LEARNING OUTCOMES

By the end of this section you should be able to:

RATIONALE

Traction, in all its many guises, is extensively used in orthopaedic practice, including paediatrics. Like many aspects of orthopaedic therapy, it does not remain constant and therefore requires a high degree of nursing input.

FACTORS TO NOTE

EQUIPMENT

Traction equipment and terminology can be confusing and anxiety provoking to nurses who do not fully understand the components and how each attaches to the other. The type and method of traction used is indicated by the type and position of the fracture, the age of the child and the desired outcome. Other factors such as trauma, surgeon’s preference and availability of equipment will also be considered. Nurses caring for patients on traction need a working knowledge of each of the various types of traction along with its rationale, correct set-up and maintenance. Folick et al (1994) recognise that there are many variations in practice, all of which fulfil the same purpose. What is essential is that a uniform approach is used once the traction is established. There are many types of traction and the names may vary from hospital to hospital. There may also be variations and alterations to accommodate individual needs.

Types of traction

Traction is either fixed or balanced:

• Fixed traction is achieved by exerting a pulling force on the point splinted between two fixed points

• Balanced traction exerts a pulling force on the part held between two mobile points, and works by using the patient’s weight against the applied load.

Both skin and skeletal traction are used for children.

Skin traction

This is the first choice of treatment and involves applying adhesive strips of material to either side of the affected limb. The limb is then bandaged, taking care to leave the knee free. The skin traction kits include cords to allow a pull to be exerted on the strips, which is transmitted from the material and skin to the underlying tissues and bone. Only a moderate amount of pull can be exerted using weights and the bed end is then elevated.

Skeletal traction

This is used at the surgeon’s preference if the alignment of the fracture is difficult to achieve and maintain and internal fixation is not possible. This involves the insertion of a sterile pin through an area of strong bone such as the femoral condyles, tibial tuberosity or calcaneum. This is performed under general anaesthetic using aseptic conditions. A metal stirrup is then attached to the pin ends and cord fastened to it. Weights are then attached to the stirrup and hang over a pulley; they are then left free hanging over the elevated bed end. Skeletal traction is also used following trauma, such as when the integrity of the skin is damaged and the application of skin traction would be difficult. Skeletal traction allows for easier access to wounds, dressings or any other injuries. It is now rarely used for children due to advances in orthopaedic surgical techniques in the management of complicated long bone fractures.

The following types of traction are most commonly used for children:

• Simple leg traction or Buck’s extensions: used for pre- and postoperative positioning and immobilisation, best for inflammatory disorders such as irritable hip syndrome – this is either fixed or balanced, and is usually skin traction.

• Gallows or Bryant’s traction: used in infants usually under 1 year of age for femoral fractures and preoperative positioning prior to hip surgery – this traction is always bilateral and is fixed (Fig. 31.1).

• Thomas splint traction: used for femoral fractures – this can be either skin or skeletal, fixed or balanced. Now often used for femoral fractures splintage to allow swelling to subside prior to internal fixation of the fracture using the Nancy nailing system (Fig. 31.2).

• Slings and springs traction: often used for children with Perthes disease or other hip conditions. Enables the child to have bed rest and the physiotherapist to teach and perform specific exercises of the hip and lower limbs.

Figure 31.1 Gallows traction. This is fixed traction.

Figure 31.2 Thomas splint. The figure shows complex traction: (1) use of Thomas splint; (2) skeletal traction; (3) skin traction (below the knee); (4) Pearson knee piece; (5) counterbalance traction. This is balanced traction.

The following forms of traction are now rarely used for children:

• Burns frame, Japanese frame or hoop traction: used in infants to correct congenital dislocation of the hip – fixed skin traction.

• Dunlop traction: used for contractures of the elbow and immobilisation of supracondylar fractures of the elbow – this can be skin or skeletal and is balanced (Fig. 31.3).

• 90–90 traction: used for displaced femoral fractures – balanced (Fig. 31.4).

• Pelvic traction: used for low back pain – fixed or balanced.

• Halter neck traction: used for torticollis, cervical injuries or disease processes – balanced (Fig. 31.5).

• Halo traction: used for cervical injuries – this is skeletal and fixed.

• Hamilton–Russell or modified Hamilton–Russell traction: used for immobilisation of fractured femur, postoperatively following hip surgery and for treatment of hip dislocation. It combines balanced traction with suspension – skin or skeletal (Fig. 31.6).

Figure 31.3 Dunlop traction. This is balanced traction.

Figure 31.4 90–90 traction. This is balanced traction.

Figure 31.5 Halter neck traction. This is balanced traction.

Figure 31.6 Hamilton–Russell traction – using skin traction.

GUIDELINES

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