Pre-operative traction for fractures of the proximal femur

Pre-operative traction following an acute hip fracture remains standard practice in some hospitals.

To evaluate the effects of traction applied to the injured limb prior to surgery for a fractured hip. Different methods of applying traction (skin or skeletal) were considered.

We searched the Cochrane Musculoskeletal Injuries Group trials register up to September 1999, MEDLINE (1966 to October 2000), CINAHL (1982 to August 2000), EMBASE (1980 to August 2000), CENTRAL (Issue 4, 2000 of The Cochrane Library), the National Research Register (Issue 3, 2000) and bibliographies of trial reports. Date of the most recent search: October 2000.

All randomised or quasi-randomised trials comparing either skin or skeletal traction with no traction, or skin with skeletal traction for patients with an acute hip fracture prior to surgery.

Both reviewers independently assessed trial quality, using a nine item scale, and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, the data are presented graphically.

Six randomised trials, mainly of moderate quality, involving a total of 938 predominantly elderly patients, were identified and included in the review. This review update includes a newly identified trial. The inclusion of this trial resulted in no important change in the results or conclusions. Five trials compared traction with no traction. The new study found a statistically significant reduction in rest pain in the traction group but did not indicate if this was clinically significant; there was no difference in analgesic use. The other four trials found no evidence of benefit from traction, either in the relief of pain, ease of fracture reduction or quality of fracture reduction at time of surgery. One of these trials included both skin and skeletal traction groups. This trial and one other which compared skeletal traction with skin traction found no important differences between these two methods, although the initial application of skeletal traction was noted as being more painful and most costly.

From the evidence available, the routine use of traction (either skin or skeletal) prior to surgery for a hip fracture does not appear to have any benefit. Where a policy of general or selective application of traction exists, the choice of method must remain a decision based on evaluation of the individual patient. Further, high quality trials would be required to confirm or refute the absence of benefits of traction.