Skeletal traction in the orthopaedic patient has roots dating back as early as 3500 BC,1 and methods of skeletal traction for the treatment of femur shaft fractures later emerged in 1907 with the work of Fritz Steinmann2 and in 1909 by Martin Kirschner.3 However, it was not until the mid-1900s that immobilization of femoral shaft fractures through skeletal traction is believed to have gained popularity.4 In current practice, skeletal traction (ie, distal femoral and proximal tibial) is predominantly used in patients with femoral shaft fractures for temporary immobilization and pain control, but its indications can be expanded to other fractures of the pelvis and lower extremity.5 Relative contraindications to the placement of skeletal traction include frail elderly patients, most femoral neck or intertrochanteric fractures,6 and certain types of open fractures. Complications such as pin tract infections, osteomyelitis, and septic arthritis are rare but have been reported.7–9 A number of anatomical studies describing the location of neurovascular structures about the knee have been published to minimize complications from incorrect pin placement.10,11 It is important to understand the regional and surface anatomy before placing skeletal traction pins, especially when doing so without fluoroscopic guidance.
CASE DESCRIPTION AND TECHNIQUE
In this video, we present a case example of a patient who sustained a right femur fracture and was indicated for placement of proximal tibia skeletal traction before being taken to the operating room. In this technique, the first step is to palpate superficial landmarks and draw out the regional anatomy ( fibular head, tibial tubercle, etc.). Previous works have described in detail the anatomic landmarks and recommended “safe zones” where pins can be placed with the lowest risk of complications.12 Proximal tibial skeletal traction is indicated in femoral shaft fractures, distal femur fractures, and fractures that may otherwise preclude the placement of distal femoral skeletal traction and is contraindicated for patients with ligamentously unstable knee injuries or a knee effusion on examination.
In the proximal tibia, the traction pin was historically placed from lateral to medial to avoid injury to the laterally based peroneal nerve when using a Steinmann pin. With fine wire traction, the pin is started on the opposite side (ie, medial) and gently malleted through the lateral soft tissue to avoid spinning near the tissues at risk. Given the triangular shape of the proximal tibia, it can be difficult to place the pin perfectly perpendicular to the axis of the bone and parallel to the floor. This procedure can be completed under local anesthesia or conscious sedation as the institutional protocol dictates. Begin initially with the pin perpendicular to the bone's cortex, and just as the pin begins to advance, adjust your hand to parallel the pin with the floor. Proceed with pin placement and traction apparatus steps as outlined in the video. Of note, previous studies have recommended pin placement to be at least 14 mm distal to the joint line to decrease the risk of intra-articular pin placement10 and to avoid placement greater than 2–2.5 cm distal to the tibial tubercle because that may increase the risk of damage to the peroneal nerve.
Proximal tibia skeletal traction was chosen in this patient to provide temporary immobilization and pain control while they awaited surgery. When placing a proximal tibia skeletal traction pin, the goals should be to place it safely, sterilely, and as comfortably for the patient as possible. To do this, it is critical to have knowledge of the regional anatomy and neurovascular structures. Skeletal traction in orthopaedic trauma patients has long demonstrated the ability to effectively aid in pain control, fracture immobilization, and restoration of limb length and alignment. Complications are rare, and pins can be placed quickly and safely with the knowledge of surface landmarks and underlying regional anatomy.
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10. DeCoster TA, Crawford MK, Kraut MA. Safe extracapsular placement of proximal tibia transfixation pins. J Orthop Trauma. 1999;13:236–240.
11. Althausen PL, Hak DJ. Lower extremity traction pins: indications, technique, and complications. Am J Orthop. 2002;31:43–47.
12. Obey MR, Berkes MB, McAndrew CM, et al. Lower-extremity skeletal traction following orthopaedic trauma: indications, techniques, and evidence. JBJS Rev. 2019;7:e4.