Chapter 6

Principles of Orthopaedic Traction Systems

by G.K. ROSE, OBE, FRCS and E.R.S. ROSS, FRCS, FCS

THE TRACTION SYSTEM

Traction means the act of exerting a pulling force and the example of a tractor pulling a plough is easy to
understand. When traction is used clinically it must be understood as part of a system of forces. Only if
the physiotherapist has an understanding of all the forces which comprise this system can she appreciate
the way in which it acts and, importantly, the parts of the system it is permissible to move temporarily for
necessary therapy. This means that the system should be as effective when it is left as it was when
approached.
The essential components of such a system are:
1. A traction force which is a vector quantity having both magnitude and direction.
2. Counter-traction. This is a second reactive force used to localise the effect of the first to a desired
area.
In order to pull out the cork a bottle can be held by its most convenient part, the shoulders. Suffice
that the counter-force acts beyond the point at which the corkscrew acts (Fig. 6/1). Personal experience
shows that the resultant has been.localised to the chosen area, the cork, and that this begins to move when
the friction between the cork and bottle is exceeded.

Traction force

In relationship to the part being treated, force may be generated internally or externally:
1. Internally from muscle activity, either spasm or voluntary contractions (Fig. 6/2).
2. Externally from gravity, i.e. the use of a weight; a part of the body
PRINCIPLES OF ORTHOPAEDIC TRACTION SYSTEMS

109

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d
if
:h
i,
e
Id
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Fig. 6/1 Traction and countertraction

Fig. 6/2 The force F generated by muscle spasm will tend to cause the femoral shaft fracture to overlap and therefore
shorten. The force to maintain the length is localised at the fracture site by traction force F and counter taction Fx. Note
that angulation of the fracture is caused by force G (gravity) and this is resisted by G +Gz • • • Gn, from appropriately
placed slings

Y
(Fig. 6/3); or a bag of water or sand (Fig. 6/4). Because, initially, this weight pulis downwards,
the force engendered may be changed in direction by a fixed pulley. A movable pulley or
pulleys may be used to gain mechanical advantage (see Fig. 6/6).
Additionally, gravity will have a direct action on the part being treated (Fig. 6/2).
110 PRINCIPLES OF ORTHOPAEDIC TRACTION SYSTEMS

Fig. 6/3 Gallows traction. Traction is provided by part of the child's weight. Care must be taken to see that the buttocks
are therefore clear of the bed, Counter-traction is provided by the rigid stand attached to the bed, which in turn pushes
against the floor

Fig. 6/4 Weight F pulling downwards is translated via pulley (P) into a transverse force. Counter-traction is Fbw
deriving partly from body-weight as this slides down the sloping bed, moderated by friction

Countertraction

This may also use gravity, or it may be provided by two fixed points joined together against which these forces react;
the classic example is the Thomas' bed knee splint (Fig. 6/5).
PRINCIPLES OF ORTHOPAEDIC TRACTION SYSTEMS 1 11

Fi. 6/5 Fixed traction. (A) The force is generated entirely by the muscle spasm around the
fracture; this pulls against the splint end (F), and the counter-traction is at Fx with pressure
against the ischial tuberosity. (B) Pressure against the ischial tuberosity can be alleviated
initially by using Fbw from sliding traction of the body-weight- this must not exceed the force
F or distraction will occur

Clinical uses of traction systems

1. The reduction and maintenance of the fracture position (Fig. 6/2).

2. The reduction of muscle spasm, and therefore pain, in inflammatory joint disease or
fractures.
3. The correction of fixed deformities.
(a) The use of external gravitational forces as in the Agnes Hunt system for the reduction
of a flexion deformity of the knee in rheumatoid arthritis, with simultaneous correction
of the posterior tibial subluxation (Fig. 6/6).
(b) The use of internally generated muscle force, e.g. in the Milwaukee spinal orthosis
(see Fig. 15/12, p. 286). Active extension of the cervical spine, pressing the occiput
downwards against the posterior support produces longitudinal traction.

TRACTION FOR FRACTURES

I the treatment of fractures two forms" of traction (often in ombinadon) are used.
112 PRINCIPLES OF ORTHOPAEDIC TRACTION'SYSTEMS

Fig. 6/6 Agnes Hunt traction for a knee-flexion contracture. By using a system similar to the Hamilton
Russell the longitudinal straightening force (F) is applied and this equals 2W. A force (S) pressing down
on the knee derives from the extension of the cord through a sling transverse over the knee; this in turn
tends to press the knee straight, but at the same time a reactive force (T) from a sling presses upward
against the head of the tibia tending to reduce the subluxation

Sliding traction (Fig. 6/4)

In this illustration traction is applied to a fractured femur in a Thomas' splint. The weight F opposes the
action of the muscles around the fracture which would cause it to overlap while counter-traction localising
the force to this site is FBW = body-weight. The problem with this form of traction is that as the muscles
providing the internal force waste, and, therefore, weaken, the force F is greater than this and the fracture
will distract, i.e. separate, and non-union is more likely. It needs careful regulating with progressive
reduction of F.

Fixed traction (Fig. 6/5A)

This is a self-contained system with only one initial force, i.e. that generated by the muscles which pull
against the end of the splint at F. Counter-traction is provided by the ring against the ischial tuberosity
(Fx). S is a screw to pull the fracture just to length, and the force in the system can be measured by using a
spring balance SB to pull on the
 PRINCIPLES OF ORTHOPAEDIC TRACTION SYSTEMS 113
|ttachment. When this just separates from the splint the force can be read off the spring balance. In the
early stages, i.e. the first week, this will be very high and commonly the foot of the bed is raised. An
element of sliding traction is now inlzoduced from body-weight (Fig. 6/5B) (moderated by friction on the
bed) ff the splint is fixed to the end of the bed to provide counter-traction. Always providing that this ding
traction is less than that in the splint, pressure on the ischial tuberosity will be reduced without distracting
the fracture. For this reason the force in the splint is measured daily and as it drops, and it does this quite
sharply in 7 to 14 days, the sliding traction element is removed by levelling the bed.
In both systems gravity acting directly tends to bow the fracture downwards and must be resisted by
carefully adjusted slings (Fig. /2).
A more directly applied form of fixed traction is an externalfixator tting skAetal traction and
counter-traction (Fig. 6/7).

6/7 External fixation. Traction can be produced locally by the threaded bars

This covers the elements of traction but confusion sometimes occurs because of the presence of
many cords and pulleys used for a different reason.
In Figure 6/8 two cords run from the top of the Thomas' splint to the bottom. These are suspension
cords. Likewise are the two cords
114 PRINCIPLES OF ORTHOPAEDIC TRACTION SYSTEMS

Fig. 6/8 A Thomas' bed knee sprint with an articulated segment allowing knee flexion. Sliding
skeletal traction is applied through the upper end of the tibia. The whole device is then
suspended by cords and pulleys; from these pulleys the cord passes over a pulley at the end of
the bed and the whole leg plus the apparatus is counter-balanced by a weight- this plays no part
n the traction system

running from the bottom of the main splint to the Pearson knee-piece on which the leg lies.
These cords are not an essential part of the traction system. However, by suspending the injured
part plus the splint in the air the patient can move more freely. This reduces the possibility of
pressure sores, aids nursing care and allows the physiotherapist to perform her task more easily.

FIXATION METHODS

Apart from 3b, page 111, all forms of traction require a satisfactory attachment to the part to be
treated: two forms are used, skin or skeletal.

Skin traction
This is obtained by using friction between the skin and a material bandaged to it to transmit the
force to a part (Fig. 6/3). The traction
n or

erial
cfion

PRINCIPLES OF ORTHOPAEDIC TRACTION SYSTEMS 115

force must be spread over a large area of skin. This reduces the force per unit area or the load on the skin
which reduces the danger of damaging the skin. The material used is adhesive or non-adhesive. Adhesive
strapping, e.g. Elastoplast, gives a better grip than non-adhesive strapping such as Ventfoam. However,
patients may be allergic to adhesive strapping, and a severe allergic response precludes its use. In general,
non-adhesive strapping tends to be non-allergic. Although 6.Skg (151b) can be applied through skin
traction, in practice it is used only where much smaller weights are required. Care must be taken not to
extend strapping above the fracture site. This will reduce or abolish the effect.

CONTRAINDICATIONS
Skin traction should not be used:
(a) where there are abrasions or lacerations;
(b) where there is circulatory impairment, e.g. varicose ulcers;
(c) where there is atrophic skin, e.g. patients on prolonged steroid
therapy.

COMPLICATIONS OF SKIN TRACTION

1. Allergy to components in the strapping.
2. Skin excoriation.
3. Pressure sores. These occur at prominent bony points, e.g. the malleoli and attachment of the tendo
calcaneus.
4. Common peroneal palsy. This may occur if the bandaging holding the longitudinal strapping rolls up
and forms a tight ring around the upper fibula.

Skeletal traction

A rigid metal pin or tensioned wire is driven into or through bone. The traction force is applied directly to
the skeleton (Fig. 6/9). Some commonly used devices are shown in Figure 23/13, page 463. A Steinmann
pin is a sturdy 4-6mm diameter stainless-steel rod with a trocar point to allow easier penetration of bone.
The Denham pin has an additional thread which grasps the cortex as the pin is screwed in. In porotic bone
commonly found in the elderly, the thread provides a better grip. A Kirschner wire is quite weak and can
easily be bent. However, if it is stretched by a tightener as shown in Figure 6/10 tension is developed in
the wire which will then support considerable loads.
116 PRINCIPLES OF ORTHOPAEDIC TRACTION SYSTEMS

Fig. 6/9 Skeletal traction (Steinmann pin) through the upper tibia

Fig. 5/10 Tension wire used in skeletal traction. (A) The screw-caliper device; (TD) a tensioning device. Either can be
used to put the wire under tension
 PRINCIPLES OF ORTHOPAEDIC TRACTION
SYSTEMS 117
Loosening of the pin and subsequent pin-track infection are the only problems. A neglected pin-track
infection could lead-to osteomyelitis.
Common peroneal nerve palsy can also occur if the leg is allowed to lie in external rotation, the
nerve may then be squeezed by the weight of the limb on a metal splint.
All complications can be minimised or indeed avoided if at least one member of the treatment team
examines the traction device at least daily.

PULLEYS
The traction in Figure 6/11 (1) shows four pulleys. Whereas the weight (water bag) hangs directly down
over the end of the bed the line of action of taste force which it produces is changed to produce two forces
A and B acting on the body at point X. One force seems to pull the leg along the bed while the other pulls
the thigh up in the air, in fact they resolve into a force C which pulls in the long axis of the femur (Fig.
6/11(2)).

2w

(3) (2)

Fig. 6/11 Hamilton Russell traction to show two principles of traction. The hanging weight (W) is by a
system of pulleys transformed into 2 forces A and !i. A has twice the value of B and together are resolved
by a parallelogram of ::forces into C which is in line with the fractured femur (2). It is the pulleys' stem
PQR (3) which produces this difference iti force in A and B. Because Q this causes a mechanical
advantage via P which makes the force in this direction 2W
118 PRINCIPLES OF ORTHOPAEDIC TRAC'I'ION ¥STEMS

Look again at Figure 6/11(1): the pulleys at the foot of the bed form a system shown
diagrammatically in Figure 6/11(3). The function of such a pulley system is to increase the mechanical
advantage of this part of the system and double the force W at X. In practice if the cord jams against the
pulley-casing all function is lost. As this can easily occur, it should be included on the daily inspection.

WEIGHTS
There are limits set on the weight used, by the size of the patient, e.g. child or adult; the type of fixation
used, e.g. skin or skeletal; by the part under treatment, e.g. cervical spine or lumbar spine; and by the
condition under treatment, e.g. a femoral neck fracture or a femoral shaft fracture. It is better to think
about the requirement in each case than to concoct a recipe book for every eventuality.

OTHER TYPES OF TRACTION

There are numerous variations of traction that the physiotherapist may meet in her work. They include
gallows traction (Fig. 6/3); Hamilton-Russell traction (Fig. 6/I1), Perkins' traction (Perkins, 1974) (these
allow early mobilisation of the knee joint) and Fisk traction. Traction may be used also i the correction of
contractures, e.g. Agnes Hunt method (Rose, 1977,) (Fig. 6/6); in the correction of spinal deformities, e.g.
halo-pelvic traction (see Chapter 16). Full details of all these, and others, will be found in books listed in
the Bibliography. It is also possible that local variants of the standard methods will be met in practice.

PHYSIOTHERAPY

This is discussed in the relevant chapters; for hip conditions (Chapter 8); for spinal deformities (Chapter
15); and for fractures (Chapter 24).

DOS AND DON'TS OF TRACTION

Do learn how the particular tracuon works before treating the patient. Do check that the weights are
hanging free before and after treating
the patient.
Do check that cords run freely in pulleys, and that pulleys rotate
freely.
 PRINCIPLES OF ORTHOPAEDIC TRACTION SYSTEMS 119
Do check the skin for any signs of pressure or inflammation.
Do check that movement of the free joints is actively possible; this is important particularly for
dorsiflexion of the ankle joint for the early detection of nerve injuries or compressions.
,Do report any adverse findings to the nurse in charge of the ward and
to the medical officer concerned.

Do not meddle with the traction unless you have been specifically
trained to do so.
Do not release the traction unless the surgeon has given instructions to
do so.
Do not loosen, or tighten, tapes, cords, screw extensions or slings of
the traction apparatus.

lrkins, G. (1974). The George-Perkins Traction. Worm Medicine, January

30.
Rose, G.K. (1977). Total functional assessment of orthoses. Physiotherapy,
63, 3, 78--83.

IBLIOGRAPHY

J.C. (1983). An Outline of Fractures, Including Joint Injuries, 8th edition. Churchill Livingstone,
Edinburgh.
A.G. and Soloman, L. (1982). Apley's System of Orthopaedics and Fractures, 6th edition.
Butterworths, London.
J. (1970). The Closed Treatment of Common Fractures, 3rd edition. : Churchill Livingstone,
Edinburgh.
R., Goodfellow, J.W. and Bullough, P. (eds) (1980). Sc/ent/fic Foundations of Orthopaedics and
Traumatology. William Heinemarm
Medical Books Limited, London.
J.D.M. (1975). Traction and OrthopaedicAppliances. Churchill
Edinburgh.