Transient common peroneal nerve palsy following skeletal tibial traction in a morbidly obese patient - case report of a preventable complication

Historically, skeletal tibial traction had been used to definitively treat closed femur fractures [1]. However, as newer surgical options have been developed, skeletal tibial traction for definitive treatment of femur fractures has fallen out of favor for all but the medically debilitated and children below 6 years of age. Rather, the use of skeletal tibial traction as a temporizing measure in major trauma centers has increased [2].Common indications for the use of skeletal tibial traction include intertrochanteric femur fractures, subtrochanteric femur fractures, femoral shaft fractures, and length unstable distal femur fractures [2]. The goal of traction is to restore the original soft tissue envelope length, by restoring the original bony length to minimize bayoneting as an objective radiological guide [2]. Benefits of skeletal traction include reduction assistance during definitive fixation, reduced incidence of malunion, and avoidance of thigh compartment syndrome [3].Due to the high incidence of ipsilateral tibial fractures and knee injuries in patients with femoral shaft fractures, as well as the disastrous consequences of placing a tibial traction pin across incidental tumors in the tibial plateau; it is of vital importance that prior to insertion of a tibial traction pin these entities be ruled out with radiographs [4-6]. If uncertainty still exists, more advanced imaging modalities like computer tomographic (CT) and magnetic resonance imaging (MRI) must be obtained. MRI is especially good at identifying ligamentous knee injuries in cases that physical examination proves inconclusive, and should be considered as reported rates of ligamentous knee injuries associated with femur fractures are up to 33% [7].In addition, one must be aware of the local anatomy neighboring the site for tibial traction pin insertion. Structures at highest risk for injury include the peroneal nerve, anterior tibial artery, and proximal tibial physis in skeletally immature patients.