Why or why not skeletal traction?

When bone fractures occur, orthopedic traction may be necessary to temporize or treat the patient. In this article, we will discuss when and what types of traction there are to perform the one that is needed for the injury and the patient.   

Skeletal Traction Indications

Why Traction?

1. Restore length and alignment of fractures and dislocations
2. Reduce pain and muscle spasm
3. Help stabilize unstable fractures and/ or dislocations
4. Prevent blood loss through hematoma formation
5. Offload a joint with an incarcerated fragment

Why Skeletal Traction?

Skeletal traction is used on fractures that cannot be splinted or may be difficult to splint. Pelvis, acetabular, hip, proximal femur, and femoral shaft fractures are good examples. Fractures of the tibia, for example, are often better and more easily treated using splints.  

The Different Types of Traction

• Distal femur traction

• • Unstable hip dislocations
  • Vertical shear pelvic ring injuries
  • Shortened intertrochanteric & subtrochanteric femur fractures
    • Avoid use in nondisplaced/minimally displaced femoral neck fractures due to the possibility of displacement
  • Shortened femoral shaft fractures
  • Incarcerated fragments in the hip joint after reduction
  • Avoid using distal femoral traction for fractures that may go into the knee joint (e.g. distal femur fractures)
  • The pin is placed medial to lateral to avoid the neurovascular bundle

• Proximal tibia traction
  • Shortened intertrochanteric & subtrochanteric fractures
  • Shortened femoral shaft fractures
  • Shortened distal femur fractures (rarely used, more common to use knee immobilizer) 
  • Morbidly obese people
  • Avoid if the knee joint is unstable or unable to be properly assessed (e.g. multi-ligament knee injury suspected)
  • The pin is placed lateral to medial to avoid the common peroneal nerve as it traverses across the fibular head

• Distal tibia fibula traction (extremely rare – these injuries are better treated in splints or braces)
  • Distal femur fractures
  • Proximal tibia fractures
  • Shortened tibial plateau fractures (ex fix within 24 hours is a better option)
  • Most often used if there is a soft tissue defect at the proximal tibia that does not allow pin placement

• Calcaneal traction (very rare)
  • Tibial shaft fractures (splinting is a better option in nearly all cases)
  • Pilon (impacted distal tibia fractures – traction is usually used with an external-fixator)
  • Subtalar fractures
  • Most often used if there is a soft tissue defect at the proximal tibia that does not allow pin placement

When NOT to perform Skeletal Traction?

• If a splint or brace can be placed (upper extremity fractures, most distal femur fractures, and lower leg fractures)
• If a hip dislocation with or without a fracture is stable
• Pathologic fracture (including osteoporosis – pins, especially the 4.0mm and larger, can cause fractures at the insertion site)
  
  • If a pin is placed through a pathologic fracture, the pin tract is considered contaminated. If wide margins resection is subsequently required, this may lead to amputation and prevent limb-salvage procedures.
• If there are skin breaks at or near the pin sites (the skin will break down if a pin is put through a laceration or abrasion)

Work up before a pin is placed:

Femur imaging – Photo courtesy Brown Emergency Blog – Timothy Boardman, 2016

• X-rays of the fracture and/ or dislocation
  • X-ray joint above and the joint below the fracture
• Knee x-rays are important especially in a proximal tibia pin when the knee cannot be properly examined. The femur views may provide a glimpse; however, dedicated knee films are best
• A neurovascular exam is critical. Motor testing can be done without doing a range of motion. Does the muscle fire? If yes, the nerve is intact. Is sensation intact in the proper distributions?  If yes, the nerve is functioning. 
• Assessment of any wounds – avoid skeletal traction if there are traumatic skin breaks in the area of the pin (including lacerations, road rash, abrasions, etc)
• Range of motion of whatever joints patients are able to move.  

Pin Pearls

• After the pin is placed it should be parallel to the knee joint and parallel to the bed
• The pin guide ensures this will happen with less effort
• A neurovascular exam should be performed after the procedure and documented
• Institutions may or may not perform post pin x-rays