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Traction for DDH

- Discussion:
    - traction is often required for Pavlik harness treatment failures or for lately diagnosed cases;
    - reduction of hip may be difficult in infants w/ delayed diagnosis of DDH;
    - in children < 3 years of age, preop traction may decrease avascular necrosis, and may improve chances of successful closed reduction;
    - children greater than 3 years of age do not benefit from preop traction;
           - in these children, femoral shortening will prevent excessive compression of femoral epiphysis & will prevent AVN;
    - several weeks of traction may be required to achieve reduction of femoral head;
           - progress w/ reduction is judged by serial radiographs, noting the relation of the ossific nucleus of the femoral head to the triradiate cartilage;
                  - if the ossific nucleus is not visible, then use the superomedial edge of the metaphysis as a reference point;
    - typically, once traction has been successful, adductor tenotomy is then performed followed by closed reduction and placement in a hip spica cast for 4 months;
           - after hip spica is removed, consider abduction splint for upto 1 year;
           - if stable closed reduction is not achieved (as noted on an intra-operative then consider open reduction;
    - as noted by Daoud, et al (1996), closed reduction was successful in 76% of children (avg age 33 months) when it was preceded by skin traction (avg 23 days);
           - these children did not require any other additional form of treatment;
           - traction was used for a mean of 8 weeks;
           - Congenital dislocation of the hip in the older child. The effectiveness of overhead traction.

- Method of Skin Traction: (from Daoud, et al (1996));
    - longitudinal adhesive straps are placed across the medial and lateral sides of the lower extremity from the hip to the ankle;
           - non circumferential transverse straps oppose the longitudinal straps to the leg;
           - over top of this, is applied firm (not tight) circumferential bias wrap;
    - mean traction wt is 27% of body wt (enough to lift buttocks slightly)
           - traction should be increased slowly upto this wt over a few days;
    - position of the leg:
           - 90 deg of flexion, neutral rotation, 20 deg of abduction;
           - note that others recommend traction w/ hip in 45 to 90 deg of flexion & 20 to 70 deg of abduction;
    - mean duration of traction should be about 3 weeks;
    - after three weeks, closed reduction is then attempted with the child under anesthesia, with arthrographic documentation;
           - adductor tenotomy is usually required bilaterally;
           - judge the adequacy of the reduction and whether the reduction is maintained with the hips in the safe

Reduction of neglected traumatic dislocation of the hip by heavy traction.

Congenital dislocation of the hip. The relationship of premanipulation traction and age to avascular necrosis of the femoral head.

Congenital dislocation of the hip in children. Comparison of the effects of femoral shortening and of skeletal traction in treatment.

The value of preliminary traction in the treatment of congenital dislocation of the hip.

Current practice in use of prereduction traction for congenital dislocation of the hip.

Congenital dislocation of the hip in the older child. The effectiveness of overhead traction.

Preliminary traction in the treatment of developmental dislocation of the hip.

Long-term Outcome of Gradual Reduction Using Overhead Traction for Developmental Dysplasia of the Hip Over 6 Months of Age