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Principles of traction Peter Davis and Lois Barr
LEARNING OUTCOMES On completion of the article the reader should be able to: 9 9 9 9
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Understand and follow the main principles of traction Set up and maintain the c o m m o n types of traction Safely and competently care for a patient in traction Identify and take action if any complications due to the traction occur.
u
UKCC CATEGORIES
o
This article will enable the reader to address PREP requirements through the following U K C C categories for professional development:
iii -I
9 9 9 9
z O
Reducing risk C a r e enhancement Practice development Education development.
Examples of how this may be achieved, and possible evidence for the reader's professional profile are given throughout the article. O t h e r ways to demonstrate your professional development may be through:
iii ii
O n~
9 Develop a teaching p r o g r a m m e for junior members of staff and implement it. 9 Reassess your care of patients on traction in light of current knowledge and if necessary produce an action plan to change practice. 9 Keeping a copy of this article, any notes you may make as a result of reading it and the w o r k from the 'reflection items' in the text.
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Peter Davis MA, BEd, RN, DN, ONC, Research Nurse, Queens Medical Centre, Nottingham, Lois Barr RGN, ONC, PGCer~, Assistant Course Director Correspondence to: Peter Davis, 83 Fosse Road, Farndon, Newark Notts NG24 3TL UKTeI.: 01636 705576; Email: peter s d a v i ~ a l k 2 I,com
A patient's freedom of movement is usually restricted for either protective and/or therapeutic reasons; the whole or part of an individual may be affected. Therapeutic restrictions promote healing and comfort and prevent further damage or injury from occurring. In situations where therapeutic restrictions of movement are necessary, the relationship between patient and nurse must be a partnership. This ensures understanding of why movement has been restricted and therefore patient anxiety is reduced and compliance increased. There are several methods of restricting movement that are used by orthopaedic nurses and traction is one of them.
ORIGINS Traction is the act of pulling or drawing. More specifically, orthopaedic traction occurs when 'a
Journal of Orthopaedic Nursing (1999) 3,222-227 9 1999Harcourt PublishersLtd
pulling force is exerted on a part or parts of the body' (Davis 1989). To be able to pull there must be something to pull against; that is, something which is pulling in the opposite direction. This is known as counter-traction and occurs when a pulling force is exerted that opposes the direct pull of the traction. Hippocrates, in 350 BC, when describing the use of traction in reduction (realignment of the bones) of a fractured leg, gave the example of two strong men pulling in opposite directions: the pull in one direction was traction, and that in the other direction, counter traction. In this example the surgeon applies the traction manually and the weight of the injured person with the fractured femur is the counter-traction. Gordon Buck in 1840 described a method of treating a fractured shaft of femur by using lengths of adhesive plaster applied longitudinally to the medial and lateral aspects of the limb. Circular bandages and an arrangement of cords secured them, pulleys and weights ensured a continuous pull that
Principles of traction
maintained alignment and fracture length. The Thomas's splint was described originally by Hugh Owen Thomas in 1876 and used in the ambulant management of chronic or subacute inflammation of the knee joint. Today his splint has a far wider range of uses.
USES Traction can be used for several reasons: 9 To reduce or hold, as in dislocations and fractures 9 To overcome the effect of the original deforming forces and thus reduce a fracture or dislocation of a joint. To control movement of an injured part of the body, thus facilitating the healing of bone. To lessen the muscle spasm that always occurs following fractures and dislocations. To prevent or correct deformity, as in contractures. For example, it can prevent or correct flexion deformity that may occur following inflammation of the hip joint due to infection. Traction overcomes the inevitable muscle spasm and prevents or corrects soft tissue contracture that would reduce the range of movement in the joint. For the same reason traction can be used to prevent contraction of healing soft tissues following joint surgery. Finally, traction may be used to rest joints, as in disease or injury. It can lessen the muscle spasm, as in back pain, or reduce the movement of diseased joints, such as in tuberculosis, and thus minimise pain and facilitate initial healing.
METHODS OF APPLYING TRACTION To apply traction a satisfactory grip must be obtained on a part of the patient's body. This may be achieved through the skin or bone and may be for short or long periods of time: 9 Manual traction is applied by the hands. As, for example, when a doctor reduces a fracture or holds an alignment whilst a cast or more permanent form of traction is being applied. 9 Skin traction is the application of the traction force over a large area of skin and this is then transmitted via the soft tissues to the bone; the maximum pull should not exceed that recommended by the manufacturers of the traction appliance, usually 10-15 lb (4.5-6.7 kg). Two common methods of applying this traction are the adhesive and non-adhesive forms. The adhesive type is not recommended for patients
223
with friable or damaged skin, as the adhesive used and the removal of the adhesive strips may cause further damage. Non-adhesive types are preferred if the traction has to be on for only a short period of time. For example, when used to reduce muscle spasm due to a fractured neck of femur in the few hours prior to surgery. Skeletal traction is the application of the traction force directly to a bone, commonly through metal pins or wires. These are then attached to some type of loop or stirrup and then by means of traction cord to weights and pulleys.
Counter-traction In any traction set-up, the whole body tends to be pulled in the direction of the traction force if counter-traction is not present. Counter-traction may be achieved in two main ways: 1. Fixed traction is the application of countertraction acting through an appliance that obtains purchase on a part of the body. To apply a force against a fixed point on the body, an appliance such as a Thomas' splint is used (see Fig. 1). The ring of the splint snugly encircles the root of the limb, i.e. the groin and hip. Traction cords are tied to the distal end of the splint and the counter-traction force passes along the sidebars of the splint to the ring, as indicated by the arrows. The grip on the leg is achieved by adhesive skin or skeletal traction. 2. Sliding or balanced traction utilises the weight of all or part of the body, acting under the influence of gravity, to provide counter-traction (Stewart & Hallett 1983). For instance, the bed is tilted so that the patient tends to 'slide' or move in the opposite direction to that of the traction force (see Fig. 2). In reality, the pull of gravity should equal that of the traction so that the two are 'balanced' and hence the patient remains stationary. The traction force is produced by weights and may be applied through a cord passing over a pulley. Suspension is not traction, as no counter-traction is necessary; it occurs when part or all of the body is suspended to increase the mobility of the patient. It
Traction
Counter-tractionforce
Adhesive skin traction
~~ ' Splintring
Fig. I Fixed skin traction using aThomas' splint. (Davis 1994 with permission from Harcourt Brace.)
224
Journal of Orthopaedic Nursing
Select one traction set up on your ward and decide whether it is fixed or sliding, skin or skeletal. Explain verbally to another nurse why you have classified the traction in this way 30 minutes Fig. 2 Sliding traction using skin extensions and weights. (Davis 1994 with permission from Harcourt Brace.)
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may be used on its own or as part of a traction/suspension system. It is sometimes confused with traction as the same types of equipment may be used to achieve both suspension and traction, and both may be carried out at the same time as part of the patient's treatment. (Box 1.)
F-
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A P P L I C A T I O N OF T R A C T I O N
0
Thomas' splint
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The correct size of Thomas' splint should always be used. It should be supplied for the specific leg, left or right, as the ring is set obliquely at an angle of 120 degrees to the medial bar. The circumference of the thigh, as high up in the groin as possible, is measured and the length of the leg from groin to base of foot (30 cm is added to the length for the correct size of splint). A splint with a half or split ring is essential as this will accommodate any initial swelling. Flannelette or domette slings are made to create a comfortable bed for the limb and then a layer of gamgee is placed along the full length of the sling. Additional gamgee pads should be available to maintain knee flexion and femoral shaft position on application. The splint should be bent to give approximately 5 degrees of flexion at the knee or a Pearson knee flexion piece available to achieve the same knee flexion or more if required. At this stage the skin or skeletal traction is applied. The prepared splint is passed over the limb maintaining manual traction if required. The splint is pushed up to the groin and the tension of the flannelette slings adjusted to maintain the normal bowing of the femur and uniformly support the limb. In addition, an opposing force must be applied to the distal end of the splint by tying off the traction cord with sufficient force to prevent the ring embedding in the groin (see Stewart & Hallett 1983). This acts as counter traction. This principle does not apply if the Thomas' splint is being used to suspend the limb. The relevant traction and/or suspension system is then applied.
femoral shaft fractures. He maintained that the knee should be held in slight flexion by means of a padded sling. The arrangement of cords and pulleys had to be exact to achieve accurate alignment of the fracture, the surrounding muscles and soft tissues, while still achieving the comfort of the patient. Today this traction is usually used in a modified form. Two forces are used to produce a resultant pull in line with the long axis of the femur (Taylor 1987). The patient should be recumbent with the hip and knee in slight flexion and the other leg lying horizontally. A near-vertical pull is exerted on the leg through a sling cradling the knee or thigh. A horizontal pull, using two pulleys, is exerted at the same time on the leg through below knee skin extensions or skeletal traction. The mechanics is such that the horizontal, two-pulley, pull is double that of the near vertical pull. The near vertical pull and the horizontal pull acting together create a resultant pull in line with the long axis of the femur. Elevating the foot of the bed produces counter traction. (See Fig. 3) A soft pillow is placed under the leg to support the thigh and lower leg, leaving the heel free from pressure. Undue pressure in the popliteal space must be prevented by ensuring the sling is well padded and the pillow not too hard. The patient should be taught to lift their buttocks off the bed by using the
l
Hamilton Russell traction Robert Hamilton Russell (1800-1933) studied the problem of how to overcome the muscle spasm of
Fig.3 Hamilton Russelltraction. (Taylor permission from Harcourt Brace.)
1997 with
Principles of traction
trapeze bar and their unaffected leg and so reduce the risk of sacral sores. This rather complicated arrangement of continuous traction requires constant supervision and exact judgement.
Bryant's or Gallows traction This is a convenient and useful form of treatment for fractures of the shaft of femur in children up to the age of 18 months or less than 16 kg. Above this age or weight there is a serious risk of vascular complications leading to ischaemic fibrosis of the calf muscles or even gangrenous changes in the foot and ankle (Taylor 1987). Traction is exerted through full-length skin extensions to both legs. The unaffected leg is always included to ensure the desired position and enable nappy changes and cleaning. The hips are flexed to 90 degrees and both legs suspended vertically. The knees are slightly flexed and sufficient weight applied so that the sacrum is lifted to just clear the bed. The weight of the child's body provides counter traction. (See Fig. 4) Clearance of the buttocks should be checked regularly, there should be just enough room for one finger between the sacrum and the bed. The weights should always be out of reach of the child. Both feet should be diligently checked for impaired circulation whilst the traction is in place. The presence of pulses does not eliminate the possibility of calf ischaemia. Skin breakdown over the malleoli, the dorsum of the foot and behind the knee should be continuously checked. Small meals should be given initially to prevent distension and vomiting but usually the child quickly adjusts. (Box 2.)
THE NURSING IN TRACTION
CARE OF PATIENTS
The nurse must have a clear understanding of how different types of traction work, and realise that although maintenance of a safe, efficient traction
Fig. 4 Bryant's- Gallows traction. (Taylor 1987with permission from Harcourt Brace.)
225
Ask one of your local traction equipment representatives to demonstrate new or existing products on your ward or unit. Offer constructive criticism and consider the pros and cons. 2 hours
system is important, the patient must not be forgotten; for example, when the nurse is setting up or attending to a traction system. The patient in traction has social and psychological needs as well as physical ones; most of these relate to maintaining a safe environment, and in helping to meet them the nurse should consider the following: 9 The traction system should be thoroughly checked at least dally and always after interventions such as physiotherapy and radiographic examination, as the system may be inadvertently altered. 9 Only traction cord should be used as this does not stretch and is of the correct circumference and strength. 9 The cords must be attached securely by standard knots that will not move or come undone - for example, a clove hitch or two half hitches (see Taylor 1987 for further details). 9 The ends of the cords should be short (5 cm) and bound back onto themselves with adhesive tape. This prevents fraying of the cord end and thus possible slipping and accidental disruption of traction. The knot itself should not be covered. It is a misconception that the tape reinforces the knot; the knot should be secure enough by itself. 9 Short cords should not be joined by knots as they would not run freely through pulleys, and if incorrectly tied would slip and come undone. 9 Cords should be checked daily for fraying, particularly where they pass over pulleys, or are rubbing against each other. Otherwise the systems' efficiency is reduced or the cord may break. 9 The line of pull of the cords should be correct and regularly checked. This ensures that the appropriate pulling force is applied for optimal therapeutic effect at all times. 9 Pulleys must be free running and oiled as necessary to prevent squeaking. Friction is thus minimised and efficiency maintained, and the patient is not disturbed by the noise. Many pulleys today have plastic components and thus need no maintenance. 9 The cords must rest comfortably in the pulley, one cord to each pulley wheel. This reduces friction and fraying of the cord.
226
Journalof OrthopaedicNursing
Patient problem/ nursing diagnosis Anxiety
Impaired skin integrity
Altered peripheral tissue perfusion
Neurovascular dysfunction Impaired physical mobility
Pain
Altered elimination
Risk of infection of pin sites
Intervention Explain nature and function of traction. Make clear the limitations of movement and activity. Respond to any questions and reassure Check that traction system is not applying harmful pressure to parts of the body. For example, the area in contact with the ring of a Thomas' splint. Assess skin covered by traction system for signs of dryness, redness or allergic reaction. Reposition patient frequently and assess general pressure risk areas. Check colour, warmth and swelling of the affected limb(s) frequently, i.e. every 30 minutes to 4 hourly due to increased risk of Deep Vein Thrombosis and Compartment Syndrome. Ask patient to report any changes of sensation or pain. Elevate limb, if not already, and encourage patient to dorsi and plantar flex the ankle. Check movement and sensation every 30 minutes to 4 hours, especially immediately after the traction applied or making alterations to weights, alignment and system generally. Ensure correct alignment of the part of the body in the traction system to maintain traction efficiency. Encourage independence in activity by providing aids and equipment. Exercise all unaffected joints and extremities. Assess pain frequently and provide appropriate analgesia. Move patient carefully and steadily to minimise pain and discomfort. Ask patient to report any changes in levels and site of pain. Ensure privacy and comfortable position when using bedpans and urinals. Encourage high fibre, high fluid intake to prevent constipation and urinary tract infection. Inspect at least daily for looseness of pins or wires and infection at the sites of insertion. Ask patient to report any pain at pin sites. Adhere to aseptic procedures and institutional protocols for changing dressing and pin site care.
9 The weight(s) used must be known and recorded in the nursing documentation, as the required pulling forces of a traction system are often changed during the course of treatment and members of the caring team need this information. 9 The weight(s) must hang free and not rest on the floor; otherwise, the efficiency of the system is not maintained. 9 To minimise discomfort for the patient, the weight(s) should not catch or jam, particularly on the bed ends, when the patient moves. 9 Weight(s) should not be hung over the patient. However, if this is necessary, an extra safety cord should be used. 9 Weight(s) should be securely attached by a fish hook (S hook), where available. This aids safe but easy removal of the weight(s) if necessary, for example during physiotherapy. 9 Pointed ends of pins or wires, used in skeletal traction, should be covered to prevent injury to the patient and staff. 9 The patient should be on a firm-based bed to give full support and comfort and allow efficient action of the traction system. 9 Bed aids should be used to keep bedclothes away from the patient as necessary, for comfort and to ensure free running of the traction cord(s).
The patient in traction will have problems and needs due to their reduced mobility and as a direct result of the traction system that should be diagnosed by the nurse. Table 1 outlines some of the problems and the required nursing intervention. (Box 3.)
ii!~i~iii!il
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Look at Table 1 and select one patient on traction. Compare the patient's documented care with that in Table 1 and review their planned care if necessary. 30 minutes
Pin site c a r e There is a lack of research and consistency in protocols related to pin site care. Treatment with skeletal traction involves the positioning of wires or pins, in or through the bone, protruding through the skin to be attached to rings or bars. This leaves an open channel from the skin normally colonised by bacteria, and the medullary cavity, which is normally sterile. There are variations in protocols but they are based on the same principles. Sims (1996) found a wide variety of pin site care practices based on doctor/nurse preference rather than research. A basic protocol should include the following:
Principles of traction 9 initial dressings should remain in place for 48 hours 9 the first dressings should be performed using an aseptic technique with normal saline and sterile sponges or cotton buds 9 the skin is eased gently away from the pin and any crusts removed 9 normal saline used to clean pin sites. Cleaned and dried with sponges or cotton buds, a new one is used for each pin 9 the pin sites are left uncovered unless discharging 9 if the pin sites are discharging dressings should be wrapped around the pin to allow drainage away from the pin site 9 the pin sites should be inspected daily
227
both daily, to prevent infection. However, it is suggested that this practice may cause corrosion of the pins and possibly increase the risk of infection.
THE
FUTURE
The use of traction has waxed and waned in developed countries but its use has never disappeared. The increased use of home care makes traction less expensive than when a long hospital admission was also required. In addition factors such as the increasing risks of acquiring untreatable infections as a result of surgery makes traction an increasingly realistic option.
REFERENCES
Compare the protocol of Sims (1996) with your own and as a unit review and discuss any potential changes. 2 hours
Seligson and Stanwyck (1982) advocated massaging to loosen the skin from around the pin site. Sims (1996) recommends dally pin site cleaning. As yet there is no conclusive research to suggest that any one solution is better than another for cleaning pin site wounds (Sproles 1985, Wallis 1991). However, R o w e (1997), found that in pin sites where no solution has been used there is the least infection rate. Henry (1996) advises the use of woven gauze as unwoven or cut gauze may leave fibres in the pin site. Henry, (1996), found that pain and redness were always the first indications of potential infection and that it is possible to confine infection to one pin site with a good technique. Over-granulation may occur around the pin and can be treated with silver nitrate compound or terra-cortril ointment. However, once the offending pin is removed the problem resolves spontaneously. Covering the wound may prevent possible contamination and touching by the patient; however, leaving it exposed allows easy observation of the site. The site is often sprayed with povidone iodine or covered with povidone iodine-soaked gauze,
Davis P S 1989 The principles of traction. Nursing (Oxford) 3 (34) 5-8 Henry C (1996) Pin sites: Do we need to clean them? Practice Nursing. Vol. 7. No. 4. pp. 12-17 Rowe S (1997) A review of the literature on the nursing care of skeletal pins in the paediatric and adolescent setting. Journal of Orthopaedic Nursing. No. 1. pp. 26-29 Seligson D & Stanwyck TS (1982) The general technique of external fixation. In Seligson D & Pope M (eds) Current concepts in external fixation New York, Grune & Stratton, pp. 100-107 Sims M (1996) Protocols for the care of external fixator pin sites. Professional Nurse. Vol. 11. No. 4. pp. 261-264 Sproles K 1985 Nursing care of skeletal pins: a closer look Orthopaedic Nursing 4(1 ) 11-19 Stewart J D M & Hallett J P 1983 Traction and orthopaedic appliances 2nd Edition London: Churchill Livingstone Taylor I 1987 Ward manual of orthopaedic traction Edinburgh: Churchill Livingstone Wallis S 1991 An agenda to promote self-care; nursing care of skeletal pin sites Professional Nurse 6 (12) 715-720
BIBLIOGRAPHY Bryant G G 1998 Modalities for immobilisation in Maher A B Orthopaedic Nursing 2nd Edition Philadelphia: W B Saunders Footner A 1992 Orthopaedic Nursing 2nd Edition London: Bailliere Tindall Nicoll K B 1977 Principles of traction in Rowe J & Dyer L Care of the orthopaedic patient Oxford: Blackwell Scientific Rowley D 1996 The management of war wounds involving bone Journal of Bone & Joint Surgery 78 (5) 706-9 Stewart J D & Hallett J P 1983 Traction and Orthopaedic Appliances Edinburgh: Churchill Livingstone
LEARNING OUTCOMES On completion of the article the reader should be able to: 9 9 9 9
z O }-.
Understand and follow the main principles of traction Set up and maintain the c o m m o n types of traction Safely and competently care for a patient in traction Identify and take action if any complications due to the traction occur.
u
UKCC CATEGORIES
o
This article will enable the reader to address PREP requirements through the following U K C C categories for professional development:
iii -I
9 9 9 9
z O
Reducing risk C a r e enhancement Practice development Education development.
Examples of how this may be achieved, and possible evidence for the reader's professional profile are given throughout the article. O t h e r ways to demonstrate your professional development may be through:
iii ii
O n~
9 Develop a teaching p r o g r a m m e for junior members of staff and implement it. 9 Reassess your care of patients on traction in light of current knowledge and if necessary produce an action plan to change practice. 9 Keeping a copy of this article, any notes you may make as a result of reading it and the w o r k from the 'reflection items' in the text.
rl
t~ z
z F-
RESTRICTING
MOVEMENT
z O u
Peter Davis MA, BEd, RN, DN, ONC, Research Nurse, Queens Medical Centre, Nottingham, Lois Barr RGN, ONC, PGCer~, Assistant Course Director Correspondence to: Peter Davis, 83 Fosse Road, Farndon, Newark Notts NG24 3TL UKTeI.: 01636 705576; Email: peter s d a v i ~ a l k 2 I,com
A patient's freedom of movement is usually restricted for either protective and/or therapeutic reasons; the whole or part of an individual may be affected. Therapeutic restrictions promote healing and comfort and prevent further damage or injury from occurring. In situations where therapeutic restrictions of movement are necessary, the relationship between patient and nurse must be a partnership. This ensures understanding of why movement has been restricted and therefore patient anxiety is reduced and compliance increased. There are several methods of restricting movement that are used by orthopaedic nurses and traction is one of them.
ORIGINS Traction is the act of pulling or drawing. More specifically, orthopaedic traction occurs when 'a
Journal of Orthopaedic Nursing (1999) 3,222-227 9 1999Harcourt PublishersLtd
pulling force is exerted on a part or parts of the body' (Davis 1989). To be able to pull there must be something to pull against; that is, something which is pulling in the opposite direction. This is known as counter-traction and occurs when a pulling force is exerted that opposes the direct pull of the traction. Hippocrates, in 350 BC, when describing the use of traction in reduction (realignment of the bones) of a fractured leg, gave the example of two strong men pulling in opposite directions: the pull in one direction was traction, and that in the other direction, counter traction. In this example the surgeon applies the traction manually and the weight of the injured person with the fractured femur is the counter-traction. Gordon Buck in 1840 described a method of treating a fractured shaft of femur by using lengths of adhesive plaster applied longitudinally to the medial and lateral aspects of the limb. Circular bandages and an arrangement of cords secured them, pulleys and weights ensured a continuous pull that
Principles of traction
maintained alignment and fracture length. The Thomas's splint was described originally by Hugh Owen Thomas in 1876 and used in the ambulant management of chronic or subacute inflammation of the knee joint. Today his splint has a far wider range of uses.
USES Traction can be used for several reasons: 9 To reduce or hold, as in dislocations and fractures 9 To overcome the effect of the original deforming forces and thus reduce a fracture or dislocation of a joint. To control movement of an injured part of the body, thus facilitating the healing of bone. To lessen the muscle spasm that always occurs following fractures and dislocations. To prevent or correct deformity, as in contractures. For example, it can prevent or correct flexion deformity that may occur following inflammation of the hip joint due to infection. Traction overcomes the inevitable muscle spasm and prevents or corrects soft tissue contracture that would reduce the range of movement in the joint. For the same reason traction can be used to prevent contraction of healing soft tissues following joint surgery. Finally, traction may be used to rest joints, as in disease or injury. It can lessen the muscle spasm, as in back pain, or reduce the movement of diseased joints, such as in tuberculosis, and thus minimise pain and facilitate initial healing.
METHODS OF APPLYING TRACTION To apply traction a satisfactory grip must be obtained on a part of the patient's body. This may be achieved through the skin or bone and may be for short or long periods of time: 9 Manual traction is applied by the hands. As, for example, when a doctor reduces a fracture or holds an alignment whilst a cast or more permanent form of traction is being applied. 9 Skin traction is the application of the traction force over a large area of skin and this is then transmitted via the soft tissues to the bone; the maximum pull should not exceed that recommended by the manufacturers of the traction appliance, usually 10-15 lb (4.5-6.7 kg). Two common methods of applying this traction are the adhesive and non-adhesive forms. The adhesive type is not recommended for patients
223
with friable or damaged skin, as the adhesive used and the removal of the adhesive strips may cause further damage. Non-adhesive types are preferred if the traction has to be on for only a short period of time. For example, when used to reduce muscle spasm due to a fractured neck of femur in the few hours prior to surgery. Skeletal traction is the application of the traction force directly to a bone, commonly through metal pins or wires. These are then attached to some type of loop or stirrup and then by means of traction cord to weights and pulleys.
Counter-traction In any traction set-up, the whole body tends to be pulled in the direction of the traction force if counter-traction is not present. Counter-traction may be achieved in two main ways: 1. Fixed traction is the application of countertraction acting through an appliance that obtains purchase on a part of the body. To apply a force against a fixed point on the body, an appliance such as a Thomas' splint is used (see Fig. 1). The ring of the splint snugly encircles the root of the limb, i.e. the groin and hip. Traction cords are tied to the distal end of the splint and the counter-traction force passes along the sidebars of the splint to the ring, as indicated by the arrows. The grip on the leg is achieved by adhesive skin or skeletal traction. 2. Sliding or balanced traction utilises the weight of all or part of the body, acting under the influence of gravity, to provide counter-traction (Stewart & Hallett 1983). For instance, the bed is tilted so that the patient tends to 'slide' or move in the opposite direction to that of the traction force (see Fig. 2). In reality, the pull of gravity should equal that of the traction so that the two are 'balanced' and hence the patient remains stationary. The traction force is produced by weights and may be applied through a cord passing over a pulley. Suspension is not traction, as no counter-traction is necessary; it occurs when part or all of the body is suspended to increase the mobility of the patient. It
Traction
Counter-tractionforce
Adhesive skin traction
~~ ' Splintring
Fig. I Fixed skin traction using aThomas' splint. (Davis 1994 with permission from Harcourt Brace.)
224
Journal of Orthopaedic Nursing
Select one traction set up on your ward and decide whether it is fixed or sliding, skin or skeletal. Explain verbally to another nurse why you have classified the traction in this way 30 minutes Fig. 2 Sliding traction using skin extensions and weights. (Davis 1994 with permission from Harcourt Brace.)
Z
0 m
may be used on its own or as part of a traction/suspension system. It is sometimes confused with traction as the same types of equipment may be used to achieve both suspension and traction, and both may be carried out at the same time as part of the patient's treatment. (Box 1.)
F-
U D
A P P L I C A T I O N OF T R A C T I O N
0
Thomas' splint
LLI
,--I
Z
0 m o~
ul LL
0 n,
o,. t~ Z
D Z
Z 0 U
The correct size of Thomas' splint should always be used. It should be supplied for the specific leg, left or right, as the ring is set obliquely at an angle of 120 degrees to the medial bar. The circumference of the thigh, as high up in the groin as possible, is measured and the length of the leg from groin to base of foot (30 cm is added to the length for the correct size of splint). A splint with a half or split ring is essential as this will accommodate any initial swelling. Flannelette or domette slings are made to create a comfortable bed for the limb and then a layer of gamgee is placed along the full length of the sling. Additional gamgee pads should be available to maintain knee flexion and femoral shaft position on application. The splint should be bent to give approximately 5 degrees of flexion at the knee or a Pearson knee flexion piece available to achieve the same knee flexion or more if required. At this stage the skin or skeletal traction is applied. The prepared splint is passed over the limb maintaining manual traction if required. The splint is pushed up to the groin and the tension of the flannelette slings adjusted to maintain the normal bowing of the femur and uniformly support the limb. In addition, an opposing force must be applied to the distal end of the splint by tying off the traction cord with sufficient force to prevent the ring embedding in the groin (see Stewart & Hallett 1983). This acts as counter traction. This principle does not apply if the Thomas' splint is being used to suspend the limb. The relevant traction and/or suspension system is then applied.
femoral shaft fractures. He maintained that the knee should be held in slight flexion by means of a padded sling. The arrangement of cords and pulleys had to be exact to achieve accurate alignment of the fracture, the surrounding muscles and soft tissues, while still achieving the comfort of the patient. Today this traction is usually used in a modified form. Two forces are used to produce a resultant pull in line with the long axis of the femur (Taylor 1987). The patient should be recumbent with the hip and knee in slight flexion and the other leg lying horizontally. A near-vertical pull is exerted on the leg through a sling cradling the knee or thigh. A horizontal pull, using two pulleys, is exerted at the same time on the leg through below knee skin extensions or skeletal traction. The mechanics is such that the horizontal, two-pulley, pull is double that of the near vertical pull. The near vertical pull and the horizontal pull acting together create a resultant pull in line with the long axis of the femur. Elevating the foot of the bed produces counter traction. (See Fig. 3) A soft pillow is placed under the leg to support the thigh and lower leg, leaving the heel free from pressure. Undue pressure in the popliteal space must be prevented by ensuring the sling is well padded and the pillow not too hard. The patient should be taught to lift their buttocks off the bed by using the
l
Hamilton Russell traction Robert Hamilton Russell (1800-1933) studied the problem of how to overcome the muscle spasm of
Fig.3 Hamilton Russelltraction. (Taylor permission from Harcourt Brace.)
1997 with
Principles of traction
trapeze bar and their unaffected leg and so reduce the risk of sacral sores. This rather complicated arrangement of continuous traction requires constant supervision and exact judgement.
Bryant's or Gallows traction This is a convenient and useful form of treatment for fractures of the shaft of femur in children up to the age of 18 months or less than 16 kg. Above this age or weight there is a serious risk of vascular complications leading to ischaemic fibrosis of the calf muscles or even gangrenous changes in the foot and ankle (Taylor 1987). Traction is exerted through full-length skin extensions to both legs. The unaffected leg is always included to ensure the desired position and enable nappy changes and cleaning. The hips are flexed to 90 degrees and both legs suspended vertically. The knees are slightly flexed and sufficient weight applied so that the sacrum is lifted to just clear the bed. The weight of the child's body provides counter traction. (See Fig. 4) Clearance of the buttocks should be checked regularly, there should be just enough room for one finger between the sacrum and the bed. The weights should always be out of reach of the child. Both feet should be diligently checked for impaired circulation whilst the traction is in place. The presence of pulses does not eliminate the possibility of calf ischaemia. Skin breakdown over the malleoli, the dorsum of the foot and behind the knee should be continuously checked. Small meals should be given initially to prevent distension and vomiting but usually the child quickly adjusts. (Box 2.)
THE NURSING IN TRACTION
CARE OF PATIENTS
The nurse must have a clear understanding of how different types of traction work, and realise that although maintenance of a safe, efficient traction
Fig. 4 Bryant's- Gallows traction. (Taylor 1987with permission from Harcourt Brace.)
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Ask one of your local traction equipment representatives to demonstrate new or existing products on your ward or unit. Offer constructive criticism and consider the pros and cons. 2 hours
system is important, the patient must not be forgotten; for example, when the nurse is setting up or attending to a traction system. The patient in traction has social and psychological needs as well as physical ones; most of these relate to maintaining a safe environment, and in helping to meet them the nurse should consider the following: 9 The traction system should be thoroughly checked at least dally and always after interventions such as physiotherapy and radiographic examination, as the system may be inadvertently altered. 9 Only traction cord should be used as this does not stretch and is of the correct circumference and strength. 9 The cords must be attached securely by standard knots that will not move or come undone - for example, a clove hitch or two half hitches (see Taylor 1987 for further details). 9 The ends of the cords should be short (5 cm) and bound back onto themselves with adhesive tape. This prevents fraying of the cord end and thus possible slipping and accidental disruption of traction. The knot itself should not be covered. It is a misconception that the tape reinforces the knot; the knot should be secure enough by itself. 9 Short cords should not be joined by knots as they would not run freely through pulleys, and if incorrectly tied would slip and come undone. 9 Cords should be checked daily for fraying, particularly where they pass over pulleys, or are rubbing against each other. Otherwise the systems' efficiency is reduced or the cord may break. 9 The line of pull of the cords should be correct and regularly checked. This ensures that the appropriate pulling force is applied for optimal therapeutic effect at all times. 9 Pulleys must be free running and oiled as necessary to prevent squeaking. Friction is thus minimised and efficiency maintained, and the patient is not disturbed by the noise. Many pulleys today have plastic components and thus need no maintenance. 9 The cords must rest comfortably in the pulley, one cord to each pulley wheel. This reduces friction and fraying of the cord.
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Journalof OrthopaedicNursing
Patient problem/ nursing diagnosis Anxiety
Impaired skin integrity
Altered peripheral tissue perfusion
Neurovascular dysfunction Impaired physical mobility
Pain
Altered elimination
Risk of infection of pin sites
Intervention Explain nature and function of traction. Make clear the limitations of movement and activity. Respond to any questions and reassure Check that traction system is not applying harmful pressure to parts of the body. For example, the area in contact with the ring of a Thomas' splint. Assess skin covered by traction system for signs of dryness, redness or allergic reaction. Reposition patient frequently and assess general pressure risk areas. Check colour, warmth and swelling of the affected limb(s) frequently, i.e. every 30 minutes to 4 hourly due to increased risk of Deep Vein Thrombosis and Compartment Syndrome. Ask patient to report any changes of sensation or pain. Elevate limb, if not already, and encourage patient to dorsi and plantar flex the ankle. Check movement and sensation every 30 minutes to 4 hours, especially immediately after the traction applied or making alterations to weights, alignment and system generally. Ensure correct alignment of the part of the body in the traction system to maintain traction efficiency. Encourage independence in activity by providing aids and equipment. Exercise all unaffected joints and extremities. Assess pain frequently and provide appropriate analgesia. Move patient carefully and steadily to minimise pain and discomfort. Ask patient to report any changes in levels and site of pain. Ensure privacy and comfortable position when using bedpans and urinals. Encourage high fibre, high fluid intake to prevent constipation and urinary tract infection. Inspect at least daily for looseness of pins or wires and infection at the sites of insertion. Ask patient to report any pain at pin sites. Adhere to aseptic procedures and institutional protocols for changing dressing and pin site care.
9 The weight(s) used must be known and recorded in the nursing documentation, as the required pulling forces of a traction system are often changed during the course of treatment and members of the caring team need this information. 9 The weight(s) must hang free and not rest on the floor; otherwise, the efficiency of the system is not maintained. 9 To minimise discomfort for the patient, the weight(s) should not catch or jam, particularly on the bed ends, when the patient moves. 9 Weight(s) should not be hung over the patient. However, if this is necessary, an extra safety cord should be used. 9 Weight(s) should be securely attached by a fish hook (S hook), where available. This aids safe but easy removal of the weight(s) if necessary, for example during physiotherapy. 9 Pointed ends of pins or wires, used in skeletal traction, should be covered to prevent injury to the patient and staff. 9 The patient should be on a firm-based bed to give full support and comfort and allow efficient action of the traction system. 9 Bed aids should be used to keep bedclothes away from the patient as necessary, for comfort and to ensure free running of the traction cord(s).
The patient in traction will have problems and needs due to their reduced mobility and as a direct result of the traction system that should be diagnosed by the nurse. Table 1 outlines some of the problems and the required nursing intervention. (Box 3.)
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Look at Table 1 and select one patient on traction. Compare the patient's documented care with that in Table 1 and review their planned care if necessary. 30 minutes
Pin site c a r e There is a lack of research and consistency in protocols related to pin site care. Treatment with skeletal traction involves the positioning of wires or pins, in or through the bone, protruding through the skin to be attached to rings or bars. This leaves an open channel from the skin normally colonised by bacteria, and the medullary cavity, which is normally sterile. There are variations in protocols but they are based on the same principles. Sims (1996) found a wide variety of pin site care practices based on doctor/nurse preference rather than research. A basic protocol should include the following:
Principles of traction 9 initial dressings should remain in place for 48 hours 9 the first dressings should be performed using an aseptic technique with normal saline and sterile sponges or cotton buds 9 the skin is eased gently away from the pin and any crusts removed 9 normal saline used to clean pin sites. Cleaned and dried with sponges or cotton buds, a new one is used for each pin 9 the pin sites are left uncovered unless discharging 9 if the pin sites are discharging dressings should be wrapped around the pin to allow drainage away from the pin site 9 the pin sites should be inspected daily
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both daily, to prevent infection. However, it is suggested that this practice may cause corrosion of the pins and possibly increase the risk of infection.
THE
FUTURE
The use of traction has waxed and waned in developed countries but its use has never disappeared. The increased use of home care makes traction less expensive than when a long hospital admission was also required. In addition factors such as the increasing risks of acquiring untreatable infections as a result of surgery makes traction an increasingly realistic option.
REFERENCES
Compare the protocol of Sims (1996) with your own and as a unit review and discuss any potential changes. 2 hours
Seligson and Stanwyck (1982) advocated massaging to loosen the skin from around the pin site. Sims (1996) recommends dally pin site cleaning. As yet there is no conclusive research to suggest that any one solution is better than another for cleaning pin site wounds (Sproles 1985, Wallis 1991). However, R o w e (1997), found that in pin sites where no solution has been used there is the least infection rate. Henry (1996) advises the use of woven gauze as unwoven or cut gauze may leave fibres in the pin site. Henry, (1996), found that pain and redness were always the first indications of potential infection and that it is possible to confine infection to one pin site with a good technique. Over-granulation may occur around the pin and can be treated with silver nitrate compound or terra-cortril ointment. However, once the offending pin is removed the problem resolves spontaneously. Covering the wound may prevent possible contamination and touching by the patient; however, leaving it exposed allows easy observation of the site. The site is often sprayed with povidone iodine or covered with povidone iodine-soaked gauze,
Davis P S 1989 The principles of traction. Nursing (Oxford) 3 (34) 5-8 Henry C (1996) Pin sites: Do we need to clean them? Practice Nursing. Vol. 7. No. 4. pp. 12-17 Rowe S (1997) A review of the literature on the nursing care of skeletal pins in the paediatric and adolescent setting. Journal of Orthopaedic Nursing. No. 1. pp. 26-29 Seligson D & Stanwyck TS (1982) The general technique of external fixation. In Seligson D & Pope M (eds) Current concepts in external fixation New York, Grune & Stratton, pp. 100-107 Sims M (1996) Protocols for the care of external fixator pin sites. Professional Nurse. Vol. 11. No. 4. pp. 261-264 Sproles K 1985 Nursing care of skeletal pins: a closer look Orthopaedic Nursing 4(1 ) 11-19 Stewart J D M & Hallett J P 1983 Traction and orthopaedic appliances 2nd Edition London: Churchill Livingstone Taylor I 1987 Ward manual of orthopaedic traction Edinburgh: Churchill Livingstone Wallis S 1991 An agenda to promote self-care; nursing care of skeletal pin sites Professional Nurse 6 (12) 715-720
BIBLIOGRAPHY Bryant G G 1998 Modalities for immobilisation in Maher A B Orthopaedic Nursing 2nd Edition Philadelphia: W B Saunders Footner A 1992 Orthopaedic Nursing 2nd Edition London: Bailliere Tindall Nicoll K B 1977 Principles of traction in Rowe J & Dyer L Care of the orthopaedic patient Oxford: Blackwell Scientific Rowley D 1996 The management of war wounds involving bone Journal of Bone & Joint Surgery 78 (5) 706-9 Stewart J D & Hallett J P 1983 Traction and Orthopaedic Appliances Edinburgh: Churchill Livingstone