Orthopedics

Feature Article 

Low Incidence of Neurovascular Complications After Placement of Proximal Tibial Traction Pins

Garret Sobol, MD; Peter Gibson, MD; Param Patel, BA; Kenneth Koury, MD; Michael Sirkin, MD; Mark Reilly, MD; Mark Adams, MD

Abstract

Skeletal tibial traction is a temporizing measure used preoperatively for femoral fractures to improve the length and alignment of the limb and provide pain relief. The goal of this study was to identify possible neurovascular morbidity associated with the use of bedside skeletal tibial traction to treat femur fractures. All femoral fractures treated with proximal tibial traction during a 10-year period at an urban level I trauma center were retrospectively reviewed. The medical record was reviewed to determine whether a pin-related complication had occurred. Records also were reviewed to identify ipsilateral multi-ligamentous knee injuries that were not diagnosed until after the application of traction. In total, 303 proximal tibial traction pins were placed. A total of 7 (2.3%; 95% confidence interval, 0.60%–4.0%) pin-related neurologic complications and zero vascular complications were noted. All complications involved motor and/or sensory deficits in the distribution of the peroneal nerve. Of the 7 complications, 6 resolved fully after surgery and removal of the pin. After traction placement, 6 (2.0%) ipsilateral multiligamentous knee injuries were diagnosed. None of these patients had a neurovascular complication. This study suggests that bedside placement of proximal tibial traction for femoral fractures is associated with a low incidence of neurovascular complications and that traction can be safely placed at the bedside by residents. A thorough neurovascular examination should be performed before insertion, and care should be taken to identify the proper starting point and reduce soft tissue trauma during pin placement. [Orthopedics. 2017; 40(6):e1004–e1008.]

Abstract

Skeletal tibial traction is a temporizing measure used preoperatively for femoral fractures to improve the length and alignment of the limb and provide pain relief. The goal of this study was to identify possible neurovascular morbidity associated with the use of bedside skeletal tibial traction to treat femur fractures. All femoral fractures treated with proximal tibial traction during a 10-year period at an urban level I trauma center were retrospectively reviewed. The medical record was reviewed to determine whether a pin-related complication had occurred. Records also were reviewed to identify ipsilateral multi-ligamentous knee injuries that were not diagnosed until after the application of traction. In total, 303 proximal tibial traction pins were placed. A total of 7 (2.3%; 95% confidence interval, 0.60%–4.0%) pin-related neurologic complications and zero vascular complications were noted. All complications involved motor and/or sensory deficits in the distribution of the peroneal nerve. Of the 7 complications, 6 resolved fully after surgery and removal of the pin. After traction placement, 6 (2.0%) ipsilateral multiligamentous knee injuries were diagnosed. None of these patients had a neurovascular complication. This study suggests that bedside placement of proximal tibial traction for femoral fractures is associated with a low incidence of neurovascular complications and that traction can be safely placed at the bedside by residents. A thorough neurovascular examination should be performed before insertion, and care should be taken to identify the proper starting point and reduce soft tissue trauma during pin placement. [Orthopedics. 2017; 40(6):e1004–e1008.]

Femoral fractures as a result of high-energy mechanisms often are associated with unstable patients. When immediate fixation cannot be performed, skeletal tibial traction is commonly used as a temporizing measure. This procedure can be performed at the bedside in the emergency department. Proximal tibial traction improves the length and alignment of the limb while providing pain relief and limiting further damage to soft tissues.1,2 Although the procedure is generally considered safe, as with all invasive procedures, placement of proximal tibial traction pins is associated with multiple potential risks and complications. Neurovascular injury after placement of bedside tibial traction pins has been reported.2–6 However, the true incidence of such complications is unknown. This study was conducted to identify possible morbidity associated with skeletal tibial traction in femur fractures. It was hypothesized that this temporizing procedure is associated with a low incidence of complications and that it can be safely performed at the bedside during resuscitation.

Materials and Methods

After institutional review board approval was obtained, a billing search was conducted to identify all cases of operative femur fractures (Current Procedural Terminology codes 27236, 27244, 27245, 27269, 27506, 17507, 27511, and 27513) treated by the orthopedic trauma service during a 10-year period at an urban level I trauma center. Included in the study were femur fractures that required preoperative placement of a proximal tibial traction pin. Pin placement was verified by 2 independent observers (G.S., P.G.) based on review of medical records and radiographs.

A retrospective chart review was performed for each patient who had placement of a tibial traction pin. Basic demographic information and the mechanism and laterality of injury, date of pin placement, and amount of time the pin was present were recorded. Femoral fractures were classified as proximal, midshaft, or distal, based on a review of radiographs. Physical examination findings, including the results of motor, sensory, and vascular examinations of the injured extremity, were reviewed at 3 separate time points: (1) before placement of the traction pin; (2) at the first documented examination after pin placement; and (3) before discharge. Any patient who had a discrepancy of findings on physical examination before and after placement of tibial traction was flagged to determine whether a complication had occurred. Patients were excluded if a complete neurovascular examination was not documented at any of these designated time points. The level of training of the individual who performed the procedure was recorded in addition to whether the pin was placed under light sedation with local anesthetic or while the patient was intubated.

A complication was defined as 1 of the following: (1) decrease in motor strength in dorsiflexion or plantarflexion of the ankle or flexion/extension of the great toe after pin placement; (2) documented decrease in or loss of sensation in the leg or foot; or (3) documented change in the findings of vascular examination, such as loss of palpable pulses or Doppler signals in the dorsalis pedis or posterior tibial arteries after pin placement. Statistical analysis was performed to determine whether the incidence of complications was associated with sex, laterality, or fracture pattern.

Finally, all included cases were reviewed to determine whether an ipsilateral knee magnetic resonance imaging scan was performed at any point during the subsequent hospital stay. Magnetic resonance imaging findings were reviewed to determine whether the patient had a multiligamentous knee injury. These injuries are considered contraindications to tibial traction7 and are not uncommon in the setting of femoral fractures.8 Similar to other definitions described in the literature, for this study, a multiligamentous knee injury was defined as a complete cruciate ligament tear (anterior cruciate ligament or posterior cruciate ligament) plus partial or complete tear of at least 1 other cruciate or collateral ligament.9

Results

A total of 1972 cases were reviewed. The authors reviewed 360 femur fractures among 359 patients who were treated preoperatively with proximal tibial skeletal traction. Of these, 14 cases were excluded because of incomplete medical records and 42 patients were intubated and sedated during the pre- and post-pin physical examinations and thus did not undergo formal motor and sensory examinations. This left a cohort of 303 fractures among 303 patients (Table 1). On average, pins were left in place for 1.3 days before surgery (range, 0–27 days). In all cases, traction pins were placed by second- or third-year residents with fully threaded Steinmann pins and power drills. The department protocol is to use 4.8-mm Steinmann pins.

Characteristics of Included Patients

Table 1:

Characteristics of Included Patients

A total of 7 (2.3%; 95% confidence interval, 0.60%–4.0%) complications were noted after proximal tibial traction (Table 2). These included 2 cases of decreased ankle dorsiflexion strength, 2 cases of decreased sensation about the dorsum of the foot, 1 case of decreased sensation about the dorsum and first web space of the foot, 1 case of decreased sensation about the dorsum of the foot and decreased ankle dorsiflexion strength, and 1 case of decreased sensation about the dorsum of the foot and loss of great toe extension strength. No vascular complications were noted. Of the 7 patients, 6 (86%) had no neurovascular deficits on arrival, and 6 (86%) of 7 patient recovered full neurologic status by the end of the hospital stay. In addition, 6 (2.0%) ipsilateral multiligamentous knee injuries, all diagnosed after pin placement, were identified. For these patients, pins were present for an average of 0.9 days (range, 0–2 days), and no neurovascular complications occurred. No significant differences in the incidence of complications were noted regarding sex, laterality, or fracture pattern (Table 1).

Description of Complications

Table 2:

Description of Complications

Discussion

Skeletal tibial traction is generally performed at the bedside in the acute setting for patients with femur fractures. The theoretical benefits of preoperative traction include maintenance of the length and alignment of the fracture in preparation for operative fixation, protection of the soft tissue envelope, and reduction of patient discomfort. Multiligamentous knee injuries and tibial plateau fractures are considered contraindications to skeletal tibial traction.10 For an unstable ligamentous knee, traction can place an undue amount of tension on the neurovascular structures that cross the knee as well as risk further soft tissue injury about the knee. At the study institution, tibial traction pins are placed at the discretion of the attending surgeon. Indications typically include femoral fractures ranging from the subtrochanteric region to the distal metadiaphyseal region without intra-articular extension. Pins are placed by residents (postgraduate years 2 and 3) at the bedside and are removed in the operating room. Department policy mandates that junior residents (postgraduate years 2 and 3) place at least 2 pins under direct supervision from a senior resident (postgraduate years 4 and 5) before they can place pins independently.

As with any invasive procedure, several risks are associated with skeletal traction placement, and isolated cases of neurovascular compromise have been reported after traction placement.2–6 Multiple studies have described the anatomy of the proximal leg and delineated the structures that are most at risk with the placement of a tibial traction pin.1,11 Lowe et al1 placed proximal tibial pins into cadaveric specimens and measured the distance from the pin to surrounding neurovascular structures. The closest structures were the anterior tibial artery (18 mm), deep peroneal nerve (24 mm), and superficial peroneal nerve (30 mm), although none were directly injured with pin placement. All structures were posterior to the trajectory of the pin. Therefore, the authors recommended taking care not to skive posteriorly during preparation or insertion of the pin. Moskovich11 also dissected cadaveric legs and described the 3-dimensional anatomy of the peroneal nerve and the anterior tibial artery. They found that the deep peroneal nerve was never more anterior than the posterior border of the tibia. Given the regional proximity of these neurovascular structures, careful neurovascular examination of the leg, both before and after traction placement, is imperative.

Proximal tibial traction pins are placed from lateral to medial to avoid the peroneal nerve. The starting point is 1 to 2 cm distal and 2 cm posterior to the tibial tubercle (Figure 1). This starting point has been described as safe for pin insertion1 and ensures bicortical transmedullary pin placement when the procedure is performed correctly (Figures 23). Under local anesthesia and mild sedation, a small longitudinal incision is made, and a large hemostat or clamp is used to spread down to bone. At the study institution, all skeletal traction pins are placed with a power drill and fully threaded Steinmann pins. Compared with smooth pins, fully threaded pins advance more easily through bone and are less prone to loosening/slipping once inserted.10 However, disadvantages include greater trauma to surrounding soft tissues and greater generation of heat when passing through bone because of the larger surface area.10 They are also more likely to bend when attached to the traction bow. These disadvantages are mitigated by careful dissection and spreading of soft tissue before pin placement and by slow and steady drilling. Larger-diameter Steinmann pins are used to prevent bending; however, this may come at the expense of excess heat generation.

Photograph showing the proper starting point for proximal tibial traction pin placement.

Figure 1:

Photograph showing the proper starting point for proximal tibial traction pin placement.

Photograph showing a properly placed proximal tibial traction pin.

Figure 2:

Photograph showing a properly placed proximal tibial traction pin.

Lateral radiograph showing bicortical transmedullary pin placement.

Figure 3:

Lateral radiograph showing bicortical transmedullary pin placement.

This study found a 2.0% (95% confidence interval, 0.55%–3.45%) incidence of neurovascular complications related to the placement of proximal tibial traction pins. All 7 cases involved motor and/ or sensory deficits (Table 2). No vascular complications were identified. All motor deficits identified in these cases involved the anterior compartment musculature, specifically, the tibialis anterior and extensor hallucis longus. Sensory deficits were in the distribution of the peroneal nerve, with all but 1 in the distribution of the superficial peroneal nerve. Of the 7 patients, 6 (86%) recovered full neurologic function before leaving the hospital, and no patient had complete loss of motor function and sensation in a specific distribution. The transient and incomplete deficits suggest that the affected nerve likely had either blunt or indirect injury, with resulting neuropraxia, as opposed to transection.

The neurologic complications observed in this study cohort have multiple potential explanations. At the study institution, residents are taught to feel anterior and posterior with the pin tip to identify an appropriate starting point in the center of the tibia in the coronal plane before driving the pin through the bone. Linn et al3 hypothesized that the complication observed in their case report likely arose from sliding or plunging too posterior while feeling with the pin or from an errant drilling attempt. Lowe et al1 found that the superficial and deep peroneal nerves were within 3 cm of the typical proximal tibial pin trajectory. Additionally, in that study, smaller 1.6-mm Kirschner wires were used and were inserted by an attending orthopedic trauma surgeon in a controlled setting. As a result, the distances that Lowe et al1 reported may be greater compared with those noted when traction is applied in the emergency department by residents with larger Steinmann pins.

The current study identified 6 cases (1.7%) of subsequently diagnosed multi-ligamentous knee injuries. For 1 patient who had peroneal nerve palsy after tibial traction, Liporace et al2 hypothesized that an incompetent lateral collateral ligament caused a traction-type injury to the peroneal nerve and a resulting foot drop.2 The nerve palsy resolved after traction was discontinued. In the current study, however, none of these 6 patients later had a neurovascular complication, and none of the patients with complications later had a multiligamentous knee injury. This is an important finding because these ligamentous injuries are considered a contra-indication to tibial traction. This finding suggests that tibial traction may still be safe, even in the setting of an undiagnosed multiligamentous knee injury. However, it is possible that the incidence of ligamentous knee injury was underreported in this study, and such injuries may have been present but undiagnosed in the complication cohort. Consequently, care should be taken to avoid applying tibial traction in the case of known or suspected multiligamentous knee injury.

Given these possible explanations, the authors recommend carefully selecting the starting point and minimizing soft tissue trauma before drilling. Before insertion, care should be taken to avoid plunging posteriorly when feeling the width of the tibia with the drill. Both before and after pin placement, careful neurovascular documentation should be performed to avoid attributing a neurologic deficit to the pin that was present on admission. Finally, it is important to maintain a high level of suspicion for multiligamentous knee injuries, given the possibility of causing a traction neuropathy in the setting of ligamentous instability.

Limitations

Limitations of this study are primarily related to its retrospective nature. The study relied on past clinical documentation to detect subtle nerve palsies, which made it difficult to eliminate reporting inconsistencies. For patients with traumatic injury in the acute setting, physical examination findings may vary between observers, and often initial and posttraction physical examinations are performed by different individuals. Therefore, observed complications may have been affected by inherent interobserver variability or by patient factors, such as varying levels of sedation and pain control. Additionally, it is possible that the nerve palsies identified in this study were related to the initial injury and either were not identified or did not manifest until after the traction pin was placed. Finally, neurovascular complications were identified based solely on physical examination, and confirmatory testing, such as electromyography, was not performed. Although the authors attempted to mitigate these limitations by flagging potential complications and performing a thorough chart review, the internal validity of the study could have been improved with prospective investigation.

Conclusion

The study findings suggest that bedside proximal tibial traction placement for femoral fractures is a low-morbidity procedure that can be safely performed in the emergency department by residents. The incidence of neurovascular complications was low, even in the setting of multiligamentous knee injury. A thorough neurovascular examination should be performed before pin insertion, and care should be taken to identify the proper starting point and reduce soft tissue trauma during pin placement.

References

  1. Lowe JA, Rister J, Eastman J, Friend J. Injury to neurovascular structures with insertion of traction pins around the knee. J Orthop. 2014; 12(suppl 1):S79–S82. doi:10.1016/j.jor.2014.04.013 [CrossRef]
  2. Liporace FA, Yoon RS, Kesani AK. Transient common peroneal nerve palsy following skeletal tibial traction in a morbidly obese patient: case report of a preventable complication. Patient Saf Surg. 2012; 6(1):4. doi:10.1186/1754-9493-6-4 [CrossRef]
  3. Linn MS, Indresano AA, Schwartz A. Popliteal artery pseudoaneurysm: an unusual complication of tibial traction. Am J Orthop (Belle Mead NJ). 2015; 44(5):E156–E159.
  4. Kirby CK, Fitts WT. The incidence of complications in the use of transfixion pins and wires for skeletal traction. Ann Surg. 1946; 123(1):27–31. doi:10.1097/00000658-194601000-00002 [CrossRef]
  5. Suri T, Dabas V, Sural S, Dhal A. Pseudoaneurysm of the anterior tibial artery: a rare complication of proximal tibial Steinmann pin insertion. Indian J Orthop. 2011; 45(2):178–180. doi:10.4103/0019-5413.77140 [CrossRef]
  6. Snyder RL, Buhr BR. Bilateral peroneal nerve injuries in a patient with bilateral femur fractures: a case report. J Orthop Trauma. 2000; 14(3):216–219. doi:10.1097/00005131-200003000-00014 [CrossRef]
  7. Althausen PL, Hak DJ. Lower extremity traction pins: indications, technique, and complications. Am J Orthop (Belle Mead NJ). 2002; 31(1):43–47.
  8. Moore TM, Patzakis MJ, Harvey JP Jr, . Ipsilateral diaphyseal femur fractures and knee ligament injuries. Clin Orthop Relat Res. 1988; 232:182–189.
  9. Cox CL, Spindler KP. Multiligamentous knee injuries: surgical treatment algorithm. N Am J Sports Phys Ther. 2008; 3(4):198–203.
  10. Matullo KS, Gangavalli A, Nwachuku C. Review of lower extremity traction in current orthopaedic trauma. J Am Acad Orthop Surg. 2016; 24(9):600–606. doi:10.5435/JAAOS-D-14-00458 [CrossRef]
  11. Moskovich R. Proximal tibial transfixion for skeletal traction: an anatomic study of neurovascular structures. Clin Orthop Relat Res. 1987; 214:264–268.

Characteristics of Included Patients

Characteristic Value No. of Complications P
Demographics .197a
  Sex, No.
    Male 218 (72%) 7 (3.2%)
    Female 85 (28%) 0 (0%)
  Age, y
    Average 37.4
    Range 10–102
Laterality, No. 1.00a
  Right 159 (52%) 4 (2.5%)
  Left 144 (48%) 3 (2.1%)
Fracture location, No. .599b
  Proximal 82 1 (1.2%)
  Shaft 200 5 (2.5%)
  Distal 21 1 (4.8%)

Description of Complications

Patient Age, y/Sex Side Mechanism Pre-Pin Examination Post-Pin Examination Complication Recovery Pin Duration, d


Motor Sensory Vascular Motor Sensory Vascular
36/M L MVA All 4/5 Normal Normal 3/5 TA Normal Normal Decreased TA Yes 0
53/M L Pedestrian struck Normal Normal Normal Normal Decreased dorsal sensation Normal Decreased dorsal sensation Yes 0
33/M R GSW Normal Normal Normal 0/5 EHL Decreased dorsal sensation Normal Loss of EHL, decreased dorsal sensation No 1
60/M L Fall from height Normal Normal Normal Normal Decreased dorsal sensation, 1st web space sensation Normal Decreased dorsal sensation, 1st web space sensation Yes 2
21/M R MVA Normal Normal Normal Normal Decreased dorsal sensation Normal Decreased dorsal sensation Yes 1
18/M R MVA Normal Normal Normal 3/5 TA Decreased dorsal sensation Normal Decreased TA, decreased dorsal sensation Yes 0
10/M R Pedestrian struck Normal Normal Normal 1/5 TA Normal Normal Decreased TA Yes 2
Authors

The authors are from the Department of Orthopaedic Surgery (GS, PG, MS, MR, MA), Rutgers New Jersey Medical School (PP), Newark, New Jersey; and the Department of Orthopaedic Surgery (KK), Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pennsylvania.

Dr Sobol, Dr Gibson, Mr Patel, Dr Koury, Dr Sirkin, and Dr Adams have no relevant financial relationships to disclose. Dr Reilly is a paid consultant for Stryker Orthopaedics.

Correspondence should be addressed to: Garret Sobol, MD, Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 90 Bergen St, 7th Fl, Ste 7300, Newark, NJ 07101-1709 ( gsobol118@gmail.com).

Received: April 11, 2017
Accepted: September 05, 2017
Posted Online: October 23, 2017

10.3928/01477447-20171012-04

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