Traction

Traction is the application of a pulling force (associated with a countertraction) applied to a body part or extremity (while the countertraction pulls in the opposing direction) for therapeutic goals e.g. in fractures for realignment (reduction) or in bone dislocations; in pain relief during muscle spasms via immobilization; prevention of spinal injury; etc.

Mechanism of Traction

1. Traction
2. Countertraction in the opposite direction
3. Vector of Force
4. Resultant Line of Pull: the midpoint of the two forces.

Principles of Traction

1. Avoid friction. There should be minimal friction within the ropes and pulley.
2. Countertraction should be used to achieve effective traction.
3. Traction must be continuous to be effective in reducing/immobilizing fractures.
   • Skeletal traction is never interrupted
   • Weights are not removed unless intermittent traction is prescribed.
4. Line of pull should be in line with the deformity.
5. Any factor that might reduce the effective pull or alter its resultant line of pull must be eliminated.
   • The patient should be positioned supine or dorsal recumbent.
   • Ropes should be unobstructed e.g. remove knots
   • Weights must hang freely and not rest on the bed or floor.
   • Knots in the rope or the footplate must not touch the pulley or the foot of the bed.

Parts of Balkan Frame

The “orthopedic bed” where traction is performed. There are:

1. Four vertical bars on each corner of the bed.
2. Two horizontal bars parallel to the bed.
3. Three (or more) cross bars, perpendicular to the bed.
4. Pulleys
5. Hanging Trapeze
6. Firm Mattress
7. Fracture Board: the board under the bed used to stability.
8. Foot Plate: used to prevent plantar flexion (foot drop) which alters the resultant line of pull.

Equipment for Balanced Skeletal Traction

1. Balkan Frame
2. Steinmann’s Pin
3. Thomas Splint
4. Pearson Attachment
5. Rest Splint
6. Sash Cord (Ropes)
7. Slings
8. Suspension Bag (5% of traction weight) tied to the suspension rope (longest rope)
9. Traction Bag with Weights (10% of total body weight)

Types of Traction

Skeletal Traction

This is performed when a strong pulling force is required, where tongs, pins, or screws into the bone from which the weight is attached.

• Weights of 25 to 40 lbs are used.
• Complications:
  • Pressure ulcers (bed sores): reposition every 2 hours while maintaining traction.
  • Constipation due to immobility (reduced stimulation of peristalsis)
  • Urinary stasis: bladder distention from urinary retention, UTI
  • Venous stasis with deep vein thrombosis, a blood clot.
  • Pneumonia due to immobility. Encourage deep breathing exercise.
  • Anorexia (loss of appetite)
  • Infection due to the invasive procedure.
• Nursing Interventions
  • Maintain effective traction
  • Maintaining positioning
  • Preventing skin breakdown (avoid pressure ulcers)
  • Monitoring neurovascular status; paresthesia, color, etc.
  • Providing pin site care (avoid infection): hydrogen peroxide (may be diluted) or povidone iodine (betadine)

Cervical Skeletal Traction

1. Gardner-Wells Tongs are commonly used, where holes are drilled into the side of the skill and tongs are inserted into the holes used to stabilize the cervical spinal cord.
2. Halo Device

Femoral Traction

1. Upper Femoral Traction: the fracture, if located in the anterior or medial thigh (femur), a lateral traction is used for medial or anterior forces. INC
2. Distal Femoral Traction: the fracture, if located in the axis of the femur INC

Perkin’s Traction

• Used for a fractured tibia and femoral shock.
• Used for trochonteric fracture of the femur in patients under 45 to 50 years of age.
• A Denham pin is inserted through the upper end of the tibia for the fracture of the femur.

Distal Tibial Traction

Stabilizes fractures in the distal tibia (shin bone) or in certain tibial plateau fractures.

• The pin is inserted five centimeters above the level of the ankle joint, midway between the anterior and posterior borders of the tibia.
• Avoid the sephanous vein, the main venous vessels of the leg.
• Place through the fibula to avoid peroneal nerve.
• Maintain partial hip and knee flexion.

Balanced Skeletal Traction

Used to stabilize a fracture of the femur. This may also be a skin-type traction. Ropes are used to maintain the bone in its proper place so that the bone can heal. This may take 4 to 6 weeks or more.

Skin Traction

This is performed for temporary traction, where only a light and/or discontinuous force is required.

• Weights of 5 to 7 lbs are used, attached to the skin via adhesives or nonadhesive tape, or with straps, boots, or cuffs.
• Complications:
  • Skin Breakdown: monitor frequently. Attachments may be removed temporarily.
  • Nerve Pressure: from tightness of the attachments; check color and tactile feeling of the patient.
  • Circulatory Impairment: from tightness of the attachments; check color and distal pulses.
• Nursing Interventions
  • Ensure effective traction; frequently check the traction devices and avoid injuries caused by the apparatus.
  • Monitoring and managing potential complications

Buck’s Traction or Extension

Used in temporary (24 to 48 hours before surgery) management of the fractures of the femoral neck, femoral shaft in older children, undisplaced fractures of the acetabulum, after reduction of hip fractures, to correct minor flexed deformities of the hip or the knee, in place of pelvic traction, and in management of lower back pain.

• Can use tape or pre-made boot.
• Weights used are not more than 4.5 kgs.
• Not used to obtain or hold reductions of fractures.

Hamilton Russell Traction

The same as Buck’s but with a swing, which may be used in more distal femur fractures in children and may be modified to hip and knee exerciser.

• Angle used is often ~20 degrees.
• Monitor the patient for complications: circulatory obstruction, neurovascular complications, etc.

Gallow’s Traction

Used in femoral shaft fractures in children less than eighteen months old, and twelve to sixteen kilograms.

• The buttocks is clear of the bed, and the legs are pointed straight up.
• Monitor for complications.

Bryant’s Traction

Used for femoral shaft fractures in infants and small children. It combines a gallow traction with a Buck’s traction.

• The mattress is raised to provide countertraction, with the infant’s hips raised by approximately 15 degrees.
• Rarely used.

Forearm Skin Traction

The use of adhesive strip (with ace wrap) used for elevation, stabilization, and reduction of pain. Can treat difficult clavicular fractures with excellent cosmetic result.

• Has risk for skin breakdown; intervene by removing and checking bandages every 24 hours.
• Elbow is flexed at 90 degrees.

Dunlop’s Traction

Used for supracondylar and transcondylar (elbow) fractures in children when closed reduction is difficult or traumatic.

• Forearm skin traction with weight on upper arm. The elbow is flexed at 45 degrees.

Head Halter Traction

A simple cervical traction for management of neck pain.

• Weight should not exceed 2.3 kg, and only used for a few hours at a time.
• A cloth wrapped around the head is pulled continuously or intermittent. May be performed while lying down or seated.

Manual Traction

This is performed by a healthcare personnel or operator instead of weights where a very specific and controlled traction force to an extremity or joint is applied.

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Balanced Skeletal Traction Procedure (POC)

• Dependent: check doctor’s orders for traction and weights.
• Greet, identify, and explain procedures to the patient for anxiety and cooperation.

1. Materials and Orthopedic Bed
   • Traction bag: 10% TBW
   • Suspension bag: 5% TBW/50% of Traction Bag
   • Thigh (Shortest), Traction (Longer), and Suspension (Longest) Lines/Ropes
2. Estimate attachment point of the Pearson attachment: tip of the hip to the knee.
3. Ensure the alignment of the Pearson attachment is parallel.
4. Insert the rest splint into the apparatus a distance roughly 3 to 5 inches.
5. Tie the thigh rope to the ischial ring on the medial side (Slipknot), point the knot away from the patient’s skin, and consume the rest of the line on the pearson attachment screw.
6. Attach slings; Principles of sling application (mn. NO PS2): Not tight or loose, One inch in between each sling, Popliteal Fossa and Heel are avoided, Smooth side to skin, and there should be Two larger and Three smaller slings.
7. Prepare to swap the Thomas splint with the Bohler-Braun frame via the three-man method.
   • #1: insertion of apparatus
   • #2: maintain manual traction, remove Bohler-Braun frame
   • #3: lift ang support leg
8. Make any necessary adjustments to slings for patient comfort and secure placement.
9. Set up traction bag. Slipknot onto steinmann hoop, 3rd pulley, then bag. Not too high nor too low.
10. Set up suspension bag. Slipknot the thigh rope on the lateral side. Slipknot the suspension rope onto the thigh rope, and pass through the 1st pulley, bag, then 2nd pulley. Lift the leg at a 45 degree angle and, placing the tie lateral to the traction line, pass under the rest splint and tie a clove-hitch knot on both the Thomas and Pearson W-ends. Consume remaining line. Let the suspension bag hang and then the leg. Remove the rest splint.
11. Principles of traction (mn. PLTAP): position dorsal recumbent, line of pull (1st, 2nd, 3rd pulley) in line with leg, traction continuity (mn. Weights hang freely, Observe bag/rope integrity, Rope in pulley, Knot distance), avoidance of friction, and provide counter traction.