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Skeletal Traction

Report in surgery ward

Unibersidad de Manila
College of Nursing
Group 3 ; Nr-31

Marie jodel Montalvo and Gemilyn Kalaw


12/1/2010
Traction
Traction has been used to treat fractures since prehistoric times and its principles
were well known to Hippocrates. Traction is the application of a pulling force to an
injured body part or extremity while counter traction pulls in the opposite direction.
The pulling force can be achieved through the use of the hands (manual traction) or
more commonly, the application of weights.

Lower extremity traction such as Buck or Russel traction, currently has limited
application in the preoperative management of a client with a fractured hip for
example, skeletal traction, however, continues to be an option for multiple trauma
clients who are not immediate candidates for open reduction and internal fixation of
orthopedic injuries.

Various types of traction may also be treatment options before and after surgical
reduction of injuries such as cervical fractures and for chronic condition such as low
back pain.

Principles in Care of the client with traction

 the line of pull should be in line with the deformity

 There should be an adequate counter traction. The weight of the body serves
as the counter traction

 apply traction continuously

 Allow the weights to hang freely. Weights should not touch the floor.

 Turn the client as indicated

 Avoid friction. There should be no knots along the rope

 Pin site care for skeletal traction:

a. Cleanse and apply antibiotic ointment as prescribed.

b. Observed site for signs and symptoms of infection e.g. redness, swelling,
pain, warmth, drainage. Notify physician if these findings are noted.

 Do neurovascular check

 Prevent complication of immobility


Skeletal traction
Skeletal traction uses pins to apply force to the bone, with skeletal traction, a
direct force can be applied after the physician aseptically inserts stainless steel pins
through the bone itself. The most common sites for pin insertions are the distal
femur, the proximal tibia and the proximal ulna. Skeletal traction can be tolerated
for longer periods than can skin traction. Weights may reach 15 pounds, although 7
to 10 pounds are commonly used.

In addition to the mode of application, traction can be categorized as static


(continuous) or dynamic (intermittent). Suspension may also be running or straight,
exerting direct pull on the affected part or balanced, exerting a pull on the affected
part and also supporting extremity in a splint.

Major disadvantages include the potential need for prolonged bed rest and
the resulting effects of extended immobility. Long term hospitalization is not always
indicated if the client in traction can qualify for home care nursing services or
depending on the type of traction receive additional treatment as an out patient.

The surgeon applies skeletal traction, using surgical asepsis. The insertion
site is prepared with a and periosteum. The surgeon makes a small skin incision and
drills the sterile pin or wire through the bone. The patient feels pressure during this
procedure and possibly some pain when the periosteum is penetrated.

After the insertion, the pin or wire is attached to the traction bow or caliper.
The ends of the pin or wire are covered with cork or tape to prevent injury to the
patient or caregivers. The weights are attached to the pin or wire bow by a rope and
pulley system that exerts the appropriate amount and direction of pull for effective
traction. The weight applied initially must overcome the shortening spasms of the
affected muscles. As the muscles relax, the traction weight is reduced to prevent
fracture dislocation and to promote healing.

Often a skeletal traction is a balance traction which supports the affected


extremity, allows for some patient movement and facilitates patients independence
and nursing care while maintaining effective traction. The Thomas splint with a
pearson attachment is frequently used with skeletal traction for fractures of the
femur because upward traction is required an overbed frame is used.

When skeletal traction is discontinued,the extremity is gently supported while


the weights are removed. The pin is cut close to the skin and removed by the
physician. Internal fixation, casts, or splints are then used to immobilize and support
the healing bone.

HERE ARE THE SITES OF SKELETAL TRACTION:

– Olecranon
– Metacarpal
– Upper end femur
– Lower end of femur
– Upper end of tibia
– Lower end of tibia
– calcaneus

HERE ARE THE COMPLICATIONS:

– Infection
– Cut out
– Application of splint difficult
– Distraction at fracture site
– Ligament damage
– Physeal damage
– Depressed scars

TYPES OF SKELETAL TRACTION

Balanced Suspension Traction

Balanced suspension traction is used to stabilize fractures of the femur. It can


be the skin or skeletal type. If it is skeletal, a pin or wire is surgically placed through
the distal end of the femur. If it is skin traction, tape and wrapping or a traction boot
of the kind described under Buck’s traction is used.

The patient is in the supine position, with the head of the bed elevated fro
comfort. As the name suggests, the affected leg is suspended by ropes, pulleys, and
weights in such a way that traction remains constant, even when the patient moves
the upper body.
Two important components of balanced suspension traction are the Thomas
splint and the Pearson attachment. The Thomas splint consists of a ring, often lined
with foam, that circles and supports the thigh. Two parallel rods are attached to the
splint and extend beyond the foot. A Pearson attachment consists of a canvas sling
that supports the calf.

Parallel rods lead from the pin sites on the distal and of the attachment for
the rope. Traction to the femur is applied through a series of ropes, pulleys, and
weights. These weights hang freely at the foot off the bed.

The skin should be inspected frequently to identify problems early. The ring
of the Thomas splint can excoriate the skin of the groin. Special padding may have
to be used. Again, the foot should always be at a right angle on the footrest to
prevent footdrop. If pins are used for fixation, aseptic technique must be used
around pin sites until they have healed. From then on, clean technique can be used.
The pin sites are cleansed carefully with soap and water and rinsed thoroughly,
unless this varies from policy. An antiseptic, such as povidone-iodine ointment, may
then be applied. Dressings are usually not required. You should, however,
constantly assess for infection at the pin sites. Indications include redness, heat,
drainage, pain, or fever. Review your facility’s policy on pin care.

Skull Tongs Traction

Skull tongs are used to immobilize the cervical spine in the treatment of
unstable fractures or dislocation of the cervical spine. Although Crutchfield tongs
were used almost exclusively in the past, Gardner-Wells skull tongs are in wide use.
Some think these are less likely to pull out than the Crutchfield tongs. The patient is
prepared for either type with a local anesthetic to the scalp. The tongs are surgically
inserted into the bony cranium, and a connector half-halo bar is attached to a hook
from which traction can be applied.

The patient is supine and is usually on a special frame instead of the regular
hospital bed. If a hospital bed is used, two or more people are required to assist the
patient with any turning movements. The head of the bed may be elevated to
provide counter traction.

Because patients remain in this type of traction for an extended period,


observe the precautions taken for the patient in other types of skeletal traction.
Difficulties with the performance of activities of daily living, infection at the tong
sites, and restlessness and boredom are common. It is useful to teach the patient
range-of-motion exercises, provide good nutrition and suggest recreational or
occupational activities.

Halo Traction
Halo traction provides stabilization and support for fractured cervical
vertebrae. The surgeon inserts pins into the skull. A half circle of metal frame
connects the pins around the front of the head. Vertical frame pieces extend from a
halo section to a frame brace that rests on the patient’s shoulders. The halo traction
allows the patient to be out of bed and mobile while stabilizing the cervical
vertebrae could injure the spinal cord.

NURSING INTERVENTION

• Maintaining effective traction

- The nurse should check the traction apparatus to see that the ropes are in
the wheel grooves of the pulleys to see that the ropes are not frayed, that
the weights hangs freely, and the knot in the rope are tied securely. The
nurse should also evaluate the patients position because slipping down in
bed results in ineffective traction.

• Maintaining positioning

- The nurse must maintain the alignment of the patient’s body in traction as
prescribed to promote an effective line of pull. The nurse positions the
patients foot to avoid foot drop (plantar flexion), inward position
(inversion), and outward rotation (eversion). The patients foot may be
supported in a neutral position by orthopedic devices. E.g. foot supports.

• Preventing skin breakdown

- The patient’s elbow frequently become sore and nerve injury may occur if
the patient reposition by pushing on the elbows. The patient frequently
push on the heel of the unaffected leg when they raise themselves. This
digging of the heel into the mattress may injure the tissue therefore the
nurse should protect the elbows, heel and impact for pressure ulcers. To
encourage movement without using elbow or heel, a trapeze can be
suspended over head within easy reach of the patient. The trapeze helps
the patient move about in bed and move on and off the bedpan.

- Specific pressure points are assessed for redness and skin breakdown. If
the patient is not permitted to turn on one side, or the other the nurse
needs to do a special effort to provide back care and to keep the bed dry
and free of crumbs and wrinkles. The patient can assist by holding the
overhead trapeze and rising the hips off the bed. If the patient cant do
this, the nurse can push down on the mattress with one hand to relieve
pressure on the back and bony prominences and to provide for some
shifting of weight. A pressure relieving air filled or high density foam
mattress overlay may reduce the risk of pressure ulcer.

• Monitoring neurovascular status

- Assessing the neurovascular status of the immobilized extremity at least


every hour initially and that every 4 hours. The nurse instruct the patient
to report any changes in sensation or movement immediately so that they
can be promptly evaluated. DVT is a significant risk for the immobilized
patient. The patient to do active flexion extension ankle exercises and
isometric contraction of the calf muscle. 10 times an hour while awake to
decrease venous stasis. In addition elastic stockings, compression
devices, and anticoagulant therapy may be prescribed to help prevent
thrombus formation.

• Providing pin site care

- The wound at the pin insertion site requires attention. This goal is to avoid
infection and development of osteomylitis. For the first 48 hours after the
insertion, the site is covered with a sterile absorbent nonstick dressing
and a rolled gauze or ace type bandage. After this time, a loose cover
dressing or no dressing is recommended. Pin site care is individually
prescribed and performed initially one or two times a day. The frequency
of the pin care needs to be increased if mechanical looseness of pins or
early signs of infection are present. Chlorhexidine solution is the most
recommended and common effective cleansing solution however saline
and water are just alternate choices. Hydrogen peroxide and betadine
solutions have been used but they are believed to be cytotoxic to
osteoblasts and may actually damage healthy tissue.

- Crushing may occur at the pin site and should remain undisturbed unless
there are contaminants signs of infection. Crust provide a normal
protective barrier and their removal may disturb healing tissue and make
it more vulnerable to infection.

- The patient should be taught to perform pin site care prior to discharge
from the hospital and should be provided with written follow up instruction
that includes the signs and symptoms of infection. They are permitted to
take showers 5 to 10 days of pin insertion and is encouraged to leave the
pins open to the water flow the sites are dried with a clean towel and left
open to air.

• Promoting exercise

- In patient exercise, assist the patient in maintaining muscle strength and


tone and in promoting circulation. Active exercises include pulling up on
the trapeze, flexing and extending the feet, and range of motion and
weight resistance exercises for non involved joints. Isometric exercise of
the immobilized extremity is important for maintaining strength in major
ambulatory muscles.