The Basics of Femoral Traction
By Greg Pereira
Orthopedic Surgery Resident – PGY5
While skeletal traction can be placed in multiple bones, the femur is one of the common choices in clinical practice. Learning the basics of femoral traction including the materials needed and the steps required to perform the procedure, is key to delivering the best care possible to the patient and will be the subject matter of the remainder of this post.
- Shortened diaphyseal femoral shaft fracture
- Unstable posterior wall acetabular fracture-dislocation (recurrent dislocation after reduction)
- Acetabular fracture with entrapped fragment
- Femoral head fracture-dislocation
- Vertical shear hemipelvis
- Subtrochanteric femur fracture
- Metadiaphyseal distal femur fracture
Most items included in the Arbutus Medical TrakPak
- Surgical marking pen
- Sterile surgical towels (4)
- Cleaning solution (ChloraPrep, DuraPrep, Betadine, alcohol) (4)
- Lidocaine 1% (20mL)
- Sterile gloves
- Vacutainer or pin caps (2)
- Rolled gauze – Kerlix
- 10-ml syringe (2)
- 16-18-gauge needle (2)
- 21-23 gauge needle (2)
- 11-blade scalpel
- Kirschner wire or Steinman pin (based on institutional preference)
- Pin driver
- Kirchner bow
- Traction rope (6 feet)
- Weights (10-25 lbs)
- Traction bed
- Counseling with Risks and Benefits
- Discuss the procedure with the patient, including the risks, benefits, steps, and rationale for doing the procedure. It is important to explain the advantages of improved pain control and fracture alignment. For cases in which articular cartilage may be protected (e.g. acetabular fracture with entrapped fragment) this may be discussed as well. Document this discussion either in your subsequent note or via consent if applicable at your institutions.
- Position the leg and mark the spots
- Bump the leg if need be to ensure the entry and exit site of the pin will be visualized. Mark out the superior pole of the patella, joint line, and adductor tubercle. Draw a line transverse line 2-3 fingerbreadths proximal to the superior of the patellar, parallel with the previously joint line. Place an “x” on this line 2-3 centimeters anterior to the adductor tubercle – this will be the entry site for the pine. As a confirmation, palpate the femur about the location you marked the “x.”
- Sterilize and anesthetize
- Sterilize the medial and lateral aspects of the leg based on the planned pin trajectory. The skin should be cleaned with whatever cleaning solution is preferred at your institution. Draw up the 20mL of lidocaine in two 10mL syringes (using an 18-gauge needle). Switch the needle on the syringe to the 21-23 gauge needles prior to injection. Use 10mL of the lidocaine on the medial side from the skin down to the level of the periosteum of the medial femur. Similarly, the lateral side of the femur (exiting site) should be anesthetized with 10mL of lidocaine to the level of the lateral femoral periosteum.
- Resterilize and drape the extremity
- Resterilize the medial and lateral aspects of the thigh that were just anesthetized. Drape the medial extremity with the sterile towels
- Make knick incision with a scalpel at the entry site (medial)
- Don sterile gloves
- Assemble pin driver, battery, and wire
- While maintaining sterility, assemble the wire driving equipment.
- Insert the pin
- Insert the pin through the knick incision down to the bone. Gently determine anterior/posterior position on the femur by marching the pin tip to the anterior and posterior edge of the femur. Place the wire around the interface of the anterior third and middle third of the femur. Advance the wire bicortically with gentle pressure and full power of the driver.
- Knick incision on the exiting site
- Once the wire has been driven bicortically, advance the wire to the lateral skin until it is barely tenting. Use the scalpel again to make a knick incision for the wire to exit. Drive the wire until there are equal lengths exposed on the medial and lateral sides. Place pin covers or vacutainers over the exposed ends. If at all concerned that you have not driven the pin bicortically, stop and obtain an AP and lateral view of the distal femur.
- Apply the Kirschner bow
- Apply the Kirchner bow to the pin and tension it by turning the handle to the right.
- Dress the Kirchner bow
- There are multiple ways to do this. Wrapping xeroform around the pin sites is good practice to minimize the risk of infection. Additionally, kerlix can be used to wrap around the Kirschner bow for extra padding.
- Set up traction
- Using your rope attach the Kirschner bow to the traction bed pulley system. Make sure to tie looped knots at both ends of the rope. These loops will make it easy to connect the Kirschner bow to the rope and the rope to the weight holding pedestal. Finally, attach your weights slowly as this will begin pulling through the fracture. The amount of weight depends on multiple factors including patient weight, location of the fracture, etc. Finally, assess the foot position to see if the patient would tolerate a pillow under the foot.
- Obtain films (if this was not performed previously)
- Get an AP and lateral view of the distal femur to ensure correct pin placement
Example Procedure Note:
Procedure: Skeletal traction – femoral traction pin
Following informed verbal consent with a discussion of risks and benefits, the patient agreed to proceed with skeletal traction, in particular femoral traction pin placement. A timeout was performed. The usual surface landmarks were marked out. The site was prepped in the usual sterile fashion with chlorhexidine. 20ml lidocaine was injected along the anticipated pin tract both medially and laterally. The site was re-prepped in a sterile fashion with chlorhexidine. A small nick incision was made with an 11-blade scalpel about the entry site. A 2.0 mm pin was inserted from medial to lateral with sterile technique using a pin driver. Tactile feedback was consistent with bicortical penetration of the pin. At the exiting site, a nick incision was made for the pin to exit the skin. The pin was driven across to have equal lengths on each side. A xeroform dressing was applied to the pin sites and kerlix wrap was used to dress the Kirschner bow. The Kirschner bow was placed and tightened. The Kirchner bow was attached to the traction bed with rope in the usual fashion. Weight was gradually applied. Post-placement films were obtained and showed an appropriate location. The patient’s neurovascular status was consistent with the baseline.