Skin Traction in Children

Traction in children uses a sustained pulling force applied to a limb to maintain fracture alignment, reduce muscle spasm, relieve pain, and provide temporary stabilisation while awaiting definitive management or allowing soft tissue recovery. Skin traction — the application of traction via adhesive or non-adhesive foam strapping attached directly to the skin of the limb — is the standard method in young children, where the forces required are low and skeletal traction (pins through bone) is generally unnecessary and carries growth plate risks. Understanding the indications, contraindications, technique, and limits of skin traction is essential for safe paediatric orthopaedic practice.

• Types of traction: (1) Skin traction — traction applied via foam strapping or adhesive extensions attached to the skin surface; relies on friction between the skin and the traction material; maximum safe force approximately 3–4 kg (limit imposed by skin tolerance — skin breakdown, pressure sores, compartment syndrome risk); suitable for children under approximately 10–12 kg body weight or under 10 years of age; (2) Skeletal traction — traction applied via a Steinmann pin or K-wire placed through bone (typically distal femur for femoral fractures, proximal tibia for acetabular fractures, calcaneus for tibial/ankle fractures); allows higher forces (5–15 kg); used in older children, adolescents, and adults; carries the risk of physeal injury, growth disturbance, infection, and nerve injury
• Traction mechanics: traction force = countertraction (the patient`s body weight via the tilted bed) + gravity; the bed is tilted so that the child`s body weight provides countertraction; for femoral fractures, the leg is elevated (Gallows traction — see below) or extended with the knee slightly flexed on a Thomas splint; for skin traction to be effective, the pull must be in the line of the limb, the strapping must be applied evenly, and the traction cord must run freely over the pulley

• Gallows traction (also called Bryant`s traction): the most widely used form of skin traction in young children for femoral shaft fractures; both legs are suspended vertically from an overhead frame (`gallows`) with the hips flexed to 90° and the knees in slight flexion; the child`s buttocks are lifted just clear of the bed surface (the body weight provides countertraction via the trunk resting on the mattress); bilateral traction is applied even for a unilateral fracture to provide stability and prevent asymmetric pull on the pelvis; traction force is the child`s body weight working through the suspended limb
• Age and weight limit for Gallows traction: strictly limited to children under 2 years of age AND under 12–15 kg body weight; the critical safety concern is vascular — the vertical position of the limb combined with the traction force can compromise arterial flow to the foot; in heavier or older children, the vascular occlusion risk becomes unacceptable; `under 2 years, under 12 kg` is the widely cited clinical rule; older/heavier children with femoral shaft fractures are managed with spica cast (under 6 years), elastic stable intramedullary nailing (ESIN — 5–11 years), or rigid IM nailing (over 11–12 years in skeletally mature adolescents)
• Monitoring during Gallows traction: neurovascular observations of both feet every 1–4 hours; check capillary refill, dorsal foot pulse (dorsalis pedis — or Doppler probe), toe temperature, sensation, and movement; immediately take the child down from traction if any sign of vascular compromise — diminished pulses, cold foot, pallor, pain; do NOT delay — vascular occlusion in the suspended limb can cause Volkmann`s ischaemic contracture of the foot or limb loss
• Application technique: non-adhesive foam traction kit (preferred in children — avoids skin sensitivity reactions); the foam strapping is applied from the ankle to mid-thigh; avoid bony prominences (malleoli, tibial crest) — pad these before applying the strapping; the spreader bar at the ankle distributes the traction force evenly across both straps and prevents the straps from constricting the ankle; the traction cord runs from the spreader bar up over the pulley; ensure the strapping is smooth with no folds or ridges that create pressure points

• Thomas splint (fixed skin traction): used for femoral fractures in older children (typically 2–10 years) and occasionally in adults as a temporary first aid/transport device; a Thomas splint consists of a padded ring that fits around the upper thigh/groin and two metal rods that extend distally beyond the foot; skin traction strapping is applied to the lower leg and attached to the distal end of the splint frame; the ring provides countertraction against the ischial tuberosity (ring sits in the groin — the femur pushes the leg away from the body against the ring); the leg is supported by fabric slings threaded through the metal rods; the fractured femur is immobilised in the splint by the combination of traction and countertraction
• Hamilton-Russell traction: a form of balanced skin traction used for femoral fractures; a sling under the knee provides a vertical lifting force while horizontal skin traction is applied to the leg; the resultant force acts along the femoral axis; the resultant pull = approximately twice the hanging weight due to the pulley arrangement; used for hip conditions (DDH, Perthes` disease pre-operatively), proximal femoral fractures, and acetabular fractures awaiting ORIF
• Thomas splint as transport immobilisation: the most important use of the Thomas splint in modern trauma is as an immediate field/transport splint for femoral shaft fractures; it dramatically reduces blood loss, pain, and further soft tissue injury by immobilising the fractured femur during transport; Sager splint and Kendrick traction device (KTD) are modern alternatives used by paramedics; the principle is identical — distract the fractured femur against the countertraction of the ring in the groin

• Gallows traction: both legs suspended vertically; hip 90°; buttocks just off bed; bilateral application; STRICTLY <2 years AND <12–15 kg; risk = vascular occlusion → Volkmann`s ischaemia of foot; hourly neurovascular checks mandatory
• Thomas splint: ring in groin (countertraction from ischium); skin traction to distal end of splint; lateral rods support the limb; primary use now = emergency transport immobilisation of femoral fractures
• Paediatric femoral shaft fracture by age: <6 months = NAI exclusion mandatory (non-ambulant infant = abuse until proven otherwise); 6 months–2 years = Gallows or spica; 2–5 years = immediate spica; 5–11 years = ESIN (titanium elastic nails); >11 years = rigid IMN (trochanteric entry)
• ESIN (elastic stable intramedullary nailing): two nails, C-shape configuration, pre-bent to 3× the canal diameter; retrograde entry through distal femoral metaphysis; fills the canal eccentrically to provide stability; contraindicated in comminuted or length-unstable fractures and children >45 kg
• Acceptable deformity in paediatric femoral fractures: up to 2 cm shortening; up to 15° sagittal angulation; up to 10° coronal angulation; up to 10–15° of malrotation in under-5s; remodelling corrects deformity at a rate of ~1° per month in the plane of joint motion
• Peroneal nerve palsy prevention: always pad the fibular head; avoid direct pressure of traction strapping over the fibular neck; test dorsiflexion and eversion at every neurovascular check
• Skin traction force limit: approximately 3–4 kg maximum; beyond this, skin breakdown occurs; this is why skin traction is only suitable for young, light children; skeletal traction via Steinmann pin is needed for higher forces (older/heavier children and adults)