In cases where it is not possible to proceed to early definitive
osteosynthesis (polytrauma, soft-tissue problems, patient condition, limited
resources), a spanning external fixator is often used. A long leg splint can
also be applied.
Temporary, proximal tibial, skeletal traction is reserved for those cases in
which it is not possible to place a spanning external fixator, or use a long
Care should be taken to protect pressure points on the skin.
AO teaching video: Skeletal traction
Tibial tuberosity/patella/common peroneal nerve
Bend the knee to make identification of the surface anatomy easier.
First, locate the prominence of the tibial tuberosity and circle it with a
Next, identify the patella, followed by the infrapatellar tendon.
Rotate the leg internally and palpate the fibular head. The location of the
peroneal nerve is just posterior to the fibular head. This area should be
avoided during pin insertion.
Use a local anesthetic injected subcutaneously down to the tibial
periosteum. Make a stab incision approximately 2.5 cm posterior to the tibial
tuberosity avoiding the peroneal nerve.
Insert a large K-wire, or a strong Steinmann pin, 1-2 cm distal to the level
of the tibial tubercle. Ensure that the pin is inserted 1 cm posterior to the
anterior cortex of the tibia to ensure that it does not cut out of the
In elderly patients with osteoporotic bone if long term temporary fixation
is required the pin may need to be incorporated into a below knee plaster.
Alternatively, two parallel pins, about 1 cm apart, preloaded, and linked
medially and laterally with Hoffmann-type external fixator clamps, will reduce
the risk of cutting out.
After the wire has been inserted, connect it to an appropriate stirrup with
7-15 kg skeletal traction. Place a padded bolster in the supracondylar region
to allow for knee flexion.
There may need to be some counter traction and the foot of the bed may need
to be elevated.