Introduction

Femoral fractures are often managed using skin traction pre-operatively. Traction limits movement and reduces the fracture to help decrease pain, spasms and swelling. It aims to restore and maintain straight alignment and length of bone following fractures.    

This clinical practice guideline aims to ensure that the application and management of skin traction is consistent and that potential complications are identified early and managed correctly.

Definition of terms 

• Fracture: Any type of break in a bone. 
• Traction: Traction is the application of a pulling force to an injured part of the body or extremity.
• Skin Traction (Bucks Traction): Skin traction is applied by strapping the patient’s affected lower limb and attaching weights.
• Counter Traction: Application of force in the opposite direction used to oppose/offset traction. 
• Neurovascular observations: Is an assessment of circulation, oxygenation and nerve function of limbs within the body. (link to Neurovascular Observations Nursing Guideline)
• Compartment syndrome: Increased pressure within one of the bodies compartments which contain muscles and nerves.

Management

Acute management

• Ensure Order for Skin traction is documented by the Orthopaedic Team-(including weight to be applied in kgs)
• Preparation of equipment
  • Hospital bed
  • Traction kit paediatric OR adult size (foam stirrup with rope and bandage)
  • Overhead traction frame
  • Pulley
  • Traction weight bag
  • Water
  • Sleek

Picture 1 - Traction Kit; Picture 2 - Foam stirrup with rope; Picture 3 -Traction weight bag 

Pain relief

• A femoral nerve block is the preferred pain management strategy and should be administered in the emergency department prior to being admitted to the ward.
• Diazepam and Oxycodone should always be charted and used in conjunction with the femoral nerve block.

Distraction and education

• Explain the procedure to the parents and patient before commencing.
• Plan appropriate distraction for patient involving parents.

Application of traction

• Ensure the correct amount of water has been added to the traction weight bag as per medical orders.
• (Formula to calculate weight in kgs to come)
• Fold foam stirrup around the heel, ankle and lower leg of affected limb. Apply bandage, starting at the ankle, up the lower leg using a figure 8 technique, secure with sleek tape.
• Place rope over the pulley and attach traction weight bag. If necessary trim rope to ensure traction weigh bag is suspended in air and does not sit on the floor.

Picture – Foam stirrup and bandage.

Ongoing management

Maintain skin integrity

• Patient’s legs, heels, elbows and buttocks may develop pressure areas due to remaining in the same position and the bandages.
• Position a rolled up towel/pillow under the heel to relieve potential pressure.
• Encourage the patient to reposition themselves or complete pressure area care four hourly.
• Remove the foam stirrup and bandage once per shift, to relieve potential pressure and observe condition patients skin.
• Keep the sheets dry.
• Document the condition of skin throughout care in the progress notes and care plan
• Ensure that the pressure injury prevention score and plan is assessed and documented. 

Traction care

• Ensure that the traction weight bag is hanging freely, the bag must not rest on the bed or the floor
• If the rope becomes frayed replace them
• The rope must be in the pulley tracks
• Ensure the bandages are free from wrinkles
• Tilt the bed to maintain counter traction

Observations

• Check the patient’s neurovascular observations hourly and record
• If the bandage is too tight it can cause blood circulation to be slowed.
• Monitoring of swelling of the femur should also occur to monitor for compartment syndrome.
• If neurovascular compromise is detected remove the bandage and reapply bandage not as tight. If circulation does not improve notify the orthopaedic team. 

Pain Assessment and Management

• Assessment of pain is essential to ensure that the correct analgesic is administered for the desired effect
• Paracetamol, Diazepam and Oxycodone should all be charted and administered as necessary.
• Pre-emptive analgesia ensures that the patient’s pain is sufficiently managed and should be considered prior to pressure area care.

Activity

• The patient is able to sit up in bed and participate in quiet activities such as craft, board games and watching TV
• Non-pharmacological distraction and activity will improve patient comfort.
• The patient is able to move in bed as tolerated for hygiene to be completed.

Theatre time

• The patient should be transported to theatre in traction to reduce pain and maintain alignment.

Special considerations

• The foam stirrup, bandage and rope are single patient use only.

Potential complications

• Skin breakdown/pressure areas
• Neurovascular impairment
• Compartment syndrome
• Joint contractures
• Constipation from immobility and analgesics

Companion documents

• Neurovascular observation nursing guideline (which includes an image of the Neurovascular Obs Chart)
• Theatre fasting guidelines
• Procedural Pain Management nursing guideline
• Constipation clinical practice guideline
• Pressure Injury nursing guideline

References

• Ahmed, A., Beaupre, L., Rashiq, S., Dryden, D., Hamm, M., Jones, A. (2011). Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Annals of internal medicine, 155(4), 234-246.
  
• Anglen, J. & Choi, L. (2005). Treatment options in Paediatric Femoral Shaft Fractures. Journal of Orthopaedic Trauma, 19 (10), 724-733.
  
• Bailey, J. (2003). Orthopaedic care. Nursing Center, 33(6), 58-63.
  
• Parker, M.  Handoll, P. (2009). Pre-operative traction for fractures of the proximal femur in adults. The Cochrane Collaboration, 1-30.
  
• Hedin, H., Borgquist, L. & Larsson, S. (2004). A cost analysis of three methods of treating femoral shaft fractures in children. Acta Orthopaedic Scand, 75 (3), 241-248.
  
• Orthopaedic Traction: Care and management (2014). The Children’s Hospital Westmead Practice Guideline.
  
• Pressure area prevention management clinical practice guideline (2014). Royal Children’s Hospital.
  
• Split Russell’s/Bucks Traction (2012). Cincinnati Children’s Health Topics.
  
• Saygi, B., Ozkan, K., Eceviz, E., Tetik, C. & Sen, C. (2010) Skin traction and placebo effect in the preoperative pain control of patients with collum and intertrochanteric femur fractures. Bullentin of the NYU Hospital for joint diseases, 68(1) 15-17.
  
• Smith, C. (1994). Nursing the patient in traction. Nursing Times, 36-39.
  
• Stewart, J. & Hallett, J. (1994). Traction and orthopaedic appliances 2^nd edition. 4-14.
  
• Styrcula, L. (1994). Traction Basics. Orthopaedic Nursing, 13(2), 71-74.
  
• Trompeter, A. & Newman, K. (2013). Femoral shaft fractures in adults. Orthopaedics and Trauma, 27(5), 322-331.
  
• Wilson, D., Curry, M. & Hockenberry, M.(2009). The child with musculoskeletal or articular dysfunction. In Hockenberry, M.J., & Wilson, D. Wong’s Essentials of pediatric nursing. (8^th ed.). (pp 1106-1173). St Louis: Mosby.
  
• Whiteing, N. (2008). Fractures: pathophysiology, treatment and nursing care. Nursing Standard, 23(2), 49-57.

Evidence table

The Evidence Table for this guideline can be viewed here. 

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Kate Glassford, Advance Practice Nurse, Platypus Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated September 2015.