Professional Documents
Culture Documents
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 limb-
length 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……..