Skeletal Traction – Indication, Uses and Complications

Last Updated on September 7, 2025

Skeletal traction is a method of applying continuous pulling force directly to bone through transosseous pins, wires, or screws in order to maintain alignment, reduce fractures, and control muscle spasm.

Unlike skin traction, where the force is transmitted indirectly through soft tissues, skeletal traction delivers the load directly to the skeletal system, allowing the use of higher and more sustained weights.

Although its use has declined with the advent of internal fixation and external fixators, skeletal traction remains an essential technique in orthopedic practice.

It is often employed as a temporary measure before definitive surgery, a stabilizing method in polytrauma, or as definitive treatment in specific settings where surgical facilities are limited. A sound understanding of its principles, techniques, and complications remains vital for the orthopedic surgeon.

Traction methods were among the earliest systematic approaches to fracture care, with early descriptions dating back to Hippocrates. Skeletal traction became widely adopted in the early 20th century, particularly after the introduction of Steinmann pins and improved surgical sterility.

Principles of Traction

The effectiveness of skeletal traction depends on several fundamental principles. Understanding these concepts ensures both therapeutic success and patient safety.

Traction and Counter-traction

Traction is the pulling force applied to the bone through the pin or wire. For traction to be effective, there must be an opposing force, counter-traction, to balance the system. Counter-traction may be provided by the patient’s body weight, by elevating the foot end of the bed, or by applying opposing traction in another direction. Without adequate counter-traction, the desired alignment cannot be achieved.

Traction is often applied to part of the body to negate the effect of the forces causing the deformity. To be effective, the traction should act on the deformity and not the whole body. To counter the effect on the whole body, we need another force that acts in the opposite direction.

This is countertraction.

If we pull a person’s hand and there is no resistance, it would result in pulling a person toward you. However, if a person holds him from the elbow, all your force is transferred to the forearm only. This is another example of traction and countertraction forces.

Countertraction is an important aspect of traction treatment.

The absence of counteraction not only results in ineffective traction but also in the discomfort of the patient.

Line of Pull

The traction force must be applied in the correct anatomical axis of the limb or fracture. An improper line of pull risks creating angulation, rotation, or distraction at the fracture site. Careful planning of pin placement and vector of traction is therefore essential.

Magnitude of Force

Because skeletal traction bypasses the skin and soft tissues, greater weights can be safely applied compared with skin traction. Typically, forces range between 5–20% of the patient’s body weight, depending on the bone and fracture pattern. The weight must be sufficient to overcome muscle spasm but not excessive enough to cause distraction or neurovascular compromise.

Continuous vs. Intermittent Traction

Traction is generally applied continuously to maintain reduction and prevent muscle spasm. Intermittent or periodic traction has little role in fracture management but may occasionally be used in physiotherapy settings for joint mobilization. Most of the intermittent tractions involve skin traction and not skeletal traction

Comfort and Alignment

Patient comfort is a critical component of effective traction. Proper padding, limb support, and frequent assessment reduce the risk of pressure sores, nerve palsies, and malalignment.

Pins and Hardware Used

Skeletal traction requires pins or wires to be driven into the bone, which allows putting traction directly on the skeleton. Therefore, it is an invasive procedure. It requires greater skill and expertise than applying skin traction.

Several devices are available, each suited to specific anatomical sites and load requirements.

Steinmann Pin

A solid, smooth stainless-steel pin, usually 3–5 mm in diameter, is commonly used for tibial, femoral, or calcaneal traction. Its simplicity and availability make it the most frequently used device worldwide.

Denham Pin

A modification of the Steinmann pin, the Denham pin contains threads in the middle that provide secure fixation within bone and reduce the risk of pin migration under heavy traction. It is often preferred in femoral and tibial applications.It is especially useful in osteoporotic skeleton.

Kirschner Wire (K-wire)

Thinner smooth wires (1.6–2.5 mm) are used in smaller bones, such as the metatarsals or olecranon. Because of their reduced diameter, they carry a higher risk of bending or loosening under sustained load, and thus are reserved for lighter traction needs.

Screws or Specialized Fixation Devices

Occasionally, cancellous screws or external fixation pins may be adapted for skeletal traction, especially when greater stability or more complex fixation is required.

Reference Table: Common Devices in Skeletal Traction

Different Types of Skeletal Traction

Skeletal traction can be a fixed type or a sliding type. Fixed skeletal traction is traction between two points, whereas sliding traction uses the patient’s weight as countertraction. [1]

Various types of skeletal traction have been developed to address specific issues. Most of them are known by the names of their inventors.

The method of skeletal traction varies with the anatomical site of application and the clinical indication. The following are the most common types used in practice.

Cervical Traction

Skull calipers are applied in cervical injury and also after surgeries on the cervical spine. Many types of calipers are available, which differ in their design and application but achieve the same purpose.

The calipers are designed to be inserted into the outer cortex of the skull. The cord is tied on the other end of the tong and passed over the pulley, and weights are attached.

Gardener-Wells tongs and Crutchfield tongs are most commonly used. Gardner-Wells tongs allow ease of application without the need for surgical exposure. Crutchfield tongs are an earlier design with sharper pin tips, now largely replaced by Gardner-Wells tongs.

Halo traction involves a circular halo ring fixed to the skull with multiple pins, connected to a traction apparatus. It provides more secure fixation and can allow for halo-gravity traction, useful in gradual correction of severe spinal deformities. [2]

The weight applied will vary with the injury level.

Femoral Traction

Proximal tibial traction [3]

Pin passed through the proximal tibia, commonly used for shaft femur fractures. Provides a good line of pull along the femoral axis. The Steinmann pin or Denham pin is inserted below the tibial tuberosity and is inserted from the lateral to the medial side. The Denham pin is threaded in the middle for better cortical hold.

The stirrup is attached, and the cord is tied to distal weights. Again, using various combinations of splints, proximal tibial traction can be modified to achieve the desired results.

Both the distal femur and proximal tibia pin traction do not control rotational alignment

Proximal tibial traction is indicated for

• Hip fractures
• Acetabular fractures [4]
• Femoral shaft fractures
• Subtrochanteric fractures

Distal Tibial Traction

This is used in fractures distal to the knee, such as upper tibial fractures. The pin is inserted about 5 cm proximal to the ankle joint from the medial to the lateral direction to protect the posterior tibial artery.

Distal femoral traction

Pin inserted just above the condyles of the femur. It is useful in proximal femur fractures, including hip injuries. To avoid quadriceps tethering, it is used only when proximal tibial traction can’t be used.

90–90 traction

A method where both hip and knee are flexed to 90 degrees. This position neutralizes muscle forces and maintains alignment effectively. This traction is used for acetabular fractures, hip fractures, and proximal femur fractures, especially when there is a ligament injury to the knee.

The Steinmann pin for traction is inserted at the lower end of the femur, slightly proximal to the adductor tubercle. The direction of insertion of the Steinman pin is from the medial to the lateral side.

The traction bow is used to transmit the weight to produce traction with an upward force. The leg is supported with U-Loops to keep it horizontally lifted. This creates a position of 90 degrees of flexion at the hip and knee, hence the name.

There could be various modifications depending on the requirements of the traction.

Lower Leg and Foot Traction

Calcaneal traction

A transverse pin is passed through the calcaneum. It is commonly used for distal tibia, ankle, or subtalar injuries. It provides strong purchase in dense cancellous bone.

The pin is inserted from medial to lateral to avoid injury to the posterior tibial neurovascular bundle, which sits posteroinferiorly to the medial malleolus. Potential risk includes damage to the medial calcaneal nerve and stiffness of the subtalar joint.

Metatarsal traction

A thick K-wire through the metatarsals, generally used for complex midfoot or forefoot injuries requiring temporary stabilization.

Upper Limb Traction

Olecranon and other upper limb skeletal tractions are rarely used now because of better surgical methods available and better implant dynamics. Early surgery allows ambulation and mobilization and which prevents joint stiffness.

Olecranon Traction

Olecranon traction is mainly used for fractures of the distal end of the humerus and the shaft of the humerus. A sturdy K-wire or cancellous screw is inserted about 3 cm distal to the tip of the olecranon. The K-wire is passed medial to lateral, perpendicular to the longitudinal axis of the ulna and connected to the traction setup.

Metacarpal Traction

Metacarpal skeletal traction is used rarely nowadays. For metacarpal traction, a K-wire is passed 2.5 cm proximal to the metacarpophalangeal joint. They were used for forearm fractures and distal radius fractures.

Reference Table: Types of Skeletal Traction

Indications of Skeletal Traction

Skeletal traction is indicated in a range of orthopedic conditions where controlled, sustained force is required for alignment or stabilization. While its role has narrowed with modern fixation techniques, several clinical scenarios still warrant its use.

Acute Fracture Management

• Femoral shaft fractures: Particularly in polytrauma patients, skeletal traction provides temporary stabilization and pain relief until definitive fixation can be performed.
• Complex tibial and distal femoral fractures: Used to maintain alignment and prevent further soft tissue damage before surgical intervention.

Cervical Spine Injuries

It is applied in unstable cervical fractures or dislocations to restore alignment, reduce subluxation, and protect the spinal cord. Halo traction may also be used preoperatively in severe spinal deformities such as scoliosis or kyphosis.

Pediatric Femoral Fractures

In selected pediatric femoral fractures (especially in very young children), traction can be used as a definitive treatment or as a bridge to spica casting. Gallows traction is one such example. But these are becoming rare due to inpatient treatment and strict immobilization, and better implant availability.

Temporary Stabilization in Polytrauma

In multiply injured patients who are hemodynamically unstable, skeletal traction provides rapid stabilization when early definitive fixation is contraindicated.

Limited Resources

In settings where surgical fixation is not available, skeletal traction may serve as definitive management, particularly for long bone fractures.

Care and Complications of Skeletal Traction

While skeletal traction is effective in selected cases, it carries potential risks. Most complications are preventable with careful technique, vigilant monitoring, and proper nursing care. Most of the complications unique to skeletal traction are due to the insertion of the pin.

Iatrogenic Injuries

These are quite rare but can happen. The injury can occur to the vessel or nerve in the vicinity. If it occurs, appropriate measures for arterial or nerve injuries should be taken. The aid of fluoroscopy to mark the direction and the pin can reduce the risk.

Infection

Insertion of the pin causes a breach in the skin and bone and creates a conduit for infections to travel from the surface to the bones. An intra-articular pin can lead to septic arthritis. Thermal necrosis of the bone can occur if high-speed drills are used and should be avoided.

To prevent the infection, the pins need frequent cleaning to drain any accumulated fluid. There should not be any crust or adhesion of the tissue to the pin, and one should be able to move the skin pin interface. Chlorhexidine swabbed gauze or sponge should be placed around the pin site, and the pin should be regularly monitored.

Superficial infection is tackled with aggressive cleaning and antibiotics. Often, oral antibiotics are enough. Deep infections may require iv antibiotics. Infection that results in osteomyelitis or loosening of the pin warrants pin removal.

Stress Risers

The insertion of a pin creates cortical defects that act as stress risers to the bone and may lead to fractures. The pins inserted in the proper sites reduce the chances of this. This is a unique complication of skeletal traction.

Stiffness and Joint Contracture

The limb on the traction needs to be exercised for individual joint motion otherwise stiffness and joint contractures may occur.

Therefore, a regular exercise schedule should be explained to the patient and monitored. The patient should be regularly evaluated for joint motion and suppleness.

Premature Physeal Closure

Premature physeal closure in children can occur if the pin inserted for skeletal traction causes injury to the physis or the infection causes damage to the physis.

References

1. Obey MR et al, Lower-Extremity Skeletal Traction Following Orthopaedic Trauma, JBJS Reviews: November 2019 – Volume 7 – Issue 11 – p e4 [Link]
2. Olson RS. Halo skeletal traction pin site care: toward developing a standard of care. Rehabil Nurs. 1996 Sep-Oct;21(5):243-6, 257. [PubMed]
3. Obey MR, Berkes MB, McAndrew CM, Miller AN. Proximal Tibia Skeletal Traction: Technique and Indications. J Orthop Trauma. 2021 Aug 1;35(Suppl 2):S44-S45. [PubMed]
4. Boissonneault AR, Schenker M, Wilson J, Schwartz A, Staley C, Maceroli M. Impact of Prolonged Skeletal Traction in Patients With Acetabular Fractures. J Orthop Trauma. 2020 Feb;34(2):77-81. [PubMed]