Traction tables are used in different types of procedures for the hip and femur, including fracture fixation, hip arthroscopy, and less-invasive arthroplasty. Although there is a relatively low incidence of traction table-related complications, usage is not without risks. Complications range from the relatively benign, such as transient postoperative groin numbness, to the catastrophic and life-threatening, such as injuries to the perineal integument and soft tissues, neurologic impairment, and iatrogenic compartment syndrome of the well leg. Although severe events are rare, they have serious implications to patient safety.
Reviewing the Current Literature
In the November 2010 Journal of the American Academy of Orthopaedic Surgeons, my colleagues and I published a review that assessed the medical literature relating to traction-table complications after surgery. In our analysis, several key themes emerged. First, greater awareness by surgeons of these events—especially for potentially catastrophic events—is critical to improving patient safety and quality. Second, certain positions on traction tables should be avoided—especially the hemilithotomy position—to avoid complications.
Third, efforts should be made to ensure that positioning and draping permit ongoing evaluation of the uninjured extremities and the overall condition of patients. For example, reduce the use of shower curtains or drapes since these make it difficult for surgeons to see the well leg or check the abdomen in trauma patients.
“Although there is a relatively low incidence of traction-table related complications, usage is not without risks.”
Specific types of patients and situations can increase the likelihood of traction-table complications. Patients with complex fracture patterns and older individuals appear to be at greater risk for these complications. Complex fractures often require longer surgery durations. This can put patients at increased risk for compartment syndrome or neurovascular injury. Elderly patients are at risk because they may have overall joint stiffness. Traction tables may force their limbs into extreme positions, such as wide abduction and external rotation. This can lead to muscle and joint damage. Although the complications suffered by elderly patients tend to be less significant, they can impact subsequent quality of life and are often preventable. Whenever possible, use freehand techniques instead of traction tables in young trauma patients, and use the scissor position in both elderly and younger patients instead of the hemilithotomy position.
Orthopedic surgeons who use traction tables for the surgical management of femoral shaft fractures should be familiar with the associated potential dangers and risks. Plans to avoid traction table-associated complications should be developed. These may include:
In addition, the experience of surgeons is critical to achieving good outcomes. Surgeons should feel comfortable asking other experts for assistance if they’re unsure about traction table use in their procedures.
Training is critical, and surgeons need to become aware that the use of traction tables can likely be avoided in many circumstances. Taking the time to learn more about traction-table complications will ultimately improve patient outcomes and decrease the personal and healthcare costs associated with these complications. My colleagues and I are planning to collaborate with the Orthopaedic Trauma Association to survey expert fracture surgeons. Our goal is to learn more about their use of traction tables to establish current trends and the incidence of complications. The hope is to use this information to develop strategies and better guidelines to enable optimal fracture care while minimizing patient harm.
Readings & Resources (click to view)
Flierl MA, Stahel PF, Hak DJ, Morgan SJ, Smith WR. Traction table–related complications in orthopaedic surgery. J Am Acad Orthop Surg, 2010:18;668-675. Available at:http://www.jaaos.org/cgi/content/abstract/18/11/668.
Stephen DJ, Kreder HJ, Schemitsch EH, Conlan LB, Wild L, McKee MD. Femoral intramedullary nailing: comparison of fracture-table and manual traction. a prospective, randomized study. J Bone Joint Surg Am. 2002;84-A:1514-1521.
Manderson EL, Nwaneri UR, Amin KB. The fracture table as a distraction mode in ankle arthroscopy.Foot Ankle Int. 1994;15:444-445.
Koval KJ, Oh CK, Egol KA. Does a traction-internal rotation radiograph help to better evaluate fractures of the proximal femur? Bull NYU Hosp Jt Dis. 2008;66:102-106.