Traction

As a general rule for femoral fractures use 10% body weight.

For counter traction elevate bed 5 cm for every 1 Kg (1 inch per 1 lb)

Knots to attach cord to traction device (click here)

Traction types and how to set up traction (click here)

Skin traction

Maximum traction weight 6.7 Kg (15lb), remember skin quality.

Adhesive

Generally for paediatric cases

Non adhesive

For Adult cases, or where thin atrophic skin

If poor quality skin reduce max weight to 4.5Kg (10 lb) or consider skeletal traction.

Skeletal traction

• Steinman pin and Bohler stirrup
• Denham pin, threaded pin engages cortex reducing movement.
• Kirschner wire, on wire tightener

Traction sites

Olecranon

K wire from medial to lateral. Right angles to logitudinal axis of ulna 3 cm distal to tip of olecranon Deep to subcutaneous border Avoid ulnar nerve Screw eye can be used directly into tip of Olecranon

Second and third metacarpals

K wire 2-2.5cm proximal to distal end second metacarpal. Wire traverses the 2nd and 3rd metacarpals transversely To lie at right angles to the longitudinal axis of the radius

Greater trochanter

Lateral surface of femur 2.5cm below the most prominent part of the greater trochanter Midway between anterior and posterior surfaces of femur

Distal femur

Beware knee stiffness, try not use for longer than 2 to 3 weeks

Remember the lateral knee joint capsule reaches 1.25-2cm above knee joint, dont forget the distal femoral physis in children.

In general, the pin should pass along or slightly posterior to the midcoronal plane of the femoral shaft. It should also pass just proximal to the adductor tubercle in order to avoid engagement of the collateral ligaments. This lies almost at the level of the proximal pole of the patella in the relaxed and extended knee.

Flex the knee slightly during insertion to draw the periarticular soft tissues into the position they will occupy while the limb is in traction, thereby reducing pressure necrosis of the skin.

Two methods 1. Line at upper pole of patella Line upwards from anterior to head of fibula. Where these two points meet insert pin 2. Just proximal to upper limit of lateral femoral condyle (3 cm proximal to lateral joint line)

Proximal tibia

Contraindicated if the knee ligaments have been injured.

Insertion point 2cm distal and posterior to Tibial tuberosity. Dont let the pin creep anteriorly while inserting the pin.

2cm behind and below Tibial tuberosity From Lateral to medial to avoid common peroneal nerve

Distal Tibia & Calcaneus

Calcaneal Traction
Ideally, the pin should be inserted as far posterior as possible while still engaging sound bone. The tendons and neurovascular bundle passing behind the malleoli and the subtalar joint are to be avoided.

Halett et al suggests for a calcaneal pin place it 2 cm below and behind the lateral malleolus or 3 cm below and behind the medial malleolus BEWARE Tornetta et al show no position is completely safe when placing a medial calcaneal pin or transcalcaneal pin. Ensure you are as far posterior as possible yet still engaging bone.

Distal Tibia   5cm above ankle joint Middle of bone   Calcaneus Beware see reference below 2 cm below and behind lateral malleolus 3 cm Below and behind medial malleolus Avoid subtalar joint

The medial calcaneus provides a small window for safe percutaneous pin placement. Posterior to the halfway point from Point A to B and posterior to the one-third mark from Point A to C remain the relatively safest regions. A more posterior placement in the safe zone is safest. Careful blunt dissection and the use of cannulas may help to avoid neurovascular injury

Halo traction

Click here for Halo application

Traction and Orthopaedic Appliances; John D.M Stewart, Jeffrey P. Hallett

Percutaneous pin placement in the medial calcaneus: is anywhere safe?
Casey D, McConnell T, Parekh S, Tornetta P 3rd. J Orthop Trauma. 2004 Sep;18(8 Suppl):S39-42.

Last updated 11/09/2015