Summary Distal femur skeletal traction is used to provisionally immobilize and reduce fractures via a transosseous pin or wire for shortened femur fractures, axial traction restores length, reducing muscle spasms and increasing tension to help control bleeding for pelvic shear or ring fractures with vertical instability of the ipsilateral hemipelvis, traction maintains alignment for binder use and reduces blood loss through muscular tamponade for unstable acetabular fracture-dislocations, traction maintains joint reduction, reduces fragment displacement, and reduces pressure necrosis of the hip articular surface or incarcerated fracture fragments A pin or wire is surgically inserted into the femur, and a weight is attached over a pulley system to apply continuous traction in the appropriate vector for fracture reduction While historically utilized for definitive treatment, skeletal traction is indicated to temporize bony and soft tissue injury while assisting with pain control Applied in anticipation of definitive operative management when other methods of closed reduction and immobilization are not suitable Anatomy Osteology distal femur medial condyle extends more distal than lateral anatomical axis of the distal femur is 6-11 degrees of valgus becomes trapezoidal in cross-section towards the knee lateral cortex of femur slopes ~10 degrees, medial cortex slopes ~25 degrees in axial plane posterior halves of both condyles are posterior to the posterior cortex of the femoral shaft femoral epicondyles located by palpating the distal femur medial epicondyle Distal to the adductor tubercle and anterior to the medial head of gastrocnemius origin lateral epicondyle Smaller and less prominent than medial epicondyle Attachment of lateral collateral ligament (LCL) adductor tubercle insertion site of adductor magnus ideal pin entry site located 0.7 cm proximal to adductor tubercle Arthrology suprapatellar pouch extends approximately 5 cm proximal to the superior pole of patella Muscles 3 compartments of the thigh anterior sartorius quadriceps posterior biceps femoris semitendinosus semimembranosus adductor gracilis adductor longus adductor brevis adductor magnus Ligaments medial collateral ligament (MCL) lateral collateral ligament (LCL) Blood Supply femoral artery and vein proximally located in the femoral triangle, medial to the femoral nerve pass through the adductor canal, where the vein shifts to a posterolateral position relative to the artery politeal artery and vein continuation of femoral artery and vein after exiting through the adductor hiatus (8-13.5 cm proximal to adductor tubercle) courses posterior to the distal femur giving off geniculate branches divides into the anterior and posterior tibial arteries at the lower border of the popliteus muscle Nerves saphenous nerve located slightly posterior to the medial epicondyle, usually between the tendons of the sartorius and gracilis muscles gives off its infrapatellar branch to supply sensation to the anteromedial knee Biomechanics traction weights determined by age, bone quality, and condition of soft tissue envelope countertraction provided by patient positioning (trendelenburg or decline), friction, body weight, or restraints applied to affected limb acetabular fracture considerations distraction of the hip joint may prevent pressure necrosis of the femoral head and acetabular articular surfaces traction can assist with offloading of incarcerated fracture fragments subluxated/dislocated femoral head due to posterior wall or quadrilateral plate fracture can benefit from longitudinal traction for maintenance of reduction vector of distal femoral traction pull is not perpendicular if femoral head medialized (protrusio) due to quadrilateral plate fracture may require use of trochanteric traction fractures through the weight bearing dome are expected to be irreducible with traction, limiting utility of distal femoral skeletal traction pelvic ring considerations reduction of ipsilateral hemipelvis in vertical shear injuries (with complete disruption of posterior sacroiliac ligamentous complex) assess for ipsilateral proximal femur which may limit utility of distal femur traction for pelvic injuries distal femoral traction is preferred in the setting of ipsilateral knee ligamentous injury, proximal tibia fracture, or presence of proximal tibia implant Preparation Patient positioning supine position the patient should be positioned lying on their back with the affected hip flexion and the knee slightly flexed (about 20-30 degrees) placing a bump under the patient's knee will help maintain this position may also use a balanced suspension to maintain knee flexion minimizes risk of traction-related peroneal nerve injury injured lower limb is suspended this position helps relax the quadriceps muscle, optimizing the femur for pin insertion slight flexion reduces tension on the femoral shaft, making the procedure safer and more effective de-rotating leg patella is facing upwards to ensure pin/wire is driven parallel to the floor and joint line/physis Equipment Steinmann pin (partially or fully threaded), Kirschner wire (smooth), or tongs threaded pins advance more quickly through bone threads may bind and damage soft tissue at entry and exit site engage cortex and less likely to loosen over time smooth pins more likely to loosen over time more difficult to advance less associated soft tissue damage less likely to bend pin diameter should be <30% of bone diameter padding or pin caps should be applied to prevent injury to providers and contralateral limb sterile surgical pin/wire driver a surgical driver is used to insert the pin tension bow (Kirschner bow) applies lateral tension to the k-wire strengthens the wire to prevent bending/mechanical failure alternatively, may use Bohler traction bow (does not provider lateral tension and requires larger pin diameter to prevent bending) sterile drapes, gloves, syringe, needles, scalpel, and antiseptic solution maintain a sterile field to reduce the risk of infection use antiseptic solution to clean the insertion site before pin placement traction bed a patient bed with traction frame post mounts note: must be compatible with the traction frame system being used traction bed frame a combination of posts and pulleys secured to the end of the traction bed used to guide the rope and weights through to apply traction note: must be compatible with the traction bed being used traction weights 10-20 lbs of traction weights 10-15% of patients body weight rope connected to the weights, strung through the traction frame, and secured to the tension bow in order to apply traction to the leg bowline and cow-hitch knots preferred over traction knot for knot security Anesthesia local Infiltration with lidocaine mark anticipated entry and exit sites for pin/wire clean the leg before performing skin wheal inject 20cc total of lidocaine, to the entry and estimated exit points for the pin, 10cc medially and 10cc laterally each with a skin wheal and to the periosteum patients with larger soft tissue envelope/body habitus may require use of a spinal needle to reach the periosteum while waiting 1-2 minutes for the local anesthetic to create the local block, finish setting up the other equipment prep the leg with drapes after skin infiltration sedation or regional anesthesia (optional) Pin/Wire Placement Pin insertion techinique ideal entry site 0.7 cm proximal to adductor tubercle adjacent to the metaphyseal flare thicker cortices in this region support more traction weight avoids intra-articular placement and minimizes risk to femoral neurovascular bundle pin trajectory should be parallel to the joint line or physis and perpendicular to the planned axis of traction inserted from the medial to lateral side to avoid femoral/popliteal neurovascular structures (located medially) during pin entry and exit sharply incise skin and bluntly dissect underlying soft tissue down to the bone with tonsil hemostat insert the pin and locate the center of the bone to ensure bicortical/transmedullary pin placement bicortical pin placement is critical to avoid causing additional fracture and minimize risk of wire loosening or thermal osteonecrosis proximal placement risks injury to the femoral artery at adductor (Hunter's) canal may place pin eccentrically (anterior third) to accomodate an intramedullary nail if planned for definitive fixation insert the pin at the marked site, advance to bone, and gently probe to locate its anterior and posterior limits before positioning it centrally or in the anterior ⅓ as preferred ensure the pin is not pushed past the posterior cortex to avoid injury to key popliteal neurovascular bundle connect the pin to the pin driver, if not already, and prepare to drive through the bone by ensuring the leg is held securely in the desired position ensure the pin is parallel to the floor and joint line and advance on full speed to avoid thermal necrosis a tactile “pop” should be felt when the pin is driven through each cortex, confirming the pin has been placed bicortically the skin may be sharply incised on the far side of the limb before pin is fully advanced dress the pin sites to protect the tissue by wrapping with occlusive mesh dressing around the pin entry and exit sites and secure with gauze Applying Traction secure tension bow to the wire attach rope to end of tension bow and guide through pulley on traction frame attach weight to end of rope to apply traction to leg 10-15% of body weight 5-9 kg (10-20 lbs) is typically sufficient hang weight slowly to allow for traction to be applied gradually ensure tension bow is lifted off tibia to prevent pressure ulcer confirm patient is in the correct position in the bed and their foot is not touching the footboard, if applicable, to ensure traction force is being applied correctly perform post-traction radiographs to verify that the fracture has been reduced adequately may be obtained 6-12 hours after traction applied to allow for adequate muscle relaxation if more reduction is needed, incrementally add weight, 2-5 lbs at a time additional blankets, positioning aids, countertraction, or balanced suspension may be required for adequate reduction Patient Monitoring After every shift or patient transfer, confirm the following: weight hanging freely and unobstructed injuried extremity not resting on footboard if patient has slid down bed, reposition them to ensure traction is being applied adequately leg de-rotated (patella towards ceiling) tension bow tight (prevent mechanical failure/bending of wire) tension bow not resting on patient's leg may need to pad to prevent soft tissue injury or pressure ulcer pin is well-padded and not causing iatrogenic injury to contralateral limb or providers Complications Pin site infections infection at the pin insertion site is one of the most common complications bacterial contamination and colonization can occur, leading to localized soft tissue infection or osteomyelitis Pin loosening and mechanical failure Skin trauma/necrosis adjacent to pin sites Iatrogenic injury to contralateral limb from pin Pulmonary complications atelectasis hospital-acquired pneumonia Venous thromboembolism ensure adequate pharmacoprophylaxis to prevent DVT and PE Muscle atrophy and deconditioning significant muscle wasting due to disuse of the affected limb Decubitus ulcers due to prolonged immobilization and bed rest Increased resource utilization requires frequent monitoring pin-site care and skin hygiene exercise and therapy services to prevent complications from immobility Inadequate fracture reduction