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Historical Background of Orthopedic Nursing

The word ‘orthopedics’ was derived from the Greek words; orthos meaning straight
or free of deformity and pais meaning child. History of the Philippine Orthopedic Center
POC started in February 9, 1945 by PCAU General Hospital. The US Army
Orthopedics also called orthopedic surgery medical specialty concerned with the established the hospital in Mandaluyong, Rizal. It was then called as Mandaluyong
preservation and restoration of function of the skeletal system and its associated Emergency Hospital. Its main purpose is to help take care of the civilian casualties of war.
structures, i.e., spinal and other bones, joints, and muscles. But its function was not only as emergency basis seeing not only victims of wars but also
all cases.
Nicolas Andry, a professor of medicine at the University of Paris published a
textbook in Orthopedics in 1741 concerning the following; In May 1945, the hospital was turned over to the Phil. Government. In August 1945,
1. Maintaining a straight child the Bureau of Health took over and only fracture cases and bone joint condition remained.
2. Straightening a deformed child
3. Finding new ways to straighten deformed child The hospital kept functioning during those difficult years and it is attributed to the
skill, ingenuity, dedication and foresight of the staff lead by Dr. Jose V. delos Santos.
In 1728-1793, John Hunter contributed to the advancement of understanding
fractures and other musculo-skeletal injuries. The hospital finally transferred to its present site in Quezon City.

Orthopedics began in the 18th century with the pioneering efforts of Jean André Review of Structure and Function of the Musculo-skeletal System
Venet, who established an institute in Switzerland for the treatment of crippled children's
skeletal deformities. I The Bones

In 1834-1891, Hugh Owen Thomas, an Englishman specialized in the treatment of A. The human skeleton consist of two main division:
chronic joint disease, fractures and dislocations. 1. Axial – body upright structure
a) Skull b) vertebral column c) ribs
In 1867-1948, Agnes Hunt, referred to as the Florence of Nightingale of Orthopedic 2. Appendicular – the body appendages
Center in Great Britain. a) Arms b) hips c) legs

The efforts of Sir Robert Jones and the massive casualties of World War I led to the B. Four major bone type
founding of many orthopedic training centers in the early 20th century. 1. Long bones - length exceeds breadth and thickness
2. Short bones - equal in main dimensions
In 1840, William Little established the Royal Orthopedic Infirmary in Great Britain. 3. Flat bones – primary made up of cancellous bone tissue
In 1857, Anthonius Methyson of Holland described the plaster bandage. 4. Irregular bones
In 1866, the New York Orthopedic Dispensary was formed.
C. Long Bones:
A vastly increased knowledge of muscular functions and of the growth and 1. Structure
development of bone was gained in the 19th century. Significant advances at this time a) Diaphysis – shaft provides strength resist bending
were the new operation of tenotomy (the cutting of tendons, which made correcting b) Metaphysis – flared portion between diaphysis and epiphysis
deformities easier), the surgical correction of clubfoot, the invention of the Thomas splint c) Epiphysis – end
(which provided better support for fractures of long bones in the limbs), and the - Primary cancellous bone
introduction of quick-setting plaster of Paris for use in orthopedic bandages. - Assist with bone development
d) Epiphyseal plate/line – between metaphysis and epiphysis
Modern orthopedics has extended beyond the treatment of fractures, broken - Cartilage growth in length of diaphysis and metaphysis
bones, strained muscles, torn ligaments and tendons, and other traumatic injuries to deal e) Periosteum – connective tissue covering bone
with a wide range of acquired and congenital skeletal deformities and with the effects of - continues at the end of bone with joint capsule but
degenerative diseases such as osteoarthritis. A specialty that originally depended on the does not cover articular cartilage
use of heavy braces and splints, orthopedics now utilizes bone grafts and artificial plastic 2. Blood supply
joints for the hip and other bones damaged by disease, as well artificial limbs special
footwear, and braces to return mobility to disabled patients. Orthopedics uses the a) Nutrient artery – tunnel in the diaphysis of long bone
techniques of physical medicine and rehabilitation and occupational therapy in addition to
those of traditional medicine and surgery. b) Periosteal vessels – supply compmact bones with nutrients
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c) Metaphyseal and epiphyseal vessels – supply the spongy V Joints
bone and narrow of the epiphysis
3 Basic Joint Types
D. Functions
1. Provides framework for the body 1. Fibrous – composed of fibrous tissue, tightly, connecting the articular surfaces of
2. Serves as lever for skeletal muscles two bones
3. Protects vital organs such as the brain, heart and lungs
4. Stores calcium and release it to the blood stream according to the body 2 types
requirement
5. Manufactures new blood cells in the red bone marrow
a) sutures – permits no movement
II Cartilage
b) syndesmosis – permits minimal movement between bones
1) Fibrocartilage – greatest tensile strength
- occurs in the intervertebral dics and in the symphysis 2. Cartilagenous joints connect two bones with cartilage, allowing only slight
pubis movement.
2) Elastic cartilage – possesses firmness and elasticity
- occurs in the external air and in the Eustachian tube 3. Synovial joints, the most common joint type, have the most complex structure and
3) Hyaline cartilage – cushions most of the joints to help soften any impact permit maximum mobility. These joints include the following
- firm yet flexible
- occurs also in the part of the nasal system, larynx, trachea a) joint capsule
and in the bronchial ring
b) synovial membrane
III Ligaments and Tendons
Ligaments – strong cords of fibrous tissue c) articular cartilage
- joint capsule provides the primary connection between the bones,
but ligament bind the joints more firmly
d) synovial cavity
Tendons – firm cords of fibrous tissue that extend from the muscle to the
periosteum FRACTURES
- connects muscle to each other to other tissue
A. Fracture is a break in the continuity of the bone. In adults this break is usually complete
IV Skeletal muscle in that the periosteum and the cortical tissue on both sides are completely severed.

a. Muscles can be long and tapered, short and blunt, triangular, quadrilateral or In pathology, a break in a bone, caused by stress. Certain normal and pathological
irregular. conditions may predispose bones to fracture. Children have relatively weak bones because
b. Muscle fiber arrangement varies of incomplete calcification, and older adults, especially women past menopause, develop
1. In some muscles, the fiber runs parallel to the muscles long axis osteoporosis, a weakening of bone concomitant with aging. Pathological conditions
2. In others, the fibers are oblique and bipennate like the feather of a quill involving the skeleton, most commonly the spread of cancer to bones, may also cause
pin weak bones. In such cases very minor stresses may produce a fracture. Other factors, such
3. Fibers curve cut from a narrow attachment at the muscles and to form as general health, nutrition, and heredity, also have effects on the liability of bones to
a triangle fracture and their ability to heal.
c. Main functions
1. Prime mover – directly brings about a desired motion An incomplete break or greenstick fracture is mere common in children. Bone broken is
2. Antagonist – muscles that directly opposes the movement under bent but securely hinged at one side.
consideration
3. Fixation – generally stabilizes a joint or its part thereby maintaining A complete fracture occurs when periosteum and cortical tissue completely severed on
position while prime mover acts both sides of bone.

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B. Fracture bone fragments are labeled according to relationship to the cortex of the body. The most important phase in obtaining the union of fracture fragments.
a. Cast
1. distal – away from b. Traction
c. Brace
2. proximal – here to d. Fixation devices
a. Internal fixation devices
b. External fixation devices
C. Causes of fracture
CARE OF PATIENT IN CAST
1. In normal bones, fracture occurs when more stress is placed upon a bone that is
able to absorb such as: Plaster Cast – is temporary immobilization device, which is made of gypsum sulfate,
rendered anhydrous by calcification when mixed with water swells and forms into hard
a) Direct blow or crushing form cement.

b) Twisting force (torsion a severe twisting of a broken bone at a side different FUNCTIONS
from where the force was actually applied. 1. To immobilize
2. To prevent or correct deformity
c) Powerful contractions – highly developed muscles contract so violently that 3. To support, maintain and protect realigned bone
muscles tear from bone sometimes pulling a small piece of bone with it. 4. To promote healing and early weight bearing

d) Fatigue and stress bone breaks after repeated stress * Cast can be applied to the extremities, to the trunk and to the extremity and trunk as in
spicas.
2. Bones weakened by a disease or tumors and subject to pathological fractures It can be applied to encase the whole area where it should be applied or it can be applied
as a splint or mold.
Classification of fractures
*Complications of cast
1. Neurovascular compromise
Broad classification 2. Incorrect fracture alignment
3. Cast syndrome, superior mesenteric artery
1. Open fracture a. Occurs with body cast
b. Traction on superior mesenteric artery causes decrease in blood supply to
2. Closed fracture bowel
c. Signs and symptoms, abdominal pain, nausea and vomiting
4. Compartment syndrome – is a condition in which increases pressure within limited
Principles of Fracture Treatment space, compromises circulation and function of the tissue within that space.
A. Reduction or realignment of bone fragments
B. Maintenance or realignment by immobilization Principle in application of plaster cast
C. Restoration of function
1. A cast is applied with padding first
A. Reduction Padding materials include the following – wadding sheet, roll cotton, stockinet felt.
1. Closed reduction – is accompanied by application of plaster cast after the It can be applied as a combination like stockinet and wadding sheet.
fracture4 have been aligned with or without the use of anesthesia, to 2. Apply it to the joint above and joint below the injured part.
include the joint above and below the fracture line. 3. Apply it in circular motion and mold it as you do the procedure by the palm.
4. Support it with the palm
2. Open reduction – immobilization is done by nails, screws, pins, wires or
rods which are inserted with or without plates. Such devices stay in the Contraindications of plaster cast application
patient indefinitely unless they produce symptoms after healing takes 1. Pregnancy
place. 2. Skin diseases

B. Immobilization For Circular Cast Application


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1. Check for doctor’s orders Care of the Patient in Cast
2. Inform and prepare the patient for the procedure. The duration of keeping the body or part of it in cast is at least 1 month. Though, it
Explain to the patient and his relatives the need for placing the affected part of the varies among patients. Factors that influence the duration are
body cast. Show an illustration of the type of cast to be applied to help them 1. Age of the patient
visualize HOW IT IS and WHAT IT IS. 2. Part of the e body affected
They are also made aware of the approximate duration for the body to remain 3. The degree of injury the affection of the part
in cast, the limitation and the discomfort arising from immobilization less boredom
and frustrating. *During the entire period that the patient is in cast, the nurse responsibility is focused on
If possible, a good cleaning bath and shampoo be given to the patient. The the following:
affected part be cleansed thoroughly with soap and water or with detergent and a. Neurovascular check
dried. If there is a wound dress it accordingly. b. Preservation of the efficiency of the cast
3. Ready all things needed for the application. c. Maintenance and promotion of the integrity of the system of the body
4. Position the extremity (by the doctor) d. Maintenance of the cleanliness of the cast
5. Apply padding including the joints above and below the fracture line with thicker
pads on the bony prominences A. Neurovascular checks
6. Soak the plaster cast into a bucket with water; leave it undisturbed until bubble
ceases, one after the other. In all casted patient, COLOR, MOTION, TEMPERATURE AND SENSATION OF TOES/FINGERS
7. Grasp both ends, when bubbles cease, towards the center without squeezing it. should be observed every 30minutes for several hours. After cast application, longer if
8. Free the end of the cast and hand it to operator. there is edema, and then regularly every 3 hours.
9. Apply cast in CIRCULAR MOTION until the whole area is covered and mold it during Circulatory impairment results in symptoms of coldness, edema, cyanosis, pain and
the process of application by the palm. finally numbness in the toes or fingers. The blanching sign will indicate whether or not
10. Support the cast while applying. there is an adequate circulation. When the nail of the thumb or great toes is compressed
11. Handle the cast with care. and immediately released, the color should go from white to pink with the same speed/. If
not, the circulation is slow and the toes or fingers need closer observation.
Moving patients or transferring with wet cast must be avoided as much as possible. Patients in arm or leg casts should be able to move and feel each toe or finger, because
If this is necessary, care must be taken to maintain the integrity of the cast. the same nerve does not innervate each other. All toes and fingers should be checked.

The excess plaster cast is trimmed by means of a trimming knife. Cast spilled on Nerve Function Test
the skin is easily removed by wiping it with a damp cloth.
Nerve Action by the nurse Action by the patient
To hasten drying of the cast, several ways can be used - Test for Sensory Function - Test for Motor Function
1. Exposure to open air or electric fan
2. Exposure to heat lamp Radial Prick web part between thumb Hyperextend the thumb
3. Placing the patient in a warm room and index finger

Care should be taken in protecting the patient form rapid drying of the cast, as this will Median Prick distal surface of index Oppose thumb and little
result to a dry outer layer while the inner layer remains wet. Complaints of discomfort finger finger flex wrist
should be investigated and appropriate measures be given to bring comfort.
Ulna Prick distal end of the small Abduct all fingers
Patients in body cast or spica cast is turned every 4-6 hours to promote even drying of the finger
cast.
Peroneal Prick lateral surface of the great toes Dorsiflex ankle second
Finishing touches on the dried cast. toe extend toes

Edges that are extremely rough should be trimmed and smoothened very slightly with a Tibial Prick medial and lateral surface Plantar flex ankle and
knife. of sole of foot flex toes

Rough edges can be covered with adhesive petals, especially if there is no stockinet Psychological Implications and Going Home In Cast
underneath the plaster and wadding sheet.
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To relieve patients’ apprehension and anxieties that crowd their minds with their cast on, c. feeling of deep pressure
the nurse can help the [patient make a start toward resolving some of the problems by d. paresthesia
helping them become to remain as independent as possible. e. motor weakness or paralysis
Instruction regarding cast care need to be received and patient can be reminded that 3. Infections, tissue necrosis due to skin breakdown
frequent rest periods for the entire body are necessary. Discussing plans with the patient a. drainage through casts
before discharge will make the transition from the hospital to another facility much b. sudden, unexplained rise in temperature
smoother and add to her peace of mind. c. hot spot felt on cast over the lesion
d. pressure on the groins, knee, ankle and metatarsals
What to observe/remarks
Spica Casts
Cast of the upper extremities 1. Signs of respiratory distress
1. Signs of impaired circulation/circulation of fingers such as 2. Signs of cast syndrome
a. cyanosis of the skin a. Prolonged nausea
b. coldness of the skin b. Repeated vomiting
c. loss of function c. Distention
d. numbness d. Vague abdominal pain
e. pulselessness of the extremity e. Absence of bowel sounds
f. severe pain 3. Pressure on the jaws, ears, face, clavicle area, anterior superior iliac crest, groin,
g. marked swelling buttocks, and above the knee.
2. Nerve damage due to pressure on the nerve as it passes over bony prominences 4. Urinary and bowel disturbances
a. pain increasing in persistence 5. Signs of plaster cast
b. anesthesia a. itchiness/burning sensation
c. feeling of deep pressure b. severe pain
d. paresthesia c. rise in the body temperature
e. motor weakness and paralysis d. disturb sleep
3. Infections, tissue necrosis due to skin breakdown e. night cries among babies
a. musty, unpleasant odor over the cast or edges of the cast f. restlessness
b. drainage through cast or windows 6. Signs of infections and tissue necrosis
c. sudden unexplained rise in temperature
d. hot spot felt on cast over lesion Turning Patient In Cast
4. Pressure on the elbows, axilla, wrists, metacarpals and iliac crest
Turning casted trunk and lower extremities must be done carefully. The Patient must be
Remarks lifted and not rolled or dumped. Support should be provided to the encased part and the
1. Avoid insertions of foreign bodies in cast whole body.
2. Avoid soiling of the cast
3. Report signs of cracks and weakness of the cast The first changing of the patients’ position is dependent on the condition of the cast
4. Maintain proper alignment of casted extremity and the body area involved. The first turning usually is to dry the posterior surface of the
5. Proper support of the cast cast as well as to provide comfort and protect against respiratory complications.

Cast of the Lower Extremities There should be no attempt to turn the patient alone if one estimates that one is
1. Observe for impaired circulation as manifested by physically unable without the patient’s assistance.
a. Cyanosis or bluish discoloration of the skin
b. coldness of sensation Turning Patient in Hip Spica 1 - 1 ½
c. loss of function of the affected extremity
d. numbness A. Supine to lateral
e. absence of pulse With 2-3 members working together the patient is gently pulled toward the unaffected
f. marked swelling side. Member remains on this side to give the patient the sense of security while the other
2. Nerve damage due to pressure on the nerve as it passes over bony prominences member moves to the opposite side of the bed where the affected leg is to arrange the
a. increasing persistent localized pain pillow along the entire length of the casted leg and back.
b. numbness in the extremity
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B. Supine to prone For traction to be effective, there must be also a pull in the OPPOSITE DIRECTION
(COUNTER TRACTION) by using the body or by elevating part of the bed toward the
One member places his hands on the patient shoulder and hips, while the other support traction.
the thighs and extremities. The member of the opposite side pulls the shoulder and thighs
as the patient is gently teased on his front. After the patient has been turned, observe the PRINCIPLES OF TRACTION
following points: 1. MAINTAIN THE ESTABLISHED LINE OF PULL
a. Toes should not dips against the mattress Weights should hang freely, not hitting the bed or resting on the floor. The position of
b. Body section of the cast plaster should not press the back, chest and the weights should be rechecked if the level of the bed is altered.
abdomen
c. Heels should be maintained in correct angulations and should be allowed AVOID
to extend beyond the mattress 1. Bumping against the weights when walking near the bed.
2. Allowing the weights to sway.
Placing Patient in Bedpan Both movements can cause pain for the patient in traction. It is preferred that
In bowel or bladder elimination, the buttocks should be lower than the head and toward the weights should not hang over the patient, if necessary, the nurse should tape the
the breast. This can be achieved by: weights so they will not fall on the patient.

a. Elevating the head part slightly and placing a small pillow under the back of 2. PREVENT FRICTION
the patient. Traction rope should rest in the groove of the pulley and move easily. The rope should
not be frayed. The nurse should TIE securely knots in the traction rope and tape the rope
b. Placing a folded cloth on the posterior aspect of the bedpan. This will absorb ends. The rope knots should not lodge against the pulley because this will interfere with
moisture and this prevents spoiling the cast. the line of pull. For the same reason, the nurse should ensure that the pulley, spreader bar
Adult patients are usually placed in their good side first. The bedpan is placed and footplate do not rest against the foot of the bed.
so that the buttocks are on the posterior section of the bedpan. Pillows,
blankets are then arranged to support the legs and back so that there will no 3. MAINTAIN COUNTER TRACTION
be back flow. To provide traction, the nurse must ensure that counter traction is maintained. If the
If patient can support himself by lifting with the aid of the overhead trapeze, weight of the patient body is to provide the counter traction, HIS BODY should not interfere
the bedpan is slipped under the buttocks. with the DIRECTION OF PULL. For instance, the feet of the patient in BUCK traction should
Bladder and bowel elimination in children with hip spica if placed in not touch the foot of the bed, or if the patient is in cervical traction, his head should not
headboard frame is not difficult if the bedpan is kept constantly in the spica touch the head of the bed.
under the buttocks.
4. MAINTAIN CORRECT BODY ALIGNMENT
Instrument for Cast Removal The patient should have correct BODY alignment while lying centered in the bed. The
1. Cast cutter (manual electric) nurse must ensure that the patient does not angle his body or lean off the side of the bed
2. Spreader because the line of traction pull would then be changed or interrupted.
3. Trimming knife
4. Bandage scissors Types of Traction
5. Plaster sears
1. SKIN TRACTION
Points to Remember Skin traction is accomplished by weights that pull on tape, sponge rubber or
1. After the cast is removed, support the part with pillow maintaining the same plastic materials attached to the skin. TRACTION on the SKIN, TRANSMITS traction to
position that existed in the cast. the musculoskeletal structures.
2. Move the extremity gently. Forms
3. Observe the skin for any abrasions and plaster sore. 1. Buck Extension
4. Wash skin with mild soap followed by application of oil or lanolin. A form of skin traction in which the pull is exerted in one plane when
partial or temporary immobilization is desirable. In Buck’s extension, strips
TRACTION of adhesive, moleskin or perforated flex foam are applied smoothly to each
Traction is the application of a pulling force to a part of the body. It is used to align and side of the affected extremity and attached to a spreader block at the foot.
immobilize fractured bones, to relieve muscle spasms and to correct flexion contractures, The extremity is wrapped with elastic bandage to improve adherence of the
deformities and dislocations. tape to the skin and prevent slipping. A traction rope is attached to the

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spreader block then over the pulley, thence to a weight hung over the side fractures of the femur. It may be used with skin traction and other balanced suspension
of the bed. apparatus. Because upward traction is required for these fractures, the patient is placed on
2. Russell’s Traction a fracture bed.
Russell traction when properly applied in good mechanical Inasmuch as fracture occurs under varying circumstances and involves individuals of
working efficiency is a comfortable device for the patient. different ages, weights and body builds, NO TWO FRACTURES ARE ALIKE and every
The equipment required is not elaborated. A single section of fractured patient require individual treatment. By same token, traction may be modified in
common Balkan frame can be attached to the bed with overhead many ways to meet a variety of special requirements, as exemplified by so called
bar directly above the injured limb. Four pulleys are used. These “BALANCED SUSPENSION TRACTION” and the “RUNNING TRACTION”.
pulleys are arranged so that one is on the overhead bar at a level
directly above the tubercle of the tibia of the fractured leg, another
is attached to the footplate and two are attached to a crossbar at 3. MANUAL TRACTION
the foot of the bed and are placed at about the level of the Means the application of traction to a part of the body by the hands of the operator.
mattress. A hammock which is used from the knee sling and When assisting with the application of traction or a cast, the nurse may be asked to apply
traction tapes form the BASIS OF TRACTION. a manual traction. This calls a firm smooth grip on the extremity and the avoidance of
sudden jerking movements.
Important points in the nursing care of patient in Russell Traction
BALANCED SUSPENSION
1. The knee sling should be smooth and its edges must not cause Balanced suspension traction is used primarily for femoral fractures in adults by means
pressure on the soft tissue over the peroneal nerve. of the Thomas splint with a Pearson attachment. Balanced suspension provides counter
2. The heel of the foot in traction should just clear the bed. traction by its own system of weights and pulleys. Therefore when the patient lifts, the
Firm pillows should support the thigh and the calf along the splint should also lift so that traction is maintained.
entire length, leaving the heel free of the bed. The Thomas splint has a sling that supports the thigh. The nurse should check for
3. The popliteal space must be watched for ridging and skin denudation. irritation from the ring to the groin, inner thigh and ischium. The Pearson attachment is
Elevation of the backrest is permitted and few difficulties are connected to the splint by the knee and supports the calf in a position parallel to and
encountered in giving nursing care because the fractured leg is not at above the bed. A Steimann pin or Kirschner wire is inserted through the distal end of the
the mercy of the gravity and will not be altered in position. femur or through the proximal or distal end of the tibia.
4. Encourage active dorsiflexion and plantar flexion of the feet. The nurse teaches the patient and family that the traction’s main purpose is to provide
sling, this allows the leg to rest comfortably and provides freedom to move without
Important features disrupting traction pull or alignment.
By using the overhead trapeze, the patient can lift the shoulders and upper body. This
1. A piece of felt should be inserted between the sling and the patient’s movement allows for change of linen from the top to the bottom of the bed. Similarly, the
skin to prevent wrinkling of the sling under the popliteal area. This will nurse can apply lotion to the patient’s back because the individual is not allowed to turn
assist in eliminating pressure sores that sometimes form at this point. for back care.
2. The heel should clear the bed. The ideal position for the heels of the
patient in Russell traction is that of a person standing with his heels UPPER EXTREMITY TRACTION
four inches apart. Abduction is to be avoided.
3. Two pillows are usually placed under the limb in traction. One under Skin/Skeletal
the thigh to maintain the desired angle and the other under the calf Sidearm traction is used to immobilized fracture of the humerus and may be applied either
down and including the Achilles tendon. a skin or skeletal traction. There is outward pull on the upper arm and an upward pull on
the forearm. For this reason, two separate set-ups of adhesive strips and elastic bone
2. SKELETAL TRACTION wraps are needed. In addition, if skeletal traction is used, a Kirschnerwire is usually
Method of traction used most frequently in the treatment of fracture of the femur, inserted trough the olecranon.
humerus and the tibia. The traction is applied directly to the bones by use of a metal pin or If the traction equipment is attached to the bed frame under the mattress, elevating the
wire (Kirschnerwire, Steimann pin), inserted into and through a bone distal to the fracture. head of the bed will not disrupt the traction pull. However, if the frame is attached so that
Usually the skin is made under local anesthesia. The pin or wire is sterilized with all the it moves when the bed position changes, the nurse should keep the head of the bed flat.
aseptic precaution of an operation. Following insertion of pins, the wound is covered with a Placing a folded blanket under the mattress near the traction frame can provide COUNTER
small gauze squares. If the wire or pin extends back to the caliper, a cork placed over the TRACTION.
end of the pin prevents the tearing of lines and other more serious accidents.
Skeletal traction is applied by weights and pulleys as described for skin traction. The
Thomas Splint with the Pearson attachment is usually used with skeletal traction in
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Skeletal position relieves pressure from the lower back by decreasing the lumbar curve. It also
Overhead 90-90 traction, there is an upward pull on the upper arm, which is at a 90degree provides counter traction. If traction increases pain to the back or legs, the nurse
to the body. The elbow is flexed at a 90degree that the forearm is suspended in a sling and should report this to the physician.
rest above and across the body. Weight is attached to the sling and to the Kirschner wire
that is usually inserted through the olecranon. 2. Pelvic sling
Because the arm is elevated, the patient should have less edema. This will be the case It is used continuously to stabilize and immobilize fractures of the pelvis. A
as long as the nurse ensures the patient keeps the involved hand supported in the sling large canvas sling attached to weights suspends the patient’s buttocks just off
and does not allow it to hang freely. the bed. The pelvic sling may also be used to compress the entire pelvis (by
applying pressure along each side), if there is a pelvic ring separation.
Compression is achieved when the physician repositions the rods from the
CERVICAL TRACTION attachment edges of the sling to grooves that are closer together toward the
patient’s midline.
Skin Cervical Halter Strict immobilization is required to maintain the traction force. The nurse
Skin traction is frequently used for patients with sprains or strains to the cervical spine and should give back care every 4 hours by sliding her hands between the sling
ruptured cervical discs. It is applied to the cervical spine by a halter with straps that go and the patient’s back. However, it is difficult to reach the buttocks for skin
under the chin and around the head of the base of the skull. After the halter is placed, the care and bathing and the patient may generally uncomfortable. For these
spreader bar and attached weights are connected. The patient may have small pillow reasons an external fixator may be inserted into each iliac crest to stabilize
under his head and should rest the back against the bed. Because cervical traction is unstable fractures of the pelvis. External fixation can reduce the patient’s pain,
usually ordered intermittently for a specified period, the nurse should teach the patient allow for his early ambulation and facilitate nursing care.
how to remove and reapply it. This information is especially important for the patient
because there may be the need to remove the halter if vomiting or choking occurs. Any NURSING PRIORITIES FOR PATIENTS IN TRACTION
severe headache or pain in the area of the traction should be reported. 1. Frequently inspection of the fracture dressing in the first 24hours after application.
A bandage that appears loose when applied may in a very few hours cause
Skeletal Cervical Tong constriction which if not relieved may lead to gangrene of the extremity.
Skeletal traction to the cervical spine is used to immobilize and reduce fractures of the 2. Dressing is applied in such a way as to leave the tips of the fingers and toes
cervical spine that may injure the spinal cord. This type of traction is always continuous exposed. Any cyanosis, loss of temperature, tingling sensation in these parts
and is applied by Gardner, Vinki or crutchfield tongs inserted into the skull. should warn the nurse that the dressings are too tight. If the condition is caused by
There should be little bleeding after the first 24hours should be reported. If the tongs a single turn of the bandage, the turn may be divided with scissors, but it is usually
loosened or slip out, emergency measures include immobilizing the patient’s head with advisable to notify the surgeon.
sandbags and notifying the physician immediately. 3. After the first 24 hours, the fracture dressing should be inspected at least 3-4 times
With the skeletal traction to the cervical spine, there is a straight line of pull and the daily. Evidences of constriction should be noted and pressure points checked – heel
head of the bed may be elevated 6 inches to provide counter traction. An overhead on the bedclothes resting on toes.
trapeze must not be used with either skin or skeletal traction because it is use could strain 4. It is also important to ask the patient if there are any painful areas.
the individual’s neck. 5. If traction is in used, the apparatus should be checked to see the ropes are in the
The physician determines the degree of stability of the spine and writes wheel of the groove of the pulleys that the supporting apparatus is free of the
specific orders for the patient to turn. If turning is allowed, the nurse should use pulleys, that the weights hang freely and that the patient has not slipped down in
the “LOGROLLING”. Technique that is, the patient is rolled as a unit so that the the bed.
spine stays aligned and is not twisted. 6. The foot must be in natural position; rotation outward or inward should be
reported. FOOT DROP is to be avoided and the patient’s foot must be maintained in
PELVIC TRACTION the neutral position supported by appropriate orthopedic devices. The rope
Types sometimes frays; therefore, it too must be inspected at least daily.
1. Pelvic belt is primarily for relief of lower back pain to the lumbar spine 7. Weights are necessary to provide constant force and may be ordinary metal
whereas the pelvic sling is used to treat a pelvic fracture. traction weights or bags of water, hot or cold. It is especially important that the
Pelvic belt traction is applied to the lumbar spine by a pelvic belt with straps knots on the traction rope be tied securely. Enough weight is applied at first to
attached to weights. It is used to reduce muscle spasms and in the conservative overcome shortening tendency of the injured limb, but is gradually lessened as the
management of low back pain and herniated lumbar disc. This traction may be ordered fracture becomes more fixed. Weights should never be removed from a patient
for intermittent periods. However, patient’s cooperation is crucial to success. with fracture unless a life-threatening situation arises. Weight and pulley is applied
The nurse should place the patient in William’s position, in which both the hips and to secure constant corrective extension.
knees are flexed at a 30degree angle and the head of the bed is slightly elevated. This 8. WHEN THERE IS PULL IN ONE DIRECTION, THERE MUST BE AN EQUAL PULL IN THE
OPPOSITE DIRECTION. Counter traction is supplied by either the patient’s body and
8
friction against the bed (fracture of the upper extremity) or by elevating the foot of
the bed (fracture of the lower extremity).

9. When traction frames are used, a trapeze may be suspended overhead within easy
reach of the patient. This apparatus is of great help in assisting the patient to
move in bed and on and off the bedpans.
NURSING CARE OF PATIENT IN TRACTION

Nursing principles and implications


The purposes of traction regardless how it is achieved are
1. To reduce and to immobilize a fracture
2. To lessen or to eliminate muscle spasms
3. To prevent fracture deformity