Traction radiographs improve evaluation of complex intertrochanteric fractures: Surgeon experience-independent...

The role of traction radiographs in the preoperative evaluation of intertrochanteric femur fractures remains controversial, with inconsistent evidence regarding their impact on fracture classification, stability assessment, and surgical decisionmaking. This nationwide simulation-based study aimed to investigate how orthopedic trauma surgeons use and interpret traction radiographs and to determine their influence on surgical planning across different levels of clinical experience.

A nationwide, cross-sectional simulation-based study was conducted among actively practicing orthopedic and trauma surgeons between October 14 and November 15, 2025, using a structured questionnaire containing simulated cases. The questionnaire included demographic characteristics, clinical experience, perceptions of traction radiographs, and case-based assessments of 15 AO Foundation/Orthopaedic Trauma Association (AO/OTA)-classified intertrochanteric fractures (31-A1, 31-A2, 31-A3). A total of 133 surgeons participated, yielding 1,995 individual case evaluations. Changes in surgical decisions before and after traction radiographs were analyzed using McNemar tests, while independent predictors were identified using generalized estimating equations (GEE).

Traction radiographs were requested in 59.5% of all assessments, with significantly higher request rates in unstable patterns (31-A2: 75%; 31-A3: 68.2%) compared with 31-A1 fractures (30%). Overall, traction imaging resulted in a 12.4% change in surgical planning, increasing to 21% among cases in which traction radiographs were obtained. Decision changes were most common in 31-A2.3 (14.9%) and 31-A3.3 (16.9%) patterns. The most frequent implant transition was from short to long proximal femoral nail (PFN) (40.8%), followed by conversion to arthroplasty (18.8%). GEE analysis demonstrated that both fracture type and requesting traction radiographs were independent predictors of surgical plan modification (odds ratio [OR]=1.55-2.40 for unstable fracture types; OR=1.60 for traction radiograph request; p<0.05 for all). Surgeon title, institutional setting, years of experience, and case volume were not associated with decision changes.

Traction radiographs provide clearer visualization of fragment configuration and medial and lateral wall integrity, leading to improved recognition of fracture instability and a measurable shift toward more durable fixation strategies. Their impact on surgical planning is most pronounced in complex or borderline-unstable fracture patterns and remains consistent across experience levels. As a low-cost and readily accessible adjunct, traction radiography represents a valuable tool in the preoperative assessment of intertrochanteric fractures. Routine use is recommended, particularly when instability is suspected or when standard radiographs provide insufficient clarity.