How long can you apply skeletal traction?

For surgical residents and orthopedic surgeons who want to learn more about performing Skeletal Traction, this article from Dr. Greg Pereira covers the top things to keep in mind when having to perform skeletal traction in the emergency department.

By Greg Pereira, MD PGY-5

Skeletal traction procedures have long been used for temporizing stabilization of complex lower extremity injuries. While it requires no general anesthesia and carries a low risk to the patient, the stress of a wide-awake procedure on an acutely traumatized patient is something that must be considered for optimal patient care. Some providers don’t perform many skeletal tractions, so these can be stressful and time-consuming procedures. To ensure timely care that minimizes stress for the patient, family, and provider, following these best practices. 

Do’s 

#1: Bring all necessary equipment to the room 

Multiple trips in and out of the patient room to obtain necessary equipment can minimize confidence in patients and family members. And when you’re a provider in a busy clinical setting, unnecessary trips in and out of a room waste valuable time. Bring all the necessary items at once to perform the skeletal traction procedure, to dress the pin and Kirshner bow (if using one), and to connect the ropes/weights to the traction bed. You will save time and inspire confidence. 

The skeletal traction kit from Arbutus Medical, the TrakPak, has nearly all the items needed to dress the pin and perform the procedure. Additionally, you will need a pin driver, nonthreaded Kirschner pin (variable diameter based on institutional preference), Kirschner bow (if required for larger diameter pins), traction bed with a pulley system), rope, and weights. 

All the items the Arbutus Medical TrakPak kit includes (above)

Pin Driver (Arbutus Medical SteriTrak)

Kirschner bow & Traction Bed

#2: Use more lidocaine than less (especially at the periosteum) 

Almost every patient will inevitably ask “How much will this hurt?” Very few of us have ever had a traction pin in our leg, so it is hard to answer this question. The key to minimizing pain is to liberally use local anesthetic (lidocaine/bupivacaine/etc.) in the pin trajectory on both sides of the femur and most importantly at the periosteum of the femur. The sharp pin will quickly advance through the soft tissue creating minimal to mild pain if adequately anesthetized with local anesthesia. 

The pain most frequently occurs at the highly innervated periosteum/cortical bone interface where the pin driver will be used to drive the Kirschner wire across the femur. Friction from the rapidly spinning pin at this interface generates significant heat which increases pain at this portion of the procedure. Anesthetizing the periosteum decreases this pain significantly and makes the procedure significantly more tolerable. 

#3: Family/visitors must leave the room 

After a high-energy trauma, concerned family members and loved ones of the patient often reasonably ask to stay with the patient for potentially stressful procedures. While the sentiment is very reasonable, It is strongly advised not to allow this. To those without medical training, driving a metal pin across the leg of an awake individual may seem barbaric or cruel. While this is standard practice, it may upset or traumatize family members and loved ones and worsen an already difficult situation. 

#4: Talk to the patient 

This may seem obvious, but having an ongoing dialogue with the patient is sometimes forgotten during procedures. Explain step-by-step what is happening to establish rapport with the patient and minimize catastrophizing of what is to come. Tell them, for example, “You are going to feel a pinch and burn” prior to injecting lidocaine, and explaining the logistics of each step. Fear of the unknown is typically greater than fear of the known. 

#5: Know your steps 

Skeletal traction procedures are often performed at academic medical centers and teaching hospitals where a more experienced provider walks a less experienced provider through the procedure. While “talking shop” is perfectly reasonable, try to discuss the broad steps of the procedure outside the room and focus on troubleshooting while with the patient. Every patient wants the most experienced provider to do their procedure, and while this will not always happen, you can inspire confidence in your patient by knowing the appropriate steps before walking in the room. 

Don’ts 

#1: Don’t forget to bump the leg 

Often after a severe lower extremity injury, the fractured bone is shortened and rotated, and the patient will be resting in a contorted position on the gurney. In these situations, using a rolled blanket bump will help align the lower extremity to pass the traction pin more easily. In cases where a bump is not used, one may drill through the fractured bone and be unable to visualize the exiting trajectory on the contralateral side. In cases where the patient is in a contorted position, it is possible to drill into the bedding. As such, prior to starting the procedure, we recommend getting the lower extremity in the optimal position with the use of a rolled blanket bump. 

#2: Don’t be afraid to ask for help from nursing or ancillary staff 

Skeletal traction procedures do not necessarily take multiple individuals to perform. However, patients in the trauma bay often have an attentive nurse nearby as well as other ancillary healthcare workers. Prior to performing the procedure, it can be helpful to ask one of these individuals for an extra set of hands. Whether it be applying counterpressure to the lower extremity while driving the pin, opening supplies to dress the Kirschner bow, providing support to the patient, etc., having an extra person in the room is often helpful. 

#3: Don’t apply the weights too fast 

After completion of the skeletal traction procedure, weight is added to the rope-pulley system. Most frequently, 10 to 20 pounds are added to counteract the shortening that occurs with the complex fractures that mandate skeletal traction. The added weight tends to come in 2.5, 5, and 10lb increments. A common mistake is to quickly add all the weights at once, which rapidly pulls traction through the fracture creating pain and discomfort. A gentler approach of slowly adding the weights is preferred for patient comfort. 

#4: Don’t drill the traction pin without checking threading 

Different pin diameters and threading preferences exist at different institutions. Know your institutional preference and check the pin before performing the procedure. Smaller diameter threaded pins have a higher likelihood of breaking after placement, so ensure you know what you are using. 

#5: Don’t forget to check approximate pin length compared to the patient’s soft tissue envelope 

With the obesity epidemic in America, longer pins are required to accommodate a morbidly obese patient’s soft tissue envelope. Unfortunately, many institutions only have one standard length of Kirschner pins used for skeletal traction. Before performing a skeletal traction procedure on a morbidly obese patient, it is helpful to put the pin (sealed in its sterile packaging) over the soft tissue envelope to assess that it is long enough to come out the other side. If there is serious concern about the length of the traction pin, contact the operating room to determine if longer options are available. If not, Bucks traction may be considered and should be discussed with the attending on-call surgeon. 

I hope these clinical pearls of the “Do’s and Don’ts” of skeletal traction help your clinical practice. While these cannot be used in lieu of clinical knowledge and bedside manner, they will help you avoid common and potentially harmful mistakes. Like any procedure, with experience, the workflow will become progressively more seamless.

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