The Journal of Pakistan Orthopaedic Association

TO FIND OUT THE EFFECTIVENESS OF SKIN TRACTION IN REDUCING PAIN IN PATIENTS WITH HIP FRACTURE PRIOR TO UNDERGOING SURGICAL INTERVENTION
Madni AA, Saqlain AH, Qureshi Asif and Hussain SS.

ABSTRACT: Objective: To find out the effectiveness of skin traction in reducing pain in patients with hip fracture prior to undergoing surgical intervention Design: Prospective and cross sectional comparative study. Place and duration of study: The department of Orthopedics Surgery, Liaquat National Hospital, Karachi. The duration of the study was 18 months (from November 2004 to March 2006). Materials and Methods: This is study of 40 patients, they were divided into two groups. Patients were randomized to apply the skin traction or not. Analgesia was prescribed in oral as well as intravenous forms which was standardized to all the cases included, for both the groups. Pain was recorded according to the Visual Analogue Scale. Chi square and T test was applied, and p value <0.05 was considered significant. Results: No significant difference was found between the two groups in terms of pain reduction. Conclusion: The routine use of skin traction in patients with hip fractures should not be considered in order to reduce the pain preoperatively. Key words: Proximal Hip Fracture, Skin Traction and Pain relieve. ...................................................................................... INTRODUCTION: Fractures of the proximal femur are generally referred to as fractures of the hip. Femoral neck fracture and intertrochanteric fracture are both common in men and women with about the same frequency. They are both more common in women than in men by a margin of three to one.1 Other risk factors include Caucasian race, osteoporosis 2 , neurological impairment, malnutrition, impaired vision, malignancy, and decreased physical activity.3 Subtrochanteric fractures, which account for 10% to 15% of proximal femoral fractures, have a bimodal distribution pattern, appearing commonly in patients 20 to 40 years of age and in those over 60 years of age.1 The prognosis for each of the three major categories of hip fractures are entirely different. These fractures are generally treated by surgical fixation either by closed reduction or by open reduction depending upon the fracture configuration and age of the patient. Hemi-arthroplasty is also considered

Correspondence: Dr. Hassan Amir-Us-Saqlain, Asst. Prof. Dept. of Orthopedics. Karachi Medical & Dental College, Abbasi Shaheed Hospital Karachi. Cell: 0300-2402285 Email:hsaqlain1972@yahoo.com 11 Vol. 21 No. 1 February 2009

The Journal of Pakistan Orthopaedic Association

according to the age of the patient, time lapse since injury and the fracture type. They were given analgesia and some sort of skin traction, before undergoing surgery with the aim of reducing pain. Skin traction consists of a rubber boot with straps around the lower leg through which the weight around 3Kg is hung. Method of application of skin traction: Skin traction is available in a prefabricated form in variable sizes, both as a self adhesive and non-adhesive forms. It is applied on the calf of the involved limb and a weight of about 2-3 kg is tied with a pulley for continuous traction. The leg is put on a small pillow to slightly flex the knee. Proposed benefits of skin traction include: 1 2 Reduction of pain.4, 5 Protection against further fracture displacement and damage to periarticular vessels and soft tissues.6 Reduction in the force required to effect fracture reduction at surgery. 7,8,9 Reminder to nursing staff of extremity injury during daily patient care. 10 Skin traction is not a benign treatment, it has been associated with: a) Pressure sores.8 b) Nerve compression.6 c) Blisters secondary to mechanical shearing forces.7 d) Interference with the nursing care.8, 9,11,12,13,14 e) Vascular compromise
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Increased pain during both application and movement by the patient in bed.15,16,17,18,19 The purpose of this study was to find out the effectiveness of skin traction in reducing pain in patients with hip fracture prior to undergoing surgical intervention at our institution. MATERIAL AND METHODS: This is a cross sectional comparative study. Patients coming to the Liaquat National Hospital in Orthopaedic department from out patients or emergency were included in the study. Patients selected according to the randomized sampling method by putting 40 folded tags in a jar in which, group A or group B was mentioned and the tag was picked up randomly after the diagnosis of the fracture. Total numbers of 40 patients were included in this study that were between ages 40-70 years who came to the hospital with in 72 hrs of injury having hip fracture including intertrochanteric and neck of femur fractures. Patients who were not included in the study were those with polytrauma, neurological deficit in the involved limb, with vascular compromise, leg ulcers, old fractures, confused and dementia patients. These patients were divided into two groups (A and B).In group (A) patients; skin traction was applied preoperatively while in group (B) no skin traction was applied. Pain was evaluated with a visual analogue score (VAS) where 0 is pain free and 10 is worse pain imaginable. The interview conducted by the resident on call and pain was evaluated thrice time, once on immediate arrival, 2nd after 4 hours and 3rd after 12 hours. Injection Toradol (ketorolac 30 mg) intravenous was
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The Journal of Pakistan Orthopaedic Association

administered on arrival in conjunction with skin traction the analgesia selected were same for all the patients which include injection Kinz 5 mg (Nalbuphine), on as required bases and the Tab Distalgesic Dextropropxephene 32.5 mg + Paracetamol 325 mg) on regular three times in a day the requirement of Nalbuphine injection reflect the extent of pain. The number of analgesics given before the surgical intervention recorded in both the groups and comparison made with regard to the number of doses of analgesics and subjective pain evaluation on the VAS. All these were recorded by the doctor in a questionnaire. Chi square and ttest was applied and p value <0.05 was considered significant using SPSS 10.0 for windows. RESULTS: 40 patients were studied 15 patients (62.5%) had the involvement of left hip while 25 patients (37.5%) had the fracture of right hip 18 patients (45%) were males and 22 patients (55%) were females. Neck of femur was involved in 17 patients (42.5%).Inter trochanteric fracture in 23 patients (57.5%). In group A (with skin traction) 10 patients (50%) were males and 10 patients (50%) were females. Neck of femur was involved in 9 patients (45%) and intertrochanteric fracture in 11 patients (55%). Right hip was involved in 7 patients (35%) while left hip in 13 patients (65%). Pain was recorded according to VSA at arrival, 4 hrs and 12 hrs after arrival to the hospital and total analgesia needed preoperatively was recorded.
TABLE I Comparison Between Group A And B And Showing P Value. P 95% Group B Mean Group A Value Confidence Std Error Std Error Mean Difference Interval Std Error Mean Mean At Arrival 6.65 (0.23) 5.70 (0.26) 0.95 (0.35) 0.01 0.24 -1.66 After 4 Hours 4.65 (0.18) 3.95 (0.27) 2.80 (0.30) 0.70 (0.33) 0.50 (0.40) 0.04 0.22 0.03 -1.36 0.32 -1.32 After 12 Hours 3.30 (0.27)

In group B (without skin traction) 8 patients (40%) were male and 12 patients (60%) female. Right side was involved in 8 patients (40%) and left hip in 12 patients (60%). 8 patients (40%) had fracture involving neck of femur while 12 patients (60%) had intertrochanteric fracture .Pain was recorded according to VAS and total analgesia needed preoperatively was recorded. Both groups were compared in terms of pain and analgesic used. No significant difference was found among the two in terms of supplementary analgesic requirement. There was reduction in pain between the first measurement and second measurement in patients in all groups, regardless of whether the traction was applied or not. However, the differences among the groups were not significant Table I. This study was randomized showing Table II. DISCUSSION: The recommended management of a fractured hip is surgical treatment within 24 hour of admission, provided that the patient is fit for an anaesthetic. Traction is a widely used and time-honored method of managing patients with fractures of the proximal femur in the interval between admission and operation. It has been thought that traction applied to the injured limb helps to reduce pain. This study suggests that this goal is not achieved, at least by skin traction and that purely placing the leg in a comfortable position on a pillow gives the least
TABLE II RANDOMIZED SELECTION. Variable. Group A. 61.6(3.09). Age Sex Male. 11 (55%). Female. 9 (45%). Site Right. 7 (35%). Left. 13 (65%) Group B. 64.3( 2.2) 7 (35%) 13 (65%) 8 (40%) 12 (60%) P Value. 0.21 0.20 0.74

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The Journal of Pakistan Orthopaedic Association

discomfort. The measurement of pain is always difficult as it is such a subjective sensation. Measuring analgesia consumption is a simple method, and the visual analogue scale has been shown to be reliable.20 Another author21 has found skin traction and a wellmolded hip spica cast is a safe, reliable treatment option for isolated, closed femoral fractures in children 2-7 years of age. Similar study had been done in Hospital in Goteborg, Sweden by Jerre R, Doshe A.18 The authors found that skin traction offered no benefits in terms of pain relief, the need for supplementary analgesics, or complications during hospitalization, and they concluded that routine use of preoperative skin traction is not warranted in hip fracture patients. In the current study, patients treated with skin traction were compared with patients not treated with skin traction (no immobilization while awaiting surgery).Visual analogue scale (VAS) was used to evaluate the reduction of pain using skin traction or no traction in patients awaiting surgery for hip fractures. No significant difference was found between the two groups in terms of pain reduction. No specific fracture pattern association was found to be related to increase or decrease pain. Pain was exclusively a subjective matter, and different patients behaved differently irrespective of the fracture and whether skin traction was applied or not. CONCLUSION: There is no role of skin traction in reducing pain preoperatively in patients with hip fracture. So it should not be routinely used for reducing pain.
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REFERENCES: 1. James GL. Campbells operative orthopaedics Ninth Edition, chapter 48;2181-2 2. Aitken JM. Relevance of osteoporosis in women with fracture of the femoral neck, Br Med J.1988; 288:597 3. Astrom J, Ahnqvist S and Beertema J. Physical activity in women sustaining fracture of the neck of the femur, J Bone Joint Surg 1987; 69-B: 381. 4. Denning F. Patient controlled analgesia. Br. J. Nurs.1993; 2, 274. 5. Halfens R, Evers G and Abu-Saad H: Determinants of pain assessment by nurses. Int. J. Nurs. Stud.1990; 27, 43. 6. Levi N .Is preoperative tibial traction responsible for peroneal nerve palsy in patients with fractured hip ? Acta Orthop Belg.1998 Sep;64(3):273-6 7. Shabat S, Gepstein R, Mann G, Kish B, Fredman B and Nyska M. Deep skin slough following skin traction for hip fractures. J Tissue viability.2002 Jul;12(3):108-12 8. Harvey CV. Challenges of traction in critical care. A case study. Critic Care Nurse Q.1998 Aug,21(2):1-13 9. Anderson G, Harper W, Connolly C, Badham J, Goodrich N and Gregg P. Preoperative skin traction for fractures of the proximal femur. A randomized prospective trial. J. Bone Joint Surg (Br) 1993; 75 (5): 794-6. 10. Tucker M A, Andrews M F, Ogle S J: Age associated change in pain threshold measured by transcutaneous neuronal electrical stimulation. Age Ageing:1998; 18, 241
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11. Billsten M, Besjakov J, Hyddmark U, Johnell O and Sernbo I. Enquiry in Sweden on the use of traction preoperatively in patients with fractures, and a radiological study on the effect of the traction on ten displaced cervical hip fractures. . Acta Orthop Scand (Suppl 270) 1996; 67: 35. 12. Finsen V. borset M, buvik G E and Haukle l. Preoperative traction in patients with hip fractures. Injury 1999; 23 (4): 241-4. 13. Needoff M. Radford P and Langstaff R. Preoperative traction for hip fractures in the elderly: a clinical trial. Injury 1993; 24 (5): 317-8. 14. Strmqvist B. Nilsson L, Egund N, Thorngren K-G and Wingstrand H. Intracapsular pressure in undisplaced fractures of the femoral neck. J Bone Joint Surg (Br) 1988; 70 (2): 192-4. 15. Roberts HC ,Eastwood H. Pain and its control in patients with fractures of the femoral neck while awaiting surgery.Injury.1994 May (25):237-39 16. Barnes P. Preoperative pillow placement under the injured extremity have better analgesic effect then skin traction for hip fracture .Evid based nurse 2002 Jan; 5(1) 24. 17. Byme T. The setup and care of a patient in Bucks traction. Orthop Nurse.1999 Mar, Apr; (2):79-83 18. Jerre R, Doshe A and Karlsson J. Preoperative skin traction in patients with hip fractures is not useful. Clin.Orthop.2000 Sep (378):169-73 19. Nichole D. Understanding the principles of traction. Nurse stand.1995 Aug 915;9(46):25-8
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20. Huskisson E C. Measurement of pain. Lancet 1974; 2, 1127. 21. Esenyel CZ, Oztrk K, Adanir O, Aksoy B, Esenyel M, Kara AN. Skin traction in hip spica casting for femoral fractures in children. J Orthop Sci. 2007 Jul;12(4):327-33.

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