CARE OF PATIENTS WITH TRACTION :

NURSING PERSPECTIVE

Traction is the use of a pulling force to treat muscle and skeleton disorders.

Traction must be applied in the correct direction and magnitude to obtain its therapeutic effects

HISTORY • Skin traction used extensively in Civil War for

fractured femurs Known as the “American Method”

• Fritz-Steinmann introduced a method of applying skeletal traction to the femur by means of two pins driven into the femoral condyles

Lorenz-Bohler – ‘The Father of Traumatology’ popularised skeletal traction by means of steinmann pins

.

PURPOSE OF TRACTION • used primarily as a short term intervention until

other modalities such as external or internal fixator are possible reducing the risk of disuse syndrome .

• to relieve pain

• reduce, align and immobilize fractures, to reduce deformities and to increase space between opposing surfaces

• to maintain proper alignment until bone develops

Foster.k.Journal of orthopedic nsg.2006;138-143

INDICATIONS

• to reduce fractures – the application of traction overcomes the injured limbs tendency to shorten ( due to muscle spasm) and holds the limb constantly in a position of corrective extension with the ends of the fractured bone aligned

• immobilization of an area

• relief from general, vague back pain

• before surgery

INDICATIONS CONTD..

• control and relieve of painful muscle spasm

• stretching adhesions

• treatment of painful arthritis, sore muscles and ligaments, dislocations, degenerated or ruptured intervertebral disks and spinal cord compression

• degenerative joint disease

• nerve root syndromes and herniated discs

CONTRA INDICATIONS

• Patients with structural diseases secondary to tumor or infection, rheumatoid arthritis and severe vascular compromise.

• Acute strains, sprains and inflammation conditions

• Malignancy

• aneurysm

ASSESSMENT

• It is important to evaluate the body part to be placed in traction and its neurovascular status and compare it to the unaffected extremity.

• As long as the client is in traction, skin integrity must be assessed and documented, examining especially for redness, bruises, and lacerations.

Diagnostic Evaluation

Radiological Evaluation while the client is in traction determines the extent of injury, maintenance of bony alignment, and the progress of healing

SKIN TRACTION

INDICATIONS

• Temporary management of # of NOF and IT #

• Management of # - Femoral shaft of older and hefty children

• Undisplaced # of acetabulum

• After reduction or dislocation of Hip

• To correct minor fixed flexion deformities of hip and knee

Special considerations……

• Abrasions and lacerations of skin in the area to which traction is to be applied

• Varicose veins, impending gangrene

• Dermatitis

• When there is marked shortening of the bony fragments as the traction weight required is greater than which can be applied through the skin

TYPES OF SKIN TRACTION

• PELVIC TRACTION

NURSING CARE

• Ensure that the pelvic girdle is of proper size for patient

• Ensure that pelvic girdle fits snugly over iliac crests and pelvis

• Inspect skin areas over iliac crests for pressure points q4h

• Provide perineal area hygiene after bedpan use

NURSING CARE CONTD..

• Ensure integrity by providing back care q4h

• Lift and turn patient’s use of trapeze if it alters compressive forces on pelvis

• Maintain bed in flat position

• Change bed linen from head to foot rather than from side to side

Buck's Traction (Buck's Extension)

NURSING CARE

• Ensure skin integrity by avoiding pressure on heel, dorsum or foot, fibular head, or malleolus

• Maintain counteraction by elevating foot of bed or keeping head of bed flat

• Encourage independence with use of trapeze

Russell's Traction (Balanced Traction)

NURSING CARE

• Assure skin integrity by avoiding pressure on heel, dorsum of foot, fibular head, or malleolus

• Maintain counteraction by elevating foot of bed or keeping head of bed flat

• Encourage independence with use of trapeze

• Ensure sling is smooth and does not apply undue pressure on popliteal space or peroneal nerve or lateral aspect of knee

BRYANT'S TRACTION

NURSING CARE

• Raise buttocks slightly from mattress

• Observe bandages carefully for slippage and bunching over heel cords

• Observe for skin sloughing on both legs

• Check feet for color, pulses, warmth, and sensation q2h to q4h

• Use harness restraint to prevent turning over

NURSING CARE CONTD..

• Avoid thick, wide diapers between legs

• Used in children younger than 3 years, weighing less than 30lb

• Ensure skin integrity with non adhesive straps and wraps that do not impair neurovascular status

• Ensure buttocks are elevated 1 to 2in. from mattress

• Ensure parents’ understanding of the purpose and use of traction

• Utilize jacket or vest restraint to prevent child from rotating in the bed

CERVICAL HEAD HALTER TRACTION

NURSING CARE • Apply manual traction if pin loosens or penetration occurs. Notify

physician immediately.

• May use turning frames or special beds for positioning

• Provide pin care according to physician’s order and institutional policy

• Take care that weight and pulley are free of wall

• Observe for pressure areas

Jaws and ears

Side of head

Back of head

• Pad as necessary for comfort

Related literature reviews…….

Effect of cervical traction on cardiovascular functions. Journal of orthopedics.2011.vol 34(7).

Study done on 96 young women randomly

divided into 3 groups to study the effect of cervical traction with different traction weights on blood pressure, heart rate, heart rate variablity and correlated autonomic adjunctment. It was found that traction weight of 10% to 20% of body weight can be safetly provided without significant cvs complications. But heavy traction weight (30%) should be avoided.

Journal of Orthopedic sports and physical therapy.2008;38(9)

The use of mechanical intermittent cervical traction combined with other interventions such as manual therapy and strengthening exercises can reduce pain and disability in patients with neck and neck-related arm pain.

Intermittent and continous cervical traction has significant effect on neck and arm pain reduction, a significant improvement in nerve function and a significant increase in neck mobility.

- Elnagger et.al.Egypt J.Neurol. Psychiat. Neurosurg. Vol.46(2),2009

Physiological effects of Intermittent traction on herniated disc, degenerative disc disease and hypomobile facet joints include

separation of vertebral bodies

distraction and gliding of facet joints

widening of intervertebral foramen

strengthening of spinal curves

stretching of spinal musculature

Graham et.al. Journal of Rehabilitation Medicine.2006.38(3):145-52

• Study on effectiveness of intermittent cervical traction therapy, using short-latency somatosensory evoked potentials (SSEP) in mild myelopathy, radiculopathy and cervical sprain.

The interpeak latencies for patients with type I & type II

myelopathy decreased, and the severity of myelopathy was inversely related to the degree of decrease. Traction therapy might improve conduction disturbance primarily by increasing the amount of blood flow from the nerve roots to the spinal parenchyma.

Journal of Orthopedic Science.Vol 7, no:2, 2002

• A multicenter randomized clinical trial was conducted to examine the effects of manual therapy, exercise and cervical traction on pain, function and disability in patients with cervical radiculopathy.

The study results concluded that the addition of mechanical cervical traction to a multimodal treatment program yields no significant additional benefit to pain, function or disability.

Ian A. young et.al. Journal on American Physical Therapy,2009

A systematic review on mechanical traction for mechanical neck disorders

The objective of the study was to assess whether mechanical traction, either alone or in combination with other forms of traetment, improves pain, function/disability, patient satisfaction and global perceived effect in adults with mechanical neck disorders.

The results of the review showed evidence of benefit favouring intermittent traction for pain reduction. Continous traction showed no significant difference in outcome.

Nadine et..al.Journal of rehabilitative medicine.2006;38:145-152

• OTHER TYPES OF SKIN TRACTION……

FORE ARM SKIN TRACTION

DOUBLE SKIN TRACTION

DUNLOP’S TRACTION

Complications

• Allergic reactions to adhesive

• Excortication of skin

• Pressure sores

• Common peroneal nerve palsy

SKELETAL TRACTION

• is a applied directly to the bone with wires or pins that are inserted during surgery.

• Used to treat the unstable spine

• Pull along axis of spine

• Preserves alignment and volume of canal

• Gardner-Wells and Crutchfield tongs commonly used

INDICATIONS

• It may be used as a means of reducing or maintaining the reduction of a fracture

• It should be reserved for those cases in which skin traction is contraindicated

GARDNER TONGS • Easy to apply

• Place directly cephalad to external auditory meatus

• In line with mastoid process

• Just clear top of ears

• Screws applied with 30 lbs pressure

NURSING CARE

• Pin site care important

• Weight ranges from 5 lbs for c-spine to about 20 lbs for lumbar spine

• Excessive manipulation with placement must be avoided

• Poor placement can cause flex/ext forces

• Can get occipital decubitus

CRUTCH FIELD TONGS

HALO TRACTION

Rinella A et.al.Perioperative halo-gravity traction in the tratment of severe scoliosis and kyphosis. Erratum in spine.2005,30(8).994

A retrospective analysis of 33 patients were done before anterior or posterior spinal fusion. Patients underwent halo-gravity traction as an adjunct to modern instrumentation methods. Halo-gravity traction was found to be a safe, well tolerated method of applying gradual, sustained traction to maximize postoperative correction in this population.

HALO VEST

• Pin site infection a risk

• Can remove pins and place in different hole

• Pin penetration can produce CSF leak

• Scars over eyebrows

• Can get sores beneath vest

Caring of halo vest and pin site care Angela Sarro et.al.American journal of neuroscience

nurses.vol.42,2010 Complications

• Pin loosening (36-60%)

• Pin site infection (20%)

• Ring migration and Loss of

immobilization (10-13%)

• Skin breakdown & Pressure sores (4-11%)

• Dysphagia(5%)

• Dural Punctures (1%)

Protocol for pin site care

• Visually assess the pin sites frequently

• Pinsite care provided atleast once per shift

• In case of crust or drainage, increase the frequency to 3 times per day.

• Clean the pin site with clean cotton tip applicator or gauze soaked in NS

• Avoid using ointments and solutions such as peroxide and chlorhexidine.

• Monitor for red flags : redness,swelling,discharge and drainage,tracking.

Halovest care

• Assess skin for redness or areas of potential skin breakdown.

• Wash under the vest with the patient lying down.

• Do not use lotions or powders underneath the vest.

• Instruct patient to wear cotton clothing under the vest for comfort and absorption of perspiration.

OLECRANON PIN TRACTION

METACARPEL PIN TRACTION

Complications • Introduction of infection into underlying areas

• Pin site infection and pin loosening

• Damage to neurovascular structures

• Ligamentous damage

• Damage to epiphyseal growth plates

• Depressed scars Hak Dj et.al.American journal of Orthopedics,2002

NURSING CARE

• Cover ends of pin with cork

• Observe site of insertion for :

Redness

Swelling

Discharge

Odor

Bleeding

• Clean skin around puncture sites as ordered

International journal of Orthopedic and Trauma Nursing(2013),19-28

Consensus Guidelines related to pin site care

Lee-smith,J.et.al(2001).Journal of Orthopedic

Nursing • Inspect the wound site within 24 hrs of

surgery

• Re-dress all pinsites after 24 hrs.

• Use only sterile NS or water to clean the exudate away from the area around the pins.

• Use a dressing that applies minimum amount of pressure and keep it continously in place.

• Aseptic technique must be rigourously maintained.

• Observe the pin site regularly for:

Increased tenderness

Increased level of exudate

Presence of pus

Odour from the site

Any signs of increased inflammatory process

Leave the wound dry after cleaning

Gently remove scabs and crusts around pin sites by cleaning with gauze

Educate patient and family to look for pin site infection during home care.

Radiographic examination

• 2-3 times in first week

• Weekly for next 3 weeks

• Monthly until union occurs

• After each manipulation

• After each weight change

NURSING MANAGEMENT OF TRACTIONCOMPLICATIONS

SKIN BREAKDOWN

• during the initial assessment, the nurse identifies sensitive, fragile skin (common in older adults)

• the nurse closely monitors the status of the skin in contact with tape or foam to ensure that shearing forces are avoided

• removes the foam boots to inspect the skin, the ankle and the Achilles tendon three times a day

• palpates the area of the traction tapes daily to detect underlying tenderness

• provide back care at least every 2 hours to prevent pressure ulcers. The patient must remain in a supine position to prevent the increased risk of the development of pressure ulcers

• uses a special mattress overlays (e.g filled, high-foam) to prevent pressure ulcers.

Shabat S et.al.Jounal of Tissue Viability.2002.12(3):108-112

• Study done on elderly patients with hip fracture. Skin traction device was found to have the disadvantage of causing serious skin slough. This inturn interferes with the normal curve of rehabilitation and can prolong hospital stay.

NERVE DAMAGE

• When traction is applied to the lower extremity, care must be taken to avoid pressure on the peroneal nerve at the point at which it passes around the neck of fibula just below the knee.

Pressure at this point can cause foot drop.

• Weakness or dorsiflexion of foot movement and inversion of the foot indicate pressure on the common peroneal nerve.

• regularly assess sensation and motion

• immediately investigate any complaint of burning sensation under the traction bandage or boot

• promptly report altered sensation or impaired motor function

CONSTIPATION AND ANOREXIA

• Encourage a diet high in fiber and fluids may stimulate gastric motility

• If constipation develops – Therapeutic measures may include: stool softeners

• To improve patient’s appetite, the nurse can identify and includes the patient’s food preferences, as appropriate, within the prescribed therapeutic diet.

VENOUS THROMBOEMBOLISM • The nurse teaches the patient to perform ankle and foot

exercises within the limits of the traction therapy every 1-2 hours when awake to prevent DVT.

• The patient is encouraged to drink fluids to prevent dehydration and associated hemoconcentration, which contributes to stasis.

• The nurse monitors the patient for signs of DVT including unilateral calf tenderness, warmth, redness and swelling (increased calf circumference)

• The nurse promptly reports finding to the physician for definitive evaluation and therapy.

CIRCULATORY IMPAIREMENT

• cold skin temperature

• decreased peripheral pulses

• slow capillary refill time

• bluish skin.

• Assess circulation of the foot or hand within 15 to 30 minutes and every 1 to 2 hours.

• The nurse encourages the patient to perform active foot exercise every hour when awake.

PRESSURE ULCERS

• The nurse examines the patient’s skin frequently for evidence of pressure or friction, paying special attention to bony prominences.

• It is helpful to reposition the patient frequently and to use protective devices (e.g elbow protectors) to relieve pressure.

URINARY STASIS AND INFECTION

• The nurse monitors the fluid intake and character of the urine.

• The nurse teaches the patient to consume adequate amounts of fluid and to void every 3-4 hours

• If the patient exhibits signs or symptoms of urinary tract infection ,the nurse notifies the physician

Parameters to be assessed…..

Circulation

Body alignment and position of the extremity

Prevention of deformity

Counter traction

Slipping

Condition of the skin

Pressure points

Complications

Patient’s comfort

HANDLING NEW TRACTION • Inspect traction apparatus frequently to ensure

♦ ropes are running straight and through the

middle of the pulleys

♦ the weights are hanging free

♦ bed clothes, the bed or the frame or bars of

the bed are not impinging on any part of

the traction apparatus

♦ check ropes frequently to be sure they are

not frayed.

• Avoid releasing weights from or altering the line of pull of the traction.

• Be sure that weights are securely fastened to their ropes

• Avoid manipulation of pins

SKIN CARE • Encourage the patient to turn slightly from side to side and to lift

hip up on the trapeze to relieve pressure on the skin on the sacrum and scapulae

• Bathe the skin beneath the ring, dry it thoroughly, and powder the skin lightly.

• Inspect skin frequently to be sure that it is not being rubbed, macerated by traction equipment; readjust splint or the extremity in the splint to free the skin from pressure

• keep skin areas around the pin sites clean and dry

. TURNING • Never lift or change traction weights without a

doctor’s order

• Do not remove traction or increase or decrease the amount of the weight without specific orders

• Always tell the patient when you’re going to remove or re-apply the tension

• Never drop a weight when reapplying traction but gradually lower the weight so the patient does not undergo sudden extreme stress

• a patient who may have the head rest up and down should be positioned

completely flat at least half the time to prevent hip flexion contractures.

• When traction is applied to the leg a foot plate may be applied to prevent foot drop

• If patient’s leg is in traction the foot should never rest

• Turning to any position is generally permitted as long as the integrity of the traction is not compromised and the patient is comfortable.

• prevent rotation of the leg and splint. The heel should not rest on the bed or pressure necrosis will develop

• If pillows are used they should be firmed so they will provide adequate support and will maintain alignment of the limb of the traction apparatus.

• the elevation of the heel should not hyperextend the knee

Attaining maximum mobility during traction The nurse encourage the patient to exercise

muscles and joints that are not in traction to guard against their deterioration.

During exercise

The nurse ensures that traction forces are maintained and that the patient is properly positioned to prevent complications resulting from poor alignment.

Maintaining Position

1. The nurse must maintain alignment of the patient’s body in traction as prescribed to promote an effective line of pull.

2. The nurse positions the patient’s foot to avoid foot drop , inward rotation, and outward rotation.

3. The patient’s foot may be supported in a neutral position by orthopedics devices.

Quality of care of patients on traction

• An observational study was conducted on 100 patients to evaluate the quality of care for patients with traction in the orthopedic unit of Shahid-Behesthi hospital, Iran.

• 47% of patients were treated by skin traction & 53% by skeletal traction.The study concluded that quality of establishing traction was good in 55% of patients, but the quality of care was poor in the domains of recording care and patient education.

Mohsen et.al. Archives of Trauma Research.2013;2(2)85-90