临床医学教学Traction-Casts-JTG.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Closed Reduction Principles,All displaced fractures should be reduced to minimize soft tissue complications,including those that require ORIF,Use splints initially,Allow for swelling,Adequately pad all bony prominences,Closed Reduction Principles,Adequate analgesia and muscle relaxation are critical for success,Reduction maneuver may be specific for fracture location and pattern,Correct/restore length,rotation,and angulation,Immobilize joint above and below,Closed Reduction Principles,Reduction may require reversal of mechanism of injury,especially in children with intact periosteum,When the bone breaks because of bending,the soft tissues disrupt on the convex side and remain intact on the concave side,Figure from Chapmans Orthopaedic Surgery 3,rd,Ed.(Redrawn from Charnley J.The Closed Treatment of Common Fractures,3rd ed.Baltimore:Williams&Wilkins,1963.),Closed Reduction Principles,Three point contact(mold)is necessary to maintain closed reduction,Removal of any of the three,forces results in loss of reduction,Figure from:Rockwood and Green:Fractures in Adults,4,th,ed,Lippincott,1996.,Closed Reduction Principles,Cast must be molded to resist deforming forces,“Straight casts lead to crooked bones”,“Crooked casts lead to straight bones”,Anesthesia for Closed Reduction,Hematoma Block,-aspirate hematoma and place 10cc of Lidocaine at fracture site,Less reliable than other methods,Fast and easy,Theoretically converts closed fracture to open fracture but no documented increase in infection,Anesthesia for Closed Reduction,IV Sedation,Versed-0.5 1 mg q 3 minutes up to 5mg,Morphine-0.1 mg/kg,Demerol-1-2 mg/kg up to 150 mg,Beware of pulmonary complications with deep conscious sedation-,consider anesthesia service assistance if there is concern,Pulse oximeter and careful monitoring are recommended,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 after 10 ply,water 24,C,unusual with fiberglass,Cuts and burns during removal,Keloid formation as a result of an injury during cast removal.From,Halanski M,Noonan KJ.J Am Acad Orthop Surg.2008.,Complications of Casts&Splints,DVT/PE-increased in lower extremity fracture,Ask about prior history and family history,Birth Control Pills are a risk factor,Indications for prophylaxis controversial in patients without risk factors,Joint stiffness,Leave joints free when possible(ie.thumb MCP for below elbow cast),Place joint in position of function,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 5 lbs,More commonly used in pediatric patients,Can cause soft tissue problems especially in elderly or rheumatoid patients,Not as powerful when used during operative procedure for both length or rotational control,Skin Traction-“Bucks”,An option to provide temporary comfort in hip fractures,Maximal weight-10 pounds,Watch closely for skin problems,especially in elderly or rheumatoid patients,Skeletal Traction,More powerful than skin traction,May 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,Traction Pin Types,Choice of thin wire vs.Steinman pin,Thin wire is more difficult to insert with hand drill and requires a tension traction bow,Tension Bow,Standard Bow,Traction Pin Types,Steinmann pin may be either smooth or threaded,Smooth is stronger but can slide if angled,Threaded pin is weaker,bends easier with higher weight,but will not slide and will advance easily during insertion,In general a 5 or 6 mm diameter pin is chosen for adults,Traction Pin Placement,Sterile field with limb exposed,Local anesthesia,+,sedation,Insert pin from known area of neurovascular structure,Distal femur:Medial,Lateral,Proximal Tibial:Lateral Medial,Calcaneus:Medial Lateral,Place sterile dressing around pin site,Place protective caps over sharp pin ends,Distal Femoral Traction,Method of choice for acetabular and proximal femur fractures,If there is a knee ligament injury usually use distal femur instead of proximal tibial traction,Distal Femoral Traction,Place pin from,medial to lateral,at the adductor tubercle-slightly proximal to epicondyle,Figures from Althausen PL,Hak DJ.Am J Orthop.2002.,Balanced Skeletal Traction,Allows for suspension of leg with longitudinal traction,Requires trapeze bar,traction cord,and pulleys,Provides greater comfort and ease of movement,Allows multiple adjustments for optimal fracture alignment,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,4,th,ed,Lippincott,1996.,Proximal Tibial Traction,Place pin 2 cm posterior and 1 cm distal to tubercle,Place pin from,lateral to medial,Cut skin and try to stay out of anterior compartment-push muscle posteriorly with pin or hemostat,Figures from Althausen PL,Hak DJ.Am J Orthop.2002.,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,Medial Structures,Lateral Structures,Figures from Althausen PL,Hak DJ.Am J Orthop.2002.,Olecranon Traction,Rarely used 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,Figure from Chapmans Orthopaedic Surgery 3,rd,Ed.,Gardner Wells Tongs,Used for C-spine reduction/traction,Pins are placed one 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,Left:“Safe zone”for halo pins.Place anterior pins about 1 cm above orbital rim,over lateral two thirds of the orbit,and below skull equator(widest circumference).,Right:“Safe zone”avoids temporalis muscle and fossa laterally,and supraorbital and supatrochlear nerves and frontal sinus medially.,Posterior pin placement is much less critical because the lack of neuromuscular structures and uniform thickness of the posterior skull.,Figure from:Botte MJ,et al.J Amer Acad Orthop Surg.4(1):44 53,1996.,Halo Application,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-lbs.,Retighten if loose,Pins only once at 24 hours,Frame prn,Figure from:Rockwood and Green:Fractures in Adults,4th ed,Lippincott,1996.,References,Freeland AE.Closed reduction of hand fractures.Clin Plast Surg.2005 Oct;32(4):549-61.,Fernandez DL.Closed manipulation and casting of distal radius fractures.Hand Clin.2005 Aug;21(3):307-16.,Halanski M,Noonan KJ.Cast and splint immobilizationcomplications.J Am Acad Orthop Surg.2008 Jan;16(1):30-40.,Bebbington A,Lewis P,Savage R.Cast wedging for orthopaedic surgeons.Injury.2005;36:71-72.,References,Halanski MA,Halanski AD,Oza A,et al.Thermal injury with contemporary cast-application techniques and methods to circumvent morbidity.J Bone Joint Surg Am.2007 Nov;89(11):2369-77.,Althausen PL,Hak DJ.Lower extremity traction pins:indications,technique,and complications.Am J Orthop.2002 Jan;31(1):43-7.,Alemdaroglu KB,Iltar S,imen O,et al.Risk Factors in Redisplacement of Distal Radial Fractures in Children.J Bone Joint Surg Am.2008;90:1224-1230.,Sarmiento A,Latta LL.Functional fracture bracing.J Am Acad Orthop Surg.1999 Jan;7(1):66-75.,Classical References,Sarmiento A,Kinman PB,Galvin EG,Schmitt RH,Phillips JG.Functional bracing of fractures of the shaft of the humerus.J Bone Joint Surg Am.1977 Jul;59(5):596-601.,Sarmiento A,Sobol PA,Sew Hoy AL,et al.Prefabricated Functional Braces for the Treatment of Fractures of the Tibial Diaphysis.JBone and Joint Surg.1984.66-A:1328-1339.,Sarmiento A,Latta LL.450 closed fractures of the distal third of the tibia treated with a functional brace.Clin Orthop Relat Res.2004 Nov;(428):261-71.,Sarmiento A.Fracture bracing.Clin Orthop Relat Res.1974 Jul-Aug;(102):152-8.,Questions,Return to,General/Principles,Index,E-mail OTA,about,Questions/Comments,If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides,please send an e-mail to,otaaaos.org,