Do Not Apply Preoperative Traction for Intertrochanteric Fractures
Preoperative traction should NOT be used for patients with intertrochanteric fractures prior to surgery. This is a strong recommendation based on high-quality evidence from the 2022 AAOS Clinical Practice Guideline 1, 2.
The Evidence is Clear and Definitive
The American Academy of Orthopaedic Surgeons issued a strong strength recommendation against preoperative traction, meaning practitioners should follow this unless there is a clear and compelling rationale for an alternative approach 2. This recommendation applies to all hip fractures, including intertrochanteric fractures specifically.
Why Traction Doesn't Help
The evidence demonstrates that preoperative traction (either skin or skeletal) provides:
- No meaningful pain relief in the immediate preoperative period 3, 4, 5
- No improvement in fracture reduction quality at time of surgery 4
- No reduction in analgesic requirements in most studies 3, 5
- No benefit for surgical outcomes or fracture healing 4, 5
The Research Details
A 2023 randomized controlled trial of 154 patients with isolated intertrochanteric fractures found no significant differences in Visual Analogue Scale (VAS) pain scores or morphine dosage between traction and no-traction groups 3. A comprehensive 2011 Cochrane review analyzing 1,654 patients across 11 trials concluded that routine traction use has no apparent benefit 4.
Minor Exception Worth Noting
One retrospective study suggested that traction applied for more than 24 hours may provide some pain relief when surgery is significantly delayed 6. However, this contradicts the guideline recommendation and represents lower-quality evidence. Given that modern hip fracture care emphasizes surgery within 24-48 hours 2, this scenario should be rare.
What to Do Instead
Focus on multimodal analgesia with peripheral nerve blocks (strong recommendation) 1, 2. Specifically, iliofascial or fascia iliaca blocks provide effective pain control while awaiting surgery and are strongly supported by evidence.
Common Pitfalls to Avoid
- Don't apply traction "because we've always done it" - the evidence doesn't support this practice
- Don't confuse preoperative traction (for pain/immobilization) with intraoperative traction on a fracture table (which may still be used during surgical reduction)
- Recognize that traction carries minor risks including skin blisters and sensory disturbances 4
The bottom line: Skip the preoperative traction, expedite surgery to within 24-48 hours, and use nerve blocks for pain control 1, 2.