A novel technique for traction table set up in extracapsular hip fractures to overcome fixed flexion deformities of both hip and knee

BACKGROUND

To achieve on-table limb traction traditionally, a supine patient has the uninjured limb in a lithotomy position. The injured limb is extended at the hip and knee; with traction and internal rotation applied via a boot strapped to the operated foot, allowing reduction of the fracture.

Fixed flexion of the hip and knee presents a logistical challenge of surgeons needing to perform traction-dependent procedures such as dynamic hip screw (DHS) fixation. Combined fixed flexion of the non-operated side presents a greater logistical difficulty as it prevents appropriate C arm positioning for fluoroscopy. Modification of C-arm positioning, as well as remote skeletal traction help to overcome these difficulties. Figure 1 shows the traditional patient position for DHS fixation.

Figure 1 .

Traditional patient position during DHS: taken from AO surgery reference https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/proximal-femur/femoral-neck-fracture-subcapital-displaced/orif-sliding-hip-screw#principles (cited October 2020). AO = ; DHS = dynamic hip screw.

TECHNIQUE

A Steinmann pin is inserted through the distal femur as an attachment point for traction. This is connected to a Bohler stirrup connected to the traction footplate (Figure 2).

Figure 2 .

Demonstration of the Bohler pin and stirrup positions. Taken intraoperatively with the patients consent.

The uninjured limb is still positioned in a Lloyd Davies boot accommodating fixed hip and knee flexion. The image intensifier is positioned on the surgeon’s side, allowing the image source (the smaller C arm component) to move under the drapes for lateral radiographs (Figure 3).

Figure 3 .

Demonstration of the image intensifier position. Taken intraoperatively with consent of the patient.

DISCUSSION

Modifications of traction table positioning have been previously described for above knee and below knee amputees, with ipsilateral proximal femur fractures.^1–4 However joint stiffness secondary to prolonged wheelchair use is less commonly encountered, and presents a bilateral rather than unilateral logistical difficulty. We recommend the described technique as an uncomplicated and cost-effective alternative means to apply traction, in patients fixed flexion lower limb deformity precluding normal traction table positioning.