Skeletal traction pin insertion (distal femoral / proximal tibial / calcaneal) and skull tongs

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• pin-site infection
• pin loosening or cutting out
• nerve injury (common peroneal nerve at the proximal tibia)
• vessel injury
• joint stiffness while in traction
• pressure sores, chest problems and DVT from bed rest
• for skull tongs: worsening of spinal cord injury during reduction, skull penetration or fracture, scalp laceration, vertebral artery injury and stroke

Pre-operative details for this operation

1. IndicationFemoral shaft fracture: temporary / definitive tractionPelvic / acetabular / proximal femur fracturePre-operative traction before nailingCervical facet dislocationHangman's fractureDisplaced type II odontoid fractureAtlantoaxial rotatory subluxationSubaxial burst fracture
2. Pin site chosen and whyProximal tibiaDistal femurCalcaneumDistal tibiaOlecranonGardner-Wells tongs
3. Distal neurovascular status beforepulses, sensation, movement; for tibial pin, common peroneal nerve function (ankle and toe dorsiflexion, first web space sensation)
4. Skull tongs: neurological examinationASIA motor and sensory; complete or incomplete injury; patient awake and able to cooperate
5. Skull tongs: contraindications checkedskull fracture, poor skull bone (Paget's, osteogenesis imperfecta), age under 3 years, atlanto-occipital dissociation, head injury needing craniotomy
6. Skull tongs: pre-reduction MRIDone: disc herniation absent / presentNot done: reason (delay would hold up decompression)

Anaesthesia and position

1. AnaesthesiaLocal infiltrationLocal with low-dose sedation (patient must stay rousable for tongs)Spinal / general (pin inserted at start of another operation)local anaesthetic drug and volume
2. SettingOTEmergency roomWard procedure room
3. Positionlimb held straight and in neutral rotation; for tongs, supine flat on a bed with shoulder counter-traction and pulley

Operative findings

1. Limb pins: pin positionentry and exit points in relation to landmarks; skin not tented or gathered
2. Tongs: pin positionIn line with external auditory meatus (neutral)Slightly posterior (flexion vector)Slightly anterior (extension vector)2-3 cm above the pinna
3. Tongs: reduction achievedlevel, final weight at reduction, X-ray / fluoroscopy findings, any over-distraction

Procedure (steps)

1. Skin preparation and drapingantiseptic; for tongs, pin sites cleaned with spirit
2. Local anaestheticskin and deep tissue down to periosteum on both sides (limb); each pin site (tongs)
3. Proximal tibial pin: site and directionat the level of the tibial tubercle, about 1.5 finger breadths behind the anterior border of the fibula; inserted from lateral to medial to protect the common peroneal nerve
4. Other limb pin sitedistal femur at level of the epicondyles / calcaneum / distal tibia just above ankle; direction chosen by knowledge of the neurovascular bundles; write the direction used
5. Skin incisionNo. 11 blade, vertical, slightly smaller than the pin diameter so the skin fits snugly
6. Pin type and insertionThreaded Steinmann pin (centre-threaded traction pin)Smooth Steinmann pinTensioned K-wire (1-2 mm, smooth) with tensioning bowdiameter, length; hand drill / power drill at low speed; limb held in neutral rotation
7. Exit sidestab over the tented skin; any skin tension released and the wound closed around the pin
8. Tongs applicationGardner-Wells tongs positioned, both pins turned in together with both hands until the torque indicator protrudes (or is flush) as per make
9. Traction set upstirrup / bow, rope, pulley, splint (Thomas / other / none), weight applied
10. Tongs: incremental weightstarting weight, increments and time interval, neuro check before each increase, lateral X-ray / fluoroscopy after each increase; weight reduced after reduction

Closure, drains and dressing

1. Pin-site dressingcircumferential gauze dressing around each pin (limb); ointment at pin sites if used (tongs)
2. Pin ends coveredcaps or guards on sharp ends
3. Neurovascular status afterlimb: pulses, peroneal nerve; tongs: full neurological examination

Specimens and implants

1. Pin / wiretype, diameter, length, make, lot if labelled
2. Tongsmake and size; skull pins single-use or reused as per unit policy
3. Traction weight at endkg (or lb)

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Traction weight and alignmentweight in kg; rope, pulley and weight hanging free; foot of bed raised for counter-traction if needed
2. Neurovascular checkslimb pins: pulses, toe movement, peroneal nerve; tongs: motor and sensory examination
3. Pin carekeep the circumferential dressing clean and dry; change only if soaked; report redness, discharge or loosening
4. Check X-rayfracture position in traction; for tongs, lateral cervical spine after each weight change
5. Pressure areasheel and back care, turning plan (log-roll for spine)
6. Exercisesquadriceps, ankle pumps, breathing exercises
7. DVT preventionas per unit protocol
8. Plandefinitive fixation / duration of traction / halo vest
9. Tongs: stop traction and inform senior ifany new neurological deficit, drowsiness or poor cooperation, or over-distraction on X-ray

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery