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 login to view 1 more bullet elderly login to view 1 more bullet sex login to view 1 more bullet 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 login to view 2 more bullets patella login to view 2 more bullets joint line login to view 1 more bullet 2cm distal to tibial tubercle login to view 1 more bullet 2cm posterior to previous mark login to view 3 more bullets Neurovascular structures to avoid: common peroneal nerve login to view 2 more bullets tibial nerve and popliteal vessels login to view 2 more bullets Preparation Patient Positioning: supine position login to view 4 more bullets de-rotating Leg login to view 1 more bullet Equipment: k-wire login to view 1 more bullet sterile surgical pin driver login to view 1 more bullet tension bow (kirschner bow) login to view 1 more bullet sterile drapes, gloves syringe, needles, scalpel, and antiseptic solution login to view 1 more bullet traction bed login to view 2 more bullets traction bed frame login to view 2 more bullets traction weights login to view 2 more bullets rope login to view 1 more bullet Anesthesia: local Infiltration with Lidocaine login to view 5 more bullets 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 login to view 1 more bullet 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 login to view 3 more bullets 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 login to view 1 more bullet leg de-rotated (patella towards ceiling) tension bow tight (pin not sagging) tension bow not resting on patient’s tibia login to view 1 more bullet 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