Skin Traction - Lower Extremity

Buck's skin traction is widely used in the lower limb for femoral fractures, lower backache, acetabular and hip fractures. Skin traction rarely reduces a fracture, but reduces pain and maintains length in fractures.


The skin is prepared and shaved -it must be dry. Friar's balsam may be used to improve adhesion. The commercially available strapping is applied to the skin and wound on with an overlapping layer of bandage. The bandage should not extend above the level of the fracture.

      Bucks Traction
      Skin Traction
    Dangers of Skin Traction
  • Distal Oedema
  • Vascular obstruction
  • Peroneal nerve palsy
  • Skin Necrosis over bony prominence's

Avoid complications resist the temptation of trying to improve adhesion by wrapping the bandages more tightly. If the tapes slip rather use skeletal traction if possible (not a child)

Gallows Traction

This is used in infants and children with femoral fractures.

    Indications Gallows Traction

  • Child must weigh less than 12 kg
  • Femoral fractures
  • Skin must be intact
Gallows Traction

Both the fractured and the well femur are placed in skin traction and the infant is suspended by these from a special frame. Vascular compromise is the biggest danger. Check the circulation twice daily. The buttocks should be just off the bed.

Femur Fractures in older children

Older children with femur fractures can be treated with skin traction in a Thomas splint. Unlike the adult the knee must be kept straight in the Thomas Splint.

Skin traction in a Thomas Splint. Thomas Traction - Child

The ring of the Thomas splint must allow two finger clearance on all sides- try it on the well leg for fit before applying. The skin strapping is applied and the Thomas Splint fitted. The ropes from the strapping are tied to the end of the Thomas splint. The outer one is passed under the Thomas splint bar and the inner one Over. This rotates the foot internally. The limb is rested on three flannel strips secured by safety pins. The Master sling is the flannel strip directly distal to the fracture.

Master sling must be just distal to the fracture

Slings of flannel 150mm wide are positioned down the length of the Thomas splint. The Master sling should be just distal to the fracture, allowing the proximal fragment to reduce under gravity.

These slings can be adjusted so that he fracture ends align in the vertical plane. The longitudinal traction needs adjustment every day in the first week. The knot at the end of the Thomas splint is loosened and the slack taken up. The quality of reduction is confirmed by regular X rays.

Inner under outer over "Inner Under
Outer Over
for counter-torque

The Thomas splint is suspended from a Balkan Frame. This is a frame attached to the bed. To allow the patient to move about in the bed e.g. to use a bed pan. The limb with the Thomas splint is suspended from the top of the Thomas Splint by means of a counter weight. The longitudinal traction exerts pressure on the groin and a further weight is placed over a pulley on the balkan frame. It is in line with the long axis of the limb at the foot of the bed. This counter acts the reactive force on the groin generated by the skin traction.

Overgrowth Slight overlapping (up to 2 cm) of the bones is acceptable, as the fracture stimulates overgrowth in the local growth plates. End-on-end reduction, as with plating and other internal fixations, sometimes results in the injured limb growing more then the uninjured. Most of the overgrowth takes place in the first year after fracture.

Femur Fractures in Adults

This requires a skeletal pin.

At Tygerberg hospital the Denham pin is commonly used. This has a threaded middle portion that keeps it in the tibia. For femoral fractures the Denham Pin through the proximal tibia. Always insert from lateral to medial in the proximal tibia, as the peroneal nerve needs to be missed and the site of exit is unpredictable. On some occasions a distal femoral site, or even the calcaneus may be used.

Proxima tibial Denham pin site
Site for prox. tibial Denham pin 2.5 cm inferior and distal to tibial tubercle
Cross section of tibia at level of Denham pin

Adult - skeletal traction for Femur fracture
Thomas Traction -Adult
Click to see annotated larger image

A Thomas splint, (check it fits, by trying on the well leg) is applied. Three flannel slings are secured by safety pins under the thigh. The "Master splint" is the one under the fracture. The correct tension on this sling will align the fracture in the lateral plane. The knee can be flexed by using a Pearson flexion splint attached to the Thomas splint at the knee. The desired knee flexion can be maintained by a rope at its end leading from the Thomas splint to the Pearson attachment. Ropes from the Denham pin can either be tied distally to the Thomas splint (static traction) or they can be led over a pulley on the end of the Balkan frame (dynamic Traction) In either case start with 7 kg ( or 10% body weight) in the long axis of the femur. This opposes the pull of the thigh muscles. As with the child, the traction is made balanced by a system of pulleys on the horizontal limb of the Balkan frame to allow the patient to move his limb. A "monkey chain" hung above the arms also allows the patient to transfer himself onto a bedpan. as he moves in the bed.

Alignment of Thomas Splint

The Thomas splint must be aligned by pointing the Balkan frame in the direction of the proximal fragment.

Displacement - proximal femur fracture Displacement of a femur fracture
Muscles displacing the femur Muscles causing the displacement
Reduction obtained by aligning Thomas splint parallel to the proximal fragment How to align the Thomas Splint.
Also raise foot-end to provide flexion

Balkan frame adjustment
Balkan Frame Adjustment: For flexion, raise pulley (a). For abduction, swing foot-end of balkan wide of bed (b)

    Displacement - Proximal femur fracture
  • Prox. Femur - Flexion
  • Prox. Femur - Abduction
  • Align frame - Flexion & Abduction
Mid-shaft fractures remain relatively un displaced as the proximal and distal muscles balance.
    Distal femur fracture displacement
  • Posterior angulation - pull of gastrocnemius
  • Solution - flex the knee as far as possible

Bed Blocks

Bed Blocks must be placed under the foot end of the bed with all the above types of traction. Raising the foot of the bed a few centimeters provides a counter force to prevent the patient being pulled distally down the bed by the longitudinal traction.