FRACTURE FEMUR

A. proximal
B. shaft
C. distal

A. PROXIMAL FEMUR FRACTURES

Intracapsular
1. Head of femur
2. Neck of femur
a) Subcapital
b) Transcervical
c) Basal

Extracapsular
1.Trochanteric fracture
a) Pertrochanteric fracture
b) Intertrochanteric fracture
c) Subtrochanteric fracture

Hip fracture risk factors

Caucasian women
Physical inactivity
Excessive alcohol intake
Use of psyschtropic meds
Senile dementia
Previous hip #

Intracapsular

fractures are important because of their propensity to damage the

small intracapsular vessels that provide the majority of the blood supply to the
femoral head
.Femoral neck fractures must therefore be diagnosed and treated appropriately in
order to reduce the morbidity from the consequences of devascularisation.
Femoral head fractures are rare intracapsular injuries, but are very different from
femoral neck fractures in that they do not cause disruption to the vessels that supply
blood to the femoral head. They usually occur secondary to femoral head
dislocation.
Fractures outside the capsule do not cause the same degree of vascular damage as
intracapsular fractures and therefore can be treated differently.
Problems associated with healing of intracapsular fractures elsewhere in the
body. No periosteal layer, all healing must be endosteal. Angiogenic-inhibiting
factors in synovial fluid - inhibit fracture repair
Pressure of the hemarthrosis can exceed the diastolic blood pressure and,
hence, embarrass the blood supply to the femoral head - intracapsular
tamponade

1) FEMORAL HEAD FRACTURES

A rare fracture
usually
with hip

Femoral Head Vascular Supply

1.) Extracapsular arterial ring
-branches of MFCA and LFCA
2.) Ascending cervical branches (retinacular arteries)
3.) Artery of ligamentum of teres

pattern that is
associated
dislocations

Pipkin Classification
Type I: Hip dislocation with fracture of the femoral head inferior to the fovea capitis
femoris (Not involving the weightbearing surface)
Type II: Hip dislocation with fracture of the femoral head superior to the fovea capitis
femoris (involving the weightbearing surface)
Type III: Type I or II injury associated with fracture of the femoral neck (an increased
risk of avascular necrosis)
Type IV: Type I or II injury associated with fracture of the acetabulum, usually the
posterior wall

2) FEMORAL NECK FRACTURES

Epidemiology
Commonest fracture in elderly
Women>Men, > caucasians
Common in women in 7&8th decades (>60yrs)

Risk factors
Bone weakening diseases
Osteoporosis
Osteomalacia
Chronic debilitating diseases
Diabetes
Disuse
Alcoholism
Mechanism of injury
1. Low-energy trauma: This is most common in older patients.

Direct: A fall onto the greater trochanter (valgus impaction) or forced external
rotation of the lower extremity impinges an osteoporotic neck onto the posterior lip of
the acetabulum (resulting in posterior comminution).

Indirect: Muscle forces overwhelm the strength of the femoral neck.

2. High-energy trauma: This accounts for femoral neck fractures in both younger
and older patients, such as motor vehicle accident or fall from a significant
height. # NOF in young adults: RTAs, fall from heights & are associated with
multiple injuries.
3. Cyclical loading-stress fractures: These are seen in athletes, military recruits,
and ballet dancers.
4. Insufficiency fractures: Patients with osteoporosis and osteopenia are at particular
risk. of injury
Anatomy

The upper femoral epiphysis closes by age 16 years.

Neck-shaft angle: 130 7 degrees
Femoral anteversion: 10 7 degrees
There is minimal periosteum about the femoral neck; any callus that forms must
do so by endosteal proliferation.
Calcar femorale: This is a vertically oriented plate from the posteromedial portion
of the femoral shaft radiating superiorly toward the greater trochanter.
The capsule is attached anteriorly to the intertrochanteric line and posteriorly 1 to
1.5 cm proximal to the intertrochanteric line.

Three ligaments attach in this region:

1. Iliofemoral: Y-ligament of Bigelow (anterior)
2. Pubofemoral: anterior
3. Ischiofemoral: posterior
Forces acting across the hip joint

Straight leg raise: 1.5 body weight

One-legged stance: 2.5 body weight
Two-legged stance: 0.5 body weight
Internal anatomy
The direction of the trabeculae parallels the direction of compressive forces. The
bony trabeculae are laid down along the lines of internal stress. There are two
trabeculae systems that cross each other at right angles.
i.
ii.

A set of vertically oriented trabeculae results from the weight-bearing forces

across the femoral head.
Horizontally oriented trabeculae result from the force of the abductor muscles.

Classification
Anatomic Location
Subcapital: femoral head/neck junction

Transcervical: midportion of femoral neck

Basicervical: base of femoral neck

Garden classification : Based on the degree of displacement on AP radiograph &

does not consider lateral/saggital plane
Type

Displacement

Extent

Alignment

Trabeculae

None

Incomplete

Valgus

Malaligned

None

Complete

Neutral

Aligned

Partial

Complete

Varus

Malaligned

Fully

Complete

Varus

Aligned, parallel

Pauwel classification: Based on vertical orientation of fracture line

Type I: <30 degrees ,Type II: 31 to 70 degrees Type III: >70 degrees

More vertical the line, more fracture instability. Horizontal line drawn through trans
tubercular plane on AP
Clinical presentation
Impacted or stress fractures; may lack deformity and they may be able to bear
weight. They may, however, demonstrate subtle findings, such as groin pain and
pain with axial compression
Displaced femoral neck fractures; typically non ambulatory on presentation
abduction (lateral rotation)
shortening
external rotation.

Pain is evident on attempted range of hip motion, with pain on axial compression,
and with tenderness to palpation of the groin.
An accurate history is important in the low-energy fracture that usually occurs in
older individuals.Obtaining a history of loss of consciousness, prior syncopal
episodes, medical history, chest pain,prior hip pain (pathologic fracture), and
preinjury ambulatory status is essential and critical indetermining optimal treatment
and disposition.
All patients should undergo a thorough secondary survey to evaluate for associated
injuries.
Radiological Evaluation
1) Radiographs
i. An anteroposterior (AP) view of the pelvis
ii. cross-table lateral view of the involved proximal femur are indicated ( frog
lateral is contraindicated)
iii. A physician-assisted internal rotation view of the injured hip is always helpful
to further clarify the fracture pattern and determine treatment plans.
iv. Full length ipsilateral femur

Shentons line disruption: loss of contour between normally continuous line

from medial edge of femoral neck and inferior edge of the superior pubic ramus

bone trabeculae angulated

lesser trochanter is more prominent due to external rotation of femur

femur often positioned in flexion and external rotation (due to unopposed

iliopsoas)

asymmetry of lateral femoral neck/head

sclerosis in fracture plane

smudgy sclerosis from impaction

nondisplaced fractures may be subtle on x-ray

2) CT scan

A computed tomography (CT) scan is of value in the trauma patient. Abdominal

pelvic CT cuts can be scanned for nondisplaced femoral neck fractures.
3) MRI
Magnetic resonance imaging (MRI) is currently the imaging study of choice in
delineating nondisplaced or occult fractures that are not apparent on plain
radiographs
Bone scans or CT scanning is reserved for those who have contraindications to MRI.
Treatment
Operative

a) Fatigue/Stress Fractures ( X-ray normal but visible on MRI/ bone scan)

Tension-sided stress fractures (seen at the superior lateral neck on an internally
rotated AP view). At significant risk for displacement; in situ screw fixation is
recommended.
Compression-sided stress fractures (seen as a haze of callus at the inferior neck)
At minimal risk for displacement without additional trauma; protective crutch
ambulation is recommended until asymptomatic. Surgery is reserved for painful,
refractory fractures.

b) Impacted/Nondisplaced Fractures ( Garden I & II) :

In situ fixation with two to three cancellous screws
Operative treatment almost always mandatory unless patient has advanced
dementia and little discomfort..
(Up to 40% of impacted or nondisplaced fractures will displace without internal
fixation & 5-15% develop osteonecrosis)
Exceptions are pathologic fractures, severe osteoarthritis/rheumatoid arthritis,
Paget disease, and other metabolic conditions.These conditions may require
prosthetic replacement.
c) Displaced Fractures (Garden III & IV)
i.

Young patient with high-energy injury and normal bone;

Hip screw with washers

Dynamic hip screw
Angled blade plate
Total hip replacement
Hemiarthroplasty

ii.

Urgent closed or open reduction with internal fixation and capsulotomy.

Primary total hip replacement ; Recent enthusiasm has been reported with
its use for acute treatment of displaced femoral neck fractures. It is
becoming the standard in active patients. Studies have reported better
functional results compared with hemiarthroplasty and internal fixation. It
eliminates the potential for acetabular erosion seen with hemiarthroplasty.

Elderly patients: Treatment is controversial. Open or closed reduction and

fixation may be considered, with a 40% reoperation rate in these patients.
Low demand and poor bone quality: Hemiarthroplasty using a cemented
unipolar prosthesis.
Severely ill, demented, bedridden patients: Consider nonoperative
treatment or prosthetic replacement for intolerable pain.
Conservative management

Non operative treatment for traumatic fractures indications

Patients who are at extreme medical risk for surgery; it may also be considered for
demented non ambulators who have minimal hip pain.
A) Children
Hip spica
Skin traction
B) Adults
Skeletal traction with 10% body weight
Pad underneath because gravity angulates fracture
Operative Treatment Principles
1. Multiple screw fixation: This is the most accepted method of fixation.
2. Sliding-screw and side plate devices: Improve resistance to shear forces in
a high Pauwel angle fractures.
3. Hemiarthroplasty & total hip replacement
Advantages over open reduction and internal fixation (ORIF)
It may allow faster full weight bearing.
It eliminates nonunion, osteonecrosis, and failure of fixation risks (>20% to
40% of cases
with ORIF require secondary surgery).
Disadvantages
It is a more extensive procedure with greater blood loss.
Bipolar versus unipolar implants
There is no proven benefit of bipolar implants over unipolar implants. Over
time, the bipolar implant may lose motion at its inner bearing and functionally
become
unipolar. A unipolar implant is a less expensive implant.
Cemented versus noncemented
There is a lower incidence of intraoperative fracture and less thigh pain.

There is a risk of intraoperative hypotension and death with pressurization of

cement.

COMPLICATIONS
Nonunion (ORIF): This is usually apparent by 12 months as groin or buttock pain,
pain on hip extension, or pain with weight bearing. It may complicate up to 5% of
nondisplaced fractures and up to 25% of displaced fractures. Elderly individuals
presenting with nonunion may be adequately treated with arthroplasty, whereas
younger patients may benefit from proximal femoral osteotomy.
Cancellous bone grafting or muscle pedicle graft has fallen out of favor.
Osteonecrosis (ORIF): This may present as groin, buttock, or proximal thigh pain; it
complicates up to 10% of nondisplaced fractures and up to 30% of displaced
fractures. Not all cases develop evidence of radiographic collapse. Treatment is
guided by symptoms. Risk of osteonecrosis may increase with increasing time to
fracture reduction. Furthermore, the quality of fracture reduction is believed to be a
more important factor.
Early without x-ray changes: Individuals may be treated with protected weight
bearing or possible core decompression.
Late with x-ray changes: Elderly individuals may be treated with arthroplasty,
whereas younger patients may be treated with osteotomy, arthrodesis, or
arthroplasty.
Fixation failure (ORIF): This is usually related to osteoporotic bone or technical
problems(malreduction, poor implant insertion). It may be treated with attempted
repeat ORIF or prostheticreplacement.
Prominent hardware may occur secondary to fracture collapse and screw backout
following fracture compression.
Dislocation (replacement): Total hip arthroplasty has a greater incidence than
hemiarthroplasty. Overall it is 1% to 2%.

TRACTION
TRACTION PROCEDURES
Traction has been used since Hippocratic times for the reduction of
fractures
and dislocations. Traction and counter traction still form the basis of
reduction of
fractures and dislocations under anesthesia. This is a traction of short
duration.
There are two types of long duration tractions.
1. Continuous traction
2. Intermittent traction
Continuous (sustained) traction: This is the traction applied over a
period of few
days or weeks. This is necessary in the management of many conditions
as given

below.
1. To maintain reduction of a fracture till the fragments are stable e.g.
Fracture shaft of femur.
2. Correction of a deformity due to muscle spasm e.g. skin traction
used in
the treatment of early stages of arthritis of the hip.
3. To immobilise an inflammed joint e.g. septic or tuberculous knee.
4. Spine: Cervical traction for reduction of cervical fracture dislocations
e.g. skull traction.
Intermittent Traction
This is the repeated application of traction of short duration of a few
minutes
to a few hours.
a) Cervical traction - for Cervical disc lesion and spondylosis with root
compression using
Cervical traction kit.
b) Pelvic traction - for Lumbar I.V.D. Lesion using Pelvic traction kit.
Types of Traction techniques
i.) Skin Traction e.g. Lower limb traction with the leg pulled by holding
the skin
of the whole leg with adhesive plaster as in the following methods.
a) Thomas splint traction.
b) Gallows traction.
c) Russel traction.
ii) Skeletal traction (Pin traction)
Here the leg is pulled by a pin through the bone. Common types are:
a) Upper tibial traction with Steinmann pin Upper tibial pin traction is
applied by passing a Stinmanns pin across the tibia 1/2" below the
tibial
tubercle.
b) Lower femoral traction with Steinmann pin passed across the femur
above the level of the condyles.
c) Lower trbial / calcaneal traction
d) Olecranon traction with K wire
e) Skull traction
Principles of Traction
The methods of traction are based on two principles described below.
1. Fixed Traction
In this method, traction is applied to the leg against a fixed point of
counter
pressure. This is done by the use of Thomas splint. The ring of the
splint is made
to hitch against the ischial tuberosity which acts as the point of counter
pressure
in the perineum.
2. Balanced Traction
In this method, while traction is applied to the leg to pull the distal
fragment
downward, the counter traction is effected by the body weight itself.
This is
achieved by resting the leg on a Thomas or Bohler Braun splint and
raising the
foot end of the bed. The leg is pulled either by skin traction or skeletal
traction.
2a. Russel Traction

This is a type of balanced traction where there is no splint. The leg is

held off
the bed with a sling at the knee level and resting on a pillow under the
calf. With a
compound system of pulleys and an overhead beam, below knee skin
traction is
applied and weights are hung at the end of the bed.

The skin can only take about 5kg traction in an adult. If more than this force is
required to obtain on maintain a reduction Skeletal traction must be used. Avoid
skeletal traction in children - growth plates can easily be damaged by skeletal
pins.
Indications for Skin Traction

Children
Temporary traction - only a few days e.g. Preoperative
Small force required to maintain reduction <5 kg

Fragile or delicate skin

In the elderly or patients with allergy to Elastoplast (Zinc)
hypoallergenic skin traction bandages are available.
Contraindications to Skin Traction

Force required > 5kg

Skin damage or sepsis in area

Indications Skeletal Traction

Adults requiring > 5kg traction

Skin damage requiring dressings
Long term

Counter Traction
Any force needs an opposing force. If traction pulls a limb distally the patient
will slide downwards towards the pulley, and the traction will not be effective.
Provide an opposing force by raising the foot of the bed on blocks. By sloping
the bed in the other direction the tendency to slide will be opposed. In Cervical
traction the front end of the bed needs raising, and with Dunlop traction
the side of the bed near the injury needs elevation.

Multiple Pulley Systems

In many situations multiple pulleys are used, so that less weights are necessary.
Multiple pulleys are commonly used in pelvic traction where high forces
(commonly up to 40 kg) may be needed.

Multiple pulleys decrease the force needed at the end rope

If a triple and double block were used as in the picture only 40/5 or 8 kg. would
be required to generate the 40 kg. lift needed.

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.
Method

The skin is prepared and shaved -it must be dry. Friar's balsammay 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.

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
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.
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.
Skin
tractio
n in a
Thom
as
Splint.

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.
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.

The Thomas splint is suspended from a Balkan Frame. This

is a frame attached to the bed. To allow the patient to move
"Inner Under
Outer Over"
for counter-torque

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.

Site for prox. tibial Denham pin 2.5 cm inferior and distal to tibial tubercle

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

Thomas Traction -Adult

Click to see annotated larger image

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 of a
femur fracture

Muscles causing the

displacement

How to align the

Thomas Splint.
Also raise foot-end to
provide flexion

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.

Halter Traction
Halter traction is used for short term cervical traction. Uses include minor neck
injuries without obvious fractures e.g. Whiplash injury, neck muscle spasm,
conservative
treatment
of
cervical
disk
lesions.

Children with cervical fractures can also be treated without skeletal pins as their
skull is too fragile to withstand pins.

Problems with Halter

Traction

Uncomfortable
Tempero-mandibular pain
Contraindicated in mandible fractures
Difficult to control flexion - extension

Flexion Extension cervical X-rays

If a patient has normal cervical X-rays, but has neck muscle spasmFlexion
Extension views may be needed to exclude serious instability of the cervical
spine. Halter traction is a good way to relieve the spasm before these X Rays can
be done. The patient is admitted and placed in Halter traction until the neck is
free of muscular spasm. Under direct supervision of the attending doctor the
flexion extension views are taken in the X ray department. The patient must have
no pain when the neck is flexed and extended. If neurological symptoms such as
parasthesia develop the X rays are abandoned.

Skull Traction
In more serious cervical injuries skull tongs such as Cones calipers are indicated.
Indications include the conservative treatment of cervical fractures and
dislocations.

Application of Cones Calipers

Shave the hair above the ear region

Local anaesthetic
Avoid masseter
Avoid Temporal artery
Small incision above ear in line with auditory meatus
Screw in pin until it just perforates outer table skull
Tie on rope

Attach weights
Position to apply the
Cone's Caliper pins in line with auditory
meatus

Direction and Weights

Force - 2.5 kg for head and 1/2 kg for each

vertebra*

Direction Neutral In line with Auditory meatus

Flexion needed - raise pulley

Extension needed - use double mattress ending

@ shoulders
*(Each uninvolved vertebra cephalad)

Complications of Cervical Traction

Bleeding - temporal artery

Pressure sore on skull - avoid downwards vector
to rope

Sepsis - from skin to subural abscess

Worsening neurological status

Squint from 6th craneal nerve fallout

Crutchfield tongs:
Allow the patient to be
easily turned, as the
caliper sits high on the
skull. Consider these in
a paralized patient.

Contraindications Skull Tongs

Children
Local sepsis
Skull fracture
The double mattress method is an effective way to extend the neck. Never place
the head pulley too low as a pressure sore can result on the occiput, especially in
the
unconscious
or
neurologically
compromised
patient.
At Tygerberg Hospital the Cone's calipers are commonly used. The Crutchfield
tongs are another caliper that fit higher on the skull vault and allow easier turning
of the paralised patient.

Reduction of Facet dislocations

Skeletal traction to the skull can be used to reduce cervical facet dislocations

Weights are serially

added while the neck is positioned in flexion After each 2.5kg weight is added a
lateral X ray is taken to determine reduction. The attending doctor checks for
neurological signs. If neurology deteriorates the weights are removed. Up to 20
kg. traction may be used in this way for a few hours only. After reduction the
neck is placed in extension and the lighter maintenance weights are used.

Dunlop Traction
The main use of Dunlop's traction is in the maintenance of reduction in
supracondyar fractures of the humerus in children.
Dunlop Traction

Supracondyar fractures in children

Allows swollen elbow to settle
Contraindicated in open fractures and skin defects

Skin traction is placed on the

forearm and A special frame
used on the side of the bed.
Traction is placed along the axis
of the forearm as well as at right
angles to the humerus by means
of a broad sling placed around
the upper arm. Bed blocks are
required on the lateral side
(fracture side up) of the bed.

If a supracondyar fracture
cannot be reduced to over 90
degrees elbow flexion, this
method of traction is an
alternative to invasive methods such as a percutaneous K-wires. It allows
swelling to subside. Do not rely on this method to reduce a supra condylar
fracture, a manipulation will still be required!

Pelvic traction for Backache

In sciatica and other backaches relief from pain can be obtained by means of
pelvic traction. Traction is applied to a pelvic harness with weights over the end
of the bed.

An alternative
in Sciatica is
the
90-90
position. By means of cushions under the knees, the hips are flexed near 90
degrees, as well as the knees. This shortens the sciatic nerve and relieves pain.

Acetabular Traction
In conservative treatment of acetabular fractures longitudinal traction in the long
axis of the limb is often used. In addition the head of the femur can be
disimpacted from the acetetabulum ( central fracture dislocations) by means of
manipulation under anesthesia. The reduction is maintained by means of lateral
traction from pins paced in intertrochanteric region.

Lateral Traction for an acetabular fracture