Classification of Fractures

A fracture is classified by the extent of the break:

A fracture is described by the extent of associated soft-tissue damage as open (or compound) or closed (or simple). The skin surface over the broken bone is disrupted in a compound fracture, which causes an external wound. These fractures are often graded to define the extent of tissue damage. A simple fracture does not extend through the skin and therefore has no visible wound.

Fig. 54-1 shows common types of fractures. In addition to being identified by type, fractures are described by their cause. A pathologic (spontaneous) fracture occurs after minimal trauma to a bone that has been weakened by disease. For example, a patient with bone cancer or osteoporosis can easily have a pathologic fracture. A fatigue (stress) fracture results from excessive strain and stress on the bone. This problem is commonly seen in recreational and professional athletes. Compression fractures are produced by a loading force applied to the long axis of cancellous bone. They commonly occur in the vertebrae of older patients with osteoporosis and are extremely painful.

FIG. 54-1 Common types of fractures.

Stages of Bone Healing

When a bone is fractured, the body immediately begins the healing process to repair the injury and restore the body’s equilibrium. Fractures heal in five stages that are a continuous process and not single stages. In stage one, within 24 to 72 hours after the injury, a hematoma forms at the site of the fracture because bone is extremely vascular. Stage two occurs in 3 days to 2 weeks when granulation tissue begins to invade the hematoma. This then prompts the formation of fibrocartilage, providing the foundation for bone healing. Stage three of bone healing occurs as a result of vascular and cellular proliferation. The fracture site is surrounded by new vascular tissue known as a callus (within 3 to 6 weeks). Callus formation is the beginning of a nonbony union. As healing continues in stage four, the callus is gradually resorbed and transformed into bone. This stage usually takes 3 to 8 weeks. During the fifth and final stage of healing, consolidation and remodeling of bone continue to meet mechanical demands. This process may start as early as 4 to 6 weeks after fracture and can continue for up to 1 year, depending on the severity of the injury and the age and health of the patient. Fig. 54-2 summarizes the stages of bone healing.

FIG. 54-2 The stages of bone healing.

In young, healthy adult bone, healing takes about 4 to 6 weeks. In the older person who has reduced bone mass, healing time is lengthened. Complete healing often takes 3 to 6 months or longer in people who are older than 70 years. Other factors also affect healing. Examples include the severity of the trauma, the type of bone injured, how the fracture is managed, infections at the fracture site, and ischemic or avascular necrosis (AVN).

Complications of Fractures

Regardless of the type or location of the fracture, several limb- and life-threatening acute and chronic complications can result from the injury. Clinical manifestations of beginning complications must be treated early to prevent serious consequences. In some cases, careful monitoring and assessment can prevent these complications:

Etiology and Genetic Risk

The primary cause of a fracture is trauma from a motor vehicle crash or fall, especially in older adults. The trauma may be a direct blow to the bone or an indirect force from muscle contractions or pulling forces on the bone. Sports, vigorous exercise, and malnutrition are contributing factors. Bone diseases, such as osteoporosis, increase the risk for a fracture in older adults (see Chapter 53). Genetic factors that increase risk for fracture are discussed with these specific health problems throughout this text.

Incidence/Prevalence

The incidence of fractures depends on the location of the injury. Rib fractures are the most common type in the adult population. Femoral shaft fractures occur most often in young and middle-aged adults. The incidence of proximal femur (hip) fractures is highest in older adults. Humeral fractures are common in adults; the older the person, usually the more proximal is the fracture. Wrist (Colles’) fractures are typically seen in middle and late adulthood and usually result from a fall.

History

If the patient is in severe pain, delay the interview until he or she is more comfortable. Then, ask about the cause of the fracture, which helps in developing an individualized plan of care. Some type of force, such as incisional, crush, acceleration or deceleration, and shearing and friction, leads to most musculoskeletal injuries. As a result, several body systems are often affected.

Incisional injuries, as from a knife wound, and crush injuries cause hemorrhage and decrease blood flow to major organs. Acceleration or deceleration injuries cause direct trauma to the spleen, brain, and kidneys when these organs are moved from their fixed locations in the body. Shearing and friction damage the skin and cause a high level of wound contamination.

Asking about the events leading to the injury helps identify which forces have been experienced and therefore which body systems or parts of the body to assess. For example, a forward fall often results in Colles’ fracture of the wrist because the person tries to catch himself or herself with an outstretched hand. Knowing the mechanism of injury also helps determine whether other types of injury, such as head and spinal cord injury, might be present.

A drug history, including substance abuse, is important regardless of the patient’s age. For example, a young adult may have had an excessive amount of alcohol, which contributed to a motor vehicle crash or to a fall at the work site. Many older adults also consume alcohol and an assortment of prescribed and over-the-counter drugs, which can cause dizziness and loss of balance.

A medical history may identify possible causes of the fracture and gives clues as to how long it will take for the bone to heal. Certain diseases such as bone cancer and Paget’s disease cause pathologic fractures that often do not achieve total healing or union.

Ask about the patient’s occupation and recreational activities. Some occupations are more hazardous than others. For instance, construction work is potentially more physically dangerous than office work. Certain hobbies and recreational activities are also extremely hazardous, such as skiing. Contact sports, such as football and ice hockey, often result in musculoskeletal injuries, including fractures. Other activities do not have such an obvious potential for injury but can cause fractures nonetheless. For instance, daily jogging or running can lead to fatigue fractures.

Physical Assessment/Clinical Manifestations

The patient with a fracture often has trauma to other body systems. Therefore assess all major body systems first for life-threatening complications, including head, chest, and abdominal trauma. For example, some fractures can cause internal organ damage resulting in hemorrhage. When a pelvic fracture is suspected, assess vital signs, skin color, and level of consciousness for indications of possible hypovolemic shock. Check the urine for blood, which indicates possible damage to the urinary system, often the bladder. If the patient cannot void, suspect that the bladder or urethra has been damaged. Complete assessment of these areas is described elsewhere in this text.

For fractures of the shoulder and upper arm, the physical assessment is best done with the patient in a sitting or standing position, if possible, so that shoulder drooping or other abnormal positioning can be seen. Support the affected arm and flex the elbow to promote comfort during the assessment. For more distal areas of the arm, perform the assessment with the patient in a supine position so that the extremity can be elevated to reduce swelling.

Place the patient in a supine position for assessment of the legs and pelvis. A patient with an impacted hip fracture may be able to walk for a short time after injury, although this is not recommended.

When inspecting the site of a possible fracture, look for a change in bone alignment. The bone may appear deformed, a limb may be internally or externally rotated, and/or one or more bones may also be dislocated (out of their joint capsules). Observe for extremity shortening or a change in bone shape.

If the skin is intact (closed fracture), the area over the fracture may be ecchymotic (bruised) from bleeding into the underlying soft tissues. Subcutaneous emphysema, the appearance of bubbles under the skin because of air trapping, may be present but is usually seen later.

Swelling at the fracture site is rapid and can result in marked neurovascular compromise. Gently perform a thorough neurovascular assessment, and compare extremities. Assess skin color and temperature, sensation, mobility, pain, and pulses distal to the fracture site. If the fracture involves an extremity and the patient is not in severe pain, check the nails for capillary refill by applying pressure to the nail and observing for the speed of blood return. If nails are brittle or thick, assess the skin next to the nail. Checking for capillary refill is not as reliable as other indicators of perfusion. Chart 54-3 describes the procedure for a neurovascular assessment, which evaluates circulation, movement, and sensation (CMS function).

Psychosocial Assessment

The psychosocial status of a patient with a fracture depends on the extent of the injury, possible complications, coping ability, and the availability of support systems. Hospitalization is not required for a single, uncomplicated fracture, and the patient returns to usual daily activities within a few days. Examples include a single fracture of a finger, wrist, foot, or toe.

In contrast, a patient suffering severe or multiple traumas may be hospitalized for weeks and may undergo many surgical procedures, treatments, and prolonged rehabilitation. These disruptions in lifestyle can create a high level of stress.

The stresses that result from a long-term condition affect relationships between the patient and family members or friends. Assess the patient’s feelings, and ask how he or she coped with previously experienced stressful events. Body image and sexuality may be altered by deformity, treatment modalities for fracture repair, or long-term immobilization. Assess the availability of support systems, such as family, church, or community groups who can help patients during the acute and rehabilitation phases needed when multiple or severe fractures occur. Active patients of any age or those who are older and live alone may become depressed during the healing process. Acute and chronic pain can decrease energy levels and may also cause sadness or depression.

Laboratory Assessment

No special laboratory tests are available for assessment of fractures. Hemoglobin and hematocrit levels may often be low because of bleeding caused by the injury. If extensive soft-tissue damage is present, the erythrocyte sedimentation rate (ESR) may be elevated, which indicates the expected inflammatory response. If this value increases during fracture healing, the patient may have a bone infection. During the healing stages, serum calcium and phosphorus levels are often increased as the bone releases these elements into the blood.

Imaging Assessment

The health care provider requests standard x-rays and tomograms to confirm a diagnosis of fracture. These reveal the bone disruption, malalignment, or deformity. If the x-ray does not show a fracture but the patient is symptomatic, the x-ray is usually repeated with additional views.

The computed tomography (CT) scan is useful in detecting fractures of complex structures, such as the hip and pelvis. It also identifies compression fractures of the spine. Magnetic resonance imaging (MRI) is useful in determining the amount of soft-tissue damage that may have occurred with the fracture.

Analysis

The most common problems for patients with fractures are:

Managing Acute Pain

Interventions

A fracture can happen anywhere and may be accompanied by multiple injuries to vital organs. Patient-centered collaborative care depends on the severity and extent of the injury and the number of fractures the patient has.

Emergency Care: Fracture

For any patient who experiences trauma in the community, first call 911 and assess for airway, breathing, and circulation (ABCs, or primary survey). Then provide lifesaving care if needed before being concerned about the fracture (Chart 54-4). If CPR is needed, ensure circulation first, followed by airway and breathing (see Chapter 36).

Chart 54-4 Best Practice for Patient Safety & Quality Care

Emergency Care of the Patient with an Extremity Fracture

1. Assess the patient’s airway, breathing, and circulation, and perform a quick head-to-toe assessment.

2. Remove the patient’s clothing (cut if necessary) to inspect the affected area while supporting the area above and below the injury. Do not remove shoes because this can cause increased trauma.

3. Remove jewelry on the affected extremity in case of swelling.

4. Apply direct pressure on the area if there is bleeding and pressure over the proximal artery nearest the fracture.

5. Keep the patient warm and in a supine position.

6. Check the neurovascular status of the area distal to the fracture, including temperature, color, sensation, movement, and capillary refill. Compare affected and unaffected limbs.

7. Immobilize the extremity by splinting; include joints above and below the fracture site. Recheck circulation after splinting.

8. Cover any open areas with a dressing (preferably sterile).

If the person is clothed, cut away clothing from the fracture site, and remove any jewelry from the affected extremity. Control any bleeding by direct pressure on the area and digital pressure over the artery above the fracture. To prevent shock, place the patient in a supine position and keep him or her warm.

After a head-to-toe assessment (secondary survey) and patient stabilization by the prehospital team, pain is managed with IV opioids such as fentanyl. Cardiac monitoring for patients who are older than 50 years is established before drug administration. To prevent further tissue damage, reduce pain, and increase circulation, the prehospital or emergency team immobilizes the fracture by splinting. An air splint or any object or device that extends to the joints above and below the fracture to immobilize it can be used as a splint. Sterile gauze is placed loosely over open areas to prevent further contamination of the wound.

In the emergency department (ED), physician’s office, or urgent care center, fracture management begins with reduction and immobilization of the fracture, while attending to continued pain assessment and management.

Reduction, or realignment of the bone ends for proper healing, is accomplished by a closed method or an open (surgical) procedure. In some cases, dislocated bones are also reduced, such as when the distal tibia and fibula are dislocated with a fractured ankle. Immobilization is achieved by the use of bandages, casts, traction, internal fixation, or external fixation.

The health care provider selects the treatment method based on the type, location, and extent of the fracture. These interventions prevent further injury and reduce pain.

Nonsurgical Management

Nonsurgical management includes closed reduction and immobilization with a bandage, splint, cast, or traction. For some small, closed bone fractures in the hand or foot, reduction is not required. Immobilization with an orthotic device or special orthopedic shoe or boot may be the only management during the healing process.

For each modality, the primary nursing concern is assessment and prevention of neurovascular dysfunction or compromise. Assess the patient’s neurovascular status every hour for the first 24 hours and every 1 to 4 hours thereafter, depending on the injury (see Chart 54-3). The patient usually reports discomfort that is unrelieved by analgesics if the bandage, splint, or cast is too tight. Elevate the fractured extremity higher than the heart, and apply ice for the first 24 to 48 hours as needed to reduce edema.

Closed Reduction and Immobilization

Closed reduction is the most common nonsurgical method for managing a simple fracture. While applying a manual pull, or traction, on the bone, the health care provider moves the bone ends so that they realign. Moderate sedation and/or analgesia is often used during this procedure to decrease pain. An x-ray shows that the bone ends are approximated (aligned) before the bone is immobilized.

Bandages and Splints

For certain areas of the body, such as the scapula (shoulder) and clavicle (collarbone), an elastic bandage or commercial immobilizer may be used to keep the bone in place during healing. Because upper extremity bones do not bear weight, splints may be sufficient to keep bone fragments in place for a closed fracture. Fig. 54-3 shows a wrist splint for fracture immobilization. Thermoplastic, a durable, flexible material for splinting, allows custom fitting to the patient’s body part. Splints for lower extremities are also custom-fitted using flexible materials and held in place with elastic bandages (e.g., ace wrap).

FIG. 54-3 A universal wrist and forearm splint used for immobilization.

Casts

For more complex fractures or fractures of the lower extremity, the physician or orthopedic technician applies a cast to hold bone fragments in place after reduction. A cast is a rigid device that immobilizes the affected body part while allowing other body parts to move. It also allows early mobility and reduces pain. Although its most common use is for fractures, a cast may be applied for correction of deformities (e.g., clubfoot) or for prevention of deformities (e.g., those seen in some patients with rheumatoid arthritis).

Several types of materials are used to make casts. The traditional plaster-of-Paris cast is no longer commonly used for management of most fractures. It requires application of a well-fitted stockinette under the material. If the stockinette is too tight, it may impair circulation. If it is too loose, wrinkles can lead to the development of pressure ulcers. Padding is applied over the stockinette, followed by wet plaster rolls wrapped around the extremity or other body part. The cast feels hot because an immediate chemical reaction occurs, but it soon becomes damp and cool. This type of cast takes 24 to 72 hours to dry, depending on the size and location of the cast. A wet cast feels cold, smells musty, and is grayish. The cast is dry when it feels hard and firm, is odorless, and has a shiny white appearance.

If the skin under the cast is open, the health care provider, orthopedic technician, or specially trained nurse cuts a window in the cast so that the wound can be observed and cared for. The piece of cast removed to make the window must be retained and replaced after wound care to prevent localized edema in the area. This is most important when a window is cut from a cast on an extremity. Tape or elastic bandage wrap may be used to keep the “window” in place. A window is also an access for taking pulses, removing wound drains, or preventing abdominal distention when the patient is in a body or spica cast.

If the cast is too tight, it may be cut with a cast cutter to relieve pressure or allow tissue swelling. The health care provider may choose to bivalve the cast (i.e., cut it lengthwise into two equal pieces) if bone healing is almost complete. Either half of the cast can be removed for inspection or for provision of care. The two halves are then held in place by an elastic bandage wrap.

Synthetic materials for casts are much more common and include fiberglass and polyester-cotton knit (Fig. 54-4). These materials are lighter than plaster and require minimal drying time. Fiberglass casts are dry in 10 to 15 minutes and can bear weight 30 minutes after application. Polyester-cotton knit casts take 7 minutes to dry and can withstand weight bearing in about 20 minutes. Some health care providers may use synthetic casts for upper extremities and plaster-of-Paris casts for lower extremities because plaster casts can bear more weight for a longer time. However, newer synthetic materials are stronger than earlier ones. Synthetic casts can be bivalved as needed.

FIG. 54-4 Application of fiberglass synthetic cast.

Casts can be generally divided into four main groups: arm casts, leg casts, cast braces, and body or spica casts. Table 54-1 describes specific casts that are used for various parts of the body.

TABLE 54-1 TYPES OF CASTS USED FOR MUSCULOSKELETAL TRAUMA

TYPE AND CHARACTERISTICS OF CAST	USE
Upper Extremity Casts
Short-arm cast (SAC) (extends from below the elbow to and including part of the hand)	Stable fractures of the wrist (metacarpals, carpals, or distal radius)
Long-arm cast (LAC) (includes the upper arm to and including part of the hand)	Unstable fractures of the wrist, distal humerus, radius, or ulna
Hanging-arm cast (same as LAC but heavier, with added loop at the mid-forearm)	Fractures of the humerus that cannot be aligned by LAC (light traction is possible while the patient is in bed or by an attached strap that extends around the neck)
Thumb spica (gauntlet) cast (similar to SAC with the thumb casted in abduction)	Fractures of the thumb
Shoulder spica cast (the shoulder is casted in abduction with the elbow flexed)	Unstable fractures of the shoulder girdle or humerus; dislocations of the shoulder
Lower Extremity Casts
Short-leg cast (SLC) (from below the knee to the base of the toes)	Fractures of the ankle, metatarsals, or foot
Long-leg cast (LLC) (from the mid-upper thigh to the base of the toes)	Unstable fractures of the tibia, fibula, or ankle
Walking cast (a walking device on the bottom of SLC or LLC)	Same as for SLC or LLC
Leg cylinder (similar to SLC, but the ankle and foot are not casted)	Stable fractures of the tibia, fibula, or knee
Long-leg cylinder (similar to LLC, but the ankle and foot are not casted)	Stable fractures of the distal femur, proximal tibia, or knee
Cast Braces (or Brace Casts) (Not As Common)
Patellar weight-bearing cast (similar to SLC or leg cylinder)	Mid-shaft or distal shaft fractures of the femur
External polycentric knee hinge cast (a hinge connects the lower and upper leg and allows 90 degrees of knee flexion)	Same as for the patellar weight-bearing cast
Body Casts (Not As Common)
Hip spica (extends from below the nipple line down the affected leg [single], down the leg and half of the unaffected leg [], or down both legs [double])	Dislocation of the hip; pelvic or hip injuries
Risser cast (the body jacket extends from the shoulders to beyond the iliac crests and hips, with a large opening over the anterior chest)	Scoliosis; thoracic spinal fractures
Halo cast (the body jacket contains a halo brace)	Fractures of the cervical spine

When a patient is in bed with an arm cast, teach him or her to elevate the arm above the heart to reduce swelling. The hand should be higher than the heart. Ice may be prescribed for the first 24 to 48 hours. When the patient is out of bed, the arm is supported with a sling placed around the neck to alleviate fatigue caused by the weight of the cast. The sling should distribute the weight over a large area of the shoulders and trunk, not just the neck. Some health care providers prefer that the patient not use a sling after the first few days in an arm cast, particularly a short-arm cast. This encourages normal movement of the mobile joints and enhances bone healing.

A leg cast allows mobility and requires the patient to use ambulatory aids such as crutches. A cast shoe, sandal, or boot that attaches to the foot or a rubber walking pad attached to the sole of the cast assists in ambulation (if weight bearing is allowed) and helps prevent damage to the cast. Teach the patient to elevate the affected leg on several pillows to reduce swelling and to apply ice for the first 24 hours or as prescribed.

A body cast encircles the trunk of the body and is not commonly used for adults. A spica cast encases a portion of the trunk and one or two extremities. A patient with either of these casts presents a special challenge for nursing care. Potential complications related to severe impairment in mobility include:

• Skin breakdown

• Respiratory dysfunction, such as pneumonia and atelectasis

• Constipation

• Joint contractures

Cast syndrome (superior mesenteric artery syndrome), an uncommon but serious complication, may be seen in orthopedic patients who have been placed in a hip spica or body cast. Partial or complete upper intestinal obstruction results in classic symptoms: abdominal distention, epigastric pain, nausea, and vomiting. The vomiting often occurs after meals, and patients may have normal bowel sounds. Partial obstruction occurs initially from compression of the third portion of the duodenum between the superior mesenteric artery and the aorta. This can progress to complete obstruction from duodenal edema caused by continued vomiting and distention. Placing a window in the abdominal portion of the cast or bivalving the cast may be sufficient to prevent or relieve pressure on the duodenum. Management of intestinal obstruction is the same as for any patient with this complication.

Before the cast is applied, explain the purpose of the cast and the procedure for its application. With a plaster cast, warn the patient about the heat that will be felt immediately after the wet cast is applied. Do not cover the new cast. Allow for air-drying.

 Nursing Safety Priority

Action Alert

When moving a patient with a wet plaster cast, handle it with the palms of the hands to prevent indentations and resulting areas of pressure on the skin. Turn the patient every 1 to 2 hours to allow air to circulate and dry all parts of the cast. Be sure to remind unlicensed assistive personnel (UAP) and the family that the cast is wet and requires special handling. If the health care provider requests that the cast be elevated to reduce swelling, use a cloth-covered pillow instead of one encased in plastic, which could cause the cast to retain heat and prevent drying. Elevation of the casted extremity reduces edema but may impair arterial circulation to the affected limb. Therefore performing a neurovascular assessment of the limb distal to (below) the cast is very important.

For preventing contamination by urine or feces, the perineal area of a dry long-leg or body cast may be covered in plastic. Fracture pans are preferred over traditional bedpans because they are smaller and more comfortable. Remind UAP to take care to prevent spillage onto the cast.

 Nursing Safety Priority

Action Alert

Check to ensure that any type of cast is not too tight, and frequently monitor neurovascular status, usually every hour for the first 24 hours after application if the patient is hospitalized. You should be able to insert a finger between the cast and the skin. Teach the patient to apply ice for the first 24 to 36 hours to reduce swelling and inflammation.

Once the plaster cast is dry, inspect it at least once every 8 hours for drainage, cracking, crumbling, alignment, and fit. Plaster casts act like sponges and absorb drainage, whereas synthetic casts act like a wick pulling drainage away from the drainage site. Padding can also absorb wound drainage. Document the presence of any drainage on the cast. However, the evidence is not clear on whether drainage should be circled on the cast because it may increase anxiety and is not a reliable indicator of drainage amount. Immediately report to the health care provider any sudden increases in the amount of drainage or change in the integrity of the cast. After swelling decreases, it is not uncommon for the cast to become too loose and need replacement. If the patient is not admitted to the hospital, provide instructions regarding cast care.

During hospitalization, assess for other complications resulting from casting that can be serious and life threatening, such as infection, circulation impairment, and peripheral nerve damage. If the patient returns home after cast application, teach him or her how to monitor for these complications and when to notify the health care provider.

Infection most often results from the breakdown of skin under the cast (pressure necrosis). If pressure necrosis occurs, the patient typically reports a very painful “hot spot” under the cast and the cast may feel warmer in the affected area. Teach the patient or family to smell the area for mustiness or an unpleasant odor that would indicate infected material. If the infection progresses, a fever may develop.

Circulation impairment and peripheral nerve damage can result from tightness of the cast. Teach the patient to assess for circulation at least daily, including the ability to move the area distal to the extremity, numbness, and increased pain.

The patient with a cast may be immobilized for a prolonged period, depending on the extent of the fracture and the type of cast. Assess for complications of immobility, such as skin breakdown, pneumonia, atelectasis, thromboembolism, and constipation. Before the cast is removed, inform the patient that the cast cutter will not injure the skin but that heat may be felt during the procedure.

Because of prolonged immobilization, a joint may become contracted, usually in a fixed state of flexion. Osteoarthritis and osteoporosis may develop from lack of weight bearing. Muscle can also atrophy from lack of exercise during prolonged immobilization of the affected body part, usually an extremity.

Traction

Traction is the application of a pulling force to a part of the body to provide reduction, alignment, and rest. It is also used as a last resort to decrease muscle spasm (thus relieving pain) and prevent or correct deformity and tissue damage. A patient in traction is often hospitalized, but in some cases, home care is possible even for skeletal traction.

Mechanical traction can be either:

• Continuous, as in fracture treatment

• Intermittent, for relief of muscle spasm in other types of musculoskeletal/neurologic trauma, such as cervical nerve root compression

Traction may also be classified as running traction or balanced suspension. In running traction, the pulling force is in one direction and the patient’s body acts as countertraction. Moving the body or bed position can alter the countertraction force. Balanced suspension provides the countertraction so that the pulling force of the traction is not altered when the bed or patient is moved. This allows for increased movement and facilitates care (Table 54-2).

TABLE 54-2 TYPES OF TRACTION USED FOR MUSCULOSKELETAL TRAUMA

Type and Characteristics of Traction	Use
Upper Extremity Traction
Sidearm skin or skeletal traction (the forearm is flexed and extended 90 degrees from the upper part of the body)	Fractures of the humerus with or without involvement of the shoulder and clavicle
Overhead or 90-90 traction, skin or skeletal (the elbow is flexed and the arm is at a right angle to the body over the upper chest)	Same as above (depends on the physician’s preference)
Plaster traction (pins inserted through the bone are fixed in the cast)	Fractures of the wrist
Lower Extremity Traction
Buck’s extension traction (skin) (the affected leg is in extension)	Fractures of the hip or femur preoperatively Prevention of hip flexion contractures Hip dislocation
Russell’s traction (similar to Buck’s traction, but a sling under the knee suspends the leg)	Fractures of the hip or distal end of the femur
Balanced skin or skeletal traction (the limb is usually elevated in a Thomas splint with Pearson’s attachment, or a Böhler-Braun splint is used)	Fractures of the femur or pelvis (acetabulum)
Spinal Column and Pelvic Traction
Cervical halter (a strap under the chin)	Cervical muscle spasms, strain/sprain, or arthritis
Cervical skeletal (e.g., halo brace, Crutchfield tongs)	Cervical fractures of the spine; muscle spasms
Pelvic belt (a strap around the hips at the iliac crests is attached to weights at the foot of the bed)	Pain, strain, sprain, or muscle spasms in the lower back
Pelvic sling (a wide strap around the hips is attached to an overhead bar to keep the pelvis off the bed)	Pelvic fractures; other pelvic injuries

The two most common types of traction are skin and skeletal traction. Skin traction involves the use of a Velcro boot (Buck’s traction) (Fig. 54-5), belt, or halter, which is usually secured around the affected leg. The primary purpose of skin traction is to decrease painful muscle spasms that accompany hip fractures. The weight is used as a pulling force and is limited to 5 to 10 pounds (2.3 to 4.5 kg) to prevent injury to the skin.

FIG. 54-5 Skin traction with a hook-and-loop fastener (Velcro) boot, commonly used for hip fractures.

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