Nonoperative treatment - Temporary traction

Traction is an option for initial treatment of unstable, displaced distal tibial fractures, especially in fractures with Tscherne grade I and II closed soft-tissue damage. Except where surgical treatment is not available, traction is inappropriate for definitive treatment of distal tibial fractures. This is because it requires prolonged bed rest and may not achieve an adequate reduction.

A 4 mm Steinmann pin, centrally threaded if available, is inserted from medial to lateral through the calcaneal tuberosity. It is vital to avoid the posterior tibial neurovascular bundle behind the medial malleolus. A 2 mm K-wire may also be used, but it will require a tensioning clamp.

The posterior tibial pulse should be located; if this is not clearly palpable, due to swelling, the pulse of the uninjured leg should be palpated and used as a reference guide to find it at the injured side.

The fracture is aligned, and reduction is maintained by applying 3-5 kg traction through an appropriate clamp on the pin or K-wire. Mild to moderate elevation of the injured limb helps control swelling. Adequate padding under the calf, to avoid heel pressure, is necessary to avoid skin breakdown. Trendelenburg positioning provides counter traction and prevents the patient from sliding down the bed. Traction should not be maintained longer than necessary, i.e., until local soft-tissue situation permits definitive treatment.

The supporting frame or pin/wire clamp should not compress the skin.

Apply dressings as needed. Pin-site care is provided according to the surgeon's routine.

Note: Watch for pin-site infection. If infection occurs, and definitive internal fixation is not yet possible, pins must be replaced using new insertion points in a safe distance to the infected pin track. Pin-track infections may compromise definitive surgical treatment.