How To Perform: Proximal Tibial Skeletal Traction

Omar F. Rahman, MD, MBA
Orthopedic Surgery Resident Physician, PGY-5
Lenox Hill Hospital – New York, NY

The application of skeletal traction in the setting of lower extremity fractures is an essential aspect of orthopedic traumatology. By applying temporary skeletal traction, fracture length, reduction, and stability can be temporized. Proximal tibial traction can be utilized for many types of orthopedic injuries including fractures and/or dislocations of the pelvis, acetabulum, and femur. While the application of a skeletal traction pin in the emergency department may sound unnerving to the junior resident, following step-by-step guidelines on its application may help alleviate some concerns. This article will discuss the proper application of a skeletal traction pin through the proximal tibia.

Before performing, it is important to understand the anatomical considerations involved in skeletal traction through the tibia. Since traction is being applied distal to the injured site, skeletal traction through the tibia is maintained via ligamentotaxis through the knee joint. Therefore before applying traction, it is critical to assess the ligamentous stability of the knee joint. The knee must be relatively stable in order to pull traction through the ligaments, specifically the medial and lateral collateral ligaments. The resident should assess varus and valgus stability of the knee grossly in 0 degrees flexion (or full extension) as well as 30 degrees of knee flexion, if possible. Both anterior and posterior stability can also be assessed if appropriate. Once the knee has been determined to be stable in the coronal plane, tibial traction can be performed.

Proximal tibial traction has multiple advantages compared to distal femoral traction. The anatomic landmarks on the proximal tibia are more reliable and identifiable compared to the distal femur especially in the trauma setting where soft tissue swelling and body habitus may obscure landmarks that may otherwise be recognizable. Moreover, the subcutaneous nature of the proximal tibia compared to the soft tissue envelope surrounding the distal femur may allow for easier passage of traction pins. However, if there is injury around the knee joint such as in the setting of a multi-ligamentous injury and/or knee dislocation, skeletal traction through the proximal tibia may not be indicated.

The supplies needed for a proximal tibial traction pin are similar to that of distal femoral traction and include the following:

Some items necessary that are included in Arbutus Medical’s TrakPak® kit

Sterile towels x 4
Sterile gloves
Surgical marking pen
Skin cleaning prep (chlorohexidine gluconate or povidone-iodine solution)
Local anesthetic (~10-20cc, 1% or 2% lidocaine with or without epinephrine)
20 cc Syringe (for anesthetic)
18G needle (to draw anesthetic)
22G needle x 2 (to inject anesthetic)
Traction pin x 1
Traction pin caps x 2 (or blood collecting tubes x 2)
Xeroform x 2 (2 x 2 cm squares)
Kerlix dressing x 3 (large)
Drill
Traction bow
Hook to connect weights to rope
Traction rope
5 lbs weights x 2 to 3
Traction Bar Attachment to Hospital Bed

Tibial traction pins are applied from a lateral to medial direction, from an anatomic area that is known to be unknown. On the lateral aspect of the proximal tibia, the major neurovascular structure in the area is the common peroneal nerve. The common location for this nerve is approximately 2 cm distal to the fibular head as the common peroneal nerve crosses within the peroneus longus muscle into the anterior compartment of the lower leg. Although this nerve is out of the way of where a proximal tibial traction pin will be placed, it is good practice to understand and be aware of the neurovascular structures at risk. The other consideration to be aware of is the extent of the knee capsule distal to the knee joint. A study in the Journal of Orthopaedic Trauma demonstrated that the knee capsule can extend up to 14 mm distal to the knee joint. It is essential to place the proximal tibial traction pin extra-capsular and greater than this length in order to be at a safe distance away from the knee joint and to avoid intracapsular penetration potentially causing a septic knee joint. Once these anatomic considerations are understood, tibial traction can be performed.

Identify and demarcate the superficial landmarks around the proximal tibia.
1. Make note of the medial and lateral knee joint lines and the four poles of the patella. The tibial tubercle and the fibular head should also be identified.
Identify the proper placement of the tibial traction pin.
1. This is generally approximately 2 fingerbreadths distal to the tibial tubercle and 2 fingerbreadths posterior and lateral on the tibia.
2. Mark this trajectory on the lateral as well as the medial side where the pin will exit.
Use the prep solution to clean the leg on both the lateral and medial aspects.
1. Start from the center and work circularly in an outward direction.
Don sterile gloves and place sterile towels around the proximal tibia.
1. Keep the knee joint in view in order to not block out any anatomical landmarks.
Apply local anesthesia around the marked trajectory of the pin on the lateral as well as the medial side where the pin would be expected to exit.
Place the traction pin on the drill and then place the traction pin on the marked skin laterally.
1. Generally, the tip of the traction pin is sharp enough to puncture through the skin.
2. A small stab incision could also be made with a #11 blade scalpel.
3. In our practice it has been found that stab incisions with a scalpel can stretch over time especially with weighted traction, therefore it is not generally used.
After going through the skin, subcutaneous, and soft tissue, palpate for bone.
1. The proximal tibia is close to the subcutaneous tissues.
2. Once on bone, walk the pin slightly anterior and slightly posterior in order to gauge that the pin is relatively central on the bone.
3. While the more critical neurovascular structures are on the posterior aspect of the tibia, it is also important to not be too anterior on the tibia to ensure that the pin has adequate depth when weighted traction is applied.
4. Confirm that the pin is parallel to the knee joint line.
5. Once confirmed placement on the tibia, drill full speed and drive the pin through the bone and through the soft tissue and skin on the medial side.
Even out the amount of the pin that is outside of the skin on both the medial and lateral sides.
1. This will ensure that there is enough space on both the medial and lateral sides for the application of the traction bow and pin caps.
Place pin caps on the tips of either side of the pin to protect both the patient and staff.
1. Alternatively, blood collecting test tubes can be utilized.
Place Xeroform over the pin sites on the skin
Apply the traction bow and wrap the pin sites with Kerlix and continue to wrap the entire traction bow with Kerlix.
1. This acts as a cushion buffer in case the traction bow ever makes contact with the patient’s skin.
Cut traction rope and apply a traction knot.
Apply rope to the traction bow with a hook and then attach traction apparatus to the bed.
Hang weights from the hook.
1. Use 5-pound increments.
Ensure that the traction bow is not resting on the patient distal to the traction pin site.
1. A fully wrapped Kerlix can be placed directly on the skin at this level to ensure the traction bow does not come in contact with the patient’s skin in order to avoid a pressure ulcer.
Obtain post-traction radiographs to determine if more or less weight is needed.

While skeletal traction may be sound daunting at first, understanding anatomical considerations, being prepared with all necessary equipment, and following these clear and concise steps will lead to success.