductions• Shoulder - relaxation, traction, gentle

rotation if necessary

Figures from Rockwood and Green, 5th ed.

Common closed reductionsHip dislocation• Relaxation, flexion,

traction, and rotation• gentle and atraumatic

Relocation should be palpable and permit significantly improved ROM. This often requires very deep sedation.

Figures from Rockwood and Green, 5th ed.

Anesthesia for closed reductions• Bier Block - superior pain relief, greater relaxation,

less premedication needed. Double tourniquet is inflated on proximal arm and venous system is filled with local.– Lidocaine preferred for fast onset – Volume = 40cc– Adults 2-3 mg/kg Children 1.5 mg/kg– If tourniquet is deflated in< 40 min then deflate for 3 sec

and reinflate for 3 min - repeat twice– Watch closely for cardiac and CNS side effects, especially

in the elderly.

Anesthesia for closed reduction

• Hematoma Block - aspirate hematoma and place 10cc of Lidocaine at fracture site– Less reliable– Fast and easy– Theoretically converts closed fx to open fx but

there is no documented increase in infection with these blocks

Anesthesia for closed reduction

• Versed - 0.5-1mg IV q 3 min up to 5mg• Morphine - 0.1mg/kg• Demerol - 1-2mg/kg up to 150 mg

– Beware of pulmonary complications with deep conscious sedation - consider anesthesia service assistance if there is concern

– Pulse oximeter and close nursing supervision are recommended

Common Splinting Techniques

• “Bulky” Jones• Sugartong• Coaptation• Ulnar gutter• Volar/Dorsal hand• Thumb spica• Posterior slab (ankle) +/- U splint• Posterior slab (thigh)

Humerus fracture with coaptation splint in place

•Note the splint ends in the axilla medially and shouldbe well padded there to avoidskin breakdown.

• Also note the lateral aspect of the splint extends over the deltoid.

Figure from Rockwood and Green, 4th ed.

Sugar Tong Splint

• Splint extends around the distal humerus to provide rotational control

• Padding should be at least 3-4 layers thick with several extra layers at the elbow

Fracture Bracing

• Allows for early functional ROM and weight bearing

• Relies on intact soft tissues and muscle envelope to maintain alignment and length

• Most commonly used for humeral shaft and tibial shaft fractures

Humerus fracture convertedto fracture brace at 10 days -Allows for early ROM of elbow with support of fracturevia principle of hydrostaticcolumn.

•Co-contractions•Snug brace during the day•Do not rest elbow on table

NOTE: PATIENT MUST TOLERATE A SNUGFIT FOR BRACE TOREMAIN FUNCTIONAL Figure from Rockwood and Green, 4th ed.

Casting

• Goal of semi-rigid immobilization while avoiding pressure/skin complications

• Often a poor choice in the treatment of acute fractures due to swelling and soft tissue complications

• Extremely technique dependent in order to achieve predictable results

Casting Techniques

• Stockinette - may require 2 different sizes to avoid overtight or loose coverage

• Padding - distal to proximal with 50% overlap - min 2 layers - extra padding at fibular head, malleoli, patella, and olecranon

• Plaster - Cold water will maximize molding time – 6 inch for thigh– 4-6 inch for leg– 4-6 inch for arm– 2-4 inch for forearm

• Fiberglass - width selection generally the same as plaster– more difficult to mold but more resistant to water and

use breakdown– generally 2-3 times stronger for any given thickness

Below Knee Cast

• Support MT heads• Ankle in neutral - apply with knee flexion• Ensure freedom of toes• Build up heel for walking casts - fiberglass

much preferred for durability

Padding for fibular head and plantar aspect of foot

Padded fibular head

Flexed knee

Neutral ankleposition Toes free

Assistant or foot stand required to maintain ankle positionFigure from: Browner and Jupiter: Skeletal Trauma, 2nd ed, Saunders, 1998.

Above Knee Cast

• Apply below knee first• Knee flexion at 5-20 degrees• Mold supracondylar femur for improved

rotational stability• Apply extra padding anterior to patella

Anterior padding

Support lowerleg/cast

Extend to gluteal crease

Figure from: Browner and Jupiter: Skeletal Trauma, 2nd ed, Saunders, 1998.

Forearm Casts/Splints

• MCP joints should be free - do not go past proximal palmar crease

• Thumb should be free to base of MC - opposition to 5th digit should be unobstructed

• Even pressure appliedto achieve best mold

• Avoid molding with anything but the heels of the palm in order to avoid pressure points

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Complications of casts/splints

• Loss of reduction• Pressure necrosis - as fast as 2 hrs• Tight cast/compartment syndrome -

univalving = 30% pressure drop bivalving = 60% pressure drop

Cutting cast padding further reduces pressure

Complications of casts/splints

• Thermal Injury - avoid plaster > 10 ply, water >24C. Unusual with fiberglass

• Cuts and burns during removal• Thrombophlebitis/PE - increases in lower

extremity fracture and immobilization but prophylaxis is debated

• Joint stiffness - leave joints free when possible (ie. Thumb MCP for below elbow cast) and place in position of function when possible

Examples -Position of Function

• Ankle - Neutral dorsiflexion - NO EQUINUS• Hand - MCP flexed (70-90degrees), IP’s in

extension

70-90 degrees

Figure from Rockwood and Green, 5th ed.

Traction

• Allows constant controlled force for initial stabilization of long bone fractures and aids in reduction during operative procedure

• Option for skeletal vs skin traction is case dependent

Skin Traction• Limited force can be applied - generally not to

exceed 10 lbs• Can cause soft tissue problems especially in

elderly or rheumatoid type skin• Not as powerful when used during operative

procedure for both length or rotational control• “Bucks Traction” - soft dressing around calf and

foot attached to weight off foot of bed

Skin Traction - “Bucks”

• An option to provide temporary comfort in intertrochanteric hip fractures

• Max of 10 lbs of traction• Watch closely for skin problems, especially

in elderly or rheumatoid patients

Skeletal Traction• More powerful with greater control than skin

traction• Permits pull up to 20% of body weight for the

lower extremity• Requires local anesthesia for pin insertion if

patient is awake• Preferred method of temporizing long bone,

pelvic, and acetabular fractures until operative treatment can be performed

Skeletal Traction• Choice of thin wire vs Steinman pin - thin

wire is more difficult to insert with hand drill and requires a tension traction bow

TENSION BOWSTANDARDBOW

Traction Pin Selection

• Steinmann pin may be either smooth or threaded – smooth is stronger but can slide if angulated – Threaded pin is weaker, will bend easier with

increasing weights, but will not slide and will advance more easily during insertion.

• In general the largest pin available is chosen, especially if a threaded pin is selected.

Skeletal Traction - Tibial

• Pin is placed 2 cm posterior and 1 cm distal to tubercle - may go more distal in osteopenic bone

• Place pin from lateral to medial, cut skin and try to stay out of anterior compartment - use hemostat to push muscle posterior

• Apply sterile dressing next to skin - consider closing if removed <24 hrs

Skeletal Traction - Femoral• Method of choice for acetabular and proximal femur fracture (esp.

in ligamentously injured knee) • Place pin from medial to lateral at the adductor tubercle - slightly

proximal to epicondyle. • Spread through tissue to bone in order to avoid injury to superficial

femoral artery

Balanced Skeletal Traction

• Allows for suspension of leg with longitudinal traction

• Requires overhead trapeze, traction cord, and pulleys

• Often helpful in initial stabilization of femur fractures in traction

•One of many options for setting up balanced suspension. • In general the thigh support only requires 5-10 lbs of weight.• Note the use of double pulleys at the foot to decrease the total weight suspended off the bottom of the bed.

Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.

Calcaneal Traction

• Most commonly used with a spanning ex fix for “travelling traction” or may be used with a Bohler-Braun frame

• Place pin medial to lateral 2-2.5 cm posterior and inferior to medial malleolus

Olecranon Traction

• Used rarely today• Small to medium sized pin placed from

medial to lateral in proximal olecranon - enter bone 1.5 cm from tip of olecranon and walk pin up and down to confirm midsubstance location.

• Support forearm and wrist with skin traction - elbow at 90 degrees

Gardner Wells Tongs

• Used for C spine reduction/traction• Pins are placed 1 finger breadth above

pinna, slightly posterior to external auditory meatus.

• Apply traction beginning at 5 lbs and increasing in 5 lb increments with serial radiographs and clinical exam

HALO

• Indicated for certain cervical fractures as definitive treatment or supplementary protection to internal fixation

• Disadvantages– Pin problems– Respiratory compromise

HALO• Technique

– Position patient maintaining spine precautions

– Fit HALO ring– Prep pin sites

• Anterior—outer half above eyebrow avoiding supraorbital artery, nerve, and sinus

• Posterior—superior and posterior to ear– Tighten pins to 6-8ft-lb– Retighten if loose

• Pins only once at 24 h• Frame prn

Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.

Questions

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