Skeletal traction for a fracture of the humerus. Instruments for skeletal traction. If necessary, give the victim pain medication

The concept of traction. With displaced fractures, especially with oblique fractures, it is very difficult to hold the bone fragments in place. correct position only with fixed bandages; As a result of fusion of incorrectly positioned fragments, shortening of the limb is noted. Based on this, treatment of bone fractures with constant traction was proposed. When treating fractures, the mechanism of displacement of fragments is taken into account. The purpose of traction is to achieve muscle relaxation; In most cases, this is already enough to install the debris in the correct position.

Thus, the purpose of a traction bandage is to establish constant stretching (traction) of the muscles of a given area of the body.

Traction methods. There are a lot of methods of traction, but they can all be divided: 1) traction by gravity: with temporary application of traction it is hanging, with permanent application it is traction on inclined plane; 2) traction with a load; 3) traction using elastic traction in devices (springs, rubber tubes, etc.). Indications for the use of traction are very diverse: it is used to treat fractures, to treat inflammatory diseases joints and bones, especially chronic ones, such as tuberculosis, to correct contraction in joints (contractures), to prevent contraction in case of certain soft tissue injuries.

Gravity traction is often used temporarily when applying a fixed bandage, for example to the spine (corset). In this case, the patient is suspended using a special collar. The collar covers the chin and the back of the head in such a way that it does not squeeze the neck at all. This allows the patient to be pulled up by a rope tied to him and thrown over a block fixed at the top so that he only rests lightly on the floor with the tips of his toes. Hanging is very tiring when this treatment is used for a longer period of time. Due to the gravity of the body, the muscles of the torso relax, and this causes the spine to straighten and stretch. When applying a bandage to lumbar region suspended using two loops covering axillary areas. A traction loop can be improvised and made from two strips of linen bandage.

If traction is applied for more than a long period, then the patient’s gravity can be used by placing the patient on an inclined plane. If you put a patient on an inclined bed with the head end raised and the foot end down, then, due to gravity, he will slide towards the foot end of the bed; if we put on the “collar” that we talked about above and attach a rope to the headboard of the bed, then the patient will slide due to gravity to the footboard of the bed, and since this is prevented by the loop, constant traction of the spine will occur. This constant traction will be stronger the more inclined the bed is placed. This method of traction is used for tuberculosis and spinal fractures. Traction with weights attached to a loop in the form of a bracelet or cuff made of thick fabric or leather is also used. This traction is used for tuberculosis of the joints.

A string tied to a loop is thrown over a block and a load in the form of a weight, a bag of sand, etc. is tied to it.

The method of attaching traction to a limb using an adhesive patch has become widespread. To do this, take a long strip of plaster 5-8 cm wide for the thigh, 4-5 cm wide for the lower leg and shoulder, 3-4 cm wide for the forearm. This strip is led along the diseased limb on one side, for example the thigh, shoulder, lower leg, bent in the form of a free loop through the joint area and placed in exactly the same way on the other side. Top ends It is better to cut it longitudinally before applying it.

To reduce the pressure of the plaster on the protruding parts of the bones in the joint area, a plate is inserted into the loop of the plaster, which, serving as a spacer, reduces the pressure of the plaster on the joint. The twine is attached to the board: a small hole is made in the center of the board, a rope is threaded through it and tied with inside thick knot. It is necessary to ensure that the board is inserted correctly, perpendicular to the strips of plaster, and not obliquely, and is wide enough, not narrower than the joint through which the strips of adhesive plaster pass.

First, you need to apply a slight traction, and only when the plaster softens due to body heat and sticks tightly, you can increase the load. The joint areas remain open. If there is damage to the skin, this obstacle is bypassed by cutting a strip of plaster lengthwise and spreading its ends in the form of a Roman numeral V. Some surgeons suggest shaving the hair on the limb and washing it with gasoline, while others do not do this and do not treat the skin at all.

A string attached to a plank is thrown over a block or pulley system. The blocks are either attached to the bed, or special stands (tires) with blocks are placed on the bed. You need to make sure that the block is level with the center of the spacer, and not above or below. In this case, the rope forms one straight line with midline adhesive strip when viewed from the side and one straight line with the axis of the limb when viewed from above. In addition, you need to make sure that the rope slides in the middle of the groove of the vertically standing block. Any incorrect placement of the block reduces the effect of traction, as does bending the rope over the edge of the bed. The rope and load must hang freely, without touching surrounding objects or the floor. The load is either sandbags or special weights in the form of plates. By using them, you can gradually, without stopping the traction, increase the load.

Skeletal traction. You can’t get by with traction using a patch, if necessary. great traction, since even the best patch gradually slides off the skin and the traction force weakens. In such cases, traction is carried out with metal knitting needles or pins.

This method is little painful and very convenient. Using a special tool under local anesthesia pierce with a knitting needle soft fabrics and drill the bone in a direction transverse to the axis of the limb and attach an arch to it, to which a rope with a load is tied.

Most often, the wire is passed through the tuberosity tibia and the calcaneus, less often the wire is passed through the epicondyles of the femur or other parts of the bones.

Instead of knitting needles, special pins are sometimes used. After sterilization, the tip is applied so that it sharp ends stuck into the bone, but they do not pass through it. Removing the staple does not present any difficulties.

Methodology skeletal traction for fractures is widely used in traumatology. The main goal This treatment consists of eliminating pain syndrome by relaxing the muscles with slow straightening and holding the bone fragments in the required position until they develop callus.

Skeletal traction eliminates the risk of developing secondary displacement of a broken bone. After this method it is significantly reduced rehabilitation period after a fracture.

Types of procedure

Traction is carried out using the adhesive or skeletal method, depending on the indications.

Adhesive stretching

This method is used only when there is a slight displacement of bone fragments. The application technique consists of gluing a 10 cm wide adhesive plaster to areas of soft tissue on the outside and then on the inside of the fracture. It is important to ensure that there are no folds or ties at the site of the protrusions of the bone fragments. Small plywood boards are attached to the end of the adhesive plaster, and circular bandages are placed on top.

The attached load with this technique should not be heavier than two kilograms.

Skeletal traction

Skeletal traction puts stress on the nearby muscles of the broken bone in order to relax them. It also eliminates the possibility of debris moving and ensures their immobility. This method has virtually no contraindications; it can be used by everyone except childhood up to five years.

Traumatologists often use Kirschner wires made of high-quality stainless steel for these purposes. The bracket, which provides a spring action and ensures reliable stretching of the spoke, is presented in the form of a steel plate.

Depending on where the affected area is located, the surgeon places the needle through certain points. For example, if the fracture covers the shoulder, use olecranon, if the lower leg is affected, then through the supramalleolar area. The doctor by examination and with the help x-rays determines which points should be used to treat a broken leg or arm, depending on its location.

After pulling, the knitting needle is secured to the bracket and a guide weight is installed. The weight of the gravity is selected taking into account the affected area and the weight of the victim.

Indications for use

Skeletal traction is indicated for patients with:

hip fracture;
lateral lesion of the neck femur;
T and U shaped;
diaphyseal fracture of the leg bones, ankles;
dislocation of the cervical vertebrae;
defeat humerus;
reduction of old hip dislocations.

Also, skeletal traction is often used in preparation for surgery or after surgical intervention patients with:

medial femoral neck fracture;
congenital hip dislocation;
non-united fracture with displacement;
bone defects;
deformity of segmental osteotomy of the femur;

The skeletal traction procedure should be carried out only under complete sterility, taking into account all the rules of asepsis and antisepsis. The manipulation is performed under local anesthesia, it is first administered to the patient at the site where the needle is laid.

There are cases when the doctor chooses not skeletal traction to treat a broken bone, but the use of a plaster cast for bone lesions without displacement. For elderly people who have developed a fracture, it is generally preferable to be treated surgically - by osteosynthesis.

Treatment process

After laying the knitting needle and installing the first weight, a control x-ray is prescribed, which determines the weight of the reducing weight. By changing the load to required weight, the x-ray should be repeated after another two days. During the entire period of treatment, the broken limb should be motionless.

Treatment is divided into three stages:

Repositional. It covers the first three days of treatment. During this period, reduction of the fragments is observed, which is regulated by radiography.
The retention stage lasts about 2–3 weeks. During this time, the fragments were observed to be in a state of reposition.
Reparation is the last stage of treatment, where signs of callus development and the formation of the necessary consolidation appear. The period covers 4–5 weeks.

How long the patient lies in this position depends on the location of the affected bone. On average it takes about 1–1.5 months.

During this period of time, it is necessary to eliminate the existing pathological mobility at the fracture site - this is the main criterion for such long-term treatment. This result must be confirmed X-ray examinations, if the indicators are favorable, the doctor transfers the patient to the fixation method of treatment.

Complete rehabilitation after skeletal treatment includes: therapeutic massage, baths, regular application elastic bandage, therapeutic exercises, physiotherapy.

special instructions

The skeletal method has many advantages, but do not forget about the disadvantages. Prolonged stay of the victim in a motionless state leads to a malfunction functional activity Gastrointestinal tract, cardiovascular system, tissue atrophy, formation of bedsores.

It is important to know that a patient undergoing skeletal traction requires daily examination not only by the doctor and medical staff, but it also requires special attention from relatives.

Complications that can cause skeletal traction include purulent infection of soft tissues. This pathology can occur if the rules of asepsis are violated when therapeutic measures fracture Purulent infection can cause osteomyelitis, and then sepsis. Such serious complications may lead to irreversible consequences. Therefore, it is important to provide proper daily care for the patient.

The classic conservative method of treating fractures is constant adhesive plaster and skeletal traction. In the first case, traction is carried out using adhesive tapes attached to the skin. Skin traction is used when holding fragments does not require much effort, most often in weakened patients.

Traction using a load attached to a metal structure (knitting needle, nail) passed through the bone or a bracket attached to it is considered more convenient and reliable. This treatment method is called skeletal traction.

A fundamental improvement of the skeletal traction method is the use of a spring-damper in the adaptive system [Mityunin I.K., 1966: Klyuchevsky V.V., 1982]. With its help, differences in the traction force of the load during limb movements are significantly reduced. As a result, the stability of the reduced position of bone fragments is significantly better preserved and the possibility of early motor activity of the limb appears. This method is called damped skeletal traction. It is classified as a functional method of treating fractures.

Among the indications for the use of constant traction are unstable fractures of the humerus, tibia and femur, when the plaster cast used after immediate reposition does not provide ideal fixation of the fragments. Among stable fractures, skeletal traction should be treated in cases where there is pronounced increasing local tissue swelling.

Constant traction is contraindicated in the presence of large areas of damage to soft tissues, mainly muscles, in the presence of an inflammatory process in the area of the fracture and at the site of the wires, in non-critical behavior of the patient in cases of intoxication, psychosis or other mental disorders. Besides. The absence of a mobile X-ray machine is considered a relative contraindication to the use of constant traction.

Traction treatment is carried out using special therapeutic splints. installed on the bed with a stitch (Böhler splint for the lower extremities) or fixed to the patient’s torso (abduction splint for the upper extremities). The limb is placed on a splint in average physiological state that ensures the balance of the antagonist muscles(their simultaneous maximum relaxation).

Skeletal traction is performed under local anesthesia. After anesthetizing the fracture area, a metal pin is passed through the bone using a drill (for example, through the heel bone for tibia fractures or through the upper metaphysis for a hip fracture). The spoke is tensioned with a clamp. behind which a load is suspended through a fishing line and a block, exerting traction along the longitudinal axis of the broken bone. To eliminate displacement of fragments at an angle and in width, it is recommended to use lateral skeletal traction.

There are three phases in the process of treating a fracture using skeletal traction.

Reposition phase lasts up to 3 days. At this time, gradual reduction of bone fragments is carried out, which is necessarily controlled by x-ray examination. Over the next two to three weeks, the fragments are kept in a state of reposition and this period is called retention phase treatment. From the moment the first signs of callus appear until sufficient consolidation is achieved, the third phase is stated - reparation . It lasts up to 4 weeks and upon completion, skeletal traction stops.

Among the positive aspects of constant traction, the following should be noted:

1) ease of implementation of the method, ease of training and technical equipment:

2) the possibility of visual observation of the fracture area and the limb as a whole:

3) availability of examination using special research methods:

4) the possibility of early functional treatment and physiotherapy.

Along with the. We must not forget about the disadvantages of constant traction. The most common is infection of the tissue at the site of insertion of the wire and the occurrence of wire osteomyelitis. The relative mobility of the limb creates the possibility of mixing fragments. When treated with constant skeletal traction, the patient is in a forced non-physiological position for a long time. And finally. The bulkiness of the equipment used makes it difficult to transport the patient, there is labor intensity in servicing the patient, as well as difficulties in physiological functions and in carrying out hygienic measures.

Focal osteosynthesis

With open reduction, fixation of bone fragments is carried out surgically, when metal structures are passed through the fracture zone. This method of treatment is called focal osteosynthesis. Depending on the location of the structure in relation to the bone, intraosseous and extraosseous osteosynthesis are distinguished.

Intraosseous focal osteosynthesis involves the use of rods, pins or wires that are inserted into the medullary canal. The structures used are made of various metals. Titanium rods are considered promising. This material is durable and does not corrode. At the same time, such rods can be modeled in accordance with existing bone bends. due to which the treatment method becomes physiological.

Using titanium rods, a variety of focal osteosynthesis, which was named tense. The gist of it is this. that two rods curved in opposite directions are used to fix the fragments. In this case, the tension of one bent rod counteracts the tension of the second rod, bent in the opposite direction. In this way, the strength of holding bone fragments in the reduced state increases.

This method of fixing fragments has a number of advantages over other treatment methods. There is no tissue compression and massive damage to the periosteum. This method is simple in technical execution, and strong retention of reduced fragments by such metal structures does not require additional fixation of the fracture area.

At the same time. intraosseous osteosynthesis has significant disadvantages. Among them, first of all, it is necessary to indicate the high traumatic nature of manipulations, which is fraught with the development of a state of shock. For the same reason, fat embolism may occur. When an infection occurs, osteomyelitis develops, and the inflammatory process spreads over a large area throughout the bone.

Focal osteosynthesis can also be performed using extraosseous screws, plates, or a combination of these metal structures. This osteosynthesis is sometimes called extraosseous osteosynthesis.

For osteosynthesis with screws (internal osteosynthesis), cortical, spongy, malleolar and mini-screws are used. Cortical screws are indicated for osteosynthesis of diaphyseal fractures in which there is a long oblique line (its length is 2 times or more than the diameter of the bone). Spongy screws are intended for fixation of fragments in case of fracture of the condyles, femur and tibia, fracture of the neck of the humerus and femur, etc. Malleolar screws are used for osteosynthesis of clavicle fractures. ankle, shoulder. These screws are promising only in cases where they perform a compression function. It is recommended to freely insert the screw into the nearest fragment through the hole and screw it into the opposite fragment using a thread.

In case of an oblique fracture with a large line, as well as in the presence of significant bone fragments, bone osteosynthesis is used. in which the fragments are fixed using so-called “cerclage sutures”. Wire, fishing line or chrome-plated catgut is used as a reinforcing material.

Extraosseous focal osteosynthesis in some cases is carried out using plates that are attached to the bone with screws. Osteosynthesis sets offered by the industry contain plates various types with round or oval holes, straight or angular. hook. T-shaped. cruciform, etc.

Unfortunately, this method of osteosynthesis has a number of disadvantages. which limit its use, including the difficulty of creating sufficient fixation of fragments, because by virtue of physical activity Over time, the bone around the screws dissolves. This determines the additional application of plaster casts for any external structures. In addition, with this method of treatment there is no autocompression and the periosteum is damaged relatively widely.

Extrafocal compression-distraction osteosynthesis

The extrafocal compression-distraction method of treatment involves fixation of bone fragments using special devices such as the design developed by G.A. Ilizarov. These devices ensure strong contact (compression) and immobility of fragments, as well as the possibility of early functional loading of the limb. This treatment method is used in the treatment of various fractures, false joints and osteomyelitis. It is indicated for the development of contractures in joints and for bone growth.

An important condition for using this method for therapeutic purposes is the need to constantly monitor good tension of the needles. This ensures structural strength and adequate retention of bone fragments in the reduction position. This circumstance, combined with certain difficulties in mastering the treatment technique, constitutes the negative side of this method.

Skeletal traction– traditional conservative method treatment of fractures in traumatology. Can be used as the main method of fixation before the formation of a primary callus or used for a short time at the stage preoperative preparation. It is applied for fractures of large bones of the lower extremities (femur, tibia), hip dislocations, fractures of the pelvis, shoulder, small tubular bones of the feet and hands, multiple fractures of the ribs and injuries to the cervical vertebrae. Provides position correction and retention of fragments. On average, it is applied for a period of 4 to 7 weeks. After the formation of the primary callus, it is replaced with a plaster or plastic bandage until the fracture heals completely.

Indications and contraindications

Skeletal traction is used as the main method of treatment or in preparation for surgery for multiple fractures of the ribs (floating fractures), fractures of the cervical vertebrae, humerus, phalanges of the fingers, metacarpal bones, femur, tibia, pelvic bones, metatarsal bones and calcaneus, with central hip dislocation and fracture dislocations ankle joint. The technique can be used for both closed and open fractures, and is one of the least traumatic interventions when fixation is necessary in patients with multiple injuries accompanied by traumatic shock or the threat of fat embolism, as well as for any other conditions that preclude the possibility of surgery.

This method of treatment cannot be used until the end of anti-shock and resuscitation measures. The technique is contraindicated in case of inflammation or extensive damage to soft tissue at the site of the wire or in the area of the fracture. This method of fixation is not used for diseases accompanied by impaired muscle tone (paralysis, paresis, myopathy, convulsions), fat embolism and suspected anaerobic infection. Mental illnesses and conditions accompanied by non-critical behavior (psychosis, senile dementia etc.).

Methodology

There are standard points for holding the knitting needles. The choice of these points is determined by the maximum effect when stretching a particular segment of the limb. The insertion sites for the pins are selected to avoid damage to blood vessels or nerves. The position of the limb during treatment is determined in such a way that the muscles are in the state of greatest relaxation (absolute physiological rest). For any injury, maximum muscle relaxation is achieved when all joints are placed in a semi-bent position, and the entire surface of the limb is placed on a splint to eliminate the influence of gravity.

Treatment phases

There are three phases of treatment:

Repositional. Lasts from several hours to 3 days. At this stage, the displacement of fragments is eliminated, the size of the loads and the direction of traction are adjusted. If necessary, apply additional traction. To confirm a satisfactory comparison of fragments, radiographs are taken in two projections.
Retention (stage of holding fragments). Lasts 2-3 weeks. The injured limb is provided with maximum rest (if possible, any movements, transportation and repositioning are avoided). Two weeks after the application of skeletal traction, a control radiography is performed in two projections.
Reparation (fracture consolidation stage). It begins when the first signs of fusion appear. Lasts 2-4 weeks. After sufficient callus has formed (clinically, when the patient is able to elevate the broken limb), the traction is removed. Usually after this a plaster cast is applied until the fragments heal completely.

The duration of each phase of treatment and the total period of skeletal traction depends on the type of fracture, condition and reparative abilities bone tissue, patient age and other factors. Average duration traction as the main method of treatment ranges from 4 to 7 weeks. When preparing for surgery, the time for using the technique is determined general condition patient, the number of necessary additional instrumental and laboratory research, presence or absence of damage skin in the operation area.

Currently, the most common types of traction are adhesive And skeletal. Adhesive traction, used for certain indications, is less common than skeletal traction.

Adhesive stretching

The method has limited indications and is used when fragments are displaced at an angle, along the periphery and across the width. Loads during this extension, even on the hip, should not exceed 4-5 kg. For the bandage, use gauze strips glued to the skin or an adhesive plaster. A wide patch is used for side stripes (6-10 cm), a narrow one (2-4 cm) for circular strengthening rounds. You can use special glues (zinc-gelatin - Unna paste, Finka's cleol). The adhesive extension is applied to clean, dry skin.

Adhesive plaster traction on the thigh is carried out by gluing longitudinal strips of plaster 8-10 cm wide along the outer and inner surfaces of the thigh (from inguinal fold to the inner femoral condyle). Wooden spacer sticks are sewn into the lower free ends of the adhesive plaster; From their center there are cords to which the load is attached. The adhesive plaster is strengthened with circular rounds of a narrow plaster.

Adhesive plaster traction on the lower leg is carried out with a continuous strip of plaster running along outer surface from the head of the fibula to outer ankle and on the inside - from the inner malleolus to the inner condyle of the tibia. A plywood board with a hole for the cord is sewn into the loop of the adhesive plaster. Load no more than 3 kg.

Skeletal traction

Is functional method treatment. The basic principles of skeletal traction are relaxation of the muscles of the injured limb and gradual loading in order to eliminate the displacement of bone fragments and their immobilization.

If indicated, the free limb can be bandaged, physiotherapy and electrotherapy can be carried out, and exercise therapy can be started early. Most often, skeletal traction is used in the treatment of oblique, helical and comminuted fractures of long tubular bones, some fractures of the pelvic bones, upper cervical vertebrae, bones in the ankle joint and heel bone.

Skeletal traction is used when there is a pronounced displacement of fragments along the length, ineffectiveness of one-step reduction, in the preoperative period to improve the alignment of bone fragments before their fixation, and also sometimes in the postoperative period.

Skeletal traction can be performed at any age (except for children under 5 years old) and has few contraindications. However, given the danger of infection of the bone at the time of applying skeletal traction during the treatment period and when removing the wire, it is necessary to perform this operation with careful observance of all rules of asepsis. The presence of abscesses, abrasions and ulcers in the intended area of insertion of the needle is a contraindication to its insertion in this place. During the treatment process, it is necessary to isolate the places where the needle exits through the skin with napkins and bandages, which are periodically moistened ethyl alcohol. When removing the needle, cut off one end of it with pliers as close to the skin as possible; the exit points of the knitting needles are carefully treated with iodine or alcohol; after this, the remainder of the needle is removed and an aseptic bandage is applied.

Currently, the most common traction is using a Kirschner wire, stretched in a special bracket. The Kirschner wire is made of special stainless steel, has a length of 310 mm and a diameter of 2 mm. The tension bracket is made of a steel plate that provides a strong spring action, which helps maintain tension on the spokes, fixed by clamps at the ends of the bracket. The CITO bracket is the simplest in design and most convenient (Fig. 1, a).

Rice. 1. Instruments for applying skeletal traction

a - CITO bracket with Kirschner wire; b - key for clamping and tensioning the spokes; c - hand drill for holding a knitting needle; d - electrical circuit for carrying out the spokes

A Kirschner wire is passed through the bone using a special hand or electric drill. To prevent the displacement of the wire in the medial or lateral direction, a special CITO clamp for the wire is used. During skeletal traction, the pin can be passed through various segments of the limbs, depending on the indications.

Application of skeletal traction for the greater trochanter. Having palpated the greater trochanter, select a point at its base, located in the posterosuperior section, through which a needle is passed at an angle of 135° to the long axis of the femur. This oblique position knitting needles and arches are created so that the arch does not cling to the bed. The direction of the traction force is perpendicular to the axis of the body. The traction force (the magnitude of the load) is calculated from an x-ray image, on which a parallelogram of forces is constructed.

Passing the wire for skeletal traction over the femoral condyles. In this case, the proximity of the knee joint capsule, the location of the neurovascular bundle and the growth zone of the femur should be taken into account. The point of insertion of the needle should be located along the length of the bone 1.5-2 cm above the upper edge of the patella, and in depth - at the border of the anterior and middle third of the entire thickness of the thigh (Fig. 2, a). In a patient under 18 years of age, the position should be 2 cm proximal to this level, since the epiphyseal cartilage is located more distally. For low fractures, the wire can be passed through the femoral condyles. It should be carried out from the inside outward so as not to damage the femoral artery.

Rice. 2. Calculation of the points of the wires for applying skeletal traction.
a - behind the distal end of the thigh; b - through the tibial tuberosity; c - through the suprascapular region

Carrying out a wire for skeletal traction on the lower leg. The pin is passed through the base of the tibial tuberosity or over the ankles of the tibia and fibula (Fig. 2, b). When traction is applied to the tuberosity, the wire is inserted below the apex of the tibial tuberosity. The insertion of the needle must be carried out only with outside lower leg to avoid damage to the peroneal nerve.

It must be remembered that in children, the wire may cut through the tibial tuberosity, tear it off, and fracture it. Therefore, they carry the wire posteriorly from the tuberosity through the metaphysis of the tibia.

The insertion of the pin into the ankle area should be carried out from the side of the inner ankle, 1-1.5 cm proximal to its most protruding part or 2-2.5 cm proximal to the convexity of the outer ankle (Fig. 2, c). In all cases, the wire is inserted perpendicular to the axis of the leg.

Skeletal traction for the tibial tuberosity is used for fractures of the femur in the lower third and intra-articular fractures, and in the ankle area for fractures of the tibia in the upper and middle third.

Passing a wire for skeletal traction through the heel bone. The pin is passed through the center of the body of the calcaneus. The projection of the needle insertion is determined as follows: mentally continue the axis of the fibula from the ankle through the foot to the sole (AB), at the end of the ankle restore the perpendicular to the axis of the fibula (AO) and construct a square (ABSO). The intersection point of the diagonals AC and BO will be the desired place for inserting the knitting needle (Fig. 33, a). You can find the needle insertion point using another method. To do this, place the foot at a right angle to the shin, draw a straight line behind the outer ankle to the sole, and divide the segment of this line from the level of the top of the ankle to the sole in half. The division point will determine the location of the needle insertion (Fig. 3, b)

a___________________________ b

Rice. 3. Calculation of the points for passing the spokes through the heel bone

Skeletal traction of the heel bone is used for fractures of the lower leg bones at any level, including intra-articular fractures and transverse fractures of the calcaneus.

In case of a fracture of the calcaneus, the direction of traction should be along the axis of the calcaneus, i.e., at an angle of 45° to the axes of the lower leg and foot, foot.

Skeletal traction technique

Skeletal traction is applied in the operating room in compliance with all aseptic rules. The limb is placed on a functional splint. The surgical field is prepared and isolated with sterile linen. The insertion and exit sites of the needle are determined, which are anesthetized with 1% novocaine (10-15 ml on each side). First, the skin is anesthetized, then the soft tissues and the last portion of the anesthetic is injected subperiosteally. The surgeon's assistant fixes the limb, and the surgeon uses a drill to pass the wire through the bone. At the end of the operation, the exits of the needle through the skin are isolated sterile wipes, glued with cleol to the skin around the needle, or with a sterile bandage. The bracket is symmetrically fixed on the knitting needle and the knitting needle is tensioned. To prevent the movement of the needle in the bone in the area where the wire exits the skin, CITO clamps are attached to it.

Calculation of loads during skeletal traction. When calculating the load required for skeletal traction on lower limb, you can take into account the mass of the entire leg, which on average is about 15%, or body weight. A load equal to this mass is suspended when the femur is fractured. For fractures of the leg bones, take half of this amount, i.e. 1/14 of the body weight. Despite the existing instructions in selecting the required mass for traction (717 body weight, taking into account the mass of the entire limb - lower 11.6 kg, upper 5 kg, etc.), the experience of long-term use of skeletal traction has proven that the mass of the load for fractures of the femur with skeletal traction varies between 6-12 kg, with tibia fractures - 4-7 kg, diaphysis fractures

When a load is applied to the distal segment from the fracture site (for example, for a hip fracture - behind the tibial tuberosity), the size of the load increases significantly; the weight of loads also increases (up to 15-20 kg) used for chronic dislocations and fractures.

When selecting a load, it is necessary to take into account that during skeletal traction the force acting on the bone is always

less cargo, since in this case it depends on the block and suspension. Thus, with skeletal traction on suspensions made of cotton cord, steel trawl and bandage, a mass loss of up to 60% of the applied mass of the load occurs. It is of interest that the traction force approaches the size of the load in systems with ball bearing blocks and a nylon fishing line suspension, where its loss is no more than 5% of the mass. The mass of the load used depends on the following indicators: a) the degree of displacement of fragments along the length; b) the age of the fracture; c) the age of the patient and the development of his muscles.

The recommended values are not absolute, but will be the initial ones in each specific case of calculating the load during skeletal traction. When calculating the load for skeletal traction in the elderly, children and people with very flabby muscles, the load is reduced accordingly, up to half of the calculated one. The load is increased with highly developed muscles.

You cannot suspend the entire design load at once, since overstimulation of the muscles by sudden stretching can cause their persistent contraction. First, hang 1/3-1/2 of the estimated load, and then every 1-2 hours add 1 kg to the required value. Only with gradual loading can good muscle stretching and, consequently, reposition be achieved. They also use other calculations of the loads necessary to apply traction, but the one we have given is the simplest.

Treatment with skeletal traction

After performing skeletal traction in the operating room, the patient is placed on a bed with a shield placed under the mattress and the initial load is suspended from the traction system. The foot end of the bed is raised from the floor by 40-50 cm to create countertraction with the patient’s own body weight. For a healthy leg, a support is placed in the form of a box or a special design (Fig. 4).

Rice. 4. Position of the patient in bed during treatment of a fracture of the femoral diaphysis with skeletal traction

Every day during the entire treatment period, the doctor uses a measuring tape and palpation to determine the correct position of the fragments and, if necessary, performs additional manual reposition of the fracture in traction. On the 3-4th day from the moment of applying traction, a control x-ray is taken in the ward on the patient’s bed. If there is no reposition of the fragments (depending on the displacement), the load is added or reduced, additional lateral or frontal traction is introduced when the displacement is widthwise or at an angle. In this case, after 2-3 days from the moment of repeated correction, a control radiography is performed. If reposition occurs, the load is reduced by 1-2 kg, and by the 20-25th day it is increased to 50-75% of the original. On the 15-17th day, a control radiography is performed to make a final decision on the correctness of the comparison of fragments.

Damper traction

It is fundamentally the new kind skeletal traction, when a spring is inserted between the bracket and the block, which dampens (quenches) the fluctuation of the traction force. The spring, which is constantly in a stretched state, provides rest to the fracture and eliminates reflex muscle contraction.

The advantage of damper traction is also the absence of the need for countertraction, i.e., raising the foot end of the bed, which is antiphysiological, since it impedes venous outflow from the upper half of the body, leads to an increase in central venous pressure, causes an upward displacement of the intestine and elevation of the diaphragm, which helps to reduce pulmonary ventilation.

When damping skeletal traction systems with steel springs, the maximum value of the traction force decreases several times, approaching the size of the load. Vibrations during the damper traction device are also damped by a nylon thread for suspending the load and ball-bearing blocks.

With significant lateral displacement of fragments tubular bone and the difficulty of their reposition, apply pressure to the displaced fragment with cutaneous pelots or pass a Kirschner wire through it. The pin is bent like a bayonet, after which it is passed to the bone, where it, resting, creates lateral traction, helping to reduce and hold the reduced fragments (Fig. 5).

Rice. 5. Elimination of lateral displacement of femur fragments using a bayonet-shaped Kirschner wire

Countertraction by resting the healthy leg on the box and raising the foot end of the bed during damper skeletal traction is not used, but is usually placed under knee-joint hard cushion, use counter supports armpit or special hammocks-corsets worn on the chest (Fig. 6).

Rice. 6. Damper traction in the treatment of diaphyseal femoral fractures

After removing the skeletal traction, 20-50 days later, depending on the patient’s age, location and nature of the damage, functional adhesive traction is continued or a plaster cast is applied and control x-rays are taken in two projections.

Indications for skeletal traction:

Closed and open fractures of the femoral diaphysis.
Lateral femoral neck fractures.
T- and U-shaped fractures of the condyles of the femur and tibia.
Diaphyseal fractures of the leg bones.
Intra-articular fractures of the distal metaepiphysis of the tibia.
Ankle fractures, Dupuytren's and Desto's fractures, combined with subluxation and dislocation of the foot.
Heel bone fractures.
Fractures of the pelvic ring with vertical displacement.
Fractures and fracture dislocations cervical region spine.
Fractures of the anatomical and surgical cervix humerus.
Closed diaphyseal fractures of the humerus.
Supra- and transcondylar fractures of the humerus.
Intra-articular T- and Y-shaped fractures of the condyles of the humerus.
Fractures of the metatarsal and metacarpal bones, phalanges of the fingers.
Preparation for repositioning stale ones (2-3 weeks old) traumatic dislocations hips and shoulders.

Indications for skeletal traction as helper method treatment in the preoperative and postoperative periods:

Medial femoral neck fractures (preoperative reduction).
Old traumatic, pathological and congenital dislocations hips before reduction or reconstruction surgery.
Ununited fractures with displacement along the length.
Defects along the bone before reconstructive surgery.
Condition after segmental osteotomy of the femur or tibia to lengthen and correct the deformity.
Condition after arthroplasty with the aim of restoring and creating diastasis between the newly formed articular surfaces.