Orthopedic Traction – Principles, Types, and Uses

Last Updated on June 13, 2025

Traction is a fundamental concept in orthopedics for managing fractures, dislocations, and certain musculoskeletal deformities. It involves the application of a pulling force to align bones, reduce dislocations, or correct deformities.

Although modern surgical fixation techniques have reduced its widespread use, traction continues to hold clinical relevance in specific scenarios such as pediatric fractures, preoperative stabilization, and resource-limited settings.

What is Orthopedic Traction?

Orthopedic traction is a technique that applies a controlled pulling force to part of the musculoskeletal system, typically to reduce fractures or dislocations or correct soft tissue deformities.

The traction force may be delivered through the skin (non-invasive) or directly to the skeleton using pins or wires (invasive). In all cases, the aim is to restore anatomical alignment, minimize pain, and facilitate proper healing, either as a temporary measure before definitive treatment or as a primary management tool.

Principles of Orthopedic Traction

Effective traction relies on a balance of biomechanical principles that ensure the desired therapeutic outcome while minimizing complications.

Line of Pull and Force Vectors

Traction must be applied along the anatomical axis of the affected bone or joint to achieve proper alignment. Deviations in the line of pull can result in inadequate reduction or unintended angular deformities.

Counter-Traction

Every traction force must be met with an equal and opposite force, known as counter-traction, to prevent unwanted body movement. This is often achieved using the patient’s body weight (e.g., elevating the foot end of the bed so the patient’s weight resists upward pull), fixed support (like a footplate), or by elevating the bed in specific ways (e.g., Trendelenburg or reverse Trendelenburg position).

Without counter-traction, traction becomes ineffective and uncomfortable, leading to pain, poor alignment, and increased risk of complications.

Duration and Monitoring

Traction is typically applied for several hours to weeks, depending on the clinical scenario. Regular monitoring is essential to assess neurovascular status, alignment, and skin integrity. Prolonged use without monitoring can lead to serious complications.

Soft Tissue Protection

Adequate padding and proper pin care (in skeletal traction) are crucial to prevent skin breakdown, pressure sores, and infections. Neurovascular checks must be performed routinely to detect any compression or ischemia early.

Types of Traction

Traction techniques can be classified in multiple ways based on how the force is applied, its purpose, and the direction in which it acts. Understanding these classifications helps guide appropriate selection and application in clinical practice.

Based on the Method of Application

Skin Traction

In this method, the traction force is applied externally through adhesive tapes, straps, or foam boots attached to the skin. It is non-invasive and generally used for short durations or in patients where skeletal traction is contraindicated.

Skeletal Traction

Here, the force is applied directly to the bone using surgically inserted pins or wires (e.g., Steinmann pins, Kirschner wires). It allows for stronger, more sustained traction and is preferred when prolonged immobilization or greater force is required.

Based on the Direction of Force

Longitudinal Traction

The force is applied along the long axis of the limb common in lower limb fractures.

Lateral Traction

The force is applied perpendicular to the body part, typically used in specific reduction maneuvers or deformity corrections.

Axial Traction

Applied in an axial direction, often seen in cervical spine injuries (e.g., with Gardner-Wells tongs).

Static Vs Dynamic Orthopedic Traction

Static Traction

A constant force is applied using fixed weights or manual positioning. Most forms of skin and skeletal traction fall into this category. It is simple to maintain but lacks adaptability to physiological changes like muscle relaxation or spasm variation.

Dynamic Traction

The traction force varies slightly with patient movement or tension changes. It typically uses springs, pulleys, or elastic systems (e.g., Thomas splint with Balkan frame). Dynamic traction is also useful in cases where gradual mobilization is also desired.

Skin Traction- Types and Uses

Skin traction involves the application of a pulling force through adhesive or foam-based attachments applied externally to the skin. It is primarily used for short-term stabilization, pain relief, or preoperative alignment, especially in pediatric or low-force applications. Because it relies on the integrity of the skin and soft tissues, the amount of weight that can be safely applied is limited (usually ≤ 4–5 kg in adults).

Buck’s Traction

One of the most commonly used types, Buck’s traction, involves a straight-line pull applied to the lower limb using foam boots or straps. It is typically used for:

• Temporary stabilization of hip fractures
• Pain relief in femoral neck fractures
• Preoperative positioning in lower limb injuries

It does not provide strong fracture reduction, but helps relieve muscle spasm and maintain limb alignment.

Russell’s Traction

A modified form of Buck’s traction, Russell’s traction adds a sling under the knee, creating a combination of vertical and horizontal forces. It allows partial limb suspension while maintaining traction on the tibia.

• Used in femoral fractures in children
• Allows better soft tissue support and patient comfort

Dunlop’s Traction

Applied to the upper limb, Dunlop’s traction combines longitudinal traction with lateral pull at the elbow. It is rarely used now for

• Supracondylar fractures of the humerus in children
• Certain elbow dislocations

Cervical Skin Traction

In some cases, soft halter or chin-occiput straps are used to apply gentle traction to the cervical spine. This is typically reserved for:

• Cervical spondylosis with radiculopathy
• Mild soft tissue injuries in the neck
• Non-operative cervical stabilization

Skin traction in the cervical region is used only for mild forces (usually < 5 lbs) due to the risk of jaw and soft tissue pressure.

Adhesive vs Non-Adhesive Skin Traction

Skin traction systems are broadly categorized into adhesive and non-adhesive types based on how the traction apparatus is secured to the limb.

Adhesive Traction

This method uses adhesive tapes or similar materials directly applied to the skin, with bandages or straps securing the weights. It is more commonly used in children and younger patients with healthy skin. Classic Buck’s traction used adhesive tapes.

 Advantages

• Stronger hold on the limb
• Less risk of slippage during movement
• Relatively lightweight materials

 Disadvantages

• Risk of skin allergy or irritation
• Difficult to apply or remove without discomfort
• Not suitable for fragile or broken skin

Non-Adhesive Traction

Non-adhesive systems use foam boots, straps, or stirrups that grip the limb without sticking to the skin. They are better suited for adults or elderly patients with compromised skin integrity.

In general, non-adhesive tractions are preferred because of fewer adverse effects. Examples are foam boot, Buck’s traction and Halter-type cervical traction

Advantages

• Safe for fragile, sensitive, or injured skin
• Easier to apply and readjust
• More comfortable for prolonged use

Disadvantages:

• Greater chance of slippage or loosening
• Less precise control of traction force
• May require more frequent monitoring

Contraindications and Complications of Skin Traction

Contraindications

• Open wounds or skin infections at the application site
• Fragile or damaged skin (e.g., in elderly patients)
• Severe peripheral vascular disease
• Where prolonged high-force traction is needed

 Common Complications

• Skin irritation or ulceration
• Pressure sores at the attachment site
• Peroneal nerve palsy (if leg rotates externally)
• Inadequate reduction due to force limitation

Skeletal Traction- Types and Uses

Skeletal traction involves the application of force directly to the bone using surgically inserted pins or wires. It is used when stronger, more sustained traction is required — typically in cases of long bone fractures, pelvic injuries, or cervical spine trauma. Skeletal traction allows greater weight application than skin traction (up to 20–25 kg) and can be maintained for longer durations.

Because it is invasive, it carries risks of infection, neurovascular injury, and demands careful nursing care and monitoring.

Implants Used in Traction

Steinman Pin

A thick metallic pin (usually 4.5–6 mm in diameter) is inserted transversely through the metaphyseal region of a long bone, such as the distal femur, proximal tibia, or calcaneus. The pin is then connected to a stirrup or bow, from which weights are suspended.

It is often used in femoral and tibial fractures.

A related option is the Denham pin, which has a threaded central portion. This design helps reduce pin migration and provides improved stability, especially in long-term traction setups or in osteoporotic bone.

Kirschner Wire (K-wire)

Uses thinner wires (usually <2.5 mm) for skeletal traction, especially in smaller bones or children. K-wires are more suitable where lighter traction forces are adequate and pin site care is easier.

Kwires are used in traction for supracondylar humerus fractures in children (almost not done now), and other pediatric traction systems

Tongs

Tongs are used for skeletal traction in cervical spine injury. Commonly used tongs are Crichton’s tongs, Gardenerwell’s tongs.

Skeletal Traction Sites

Calcaneal Traction

A Steinmann pin is inserted through the calcaneus (heel bone) for distal traction on the leg. Commonly used in:

• Tibial fractures
• Foot or ankle injuries
• Distal femoral fractures (when distal femoral traction is contraindicated)

Provides a straight-line pull along the lower limb, often combined with a Thomas splint for support.

Proximal Tibial Traction

The pin is inserted transversely through the proximal tibia, just below the tibial tuberosity. It provides a powerful pull along the limb and is commonly used in:

• Femoral shaft fractures
• Hip fracture stabilization

Care must be taken to avoid injury to the popliteal vessels or tibial growth plate (in children).

Similarly, distal tibial pin traction is used where the Steinman pin is passed in the distal tibia.

In old unreduced Hip dislocation, the trochanteric insertion of the pin is used for lateral traction at the trochanter at along with longitudinal traction by tibial pin.

Cervical Skeletal Traction

this involves insertion of tongs in the skull under sterile conditions, and applying the traction in cases of cervical spine dislocations, odontoid fractures or preoperative spinal stabilization

Following are specialized device for cervical spine traction

• Gardner-Wells tongs
• Crutchfield tongs
• Halo vest systems

Cervical traction requires intense monitoring due to the risk of pin loosening, cranial perforation, or neurological compromise.

Clinical Indications/Uses of Orthopedic Traction

Orthopedic traction is used in both acute and chronic settings, either as a primary treatment, a temporary stabilization measure, or a supportive technique alongside definitive management. Its use depends on factors such as patient age, fracture configuration, resource availability, and the need for soft tissue rest or deformity correction.

Fracture Reduction

Traction helps realign displaced bone fragments by applying controlled tension across the fracture site. It is particularly useful in:

• Femoral shaft fractures in children
• Intertrochanteric fractures (temporarily, before surgery)
• Tibial and humeral fractures where surgical fixation is delayed or contraindicated

Preoperative Stabilization

In polytrauma or high-energy injuries, traction can help to

• Maintain limb length and alignment
• Reduce pain and muscle spasm
• Protect soft tissue and vascular structures until the patient is fit for surgery

This is commonly practiced in hip fractures, femoral shaft fractures, and cervical spine injuries.

Cervical Spine Injuries

Traction is used to:

• Reduce cervical spine dislocations
• Temporarily stabilize odontoid or atlas fractures
• Relieve neural compression (in specific cases of radiculopathy)

Both skin and skeletal traction methods may be used depending on severity and anatomical level.

Congenital and Acquired Deformity Correction

Gradual traction can be applied to stretch contracted tissues and correct deformities in conditions like:

• Congenital clubfoot
• Joint contractures
• Spinal scoliosis or kyphosis (in halo-gravity traction setups)

Pain Relief and Muscle Spasm Reduction

This is done in selected cases of

• Cervical spondylosis
• Joint inflammation with secondary muscle guarding
• Soft tissue contractures

Short-term intermittent traction helps decompress neural structures and reduce soft tissue tension.

Complications of Traction

Complications may arise from improper technique, prolonged use, inadequate monitoring, or patient-specific factors like skin fragility or poor vascular supply.

Skin Complications

• Pressure sores and abrasions: Especially with skin traction and inadequate padding
• Allergic reactions or skin blistering: From adhesive tapes
• Infection at pin sites: A common risk in skeletal traction requiring daily pincare

Regular inspection can reduce skin complications.

Neurovascular Compromise

• Compression of nerves: e.g., peroneal nerve palsy in leg traction with external rotation
• Vascular impairment: Excessive or misaligned traction can lead to compression of the vessel by bone fragments resulting in compromise of distal circulation
• Compartment syndrome: Though rare, improper traction setup may contribute in high-energy injuries

Mechanical Issues

• Over-distraction: Can lead to malalignment or increased soft tissue tension
• Inadequate counter-traction: Results in body shift instead of focal force application
• Loss of reduction: Due to slippage of skin traction or loosening of pin assemblies

Joint Stiffness and Muscle Atrophy

Prolonged immobilization in traction setups can lead to:

• Stiff joints (especially knee and ankle)
• Disuse atrophy of surrounding musculature
• Delayed rehabilitation

Range-of-motion exercises of adjacent joints should be encouraged early when feasible.

Systemic Complications

• Deep vein thrombosis (DVT): Due to immobilization, especially in the lower limbs
• Pulmonary complications: Atelectasis or hypostatic pneumonia in bed-bound patients
• Urinary tract infections: Secondary to prolonged recumbency or catheter use

Modern Relevance and Limitations

The role of traction in orthopedic practice has evolved significantly. With the advent of internal fixation techniques, early mobilization protocols, and improved surgical access, traction is now used more selectively, often as a temporary, adjunctive option.

Most long bone fractures that once required weeks of traction can now be stabilized surgically within hours to days.

Despite its decline, traction remains relevant in several contexts:

• Pediatric fractures: Where surgical intervention is often avoided due to open growth plates, though better implants now are decreasing the need for traction regimes.
• Cervical injuries: As preoperative stabilization or for realignment in cervical dislocations
• Polytrauma settings: Where temporary traction aids in limb alignment while awaiting definitive care
• Resource-limited environments: Where surgical options may be unavailable or unaffordable

Limitations of Traction

• Prolonged bed rest: Increases risk of systemic complications
• Patient discomfort: Especially with skeletal traction or in elderly patients
• Requires strict monitoring: Demands trained nursing care and equipment adjustments
• Limited precision: Compared to surgical fixation, traction offers less exact control of alignment

While not as central as it once was, traction continues to play a valuable role in orthopedic conservative care models, pediatric cases, and staged trauma protocols.

Authoring Surgeon’s Notes

In clinical practice, traction still remains a foundational skill, not just a historical curiosity. Understanding its principles is essential for orthopedic training.

One of the core concepts, along with traction, is countertraction and is often misunderstood or under-applied. One needs to focus on the weights and vectors, but should not forget that without proper resistance, often just a change in bed position or thoughtful positioning, the entire construct becomes ineffective.

Though the role is declining, in pediatric orthopedics, traction offers a rare opportunity to treat fractures conservatively while respecting growth plates and minimizing surgical morbidity.

Sources

A list of key clinical references used in preparing this article is provided below for transparency and professional context.

• Choudhry B, Leung B, Filips E, Dhaliwal K. Keeping the Traction on in Orthopaedics. Cureus. 2020 Aug 25;12(8):e10034. [PubMed]
• Wang JH, Daniels AH, Palumbo MA, Eberson CP. Cervical Traction for the Treatment of Spinal Injury and Deformity. JBJS Rev. 2014 May 27;2(5):e4. [PubMed]
• IDeFroda SF, Gil JA, Born CT. Indications and anatomic landmarks for the application of lower extremity traction: a review. Eur J Trauma Emerg Surg. 2016 Dec;42(6):695-700. [PubMed]