Skeletal Traction Types & Indications

Skeletal Traction is a temporary treatment method used in emergency department in some type of lower extremity fractures. It’s more powerful and has greater fragment control than skin traction.

It permits pull up to 15% to 20% of body weight for the lower extremity.

There is also a skin traction which is a less invasive than skeletal traction, in this method, splints, bandages, or adhesive tapes may be applied to the skin.

A comparative evaluation of the efficacy between skeletal traction and skin traction in pre-operative management of femur shaft fractures shown that both of them were equally effective in controlling pre-operative pain in adult patients with femoral shaft fractures and does not affect intra-operative blood loss and post-operative management.

Skeletal traction may be the definitive treatment in patients who are too sick for surgical treatment.

It is important to insert the pin from the area of most risk to the area of least risk, as the direction of the pin can be controlled only during its insertion and the path cannot be altered once it exits bone.

See Also: Pelvic Fractures

Skeletal Traction Indications:

1. Temporary management of neck of femur fractures.
2. Femoral shaft fracture in children (It is mostly a final treatment).
3. Undisplaced fracture of acetabulum.
4. After reduction of dislocation of the hip.

Choice of thin Kirschner wire (K-wire) versus Steinmann pin:

Kirschner wire (K-wire):

K-wire is more difficult to insert with a hand drill and requires a tension traction bow.

The Steinmann pin:

Steinmann pin may be either smooth or threaded:

• A smooth pin is stronger but can slide easily through bone.
• A threaded pin is weaker and bends more easily with increasing weights, but it will not slide, and will advance more easily during insertion.

Partially threaded pins are more difficult to insert than the threaded and smooth pins because the non-threaded portion is more difficult to advance through bone.

In general, pin size is based on the diameter of the bone and the pin diameter should always be less than 30 percent of the diameter of the bone. Smaller smooth pins should be used in children with open physes.

The pin should be placed parallel to the joint and in appropriate relation to the limb axis.

Types of skeletal traction:

1. Tibial Skeletal Traction:

• The pin is placed 2 cm posterior and 1 cm distal to the tibial tubercle, it may go more distal in osteopenic bone.
• The pin is placed from lateral to medial to direct the pin away from the common peroneal nerve and anterior tibial artery.
• The skin is released at the pin’s entrance and exit points.
• Optimally, avoid penetrating the anterior compartment.
• A sterile dressing is applied next to the skin. Sharp ends should be protected.

Contraindications for placement of proximal tibial traction pins include:

1. ligamentous injury to the ipsilateral knee (check for swelling of knee after initial injury or when the patient is in traction),
2. a patient who is skeletally immature (may cause recurvatum injury due to damage to the tibial physis),
3. ipsilateral long stem TKA,
4. tibial plateau fracture with metaphyseal comminution.

2. Femoral Skeletal Traction:

• This is the method of choice for pelvic, acetabular, and many femoral shaft fractures (especially in knees with ligamentous injuries).
• The pin is placed from medial to lateral (directed away from the neurovascular bundle) at the adductor tubercle, slightly proximal to the femoral epicondyle.
• The location of this pin can be determined from the anteroposterior (AP) knee radiograph using the patella as a landmark.
• One should spread through the soft tissue to bone to avoid injury to the superficial femoral artery

3. Calcaneal Skeletal Traction:

• Calcaneal Skeletal Traction is most commonly used with a spanning external fixation for “traveling traction,” or it may be used with a Bohler-Braun frame.
• It is used for irreducible rotational ankle fractures, some pilon fractures, and extremities with multiple ipsilateral long bone fractures or compromised soft tissues.
• The pin is placed from medial to lateral, directed away from the neurovascular bundle, 2 to 2.5 cm posterior and inferior to the medial malleolus.

See Also: Ankle Anatomy

Traction for Femoral Fractures

Treatment of femoral diaphyseal fractures by traction should be reserved for cases for which no other method is available.

There are six basic methods of skeletal traction of the femoral fractures:

1. Thomas splint:

Thomas splint with a Pearson knee piece attached to the splint. The Thomas splint supports the leg and balanced traction is applied.

After 4 to 6 weeks the knee piece is applied and knee mobilization commenced.

This was a commonly used traction apparatus.

2. Braun traction:

Braun traction and a weight and pulley system is a very simple traction system that permits traction in the longitudinal axis of the femur. Control of the femoral fragments was difficult.

The system, using skin rather than skeletal traction, is still used for temporary traction prior to femoral diaphyseal surgery.

3. Hamilton-Russell traction:

Hamilton-Russell traction, which uses a one-pulley system to provide support for the femur and to apply traction.

The mechanical advantage offered by two pulleys at the foot of the bed theoretically meant that the longitudinal pull was twice as great as the upward pull and the resulting traction was at an axis of 30 degrees to the horizontal, approximately in line with the femur.

This method of traction does not adequately control the femoral fragments and it was sometimes used after a period of skeletal traction.

4. Perkins traction:

This is essentially a straight pull along the axis of the femur through a proximal pin but without a splint. The control of femoral alignment was poor and malunion was common.

Perkins believed in early knee mobilization and advocated the use of a split bed later in the treatment of femoral diaphyseal fractures.

In this system the patients sat on a bed with the knee flexed over the mattress and knee movement was encouraged while longitudinal traction was maintained.

5. Fisk traction:

This consists of a short Thomas splint and a hinged knee piece.

Traction in the axis of the femur was maintained using a proximal tibial transosseous pin but the patient could flex the hip and knee by pulling on a separate cord attached to the end of the thigh splint.

6. 90-90 traction:

In this method, the thigh is pulled upward and both hip and knee are at 90 degrees.

The advantage of this method is that gravity does not cause posterior sag of the femoral fragments.

It was used for proximal femoral diaphyseal fractures when the proximal femoral fracture was flexed by the unopposed action of iliopsoas.

The method is still used for pediatric femoral fractures.

Skeletal Traction Complications

Skeletal Traction Complications may include:

1. Pin tract infection: Patients should be closely evaluated for pin tract infection and decubiti secondary to prolonged immobilization.
2. Pressure sores.
3. Nerve compression injury.
4. Joint stiffness.
5. Deep vein thrombosis (DVT).

References

1. Campbel’s Operative Orthopaedics 12th edition Book.
2. Rockwood and Green’s Fractures in Adults 8th Edition book.
3. Agbley DYD, Holdbrook-Smith HA, Ahonon Y. A comparative evaluation of the efficacy between skeletal traction and skin traction in pre-operative management of femur shaft fractures in Korle Bu Teaching Hospital. Ghana Med J. 2020 Sep;54(3):146-150. doi: 10.4314/gmj.v54i3.4. PMID: 33883758; PMCID: PMC8042791.
4. Althausen PL, Hak DK. Lower extremity traction pins: indications, technique and complications. Am J Orthop (Belle Mead NJ). 2002; 3. 31(1):43-7.
5. Kwon, et al. Lateral femoral traction pin entry: risk to the femoral artery and other medial neurovascular structures. J Orthop Surg Res. 2010;5:4.
6. Merk Bradley R. Femoral and tibial traction pin placement. In: Stern, Steven H (Eds). Key Techniques in Orthopaedic Surgery. NewYork: Thieme; 2001. pp. 321-5.
7. Wheeless III, Clifford R. Femoral and tibial traction pins. Wheeless’ Textbook of Orthopaedics; 2010.