Skeletal Traction

SKELETAL TRACTION

Skeletal traction is applied directly to the bone. This method of traction is used occasionally to treat fractures of the femur, the tibia, and the cervical spine. The traction is applied directly to the bone by use of a metal pin or wire (eg, Steinmann pin, Kirschner wire) that is inserted through the bone distal to the fracture, avoiding nerves, blood vessels, muscles, tendons, and joints. Tongs applied to the head (eg, Gardner-Wells or Vinke tongs) are fixed in the skull to apply traction that immobilizes cervical fractures.

The orthopedic surgeon applies skeletal traction, using surgi-cal asepsis. The insertion site is prepared with a surgical scrub agent such as povidone-iodine solution. A local anesthetic is ad-ministered at the insertion site and periosteum. The surgeon makes a small skin incision and drills the sterile pin or wire through the bone. The patient feels pressure during this proce-dure and possibly some pain when the periosteum is penetrated.

After insertion, the pin or wire is attached to the traction bow or caliper. The ends of the wire are covered with corks or tape to prevent injury to the patient or caregivers. The weights are at-tached to the pin or wire bow by a rope-and-pulley system that exerts the appropriate amount and direction of pull for effective traction. Skeletal traction frequently uses 7 to 12 kg (15 to 25 lb) to achieve the therapeutic effect. The weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent frac-ture dislocation and to promote healing.

Often, skeletal traction is balanced traction, which supports the affected extremity, allows for some patient movement, and facili-tates patient independence and nursing care while maintaining ef-fective traction. The Thomas splint with a Pearson attachment is frequently used with skeletal traction for fractures of the femur (see Fig. 67-5). Because upward traction is required, an overbed frame is used.

When skeletal traction is discontinued, the extremity is gently supported while the weights are removed. The pin is cut close to the skin and removed by the physician. Internal fixation, casts, or splints are then used to immobilize and support the healing bone.

Nursing Interventions

MAINTAINING EFFECTIVE TRACTION

When skeletal traction is used, the nurse checks the apparatus to see that the ropes are in the wheel grooves of the pulleys, that the ropes are not frayed, that the weights hang free, and that the knots in the rope are tied securely. The nurse also evaluates the patient’s position, because slipping down in bed results in in-effective traction.

MAINTAINING POSITIONING

The nurse must maintain alignment of the patient’s body in trac-tion as prescribed to promote an effective line of pull. The nurse positions the patient’s foot to avoid footdrop (plantar flexion), in-ward rotation (inversion), and outward rotation (eversion). The patient’s foot may be supported in a neutral position by ortho-pedic devices (eg, foot supports).

PREVENTING SKIN BREAKDOWN

The patient’s elbows frequently become sore, and nerve injury may occur if the patient repositions by pushing on the elbows. In addition, patients frequently push on the heel of the unaffected leg when they raise themselves. This digging of the heel into the mattress may injure the tissues. Therefore, the nurse should pro-tect the elbows and heels and inspect them for pressure areas. To encourage movement without using the elbows or heel, the nurse can suspend a trapeze overhead within easy reach of the patient. This apparatus helps the patient to move about in bed and to move on and off the bedpan.

Specific pressure points are assessed for redness and skin break-down. Areas that are particularly vulnerable to pressure caused by traction apparatus applied to the lower extremity include the ischial tuberosity, popliteal space, Achilles tendon, and heel. If the patient is not permitted to turn on one side or the other, the nurse must make a special effort to provide back care and to keep the bed dry and free of crumbs and wrinkles. The patient can as-sist by holding the overhead trapeze and raising the hips off the bed. If the patient cannot do this, the nurse can push down on the mattress with one hand to relieve pressure on the back and bony prominences and to provide for some shifting of weight. A pressure-relieving air-filled or high-density foam mattress overlay may re-duce the risk of pressure ulcer.

For change of bed linens, the patient raises the torso while nurses on both sides of the bed roll down and replace the upper mattress sheet. Then, as the patient raises the buttocks off the mattress, the nurses slide the sheets under the buttocks. Finally, the nurses replace the lower section of the bed linens while the patient rests on the back. Sheets and blankets are placed over the patient in such a way that the traction is not disrupted.

MONITORING NEUROVASCULAR STATUS

The nurse assesses the neurovascular status of the immobilized ex-tremity at least every hour initially and then every 4 hours. The nurse instructs the patient to report any changes in sensation or movement immediately so that they can be promptly evaluated. DVT is a significant risk for the immobilized patient. The nurse en-courages the patient to do active flexion–extension ankle exercises and isometric contraction of the calf muscles (calf-pumping exer-cises) 10 times an hour while awake to decrease venous stasis. In ad-dition, elastic stockings, compression devices, and anticoagulant therapy may be prescribed to help prevent thrombus formation.

Prompt recognition of a developing neurovascular problem is essential so that corrective measures can be instituted promptly.

PROVIDING PIN SITE CARE

The wound at the pin insertion site requires attention. The goal is to avoid infection and development of osteomyelitis. Initially, the site is covered with a sterile dressing. Subsequent care of the pin site is individually prescribed and performed three times a day. The nurse must keep the area clean. Slight serous oozing at the pin site is expected, but crusting should be prevented. The nurse assesses the pin site and drainage for signs of infection, such as redness, tenderness, and purulent drainage. The patient may experience discomfort at the pin site due to traction on the skin caused by an unsupported muscle.

PROMOTING EXERCISE

Patient exercises, within the therapeutic limits of the traction, as-sist in maintaining muscle strength and tone and in promoting cir-culation. Active exercises include pulling up on the trapeze, flexing and extending the feet, and range-of-motion and weight-resistance exercises for noninvolved joints. Isometric exercises of the immo-bilized extremity (quadriceps-setting and gluteal-setting exercises) are important for maintaining strength in major ambulatory mus-cles (see Chart 67-3). Without exercise, the patient will lose mus-cle mass and strength, and rehabilitation will be greatly prolonged.