Skill 9-18

Caring for a Patient in Skeletal Traction

Traction is the application of a pulling force to a part of the body to promote and maintain alignment to an injured part of the body (Hinkle et al., 2022). Skeletal traction provides pull to a body part by attaching weight directly to the bone through pins, screws, wires, or tongs inserted into the bone (Choudhry et al., 2020). It is used to immobilize a body part for prolonged periods. This method of traction is used to treat fractures of the femur, tibia, and cervical spine.

Traction must be applied in the correct direction and magnitude to obtain the therapeutic effects desired. The affected body part is immobilized by pulling with equal force on each end of the injured area, mixing traction and countertraction. Weights provide the pulling force or traction. The use of additional weights or positioning of the patient's body weight against the traction pull provides the countertraction. See Box 9-2 Principles of Effective Traction in Skill 9-17.

Nursing responsibilities related to skeletal traction include maintaining the traction, maintaining body alignment, monitoring neurovascular status, promoting exercise, preventing complications from the therapy and immobility, and preventing infection by providing pin-site care. A growing evidence base supports effective management of pin sites but with no clear consensus (Cam & Korkmaz, 2014; Ktistakis et al., 2015; Lagerquist et al., 2012; Lethaby et al., 2013). There remains considerable diversity of practice in caring for pin sites (Abbariao, 2018; Kazmers et al., 2016; Lethaby et al., 2013: Walker et al., 2018). Pin-site care varies based on prescribed interventions and facility policy. Dressings may be applied for the first 48 to 72 hours, and then sites may be left open to air (Abbariao, 2018). Pin-site care may be performed frequently in the first 48 to 72 hours after application, when drainage may be heavy; other evidence suggests pin care should begin after the first 48 to 72 hours (Abbariao, 2018). Pin-site care may be done daily or weekly or not at all (Georgiades, 2018; Lagerquist et al., 2012; Timms & Pugh, 2012). Pin-site care is completed using aseptic technique in the immediate postoperative period. Refer to specific patient prescribed interventions and facility guidelines.

Delegation Considerations

The care of a patient with skeletal traction may not be delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, care for these patients may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Sterile applicators
Cleansing agent for pin care, sterile normal saline for initial cleaning, but may be an antimicrobial such as chlorhexidine or povidone-iodine (Hickey & Strayer, 2020; Sáenz-Jalón et al., 2020; Walker et al., 2018), per prescribed intervention or facility policy
Sterile container
Antimicrobial ointment, per prescribed intervention or facility policy
Sterile gauze or dressing, per prescribed intervention or facility policy
Analgesic, as prescribed
Sterile or nonsterile gloves for performing pin care, depending on prescribed intervention or facility policy
Additional PPE, as indicated

Assessment

Review the patient's health record and care plan to determine the type of traction, traction weight, and line of pull. Assess the traction equipment to ensure proper function, including inspecting the ropes for fraying and proper positioning. Assess the patient's body alignment. Assess the patient's pain and need for analgesia before providing care. Perform skin and neurovascular assessments. Inspect the pin insertion sites for inflammation and infection, including swelling, cloudy or offensive drainage, pain, or redness. Assess for complications of immobility, including alterations in respiratory function, constipation, alterations in skin integrity, alterations in urinary elimination, and muscle weakness, contractures, thrombophlebitis, pulmonary embolism, and fatigue.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

ADL deficit
Infection risk
Disturbed body image

Outcome Identification and Planning

The expected outcomes to achieve when applying and caring for a patient in skeletal traction are that the traction is maintained appropriately, and the patient maintains proper body alignment. Other outcomes that may be appropriate include that the patient reports an increased level of comfort, and the patient is free from infection and injury.

Implementation

Action	Rationale
1. Review the health record and the care plan to determine the type of traction being used and the prescribed care.	Reviewing the health record and care plan validates the correct patient and correct procedure.
2. Perform hand hygiene. Put on PPE, as indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient. Explain the procedure to the patient, emphasizing the importance of maintaining counterbalance, alignment, and position.	Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect.
4. Perform a pain assessment and assess for muscle spasm. Administer prescribed medications in sufficient time to allow for the full effect of the analgesic and/or muscle relaxant.	Assessing for pain and administering analgesics promote patient comfort.
5. Close the curtains around the bed and close the door to the room, if possible. Place the bed at an appropriate and comfortable working height (VHACEOSH, 2016).	Closing the door or curtains provides for privacy. Proper bed height prevents back and muscle strain.
6. Ensure the traction apparatus is attached securely to the bed. Assess the traction setup, including application of the prescribed amount of weight. Be sure that the weights hang freely, not touching the bed or the floor (Figure 1).	Proper traction application reduces the risk of injury by promoting accurate counterbalance and traction function.
7. Check that the ropes move freely through the pulleys. Check that all knots are tight and are positioned away from the pulleys. Pulleys should be free from the linens.	Free ropes and pulleys ensure accurate counterbalance and traction function.
8. Check the alignment of the patient's body, as prescribed.	Proper alignment maintains an effective line of pull and prevents injury.
9. Perform a skin assessment. Pay attention to pressure points, including the ischial tuberosity, popliteal space, Achilles tendon, sacrum, and heel.	Skin assessment provides early intervention for skin irritation, impaired tissue perfusion, and other complications.
10. Perform a neurovascular assessment. Assess the extremity distal to the traction for edema and peripheral pulses. Assess the temperature and color and compare with the unaffected limb. Check for pain, inability to move body parts distal to the traction, pallor, and abnormal sensations. Assess for indicators of deep vein thrombosis, including calf tenderness, and swelling.	Neurovascular assessment aids in early identification and allows for prompt intervention should compromised circulation and oxygenation of tissues develop.
11. Assess the site at and around the pins for redness, edema, and odor. Assess for skin tenting, prolonged or purulent drainage, elevated body temperature, elevated pin-site temperature, and bowing or bending of the pins.	Pin sites provide a possible entry for microorganisms. Skin inspection allows for early detection and prompt intervention should complications develop.
12. Provide pin-site care, based on prescribed interventions and/or facility policy and procedure.	Performing pin-site care may help to reduce the risk of pin site infection and associated complications (Abbariao, 2018; Sáenz-Jalón et al., 2020; Kazmers et al., 2016; Lethaby et al., 2013).
a. Using sterile technique, open the applicator package and pour the cleansing agent into the sterile container.	Using sterile technique in the initial 2 to 3 days may reduce the risk for transmission of microorganisms (Hickey & Strayer, 2020; Kazmers et al., 2016).
b. Put on the sterile gloves.	Gloves prevent contact with blood and/or body fluids.
c. Place the applicators into the solution.
d. Clean the pin site, starting at the insertion area and working outward, away from the pin site (Figure 2).	Cleaning from the center outward ensures movement from the least to most contaminated area.
e. Use each applicator once. Use a new applicator for each pin site. Depending on prescribed intervention and facility policy, gently remove crusts or scabs appearing at the pin site if they can be removed easily; leave in place if there is difficulty during removal.	Using an applicator once reduces the risk of transmission of microorganisms. Removal of crusts is controversial; some evidence suggests removal of crusts prevents excessive pressure at site and allows for drainage and prevents infection (Abbariao, 2018; Cam & Korkmaz, 2014; Walker et al., 2018). Other evidence suggests crusts should be left in place to act as a biologic barrier to prevent introduction of microorganisms and decrease the risk of pint site infection (Abbariao, 2018; Georgiades, 2018; Walker et al., 2018).
13. Depending on prescribed interventions and facility policy, apply the antimicrobial ointment to pin sites and apply a dressing. Remove gloves and dispose of them appropriately. Perform hand hygiene.	Antimicrobial ointment may help reduce the risk of infection (Hickey & Strayer, 2020; Kazmers et al., 2016; Lethaby et al., 2013). A dressing may aid in protecting the pin sites from contamination and in containing any drainage. Disposing of gloves reduces the risk of microorganism transmission. Hand hygiene prevents the spread of microorganisms.
14. Perform range-of-motion (ROM) and active exercises on all noninvolved joints, unless contraindicated. Encourage the patient to cough and deep breathe every 2 hours.	ROM and active exercises promote joint, help maintain muscle strength and tone, and promote circulation (Hinkle et al., 2022). Coughing and deep breathing reduce the risk of respiratory complications related to immobility.
15. Place the bed in the lowest position that still allows the weight to hang freely. Make sure the call bell and other essential items are within easy reach.	Proper bed positioning ensures effective application of traction without patient injury. Having the call bell and other items in easy reach contributes to patient safety.
16. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the traction was maintained appropriately, the patient has maintained proper body alignment, the patient has reported an increased level of comfort, and the patient is free from infection and injury.

Documentation

Guidelines

Document the time, date, type of traction, and the amount of weight used. Include skin and pin-site assessments, and pin-site care. Document the patient's response to the traction and the neurovascular status of the extremity.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

While performing a pin-site assessment for your patient with skeletal traction, you note that several of the pins move and slide in the pin tract: Assess the patient for other symptoms, including signs of infection at the pin sites, pain, and fever. Assess for neurovascular changes. Communicate with the health care team regarding the findings.

Special Considerations

Normal changes at the pin site related to the inflammatory response after insertion include redness, warmth, and serosanguineous drainage and usually subside 72 hours after insertion (Hinkle et al., 2022). If a pin site becomes unusually painful or tender, or if you notice any fluid discharge after the initial insertion period, it may be a signal that the pin has loosened or become infected. Other signs of infection may include the presence of purulent drainage, tenting of the skin at pin site, odor and fever (Hinkle et al., 2022). Communicate these symptoms to the health care team.
Assess the patient for chronic conditions, such as diabetes mellitus, peripheral vascular disease, and chronic obstructive pulmonary disease, which can increase a patient's risk for complications when skeletal traction is in use.
Never remove the weights from skeletal traction unless a life-threatening situation occurs. Removal of the weights interferes with therapy and can result in injury to the patient.
Jarring movements can disrupt traction. Use smooth, coordinated effort whenever you must reposition the patient.
Inspect the pin sites for inflammation and evidence of infection at least every 8 hours. Prevention of osteomyelitis is of utmost importance (Abbariao, 2018; Kazmers et al., 2016).

EVIDENCE FOR PRACTICE

External Fixator Pin-Site Care

Different methods of cleansing external fixator percutaneous pin sites have been suggested to prevent pin-site infections, with no clear consensus on a cleansing regimen or other aspects of pin-site care (Kazmers et al., 2016; Lathaby et al., 2013). Chlorhexidine-alcohol solution and povidone-iodine solution are commonly used to provide pin-site care. Is there a significant difference between the number and severity of infections in fixators among those who are cared for using one or the other of these solutions?

Related Evidence

Sáenz-Jalón, M., Sarabia-Cobo, C. M., Bartolome, E. R., Fernández, M. S., Vélez, B., Escudero, M., Miguel, M. E., Artabe, P., Cabañas, I., Fernández, A., Garcés, C., & Couceiro, J. (2020). A randomized clinical trial on the use of antiseptic solutions for the pin-site care of external fixators: Chlorhexidine-alcohol versus povidone-iodine. Journal of Trauma Nursing, 27(3), 146-150. https://doi.org/10.1097/JTN.0000000000000503

This randomized clinical trial investigated the superiority of chlorhexidine-alcohol solution versus povidone-iodine solution for external fixator pin-site care in pin-site infection. The study took place in one hospital in Spain with 128 patients who underwent placement of an external fixator. Participants were randomly assigned to receive pin-site care using either a 2% chlorhexidine-alcohol solution or a 10% povidone-iodine solution. The average number of pins per patient was 4.3 with a total 568 of pins initially available for analysis. Ultimately, 489 pins were analyzed for the development of a pin-site infection, with 79 pins not analyzed for various reasons, including improper collection of the sample and inappropriate condition of the sample upon arrival to the laboratory. The majority of patients (82%) remained free of pin-site infection. Results indicated no significant differences of rate of infection between groups. Statistically significant differences were found regarding time and infection variables. The longer the person had the fixator, the higher the risk of infection (P = .002). The researchers concluded both chlorhexidine-alcohol and povidone-iodine solutions are equally effective for preventing infection in external fixator pin sites. The researchers suggested other factors should also be taken into consideration when developing pin-site care guidelines, including cost and simplicity of use to optimal care.

Relevance for Nursing Practice

The results of this study suggest that implementing pin-site care with either antimicrobial solution is effective in preventing pin-site infections and that other factors should also be considered to ensure consistent implementation of pin-site care. Nurses should consider adoption of evidence-based pin-site care guidelines to support quality patient care and improve patient outcomes.

EVIDENCE FOR PRACTICE

External Fixator Pin-Site Care

The goal of pin-site care is to reduce the risk for or, when possible, prevent pin-site infection. Removal of crusts from pin sites is controversial; some evidence suggests removal of crusts prevents excessive pressure at site and allows for drainage and prevents infection (Abbariao, 2018; Cam & Korkmaz, 2014; Walker et al., 2018). Other evidence suggest crusts should be left in place to act as a biologic barrier to prevent introduction of microorganisms and decrease the risk of pin-site infection (Abbariao, 2018; Georgiades, 2018; Walker et al., 2018).

Related Evidence

Georgiades, D. S. (2018). A systematic integrative review of pin site crusts. Orthopaedic Nursing, 37(1), 36-42. https://doi.org/10.1097/NOR.0000000000000416

Refer to details in Skill 9-19, Evidence for Practice.

section name header

Skill 9-18

EVIDENCE FOR PRACTICE

EVIDENCE FOR PRACTICE