How to Perform: Distal Femoral Traction

Distal Femoral Traction – How to Perform

By Stephen R. Stephan
Orthopedic Surgery Resident – PGY5

Distal femoral traction pins are indicated for a variety of different etiologies and fractures.  Typically, they are placed for femoral fractures, acetabular fractures, and pelvic fractures, where you want to maintain length, or even hold a reduction.  The process can be daunting, as these procedures are typically done during busy times and by a junior resident.  Oftentimes, the patients are in distress and the skeletal traction pin will be essential to their prognosis.  For these reasons, formulating a streamlined approach to the procedure is important.  In this text, we will provide step-by-step instructions on how to place a distal femoral traction pin.  

The most important aspect of placing skeletal traction is having all your supplies readily available, preferably in one location.  Every institution has their own way of doing things, with some institutions having ready-made kits versus others where you have to grab all the supplies separately.  

Supplies needed for distal femoral traction pin:

1. Sterile towels x 4 
2. Sterile gloves
3. Marking pen
4. Cleaning solution
5. Local anesthetic ~ 20cc
6. Syringe for anesthetic
7. 18G needle to aspirate anesthetic
8. 23G needles x 2 for injection anesthetic
9. Traction pin x 1
10. Traction pin caps x 2
11. Xeroform/Adaptic x 2 (small pieces)
12. Kerlix dressing x 1 (large)
13. Drill
14. Needle driver
15. Traction bow
16. Hook to connect weights to rope
17. Traction rope
18. Weights
19. Traction apparatus for the bed

Once you have all of these supplies readily available, then it’s time to place the traction pin.  These instructions will specifically pertain to distal femoral traction placement.  

Steps for placing distal femoral traction:

1. Place a pillow under the patient’s knee, on the ipsilateral side to where you are placing the traction pin.  
   1. This will allow you to place your traction pin without having the contralateral leg in the way. 
2. Palpate the landmarks and mark them with a surgical marker.
   1. Patella, joint line, tibial tubercle, adductor tubercle 
3. Mark your trajectory for the traction pin
   1. Typically, you want to place the traction pin 1-2cm proximal to the superior pole of the patella, parallel with the joint line.  Mark this line all the way across the thigh.  
   2. On the anterior/posterior plane – want to place a dot or an “x” along your marked line and 2 cm anterior to the level of the adductor tubercle.  
4. Use a cleaning solution to clean the leg.
   1. Always clean a larger area than you think you will need. 
5. Put on sterile gloves.
6. Place sterile towels around your site, making sure you do not drape yourself out.  
7. Draw up the local anesthetic with the 18G needle and inject 10cc into where you marked the “x” or dot for inserting the traction pin, and also inject another 10cc into where you anticipate the traction pin exiting the skin. 
8. Place the traction pin onto the drill.
9. Insert traction pin onto your mark, from medial to lateral.  
   1. When initially going through the skin, feel for bone. 
   2. When you feel the bone, feel the anterior and posterior borders of the femur, using the tip of the traction pin.  
   3. Typically, you want to be in the anterior third or half of the bone.  
   4. Full speed on the drill.
   5. Drive the wire through the bone and through the skin on the other side
   6. Try to stay parallel with your joint line. 
10. Place pin caps on the end of the pin to protect the patient and staff. 
11. Obtain AP and lateral x-rays to confirm the placement of the traction pin.  
12.  Using needle driver, bend the tips of the traction pin to 90 degrees
13. Place Xeroform/Adaptic over the pin where it exited the skin.
14. Apply traction bow.
15. Wrap pin sites with Kerlix and also extend this onto the traction bow on the side that will be closer to the patient, to act as a buffer to prevent it from lying on the patient and causing a pressure sore. 
16. Measure and cut the rope. 
17. Attach rope to traction bow with hook.
18. Attach traction apparatus to the bed. 
19. Place patient’s knee on pillows to be in line with the pull of the traction. 
20. Hang weights from hook.  
21. Ensure the traction bow is not resting on the patient.  
22. Repeat x-rays with traction in place.  

Typically, traction pin placement occurs in the emergency department, prior to the patient receiving a hospital bed.  You can always perform the skeletal traction pin placement on the ED gurney, and then wait until the patient is on the floor to attach the traction apparatus to the bed.  Ultimately, you want to provide the patient with the most efficient and streamlined care to help them in their situation.  

Again, the key to this procedure is being prepared and having all of the materials in one place.  Having to go back and forth to get things will make you stressed and possibly hurt the patient.  At our institution, we have all our supplies in one room, where we can place everything onto a cart to roll down to the ED or the patient’s room.  Most of our smaller supplies, like the rope or needle driver, are in a “traction pin backpack” which we always keep stocked.