Basic principles and advantages of the method
Skeletal traction has historically been one of the baseline tools in traumatology, especially in the treatment of adult patients where heavy weights are required. Treatment success is based on three fundamental principles:
- Relaxation. Gradual and complete relaxation of the muscles of the injured segment.
- Reduction. Smooth elimination of bone fragment displacement under the action of a directed force.
- Fixation. Maintenance of the achieved anatomical position through continuous traction until primary callus formation.
Unlike solid plaster casts, this method leaves the injury site completely open. This gives the physician the ability to visually monitor the condition of the soft tissues, freely perform dressings and therapeutic procedures. In addition, the traction vector has high variability—the direction can be precisely adjusted depending on the nature of the fracture.
Types of continuous traction
Depending on the required force and the risks of additional bone trauma, two types of traction are distinguished:
- Skeletal traction. Traction is applied directly to the bone (via a wire or screw). Optimal for using heavy weights.
- Skin traction. The force is transmitted through the skin using adhesive tape, glue, or special cuffs. Used when light weights are needed. Adhesive (plaster tape) traction is often used in pediatric practice to avoid traumatizing the growing bone. Cuff traction is demanded in orthopedics for joint unloading in deforming osteoarthritis.
Application technique and biomechanics
Applying skeletal traction is a surgical intervention and requires flawless adherence to asepsis rules.
In most cases, a Kirschner wire is used. Using a manual or electric drill, it is passed through the bone, and then tensioned and fixed in a special device—for example, a TsITO bow. Basic biomechanics consist of traction strictly along the axis of the injured segment.
Wire insertion points are strictly regulated by anatomy. Thus, for the supracondylar zone of the femur, the following landmarks exist:
- Direction: the wire is inserted from inside to outside.
- Adult patients: the insertion point is located 1.5–2.0 cm above the upper edge of the patella, exactly at the middle of the anteroposterior diameter of the thigh.
- Children under 18 years of age: the insertion point is shifted more proximally.
Limitations, contraindications, and risks
The method requires long-term compliance with a strict regimen and effectively "chains" the patient to the bed, rendering them non-transportable. This imposes a number of limitations:
- Psychological status. Conscious cooperation is required. Inadequacy (state of affect, dementia, alcohol/drug delirium, chronic mental illness) or age under 5 years are absolute contraindications.
- Somatic status. The method is contraindicated in somatically severe patients, especially of advanced age. Forced physical inactivity threatens the development of hypostatic pneumonia, pressure ulcers, and exacerbation of cardiorespiratory failure.
- Local contraindications. The presence of pustules, ulcers, or abrasions in the area of the intended insertion.
The main specific complication of the method is associated with infection. Inflammatory processes at the wire insertion sites can progress up to severe pin-site osteomyelitis.
Briefly: answers to topical questions
Through which main bone anatomical regions are wires inserted during skeletal traction of the limbs?
The main bone anatomical regions for wire insertion during skeletal traction of the limbs are:
- Supracondylar zone of the femur
- Tibial tuberosity
- Supramalleolar region
- Calcaneus
- Olecranon
Also, depending on indications, wires can be inserted through the greater trochanter of the femur and the nail phalanges of the toes or fingers.
What are the anatomical landmarks and direction of wire insertion through the tibial tuberosity?
The wire through the tibial tuberosity is inserted strictly in the direction from outside to inside to prevent injury to the common peroneal nerve.
Anatomical landmarks depend on the patient's age:
- In adults — the insertion point is located 1 cm distal and 1.5 cm dorsal to the apex of the tuberosity.
- In children — the wire is passed through the metaphysis of the tibia (behind the tuberosity 4–5 cm distal to the lower pole of the patella). This is necessary to prevent wire cut-through and avoid damage to the growth plate.
What are the landmarks and rules for inserting a Kirschner wire through the calcaneus?
The wire through the calcaneus is inserted in the frontal plane, strictly perpendicular to the axis of the limb segment. Two methods are used to determine the insertion point:
- Square method — the point of intersection of the diagonals of a square whose sides are formed by perpendiculars dropped from the apical edge of the lateral malleolus to the posterior surface of the lower leg and to the plantar surface.
- Alternative method — the foot is set at a right angle, a line is drawn behind the lateral malleolus to the sole. The segment of this line up to the level of the malleolus apex is divided in half.
How is the weight load calculated during skeletal traction for fractures of the femur and lower leg bones?
The weight load is calculated approximately based on the mass of the limb segment and the patient's body weight, and also depends on fragment displacement, the age of the fracture, and muscle mass.
The following calculations are used for the lower extremities:
- Femoral fracture — the weight load is about 1/7 (or 15%) of the patient's body weight (on average 6–12 kg).
- Lower leg fracture — the weight load is about 1/14 (or 10%) of the patient's body weight (on average 4–7 kg).
It is forbidden to hang the entire calculated load at once: start with 1/3–1/2 of the calculated load, gradually increasing the mass.
On what standard splint is the lower extremity placed during skeletal traction?
During skeletal traction, the lower extremity is placed on a standard Böhler splint (Böhler splint).
It is used to balance the pull of antagonist muscles and give the limb the correct position. An important rule of positioning is that the patient's knee joint space must strictly correspond to the bend of the splint. The patient is placed on a bed with a rigid board under the mattress.
The principles of skeletal traction are the "RRR" rule: Relaxation (of muscles) → Reduction (of fragments) → Fixation (of the result).
Class and exam questions
How does skeletal traction differ from skin traction?
In skeletal traction, traction is applied directly to the bone, which allows the safe use of heavy weights. Skin traction (adhesive tape or cuff) is fixed to the skin, used for light forces, and minimizes trauma.
Why is patient non-compliance an absolute contraindication?
Treatment effectiveness depends on the long-term maintenance of correct directed traction. A patient in a state of delirium, dementia, or a child under 5 years old cannot consciously follow the regimen, which will inevitably lead to structural failure and secondary displacement of fragments.
Can skeletal traction be applied directly in the hospital ward?
No. Passing a wire through the bone is equated to a surgical operation. To avoid the development of purulent complications (up to pin-site osteomyelitis), the procedure is performed only in an operating room or a sterile dressing room.
What else to study on this topic
- Complications of plaster casts (phlyctenulae, neuritis, pressure ulcers)
- Mechanism of secondary fragment displacement following edema reduction
- Synthetic polymers in traumatology: Polivik, Scotchcast, Softcast
- Indications for off-the-shelf orthoses and braces
- Specific features of skin traction in pediatric traumatology
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