Eur J Trauma Emerg Surg
DOI 10.1007/s00068-016-0712-3
REVIEW ARTICLE
Indications and anatomic landmarks for the application of lower
extremity traction: a review
S. F. DeFroda1 · J. A. Gil1 · C. T. Born2
Received: 31 March 2016 / Accepted: 19 July 2016
© Springer-Verlag Berlin Heidelberg 2016
Abstract
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 deep
anatomy crucial to successful placement.
Methods Review was performed via PubMed search as
well as referencing the Orthopaedic literature. Relevant
articles to the anatomy of the knee, ankle and calcaneus as
they pertain to traction placement were referenced in com-
piling the optimal recommendations for traction placement.
Conclusion By palpating and marking superficial land-
marks and observing specific anatomic relationships, safe
application of traction pins can be performed while mini-
mizing iatrogenic injury to vital anatomic structures, and
avoiding intra-articular placement which could potentially
lead to joint infection.
Keywords Skeletal traction · Fracture · Lower extremity ·
Trauma
* S. F. DeFroda
sdefroda@gmail.com
1
Department of Orthopaedics, Alpert Medical School
of Brown University, 593 Eddy Street, Providence, RI 02903,
USA
2
Division of Orthopaedic Trauma, Department
of Orthopaedics, Alpert Medical School at Brown University,
Providence, RI, USA
Introduction
Immobilization of proximal lower extremity fractures is
difficult to achieve with a splint alone. Often times more
invasive techniques such as the application of skeletal trac-
tion are required to achieve adequate immobilization in the
setting of certain fractures such as unstable posterior wall
acetabulum fractures following hip dislocations, subtro-
chanteric femur fractures, and femoral shaft fractures [1].
Additionally, calcaneal traction may be required in the
emergent setting for impacted, shortened tibial plafond
fractures or subtalar dislocations [1]. The body’s attempt
to naturally splint fractures in a position of stability may
result in shortening of long bone fractures such as the
femur. Additionally, damage to articular cartilage resulting
from impingement of cartilage on bone is a concern in the
setting of hip fracture dislocations and tibial plafond frac-
tures. These situations may require offloading of the articu-
lar surface via traction.
Placement of skeletal traction is not without the potential
for complications. If the traction pin is not adequately secured
in cortical bone it can pull out resulting in a cortical defect
that may predispose that region to fracture from the result-
ant stress riser when the leg is manipulated during surgery or
postoperatively during rehabilitation. Additionally, if traction
pins are placed solely through a single cortex (“transcortical”)
rather than bi-cortical, the resulting stress riser may lead to
fracture if not protected [2]. Secondary pin-tract osteomyelitis
may also occur from the thermal necrosis of transcortical pin
placement similar to that seen with malpositioned external
fixation pins. There is also a risk of developing a septic joint if
the traction pin is placed intraarticularly [3, 4]. Septic arthri-
tis is more common following application of a circular fixator
than a traction pin, with the complication being reported up to
48 weeks after removal [5–8]. Septic joint following traction
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 S. F. DeFroda et al.

pin placement has been reported in the ankle as well as the
knee with higher rates in the knee compared to the ankle
(1.5–9.5 vs 1.5–5 %) [5, 7–11]. Such complications have led
to various anatomic studies with regards to safe placement of
proximal tibial traction. DeCoster et al. dissected 35 cadav-
ers (70 knees), dividing the knee into four zones: anterior,
posteromedial, posterolateral, and posterior. It was found that
the distal most insertion of the capsule occurs in the posterior
aspect of the knee ~30 mm distal to the tibial plateau based on
the attachment of the PCL. The capsule attaches slightly more
proximally in the anterior aspect of the tibia; ~6–14 mm dis-
tal to the joint line. Posteromedially the capsular attachment
was found to be 12 mm distal to the joint line, and posterolat-
erally the capsule was found to attach from 8 to 14 mm distal
to the joint line [12]. This led the authors to conclude that pin
placement was safe if the pin is placed more than 14 mm dis-
tal from the joint, but noted that if more proximal placement
were required it could be safely achieved anteriorly as long as
placement of the pin is 6 mm distal to the joint [12].
shaft fractures. Optimal placement of the traction requires
placement of the traction pin at the metaphyseal diaphy-
seal junction of the femur. Placement through the femur as
opposed to the tibia allows for direct traction through the
injured bone as opposed to pulling traction through the
knee, which may, potentially, also be injured [13]. Prior to
application of traction, informed consent must be obtained
and the appropriate supplies should be collected: marking
pen, lidocaine, skin prep, scalpel, Kelly clamp, traction pin
(Steinman or Denham pin), drill, sterile gloves, traction
bow, rope, 20–30 lbs of weight, traction bed, and an assis-
tant, if available. It is important to palpate superficial land-
marks and draw them on the patient to guide pin placement.
Typically femoral traction pins are placed from medial to
lateral to avoid the femoral neurovascular bundle [13, 14].
Medial pin placement may be difficult in a multiply injured
patient because it requires moving the contralateral limb
out of the way or elevating the injured limb to gain access
medially. One study, investigated lateral placement of distal
femoral traction and found that there was minimal risk to

Indications

Skeletal traction is typically indicated for shortened or unsta-

ble fractures of the lower extremity. Unstable hip disloca-
tions or acetabulum fractures may require traction to main-
tain a concentric hip joint or to offload articular cartilage
impingement prior to definitive fixation [1]. Shortened femo-
ral shaft or subtrochanteric fractures can benefit from either
distal femoral or proximal tibial traction. Distal traction is
typically indicated for tibial plafond fractures, unstable tibial
plateau fractures or unstable subtalar injuries [1]. Traction is
rarely e contraindicated, however, there are number of sce-
narios in which it may not be needed or may be delayed.
Typically traction should not be placed in the setting of acute
open fractures, as patients should be going to the operating
theater rapidly to be stabilized. Once the acute injury has
been assessed, however, traction may be a valid treatment
option to immobilize the extremity until definitive manage-
ment can be achieved. A relative contraindication for traction
is in an older or frailer patient who is comfortable despite
radiographic shortening. While traction can temporarily
assist with localized stabilization and internal splinting of the
injury it may not be necessary if the patient is comfortable
and understands the risks of not being properly immobilized.

Fig. 1  Distal femoral traction pin landmarks. a The patella is marked

Technique
Distal femoral
Distal femoral traction is generally indicated for unstable
hip dislocations and acetabular fractures as well as femoral
(four dots), as well as the lower pole of the patella and the patellar
tendon. The adductor tubercle is marked (circle). A mark is made
~2 cm proximal to the superior pole of the patella. b A mark is made
~3 finger breadths medial to the midline. Note that the intersection of
this line and the line 2 cm proximal to the patella is slightly proximal
to the level of the adductor tubercle. c, d AP and lateral radiograph
following traction pin placement

13
Indications and anatomic landmarks for the application of lower extremity traction: a review

the femoral artery and saphenous nerve with the superior

medial geniculate artery being at the highest risk of iatro-
genic injury at the level of the superior pole of the patella
[14]. The authors also noted that placing distal femoral
traction at 2 cm proximal to the superior pole of the patella
was the safest with regards to medial structures while limit-
ing the risk of diaphyseal pin placement which can lead to
an iatrogenic stress riser following removal [14].
Once the patient is positioned with the knee slightly
flexed, landmarks should be marked (Fig. 1a, b). Palpate
the patella as well as the joint line. Placement at the meta-
diaphyseal junction is best done by drawing a line approxi-
mately 2 cm (2 finger breadths) proximal to the superior
pole of the patella and palpating the adductor tubercle (2–3
finger breadths from midline) medially for the start point
in the sagittal plane, which should be slightly proximal to
the adductor tubercle based on the line a 2 cm [15]. The
skin is prepped and lidocaine is injected superficially at the
skin and deeper at the periosteum. Subsequently, a longitu-
dinal incision in the skin is made parallel to the femur. A
Kelly clamp is inserted until bone is felt and the soft tis-
sue is dilated via spreading as the Kelly is removed. Next,
the pin should be placed on the medial femoral cortex and Fig. 2  Proximal tibial traction pin landmarks. a The patella is
marked (four dots), as well as the inferior pole of the patella and the
“walked” anteriorly and posteriorly to ensure placement in patellar tendon. The fibular head is marked laterally (circle) as well as
the center of the bone. If available, an assistant should stand the medial and lateral joint line (two horizontal lines) and the tibial
at the foot of the bed to ensure the pin is perpendicular to tubercle (upside down “U”). A horizontal mark is made 2 cm distal to
the bone in the axial plane and parallel to the marked joint the tibial tubercle. b The lateral start point is determined by drawing
a line 2 cm lateral to the mark drawn in (a). c, d AP and lateral radio-
line in the coronal plane. The drill is attached to the pin and graph following traction pin placement
it is advanced until skin tenting is noted on the lateral aspect
of the leg. Lidocaine is injected and a counter incision is
made in the skin at the peak of the tented skin and the pin traction is often easier to apply compared to distal femo-
is advanced until the threads of the pin are felt to engage ral traction, especially in obese patients whose soft tis-
both cortices. Correct placement of the pin should be con- sue may make it difficult to identify the landmarks of the
firmed radiographically, followed by placement of the trac- distal femur. Contrary to distal femoral traction, proxi-
tion bow and 20–30 lb of traction that is hung off the side of mal tibial traction is inserted from lateral to medial to
a traction bed (Fig. 1c, d) [13, 15]. One study examined the prevent iatrogenic injury to the peroneal nerve [13]. The
rate of intra-articular pin placement when using the adduc- same materials previously described for distal femoral
tor tubercle as a proximal landmark compared to insertion traction should be gathered. The landmarks that should
2 cm superior to the patella. Pins placed at the level of the be palpated and marked include the patella, patellar
tubercle were intra-articular 29 % of the time, compared to tendon, tibial tubercle, joint line and head of the fibula
0 % of the time when selecting an entry point 2 cm proxi- (Fig. 2a, b). To achieve placement in metaphyseal bone,
mal to the patella [16]. An additional study examined the the operator should mark 1–2 cm distal to the tuber-
capsular attachments at the distal femur and found that the cle (1–2 finger breadths) and 2–3 cm lateral (2 finger
medial capsular attachment was up to 74 % of the diameter breadths) [19]. Once again, following administration of
of the femur at the level of the adductor tubercle [17]. The local anesthetic and skin prep, an incision parallel to the
risk of hardware infection following skeletal traction fixa- long axis of the bone is made. The soft tissue is spread
tion is relatively low, with one study of 520 femur fractures with the Kelly clamp and the traction pin should be cen-
reporting an infection rate of 0.9 % [18]. tered on the tibia. The tibia has a triangular cross section
so the pin may not be completely perpendicular to the
Proximal tibial cortex upon entry. An assistant should once again stand
at the foot of the bed to help guide proper placement
Proximal tibial traction is typically used in the setting of of the pin. Radiographs should be obtained to confirm
femoral shaft or subtrochanteric fractures. This type of placement (Fig. 2c, d). Intra-articular pin placement is

13

Fig. 3  Distal tibial–fibular traction pin landmarks. a The anterior joint line is marked (horizontal line). b A mark is made 5 cm proximal to the
joint line. c The medial malleolus is marked and the start point is determined 5 cm proximal to the joint on the posterior aspect of the fibula
avoided by staying at least 14 mm distal to the joint line.
If closer placement to the joint line is required, it is best
to move the pin more anterior where the joint capsule
only projects an average of 6 mm beyond the joint line
[12].
Distal tibial–fibular
Fractures distal to the knee require more distal traction
through the distal tibia or calcaneus. Distal tibial–fibu-
lar traction is less commonly used than distal femoral
and proximal tibial traction; however, it may be useful
in the setting of shortened tibial plateau fractures [1].
Placement is from lateral to medial both to avoid the
superficial peroneal nerve and to ensure placement of
the pin through the fibula. To avoid intra-articular pin
placement, a line should be marked 5 cm proximal to
the ankle joint (Fig. 3) [11]. The trajectory of the pin is
similar to the trajectory of syndesmotic screw insertion,
aiming slightly posterior to anterior through the fibula
and through of the tibia engaging four cortices. Septic
arthritis following pin placement is less common in the
ankle than the knee [3]. Vives et al. found the superior
reflection of the ankle capsule to be ~3.2 cm from the
medial malleolus and 2.1 cm from the anterior joint line.
This led the authors to recommend pin placement more
than 3 cm proximal to the tip of the medial malleolus
and 2 cm proximal to the anterior joint line to avoid
intra-articular placement [20].
13
S. F. DeFroda et al.
Calcaneal
Calcaneal traction can be utilized for tibial fractures, pilon
fractures of the tibia, as well subtalar injuries [1]. Place-
ment should be from medial to lateral to avoid injury to the
posterior tibial neurovascular bundle. This approach, how-
ever, most commonly places the medial calcaneal nerve at
risk [21]. In addition to the materials used for placement
of the aforementioned types of traction, a portable fluoros-
copy machine can be used to confirm starting point prior
to entry. Landmarks that should be palpated and marked
include the medial malleolus, posterior tip of the calcaneus
and the tibiotalar and subtalar joint (Fig. 4a, b). A line can
be drawn from the medial malleolus to the tip of the cal-
caneus, with the start point approximately two-thirds from
the malleolus and one-third from the tip of the calcaneus.
Kwon et al. performed a cadaveric study to determine the
medial calcaneal safe zone for pin placement. The neuro-
vascular bundle was an average 3.4 cm from the postero-
inferior tip of the calcaneus with the posterior tibial nerve
being the closest structure [22]. Based on this data, they
defined a circular “safe zone” with a radius of 3.3 cm from
the posteroinferior tip of the calcaneus and recommend
placement in the middle of this, ~1.6 cm from the tip [22].
This distance was best approximated using fluoroscopy to
align the hilt of a number 10 scalpel with the posteroinfe-
rior tip of the calcaneus and marking the tip of the blade
as the entry point (Fig. 4a) [22]. Some authors argue that
even accurate placement within this safe zone may place
Indications and anatomic landmarks for the application of lower extremity traction: a review
Fig. 4  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
the medial calcaneal nerve at risk due to its unpredictable
course [21, 23]. Tornetta et al. argue that the medial calca-
neal pin should be placed slightly more posterior along the
calcaneus than 1.6 cm to avoid potential injury to posterior
branches of the lateral plantar nerve [23]. Once the pin is in
place and confirmed radiographically, traction or external
fixation may be applied (Fig. 4c).
Conclusion
Skeletal traction is a useful adjunct to immobilization in
both the emergent and operative setting when utilized for
the correct injury patterns. Skeletal traction can be applied
quickly and safely causing minimal disruption to the soft
tissues while allowing for temporary stabilization in the
critically injured patient. To safely and appropriately apply
traction while minimizing iatrogenic injury, knowledge of
the local anatomic landmarks is required. Adequate palpa-
tion and marking of the extremity along with the use of
fluoroscopic imaging when available can help assure safe
placement of traction. Utilizing the assistance of a second
person who has knowledge of traction can facilitate with
the application of traction by adding a visual perspec-
tive in another plane of fixation. By adhering to the ana-
tomic guidelines and principals of traction, application of
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
skeletal traction can be done safely and effectively when
needed.
Compliance with ethical standards
No human participants or animals were utilized in this work. Informed
consent was obtained for the usage of any patient imaging at the time
of their initial procedure
Conflict of interest Dr. Christopher Born is a consultant for Styker
and receives research funding from Stryker and the Foundation of
Orthopaedic Trauma. He has stock options in Illuminoss and Bioin-
traface. Dr. Steven DeFroda and Dr. Joseph Gil have no conflicts or
financial interests to report. No funding was received for this work.
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