TRACTION AND EXTENSION – Immobilization and Ambulation – Methods, Nurse’s Responsibility, Procedure and After Care.
The goals of treatment of fracture are to restore an injured part for its maximum functioning to prevent complications and to obtain the best possible cosmetic result. Most fractures are treated by ‘reduction’ and ‘immobilization’. Traction is one method of reducing a fractured bone. Fractures may be reduced in three ways:
1. By manipulation (closed reduction)
2. By operative procedure (open reduction)
3. By reduction (traction and extension)
Fracture reduction performed in an attempt to restore the injured bone’s normal anatomic alignment, position and length in order to bring the fracture fragments into close approximation so that healing could be promoted.
Closed reduction (manipulation) is performed by manually applying the traction to lock the ends of the fragments together and thus restore the normal bone alignment. The three basic maneuvers used during manipulations are traction and counter traction, angulation and rotation.
When closed reduction is used the client is usually given a general anaesthetic. The doctor then reduces the fracture by pulling on the distal fragment (manual traction) while another person applies counter traction to the proximal fragment until the bone fragments reconcile their normal alignment. The doctor also may apply direct pressure on the site of the fracture to correct angulation or lateral displacement. Following a closed reduction, X-ray films are taken and a plaster cast is applied.
Open traction is performed under surgical asepsis. After making an incision, the fractured bones are reduced under direct vision. Various internal fixation devices are applied to the bone to maintain the normal alignment. This device consists of metallic screws and plates, pins, wires, nails or rods. These may be placed through the bone fragments or fixed to the sides of the bones or inserted directly into the medullary cavity. When screws and plates inserted, they must be made of same metal to avoid possible electrolytic reaction. While internal fixation devices initially help to immobilize a fracture and prevent deformity, they are not a substitute for bone healing. If proper bone healing does not occur, the metallic structures may become loose or even break, thereby failing to achieve the purpose. For some fractures, the open reduction is the choice of treatment, but it has many potential hazards such as:
a. Introduction of infection into bone.
b. Accidental injury to the major nerves and blood vessels during surgery.
c. Additional damage to the bone or adjacent structures caused by the metallic fixation devices.
d. Impaired circulation due to the destruction of small blood vessels around the bones during surgery.
X-ray films are taken during and following open reduction to evaluate the alignments of the fractured bone.
Reduction traction means the restoration of displaced bony parts to its normal alignment, position and length. It is used to bring the displaced fragments of the broken bone into close approximation to one another and to maintain proper alignment until the healing take place completely.
Nurses are more concerned with the traction as they work in the ward for their maintenance. Traction is an application of a mechanical pull to a part of the body for the purpose of extending and holding that part in a desired position. Therapeutic traction is accomplished by exerting a pull on the head, body or limbs in two directions, i.e., traction and a counter traction. Traction is applied in the direction in which the weight is applied and the counter traction is applied in opposite direction. The weight applied, exerts a pull on the body and it is equal to the amount of weight applied. Counter traction may be either the weight of the body (when the body is in an inclined position) or other weights applied and are always equal to the traction applied.
The counter traction may be obtained by elevating the bed in such a way that the client’s body weight opposes the pull of traction, e.g., the foot of the bed is elevated when traction is applied to the lower extremities, the head end is elevated when traction is applied to the lower extremities, the head end is elevated when a skull traction is applied. If the bed is not tilted properly, the counter traction achieved will be inadequate and the client will tend to slide in the direction of traction force, thus, the purpose of the traction will not be achieved.
Purpose of Traction
1. To restore and maintain the proper alignment of the broken bones, in a fractured site.
2. To relieve pain caused by muscle spasm.
3. To prevent deformities.
4. To correct deformities.
5. To treat dislocations and spinal cord compressions due to prolapsed intervertebral disc.
6. To immobilize a part.
Methods of Applying Traction
Traction is applied by a system of ropes and pulleys. The weights are attached to a fixed point below the area of injury or disease. They are different types of tractions:
1. Skin Traction:
Skin traction is achieved by clinging wide bands of adhesives directly to the skin and applying weights to these bands. The pull of the weight is transmitted indirectly to the involved bone. Buck’s extension, Bryant’s traction and Russell traction are the three most common forms of skin traction used in injury to the lower extremities.
2. Skeletal Traction
In skeletal traction, the traction is applied directly to the bone. Under strict aseptic precautions, a rustless pin or wire (e.g., Steinmann pin or Kirschner wire) is inserted through the bone fragment distal to fracture and out through the skin on the opposite side of the limb. A metal U-shaped spreader is then attached to the wire or pin and the weights are attached to the spreader. Skeletal traction can be used for the fracture of the femur, tibia, humerus and cervical spine. In case of cervical spine, the traction is achieved by the use of Crutchfield tongs applied to the skull.
3. Specific Types of Tractions
Pelvic traction, head halter traction are the examples.
1. Traction is applied under the guidance of a doctor. Ask for the specific instructions regarding the types of traction, the amount of weight to be applied etc.
2. The extremity should be supported and stretched in a direction that will bring the displaced bone fragments to its normal alignment; at the same time, there should be no overstretching because it results in an excessive gaping of bone fragments.
The traction forces must remain constant (in amount and direction) until bone union occurs.
3. By the periodic inspection (daily) ensure that the apparatus is accomplishing its purpose and that the equipment is as safe as possible.Traction ropes should be of adequate strength to support the weights without breaking. See that the frayed rope is replaced with fresh rope to prevent accidental breakage.
4. Traction ropes must be of proper length and contain no unnecessary knots which may be caught in the pulleys. If the rope is too short, the weights may be pulled up against the pulleys. If the rope is too long, the weights may rest on the floor.
5. The ropes should be taut and ride easily over the pulleys. Make certain that the ropes do not slip out of the wheel grooves of pulleys. All pulleys should be lubricated with a small amount of mineral oil before threaded with ropes.
6. The ropes and pulleys should be unobstructed, freely movable and in straight alignment. Weights should hand free, to maintain an even, constant pulling force in a straight line. Weights should not rest on bed, floor or on the chair etc. if the weights supported, the purpose of the traction is foiled.
7, Examine the knots frequently to make sure that they are taut. Knots used for traction equipment should not slip.
8. Traction weights may be made of metal or sand bags of known weight. No alteration in the weight should be made unless is ordered by the doctor.
9. Keep the weights visible so that they are neither displaced, nor kicked over.
10. See that the traction equipments are placed in such a way that the nurses or the client’s attenders will not bump against the weights when attending the client. This can be painful to the client and may cause damage to the diseased bone.
11. Check the position of the client, making sure that his body weight is counteracting the pull of the weights. Counter traction is achieved by raising or lowering the foot or head end of the bed. Should the client slip down in bed and his feet are resting against the foot board, there will be a loss of force exerted on the limb. Remember, it is not necessary to lift the weights when pulling the client up. Lifting the weights makes an interruption to the traction force applied.
12. Observe the client’s posture in bed and position of joints for proper alignment.
13. Observe all bony prominences for signs of impaired circulation and tissue necrosis. Frequent skin care and the care of the pressure points are necessary to prevent tissue necrosis. The bony prominences should be protected with an adequate padding.
14. Never allow the client to sit up in bed even for a short period.
15. Never change the height of the elevating blocks (shock blocks), knee rests etc., without the doctor’s permission. Do not place pillows under a limb in traction without the doctor’s permission. If pillows are permitted initially the doctor should place them, so that the limb is positioned as desired with effective traction. Pillows placed under the limbs, increases the changes in thrombosis.
16. Watch for the complications that a client in traction may develop. Some of the complications are hypostatic pneumonia, atelectasis, constipation, faecal impaction, abdominal distension, urinary distension, kidney stones, impaired circulation, nerve damage, wound infection, disused osteoporosis, muscle atrophy, disorientation.
17. Check the doctor’s orders to determine whether a client can turn or if traction can be removed periodically. Also identify contra-indicated positions. With the physician’s permission, a client may be turned slightly towards the limb which is in traction to give back care.
18. When trapeze bar is used for clients in traction, instruct the client to lift himself straight up, so that the amount of pull exerted on the limb in traction will not be altered. The client may use the trapeze bar with overhead frame when changing the bottom sheets, giving bed pans, giving back care etc.
19. Check for the outward position of the foot and foot drop on the affected limb. The foot drop may be prevented by a strip of adhesive attached to the plantar surface of the foot and extending beyond the toes to a rope that is passed through a pulley with a weight. This should maintain the normal position of the foot and at the same time should not interfere with the traction pull on the limb.
20. Never leave the client in traction alone in a room. It will create insecure feelings in the client.
21. When changing the bottom sheets, always begin with the unaffected side. This decreases the number of times the affected side is disturbed.
See that the mattress is not sagging. If sagging, it should be supported with fracture boards.
22. Provide diversional and recreational therapy for these patients to prevent boredom.
23. Use bed cradles to support the weight of the bed clothes. The bed clothes should not hang over the traction ropes, because it will also add to the weight used in the traction. It can also disturb the traction if pulled carelessly.
24. Every complaint of the client should be listened to. Never ignore a complaint however small it may appear to be.
NURSE’S RESPONSIBILITY IN THE APPLICATION OF BUCK’S EXTENSION (SKIN TRACTION)
1. Check the client’s name, bed number and other identifying data.
2. Check the nature of the client’s injury and the general condition of the patient.
3. Check the purpose of traction.
4. Check the doctor’s orders for the type of traction to be applied.
5. Check for any specific instructions regarding the application of traction, duration of traction, movements and positions allowed and not allowed etc.
6. Check the client’s abilities and limitations.
7. Check the client’s consciousness and the ability to follow instructions.
8. Assess the potential complications associated with the use of traction and the preventive measures.
9. Check the integrity of skin where the traction is to be applied.
10. Check the articles available in the client’s unit.
PREPARATION OF THE ARTICLES
1. Adhesive plaster
Purpose: to apply on the skin for use as a traction strip.
Purpose: to cut the plaster
3. Tr. Benzoin
Purpose: to promote adhesion of the adhesive plaster, and to maintain the integrity of the skin.
4. Spreader (rectangular wooden piece)
Purpose: to keep the traction strips off the malleous and to apply the weight.
5. Roller bandages
Purpose: to cover and secure the traction tapes (adhesive plaster) and keep them from slipping out of place when weight is applied.
6. Traction ropes
Purpose: to apply the weight
7. Cotton balls in a container
Purpose: to apply Tr. Benzoin
8. Kidney tray and paper bag
Purpose: to receive the waste
9. Cross bars and clamps
Purpose: to fix the pulleys in position
Purpose: to apply the traction freely in the direction as desired.
11. Bed blocks
Purpose: to raise the foot end of the bed to apply counter traction.
12. Measuring tape
Purpose: to measure the length of the tape required
13. Weights as ordered
Purpose: to apply traction
14. Balken frame with trapeze bar
Purpose: to suspend the cross bars, pulleys etc., and also to help the client to lift his body when needed.
15. Thomas splint (if ordered)
Preparation of the Client and the Environment
1. Explain the procedure to the client and his relatives and the reasons for applying the traction.
2. Inform the client for the movements allowed and the movements contra-indicated. Explain him that moving in the contraindicated positions will foil the purpose of traction.
3. Reassure the client that the initial discomfort caused by the traction will disappear soon and he will be more comfortable when the muscles are relaxed by the traction. (Pain is due to muscle spasm).
4. Inform the client how long the traction will be maintained.
5. Explain to the client how long the traction will be maintained.
6. Prepare the skin for the application of skin traction. The skin is shaved to remove the hairs, otherwise removal of the adhesive strips will be painful for the client. Clean the area with soap and water, dry well and apply Tr. Benzoin.
7. Examine the area for any cuts or skin lesions.
8. Place the client on a firm mattress with fracture boards under it.
9. Fix a balken frame to the bed which will be helpful for the client to raise his body without interfering with the traction during the use of bed pans etc. the client will have confidence to raise his body. Fix the cross bar and pulleys on the balken frame or on the foot end of the bed.
10. Arrange all the articles needed for the traction on the bedside table conveniently, both for the doctor and the nurse.
11. Remove un-necessary articles from the client’s unit that may obstruct the passage.
12. Provide privacy and remove the garments from the affected limb and cover the client, with a sheet or a bath blanket.
13. Keep the client on centre of the bed in good body alignment. The feet of the client should not touch the foot end of the bed.
14. Remove the back rest and pillow kept under the client. Pillows are allowed only if desired by the doctor.
Steps of Procedure
1. Wash and dry hands
Reason: to prevent cross infection
2. Measure the length of the tape (adhesive) needed. Measure the length 4 inches above the knee to the malleolus and add 10 inches to extend beyond the foot and to cover the spreader and then double it to cover the opposite side of the leg.
Reasons: correct length of the tape helps in the correct application of the traction, and prevents wastage of the adhesive plaster.
3. In the centre of the strip, at the sole of the foot, place the spreader. Use a spreader of correct width.
Reasons: the spreader prevents pressure along the sides of the foot. If the spreader is too narrow, the traction tapes will rub against the areas of the skin over the malleoli. If the spreader is too wide, it will pull the traction strips away from the skin.
4. The spreader is held in place by a second strip of adhesive which should extend 10 to 12 inches on each side of the wood to prevent adhesion to the malleoli.
Reasons: the second strip fixed to the adhesive surface of the first strip will prevent the plaster from wrinkling.
5. Apply the adhesive strips smoothly without wrinkles on the lateral and medial aspect of the thigh and the lower leg. The crest of the tibia and the patella are not covered with the strapping.
6. Secure the adhesive strips in place by bandaging the leg. Bandages must be applied firmly, but not so tightly to interfere with the blood or nerve supply to the limb.
Reasons: unless fixed with the bandages, the traction strips will be pulled away from the skin when the weight is applied.
7. Thread the traction rope to centre of the spreader and pass it through pulleys and apply the weight as ordered.
Reasons: the height of the pulley should be adjusted with the centre of the spreader to keep the ropes and pulleys in straight alignment.
8. Raise the foot end of the bed on bed blocks.
Reasons: to obtain counter traction.
After Care of the Patient and the Articles
1. Check the whole system of traction for its working order.
a. The ropes and the pulleys are unobstructed, freely movable and in straight alignment.
b. The weights are neither pulled against the pulleys nor rested on the floor. See that the weights hang freely without touching the bed, bedding, and the body of the client.
c. There should be no knots obstructing the free movement of the rope through the pulleys.
d. The knots are secure and are not easily slipped off.
e. The traction will not be obstructed by passers-by.
f. The bony prominences are protected.
g. The knees are slightly flexed to prevent hyperextension.
h. If the sand bags are used as weight, mark it with the amount of weight.
i. The client is in a good body alignment
j. The client is placed in the centre of the bed and the feet are not supported against the foot end of the bed.
k.No unnecessary pillows under the limbs except that are permitted by the doctor (a small knee pillow).
l.The bed clothes are not hanging over the traction ropes.
m.The bandages are neither too tight nor too loose. There is no swelling and discoloration of the limbs distal to the bandaged limb.
n.The toes are freely movable.
o.No discomfort experienced by the client after the traction is applied.
2. Watch for the early signs of complications developing due to traction. Investigate all the symptoms indicative of developing complications and all complaints stated by the client in traction. If symptoms of neuro-vascular damage appear in an extremity that is in traction, immediately remove the weight, unwrap the bandage and inform the doctor immediately.
3. Frequent skin care and care of the pressure points are necessary to prevent skin breakdown.
4. Any alternation in the amount of weight, height of the elevating blocks, position of the client in bed etc. should be done only with the permission of the doctor.
5. Give recreational and diversional therapy to the client.
6. Encourage self care as much as possible.
7. Encourage exercises of all joints especially the joint above and below the structures.
8. Record the type of traction applied with date and time on the nurse’s record.
9. Frequent visits to the client should be made to observe the client and to make him feel that he is not regarded.
10. If the client is to be transferred from one department to another, the weights should be steadied and kept swinging while the client is transferred. If the weights are removed, the whole purpose of the traction is foiled.
11. When the clients are removed from traction after they are immobilized for few weeks, they find themselves quite weak due to the muscle atrophy that has taken place due to the immobility of muscles. They also feel unsteady due to orthostatic hypotension especially if the client was in a head lowered position. So these clients are helped to assume upright position very slowly. Crutches may be provided for a short while to support them in walking.
12. When the traction is removed, it should be entered on the nurse’s record with date and time. Record the response of the client to activity.
BRYANT’S TRACTION (GALLOW’S TRACTION)
Bryant’s traction which is a skin traction applied to both lower limbs can be used to reduce fractures of the femur in children under 6 years. Both legs are suspended vertically with the hip flex at 90 degree and the knees are extended. The buttocks are slightly elevated from the mattress. Therefore, the body weight is used to provide the counter traction.
Bryant’s traction is preferred to Buck’s extension in children under 6 years. Children do not have enough body weight to provide effective counter traction to the horizontal pull of the Buck’s extension. However, the Bryant’s traction is not used for children above 6 years because the counter traction provided by the weight of the trunk is not sufficient and also the position assumed in Bryant’s traction reduces the arterial circulation to the feet.
Russell’s traction may be used in the treatment of fracture of the shaft of the femur. It may be applied as either skin or skeletal traction. Russell’s traction creates a forward and upward pull on the leg by applying vertical traction at the knee, at the same time a horizontal force is exerted on the tibia and fibula as in a Buck’s extension. The knee joint is bent and the client can move about with relative ease with Russell’s traction.
The traction is applied as in Buck’s extension and a sling passes below the knee. A cord is attached to the sling and passes up vertically to a pulley on the overhead beam and then passed over several pulleys and back to the pulley at the foot end of the bed on which the weight is added. A foot support with a sling is provided to prevent foot drop.
Skeletal traction is accomplished by introducing a metal wire (Kirschner wire) or metal pins (Steinmann pins) or metal tongs (crutch/field tongs used in skull traction) under strict aseptic technique through the bones beneath the fracture. A traction bow (stirrups or calipers) is then attached to the wire or pin and the traction force is applied to this bow.
Bone infection may develop with skeletal traction and it can be avoided by:
a. Preparing the skin for any orthopaedic surgeries.
b. Inserting the pins under strict aseptic techniques.
c. Avoiding an area that is already infected.
d. Daily observation of the skin around the site of insertion of pins and detecting the signs of infection such as redness, drainage, bad odor etc.
e. Daily cleaning of the areas around the pins with spirit.
f. Protecting the wound at the pins with sterile dressings and changing the dressings as and when needed.
g. Instructing the client who has skeletal traction not to touch the skin around the insertion of wires or pins.
When caring for a client with skeletal traction, the nurses should keep in mind all the precautions as for a skin traction. In addition, she have to take care to prevent infection introduced into the bones. The sharp ends of the wires and pins that extend beyond the bow should be covered with corks and dressings to prevent bed linens from catching on the sharp points and to prevent scratching the client’s skin or that of persons giving care. Loose wires or pins should be reported to the doctor immediately.
The skeletal traction provides a better traction because:
1. It can be used for relatively longer period of time.
2. It applies traction directly to the bone.
3.It can be used with heavier weights.
4. It is highly effective in treating fractures in bones surrounded by large muscle masses and in reducing unstable fractures/dislocations.
5. Since the traction is applied with a Thomas splint, the entire leg is supported and therefore it is comfortable for the client.
6. Since it allows a slight flexion of the knee joint, the skeletal traction is comfortable for the client.
AUTHOR: SHRUTI NAIR