Overview
Calcaneal traction is accomplished with placement of a pin across the posterior aspect of the calcaneus and attachment to a pulley system secured to a bed.
Indications for Use
Tibial shaft fractures
Precautions
- 1.
The pin should be inserted from the “medial” aspect to avoid injury to the medial calcaneal nerve and lateral plantar nerve.
- 2.
Ensure that the pin is placed with use of the sterile technique. Do not place pins through or near open wounds.
- 3.
Ensure that the pin is placed perpendicularly to the axis of the limb and in a straight horizontal plane.
- 4.
Place traction weights gently!
- 5.
Once traction has been established, ensure that the traction bow is not in contact with the skin.
- a.
A pressure ulcer can be easily created by the traction bow.
- b.
To ensure that the traction bow does not create a pressure ulcer, the bow should be overwrapped in rolled gauze.
- a.
- 6.
Apply rubber stoppers to the ends of the pin to prevent injury to the patient or healthcare workers.
Pearls
- 1.
Close coordination with the operating surgeon is mandatory when placing patients into traction.
- 2.
Insertion of calcaneal traction can be completed under a local anesthetic, but conscious sedation is preferred.
- 3.
If only a local anesthetic is being used, then consider increasing the amount and adding bupivacaine.
- 4.
If the patient is going to go to the operating room for definitive fixation shortly after placement of calcaneal traction, then elective intubation prior to placement may be prudent.
- 5.
Before placement of calcaneal traction, ensure that the patient is on a bed that is capable of having a traction frame attached to it.
- 6.
Placement of a pin is easiest when all the equipment are organized. Having two bedside tables facilitates organization and maintenance of a sterile environment.
- 7.
Having an assistant is not mandatory but is extremely helpful.
- 8.
A hand drill or a power drill may be used. We prefer using a power drill, especially in younger patients with good bone stock.
Equipment
- 1.
Sterile technique items:
- a.
Sterile gloves
- b.
4 × 4 in. gauze
- c.
Antiseptic: Chlorhexidine or betadine
- d.
Sterile drapes or blue towels
- a.
- 2.
Local anesthesia items:
- a.
Syringe: A 10-mL syringe
- b.
Needles:
- (1)
A large-bore, blunt-tipped drawing-up needle
- (2)
A 2-in., 21-gauge needle
- (1)
- c.
Anesthetic: Lidocaine, 10 mL of 2%
- a.
- 3.
Items for insertion of the pin:
- a.
A 15-blade scalpel
- b.
A hemostat
- c.
Kirschner wire, 0.0625 in. in diameter
- d.
A power drill and battery
- e.
A pin driver attachment
- a.
- 4.
Items for establishing traction:
- a.
A Kirschner traction bow
- b.
Large pin cutters
- c.
Xeroform
- d.
Two rubber stoppers (if specialized rubber stoppers are not available, then find two blood vials and take the rubber tops off)
- e.
2 × 6 in. rolled gauze
- f.
A pulley and frame: a bed frame with an attached single pulley
- g.
Weights: six 5-lb weights with an associated hanger
- h.
Cord: a braided traction cord
- a.
Basic Technique
- 1.
Patient positioning:
- a.
Ensure that the patient is on a bed that accepts external frames.
- b.
The patient is supine.
- c.
A bump is placed under the Achilles tendon to elevate the limb.
- d.
A bump may be placed under the hip of the affected limb to internally rotate the limb.
- a.
- 2.
Landmarks:
- a.
Inferior aspect of the medial malleolus
- b.
Posterior-inferior aspect of the calcaneus
- a.
- 3.
Steps:
- a.
Ensure that the patient is adequately sedated.
- b.
Position the patient.
- c.
Set up back tables using the sterile technique.
- d.
Palpate the landmarks.
- e.
Prepare the skin with an antiseptic solution.
- f.
Place sterile drapes.
- g.
Administer local anesthesia.
- h.
Insert the pin.
- i.
Set up the traction apparatus.
- j.
Apply traction.
- a.
Detailed Technique
- 1.
Ensure that the patient is adequately sedated.
- 2.
Position the patient:
- a.
Supine
- b.
Place a bump under the hip if desired.
- a.
- 3.
Set up back tables using the sterile technique. Open all sterile equipment, including instruments for local anesthesia.
- 4.
Palpate the landmarks.
- a.
The medial malleolus is palpated.
- b.
The posterior-inferior aspect of the medial calcaneus is palpated.
- c.
The entry site is posterior to the halfway point along a line from the medial malleolus to the posterior-inferior aspect of the calcaneus ( Fig. 17.1 ).
- a.
