The Closed Treatment of

Fractures: Traction and Casting

Dr. Michelle Ghert
McMaster University

Major Resources
The Closed Treatment of Common
Fractures, John Charnley, 1961
Operative Orthopaedics, Chapman, 2001

Biology of Closed Treatment

Movement at fracture site stimulates callus
sleeve
Eventually immobilizes the fracture

Harmful effects of operative

management
ischemia
osteogenic activity
prior to refinement
of AO technique-->
failure of internal
fixation

Supracondylar Fracture of the Adult

Femur, Neer et al, JBJS 1967

110 supracondylar femur fractures

1942-1966
internal fixation in 36
Clinical outcomes
satisfactory outcome still possible with
<20 degrees of motion

Results
43/48 (90%) excellent or satisfactory in casting
15/29 (51%) excellent or satisfactory in ORIF
Complications:
7 in casting
36 in ORIF

Conclusion: operative management not

indicated

Failed ORIF

Harmful effects of closed

treatment
few
angulation
stiffness

Mechanics of reduction

mental picture of reduction

Importance of intact soft-tissue envelope
LIGAMENTOTAXIS
Increase initial deformity

Intact Soft Tissue hinge

Intact Soft Tissue Hinge

Mechanics of traction

Reduction
Splinting
hydraulic effect on soft-tissue envelope
Secure fixation of fracture yet preserve joint
function

Mechanics of casting
3-point fixation
Not just a passive mold
Padding must be at appropriate thickness
and placement

3-point Mold

Law of Closed Treatment

After the fracture of the shaft of a long bone,
the associated joints will tolerate fixation
for the duration of normal union without
either permanent or significant loss of
motion.

Cast padding

Introduced in Italy 1948

Accommodates for swelling reduction
Firmer grip on limb
it must not obscure the shape of the limb
by being put on in careless and ugly lumps.

Triple sequence
1. Examination and rehearsal
2. Reduction
3. Plastering and molding

1. Examination and Rehearsal

Effect of gravity
Amount of force
Range of excursion
Key point to hold reduction

2. Reduction
Relaxation of muscles is essential
Recreate deformity
3-point hold

3. Casting and molding

3-point molding
Maintain reduction

Traction: History
Guy de Chauliac 600
years ago
Sir Hugh Owen
Thomas in 1890

Traction: History
Gurdon Buck 1861:
Bucks traction

Traction: History
Combination of
traction and
suspension introduced
by Nathan Smith 1867

Traction: History
Traction by skeletal
pins introduced by
Fritz Steinmann of
Switzerland in1907

Traction: Indications

Vertical instability fractures of pelvis

Fractures of the hip, femur and tibia
Posterior hip dislocations
Emergency measure prior to operative
stabilization

Traction: Principles
Traction suspension:
splint takes second
place to action of
traction force
Thomas method:
traction holds
reduction and
alignment is controlled
by splint

Split Russell Traction

Split Russell Traction

Balanced Suspension with

Thomas Splint

Balanced Suspension with

Thomas Splint

Pearson attachment

Balanced Suspension with

Thomas Splint
The major part of the
count-traction is taken
against the perineum
and the fatty folds of
the buttock.

Specific fractures
Both bone forearm in children
Colles
Femoral shaft

Radius and Ulna in Children

Middle 1/3
Vertical traction technique
Counter traction by gravity
Patient anesthetized for relaxation

Finger trap traction

Finger traps on IV
stand
Thumb, index and
middle finger separate
Elbow at 900
If long traction is not
enough, increase
deformity and
straighten

Casting
Enclose thumb to IP joint
Allows opposition but does not displace
radius

Casting
3-point bend in cast:
a curved cast means a
straight bone
Shape of cast will be
opposite of deformity

Mold in oval cross-section

Casting vs. Splinting

Garfin et al, JBJS 1981:
Quantification of Intracompartmental
Pressure and Volume under Plaster Casts
Canine model
Significant intracompartmental pressure
increase with casting
65% reduced if cut and split
80% reduced if webril cut as well

Colles fracture

Dorsal shift and tilt, radial shift

Volar soft-tissue rupture
Dorsal soft-tissue hinge
Elderly: dorsal comminution

Hematoma block
Area is prepped and draped
Hematoma aspirated and 5-10 ml of local
anesthetic without epinephrine is injected

Increased risk of infection?

Johnson et al, Orthopaedic Review, 1991:
132 distal radius fractures treated with
hematoma block and reduction
Compared to 100 patients treated with
either general anesthesia or IV regional
No infections or complications

Reduction: disimpaction
analagous to
meshing of two
gear-wheels

Reduction
Volar flexion and
translation
Pronate forearm to
stabilize fragment
Ulnar deviation

Casting
Start with radial slab
3-point fixation
Ulnar deviation

Fractures of the femoral shaft:

Adults
Dorsal angulation is well-tolerated
Varus/valgus <100 tolerated by knee joint
Traction indicated as provisional measure in
unstable patient

Tibial pin insertion

Sterile technique
Insert pin from medial
to lateral (minimize
risk to peroneal nerve)
Level of tibial tubercle

Tibial pin insertion

Anesthetize skin and
deep tissues down to
periosteum with local
anesthetic
Longitudinal incision
Hold leg in neutral
rotation
Hand drill only

Thomas BST
Pearson attachment to
Thomas leg splint at
knee
Forms cradle for leg

Thomas BST
Sequence
of suspension:
1. Proximal ring
(counter-traction)
2. Distal Pearson
(fracture suspension)
3. Traction bow
(holds reduction)

Pediatric Femoral Shaft Fractures

Tend to shorten due to pull of thigh muscles
and ballooning of fascia
distal fragment displaces posteriorly
secondary to gastroch
AIM: 1 cm shortening, correct rotation, no
angulation

Pediatric Femoral Shaft

2 weeks in Thomas traction then spica
casting vs immediate spica
If in traction: check films and adjust

Spica Casting
Latin word spica=ear of wheat
v-shaped crossing resembling spike of grain

Spica cast
General anesthetic vs.
conscious sedation
Spica table
shoulder and upper
thorax on table, pelvis
on perineal post

Spica Cast
Cast extends from
xyphoid process to
metatarsal head
closed reduction of
femur under fluoro
extra padding on
ASIS, sacrum, ribs
Allow other hip to flex
900

Hip Spica

Cast Wedging
Correct fracture
alignment
uniplanar or biplanar
opening--> lengthens,
closing--> shortens

Central Hinge Wedging

neither shortens nor
lengthens
Hinges cast directly
over fracture site
Technique involves
marking location of
fracture site on cast
Combination of
opening and closing
wedge

Literature Review
Infante et al, CORR, 2000
190 immediate hip spica casts on children
with isolated femoral shaft fractures
Conscious sedation/general anesthesia
All united within 8 weeks
No significant residual deformities
No complications

Literature Review
Ferguson et al, JPO, 2000
prospective study, 101 children treated with
immediate spica casting
excellent results with few complications
8 with unacceptable shortening
Control of alignment not a problem

Immediate spica vs. traction

Wright, Canadian Journal of Surgery, 2000
Meta-analysis of 15 cohort studies
comparing methods of management of
children with femur fractures
Results: costs and malunion rates of early
application of a hip spica cast were lower
than for traction

Yandow et al, JPO 1999

181 fractures over 10 year period

59 underwent spica casting within 48 hours
122 underwent traction and delayed casting
Average follow-up 8.9 years

Yandow et al, JPO 1999

No significant clinical difference in limblength inequalities, or rotational or angular
deformities
Average hospital stay 17.3 (traction) vs. 2.2
days (casting) (P<0.001)
83% increase in patient charge in traction
group

Summary: Traction and Casting

Mental rehearsal of reduction
Understand forces and anatomy of fracture
mechanics of soft-tissue hinge and 3-point
mold
concept of traction/suspension
muscle relaxation essential..