Preoperative skeletal versus cutaneous traction for femoral shaft fractures treated within 24 hours

Prehospital Trauma Compendium: Management of Suspected Femoral Shaft Fractures - A position statement and resource document of NAEMSP

Emergency medical services (EMS) clinicians encounter patients with suspected femoral shaft fractures due to both blunt and penetrating trauma. Traction splinting is commonly used by many EMS systems on the premise that it might reduce the perceived risk for hemorrhage and can help reduce pain. It has been called into question whether femoral shaft fractures are truly causative of hemorrhagic shock. Additionally, traction splinting has been associated with iatrogenic injuries, especially if applied to patients with co-morbid lower extremity and pelvic injuries. The application of a traction splint is also an infrequent EMS intervention, raising concerns about skill decay and maintenance of competency. Non-traction splinting, or static splinting, is also a therapeutic option in the field management of suspected femur fractures. Because the benefits of traction splinting versus static splinting of suspected femur fractures in the EMS setting are uncertain, the National Association of EMS Physicians (NAEMSP) performed a review of the evidence regarding EMS management of femoral shaft fractures and developed the following recommendations and summarization of the evidence.

The use of skin traction as an intraoperative adjunct for correction during pediatric neuromuscular scoliosis correction

PURPOSE

Intraoperative traction can improve deformity correction during posterior spinal fusion (PSF). This is commonly done with invasive distal femoral or pelvic pins, or traction boots. The novel technique of intraoperative skin traction (ISkinT) avoids risks associated with intraoperative skeletal traction (ISkelT) or hyperlordosis with extended hip position. We aimed to describe ISkinT and assess its safety and efficacy in PSF in non-ambulatory scoliosis.

METHODS

Retrospective review of patients aged 10-21yo who underwent T2-pelvis PSF with ISkinT from 2017 to 2023. Demographics and radiographic measurements were statistically compared to a published cohort that used ISkelT.

RESULTS

42 patients treated with ISkinT were included and compared to 41 patients treated with ISkelT. ISkinT was applied by a cranial attachment and an average of 12% body weight to the pelvis with the hips and knees flexed, using tape-rope-weight system with Trendelenburg assistance. The preop major Cobb was 90°±21° in the ISkinT cohort and 91°±17° in the ISkelT cohort (p = 0.743; d = 0.07), which corrected 75% in ISkinT and 53% in ISkelT (p < 0.0001; d = 1.3). Preop pelvic obliquity averaged 23°± 10° in ISkinT and 34°±14° in ISkelT that corrected 74% in ISkinT and 65% in ISkelT (p < 0.0001; d = 0.95). No intraop or postoperative skin traction-related complications occurred, including neuromonitoring complications (obtained in 88%).

CONCLUSION

In non-ambulatory neuromuscular pediatric scoliosis patients, ISkinT during PSF to the pelvis is a safe and effective technique for deformity correction. There were no associated complications and no difference of corrective capacity for ISkinT compared to ISkelT. ISkinT can be considered for T2-pelvis PSF for pediatric scoliosis.

Rate of skin and nerve complications as a result of cutaneous traction with modern foam boots

INTRODUCTION

Cutaneous traction is used to temporize lower extremity fractures and relies on friction between the skin and surrounding material to apply a longitudinal force. This circumferential compressive force can lead to pressure sores, skin sloughing, or compressive neuropathies. These complications have been reported in up to 11% of patients when the cutaneous traction relies on adhesive tapes, plaster, and rubber bandages being in immediate contact with the skin. The rates of these complications are not well documented when using modern foam boots.

METHODS

A retrospective chart review was performed on all orthopedic trauma patients who suffered pelvic or lower extremity injuries between March 1st, 2020 and April 30th, 2021 at a single Level-1 trauma center. We included all patients with femoral fractures, axially unstable pelvic ring and/or acetabular fractures, and unstable hip dislocations temporized with the use of cutaneous traction. All patients had intact skin and lower extremity nerve function prior to application.

RESULTS

There were 138 patients identified with 141 lower extremities. The average patient age was 50.7 (6-100) years. Mean traction weight of 9.8 (5-20) pounds. Average traction duration was 20.9 (2.3-243.5) hours. At the time of traction removal, there was 1 (0.7%) new skin wound and 0 nerve palsies. The new skin wound was a stage one heel pressure sore and did not require further treatment.

CONCLUSION

Cutaneous traction with a modern foam boot was found to have a skin complication rate of 0.7% and a nerve palsy complication rate of 0% for an overall complication rate of 0.7%, which has not been previously established and is lower than historically reported complication rates of 11% when utilizing adhesive and plaster directly on skin. Foam boot Cutaneous traction may be considered a safe option for traction placement.

Skeletal Traction for Isolated Femur Fractures Does Not Reduce Opioid Consumption

OBJECTIVES

Isolated femoral shaft fractures can be treated preoperatively with skeletal traction (TXN) or maintenance of a position of comfort (COMF). The goal of this retrospective review was to determine whether preoperative opioid consumption differs significantly between these forms of treatment.

METHODS

DESIGN

Case-control retrospective study.

SETTING

Two academic Level 1 trauma centers.

PATIENT SELECTION CRITERIA

Patients presenting to the emergency department with isolated OTA/AO 32A-C femoral shaft fractures from 2017 to 2020.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was preoperative opioid consumption (morphine milligram equivalents) comparing patients treated with application of TXN or placed in a position of COMF.

RESULTS

Two hundred and twenty patients were studied (COMF n = 167, TXN n = 53). Multivariate regression analysis revealed significantly greater preoperative opioid consumption in the emergency department for the TXN group compared with COMF (2.6 more morphine milligram equivalents [confidence interval, 0.23-4.96], P = 0.031). There was no difference in preoperative opioid consumption between groups on the hospital floor ( P = 0.811) nor during the entire preoperative course ( P = 0.486). The total preoperative rate of opioid consumption (morphine milligram equivalents/hour) did not differ ( P = 0.825).

CONCLUSIONS

Patients with isolated femoral shaft fractures treated preoperatively with skeletal traction consumed more opioids in the emergency department compared with patients treated in a position of comfort, but no difference in opioid consumption was observed between groups for the entire preoperative course. A position of comfort may be considered as an acceptable alternative to skeletal traction for patients with isolated femur fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The use of skin traction in the adult patients with proximal femur fracture. What are the effects, advantages and disadvantages? A scoping review

BACKGROUND

Hip surgery is normally the chosen therapy for proximal femur fractures. Surgery within 24-48 h after hip fracture is recommended, but surgery may not always be performed promptly. Consequently, skin-traction is applied to reduce complications. The purpose of this review is to assess both advantages and disadvantages of skin traction.

METHODS

A scoping review was conducted. The research question was: which are the effects of skin traction, its advantages and disadvantages in adult patients with proximal femur fractures hospitalised in orthopaedic wards? The search was done in the databases PubMed, CINAHL, Cochrane, Embase, DOAJ, ClinicalTrials.gov and OpenDissertation.

RESULTS

9 records were included, skin traction effects were summarised in 7 categories: pain, pressure sores, comfort and relaxation, thromboembolism, damage from adhesive, complications and quality of care. The possible advantage is pain reduction between 24 and 60 h, the possible disadvantage is skin damage.

DISCUSSION AND CONCLUSION

The routine use of skin traction does not appear recommended, but more consistent evidence is necessary to make clinic decisions. Future RCTs could focus on the effects of skin traction 24-60 h after hospitalisation and before surgery.

Implementing an Educational Module for Orthopaedic Residents Placing Skeletal Traction

INTRODUCTION

Although placement of a distal femoral traction (DFT) pin is a relatively simple procedure used to stabilize femoral and pelvic fractures, it places patients at risk of iatrogenic vascular, muscular, or bony injury. We designed and implemented an educational module combining theory and practical experience to standardize and improve resident teaching on the placement of DFT pins.

METHODS

We introduced a DFT pin teaching module into our second-year resident "boot camp," which is used to help prepare residents for taking primary call in the emergency department at our level I trauma center. Nine residents participated. The teaching module included a written pretest, an oral lecture, a video demonstration of the procedure, and a practice simulation on 3D printed models. After completing the teaching, each resident underwent a written examination and proctored live simulation involving 3D models using the same equipment available in our emergency department. Pre-teaching and post-teaching surveys were used to assess resident experience and confidence with placing traction in the emergency department.

RESULTS

Before the teaching session, the rising postgraduate year 2 residents scored an average of 62.2% (range, 50% to 77.8%) on the DFT pin knowledge quiz. This improved to an average of 86.6% (range, 68.1% to 100%) (P = 0.0001) after the teaching session. After completing the educational module, they also demonstrated an improvement in confidence with the procedure, from 6.7 (range, 5 to 9) to 8.8 (range, 8 to 10) (P = 0.04).

DISCUSSION

Despite reporting high levels of confidence in their ability to place traction pins before starting the postgraduate year 2 consult year, many residents also reported anxiety around the accurate placement of traction pins. Early results of our training program showed improved resident knowledge of safe placement of traction pins and improved confidence with the procedure.

Evaluation of spin in the abstracts of orthopedic trauma literature: A cross-sectional review

OBJECTIVES

A cross-sectional analysis of orthopedic trauma randomized controlled trial (RCT) abstracts to assess the frequency and manifestations of spin, the misrepresentation or distortion of research findings, in orthopedic trauma clinical trials.

METHODS

The top 5 orthopedic trauma journals were searched from January 1, 2012, to December 31, 2017. RCTs with nonsignificant endpoints (p > .05) were analyzed for spin in the abstract. The primary endpoint of our investigation was the frequency and type of spin. The secondary endpoint was to assess whether funding source was associated with the presence of spin. Due to the low reporting of funding sources no statistics were able to be computed for this outcome.

RESULTS

Our PubMed search yielded 517 articles. Primary screening excluded 303 articles, and full text evaluation excluded an additional 161. Overall, 53 articles were included. Spin was identified in 35 of the 53 (66.0%) abstracts analyzed. Evidence of spin was found in 21 (39.6%) abstract results sections and 22 (41.5%) abstract conclusion sections. Of the 21 RCTs reporting a clinical trial registry, 3 (14.3%) had evidence of selective reporting bias.

CONCLUSIONS

Orthopedic trauma RCTs from highly ranked journals with nonsignificant endpoints published from 2012 to 2017 frequently have spin in their abstracts. Abstracts with evidence of spin may influence a reader's perception of new drugs or procedures. In orthopedic trauma, the implications of spin may affect the treatment of patients with orthopedic trauma, so efforts to mitigate spin in RCT abstracts must be prioritized.

A comparative evaluation of the efficacy between skeletal traction and skin traction in pre-operative management of femur shaft fractures in Korle Bu Teaching Hospital

OBJECTIVES

This study is to compare the outcomes of pre-operative skeletal and skin traction in adult femoral shaft fractures awaiting surgical fixation within two weeks of presentation to the Accident Center of Korle Bu Teaching Hospital.

METHODS

This study was a clinical trial on 86 recruited patients with closed femoral shaft fractures sustained within 24 hours of presentation grouped into 2 groups. Descriptive and inferential statistics comprising frequency, percentage, Chi-square, independent sample t-test and Mann-Whitney U test were used in analysing the data.

RESULTS

Of the total number of patients involved in the study, 74% (n=64) were males and 26% (n=22) were females with a mean age of 39.49 (SD ±15). There was no statistically significant difference in the mean visual analogue scale (VAS) pain assessment between the Skin traction group and Trans-tibia skeletal traction group after traction. With regards to complications, the difference between the Skin traction group and the Skeletal traction group was statistically significant (P=0.001). Moreover, the mean blood loss compared with the open type of reduction in the Transtibia skeletal traction group was significantly less than the Skin traction group (p=0.000).

CONCLUSION

This study has shown that both Skeletal traction and Skin traction were equally effective in controlling pre-operative pain in adult patients with femoral shaft fractures and does not affect intra-operative blood loss and post-operative management. Therefore, pre-operative Skin traction can be considered a useful and cost-effective method of maintaining alignment and pain relief in adult femoral shaft fractures.

FUNDING

Personal Funding.

Pain relief after more than 24 hours of preoperative skin traction in patients with intertrochanteric fractures: A retrospective comparative cohort study

AIM

The primary aim of the study was to investigate pain relief after more than 24 h of preoperative skin traction (because of delay in surgery due to comorbidities and system issues) in patients with intertrochanteric fractures.

METHOD

We performed a retrospective comparative cohort study of 56 patients who underwent intramedullary nailing for the treatment of intertrochanteric fractures and who had waited for surgery for more than 48 h after admission due to comorbidities or system issues. Preoperative therapy was randomly selected with a ratio of one to two and patients classified as skin traction (n = 18) or no traction (n = 38). The Verbal Rating Scale (VRS) was used to assess pain at 12-60 h post-admission.

RESULTS

There was no significant difference in VRS at 12 h after admission (1.1 ± 1.0 vs. 0.8 ± 0.9, p = 0.73), but patients who received skin traction had a lower VRS pain score at 24-60 h after admission compared to those with no traction (24 h, 0.4 ± 0.8 vs. 1.1 ± 1.0, p < 0.05; 36 h, 0.2 ± 0.5 vs. 0.9 ± 0.9, p < 0.05; 48 h, 0.2 ± 0.4 vs. 0.8 ± 0.9, p < 0.05; 60 h, 0.2 ± 0.4 vs. 0.9 ± 0.9, p < 0.05).

CONCLUSION

Skin traction for patients with intertrochanteric fractures for more than 24 h preoperatively resulted in a lower VRS pain score. Therefore, more than 24 h of preoperative skin traction for patients with intertrochanteric fractures may give effective pain relief in situations where surgery is delayed.

Orthopaedic traumatology: fundamental principles and current controversies for the acute care surgeon

Multiply injured patients with fractures are co-managed by acute care surgeons and orthopaedic surgeons. In most centers, orthopaedic surgeons definitively manage fractures, but preliminary management, including washouts, splinting, reductions, and external fixations, may be performed by selected acute care surgeons. The acute care surgeon should have a working knowledge of orthopaedic terminology to communicate with colleagues effectively. They should have an understanding of the composition of bone, periosteum, and cartilage, and their reaction when there is an injury. Fractures are usually fixed urgently, but some multiply injured patients are better served with a damage control strategy. Extremity compartment syndrome should be suspected in all critically injured patients with or without fractures and a low threshold for compartment pressure measurements or empiric fasciotomy maintained. Acute care surgeons performing rib fracture fixation and other chest wall injury reconstructions should follow the principles of open fracture reduction and stabilization.

Surgical Management of Musculoskeletal Trauma

Musculoskeletal injuries cause a significant burden to society and can have a considerable impact on patient morbidity and mortality. It was initially thought that these patients were too sick to undergo surgery and later believed that they were too sick not to undergo surgery. The pendulum has subsequently swung back and forth between damage control orthopedics and early total care for polytrauma patients with extremity injuries and has settled on providing early appropriate care (EAC). The decision-making process in providing EAC is reviewed in an effort to optimize patient outcomes following severe extremity trauma.

Rectus femoris muscle atrophy and recovery caused by preoperative pretibial traction in femoral shaft fractures-comparison between traction period

BACKGROUND

Skeletal traction is performed to temporarily stabilize fracture sites before surgery in patients with femoral fracture. To date, however, there is no study evaluating the difference in the degree of the recovery, of the muscle strength, as well as muscle atrophy following skeletal traction. The purpose of this study was to compare the degree of recovery of rectus femoris muscle strength after surgery in association with muscle atrophy by analyzing the duration of preoperative tibial traction, age and sex in patients with femoral fracture.

HYPOTHESIS

Rectus femoris muscle atrophy will progress depending on the duration of preoperative tibial traction, age and sex in patients with femoral fracture.

PATIENTS AND METHOD

Thirty-one patients who underwent preoperative pretibial skeletal traction and intramedullary nailing were divided into two groups according to the traction period: group A (n=12) with a duration of traction of <7 days (mean: 4.08±1.78 days) and group B (n=19) ≥7 days (mean: 13.63±7.17 days). The degree of muscle atrophy and recovery were compared between the two groups, according to age and gender. The degree of muscle atrophy was measured by the difference in thickness of the rectus femoris between pre- and post-traction using ultrasound. The degree of muscle recovery was evaluated by the Q-setting and heel off time. Clinical outcome was evaluated by the non-union rate and Lysholm score.

RESULTS

The degree of muscle atrophy was 0.99±0.14mm in group A and 2.22±0.11mm in group B (P<0.001). The Q-setting time was 4.83±0.94 days in group A and 6.56±1.38 days in group B (P=0.001). Heel off time was also shorter in group A at 2.58±0.90 days, taking 3.72±1.27 days in group B (P=0.012). The recovery rate in the rectus femoris was significantly higher in group A than in group B (P<0.001). There was no significant difference in non-union rate between group A and B (P=0.672) but the mean Lysholm score at the last follow-up was significantly higher in group A than in group B (P=0.006). However, no significant differences were detected in the mean thickness of the rectus femoris, Q-setting, and heel off time between the different age and gender groups (P<0.05).

CONCLUSIONS

The prolonged duration of preoperative skeletal traction indicates not only that the resulting disuse atrophy would progress further but also that the muscle atrophy would be accelerated more rapidly for shorter periods of time, based on a cut-off value of 7 days. In addition, the rate of rectus femoris muscle recovery and clinical outcomes were lower in patients undergoing traction for longer periods of time. This indicates that it would be effective for increasing the rate of the recovery and minimizing the occurrence of post surgical complications if surgeons could perform surgery at the earliest possible opportunity following traction, within seven days after the onset of trauma.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Intraoperative Distal Femoral Fine Wire Traction to Facilitate Intramedullary Nailing of the Femur

Many techniques have been employed to facilitate intramedullary nailing of femur fractures. Maintaining limb length during the operation can be difficult. The authors describe the use of distal femoral fine wire skeletal traction as a technique to maintain reduction while allowing intramedullary nailing of femur fractures. This technique is safe, is effective, and negates the need for a fracture table or an assistant.

The Effect of Skin Traction on Preoperative Pain and Need for Analgesics in Patients With Intertrochanteric Fractures: A Randomized Clinical Trial

BACKGROUND

Preoperative skin traction is applied for many patients with hip fracture. However, the efficacy of this modality in pain relief is controversial.

OBJECTIVES

The aim of the current study was to investigate the effects of skin traction on pain in patients with intertrochanteric fractures.

PATIENTS AND METHODS

A total of 40 patients contributed in this randomized clinical trial. Patients were randomly allocated into two equal groups: the skin traction (3 kg) and control groups. The severity of pain was recorded at admission and 30 minutes, one, six, 12, and 24 hours after skin traction application utilizing a Visual Analogue Scale (VAS). In addition, the number of requests for analgesics was recorded. Finally, the mean severity of pain in each measurement and the mean number of analgesic requests were compared between the two groups.

RESULTS

The severity of pain was significantly decreased in skin traction group only at the end of the first day after traction application (2.7 ± 0.8 vs. 3.3 ± 0.9; P = 0.042), while there was no significant difference between the two groups in other pain measurements. The number of requests for analgesics was the same between the two groups.

CONCLUSIONS

Although skin traction had no effect on analgesic consumption, it significantly decreased the pain at the end of the first day. The application of skin traction in patients with intertrochanteric fractures is recommended.

A prospective study of pain reduction and knee dysfunction comparing femoral skeletal traction and splinting in adult trauma patients

OBJECTIVES

To determine if distal femoral traction pins result in knee dysfunction in patients with femoral or pelvic fracture, and to determine if skeletal traction relieves pain more effectively than splinting for femoral shaft fractures.

DESIGN

Prospective cohort trial.

SETTING

Level I urban trauma center.

PATIENTS/PARTICIPANTS

One hundred twenty adult patients with femoral shaft, acetabular, and unstable pelvic fractures.

INTERVENTION

Patients with femoral shaft fractures were placed into distal femoral skeletal traction or a long-leg splint, based on an attending-specific protocol. Patients with pelvic or acetabular fractures with instability or intraarticular bone fragments were placed into skeletal traction.

MAIN OUTCOME MEASUREMENTS

An initial Lysholm knee survey was administered to assess preinjury knee pain and function; the survey was repeated at 3- and 6-month follow-up visits. Also, a 10-point visual analog scale was used to document pain immediately before, during, and immediately after fracture immobilization with traction or splinting.

RESULTS

Thirty-five patients (29%) were immobilized with a long-leg splint, and 85 (71%) were immobilized with a distal femoral traction pin. Eighty-four patients (70%) completed a 6-month follow-up. Lysholm scores decreased by a mean 9.3 points from preinjury baseline to 6 months postinjury in the entire cohort (P < 0.01); no significant differences were found between the splint and traction pin groups. During application of immobilization, visual analog scale pain scores were significantly lower in traction patients as compared with splinted patients (mean, 1.9 points less, P < 0.01). Traction pins caused no infections, neurovascular injuries, or iatrogenic fractures.

CONCLUSIONS

Distal femoral skeletal traction does not result in detectable knee dysfunction at 6 months after insertion, and results in less pain during and after immobilization than long-leg splinting.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.