6. “Pinless”Calcaneus traction
D. Heim, M. Schi.itz, P. Holzach, P. Matter, Spital Davos CH-7270 Davos Platz
6.1Inaction Calcaneus traction is a common procedure for fractures of the tibia (shaft and proximal segment), for pilon fractures and for displaced malleolar fractures in cases in which immediate internal fixation is inappropriate because of critical soft tissue conditions. Calcaneus traction is also widely used together with medullary nailing of tibia1 shaft fractures using the extension table. The usual method for calcaneus traction is insertion of a Kirschner wire or a threaded or non *aded pin into the dorsal third of the local anaesthesia (Heim and calcaneus under Baltensweiler, 1981). Although osteitis induced by a pin or wire track infection is rare, it still presents a disastrous complication. It is seen more often in cases of pin traction than in wire traction (Rohaq 1%9). Chronic osteitis of the calcaneus often ends in total calcanectomy with persistent walking difficulties (Martini and Daoud, 1971). Thus, if communication between the calcaneus bone and the exterior can be avoided, it would certainly lower the risk of such a troublesome complication.
Fig. 1: To get a good grip of the tips of the pinless clamp in the calcaneus bone, it is very important to make 4 to 6 rocking movements of about 600 with the handles.
The pinless external fiiator seems to be a treatment alternative to the transosseous insertion of a pin. The sharp tips allow safe anchorage in the calcaneal bone and traction can be applied in the conventional manner.
The patient lies supine, the leg is elevated, the foot is held in external rotation of about 15O - W. The insertion points for the two tips of the clamp lie midway between the distal tip of the fibula and the posterior tip of the calcaneus. The skin and periosteum are infiltrated with a short acting local anaesthetic and small skin incisions of about 5 mm are made on each side of the heel. The clamp is then anchored by exerting gentle pressure on the handles to avoid penetration of the bone. To get a good grip with the tips, it is very important to make four to six rocking movements of about 60° with the handles (Fig. 1). Then the handles of the clamp are removed, a cord is put around the hinge and traction of about 3 to 4 kg is applied in the usual manner (Fig. 2).
Fig. 2: Calcaneus traction using the pinless clamp plus connection to a traction wire around the hinge. If traction is used for medullary nailing using the extension table, connection to the clamp’s rotating post with the distraction device of the table is performed (Fig.
Heim: Pinks
s 45
calcaneustraction
3). For safe connection, distal end for anchorage
the rotating post has a rounded in the extension table.
Fig. 3: Use of the pinless clamp for calcaneus traction in a patient being prepared for closed medullary nailing on the extension table. Calcaneus traction is discontinued at the moment of delayed definitive internal fixation or at the end of the nailing procedure.
6.3 Resulti From January to April, 1992, 11 patients were treated using the above-mentioned technique. There were 8 female and 3 male patients with an average age of 46 years (27 to 74 years). 7 patients suffered from a fracture after a skiing accident and 4 sustained their fractures as pedestrians. There were 4 displaced malleolar fmctures type B (Fig. 4), 4 fractures of the tibia1 plateau with important valgus deformity in lateral or bicondylar fractures and 2 complex diaphyseal fractures of the tibii. Traction was applied for an average of 5 days (3 to 8 days) until the local conditions permitted internal fixation. Calcaneus traction for immediate medullary nailing on the extension table using an unreamed tibia1 nail was used for one patient with a diaphyseal segmental fracture.
Fig. 4b: The pinless clamp is applied and calcaneus traction of 4 kg is applied, the fracture is reduced and is maintained in a good position until internal fixation is possible. Two minor local complications were noted: in one female patient (age 55) too much pressure was applied on the handles and the clamp broke into the cancellous bone of the calcaneus, one male patient (age 41) complained about temporary disaesthesia on his heel. No clamp pulled out during traction and no superficial or deep infection occurred. After removal of the clamp the skin incisions were left open for spontaneous closure. In an additional patient, traction was performed on the tibiil t&erc&ty for a distal femur fracture for 6 days until the patients general condition permitted an internal fixation using a DCS (dynamic condylar screw) (Fig. 5).
Fig. 4: Use of the pinless clamp for calcaneus traction in a case of severely displaced malleolar fracture.
Fig. 5: Example of the use of a pinless clamp for traction on the tibia1 tuberosity in a patient with a distal femur fracture, whose general condition had to improve before internal fixation could be carried out
6.4 concltitm
Fig. 4a: type B.
Initial X-rays
with
displaced
malleolar
fracture
In cases of severely displaced malleolar fractures, pilon fractures, proximal tibia1 fractures and critical soft tissue conditions in diiphyseal tibia1 fractures, a delayed internal fixation is often necessary (Miiller et al., 1991). Fracture stabilization and maintenance of reduction can be achieved by simple calcaneus traction until soft tissue conditions allow internal fixation. Using the pinless clamp
S46
no transosseous insertion of pins is necessary, thus reducing the risk of calcaneus osteitis. Application of the Pinless fixator is simple, can be performed under local anaesthesia, and enhances the patient’s comfort until a definitive operation is performed. Complications are rare and can be avoided by correct use of the clamp. pull-out of the clamp was not observed in our small series. The same method of pinless traction can be used for closed medullary nailing on the extension table and for traction on the tibial tuberosity in the rare cases of delayed internal fixation of fractures of the femur.
6.!5References Heim U., Baltensweiler J. (1981) Checkliste Traumatologie. Thieme Verlag Martini M., Daoud A. (1971) L.e traitement chroniques du calcan&rm par osGites calcanectomie. Rev. Chir. Orthop. 57~415-419
des la
Mijller ME, Allgower M., Schneider R, Willenegger H. (1991) Manual of internal fixation. 3rd Edition, Springer Verlag Rohan N.J., Miller W.E. (1%9) Osteomyelitis. South Med. J. 62:13X-1319
Pin
Track
D. Heim, M. Schi.itz, P. Holzach, P. Matter, Spital Davos CH-7270 Davos Platz
6.1Inaction Calcaneus traction is a common procedure for fractures of the tibia (shaft and proximal segment), for pilon fractures and for displaced malleolar fractures in cases in which immediate internal fixation is inappropriate because of critical soft tissue conditions. Calcaneus traction is also widely used together with medullary nailing of tibia1 shaft fractures using the extension table. The usual method for calcaneus traction is insertion of a Kirschner wire or a threaded or non *aded pin into the dorsal third of the local anaesthesia (Heim and calcaneus under Baltensweiler, 1981). Although osteitis induced by a pin or wire track infection is rare, it still presents a disastrous complication. It is seen more often in cases of pin traction than in wire traction (Rohaq 1%9). Chronic osteitis of the calcaneus often ends in total calcanectomy with persistent walking difficulties (Martini and Daoud, 1971). Thus, if communication between the calcaneus bone and the exterior can be avoided, it would certainly lower the risk of such a troublesome complication.
Fig. 1: To get a good grip of the tips of the pinless clamp in the calcaneus bone, it is very important to make 4 to 6 rocking movements of about 600 with the handles.
The pinless external fiiator seems to be a treatment alternative to the transosseous insertion of a pin. The sharp tips allow safe anchorage in the calcaneal bone and traction can be applied in the conventional manner.
The patient lies supine, the leg is elevated, the foot is held in external rotation of about 15O - W. The insertion points for the two tips of the clamp lie midway between the distal tip of the fibula and the posterior tip of the calcaneus. The skin and periosteum are infiltrated with a short acting local anaesthetic and small skin incisions of about 5 mm are made on each side of the heel. The clamp is then anchored by exerting gentle pressure on the handles to avoid penetration of the bone. To get a good grip with the tips, it is very important to make four to six rocking movements of about 60° with the handles (Fig. 1). Then the handles of the clamp are removed, a cord is put around the hinge and traction of about 3 to 4 kg is applied in the usual manner (Fig. 2).
Fig. 2: Calcaneus traction using the pinless clamp plus connection to a traction wire around the hinge. If traction is used for medullary nailing using the extension table, connection to the clamp’s rotating post with the distraction device of the table is performed (Fig.
Heim: Pinks
s 45
calcaneustraction
3). For safe connection, distal end for anchorage
the rotating post has a rounded in the extension table.
Fig. 3: Use of the pinless clamp for calcaneus traction in a patient being prepared for closed medullary nailing on the extension table. Calcaneus traction is discontinued at the moment of delayed definitive internal fixation or at the end of the nailing procedure.
6.3 Resulti From January to April, 1992, 11 patients were treated using the above-mentioned technique. There were 8 female and 3 male patients with an average age of 46 years (27 to 74 years). 7 patients suffered from a fracture after a skiing accident and 4 sustained their fractures as pedestrians. There were 4 displaced malleolar fmctures type B (Fig. 4), 4 fractures of the tibia1 plateau with important valgus deformity in lateral or bicondylar fractures and 2 complex diaphyseal fractures of the tibii. Traction was applied for an average of 5 days (3 to 8 days) until the local conditions permitted internal fixation. Calcaneus traction for immediate medullary nailing on the extension table using an unreamed tibia1 nail was used for one patient with a diaphyseal segmental fracture.
Fig. 4b: The pinless clamp is applied and calcaneus traction of 4 kg is applied, the fracture is reduced and is maintained in a good position until internal fixation is possible. Two minor local complications were noted: in one female patient (age 55) too much pressure was applied on the handles and the clamp broke into the cancellous bone of the calcaneus, one male patient (age 41) complained about temporary disaesthesia on his heel. No clamp pulled out during traction and no superficial or deep infection occurred. After removal of the clamp the skin incisions were left open for spontaneous closure. In an additional patient, traction was performed on the tibiil t&erc&ty for a distal femur fracture for 6 days until the patients general condition permitted an internal fixation using a DCS (dynamic condylar screw) (Fig. 5).
Fig. 4: Use of the pinless clamp for calcaneus traction in a case of severely displaced malleolar fracture.
Fig. 5: Example of the use of a pinless clamp for traction on the tibia1 tuberosity in a patient with a distal femur fracture, whose general condition had to improve before internal fixation could be carried out
6.4 concltitm
Fig. 4a: type B.
Initial X-rays
with
displaced
malleolar
fracture
In cases of severely displaced malleolar fractures, pilon fractures, proximal tibia1 fractures and critical soft tissue conditions in diiphyseal tibia1 fractures, a delayed internal fixation is often necessary (Miiller et al., 1991). Fracture stabilization and maintenance of reduction can be achieved by simple calcaneus traction until soft tissue conditions allow internal fixation. Using the pinless clamp
S46
no transosseous insertion of pins is necessary, thus reducing the risk of calcaneus osteitis. Application of the Pinless fixator is simple, can be performed under local anaesthesia, and enhances the patient’s comfort until a definitive operation is performed. Complications are rare and can be avoided by correct use of the clamp. pull-out of the clamp was not observed in our small series. The same method of pinless traction can be used for closed medullary nailing on the extension table and for traction on the tibial tuberosity in the rare cases of delayed internal fixation of fractures of the femur.
6.!5References Heim U., Baltensweiler J. (1981) Checkliste Traumatologie. Thieme Verlag Martini M., Daoud A. (1971) L.e traitement chroniques du calcan&rm par osGites calcanectomie. Rev. Chir. Orthop. 57~415-419
des la
Mijller ME, Allgower M., Schneider R, Willenegger H. (1991) Manual of internal fixation. 3rd Edition, Springer Verlag Rohan N.J., Miller W.E. (1%9) Osteomyelitis. South Med. J. 62:13X-1319
Pin
Track
