Skin traction overview

Traction is used for various conditions which affect children. It is a pulling force through power; the application of a sustained pull on a limb/muscle maintains the position of a fractured bone, or corrects a deformity.

Reasons for traction

• Stabilization and maintenance of position of a limb.
  
• Rest and immobilization of a limb which is affected by trauma or infection such as septic arthritis.
  
• Pain relief from irritable hip/slipped upper femoral epiphyses.
  
• Correction of orthopaedic conditions which may be congenital, e.g. hip dysplasia, or acquired, e.g. Perthes disease, which is a hip disorder.
  
• Alleviation of muscle spasm, e.g. locked knee.
  
• Prior to surgery, to allow a joint to be relieved of its pressure, e.g. the ball and socket joint where the head of the bone is pulled away from its socket as in the hip/shoulder joint.

Children of all ages may at some time in their lives require a period of bed rest for the application of traction to assist in alleviating their condition.

Types of traction

• Fixed: The pull is applied between two fixed points, e.g. a fractured femur where the skin extension tape cords are tied to the end of the splint or the bed. The counter-pressure is exerted by the ring of a Thomas splint against the ischial tuberosity of the pelvis.
  
• Balanced traction: This is the pull between weights attached to the end of the skin extension tapes, with the counter-traction applied by the child’s weight, such as in Pugh’s traction.

Application types

• Gallows: Modified gallows/hoop traction is used in the treatment of hip dysplasia for babies, or to treat babies/toddlers with a fractured shaft femur (for a child below 2–14 kg approximately). This traction allows the hips to be abducted to a maximum 60 degrees, post 24 hours application. It should not be used for longer than 3–4 weeks. Gallows traction is advantageous for a child who may be nursed at home, if there is a children’s community team specialized in orthopaedic conditions available and can visit daily.
  
• Pugh’s traction: This is a kind of straight leg traction and is used in the following situations:
  
  
  
  • in pre-operative conditions, e.g. in slipped upper femoral epiphyses (SUFE);
    
  • post-operatively to allow the joint to heal following hip/knee surgery;
    
  • if there is infection in a joint;
    
  • in Perthes disease and
    
  • to rest/immobilize the joint.

Applying balanced traction

Balanced traction is generally applied following trauma when the child is very agitated with pain and fear. Prior to application, it is essential to consider the expertise of the staff, the child’s needs at the time, the choice of equipment, and the pre- and post-application needs. An assessment must be carried out before the application as to whether the child will need analgesia/sedation, or Entonox for the procedure.

Whenever traction is applied, it is essential that staff have the expertise to apply the traction safely, and this would include a play therapist to aid distraction; Equipment must be prepared including attachment of a balkan beam frame, if necessary. An important part of the application is a thorough explanation of the procedure, including the reasons for it and the approximate time it will be necessary to leave the child in traction, bearing in mind the child’s cognition, and consent for the procedure from both child and parents/carer.

Types of extension tapes

There are two types of extension tapes:

• adhesive: used in gallows/hoop/balanced traction
  
• non-adhesive: used in Pugh’s/simple straight leg traction.

If the tapes are to stay attached for more than one week, then adhesive tape is preferable. If the tapes are to be removed more than once a day, consider using non-adhesive tape. However, if the child is restless and cannot tolerate the frequent application and removal, consider using adhesive tape. Whichever is used, it must be appropriate for the treatment.

Equipment

• Skin adhesive spray: to enhance adherence when using adhesive tapes
  
• Tapes
  
• Bandages
  
• Weights held in a cradle for safety
  
• Splints
  
• Extra cord
  
• Bed that can be elevated at the foot end, and any other equipment that the bed may need, such as balkan beams
  
• Hoops.

If a Thomas splint is to be used, measuring the upper thigh will help to determine the size of the ring. Measuring the circumference of the good thigh at its widest part and adding extra centimetres to allow for swelling, which can be caused by internal bleeding, bruising, and the irregularity of the bones, will be necessary to achieve the correct size. This is also the correct time to examine the skin for any integrity such as wounds. Ensure the documentation includes the size of splint, the type of extension tapes, the skin integrity and the sedation or analgesia given.

Procedure

• Measure from the maleoli to the upper thigh or tibial tuberosity on both sides. Ensure that all bony prominences have padding to cover them.
  
• When using adhesive tapes, peel the plaster back as you are applying it, to prevent wrinkles which may cause skin damage.
  
• When applying the outer bandage, keep the knee free, begin at the maleoli, leaving the foot free and do not apply too tightly.
  
• Weights: ensure the correct sizes are put in a safety cradle, and are not too heavy, which would cause the counter-production of balanced traction. Ensure the child is lying flat, so that the weights will not rest on the floor when the child is sleeping.
  
• Attach the cord to the weights, ensuring they are taped safely to their harness, to prevent them falling off and causing injury.
  
• Elevate the foot of the bed to ensure counter-balance.
  
• If the tapes are attached to a hoop or gallows frame, ensure there is a hand-free area under the child’s bottom to provide the traction.

Post-application care

• Neurovascular observations: 1–4 hourly to prevent risk of compartment syndrome.
  
• Ensure the adherence of the tapes twice daily, and observe the tissue integrity.
  
• Analgesia: an anti-spasmodic may be considered by the medical team.
  
• Physiotherapist input for prevention of muscle wastage, foot drop and to provide muscle exercises.
  
• Distraction and play involvement.
  
• Holistic care.
  
• Dietician involvement.
  
• Bowels/urine recording.