Passage Of Guidewire Research Articles

Prospective Randomized Clinical Trial Investigating the Effect of the Reamer-Irrigator-Aspirator on the Volume of Embolic Load and Respiratory Function During Intramedullary Nailing of Femoral Shaft Fractures.

We sought to determine whether the use of the Reamer-Irrigator-Aspirator (RIA) device resulted in a decreased amount of fat emboli compared with standard reaming (SR) when performing intramedullary (IM) nailing of femoral shaft fractures. Prospective randomized clinical trial. Multi-centered trial, level I trauma centers. All eligible patients who presented to participating institutions with an isolated femoral shaft fracture amenable to fixation with antegrade IM nailing. Thirty-one patients were enrolled: nine were excluded because of technical difficulties with the transesophageal echocardiogram (TEE) recording. Therefore, the study comprised 22 patients: 11 patients randomized to the SR group and eleven patients randomized to the RIA group. Antegrade IM nailing of a femoral shaft fracture with standard reamers or the RIA device. All patients were monitored intraoperatively with a continuous TEE to assess embolic events in the right atrium. A radial arterial line was used to monitor blood gases and potential systemic effects of emboli. Duration, size, and severity of emboli as measured by TEE. The operative procedure was divided into 6 distinct stages: preoperative, reduction, guidewire passage, reaming, nail insertion, and postoperative. There was no significant difference in emboli between the RIA and SR groups preoperatively, during fracture reduction, guidewire insertion, or postoperatively. Measured with a standardized scoring system, there was a modest reduction in total emboli score in the RIA group during reaming (SR 5.30 [SD; 1.81] vs. RIA 4.05 [SD; 2.19], P = 0.005) and during nail insertion (SR 5.09 [SD; 1.74] vs. RIA 4.25 [SD; 1.89], P = 0.03). We were unable to correlate this reduction with any improvement in physiologic parameters (mean arterial pressure, end-tidal CO2, O2 saturation, pH, paO2, and paCO2). This study showed a modest reduction of embolic debris during the reaming and nail insertion segments of the operative procedure. We were unable to correlate this with any change in physiologic parameters. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

How to Improve Cannulation Rates During Endoscopic Retrograde Cholangiopancreatography

How to Improve Cannulation Rates During Endoscopic Retrograde Cholangiopancreatography

Percutaneous biliary approach as a successful rescue procedure after failed endoscopic therapy for drainage in advanced hilar tumors.

Palliative endoscopic or percutaneous biliary drainage is used for unresectable advanced hilar cancer (HC). The best option for drainage in Bismuth type III or IV HC has not been established. The aims of this study are to identify factors predictive of endoscopic stenting failure and evaluate the effectiveness of rescue percutaneous stenting in patients with advanced HC. Data from 110 patients with inoperable advanced HC were retrospectively reviewed. All received bilateral self-expandable metallic stents. Patients were divided into three groups: I, successful initial endoscopic stenting; II, unsuccessful initial endoscopic stenting, followed by percutaneous stenting; and III, initial percutaneous stenting. We analyzed clinical results and radiologic tumor characteristics. Baseline characteristics and clinical outcomes of all groups were similar, except the hospital stay was longer in group III than group I. Technical success rate was higher in groups II and III (100%) than in group I (72.4%). The functional success rate, stent patency time, patient survival time, and complication rate were similar between groups. Endoscopic stenting failed because of guide-wire passage failure (n = 12) or stent passage failure (n = 7). The only factor significantly associated with endoscopic failure was a smaller left intrahepatic duct-common bile duct angle. As clinical outcomes were generally similar between approaches, percutaneous stenting is recommended for patients with Bismuth type III or IV advanced HC. Acute left intrahepatic duct-common bile duct angulation predicts endoscopic stenting failure. If endoscopic stenting fails, immediate conversion to the percutaneous approach is a necessary and effective rescue method.

A pitfall in selecting promising septal collateral channels in percutaneous coronary intervention with a retrograde approach

Introduction: In percutaneous coronary intervention (PCI) with a retrograde approach, successful guide wire passage through the collateral channels is indispensable. However, success of the procedure depends on the quality of collateral channels, and vascular tortuosity is one of the most common obstacles for successful guidewire passage. Case Presentation: Herein, we present a case of PCI with retrograde approach for chronic total occlusion at the ostium of the left anterior descending coronary artery. A highly tortuous morphology of the right posterior descending artery (PDA) and septal channels bifurcating from the right PDA with marked angulations were recognized in angiographic images from multiple directions. We could advance a guidewire to the optimal route of the septal collateral channel with guidance provided by these images and successfully completed all PCI procedures. Conclusions: To pass a guidewire through collateral arteries in PCI with a retrograde approach, careful inspection of angiographic images for thoroughly understanding the optimal route through the collateral vasculature is of great significance.

ERCP through a gastrojejunal lumen-apposing stent.

Figure 2. Fluoroscopic view showing passage of guidewire into the distal duodenum. We present a case of an 84-year-old man who had received a diagnosis of pancreatic head adenocarcinoma 2 years earlier. At that time, he had received bile and pancreatic duct stents with resolution of jaundice and improvement in diarrhea. Over the past month, the patient started experiencing epigastric pain, nausea, and vomiting. Cross-sectional imaging demonstrated no significant change in pancreatic mass size, with intact stents and stable pneumobilia. An upper endoscopy was then performed, demonstrating narrowing of the second portion of the duodenum with inability of the endoscope to traverse this segment. Contrast medium was injected into the duodenal bulb and showed evidence of severe narrowing of the second portion of the duodenum (Fig. 1). A long ERCP guidewire was advanced through the upper endoscope past the duodenal narrowing and looped in the distal duodenum (Fig. 2). The endoscope was then withdrawn while the guidewire was maintained in place. A dilation balloon was advanced over the guidewire into the distal duodenum and inflated to 18 mm (Fig. 3). A linear echoendoscope was then advanced into the stomach. The dilated balloon was identified and punctured with a 19-gauge needle and immediate dissipation of contrast medium into the small intestine was observed (Fig. 4). Another guidewire was advanced through the 19-gauge needle into the small intestine. A Boston-Scientific (Marlborough, Mass) electrocautery-enhanced Axios stent was then deployed over the guidewire into the lumen of the small intestine (Fig. 5). The stent was then dilated with a 13.5-mm dilation balloon (Fig. 6). The final endoscopic and fluoroscopic appearance appeared satisfactory. The patient did well after the procedure, with resolution of symptoms, and was discharged the next day after tolerating a regular diet. However, the patient presented about 2 weeks later with right upper-quadrant pain, fever, and an increase in bilirubin from 0.4 to 2.6 mg/dL. A transabdominal US showed worsening intrahepatic biliary dilatation. Intravenous antibiotics were started, with improvement in symptoms but persistence of laboratory abnormalities. We then discussed with the patient the options of percutaneous drainage, EUS-guided hepaticogastrostomy, or an attempt at exchanging the stent through the newly placed Axios stent. The patient opted for an endoscopic

Patterns of ST segment resolution after guidewire passage and thrombus aspiration in primary percutaneous coronary intervention (PPCI) for acute myocardial infarction

BackgroundST segment elevation allows the rapid identification of patients with acute myocardial infarction who benefit from emergency reperfusion. Primary percutaneous coronary intervention (PPCI) has emerged as the preferred perfusion strategy...

SpyGlass cholangioscopy-assisted guidewire placement for post-LDLT biliary strictures: a case series.

Anastomotic biliary strictures are common in patients that undergo living donor liver transplantation. Although endoscopic management has the advantage over percutaneous approaches, the initial success rate for the endoscopic management is unsatisfactory. The SpyGlass system can be a useful device in patients with a severe anastomotic stricture. The SpyGlass cholangioscopy-assisted guidewire placement was performed in 15 patients with a difficult guidewire placement in which the guidewire could not transverse the stricture with conventional methods for 10min or more. The visualization rate of the stricture orifice was 93.3% (14 of 15 patients). The total success rate of the SpyGlass cholangioscopy-assisted guidewire placement was 60% (9 of 15 patients). No procedure-related complications occurred during or after the SpyGlass cholangioscopy-assisted guidewire placement. This series demonstrated that the SpyGlass cholangioscopy-assisted guidewire placement is a useful method when the guidewire passage of the strictures site is impossible by conventional methods.

A guidewire introducer as a ureteral foreign body: A case report.

A 63-year-old male, previously treated for a ureteral tumour by a right-sided segmental ureterectomy and end-to-end anastomosis of ureteral segments, was referred to our clinic for endoscopic follow-up. During his follow-up, he was diagnosed with partial right-sided ureteral stricture which eventually progressed to complete obstruction. During the ureteroscopy, as the stenotic segment did not allow passage of an hydrophilic guidewire, an antegrade-retrograde approach was decided. On the antegrade endoscopic view, a near-complete stenosis was diagnosed and a nephrostomy catheter (12 Fr) was placed. A second intervention was planned and from the nephrostomy tract, the ureteroscope was placed into the right pyelocaliceal system. The diagnostic ureteroscopy revealed a foreign object proximal to the stenotic area. Right-sided segmental ureterectomy of the stenotic segment with ureteroneocystostomy and removal of the foreign object was performed. This is the only case in literature to reveal a guidewire introducer as a ureteral foreign body. This case also highlights the importance of the fragility of the ureter, the importance of the equipment, of always being watchful during a surgery, and the importance of checking the integrity of the equipment at the end of each procedure.

High-grade culprit lesions are a common cause of ST-segment elevation myocardial infarction.

Conventional knowledge holds that the majority of ruptured atherosclerotic plaques causing ST-segment elevation myocardial infarction (STEMI) are found in moderate stenoses that produce < 50% loss of arterial diameter. This study aimed to analyse the culprit lesions in patients who presented with STEMI and underwent primary percutaneous coronary intervention (PPCI) at our institution. Patients who underwent PPCI between June 2008 and August 2010 at our institution were included in the analysis. Quantitative coronary angiography was performed for the culprit lesions immediately after antegrade flow was restored by thrombectomy, low-profile balloon predilatation or guidewire crossing. A total of 1,021 patients were included in the study. The mean age was 57 ± 12 years and 85.2% were male. Lesion measurement was done after coronary flow was restored by thrombectomy (73.1%), balloon dilatation (24.1%) and following guidewire passage across the lesion (2.8%). Mean minimal luminal diameter was 1.1 ± 0.5 mm, mean reference vessel diameter was 2.8 ± 0.6 mm, mean diameter stenosis was 61 ± 16% and mean lesion length was 16 ± 6 mm. Most (80.2%) of the culprit lesions had diameter stenoses > 50% (p < 0.01). Although balloon angioplasty was performed in 24.1% of the patients, the majority (64.2%) still had diameter stenoses > 50%. High-grade stenoses (> 50%) were more frequently observed in male patients (p = 0.04). Contrary to the existing paradigm, we found that most of the patients with STEMI in our institution had culprit lesions with diameter stenosis > 50%.

Ultrasound-guided percutaneous central venous catheterization in infants: Learning curve and related complications.

Background:This study was performed to evaluate the learning curve and related complications of ultrasound (US) guided central venous catheter (CVC) insertion in infants.Materials and Methods:This study was performed in Imam Hosein Hospital of Isfahan from September 2014 to March 2015. Participants were infants consecutively candidate for CVC insertion. Three steps were designed to complement the learning. For each step of learning, 20 patients were considered and for every patient one CVC was inserted: (1) In the first step, venous puncture and guide wire passage was performed by an experienced radiologist and the surgeon was taught how to do it, then CVC was placed by the surgeon. (2) In the second step, venous puncture and guide-wire passage was performed by the surgeon under the supervision of the same radiologist, and then CVC was placed by the surgeon. (3) In the third step, US-guided CVC insertion was performed by the surgeon completely, and the radiologist came to the operating room only if it was necessary. In each of these steps, the time spent of the US probe on the skin until the guide wire passage into the vein was recorded for every patient. All perioperative complications were recorded.Results:The mean point for the time spent of the US probe on the skin until the guide wire passage into the vein was 84.9 ± 13.6, 119.1 ± 15.2, and 90.3 ± 11.2 s in the step 1, 2 and 3, respectively (P = 0.04). There was no significant difference between the frequencies of complications among tree steps.Conclusion:US-guided percutaneous CVC insertion is a safe and reliable method which can be easily and rapidly learned.

Difficult cannulation as defined by a prospective study of the Scandinavian Association for Digestive Endoscopy (SADE) in 907 ERCPs

Background. The definition of a “difficult” cannulation varies considerably in reports of endoscopic retrograde cholangiopancreatography (ERCP). Aims. To define a difficult cannulation, which translates into higher risk of post-ERCP pancreatitis. Patients and methods. Prospective consecutive recording of 907 cannulations in Scandinavian centers done by experienced endoscopists. Inclusion: indication for biliary access in patients with intact papilla. Exclusion: acute non-biliary and chronic pancreatitis at time of procedure. Results. The primary cannulation succeeded in 74.9%, with median values for time 0.88 min (53 s), with two attempts and with zero pancreatic passages or injections. The overall cannulation success was 97.4% and post-ERCP pancreatitis (PEP) rate was 5.3%. The median time for all successful cannulations was 1.55 min (range 0.02–94.2). If the primary cannulation succeeded, the pancreatitis rate was 2.8%; after secondary methods, it rose to 11.5%. Procedures lasting less than 5 min had a PEP rate of 2.6% versus 11.8% in those lasting longer. With one attempt, the PEP rate was 0.6%, with two 3.1%, with three to four 6.1%, and with five and more 11.9%. With one accidental pancreatic guide-wire passage, the risk of the PEP was 3.7%, and with two passages, it was 13.1%. Conclusions. If the increasing rate of PEP is taken as defining factor, the wire-guided cannulation of a native papilla can be considered difficult after 5 min, five attempts, and two pancreatic guide-wire passages when any of those limits is exceeded.

Renal Subcapsular Hematoma after Percutaneous Transfemoral Angiography

Vascular complications after percutaneous angiography include hematoma, pseudoaneurysm, arteriovenous fistula, thromboembolism, arterial laceration and infection. Hematomas may occur in the groin, thigh, retroperitoneal, intraperitoneal, or abdominal wall. A 54-year-old female underwent percutaneous transfemoral angiography for the evaluation of cerebral aneurysm. Renal subcapsular hematoma developed 3 hours after the procedure. Renal subcapsular hematoma after percutaneous angiography is very rare. We investigated the possible causes of renal subcapsular hematoma. To avoid this rare complication, we need to perform guide-wire passage carefully from the beginning of the procedure under full visual monitoring.

Response to Letter Regarding Article, “Histopathology of Embolic Debris Captured During Transcatheter Aortic Valve Replacement”

Transcatheter aortic valve replacement (TAVR) involves the introduction of a large-bore catheter system into a major artery or the left ventricle and the passage of guidewires, temporary pacemakers, balloons, and the valve-containing delivery system through the vascular bed to enable the delivery and eventual deployment of a previously crimped bioprosthesis in the aortic root. Appropriate anticoagulation is mandatory to minimize thrombus formation throughout the course of this relatively complex procedure. Fanning and colleagues, just as we were, are surprised by the relatively high thrombotic load captured in the embolic protection filters during TAVR. We reported suboptimal activated clotting times not reaching the intended target of 250 to 300 seconds that might have contributed to these findings.1 In our understanding, no consensus guidelines have so far formally recommended target activated clotting time levels >300 seconds. Indeed, the referenced American College of Cardiology Foundation/American Association for Thoracic Surgery/Society for Cardiac Angiography and Interventions/Society of Thoracic Surgeons expert consensus document on TAVR reads …

A case of CTO treated with minimum use of contrast media

The retrograde approach is a novel technique for improving the success rate of guidewire passage through chronic total occlusion (CTO). In addition, this technique, especially when intravascular ultrasound-guided reverse controlled antegrade and retrograde subintimal tracking is employed, may help the operator to save on the contrast media used. In the case reported here, only 10 ml of contrast media was used in percutaneous coronary intervention for CTO.

Endoscopic ultrasound-guided cholangiography and intraluminal needle puncture through a tight subhilar bile duct stricture for biliary stenting following failed ERCP

Endoscopic therapy by endoscopic retrograde cholangiopancreatography (ERCP), stricture dilation, and sequential multiple stent placement is the standard treatment option for benign biliary strictures, and has favorable results [1]. Occasionally, tight biliary stricture can pose a technical challenge by not allowing the guide wire to pass. Recently, endoscopic ultrasound (EUS)-guided biliary access has been shown to be safe and successful in cases of failed ERCP due to inability to cannulate [2]. It is not known whether the EUS-guided rendezvous procedure also facilitates guide wire passage across difficult strictures. We report a case of post-cholecystectomy subhilar stricture in which ERCP-guided passage of the guide wire across the stricture was unsuccessful. Hence, EUS-guided cholangiography was carried out followed by intraluminal needle puncture of the stricture with a 18-gauge needle device to pass the guide wire, with completion of the ERCP and stenting.

Transurethral neo-orifice (TUNO) a novel technique for management of upper pole obstruction in infancy

Ureteral duplication is the most common urologic abnormality. The upper pole ureter can sometimes be associated with a ureterocele. In rare cases the ureteral insertion is extravesical and can result in significant hydroureteronephrosis. Patients can present with urinary tract infection, abdominal mass or urinary obstruction. Traditional procedures include ureteral reimplantation, ureteroureterostomy or heminephroureterectomy. These reconstructive procedures are technically challenging in small infants, especially when the hydroureteronephrosis is severe. In some cases a distal cutaneous ureterostomy is performed for immediate drainage followed by definitive surgery when the child is older. We describe our initial experience with a novel cystoscopic technique which provides drainage of the upper pole ureter and avoids the need for an incision or stoma. A 3 month-old boy presented with urinary tract infections and failure to thrive. Ultrasound revealed severe upper pole hydroureteronephrosis. Voiding cystourethrography did not reveal vesicoureteral reflux or the presence of a ureterocele. The patient underwent cytoscopy. The ectopic ureteral orifice was not identified. A transurethral, transvesical needle puncture and confirmatory ureteropyelography was used to access the dilated upper pole ureter. Guidewire passage, followed catheter dilation then allowed creation of a new ureteral orifice using a holmium laser. The patient tolerated the procedure well. He was discharged after overnight observation. The hydronephrosis improved, urinary tract infections have not recurred and the patient rapidly improved feeding and weight gain. Trans-Urethral Neo-Orifice creation is a minimally invasive option for initial decompression for patients with obstructive ureteral ectopia.

A prospective randomized study of thin versus regular-sized guide wire in wire-guided cannulation

Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable tool in the diagnosis and management of various pancreatobiliary disorders. Our aim was to evaluate whether the combination of a thin guide wire and a thin sphincterotome would facilitate selective cannulation of the bile duct and reduce the incidence of post-ERCP pancreatitis (PEP) by reducing papillary trauma when compared with a regular-sized hydrophilic guide wire. Between June 2011 and February 2012, we performed 100 biliary cannulations for a native papilla in a randomized controlled trial. Having given their written informed consent, patients were randomly assigned to a 0.025-inch guide wire and sphincterotome group (n = 50) or to a 0.035-inch guide wire and sphincterotome group (n = 50). Number of cannulation attempts, number of accidental guide wire passages into the pancreatic duct, secondary cannulation techniques after failed primary cannulation, time to change the technique, and time for successful cannulation were collected in a database. Patients were followed up after ERCP, and all post-ERCP complications were recorded. Primary cannulation was successful in 80 %. With accessory techniques, cannulation of the biliary duct was achieved in every case except one. There was no difference in primary cannulation rate between the 0.025-inch and 0.035-inch wire groups (n = 40 in each group). PEP was diagnosed in two patients (2.0 %), one in each study group. Postsphincterotomy bleeding occurred in one patient (1.0 %). The thickness of the hydrophilic guide wire does not appear to affect either the success rate of primary cannulation or the risk of complications.

Clinical Implications and Applications of the Twinkling Sign in Ureteral Calculus: A Preliminary Study

Twinkling is an artifact seen on color Doppler ultrasound as a rapidly changing mixture of red and blue behind a stationary echogenic structure. We studied the presence or absence of this artifact in ureteral calculi detected on ultrasound and correlated it with clinical parameters. We evaluated 284 ureteral calculi seen on color Doppler ultrasound. The twinkling artifact was graded as 0 to 2 and correlated with the presence or absence of pain, symptom duration, degree of hydronephrosis and passage of a Glidewire® guidewire across the ureteral calculus during ureterorenoscopy. The presence or absence of twinkling was not associated with the degree of hydronephrosis. Twinkling was absent in 92% of patients with significant pain and grade 2 twinkling was seen in 69.5% without significant pain. Twinkling was dominantly absent in patients with a recent colic episode, while 77% who presented 2 to 15 days after a colic episode had grade 2 twinkling. The guidewire was difficult to pass in cases with absent twinkling compared to those with grade 2 twinkling, in which the guidewire and ureteral catheter crossed the calculus easily. Absent twinkling is associated with significant pain, a recent colic episode and difficult guidewire passage across the calculus. These findings suggest that absent twinkling implies significant obstruction, while its presence indicates no significant obstruction.

Post-OLT Anastomotic Strictures with Apparent Total Occlusion: Looks Are Deceiving

Purpose: Post-orthotopic liver transplant (OLT) strictures are diagnosed and managed by endoscopic retrograde cholangiopancreatogram (ERCP) and managed with dilation and stenting. We describe a series of cases of anastomotic strictures with apparent total occlusion that were successfully managed non-operatively. Methods: We reviewed all ERCPs done at a single tertiary care hospital between December 2008 and November 2011, and identified patients who were post-OLT and had total obstruction at the biliary anastomosis on ERCP. Total obstruction was defined as no contrast flowing proximal to the anastomosis on balloon occlusion injection and inability to pass a guide wire (Jag, glide). A total of 6 patients were found to meet our criteria. Data was collected regarding age, sex, date of transplant, indication for ERCP, bilirubin levels, PTC findings, findings on follow up ERCPs and need for surgical revision. Results: The indication for ERCP in all patients was abnormal liver enzymes and dilated ducts on imaging. The total bilirubin at the time of diagnosis ranged from 1.5 to 5.2 mg/dl (only one patient had total bilirubin >2 mg/dl.). The time of diagnosis was from 7 months to 7 years after OLT. All six patients underwent percutaneous transhepatic cholangiogram (PTC) within one day to two weeks of ERCP. PTC revealed total occlusion in 1 patient and high grade obstruction at the level of the biliary anastomosis in 5 patients. All patients had external biliary drainage established at initial PTC. Four of the patients could be managed by internalization of biliary drain by subsequent PTC, rendezvous ERCP and maximal parallel stent placement or fully covered self-expanding metal stent placement. One patient failed endoscopic management because of difficult ERCP and required hepaticojejunostomy. One patient had PTC and is awaiting repeat ERCP. The mean number of ERCP per patient was 3.3 and PTC was 4.3, with a single patient requiring 8 ERCP and 12 PTC due to recurrent stones and bile leak. Conclusion: Patients with apparent total occlusion on ERCP had only modest elevation of bilirubin indicating that these patients did not have a true total occlusion. We believe that dilatation of the donor bile duct may cause tortuosity at the anastomotic site which acts as a valve-like mechanism preventing passage of contrast or guidewire through the anastomosis. This does not preclude endoscopic management. ERCP with dilation and stent placement is possible once decompression is achieved via PTC.

Preoperative Skeletal Versus Cutaneous Traction for Femoral Shaft Fractures Treated Within 24 Hours

To compare the advantages and disadvantages of preoperative cutaneous traction versus skeletal traction in adults with diaphyseal femur fractures amenable to fixation within 24 hours. Randomized prospective trial. Level I trauma center in a major metropolitan area. Sixty-five patients with 66 femur fractures were prospectively enrolled and randomized to a traction group from July 2009 to July 2010. Time of application for on call physicians/practitioners, pain relief after application of traction; time of reduction in the operating room theater, and evaluation of pain medication consumption before stabilization. Thirty-seven patients received cutaneous femoral traction, whereas 29 patients received skeletal traction. There was a significant reduction in time of application for the cutaneous traction (24.30 ± 24.74 minutes) compared with skeletal traction (57.10 ± 33.60 minutes) (P ≤ 0.001). There was no statistically significant difference in visual analog scale (VAS) scores when compared with pretraction application pain assessment and posttraction pain assessment between the cutaneous and skeletal traction groups with a decrease in the VAS of (0.56 ± 3.73 and 0.54 ± 2.76), respectively (P = 0.99). There was no difference in pain medication requirements between groups (0.12 ± 0.17 mg/kg for cutaneous versus 0.09 ± 0.14 mg/kg for skeletal, P = 0.39). There was no significant difference in reduction time of the fracture (skin incision or opening reamer to guide wire passage) in the operating room between cutaneous traction versus skeletal traction (P = 0.59). Use of cutaneous traction for diaphyseal femur fractures when compared with skeletal traction results in a statistically significant reduction in time of application to the on call practitioner with no complications or detrimental change in operative time and no difference in VAS pain scores or narcotic usage.