Femoral Skeletal Traction

Published on 16/03/2015 by admin

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Last modified 22/04/2025

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Chapter 15 Femoral Skeletal Traction

Overview

Femoral traction is accomplished with placement of a pin across the distal femur and attachment to a pulley system secured to the bed.

Indications for use

1. Acetabular fractures
2. Proximal femur fractures

Precautions

1. Do not set up femoral traction until confirming that no skeletal injury is present about the knee.

a. Confirmation that no skeletal injury is present about the knee can be ascertained via a clinical examination in an alert and oriented patient or with radiographs.
b. Note that femoral traction continues to be indicated when a ligamentous injury to the knee is present.

2. The pin must be inserted from the medial aspect to avoid injury to the femoral artery.
3. Ensure that the pin is placed under sterile technique. Do not place pins through or near open wounds.
4. Ensure that the pin is placed perpendicularly to the axis of the limb and in a straight horizontal plane.
5. Place traction weights gently!
6. Once traction has been established, ensure that the traction bow is not in contact with the skin.

a. A pressure ulcer can be created easily by the traction bow.
b. To ensure that the traction bow does not create a pressure ulcer, the bow should be overwrapped in rolled gauze.

7. Apply rubber stoppers or similar end caps to the ends of the pin to prevent injury to the patient or health care workers.

Pearls

1. Close coordination with the operating surgeon is mandatory when placing patients into traction.
2. Insertion of femoral traction can be completed under local anesthetic, but conscious sedation is preferred.
3. If only a local anesthetic is being used, consider increasing the amount and adding bupivacaine.
4. If the patient is going to go to the operating room for definitive fixation shortly after placement of femoral traction, elective intubation prior to placement may be prudent.
5. Before placement of femoral traction, ensure that the patient is on a bed that is capable of having a traction frame attached to it.
6. Placement of a femoral pin is easiest when all the equipment is organized. Having two bedside tables facilitates organization and maintenance of a sterile environment.
7. Having an assistant is not mandatory but is extremely helpful.
8. A hand drill or power drill may be used. We prefer using a power drill, especially in younger patients with good bone stock.

Equipment

1. Sterile technique items:

a. Sterile gloves
b. 4 × 4 inch gauze
c. Antiseptic: Chlorhexidine or Betadine
d. Sterile drapes or blue towels

2. Local anesthesia items:

a. Syringe: 10-mL syringe
b. Needle:

(1) Large-bore, blunt-tipped, drawing-up needle
(2) 2-inch, 21-gauge needle

c. Anesthetic: Lidocaine, 10 mL of 2%

3. Items for insertion of pin:

a. #11 blade scalpel
b. Straight hemostat
c. Centrally threaded Steinmann pin (also known as a Denham nail), 4 × 225 mm or 5 × 225 mm (Figure 15-1)
d. Power drill and battery (Figure 15-2)
e. Jacobs chuck and key (Figure 15-3)

4. Items for establishing traction:

a. Böhler’s stirrup (also known as a traction bow) (Figure 15-4)
b. Large pin cutters
c. Xeroform
d. Two rubber stoppers (if specialized rubber stoppers are not available, find two blood vials and take the rubber tops off)
e. 2 × 6 inch rolled gauze
f. Pulley and frame: bed frame with attached single pulley
g. Weights: six 5-lb weights with associated hanger
h. Cord: braided traction cord

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Figure 15-1

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Figure 15-2

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Figure 15-3

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Figure 15-4

Basic technique

1. Patient positioning:

a. Ensure the patient is on a bed that accepts external frames.
b. The patient is supine.
c. A bump is placed under the knee.

(1) The amount of knee flexion correlates with the desired degree of knee flexion when traction is applied.
(2) Typically 20 degrees is sufficient.
(3) A bump also may be placed under the thigh to prevent the leg from falling into external rotation.

2. Landmarks:

a. Superior pole of the patella
b. Anterior and posterior cortices of the femur

3. Steps:

a. Ensure the patient is adequately sedated.
b. Position the patient.
c. Set up back tables using the sterile technique.
d. Palpate landmarks.
e. Prepare the skin with an antiseptic solution.
f. Place sterile drapes.
g. Administer local anesthesia.
h. Insert the pin.
i. Set up the traction apparatus.
j. Apply traction.

Detailed technique

1. Ensure the patient is adequately sedated.
2. Position the patient:

a. Supine
b. Place a bump under the thigh, if desired.

3. Set up back tables using the sterile technique.

a. Open all sterile equipment, including instruments for local anesthesia.
b. Assemble the drill (Figures 15-5 and 15-6).

4. Palpate landmarks with the knee in full extension.

a. The superior pole of the patella is palpated.
b. The entry site is at this level, just above the mid coronal plane on the medial aspect of the limb.
c. Mark the entry site (Figure 15-7).

5. Place a knee bump, if desired.
6. Prepare the skin with an antiseptic solution.

a. Prepare the leg in a wide fashion.
b. Ensure that both the medial entry site and lateral exit site are included.

(1) It is helpful to have an assistant hold the leg in the air.
(2) Holding the leg in the air is usually possible only if the patient is intubated.

7. Place sterile drapes.

a. If the leg was elevated, place a sterile drape under the leg befoe draping out the relevant area.
b. Drape out all four aspects: proximal, distal, medial, and lateral.

8. Administer local anesthesia.

a. Prepare the anesthetic by drawing up 10 mL of 2% lidocaine.
b. Inject the anesthetic medially and laterally.

(1) Insert the needle 90 degrees to the skin on the medial aspect.
(2) Advance the needle until contact is made with bone.
(3) Aspirate the needle before injection to ensure that intravascular placement has been avoided.
(4) Inject 2 mL directly into the bone to anesthetize the periosteum.
(5) Withdraw the needle and continue to inject another 3 mL of anesthetic.
(6) Repeat on the lateral aspect.

9. Insert the pin.

a. Make a vertical stab incision in the skin at the entry site.
b. Perform blunt dissection with a straight hemostat through the soft tissue to the medial cortex.
c. Insert the Steinmann pin using the drill through the medial and lateral cortices (Figure 15-8).

(1) The pin must be kept parallel to the floor to ensure it is the horizontal plane.
(2) The pin should be inserted parallel to the knee joint line.
d. Once the lateral soft tissue is entered with the Steinmann pin, carefully palpate where the pin will exit the skin.
e. Make a small stab incision to allow pin passage through the lateral skin.
f. Continue to insert the pin until equal lengths are present on either side of the limb.

10. Set up the traction apparatus:

a. Attach a traction bow (Figure 15-9).
b. Cut excess length from the Steinmann pin with large pin cutters, if necessary. Hold the pin with a hemostat to prevent the cut pin fragment from becoming a flying object.
c. Apply rubber stoppers to the ends of the pin.
d. Wrap small strips of Xeroform around skin exit sites.
e. Hold an unraveled roll of gauze at the apex of the bow.
f. Wrap the entire traction bow and roll of gauze with 6-inch rolled gauze to secure the rubber stoppers and rolled gauze pad.
g. Set up the bed frame and pulley (Figure 15-10).
h. Attach the cord.

(1) First, pass the cord through the pulley.
(2) Tie the cord to the traction bow using a surgeon’s knot.
(3) Tie a slipknot in the free end (also known as an overhand knot with a draw-loop).

11. Apply traction.

a. Hang weight from the slip knot.
b. Twenty percent of a patient’s weight should be applied (typically 20 to 25 lb).

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Figure 15-5

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Figure 15-6

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Figure 15-7

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Figure 15-8

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Figure 15-9

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Figure 15-10

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