When to Place Distal Femoral Traction

This can vary based on institution. It is important to consider the fact that pretty sick patients may not be able to tolerate a surgery and skeletal traction can be a viable damage control method for provisionally treating patients.

Here is the list of what our institution commonly uses skeletal traction for.

• Unstable native hip dislocations (such as in the setting of posterior acetabular wall fractures)

• Very unstable acetabular fractures (protrusio acetabuli, or severely comminuted acetabular fractures)

• Loose bodies in the hip joint. Goal is to keep the cartilage surface from being damaged by loose bodies such as bone or bullets.

• Femoral shaft fractures in people with brain injuries (may not be fit for surgery for a long time)

• Severe midshaft femur fractures, either severely angulated or impending skin penetration, or concern for significant bleeding into the thigh

• There can be >1L of blood loss in the thigh, placing tension on the musculature with traction closes down the potential volume and can theoretically decrease bleeding

• Shortened femoral shaft fractures (can help make reduction during surgery easier)

• Ipsilateral to vertical shear pelvis fracture

Equipment list

I like to keep this traction pin equipment list on a note taking app on my phone. When I’m on call I can just text the ED the supplies I need so things are around before I get to the hospital while on home call

• This list will likely vary depending on how the hospital your at packages the equipment

Equipment:

Sterile Batteries

Skeletal traction kit (Includes Steimen pins, traction bow)

Steimen pin set (avoid pins with threads they can take too much bone with them when pulling them out)

Power cordless drill kit

Pack of sterile towels

15 or 11 blade

Betadine scrub brush x 2,

Betadine solution

Traction bed

Traction cart (weights and bed set up)

Rope

Sterile gloves multiple pairs

If local is required:

60ml of lidocaine (1ml per kg limit)

60ml syringe (or multiple 10ml syringes)

18 – 22 gauge needles, may need a spinal needle if bone more than 1.5 inches from skin

• Make sure u have correct traction bow, if using a small Steimen pin, it should be a tensioning bow (these usually come in the traction kits)

• If you don’t use a tensioning bow the smaller diameter pins will bend too much

Tension Bow

• 15lbs of traction is a good start, shooting for ~10% of body weight, (10lbs if bad femur in kids, check with attending)

• Bad acetabular fractures may require ~30lbs in some patients.

• Get post traction xrays to check your reduction and pin placement

Steps

• Verify traction site with xrays ahead of time, everytime. (It looks very bad to put a traction pin into a fractured calcaneus!)

• Notify the other teams of your intention to get sedation set up 

• (Propofol use is common, if not hypotensive. If hypotensive ketamine is an option)

• If patient very unstable you can just do local anesthetic (1ml/kg limit)

• 20-30ml of lidocaine per side. Use half superficial and half deep

• Make larger superficial wheal over the exiting side

• Track down help to hold patient if needed (keep the patient’s leg from moving)

• Ensure location and that you’ve viewed all the imaging

• You can’t pull traction through an unstable knee (if you’re aren’t careful you would be pulling through the vessels and nerves, this is very bad).

• For femoral shaft fractures shoot for distal femur

• For distal femur fractures using a knee immobilizer is usually preferred

• If floating knee (femur fracture with tibia fracture) consider calc traction

• The more proximal traction that you can use is generally better than distal traction (femur > knee > calc)

• Set up bed first with bars and rope 

• Set up your equipment ahead of time

• Open traction kit in sterile fashion along with cordless drill, batteries, Steimen pin set, 11 blade knife, towels

• You don’t always need the Steimen pin set if the correct Steimen pins are placed in the traction kits

• With sterile gloves, set up your cordless drill with the attachment that lets you “grab” pins, find your pin size (2 – 2.5mm pin)

• Start sedation 

• Reduce leg coach your holders

•  Chloroprep or betadine the whole area, give yourself extra space

• I also like using the betadine scrub brushes or betadine with gauze

• Lay out sterile towels covering a good working space

• Distal femur traction

• Goal is 1-2 fingerbreadths proximal from the superior patella pole

• I usually use 1 fingerbreadth for adults

• Too proximal is bad, because it is close to Hunter’s canal and close to the neurovascular bundle

• Also the traction bow won’t fit around the knee

• Avoid being too distal, you don’t want to pass through the intercondylar notch

• Palpate the distal femur

• Check your finger measurement for how proximal

• Poke your pin down to bone targeting the middle of the femur

• Walk the pin until you feel the anterior aspect, then walk the pin posterior until you start to feel the drop off towards the posterior aspect (always staying very close to bone)

• Split the difference and hit the middle

• Screw the pin across keeping the pin parallel to the joint and horizontal to the bed (often have to drop your hand and move the other leg out of the way)

• Start medial and go lateral it is okay to screw the pin clockwise, some like to oscillate

• Feel two cortices

• Go through the skin on the lateral side ensuring equal length of the pin sticking out on both sides

• Make skin incisions on the pin entry to allow the pin to move when put on traction without tensioning the skin (if you don’t release the skin it can cause skin necrosis)

• Apply half of a betadine sponge over the pin on each side

• Apply tensioning traction bow

• Bend over the ends of the pin so no sharp ends are exposed

• Another option is to pad the sharp ends with extra betadine sponge and then secure in place with acewrap

• Tie very secure knots to the bow and the weights (patients sometimes thrash around

• I like bowline knots, typical square knots, slip knots…

• Slowly hang the traction weights

• Ensure that the traction bow is not resting on skin 

• Ensure that weights have a long way to travel before hitting the ground (rope stretches and patients slide down the bed)

• Sometimes you can remove the foot/end of the bed if the patient’s feet are about to hit the end of the bed

• Get post traction xrays of fracture site and traction pin site.

Proximal Tibial Traction

• Same set up except target is just below the tibial tubercle

• Start point is lateral to medial (lateral is closer to common peroneal and you have more control at your start site)

• Never pull traction through an unstable knee (dislocations, concern for ligament injury, type 4, 5, 6 plateaus…etc)

• Don’t place pin too anterior in the tibia, the cortex can fracture if the pin is too close to the anterior surface

• Don’t use in kids (can cause deformity)

• For further details check out Wheeless’

Calcaneus Traction

• Same set up, target is ¾ of the distance from the tip of the medial mal to the end of the calcaneus.

• Start medial (side of neurovascular bundle) and shoot lateral

• Feel the dorsal and plantar edges and shoot through the middle splitting the difference

• Check out this video for more details