Summary Purpose: tibial traction can be used for very distal femoral fractures, larger patients where there is too much tissue around the distal femur, or when the skin is too damaged around the distal femur (burns, lacerations) Mechanism: a pin or wire is surgically inserted into the tibia, and a weight is attached to apply continuous traction, keeping the bone in the correct position to avoid further displacement Indications: it’s commonly used for severe fractures, when other methods like casting are not suitable, or when there are concerns about misalignment or instability in the bone. it also aids in managing soft tissue injuries or deformities Epidemiology Incidence relatively common 10-15% of all femur fractures often result from trauma Demographics young patients sports injuries and high-energy trauma elderly falls or low-energy trauma and may have a higher risk of complications like delayed healing or non-union sex men are at higher risk, particularly in younger age groups due to their higher activity levels and involvement in more high-risk behaviors Risk Factors trauma: high-energy trauma such as motor vehicle accidents, sports injuries, and falls (especially in the elderly) are the primary risk factors comorbidities: diabetes, vascular diseases, or neurological conditions can impair bone healing and increase complications osteoporosis: In older adults, weakened bones due to osteoporosis increase the likelihood of fractures Indications femoral shaft fractures (temporary stabilization before definitive fixation) hip fractures (temporary traction, especially in unstable fractures) acetabular fractures (to help maintain hip joint congruity) patient’s with femur or acetabular fractures who may be delayed in going to the OR due to polytrauma to prevent fat embolism and improve pain control Anatomy Proximal tibia landmarks: tibial tubercle a prominent bony landmark on the anterior surface of the tibia, commonly associated with the attachment of the patellar tendon. note: Avoid direct placement here to prevent injury to soft tissues and tendons patella helps orient the pin placer and clearly identify the knee joint important to avoid damaging patellar tendon and joint capsule joint line keeps the pin parallel to the joint line when driving through the bone 2cm distal to tibial tubercle helps determine entry site location and avoid the knee joint 2cm posterior to previous mark helps determine pin entry site aligns with the marks made 2cm below tibial tubercle helps assure pin placer they are in the right spot Neurovascular structures to avoid: common peroneal nerve located laterally, near the fibular neck damage to this nerve can result in sensory and motor deficits in the lower leg and foot tibial nerve and popliteal vessels these structures lie posterior to the tibia, within the popliteal fossa care must be taken to prevent injury to these vital structures during the procedure, as damage can affect leg function and circulation Preparation Patient Positioning: supine position the patient should be positioned lying on their back with the affected leg extended and the knee slightly flexed (about 20-30 degrees) placing a bump under the patient's knee will help maintain this position 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 being driven through the bone while remaining parallel to the floor and the joint line Equipment: k-wire a thin, steel pin inserted percutaneously for temporary bone stabilization sterile surgical pin driver a surgical drill is used to insert the pin tension bow (kirschner bow) apply lateral tension to the k-wire, which strengthens the wire and helps maintain adequate traction 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 Anesthesia: local Infiltration with Lidocaine 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 on larger patients you may find you need to obtain 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, etc. after skin wheal sedation or regional anesthesia (optional) Placement Pin insertion technique: for tibial traction, the pin is inserted from the lateral to medial side to avoid key neurovascular structures during pin entry and exit before driving the pin, locate the center of the bone to ensure bicortical pin placement bicortical pin placement is critical to avoid causing additional fracture 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 third as preferred be mindful of the slope of the face of the tibia angle the pin or diverge, looking to see that the angle between anterior and posterior limits is equally divergent from neutral ensure the pin is not pushed past the posterior limit to avoid contacting key neurovascular structures remove the pin from the leg and perform a longitudinal skin nick at the desired pin entry site with an 11 blade reinsert the pin through the skin nick to the entry site located on the bone 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. have someone hold the leg if needed due to the slope of the tibial face, start with the pin perpendicular to the bone, pointing posteriorly, to avoid skiving off the tibia. Start by creating a burr on the bone, then drop the pin driver to be parallel with the floor and continue driving through the bone progress quickly to minimize heat generation a tactile “pop” should be felt when the pin is driven through each cortex, confirming the pin has been placed biocortically dress the pin sites to protect the tissue by wrapping xeroform around the pin entry and exit sites. Secure the xeroform with gauze Applying Traction secure tension bow to the wire attach rope to end of tension bow and guide through pulley on traction frame apply weight-based traction: 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 additional imaging to verify that the fracture has been reduced adequately if more reduction is needed, incrementally add weight, 2-5 lbs at a time Patient Monitoring Every shift, confirm weight hanging freely and not obstructed patient’s foot not touching 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 (pin not sagging) tension bow not resting on patient’s tibia may need to pad with gauze if becoming an issue pin not poking into other leg Complications Pin-Track Infections infection at the pin insertion site is one of the most common complications bacterial contamination can occur, leading to localized infections or even osteomyelitis Muscle Atrophy significant muscle wasting due to disuse of the affected limb may require extensive rehabilitation post-healing Prolonged Bed Immobilization with Resultant Bed Sores Increased Resource Utilization Inadequate Fracture Reduction