Finally i was able to do a proper tibial pin traction after assisting for once. My first impression of tibial pin traction was ~ we were inducing harm to the patient rather than for good. Why i made such impressions were because i was standing in the third person's view.. A doctor is applying pin poking and screwing thru and thru the bones and on the other hand the patient screaming for help echoing around the whole ward due to more pain induced by the doctor besides having a femur fracture above it. But , thru deep considerations and weighing the pros and cons, i think its a doing good procedure than doing harm though we just give local anaesthesia to the patient which only contribute a chicken dose of pain relief effect.
After some deep thoughts , i began to realise the fact that in a patient having long bone fracture over the lower limbs , there will be a muscular spasm going on around the fracture area. The strong musculature will cause more displacement and deformed bone.Besides., any mechanical movement will induce more pain via the friction between the fractured bone with the soft tissues. So, the purpose of doing the tibial pin traction is actually to immobilize the bones, reduce the muscular spasm( by using the bla bla bla law) ,to relief pain and for an easier operative procedure. And thru immobilization , there wont be any mechanical movement which can aggravate more pain.
The day when i oncall where i had an opportunity to apply a tibial pin traction for a patient who alleged domestic injury and sustained fracture over the femur.
What i needed was a blade size 11 or 10, local anaesthesia ~ lignocaine, syringe and needles, povidone iodine and normal saline, tibial pin , T- handle (for screwing purpose) and also a bohler braun frame ( for elevation of leg, padding and a connector to the pulley) , lastly the traction weight which is 10% of the weight of the patient.
Initially, i had to mark the place i need to cut which is first to allocate the location of tibial tuberosity, and go lateral 2FB and inferiorly 2FB. the reason to go laterally was that i was not suppose to hit the common peroneal nerve. So, by going laterally, i could push away the nerve avoid cutting the nerve that night cause foot drop. So , after marking the point of incision, we should test for any pre- procedure foot drop. And to compare with the post-procedure foot drop. To see whether the foot drop were induced by us or it had been originally torn as these are medicolegal stuff that we need to be concerned about.
After getting the skin drapped under sterile technique and areas of incision cleaned with povidone and NS, i started giving LA to the patient on the incisional site. Then to test whether the anaesthesia taken effect or not, i had to pinch the skin with forceps. If the area got numbed, i couls start doing a 1cm longitudinal incision on the marking area. And then using a dilator to open up the fascia. Tibial pin applied and screw from lateral to medial. It shud be crossing thru the metaphyseal area which shud be softer than the cortical region. So, when felt a give way, meaning that it had already poked thru the bone. So, another incisionon on the other site can be done~ also 1cm longitudinal incision. Before that, to give LA for anesthesia. After all and all, apply stirrup and place the leg in a BBF and lastly connect to a tractional weight for ~5kg (standard weight).
Make sure that the ASIS-patella-2nd toe are is aligned.With enough padding on fracture site to prevent presuure between bone and soft tissue causing necrosis. leave ankle free to allow exercise and prevent foot drop. For tibial pin care, flavin dressing daily at the pin tract site is a must. And to watch out for tibial pin infection as it could cause further osteomyelitis to the patient.Make sure the countertraction is there or else the whole procedure serve no purpose.
As the rules of dealing with fracture is to reduce, hold and exercise, we need to permanently hold it via platting or intramedullary nail/ interlocking nails base on specialist preference and which are the best for the patient. After operative procedure, sending for physiotherapy is a must to prevent joint contractures by starting with quadriceps strengthening exercise, buttock lifting and ankle foot pump exercise and lastly for Non weight bearing crutches for at least 12 weeks. So that the bone will unite without causing refracture of bone as the load sharing is there.
After some deep thoughts , i began to realise the fact that in a patient having long bone fracture over the lower limbs , there will be a muscular spasm going on around the fracture area. The strong musculature will cause more displacement and deformed bone.Besides., any mechanical movement will induce more pain via the friction between the fractured bone with the soft tissues. So, the purpose of doing the tibial pin traction is actually to immobilize the bones, reduce the muscular spasm( by using the bla bla bla law) ,to relief pain and for an easier operative procedure. And thru immobilization , there wont be any mechanical movement which can aggravate more pain.
The day when i oncall where i had an opportunity to apply a tibial pin traction for a patient who alleged domestic injury and sustained fracture over the femur.
What i needed was a blade size 11 or 10, local anaesthesia ~ lignocaine, syringe and needles, povidone iodine and normal saline, tibial pin , T- handle (for screwing purpose) and also a bohler braun frame ( for elevation of leg, padding and a connector to the pulley) , lastly the traction weight which is 10% of the weight of the patient.
Initially, i had to mark the place i need to cut which is first to allocate the location of tibial tuberosity, and go lateral 2FB and inferiorly 2FB. the reason to go laterally was that i was not suppose to hit the common peroneal nerve. So, by going laterally, i could push away the nerve avoid cutting the nerve that night cause foot drop. So , after marking the point of incision, we should test for any pre- procedure foot drop. And to compare with the post-procedure foot drop. To see whether the foot drop were induced by us or it had been originally torn as these are medicolegal stuff that we need to be concerned about.
After getting the skin drapped under sterile technique and areas of incision cleaned with povidone and NS, i started giving LA to the patient on the incisional site. Then to test whether the anaesthesia taken effect or not, i had to pinch the skin with forceps. If the area got numbed, i couls start doing a 1cm longitudinal incision on the marking area. And then using a dilator to open up the fascia. Tibial pin applied and screw from lateral to medial. It shud be crossing thru the metaphyseal area which shud be softer than the cortical region. So, when felt a give way, meaning that it had already poked thru the bone. So, another incisionon on the other site can be done~ also 1cm longitudinal incision. Before that, to give LA for anesthesia. After all and all, apply stirrup and place the leg in a BBF and lastly connect to a tractional weight for ~5kg (standard weight).
Make sure that the ASIS-patella-2nd toe are is aligned.With enough padding on fracture site to prevent presuure between bone and soft tissue causing necrosis. leave ankle free to allow exercise and prevent foot drop. For tibial pin care, flavin dressing daily at the pin tract site is a must. And to watch out for tibial pin infection as it could cause further osteomyelitis to the patient.Make sure the countertraction is there or else the whole procedure serve no purpose.
As the rules of dealing with fracture is to reduce, hold and exercise, we need to permanently hold it via platting or intramedullary nail/ interlocking nails base on specialist preference and which are the best for the patient. After operative procedure, sending for physiotherapy is a must to prevent joint contractures by starting with quadriceps strengthening exercise, buttock lifting and ankle foot pump exercise and lastly for Non weight bearing crutches for at least 12 weeks. So that the bone will unite without causing refracture of bone as the load sharing is there.
* image taken from http://wheelessonline.com/tibtrac.jpeg
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