Skeletal traction and osteosynthesis

Methods of continuous traction and immobilization

Continuous traction is used to eliminate displacement of bone fragments and fix them. There are two main types:

• Skin traction — performed using adhesive or non-adhesive bandages (e.g., on a CITO splint for humerus fractures).
• Skeletal traction — the most effective and common method in surgical practice.

For successful treatment and immobilization of the injured limb, it must be placed in the mid-physiological position:

• Upper extremity: the shoulder is abducted by 45° and flexed forward by 35°, while the elbow joint is fixed in flexion at an angle of 110°.
• Lower extremity: the hip joint is flexed at 40°, the knee joint at 140°, and the foot is set at an angle of 40°.

There is also non-skeletal continuous traction using straps, cuffs, and slings. A classic example is Glisson's loop, used for fractures of the cervical and upper thoracic vertebrae. The loop is securely fixed to the head of the bed. To achieve reduction, the head of the bed is raised to a height of 50–60 cm, and after successful alignment of the vertebrae, the height is reduced to 25–30 cm to maintain retention.

Open osteosynthesis: types and disadvantages

Surgical treatment of fractures is indicated when conservative methods are ineffective. Traditional open interventions are divided into two groups:

1. Intramedullary osteosynthesis. In diaphyseal fractures (e.g., of the femur) with displacement, a metal rod is inserted into the medullary canal of the proximal fragment and then advanced into the distal fragment for rigid fixation.
2. Extramedullary (plate) osteosynthesis. Fragments (e.g., of the humerus) are rigidly fixed using a metal plate and screws to ensure their complete immobility.

Despite high fixation strength, open techniques that require direct exposure of the fracture site have serious disadvantages:

• Additional trauma is inflicted on the bone tissue and surrounding soft tissues due to the surgical approach.
• During intramedullary pin insertion, the bone marrow is inevitably destroyed along the entire length of the operated bone.
• A secondary, equally complex surgery is required to remove the hardware after fracture consolidation (union).

External fixation compression osteosynthesis

To avoid the drawbacks of open surgeries, modern surgery employs external fixation devices (Ilizarov, Gudushauri, Volkov-Oganesyan devices).

The principle of the method is that fixing metal pins are inserted through healthy bone outside the fracture zone itself (externally).

Key advantages of the method:

• Closed reduction: precise alignment of fragments is achieved without soft tissue incision or bone exposure.
• Compression: a system of rods and nuts creates tight opposing pressure between bone fragments, which significantly stimulates and accelerates bone union.
• Prevention of purulent complications: there is no foreign body (metal) directly in the inflammation focus, minimizing the risk of infection.

The method is indicated for fresh fractures, as well as delayed union, nonunions (pseudarthrosis), and bone end osteomyelitis.

Outcomes and potential complications

Complications in managing a patient with a fracture can occur at any stage: from first aid provision at the scene to specialized hospital treatment.

Fracture treatment outcomes are classified as follows:

1. Complete recovery: full restoration of the anatomical integrity of the bone and limb function is achieved.
2. Anatomical restoration with functional deficit: the bone has healed correctly, but due to prolonged immobilization, muscle atrophy, stiffness, or joint contractures have developed.
3. Malunion with preserved function: anatomical deformation is present, but limb function is successfully compensated.
4. Malunion with impaired function: change in bone shape (e.g., shortening or curvature) leads to limping or limited range of motion.
5. Pseudarthrosis (false joint): a condition characterized by the absence of bony union (unhealed fracture) and persistent pathological mobility in the trauma zone.
6. Post-traumatic osteomyelitis: a severe complication characterized by the development of a purulent-necrotic process directly within the bone tissue.

Class and exam questions

What else to study on this topic

• Detailed technique of skeletal traction and patient management guidelines.
• Bone-plastic surgeries ("Russian lock" procedure) for pseudarthroses.
• Mechanisms of delayed bone consolidation and pseudarthrosis formation.
• Complications at the stages of first aid provision and hospital treatment of fractures.

Other topics in "CHAPTER 10. GENERAL ISSUES IN TRAUMATOLOGY"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.