Figure 4 - available from: European Journal of Trauma and Emergency Surgery
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Calcaneal traction pin landmarks. a The joint line and medial malleolus are marked. The posteroinferior of the calcaneus is marked and a line is drawn from this landmark to the medial malleolus and divided into thirds. A scalpel or measurement of ~1.6 mm can be used to identify the “safe zone” (circle), in the posterior 2/3 of the line. b Final identification of the calcaneal landmarks including the circular “safe zone”: with a radius of 1.6 cm. c Lateral radiograph following traction pin placement
Source publication
Purpose:
Fractures of the lower extremity, particularly of the femur and acetabulum, may be difficult to immobilize with splinting alone. These injuries may be best stabilized with the application of various types of skeletal traction. Often, traction is applied percutaneously in an emergent setting, making the knowledge of both superficial and de...
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Citations
... The outer point was the optimal position of the percutaneous Kirschner wire (K-wire) (Figure 2). 20 After applying local anesthesia to the entrance area, a K-wire was extended parallel to the ground from the medial to the lateral of the calcaneus. A puller was then connected to the K-wire. ...
... The weight was adapted to the traction system to be less than 1/10 of the body weight. 20 Anteroposterior and lateral radiographs were taken to observe the reduction after the procedure (Figure 3). Daily bedside assessments were performed to observe the reduction and ensure the satisfactory alignment of the fracture without shortening or lengthening. ...
Objective: We aim to compare of effectiveness, functional results, and complication rates of splinting and skeletal traction at initial management of ankle fracture-dislocations.
Methods: Patients who applied for ankle fracture-dislocation between 2013 and 2021, who could not be treated with acute definitive surgery, and who underwent short leg splint or calca�neal skeletal traction in the period up to definitive surgery were evaluated retrospectively. Of the 84 patients included in the study, 48 (57%) were followed up with short leg splint and 36 (43%) with calcaneal skeletal traction. Comparisons between groups were made by collecting demographic data, waiting time until surgery, and preoperative and postoperative complications. In addition, the American Orthopedic Foot and Ankle Association score was used to evaluate functional outcomes.
Results: The rate of loss of reduction was significantly higher in those who underwent calcaneal skeletal traction (P=.034). The number of patients who developed skin necrosis in the period until definitive surgery was higher in those who underwent calcaneal skeletal traction (P=.048). When the ankle range of motion was evaluated in the postoperative follow-up period, the number of patients with limited range of motion was signifi�cantly higher in those who underwent calcaneal skeletal trac�tion (P=.012). No significant correlation was found between the postoperative 12th month American Orthopedic Foot and Ankle Association scoring and the temporary stabilization method.
Conclusion: There was a significant increase in reduction loss, skin necrosis development rate, and limitation in postoperative joint range of motion in the preoperative period compared to short leg splint in patients who underwent calcaneal skeletal traction as a temporary stabilization method in ankle fracture�dislocation patients
... Traditionally, acute treatment of PFFs involves lower-limb skin or skeletal traction [3][4][5], and then intramedullary nailing is considered to be the definitive treatment in the majority of trauma patients [6][7][8][9][10]. With the extensive use of external fixators in trauma surgery, some literature has described the application of an external fixator to the PFF as the definitive treatment, but it is associated with extensive soft tissue damage, severe open fractures [11,12], and poor general conditions [13][14][15][16][17]. Traditional lower-limb traction and the aforementioned methods of external fixation still have some faults [3,4,18], including cortical defects, pin tract infection, secondary pin-tract osteomyelitis, or septic arthritis if placed intra-articularly [19]. In addition, longterm traction and unstable external fixation may result in a high risk of bedsores, pneumonia, deep vein thrombosis, and urinary tract infection [20]. ...
Background and aim
Acute treatment of young patients with proximal femoral fracture (PFF) remains a challenge for trauma surgeons due to major fracture displacement and heavy pain in clinical practice. Traditional methods have a variety of intrinsic defaults and cannot successfully manage the requirements of young patients. Benefiting from our anatomic research, we explored a new method of external fixation for this specific trauma and evaluated its feasibility and clinical outcomes.
Material and methods
Twenty-three young multiple-trauma patients with PFF were included in this study. Surgical treatment was applied using an external fixator via the anterior inferior iliac spine (AIIS). Electronic patient records, surgical characteristics, clinical outcomes, and complications were reviewed for each patient.
Results
The mean surgical time was 30.3 ± 7.3 min. The mean blood loss was 25.3 ± 10.8 mL. No iatrogenic nerve palsy, pin tract infection, failure of external fixation, or bedsores were observed. The postoperative visual analog scale score was significantly lower than the preoperative score ( P < 0.01). The mean fracture reduction rate of the femur was 58.1 ± 17.0%, and the mean degree of reduction was 13.5 ± 6.9°. The mean external fixation time was 7.6 ± 4.0 days and intramedullary nailing was performed. The mean hospital, follow-up, and healing times were 28.7 ± 8.7 days, 23.5 ± 7.9 months, and 22.8 ± 5.7 weeks, respectively. The Harris Hip Score indicated excellent or good results in 20 patients.
Conclusion
Collectively, the results of this study revealed that external fixation via the AIIS is a safe, rapid, and effective method for acute treatment of PFF in young patients.
... Skeletal traction is indicated for those with shortened unstable fractures/dislocations of the extremity. This is particularly relevant for the lower limb where it may be difficult to immobilize with splinting alone or require greater force than what skin traction could provide [21,22]. ...
... Local anaesthetic is infiltrated and a counter incision is made. Once radiologically confirmed satisfactory placement, traction bow is secured to pin and 9-14 kg of traction that is hung off the side of traction bed and the lower leg is supported with U-Loops ( Figure 15) [16,22,23]. ...
... The entry point is 2/3 from the line drawn from medial malleolus to tip of calcaneum ( Figure 21). Local anaesthesia is infiltrated to skin and the pin is positioned in place after dissection and radiologically confirmed then the pin is advanced, finally, the counter skin is infiltrated, incision is made, pin is advanced further and traction bow is applied so weights can be applied [22,24,25]. Potential risk includes damage to medial calcaneal nerve and stiffness of subtalar joint. ...
The trauma and orthopaedic speciality continues to advance as surgery becomes more accessible and safe. However, the bygone days of treatment with traction still has its merits and should remain a part of practitioner's repertoire. This will allow the practitioners to be resourceful in times of unexpected scenarios.
We aim to write this article to describe indications, applications of various forms of traction, and their relevant complications.
... Inspired by the "traveling traction" [14], the insertion point of this technique is the common bone traction point for lower limb fractures, such as that in femoral supracondylar, tibial tubercle, and calcaneal traction. Previous reports have described the selection of the entry points and safety zones in detail [9,[15][16][17]. We believe that palpation and accurate marking of the insertion points are important steps for reducing the incidence of complications. ...
Background and Objective: Different external skeletal fixators have been widely used in preoperative traction of high-energy tibial fractures prior to a definitive surgical treatment. However, early complications associated with this staged treatment for traction and soft tissue injury recovery have rarely been discussed. This study aimed to analyze the early complications associated with preoperative external traction fixation in the staged treatment of tibial fractures.
Materials and Methods: A total of 402 patients with high-energy tibial fractures treated using preoperative external traction fixation at a level-1 trauma center from 2014 to 2018 were enrolled in this retrospective study. Data regarding the demographic information, Tscherne soft tissue injury, fracture site, entry point placement, and duration of traction were recorded. Procedure-related complications such as movement and sensation disorder, vessel injury, discharge, infection, loosening, and iatrogenic fracture were analyzed.
Results: The mean patient age was 42.5 (18–71) years and the mean duration of traction was 7.5 (0–26) days. In total, 19 (4.7%) patients presented with procedure-related complications, including technique-associated complications in 6 patients and nursing-associated complications in 13. Differences in the incidence of complications with respect to sex, affected side, soft tissue injury classification, and fracture sites were not observed. However, the number of complications due to hammer insertions was significantly fewer than those due to drill insertions (2.9% vs. 7.4%).
Conclusion: The application of preoperative external traction fixation had been proved to be an ideal alternative treatment for high energy tibial fractures. In this study, we found the incidence of early complications of the fixation is low, and it is not significantly associated with the severity of soft tissue injury and fracture site. Although relatively rough and more likely to cause pain, complications of hammer insertions were significantly fewer than drill insertions. The possible reason was higher probability of heat damage and loosening by drilling.
... Long-term skeletal traction is indicated in medically unfit and limited resources patients [2] . Application of Skeletal traction should be done meticulously in sterile conditions and within safe zones utilizing anatomical landmarks as described [3] . Improper aseptic technique, thermal necrosis, prolonged duration; poor tract care and comorbid conditions can lead to complications like skin discharge, pin loosening, septic arthritis, and osteomyelitis [4] . ...
... In order to limit complications, it is critical to have an understanding of surface landmarks and underlying regional anatomy. The authors of previous anatomical studies and reviews have described these anatomical landmarks and have recommended "safe zones" where pins can be placed with the lowest risk of complications [49][50][51][52][53][54] . ...
... Kwon et al., in a cadaveric study, suggested that medial calcaneal pin placement within a "safe zone" (within a 3.1-cm radius from the posteroinferior part of the calcaneus) can decrease the risk of injury to the medial calcaneal nerve 53 . Specifically, they recommended pin placement 1.6 cm from the posteroinferior tip (i.e., approximately half of the radius); however, others have argued that, given its unpredictable course, the nerve still remains at risk 49,50,52,54 . Additionally, to avoid injury to posterior branches of the lateral plantar nerve, others have argued that the pin should be placed ,1.6 cm from the posteroinferior tip of the calcaneus 54 . ...
» Skeletal traction is a fundamental tool for the orthopaedic surgeon caring for patients with traumatic pelvic and lower-extremity injuries.
» Immobilization of fractures in the pelvis, acetabulum, and proximal part of the femur can be difficult with traditional splinting techniques. Skeletal traction has proved to be an effective alternative means of immobilization in such cases.
» Traction may be utilized for both temporary and definitive treatment of a variety of orthopaedic injuries.
» With the appropriate knowledge of regional anatomy, skeletal traction pins can be placed safely and with a low rate of complications.
» Several methods for placing skeletal traction have been described, and it is critical for orthopaedic surgeons not only to be proficient in their application but also to understand the appropriate indications for use.
... In bedridden patients, it prevents further fracture displacement and limb shortening which can occur during mobilisation for hygiene care. Finally, it offloads the hip joint, decreasing damage on the articular cartilage (DeFroda et al., 2016), often already compromised in older patients with fragility hip fracture. ...
Abstract
Background
Femoral fractures are a major healthcare problem worldwide. One of the most difficult issues is their preoperative care, which is still managed by either skeletal or skin traction in some countries, including Italy. These issues are discussed and compared with the contemporary literature.
Objective
This study aims to analyse the distribution of these treatment options within the orthopaedic community and the reasons for their use, as well as to identify how this may impact nursing care in terms of pain management, hygiene care, venous thromboembolism (VTE), prophylaxis and prevention of pressure ulcers.
Design
For this cross-sectional study, a 12-item survey was administered to the nursing staff, consultants and residents of the Orthopaedic Units in three different hospitals in NorthEastern Italy. The questionnaire investigated the routine use of skeletal or skin traction for the preoperative management of hip fractures.
Findings
136 surveys were completed, providing a response rate of 87.74%. Preoperative traction for hip fractures was still in use in the three hospitals, mainly applied by experienced surgeons for subtrochanteric fractures. Pain management, VTE and pressure ulcer prevention were perceived as worse only with skeletal traction, while hygiene was described as more difficult with both skeletal and skin traction.
Conclusions and recommendations
Based on the data and the literature revision, skin or skeletal traction for patients with proximal femoral fractures should be discouraged as standard practice. This is supported widely in the internationally literature, and consideration of knowledge translation strategies should be made to refine current practice in these settings.
Background:
Different external skeletal fixators have been widely used in preoperative traction of high-energy tibial fractures prior to a definitive surgical treatment. However, the early complications associated with this staged treatment for traction and soft tissue injury recovery have rarely been discussed.
Aim:
To analyze the early complications associated with preoperative external traction fixation in the staged treatment of tibial fractures.
Methods:
A total of 402 patients with high-energy tibial fractures treated using preoperative external traction fixation at a Level 1 trauma center from 2014 to 2018 were enrolled in this retrospective study. Data regarding the demographic information, Tscherne soft tissue injury, fracture site, entry point placement, and duration of traction were recorded. Procedure-related complications such as movement and sensation disorder, vessel injury, discharge, infection, loosening, and iatrogenic fractures were analyzed.
Results:
The mean patient age was 42.5 (18-71) years, and the mean duration of traction was 7.5 (0-26) d. In total, 19 (4.7%) patients presented with procedure-related complications, including technique-associated complications in 6 patients and nursing-associated complications in 13. Differences in the incidence of complications with respect to sex, affected side, soft tissue injury classification, and fracture sites were not observed. However, the number of complications due to hammer insertion was significantly reduced than those due to drill insertions (2.9% vs 7.4%).
Conclusion:
We found a low incidence of early complications related to the fixation. Furthermore, the complications were not significantly associated with the severity of the soft tissue injury and fracture site. Although relatively rough and more likely to cause pain, the number of complications associated with hammer insertion was significantly smaller than that of complications associated with drill insertion.
