How to apply a skin traction

Skin traction is one of two basic types of traction used for the treatment of fractured bones. It works by applying weight to tape, sponge rubber, or canvas materials which have been attached to the skin surrounding the damaged body structure.

The amount of weight which can be applied to skin traction is limited to the tolerance of the skin. Skin traction is used for the control of muscle spasm and to provide immobilisation, in this case while Bob awaited theatre in the morning. If prolonged or heavy traction weight is needed then skeletal traction is usually used rather than skin traction.

Traction must be applied in the direction and magnitude to obtain its desired effect. As soft tissue and muscle relax, the amount of weight required may change to maintain the desired pulling force. When traction is applied countertraction needs to be considered. Countertraction is a force acting in the opposite direction, for Bob this was achieved by elevating the foot of the bed.

When applying traction there are many factors to be considered for example, any factor which might reduce the pull or alter the line of pull must be eliminated. Skin should be assessed for abrasions and circulatory problems before the application of skin traction, as it must be in a healthy condition to tolerate the traction. The patient should be in good body alignment in the middle of the bed. Ropes and weights must be unobstructed. Knots in the rope or footplate must not touch the pulley or the foot of the bed.

There are three main types of skin traction used in the care of adults, these are, Buck’s extension traction, Russell’s traction and Dunlop’s traction:

Buck’s traction is a form of traction where pull is exerted in one plane. It is used when partial or temporary immobilisation is required, and it is used to provide comfort following injury while awaiting surgical fixation, especially in hip and femur injuries. To apply Buck’s traction, foam rubber padded straps are placed with the foam surface against the skin on each side of the affected leg. A loop of tape is extended beyond the sole of the foot, and a spreader is applied to the distal end of the tape which prevents pressure along the side of the foot. The malleolus and proximal fibula are protected with cast padding, this prevents pressure sores and skin necrosis. While one person supports the leg, another wraps elastic bandage in a spiral fashion over the traction tape beginning from the ankle. The elastic bandage helps to prevent slipping, and a sheepskin pad is placed under the leg to reduce friction. If Buck’s traction with a foam boot is applied, the heel of the affected leg must be placed well into the heel of the boot. Velcro straps are then secured around the leg. Weights are applied to the rope fixed to the spreader or footplate and passed over a pulley fastened to the bed end.

Russell’s Traction can be used for fractues of the tibial plateau, it works by supporting the flexed knee in a sling and applying a horizontal pulling force by use of traction tape and elastic bandage attached to the lower leg.

Dunlop’s Traction is used for fractures of the upper extremities. It works in the form of horizontal traction which is applied to the abducted humerous, while vertical traction is applied to the flexed forearm.

Nursing Considerations

To ensure that traction is effective, countertraction must be maintained, and wrinkling and slipping of the traction bandage must be avoided. Positioning of the patient is important, and proper positioning i.e. with good body alignment in the middle of the bed, must be maintained to keep the affected limb in a neutral position. The patient cannot be moved from side to side but can only shift position slightly to prevent bony fragments from moving against one another.

The patient in traction will have restricted mobility and independence, being confined to a limited space may become frustrating. Traction equipment can often look threatening, and the patient may express anxiety over their injury and subsequent changes this will present. Therefore a therapuetic relationship with your patient and an ability to assess their psychological responses to their situation is important. The body part placed in traction should be assessed for colour, temperature, oedema, pulse, sensation, moveability and skin integrity. Potential problems for the patient may include pressure sores, constipation, urinary tract infection, loss of appetite, deep vein thrombosis, lung congestion, skin breakdown, nerve pressure from the skin traction, and circulatory impairment.

(Glanze, W., 1990; Smeltzer & Bare, 1996).


Skin traction is one of two basic types of traction used for the treatment of fractured bones. It used weights applied to tape, sponge rubber or canvas materials attached to the skin surrounding the damaged body structure to be effective. Integrity of the skin and skin tolerance need to be considered before the use of skin traction, which is usually used for the control of muscle spasm or short term immobilisation. Skeletal traction is used for prolonged or heavy weighted traction. There are three main types of skin traction used in the care of adults, Buck’s traction, Russell’s traction and Dunlop’s traction. When caring for the patient in traction some of the things the nurse should consider include: maintaining effective traction, the psycological impact on the patient, and the potential for physiological complications.

Come in 2 sizes (Child and Adult) and 2 types (adhesive and non-adhesive). Generally adhesive is used for children, and non-adhesive for older children and adults.

They contain a skin extension and a bandage, Calico slings & safety pins, Two tongue depressors taped together, Tape measure, Scissors


  • Explain to child and parents what you are going to do, and why
  • Ensure adequate analgesia has been established
  • Ideally this should be a femoral nerve block
  • Measure the good leg from the inner thigh ( at the pubis ) and the heel, and add 20-30 cms
  • Measure the circumference of the good thigh at its widest part, and add several cms ( to allow for swelling )
  • Select a left or right sided splint, of the correct size
  • Choose the size closest to your measurements, but round-up
  • The frame sizings are usually written on the rings at the top
  • Apply calico slings to the selected frame by looping them around the steel rods.
  • Secure them with safety pins.
  • Put the safety pins on the lateral side, and at the back, so they are out of the way
  • Do not use tubigrip (or similar stretchy material)

How to apply a skin traction


  • Apply firm manual traction to the limb maintaining the foot in a dorsiflexed position
  • Support the knee and thigh
  • Apply the skin extension longitudinally around the leg. It should extend to the upper part of the thigh along both sides. The spongy part should be located symmetrically under the sole of the foot, with a gap of 4 cm between it and the foot ( to allow for plantar flexion ). The foam should extend to cover each malleolus for protection
  • The skin traction should then be secured from thigh to the ankle using crepe bandages. It is a good idea to leave the knee and fibula head free from the bandage to reduce the risk of peroneal nerve compression at the fibular head
  • Whilst maintaining traction, put the frame carefully in place. It should fit snugly into the groin, and up against the ischial tuberosity. In boys ensure testicles are not squashed. The leg should be on top of the calico slings
  • The traction cords are now pulled tight around the W shape at the bottom of the splint and secured firmly. The taped tongue depressor are inserted between the cords and twisted round several times ( ie used as a Windlass ). This creates the traction. One suggested way of doing all this is shown below in the diagrams
  • When completed – the leg should be elevated
  • It is important that circulatory observations are performed after application of the splint (colour, sensation, warmth and movement ), and that the limb is re-X-ray’

How to apply a skin traction How to apply a skin traction


Taylor L (1987) Ward Manual of Orthopedic Traction. Churchill Livingstone Royal College of Nursing 2002). A Traction Manual. RCN, London

Content by Dr Ian Higginson; Steve Ball, Dr Íomhar O’ Sullivan 05/06/2005, 10/02/2007. Last review Dr ÍOS 17/06/21 .

Skin traction is used to control muscle spasms and to immobilize an area before surgery. Skin traction is accomplished by using a weight to pull on traction tape or on a foam boot attached to the skin. The amount of weight applied must not exceed the toler ance of the skin. No more than 2 to 3.5 kg (4.5 to 8 lb) of trac-tion can be used on an extremity. Pelvic traction is usually 4.5 to 9 kg (10 to 20 lb), depending on the weight of the patient.

Types of skin traction used for adults include Buck’s extension traction (applied to the lower leg), the cervical head halter (occa-sionally used to treat neck pain), and the pelvic belt (sometimes used to treat back pain).

Buck’s Extension Traction

Buck’s extension traction (unilateral or bilateral) is skin traction to the lower leg. The pull is exerted in one plane when partial or temporary immobilization is desired (see Fig. 67-4). It is used to provide immobility after fractures of the proximal femur before surgical fixation.

How to apply a skin traction

Before the traction is applied, the nurse inspects the skin for abrasions and circulatory disturbances. The skin and circulation must be in healthy condition to tolerate the traction. The ex-tremity should be clean and dry before the foam boot or traction tape is applied.

To apply Buck’s traction, one nurse elevates and supports the extremity under the patient’s heel and knee while another nurseplaces the foam boot under the leg, with the patient’s heel in the heel of the boot. Next, the nurse secures Velcro straps around the leg. Traction tape overwrapped with elastic bandage in a spi-ral fashion may be used instead of the boot. Excessive pressure is avoided over the malleolus and proximal fibula during applica-tion to prevent pressure ulcers and nerve damage. The nurse then passes the rope affixed to the spreader or footplate over a pulley fastened to the end of the bed and attaches the weight—usually 5 to 8 pounds—to the rope.

Potential Complications

Skin breakdown, nerve pressure, and circulatory impairment are complications that may develop as a result of skin traction. Skin breakdown results from irritation caused by contact of the skin with the tape or foam and shearing forces. Older adults are at greater risk for this complication because of their sensitive, fragile skin.

Nerve pressure results from pressure on the peripheral nerves. Footdrop may occur if pressure is applied to the peroneal nerve at the point at which it passes around the neck of the fibula just below the knee.

Circulatory impairment is manifested by cold skin tempera-ture, decreased peripheral pulses, slow capillary refill time, and bluish skin. Deep vein thrombosis (DVT), a serious circulatory impairment, is manifested by calf tenderness, swelling, and a pos-itive Homans’ sign.

Nursing Interventions


To ensure effective skin traction, it is important to avoid wrinkling and slipping of the traction bandage and to maintain counter-traction. Proper positioning must be maintained to keep the leg in a neutral position. To prevent bony fragments from moving against one another, the patient should not turn from side to side; however, the patient may shift position slightly with assistance.


Skin Breakdown.

During the initial assessment, the nurse iden-tifies sensitive, fragile skin (common in older adults). The nurse also closely monitors the reaction of the skin in contact with tape or foam to ensure that shearing forces are avoided. The nurse per forms the following procedures to monitor and prevent skin breakdown:

· Removes the foam boots to inspect the skin, the ankle, and the Achilles tendon three times a day. A second nurse is needed to support the extremity during the inspection and skin care.

· Palpates the area of the traction tapes daily to detect under-lying tenderness.

· Provides back care at least every 2 hours to prevent pressure ulcers. The patient who must remain in a supine position is at increased risk for development of a pressure ulcer.

· Uses special mattress overlays (eg, air-filled, high-density foam) to minimize the development of skin ulcers.

Nerve Pressure.

Skin traction can place pressure on peripheralnerves. When traction is applied to the lower extremity, care must be taken to avoid pressure on the peroneal nerve at the point at which it passes around the neck of the fibula just below the knee. Pressure at this point can cause footdrop. The nurse questions the patient about sensation and asks the patient to move the toes and foot. Dorsiflexion of the foot demonstrates function of the pero-neal nerve. Weakness of dorsiflexion or foot movement and in-version of the foot might indicate pressure on the common peroneal nerve. Plantar flexion demonstrates function of the tib-ial nerve.

The following are important points to keep in mind when car-ing for the patient in traction:

· Regularly assess sensation and motion.

· Immediately investigate any complaint of burning sensation under the traction bandage or boot.

· Promptly report altered sensation or motor function.

Circulatory Impairment.

After skin traction is applied, the nurseassesses circulation of the foot or hand within 15 to 30 minutes and then every 1 to 2 hours. Circulatory assessment consists of the following:

· Peripheral pulses, color, capillary refill, and temperature of the fingers or toes

· Indicators of DVT, including calf tenderness, swelling, and a positive Homans’ sign

The nurse also encourages the patient to perform active foot exercises every hour when awake.

Femoral traction splints are designed to apply traction to the lower portion of the leg, distal to the fracture, usually by pulling the ankle away from a stabilized pelvis. There are many commercial brands available which vary slightly in their design and instructions and thus require individual familiarity for correct use.

Traction splints may also reduce and/or decrease pain and bleeding due to femur fractures, particularly those that are shortened.


Femoral shaft fracture

Femoral traction splints are used to stabilize femur fractures prior to definitive care (eg, operative fixation).


Ipsilateral fracture(s) of the ankle, foot, and/or lower leg

Ipsilateral knee injury

Although traction is beneficial to femur fractures, it can be harmful to fractures or ligament injury distal to the femur fracture.


Vascular or nerve traction injuries


Commercially available femoral traction splint kit (eg, Hare®, Sager®, Ferno-trac TM , Kendrick TM )

Drugs for analgesia/sedation (eg, fentanyl , morphine , propofol )

Additional Considerations

Traction splints may not be as effective on proximal femur fractures.

Relevant Anatomy

The femoral shaft excludes commonly fractured parts of the femur such as hip and supracondylar fractures.


Lie the patient supine with the injured lower extremity supported.

Step-by-Step Description of Procedure

Follow the instructions and recommendations for the specific product being used.

Ensure that the stretcher or table is long enough to support the distal end of the device (eg, 20 cm [8 inches] beyond the ipsilateral foot). Use the contralateral, uninjured leg as a landmark if the injured leg is shortened.

Give the patient adequate analgesia.

Stabilize the device against the pelvis and the ankle as directed by the product instructions, including the proper sequence of these steps.

Lock the ankle attachment.

Position any leg support straps as directed (eg, 2 above the knee and 2 below).

Apply longitudinal traction on the ankle to straighten and lengthen the shortened leg to the length of the contralateral leg. Use about 10% of the patient’s body weight or up to about 7 kg (15 pounds).

Lock the device in place as directed.

Check for distal neurovascular status (eg, capillary refill, distal sensation, toe flexion and extension).


Remove the traction splint as soon as possible when definitive care is available.

Warnings and Common Errors

Assess distal pulses both before and after splint application.

Ensure adequate traction is applied by using the traction scale if available on the specific device.

Ensure adequate traction by frequently assessing pain relief and length of extremity compared to uninjured side.

Tips and Tricks

Use adequate analgesia (usually IV opioids) because traction splinting of femur fractures is painful.

Was This Page Helpful?

Also of Interest

MSD and the MSD Manuals

Merck and Co., Inc., Kenilworth, NJ, USA (known as MSD outside the US and Canada) is a global healthcare leader working to help the world be well. From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world. The Manual was first published in 1899 as a service to the community. The legacy of this great resource continues as the MSD Manual outside of the United States and Canada. Learn more about our commitment to Global Medical Knowledge.

As a general rule for femoral fractures use 10% body weight.

For counter traction elevate bed 5 cm for every 1 Kg (1 inch per 1 lb)

Knots to attach cord to traction device (click here)

Traction types and how to set up traction (click here)

Skin traction

Maximum traction weight 6.7 Kg (15lb), remember skin quality.


Generally for paediatric cases

Non adhesive

For Adult cases, or where thin atrophic skin

If poor quality skin reduce max weight to 4.5Kg (10 lb) or consider skeletal traction.

Skeletal traction

  • Steinman pin and Bohler stirrup
  • Denham pin, threaded pin engages cortex reducing movement.
  • Kirschner wire, on wire tightener

Traction sites



K wire from medial to lateral.

Right angles to logitudinal axis of ulna

3 cm distal to tip of olecranon

Deep to subcutaneous border

Avoid ulnar nerve

Second and third metacarpals

K wire 2-2.5cm proximal to distal end second metacarpal.

Wire traverses the 2nd and 3rd metacarpals transversely

To lie at right angles to the longitudinal axis of the radius

Greater trochanter

Lateral surface of femur

2.5cm below the most prominent part of the greater trochanter

Midway between anterior and posterior surfaces of femur

Distal femur

Beware knee stiffness, try not use for longer than 2 to 3 weeks

Remember the lateral knee joint capsule reaches 1.25-2cm above knee joint, dont forget the distal femoral physis in children.

In general, the pin should pass along or slightly posterior to the midcoronal plane of the femoral shaft. It should also pass just proximal to the adductor tubercle in order to avoid engagement of the collateral ligaments. This lies almost at the level of the proximal pole of the patella in the relaxed and extended knee.

Flex the knee slightly during insertion to draw the periarticular soft tissues into the position they will occupy while the limb is in traction, thereby reducing pressure necrosis of the skin.

Line at upper pole of patella

Line upwards from anterior to head of fibula.

Where these two points meet insert pin

Just proximal to upper limit of lateral femoral condyle

Proximal tibia

Contraindicated if the knee ligaments have been injured.

Insertion point 2cm distal and posterior to Tibial tuberosity. Dont let the pin creep anteriorly while inserting the pin.

2cm behind and below Tibial tuberosity

From Lateral to medial to avoid common peroneal nerve

Distal Tibia & Calcaneus

Calcaneal Traction
Ideally, the pin should be inserted as far posterior as possible while still engaging sound bone. The tendons and neurovascular bundle passing behind the malleoli and the subtalar joint are to be avoided.

Halett et al suggests for a calcaneal pin place it 2 cm below and behind the lateral malleolus or 3 cm below and behind the medial malleolus BEWARE Tornetta et al show no position is completely safe when placing a medial calcaneal pin or transcalcaneal pin. Ensure you are as far posterior as possible yet still engaging bone.

5cm above ankle joint

2 cm below and behind lateral malleolus

3 cm Below and behind medial malleolus

The medial calcaneus provides a small window for safe percutaneous pin placement.
Posterior to the halfway point from Point A to B and posterior to the one-third mark from Point A to C remain the relatively safest regions.

A more posterior placement in the safe zone is safest.

Careful blunt dissection and the use of cannulas may help to avoid neurovascular injury

Background: Preoperative skin traction is applied for many patients with hip fracture. However, the efficacy of this modality in pain relief is controversial.

Objectives: The aim of the current study was to investigate the effects of skin traction on pain in patients with intertrochanteric fractures.

Patients and methods: A total of 40 patients contributed in this randomized clinical trial. Patients were randomly allocated into two equal groups: the skin traction (3 kg) and control groups. The severity of pain was recorded at admission and 30 minutes, one, six, 12, and 24 hours after skin traction application utilizing a Visual Analogue Scale (VAS). In addition, the number of requests for analgesics was recorded. Finally, the mean severity of pain in each measurement and the mean number of analgesic requests were compared between the two groups.

Results: The severity of pain was significantly decreased in skin traction group only at the end of the first day after traction application (2.7 ± 0.8 vs. 3.3 ± 0.9; P = 0.042), while there was no significant difference between the two groups in other pain measurements. The number of requests for analgesics was the same between the two groups.

Conclusions: Although skin traction had no effect on analgesic consumption, it significantly decreased the pain at the end of the first day. The application of skin traction in patients with intertrochanteric fractures is recommended.

Keywords: Analgesics; Intertrochanteric Fractures; Pain; Skin; Traction; Visual Analog Scale.

Fractures of the upper end of the femur should be treated operatively.

They should only be considered for nonoperative fracture treatment if there are neither facilities, nor skills, for surgical treatment.

2. First Aid

The ABC of primary care for the injured always takes precedence over the fracture treatment. Once the safety of the patient has been established, attention is directed to the fracture.
It is important in treating any femoral fracture to splint the whole leg as soon as possible, and before transport of the patient. For that purpose you need two firm boards or sticks along the leg, suitably padded, one on the inside and one along the leg and the body on the outside.

Any soft material such as clothing, blankets, etc. can be used as emergency padding.

The splints should then be kept in place by bandages around both splints and .

. the leg as well as the body.

Suitably splinted, the patient can be transported to the chosen hospital facility.

If no boards are available some stabilization can be achieved by splinting the fractured leg to the uninjured leg, with padding in between.

3. Principles

Once a radiological diagnosis has been made, decisions about non-operative management can be taken.

For non-impacted intracapsular fractures, the best non-surgical care is to relieve pain and mobilize the patient despite the fracture. These fractures will not unite with non-surgical treatment and mobilization of the patient as a whole is of paramount importance.

If a radiological diagnosis is not available, the possibility of a displaced intracapsular fracture of the proximal femur may be suggested by external rotation with slight to moderate shortening (2.5 – 5 cm), which increases only slightly with proximally directed pressure on the leg. Non-operative treatment of such patients is not based upon bone healing, which, as noted, does not occur without surgical treatment. Traction can be omitted, or discontinued and the patient mobilized as soon as comfort permits.

If there is marked thigh shortening which increases progressively, or is associated with palpable bone deformity, the patient is more likely to have an extracapsular fracture with potential for healing. Patients with these injuries are reasonable candidates for 6-8 weeks of traction, as described below, followed by progressive ambulation, with delayed weightbearing, in hopes of avoiding excessive deformity.

For proximal femur fractures that are likely to be extracapsular (pertrochanteric or subtrochanteric), the non-operative regimen is as follows.

Straight skin traction

Nonoperative treatment means that the patient will be in some form of traction for at least 6-8 weeks, often 10-12 weeks.

The preliminary treatment usually is straight skin traction, later converted to skeletal traction.

Note the padding under the patient’s calf, to keep the heel from pressing on the bed beneath it.

Disadvantages of prolonged skin traction are:

  • Loosening
  • Constriction
  • Friction with skin irritation
  • Allergy

Hamilton-Russell (balanced) skin traction

If skin traction is likely to be used for more than 24 hours, greater patient comfort and better control of the fracture can be achieved by using Hamilton-Russell skin traction.

To apply Hamilton-Russell traction, a dedicated orthopedic bed, or a standard bed in combination with a mobile Balkan beam frame, is needed.

A padded sling is placed behind the slightly flexed knee and skin traction applied to the lower leg. The traction cord and pulley system are shown here.

The principle of the parallelogram of forces determines that the upward pull of the sling and the longitudinal pull of the skin traction create a resolution of force in the line of the femur, as illustrated.

This configuration of traction and leg support also can be adjusted to control femoral rotation, by directing the upward support medially or laterally. Generally, to minimize external rotation at the fracture, the patella should be pointing upward, nearly perpendicular to the bed surface.

A simpler alternative to this technique involves two separate systems.

  1. a sling suspended from the overhead frame, or supported with a rope and pulley counterweight, to provide an upward force, which lifts the leg off the bed
  2. longitudinal (distal) traction applied with skin or skeletal technique.

The resulting vector force, as illustrated, is oblique, the vector sum of the upward and distal forces applied by the two weights.

Note: With any longitudinal traction, the foot of the bed must be raised, tilting the bed, to avoid the traction weight’s pulling the patient down the bed.

Background: Proximal femur fractures are one of the most common injuries necessitating operative treatment. The aim of this prospective study was to evaluate and compare the possible effects of the preoperative application of a skin traction device, with or without weights, on pain relief in patients with acute proximal femur fracture.

Materials and methods: This study included 108 pre-operative patients with hip fractures. The subjects were randomly divided into three groups, and the following treatments were administered: Group 1, skin traction with 2 kg of weights; Group 2, skin traction without weights; and Group 3, pillow placement under the affected limb.

Results: Pain was assessed using the visual analog scale (VAS). No significant differences were observed in the scores of the three groups before the pain relief treatment. All three modes of treatment resulted in significant pain reduction in subjects. Patients treated without a weight-loaded skin traction kit had better pain relief compared to the other two groups; this outcome was statistically significant.

Conclusion: This study indicates that pillow placement under an injured limb can be safely used instead of traction, which has no significant benefit. However, an external device, such as a skin traction kit without weight, may be used in patients with persistent pain; this external device may have an additive placebo effect, as was proven in this study.

Adjust length to the above measurement. ensuring the Hoop is at an angle with the lateral (outside leg) higher than the medial (inside leg).

How to apply a skin traction

Set up

  • Apply the hoop Pad (to reduce pressure and secure to tight)
  • Apply the 4 slings (lowest should be 40cm from base)
  • Apply padding along slings
  • Creat a small padding for behind the knee

How to apply a skin traction


  • Ensure Adequate analgesia (this hurts) – typically Opiates and entonox
    • Femoral nerve block may be helpful (however, this is variable due to the innovation of the femur and reduces the more distal the fracture)

    The Knot

    How to apply a skin traction1. take the strings and pass one over and one under the sides of the frame.

    2. secure tightly with a Reef Knot

    3. pass strings down (one over and one under) around the base, bringing them back over the Reef Knot and back around the base. This makes a pulley system.

    4. Tension the pulley system and tie-off using a bow

    5. Pass the tongue depressors (2 tongue depressors tapped together), twist the tongue depressors to achieve the required tension, and lock off against the side.

    Traction is force applied by weights or other devices to treat bone or muscle disorders or injuries.


    Traction treats fractures, dislocations, or muscle spasms in an effort to correct deformities and promote healing.


    Traction is referred to as a pulling force to treat muscle or skeletal disorders. There are two major types of traction: skin and skeletal traction, within which there are a number of treatments.

    Skin traction

    Skin traction includes weight traction, which uses lighter weights or counterweights to apply force to fractures or dislocated joints. Weight traction may be employed short-term, (e.g., at the scene of an accident) or on a temporary basis (e.g., when weights are connected to a pulley located above the patient's bed). The weights, typically weighing five to seven pounds, attach to the skin using tape, straps, or boots. They bring together the fractured bone or dislocated joint so that it may heal correctly.

    In obstetrics, weights pull along the pelvic axis of a pregnant woman to facilitate delivery. In elastic traction, an elastic device exerts force on an injured limb.

    Skin traction also refers to specialized practices, such as Dunlop's traction, used on children when a fractured arm must maintain a flexed position to avoid circulatory and neurological problems. Buck's skin traction stabilizes the knee, and reduces muscle spasm for knee injuries not involving fractures. In addition, splints, surgical collars, and corsets also may be used.

    Skeletal traction

    Skeletal traction requires an invasive procedure in which pins, screws, or wires are surgically installed for use in longer term traction requiring heavier weights. This is the case when the force exerted is more than skin traction can bear, or when skin traction is not appropriate for the body part needing treatment. Weights used in skeletal traction generally range from 25–40 lbs (11–18 kg). It is important to place the pins correctly because they may stay in place for several months, and are the hardware to which weights and pulleys are attached. The pins must be clean to avoid infection. Damage may result if the alignment and weights are not carefully calibrated.

    Other forms of skeletal traction are tibia pin traction, for fractures of the pelvis, hip, or femur; and overhead arm traction, used in certain upper arm fractures. Cervical traction is used when the neck vertebrae are fractured.

    How to apply a skin traction

    Proper care is important for patients in traction. Prolonged immobility should be avoided because it may cause bedsores and possible respiratory, urinary, or circulatory problems. Mobile patients may use a trapeze bar, giving them the option of controlling their movements. An exercise program instituted by caregivers will maintain the patient's muscle and joint mobility. Traction equipment should be checked regularly to ensure proper position and exertion of force. With skeletal traction, it is important to check for inflammation of the bone, a sign of foreign matter introduction (potential source of infection at the screw or pin site).


    Both skin and skeletal traction require x rays prior to application. If skeletal traction is required, standard pre-op surgical tests are conducted, such as blood and urine studies. X rays may be repeated over the course of treatment to insure that alignment remains correct, and that healing is proceeding.

    Normal results

    There have been few scientific studies on the effects of traction. Criteria (such as randomized controlled trials and monitored compliance) do exist, but an outcome study incorporating all of them has not yet been done. Some randomized controlled trials emphasize that traction does not significantly influence long-term outcomes of neck pain or lower back pain.

    The application of skeletal traction in the setting of lower extremity fractures is an essential aspect of orthopedic traumatology. By applying temporary skeletal traction, fracture length, reduction, and stability can be temporized. Proximal tibial traction can be utilized for many types of orthopedic injuries including fractures and/or dislocations of the pelvis, acetabulum, and femur. While the application of a skeletal traction pin in the emergency department may sound unnerving to the junior resident, following step-by-step guidelines on its application may help alleviate some concerns. This article will discuss the proper application of a skeletal traction pin through the proximal tibia.

    Before performing, it is important to understand the anatomical considerations involved in skeletal traction through the tibia. Since traction is being applied distal to the injured site, skeletal traction through the tibia is maintained via ligamentotaxis through the knee joint. Therefore before applying traction, it is critical to assess the ligamentous stability of the knee joint. The knee must be relatively stable in order to pull traction through the ligaments, specifically the medial and lateral collateral ligaments. The resident should assess varus and valgus stability of the knee grossly in 0 degrees flexion (or full extension) as well as 30 degrees of knee flexion, if possible. Both anterior and posterior stability can also be assessed if appropriate. Once the knee has been determined to be stable in the coronal plane, tibial traction can be performed.

    Proximal tibial traction has multiple advantages compared to distal femoral traction. The anatomic landmarks on the proximal tibia are more reliable and identifiable compared to the distal femur especially in the trauma setting where soft tissue swelling and body habitus may obscure landmarks that may otherwise be recognizable. Moreover, the subcutaneous nature of the proximal tibia compared to the soft tissue envelope surrounding the distal femur may allow for easier passage of traction pins. However, if there is injury around the knee joint such as in the setting of a multi-ligamentous injury and/or knee dislocation, skeletal traction through the proximal tibia may not be indicated.

    The supplies needed for a proximal tibial traction pin are similar to that of distal femoral traction and include the following:

    How to apply a skin traction

    Some items necessary that are included in Arbutus Medical’s TrakPak® kit

    1. Sterile towels x 4
    2. Sterile gloves
    3. Surgical marking pen
    4. Skin cleaning prep (chlorohexidine gluconate or povidone-iodine solution)
    5. Local anesthetic (

    Tibial traction pins are applied from a lateral to medial direction, from an anatomic area that is known to be unknown. On the lateral aspect of the proximal tibia, the major neurovascular structure in the area is the common peroneal nerve. The common location for this nerve is approximately 2 cm distal to the fibular head as the common peroneal nerve crosses within the peroneus longus muscle into the anterior compartment of the lower leg. Although this nerve is out of the way of where a proximal tibial traction pin will be placed, it is good practice to understand and be aware of the neurovascular structures at risk. The other consideration to be aware of is the extent of the knee capsule distal to the knee joint. A study in the Journal of Orthopaedic Trauma demonstrated that the knee capsule can extend up to 14 mm distal to the knee joint. It is essential to place the proximal tibial traction pin extra-capsular and greater than this length in order to be at a safe distance away from the knee joint and to avoid intracapsular penetration potentially causing a septic knee joint. Once these anatomic considerations are understood, tibial traction can be performed.

    1. Identify and demarcate the superficial landmarks around the proximal tibia.
      1. Make note of the medial and lateral knee joint lines and the four poles of the patella. The tibial tubercle and the fibular head should also be identified.
      2. How to apply a skin tractionHow to apply a skin traction
      1. This is generally approximately 2 fingerbreadths distal to the tibial tubercle and 2 fingerbreadths posterior and lateral on the tibia.
      2. Mark this trajectory on the lateral as well as the medial side where the pin will exit.
      3. How to apply a skin tractionHow to apply a skin traction
      1. Start from the center and work circularly in an outward direction.
      1. Keep the knee joint in view in order to not block out any anatomical landmarks.
      2. How to apply a skin traction
      1. Generally, the tip of the traction pin is sharp enough to puncture through the skin.
      2. A small stab incision could also be made with a #11 blade scalpel.
      3. In our practice it has been found that stab incisions with a scalpel can stretch over time especially with weighted traction, therefore it is not generally used.
      1. The proximal tibia is close to the subcutaneous tissues.
      2. Once on bone, walk the pin slightly anterior and slightly posterior in order to gauge that the pin is relatively central on the bone.
      3. While the more critical neurovascular structures are on the posterior aspect of the tibia, it is also important to not be too anterior on the tibia to ensure that the pin has adequate depth when weighted traction is applied.
      4. Confirm that the pin is parallel to the knee joint line.
      5. Once confirmed placement on the tibia, drill full speed and drive the pin through the bone and through the soft tissue and skin on the medial side.
      1. This will ensure that there is enough space on both the medial and lateral sides for the application of the traction bow and pin caps.
      2. How to apply a skin traction
      1. Alternatively, blood collecting test tubes can be utilized.
      1. This acts as a cushion buffer in case the traction bow ever makes contact with the patient’s skin.
      1. Use 5-pound increments.
      1. A fully wrapped Kerlix can be placed directly on the skin at this level to ensure the traction bow does not come in contact with the patient’s skin in order to avoid a pressure ulcer.

      While skeletal traction may be sound daunting at first, understanding anatomical considerations, being prepared with all necessary equipment, and following these clear and concise steps will lead to success.

      Periprosthetic fractures of the femur and acetabulum are often treated operatively.

      Traction and bed rest are usually used as a temporary management strategy prior to operative treatment for unstable fracture types.

      Nonoperative treatment means that the patient will be in a form of traction for at least 6-8 weeks, often 10-12 weeks.

      The initial treatment is usually skin traction, later converted to skeletal traction.

      Disadvantages of prolonged skin traction are:

      • Loosening
      • Constriction
      • Friction
      • Allergy

      If skin traction is likely to be used for more than 24 hours, greater patient comfort and better control of the femoral fracture can be achieved by using Hamilton-Russell skin traction.

      A padded sling is placed behind the slightly flexed knee and skin traction applied to the lower leg. The traction cord and pulley system is as illustrated.

      The principle of the parallelogram of forces determines that the upward pull of the sling and the longitudinal pull of the skin traction create a resulting force in the line of the femur, as illustrated.

      This configuration of traction also allows control of rotation, by side-to-side adjustment of the pulley above the knee.

      2. Skin traction

      Skin traction over the end of the bed with 7 kg will be the initial treatment of a femoral fracture.

      This photograph shows a commercially available skin traction kit.

      Prior to the application of the adhesive traction strip, the skin is painted with friar’s balsam.

      The strip is then applied below the level of the fracture on the medial and lateral aspects of the leg as shown, carefully avoiding any creases.

      To prevent the development of blisters, the skin traction needs to be applied without folds or creases in the adhesive material and the covering bandage should be non-elastic.

      Should a crease be inevitable, due to the contour of the limb, the creased area should be lifted, partially slit transversally and the edges overlapped.

      Once the adhesive strip is satisfactorily in place, ensuring that the padded lower section overlies the malleoli, a spiral inelastic bandage is carefully wrapped around the limb from just above the malleoli to the top of the strip.

      Apply the overlying bandages spirally overlapping by half.

      The traction strip should be applied to the level of the fracture only, but not above.

      3. Skeletal traction via distal femur pin


      • Sterile towels
      • Disinfectant
      • Syringe
      • Needles
      • Local anesthetic
      • Scalpel with pointed blade
      • Sharp pointed Steinmann pin or K-wire
      • Jacobs chuck with T-handle or wire driver
      • Stirrup
      • Traction bowl
      • Weights
      • Rope
      • Traction setup on hospital bed


      After painting the skin with antiseptic and draping with sterile towels, inject a bolus of local anesthesia on each side of the distal femur (into the medial skin at the proposed site of pin insertion and laterally at the anticipated exit point). Infiltrate down to the periosteum, roughly 2-3 fingers above the superior pole of the patella.

      Pin insertion

      Flex the knee to 30° palpating the patella for neutral rotation. At the entry point, a stab incision is made through the skin with a pointed scalpel.

      A Steinmann pin or K-wire, mounted in the T-handle or wire driver, is inserted manually at a point about 2-3 fingers above the superior pole of the patella.

      As the pin is felt to penetrate the far cortex, check that the exit will coincide with the area of local anesthetic infiltration. If not, inject additional local anesthetic. Once the point of the pin clearly declares its exit site, make a small stab incision in the overlying skin.

      Ensure that there is no tension on the skin at the entry and exit points. If there is, then a small relieving incision may be necessary.

      Connect the pin with an appropriate traction stirrup.

      Be sure to pad the extremity from the traction bow.

      Pin care

      To prevent pin track infection, apply a slit gauze swab around the pin and do not remove the crust that develops around the pin on the skin. The gauze swab should only be changed infrequently.


      The pull on the femur (weight at the end of the traction) should be enough to correct length and to reduce the fracture.

      For maintenance traction 10% of the patient’s body weight is usually sufficient.

      The pull should always be in line with the femur.

      The thigh can be supported on a firm triangular foam wedge, or by folded pillows.

      4. Skeletal traction via tibial pin


      • Sterile towels
      • Disinfectant
      • Syringe
      • Needles
      • Local anaesthetic
      • Scalpel with pointed blade
      • Sharp pointed Steinmann pin, or Denham pin
      • Jacobs chuck with T-handle
      • Stirrup


      After painting the skin with antiseptic and draping with sterile towels, inject a bolus of local anesthesia on each side of the tibial tuberosity, into the lateral skin at the proposed site of pin insertion and medially at the anticipated exit point, infiltrating down to the periosteum.

      Pin insertion

      At the entry point, a stab incision is made through the skin with a pointed scalpel.

      A Steinmann pin or K-wire, mounted in the T-handle or K-wire driver, is inserted manually at a point about 2 cm dorsal to the tibial tuberosity.

      As the pin is felt to penetrate the far cortex, check that the exit will coincide with the area of local anesthetic infiltration. If not, inject additional local anesthetic. Once the point of the pin clearly declares its exit site, make a small stab incision in the overlying skin.

      Once the pin is in place, ensure that there is no tension on the skin at the entry and exit points. If there is, then a small relieving incision may be necessary.

      Connect the pin with an appropriate traction stirrup.

      It is important that the stirrup be freely mobile around the traction pin, to prevent rotation of the pin within the bone. Rotating pins loosen quickly and significantly increase the risk of pin track infection.

      Be sure to pad the extremity from the traction bow.


      The pull on the femur (weight at the end of the traction) should be enough to correct length and to reduce the fracture.

      For maintenance traction 10% of the patient’s body weight is usually sufficient.

      The pull should always be in line with the extremity.

      The thigh can be supported on a firm triangular foam wedge, or by folded pillows.

      For people with hip fractures, traction involves either using tapes (skin traction) or pins (skeletal traction) attached to the injured leg and connected to weights via a pulley. The application of traction before surgery is thought to relieve pain and make the subsequent surgery easier. Where traction is not used, the injured limb is usually placed on a pillow and the patient encouraged to adopt a position of greatest comfort.

      This review summarising the evidence from randomised controlled trials included 11 trials with 1654 participants. Consistent with the general hip fracture population, most of the trial participants were older persons of around 80 years of age and the majority were female. Ten trials compared traction versus no traction and two trials, including one of the preceding 10 trials, compared skin and skeletal traction. As well as limitations in the trial methods, there were very limited data for pooling and a lack of information about the longer-term consequences of applying or not applying traction. Nonetheless, the evidence from the 10 trials consistently showed no evidence to support the supposed advantages of traction described above. There were inconclusive data for pressures sores (skin ulcers) and other complications. One trial reported three adverse effects (sensory disturbance and skin blisters) related to skin traction; all were minor.

      From the evidence available, the routine use of traction (either skin or skeletal) prior to surgery for a hip fracture does not appear to have any benefit. However, the evidence is also insufficient to rule out the potential advantages for traction, in particular for specific fracture types, or to confirm additional complications due to traction use.

      Given the increasing lack of evidence for the use of pre-operative traction, the onus should now be on clinicians who persist in using pre-operative traction to either stop using it or to use it only in the context of a well-designed randomised controlled trial.

      Following a hip fracture, traction may be applied to the injured limb before surgery. This is an update of a Cochrane review first published in 1997, and previously updated in 2006.

      To evaluate the effects of traction applied to the injured limb prior to surgery for a fractured hip. Different methods of applying traction (skin or skeletal) were considered.

      We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2011), the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2011, Issue 4), MEDLINE (1948 to April week 2 2011), EMBASE (1980 to 2011 week 16), and CINAHL (1982 to 1 April 2011), conference proceedings, trials registries and reference lists of articles.

      All randomised or quasi-randomised trials comparing either skin or skeletal traction with no traction, or skin with skeletal traction for patients with an acute hip fracture prior to surgery.

      At least two authors independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, data were pooled.

      One new trial was included in this update. In all, 11 trials (six were randomised and five were quasi-randomised), involving a total of 1654 predominantly elderly patients with hip fractures, are included in the review. Most trials were at risk of bias, particularly that resulting from inadequate allocation concealment, lack of assessor blinding and incomplete outcome assessment. Only very limited data pooling was possible.

      Ten trials compared predominantly skin traction with no traction. The available data provided no evidence of benefit from traction either in the relief of pain (pain soon after immobilisation (visual analogue score 0: none to 10: worst pain): mean difference 0.11, 95% CI -0.27 to 0.50; 3 trials), ease of fracture reduction or quality of fracture reduction at time of surgery. There were inconclusive data for pressures sores and other complications, including fracture fixation failure. Three minor adverse effects (sensory disturbance and skin blisters) related to skin traction were reported.

      One of the above trials included both skin and skeletal traction groups. This trial and one other compared skeletal traction with skin traction and found no important differences between these two methods, although the initial application of skeletal traction was noted as being more painful and more costly.

      1-28. SKIN TRACTION

      a. Prior to application of the skin traction, inspect the skin for rashes, abrasions, or signs of circulatory impairment since the skin must be healthy in order to tolerate the traction. Check with the physician as to whether the skin should be shaved. Shaving is not always advisable because of the possibility of skin irritation or subsequent ingrowing hair problems. The extremity should be clean and dry before anything is applied to the skin.

      b. Assist with the application of skin traction and arrangement of the traction apparatus as directed by the physician. Understand the nature of the traction and the patient movement that is permissible while still maintaining the desired traction pull. The basic position of the patient and permissible movement differ according to the type of traction used and these factors determine the basic nursing care plan. The following paragraphs discuss several of the most commonly used forms of skin traction.

      These Nursing411 wings incorporate the white heart of international nursing with the
      golden wings of an angel, symbolizing Nursing’s selfless dedication
      to the service of mankind.

      The Brookside Associates Medical Education Division develops and distributes medical information that may be useful to medical professionals and those in training to become medical professionals. This website is privately-held and not connected to any governmental agency. The views expressed here are those of the authors, and unless otherwise noted, do not necessarily reflect the views of the Brookside Associates, Ltd., or any governmental or private organizations. All writings, discussions, and publications on this website are unclassified.

      � 2008 Medical Education Division, Brookside Associates, Ltd. All rights reserved

      How to apply a skin traction

      Whenever traction is applied, countertraction must be used to achieve effective traction. Countertraction is the force acting in the opposite direction. Usually, the patient’s body weight and bed position adjustments supply the needed countertraction.

      The following are additional principles to follow when caring for the patient in traction:

      · Traction must be continuous to be effective in reducing and immobilizing fractures.

      · Skeletal traction is never interrupted.

      · Weights are not removed unless intermittent traction is pre-scribed.

      · Any factor that might reduce the effective pull or alter its resultant line of pull must be eliminated:

      – The patient must be in good body alignment in the cen-ter of the bed when traction is applied.

      – Ropes must be unobstructed.

      – Weights must hang free and not rest on the bed or floor.

      – Knots in the rope or the footplate must not touch thepulley or the foot of the bed.

      There are several types of traction. Straight or running traction applies the pulling force in a straight line with the body part rest-ing on the bed. Buck’s extension traction (Fig. 67-4) is an exam-ple of straight traction. Balanced suspension traction (Fig. 67-5) supports the affected extremity off the bed and allows for some patient movement without disruption of the line of pull.

      How to apply a skin traction

      How to apply a skin traction

      Traction may be applied to the skin (skin traction) or directly to the bony skeleton (skeletal traction). The mode of application is determined by the purpose of the traction. Traction can be applied with the hands (manual traction). This is temporary traction that may be used when applying a cast, giving skin care under a Buck’s extension foam boot, or adjusting the traction apparatus.

      the exertion of a pulling force, as that applied to a fractured bone or dislocated joint to maintain proper position and facilitate healing, or, in obstetrics, that along the axis of the pelvis to assist in delivery of a fetal part. It also may be used to overcome muscle spasms in musculoskeletal disorders such as herniated disk, to lessen or prevent contractures, and to correct or prevent a deformity.

      Traction may be applied by means of a weight connected to a pulley mechanism over the patient’s bed; this is known as weight traction. In elastic traction an elastic appliance exerts a pulling force upon the injured limb. In skeletal traction, a type for long-term heavyweight use, force is applied directly upon a bone by means of surgically installed pins and wires or tongs. Splints and reinforced garments, such as surgical corsets and collars, also may be employed to provide forms of traction. In skin traction, a temporary and lightweight type, moleskin or some other type of adhesive bandage is used to cover the affected limb, and traction is applied to the bandage.

      How to apply a skin traction

      Patient Care . Patients in prolonged traction must be protected from the hazards of immobility. The integrity of the skin must be maintained and pressure sores avoided. A trapeze bar over the bed may be prescribed to give patients greater freedom in moving themselves about in bed and help them feel more independent. Patients should be instructed to lift themselves straight up so as not to alter the position of the affected limb in traction.

      The apparatus used for traction must be checked frequently to be sure the weights are hanging free and exerting the required amount of pull. The patient’s body weight should counteract the pull of the weights, i.e., the feet should not be resting against the footboard nor should the body position interfere in any way with the tension on the ropes of the traction apparatus.

      The physical therapist, nurse, and occupational therapist often work together to plan and implement a program of structured exercise for maintaining the patient’s muscle tone and joint mobility. Muscle strengthening is another component of care for some patients in traction. Prevention of the hazards of immobility must be a high priority.

      A fracture of the Pelvis occurring with a fracture of the Femur is generally a contraindication for the use of a traction splint of any type. A Sager® Emergency Traction Splint is not contraindicated when MAST Trousers are used to immobilize the fractured Pelvis. In this situation, Sager® Splints may be applied over MAST Trousers if treatment of the fractured Femur is indicated or desired. Sager’s traction is quantifiable and gentle and will not disrupt or move Pelvic bones immobilized by MAST Trousers. Supracondylar fractures of the distal end of the Femur are contraindicated because traction can cause anterior rotation of the distal bone fragment – forcing the sharp fractured bone end down into the Popliteal Artery and Nerve. These fractures should be splinted as found. Compound fractures of the Femur with bone fragments sticking through the skin may be a contraindication. Guidelines by local protocol or instructions by a Medical Consultant should be followed. Fractures of the Ankle and Foot are also contraindicated. Pressure from the ankle harness and from traction is not therapeutic. The indications and contraindications listed above are only intended as a basic reference tool. Please defer to federal, state, and/or local protocol for definitive analysis and guidelines. Warning: All Operators should receive full and proper initial and refresher instruction sessions from a qualified person on detailed use of this equipment and regarding the particular situations in which it should be used.

      How much traction should I apply?

      Apply the amount of traction recommended by your medical consultant, or that required by protocol. For adults, the American Academy of Orthopedic Surgeons recommends gentle traction to a maximum of 7kg (15 pounds) per fractured femur (14kg (30 pounds) for a bilateral fracture. A general rule of thumb is 10% of the patient’s body weight per fractured femur. For example; if a patient weighing 45kg (100 pounds) has a single fracture, the appropriate amount of traction would be 41⁄2kg (10 pounds). If that same person has a bilateral fracture, 9kg (20 pounds) would be estimated.

      Skeletal traction is a treatment method for broken bones. It’s a system where a combination of pulleys, pins, and weights are used to promote the healing of fractured bones. These are usually in the lower body.

      In skeletal traction, a pin is placed inside your bone. That pin provides a base for a pulley system. It uses gradual pulling force to realign broken bones and promote proper healing.

      There are two common types of traction. These include skin traction and skeletal traction. The difference lies in where the pin, or base, is placed. Skeletal traction uses a pin inserted into your bone. In skin traction, a splint or adhesive is applied to your skin.

      When Is Skeletal Traction Used?

      Skeletal traction is a treatment method for broken bones that dates back to the 13th century. It’s mainly used for treating broken bones in the lower body.

      These days, it’s used as a pre-operative treatment. Using skeletal traction can help realign your bones when your fracture is unstable.

      Skeletal traction is commonly used for fractures in the following bones:

      • Upper leg bone (femur)
      • Lower leg bone (tibia)
      • Upper arm bone (humerus)
      • Hips
      • Pelvis
      • Lower spinal area (cervical spine)

      An orthopedic surgeon will insert a pin in a certain part of your bone when performing skeletal traction. Where the surgeon places the pin will depend on which bone you’ve broken and how it needs to be fixed. Local anesthesia is applied before this happens.

      A weight of up to 15 pounds is attached to one end of the pulley in the traction mechanism. This provides a force to adjust the bones after a fracture. It also helps them return to their proper place.

      A system of pulleys will realign the broken bone properly, preparing you for a successful surgery. Your doctor might also recommend traction as a way to promote proper healing without surgery.

      Benefits of Skeletal Traction

      Breaking a bone can be a very painful experience. It can also cause you a lot of inconveniences. It’s important to take all the necessary steps to make sure your broken bone heals properly. Otherwise, you could be dealing with the same problem for quite some time.

      Skeletal traction is designed to put your bones back in place after a traumatic fracture. Accidents can make your bones break into small pieces. This makes it hard to regain the full use of them without the proper treatment.

      The muscle around your broken bone can contract. This makes the bones shorten as they heal and is common when a child breaks their leg. It can result in one leg growing longer than the other.

      Skeletal traction can be used as a temporary measure or as a treatment recommendation. The main benefits of skeletal traction are:

      • Joint or bone immobilization
      • Reduce or realign dislocations and fractures
      • Prevent and reduce muscle spasm
      • Pressure and pain relief
      • Relieve spinal nerves
      • Promote patient comfort until a treatment option is decided

      Complications of Skeletal Traction

      There are lots of benefits to be had from skeletal traction. But as with most medical treatments, there can be complications too.

      The complications are associated with lack of movement and the effects of suspended limbs. Some of the complications skeletal traction can cause include the following.

      Infection. In skeletal traction, a metal pin is inserted into your bone. This pin acts as a base for reducing the fracture. The insertion site can become infected, whether it is in bone or soft tissue.

      Pressure sores. Pressure sores are also known as pressure ulcers or bedsores. They can happen when you’re lying in the same position for an extended period of time. They often form in areas where your bones are close to your skin.

      Nerve damage. There are different ways your nerves can be damaged when undergoing skeletal traction. Pin insertion and wire arrangement are factors, but more research is needed in the area.

      Misalignment of the bone or joint. Medical staff will make every effort to realign your joints or broken bone correctly. Misalignment can happen in some cases.

      Stiff joints. Your joints can become stiff from traction. This is possibly due to reduced blood flow.

      Wire malfunction. The wires that suspend your limb during skeletal traction can sometimes malfunction or break.

      Deep vein thrombosis (DVT). DVT is when you develop a large blood clot in your deep veins. It usually happens in your legs when you’re unable to move for a long period of time.

      Show Sources

      ‌AO Surgery Reference: “Traction and bed rest.”

      International Journal of Orthopaedics Sciences: “Skeletal traction for the management of lower limb fractures: Its relevance today.”

      JOHNS HOPKINS: “Bedsores.”

      Journal of Orthopaedics: “Injury to neurovascular structures with insertion of traction pins around the knee.”

      MAYO CLINIC: “Deep vein thrombosis (DVT).”

      MEDECINS SANS FRONTIERES: “Skeletal Traction Standard Operation Procedure.”

      a method of treating patients with injuries (fractures, dislocations) and certain diseases of the supportive and locomotor apparatus (limbs and spinal column). Traction is used to restore the normal anatomical alignment of portions (segments) of the limbs in dislocations and of broken ends of bones in fractures, in sprains of persistently contracted muscles (contractures), and in the stretching of tissues surrounding a joint and to correct deformities of the joints and spinal column (by acting on the ligaments and muscles). Traction is also used in preparation for various surgical interventions and to hold the trunk and limbs in the correct position after a deformity has been surgically corrected.

      Traction can be constant, that is, last for some time (three to four weeks or more) or be instantaneous (momentary). Constant traction, besides its corrective effect, has a pro-longed, gradual, relaxing effect on the muscles, ensures physiological rest by creating the best conditions for the circulation of blood and lymph, and permits functional treatment (graduated physical exercise, massage) to be started early. Traction can be applied to the limbs and spinal column in various ways, depending on the pathology involved and the treatment: in bed, on an inclined surface, on a special extension table, or under water. Patients with traumatic in-juries can be placed in traction by means of special splints using long needles or clamps attached to the bone (skeletal traction) or by means of soft braces secured to the limb with adhesive plaster or kleol (solution of rosin; adhesive-plaster traction) or cuffs with lacing. Spinal traction is secured by using special loops or clamps (attached to the head), soft straps, or a belt (attached to the pelvis). In traction the pull is created by suspending weights from strings drawn over pulleys. To create counterpull in traction of the lower limbs, the foot end of the bed is raised; in traction involving the head and using straps, the head end is raised.

      Traction on extension tables is used for various diseases of the spinal column. It is exerted by the pull of a weight, spring rod, or rod of a special apparatus driven by electricity. Tensile force is increased by tilting the tabletop and by the mobility of the panels.

      Instantaneous traction is exerted by the physician’s hands or by special apparatus (pulling apparatus) usually to align broken ends of bones in fractures or to reduce dislocations and is followed by fixation with a plaster cast or splints. In some spinal diseases and contractures of the lower limbs, use is made of traction in warm water to ensure better relaxation of the muscles. Traction is applied in a pool both in a vertical direction (the patient rests his head on a headrest and his arms on the elbowrest of a device immersed in the water; weights are suspended from the patient’s waist or lower leg) and in a horizontal direction (the patient’s trunk is held fast in a special bath by a soft belt around the chest while traction is exerted on the pelvis).

      All of Healthily’s articles undergo medical safety checks to verify that the information is medically safe. View more details in our safety page, or read our editorial policy.

      Traction is the use of weights, ropes and pulleys to apply force to tissues surrounding a broken bone.

      It is sometimes used to keep a broken leg in the correct position during the early stages of healing, or to ease the pain of a fracture while a patient is waiting for surgery.

      When traction is used

      There are several situations when traction may be used. For example, it may be used to:

      • realign and fix bone fractures, such as a broken leg
      • help reduce pain before surgery
      • treat bone deformities caused by conditions such as scoliosis (abnormal curvature of the spine)
      • correct a muscle contracture (shortening of a muscle)

      Types of traction

      The two main types of traction are:

      • skin traction
      • skeletal traction

      Skin traction

      Skin traction is usually carried out while a person is lying in a hospital bed. It uses equipment such as splints, bandages, adhesive tape and special gloves and boots that are attached to weights.

      A pulling force is applied through soft tissues, such as the skin, muscles and tendons. The affected area of the body is pulled up using a pulley system attached to the bed.

      Skeletal traction is used when a greater force needs to be applied. The force is applied directly to the skeleton, which means additional weight can be added without the risk of damaging the surrounding soft tissues.

      The skin can usually support up to 3.5kg (8lb), whereas the skeleton can support up to 12kg (25lb).

      During skeletal traction, pins, wires or screws are surgically implanted into the bone. This can be done using either a local anaesthetic or a general anaesthetic (painkilling medication).

      After the pins, wires or screws have been implanted, weights are attached to them so that the affected body part can be pulled into the correct position.

      How long skeletal traction needs to be used for will depend on how badly injured the bones are.

      Does traction work?

      Despite being used as a treatment for hundreds of years, there is little scientific evidence to support the use of traction.

      Skin or skeletal traction was often routinely applied to the limb of a fractured hip before surgery. However, recent research has shown this appears to have little or no benefit.

      There is also little evidence to show traction is an effective method of treating spinal conditions such as:

      Several studies have either produced inconclusive results or concluded that there are more effective methods of treating these conditions, such as exercise and physiotherapy.

      Although skin and skeletal traction may be used to treat certain types of fracture, traction is not usually needed for minor fractures.

      Traction is the use of a pulling force to treat muscle and skeleton disorders.


      Traction is usually applied to the arms and legs, the neck, the backbone, or the pelvis. It is used to treat fractures, dislocations, and long-duration muscle spasms, and to prevent or correct deformities. Traction can either be short-term, as at an accident scene, or long-term, when it is used in a hospital setting.

      Traction serves several purposes:

      • it aligns the ends of a fracture by pulling the limb into a straight position
      • it ends muscle spasm
      • it relieves pain
      • it takes the pressure off the bone ends by relaxing the muscle

      There are two main types of traction: skin traction and skeletal traction. Within these types, many specialized forms of traction have been developed to address problems in particular parts of the body. The application of traction is an exacting technique that requires training and experience, since incorrectly applied traction can cause harm.

      Positioning the extremity so that the angle of pull brings the ends of the fracture together is essential. Elaborate methods of weights, counterweights, and pulleys have been developed to provide the appropriate force while keeping the bones aligned and preventing muscle spasm. The patient’s age, weight, and medical condition are all taken into account when deciding on the type and degree of traction.


      People who are suffering from skin disorders or who are allergic to tape should not undergo skin traction, because the application of traction will aggravate their condition. Likewise, circulatory disorders or varicose veins can be aggravated by skin traction. People with an inflammation of the bone (osteomyelitis) should not undergo skeletal traction.


      Skin traction

      Skin traction uses five-to seven-pound weights attached to the skin to indirectly apply the necessary pulling force on the bone. If traction is temporary, or if only a light or discontinuous force is needed, then skin traction is the preferred treatment. Because the procedure is not invasive, it is usually performed in a hospital bed.

      Weights are attached either through adhesive or nonadhesive tape, or with straps, boots, or cuffs. Care must be taken to keep the straps or tape loose enough to prevent swelling and allow good circulation to the part of the limb beyond the spot where the traction is applied. The amount of weight that can be applied through skin traction is limited because excessive weight will irritate the skin and cause it to slough off.

      Specialized forms of skin traction have been developed to address specific problems. Dunlop’s traction is used on children with certain fractures of the upper arm, when the arm must be kept in a flexed position to prevent problems with the circulation and nerves around the elbow. Pelvic traction is applied to the lower spine, with a belt around the waist. Buck’s skin traction is used to treat knee injuries other than fractures. The purpose of this traction is to stabilize the knee and reduce muscle spasm.

      Skeletal traction

      Skeletal traction is performed when more pulling force is needed than can be withstood by skin traction; or when the part of the body needing traction is positioned so that skin traction is impossible. Skeletal traction uses weights of 25-40 pounds.

      Skeletal traction requires the placement of tongs, pins, or screws into the bone so that the weight is applied directly to the bone. This is an invasive procedure that is done in an operating room under general, regional, or local anesthesia.

      Correct placement of the pins is essential to the success of the traction. The pin can be kept in place several months, and must be kept clean to prevent infection. Once the hardware is in place, pulleys and weights are attached to wires to provide the proper pull and alignment on the affected part.

      Specialized forms of skeletal traction include cervical traction used for fractures of the neck vertebrae; overhead arm traction used for certain types of upper arm fractures; and tibia pin traction used for some fractures of the femur, hip, or pelvis.


      X rays are done prior to the application of both forms of traction, and may be repeated during treatment to assure that the affected parts are staying in alignment and healing properly. Since the insertion of the anchoring devices in skeletal traction is a surgical procedure, standard preoperative blood and urine testing are done, and the patient may meet with an anesthesiologist to discuss any health conditions that might affect the administration of anesthesia.


      Aftercare for skin traction involves making sure the limb stays aligned, and caring for the skin so that it does not become sore and irritated. The patient should also be alert to any swelling or tingling in the limb that would suggest that the limb has been wrapped too tightly.

      Aftercare for skeletal traction is more complex. The patient is likely to be immobile for an extended period. Deep breathing exercises are taught so that respiratory function is maintained during this time of little activity. Patients are also encouraged to do range-of-motion exercises with the unaffected parts of the body. The patient is taught how to use a trapeze (an overhead support bar) to shift on and off a bedpan, since it is not possible to get up to use the toilet. In serious injuries, traction may be continued for several months until healing is complete.


      The main risks associated with skin traction are that the traction will be applied incorrectly and cause harm, or that the skin will become irritated. There are more risks associated with skeletal traction. Bone inflammation may occur in response to the introduction of foreign material into the body. Infection can occur at the pin sites. If caught early, infection can be treated with antibiotics, but if severe, it may require removal of the pin.

      Both types of traction have complications associated with long periods of immobility. These include the development of bed sores, reduced respiratory function, urinary problems, and circulatory problems. Occasionally, fractures fail to heal. Being confined to traction for a long period can take a an emotional toll on the patient, also.

      Normal results

      When correctly applied, traction generally produces very good, if slow, results.



      “Traction.” In Everything You Need to Know About Medical Treatments. Springhouse, PA: Springhouse Corp., 1996.

      Femur fractures can be successfully immobilized using a traction splint. A femur fracture is complicated due to the amount of bleeding that can occur from the broken bone. In addition, the thigh muscles will contract and pull the fractured ends so they overlap or pass each other. This increases the size of the thigh, which leads to more blood loss, pain and internal soft tissue injury.

      Traction splints provide a counter-pull to reduce the size of the thigh and realign the fractured femur. This helps reduce blood loss, alleviate pain and minimize further injury. The most common traction splints you’ll see in the field are the Hare (bipolar) and the Sager (unipolar).

      Hare Traction Splint (Bipolar Traction Splint)

      The Hare is a bipolar traction splint, which means it uses two external poles to support the injured leg.


      • Suspected femur fracture


      • The injury is within 1-2″ of the knee or ankle
      • The knee is injured
      • The hip is injured
      • The pelvis is injured
      • There’s a partial amputation or avulsion with bone separation and the distal limb is connected by only marginal tissue

      How to Apply

      1. Assess distal PMS.
      2. Stabilize the injured leg by applying manual traction.
      3. Measure the splint on the uninjured leg and adjust the length accordingly.
      4. Position the splint under the injured leg until the ischial pad rests against the bony prominence of the buttocks. Once the splint is in position, raise the heel stand.
      5. Attach the ischial strap over the groin and thigh.
      6. Secure the ankle strap with the patient’s foot in an upright position.
      7. Attach the “S” hook to the “D” ring and apply mechanical traction; continue until it’s equal with the manual traction and the pain and muscle spasm are reduced.
      8. Attach the leg support straps.
      9. Recheck the ischial strap and ankle hitch to ensure both are securely fastened.
      10. Reassess distal PMS.

      Sager Traction Splint (Unipolar Traction Splint)

      The Sager is a unipolar traction splint, which means it uses one external pole to support the injured leg.


      • Suspected femur fracture


      • The injury is within 1-2″ of the knee or ankle
      • The knee is injured
      • The hip is injured
      • The pelvis is injured
      • There’s a partial amputation or avulsion with bone separation and the distal limb is connected by only marginal tissue

      How to Apply

      1. Assess distal PMS.
      2. Position the splint on the inside of the injured leg and adjust the length so it extends approximately 4″ beyond the heel.
      3. Attach the strap to the thigh.
      4. Secure the ankle strap with the patient’s foot in an upright position and attach it to the splint.
      5. Apply traction by extending the splint to 10% of the patient’s body weight.
      6. Attach the leg support straps.
      7. Recheck the ischial strap and ankle hitch to ensure both are securely fastened.
      8. Reassess distal PMS.

      Filed Under: Guides Tagged With: splints


      Rebecca Adams-Hall says

      Im a Student Paramedic , currently starting an assignment on traction splinting and was wondering if you have any unto date research on the pro’s and cons of traction splinting?
      much appreciated.

      The skin can only take about 5kg traction in an adult. If more than this force is required to obtain on maintain a reduction Skeletal traction must be used. Avoid skeletal traction in children – growth plates can easily be damaged by skeletal pins.

        Indications for Skin Traction
      • Children
      • Temporary traction – only a few days e.g. Preoperative
      • Small force required to maintain reduction Contraindications to Skin Traction
      • Force required > 5kg
      • Skin damage or sepsis in area
      • Adults requiring > 5kg traction
      • Skin damage requiring dressings
      • Long term

      Counter Traction

      Any force needs an opposing force. If traction pulls a limb distally the patient will slide downwards towards the pulley, and the traction will not be effective. Provide an opposing force by raising the foot of the bed on blocks. By sloping the bed in the other direction the tendency to slide will be opposed. In Cervical traction the front end of the bed needs raising, and with Dunlop traction the side of the bed near the injury needs elevation.

      Multiple Pulley Systems

      In many situations multiple pulleys are used, so that less weights are necessary. Multiple pulleys are commonly used in pelvic traction where high forces (commonly up to 40 kg) may be needed.

      Multiple pulleys decrease the force needed at the end rope

      If a triple and double block were used as in the picture only 40/5 or 8 kg. would be required to generate the 40 kg. lift needed.

      Purpose: To study the influence on pain and handling of different preoperative immobilization procedures for hip fractures.

      Method: 123 consecutive patients with displaced cervical and trochanteric hip fractures were randomized to skin traction, placement in a special foam pillow (Lasse pillow), and comfortable placement with an ordinary pillow under the hip from admission to operation. The effect on pain alleviation was evaluated with a Visual Analogue Scale and by the number of doses of analgesics administered. The processing time through the emergency department, X-ray department and to the ward as well as time to operation was registered.

      Results: No clinically significant difference in the VAS pain evaluation was found. There was no difference in the total consumption of analgesics in the emergency department or on the ward and no effect of immobilization type on the processing time or time to operation. Fracture type did not affect the outcome. Approximately one third of the patients found placement on a regular pillow or the application of skin traction uncomfortable as opposed to only one of 19 of the patients lying in the special Lasse pillow. There was no other difference in processing time with regard to different forms of pillow nursing and skin traction.

      Conclusion: The most convenient immobilization should be chosen as there is no significant difference concerning pain and handling time. Increased attention to analgesic medication and rapid handling to be operated are of importance to promote the rehabilitation process.