Safety of skeletal traction through the distal femur, proximal tibia, and calcaneus


Department of Orthopaedics, University of Southern California, Los Angeles, CA, USA


Introduction: Skeletal traction provides pain relief and temporary stability in patients anticipating surgery for a variety of lower-extremity fractures. Recent literature suggests that distal femoral traction provides pain relief and is safe; however, data regarding proximal tibial and calcaneal pins are primarily historical and limited. The purpose of this study is to document complications associated with distal femur, proximal tibia, and calcaneal traction pin placement. Materials and Methods: We identified patients with the distal femur, proximal tibia, and calcaneal traction pin placement from January 2013 to June 2016. Chart review was utilized to identify any complications, including nerve or vascular injuries, need for revision, or infection. Results: Five hundred and nineteen traction pins were eligible for review, consisting of 120 calcaneal traction pins, 129 distal femoral pins, and 270 proximal tibia traction pins. Primary diagnosis was defined as 305 femur fractures (58.8%), 60 tibial shaft fractures (11.6%), 60 acetabular fractures (11.6%), 38 pilon fractures (7.3%), 30 pelvic ring injuries (5.8%), 21 tibial plateau fractures (4.0%), and 5 hip dislocations (1.0%). We identified 17 (3.3%) adverse events potentially attributable to traction pin insertion. Pins that became infected were found to have been in place for a significantly longer duration (18.3 days compared to 5.8 days, p  = 0.0001). Conclusions: Traction pin placement for skeletal traction is generally an uncomplicated procedure. Duration of pin placement is significantly related to the likelihood of pin site infection.


1. Althausen PL, Hak DJ. Lower extremity traction pins: Indications, technique, and complications. Am J Orthop (Belle Mead NJ) 2002;31:43‑7. 
2. Lowe JA, Rister J, Eastman J, Freind J. Injury to neurovascular structures with insertion of traction pins around the knee. J Orthop 2015;12:S79‑82. 
3. Austin DC, Donegan D, Mehta S. Low complication rates associated with the application of lower extremity traction pins. J Orthop Trauma 2015;29:e259‑65. 4. Specht LM, Gupta S, Egol KA, Koval KJ. Heterotopic ossification of the quadriceps following distal femoral traction: A report of three cases and a review of the literature. J Orthop Trauma 2004;18:241‑6. 
5. Taylor BC, Bramwell TJ, Formaini N. Gas gangrene as a result of femoral traction pin placement. Case Rep Orthop 2011;2011:459812. 
6. Liporace FA, Yoon RS, Kesani AK. Transient common peroneal nerve palsy following skeletal tibial traction in a morbidly obese patient – Case report of a preventable complication. Patient Saf Surg 2012;6:4. 
7. Linn MS, Indresano AA, Schwartz A. Popliteal artery pseudoaneurysm: An unusual complication of tibial traction. Am J Orthop (Belle Mead NJ) 2015;44:E156‑9. 
8. Bumpass DB, Ricci WM, McAndrew CM, Gardner MJ. A prospective study of pain reduction and knee dysfunction comparing femoral skeletal traction and splinting in adult trauma patients. J Orthop Trauma 2015;29:112‑8. 
9. Casey D, McConnell T, Parekh S, Tornetta P 3rd. Percutaneous pin placement in the medial calcaneus: Is anywhere safe? J Orthop Trauma 2004;18:S39‑42.
10. Ahlborg HG, Josefsson PO. Pin‑tract complications in external fixation of fractures of the distal radius. Acta Orthop Scand 1999;70:116‑8. 
11. Camathias C, Valderrabano V, Oberli H. Routine pin tract care in external fixation is unnecessary: A randomised, prospective, blinded controlled study. Injury 2012;43:1969‑73. 
12. Cavusoglu AT, Er MS, Inal S, Ozsoy MH, Dincel VE, Sakaogullari A. Pin site care during circular external fixation using two different protocols. J Orthop Trauma 2009;23:724‑30. 
13. Egol KA, Paksima N, Puopolo S, Klugman J, Hiebert R, Koval KJ. Treatment of external fixation pins about the wrist: A prospective, randomized trial. J Bone Joint Surg Am 2006;88:349‑54. 
14. Hutson JJ Jr., Zych GA. Treatment of comminuted intraarticular distal femur fractures with limited internal and external tensioned wire fixation. J Orthop Trauma 2000;14:405‑13. 
15. Hutson JJ Jr., Zych GA. Infections in periarticular fractures of the lower extremity treated with tensioned wire hybrid fixators. J Orthop Trauma 1998;12:214‑8. 
16. Kirby CK, Fitts WT. The incidence of complications in the use of transfixion pins and wires for skeletal traction. Ann Surg 1946;123:27‑31. 
17. Patterson MM. Multicenter pin care study. Orthop Nurs 2005;24:349‑60. 18. Nigam V, Jaiswal A, Dhaon BK. Local antibiotics: Panacea for long term skeletal traction. Injury 2005;36:199‑202. 
19. Lethaby A, Temple J, Santy‑Tomlinson J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database Syst Rev 2013;12:CD004551.