Traction & Bucks Traction by Josephine A.

Kruse Introduction: This paper will discuss the application of Bucks traction and give background information on the topic of traction in general. With the advances in surgical reductions of fractures has come a massive reduction in the use of traction. As a result the working knowledge of this modality has declined amongst nursing staff. In talking to her colleagues on the orthopaedic ward as well as the A&E nurses the author came to the conclusion that a good working knowledge would not only be of help but also necessary as some consultants still request Bucks traction for their patients. Some nightshifts have seen the After Hours Director of Nursing (ADON) as the only person in the hospital with any knowledge on the subject matter The first section of the paper will begin with some background information on the principles of traction in general to then focus on Bucks traction in particular. Equipment needed to setup Bucks traction and the application will be discussed, as will the nursing care. Traction in General: The principles of traction are a pulling force that is applied to part of the body, the limbs, the pelvis or the spine and a pulling force applied in the opposite direction called countertraction. The forces involved in traction are based on Newtons third law of motion, which states that for every action there has to be an equal, and opposite reaction (Physicics book). In other words to pull an object into one direction an equal counter-thrust in the opposite direction has to be present (Footner, 1992 and Dave, 1995). Traction can be achieved via the use of hands as in manual traction, the use of robes, splints, pulleys and weights as in skin traction and through pins, wires

and tongs inserted into the bone as in skeletal traction (Taylor, 1987 and Osmond, 1999). Josephine A. Kruse Learning Contract 1The use of traction dates as far back as 3000 years. The Aztecs and the ancient Egyptians used manual traction and made splints out off tree branches and bark (Styrcula, 1994 a and Osmond, 1990) and Hippocrates (350 BC) wrote about manual traction and the forces of extension and counterextension (Styrcula, 1994 a: 71). In 1340 the French surgeon Guy de Chauliac wrote about isotonic traction with weights suspended at the foot of the patients bed, but due to practical considerations it took till around 1829 when continuous traction was applied more widely (Peltier, 1968: 1603). Around 1848 Josiah Crosby an American physician was the first to effectively promote and demonstrate skin traction not only as a treatment of fractures but also to treat deformity of the hip (Peltier, 1968: 1609). It was this application that caught the attention of Gurdon Buck who around 1861 despite his acknowledgement of Crosbys work had the skin traction named after him. It was not till 1921 however that the Australian surgeon Hamilton Russell expanded on the concept of Bucks traction by making use of Potts (1780) doctrine that fractured limbs should be placed in a position in which the muscles are most relaxed, namely hip and knee flexion, by developing the Hamilton Russell traction (Peltier, 1968: 1612). Twenty-six years prior though, in December 1895 a German professor of physics named Rntgen published his observations with a new type of rays which started a new era in the research of fracture treatment (Peltier, 1968:1613). Using x-rays to assess fracture treatment the orthopaedic world was faced with the astonishing fact that treatment with bucks traction was not satisfactory in 100% of cases and by 1907 Fritz Steinmann had

successfully developed skeletal traction by the use of pins driven into the femoral condyles (Peltier, 1968: 1615). Traction has been the mainstay of orthopaedic management till the 1940s when internal fixations using nails, pins and plates became common practice (Reference). These advances in surgical reduction of fractures coupled with economic necessity of shorter hospital stays and research that queries the effectiveness of traction have lead to a decline in its use. This in turn has resulted in a decline in the knowledge of nursing staff highlighting the need for simple, no fuss instructions. Josephine A. Kruse Learning Contract 2The uses for traction documented throughout the literature are many: Traction is used to promote rest/immobilisation, which restores and maintains alignment allowing bones and soft tissue to heal (Taylor, 1987; Dave 1995 and Redemann, 2002). It helps to rest inflamed joints and corrects deformities, overcomes muscle spasms and therefore aids in the relieve of pain (Taylor, 1987; Dave, 1995 and Osmond, 1999). Osmond (1999) states that it reduces subluxations or dislocations of joints and Styrcula (1994a) and Rosen, Chen, Hiebert and Koval (2001) credit the use of traction with a reduction in force required when performing fracture reduction during surgery. Finally traction is also said to promote movement and exercise (Dave, 1995 and Redemann, 2002). The mechanism of traction involves not only the actual traction pull but also a force known as countertraction, a pull in the opposite direction, essential for the effectiveness of traction. Countertraction prevents the patient from being dragged into the traction pull direction. Without it, muscle spasms could not be overcome and all benefits of traction would not come to pass. There are two types of mechanics for the traction set-up, which use countertraction in two distinct ways. The first is called balanced traction, also known as running or

sliding traction. Here the traction is applied via the patients skin or with skeletal methods. Weights and pulleys are used to apply a direct force while the weight of the patients body in combination with elevation of the bed away from the pull of traction provide the countertraction (Taylor, 1987, Styrcula, 1994a; Dave, 1995 and Osmond, 1999). Bucks Traction would be an example of this. The second type is called fixed traction were traction and countertraction are exerted between two fixed points not requiring weights or bed elevation to achieve traction and countertraction. The Thomas splint is an example for this type of system (Taylor, 1987, Styrcula, 1994a; Dave, 1995 and Osmond, 1999). Josephine A. Kruse Learning Contract 3The mechanical components of traction systems, pulleys, vector forces and friction, are related to several factors: the way in which countertraction is applied and the angle, direction and number of traction forces applied (Taylor, 1987: 3). The angle and direction of the traction pull depends on the position of the pulleys and the number of pulleys effects the amount of pull being applied. A single pulley provides the same amount of traction pull as the amount of weight applied. When there are two pulleys in line of the same traction weight the so called block and tackle effect almost doubles the amount of pull exerted. Vector forces are another component that has a bearing on the amount of pulling force. A vectored force is created by applying traction forces in two different but not opposite directions to the same body part. This results in a force double the actual traction pull (Taylor, 1987 and Styrcula, 1994a). Friction is always present in any traction system. Friction gives resistance to the traction pull thus reducing the traction force. It needs therefore be minimised whenever and however possible (Taylor, 1987 and Styrcula, 1994a). The classifications of traction are based on the way hold on the body is achieved: 1. Manual traction refers to a pulling force applied by a person to the effected body

part via their hands. It must be a constant and gentle pull. Manual traction is used to reduce simple fractures prior to plaster application or during surgery. It is also used during traction set-up and if there is a need to temporally release the traction weight (Taylor, 1987; Styrcula, 1994a and Osmond, 1999). 2. Skeletal traction refers to pulling forces that are applied directly to the skeleton via pins, wires or screws that have been inserted into the bone (Taylor, 1987; Styrcula, 1994a and Osmond, 1999). Due to this greater weights can be used. Skeletal traction is used for unstable fractures, for control of rotation where greater weights up to 25 pounds are needed and for fractures requiring long-term traction (Styrcula, 1994a and Osmond, 1999). Josephine A. Kruse Learning Contract 43. Skin traction finally refers to any traction where the pulling force is applied to the affected body part via the soft tissues (Taylor, 1987; Styrcula, 1994a and Osmond, 1999). This can be done in a variety of ways: adhesive and non-adhesive skin extensions, splints, slings, foam boots, pelvic slings and cervical halters (Taylor, 1987; Styrcula, 1994a and Osmond, 1999). Because skin traction is applied to the skin the grip is less secure, limiting the strength of the traction force. In other words the amount of weight that can be used (Taylor, 1987; Styrcula, 1994a and Osmond, 1999). Weight should not exceed 7-9 pounds (3-4 kg) (Taylor, 1987; Osmond, 1999 and Redemann, 2002). Skin traction is used for short periods of time most commonly for the temporary management of femur fractures and dislocations and to reduce muscle spasms and pain prior to surgery (Taylor, 1987; Styrcula, 1994a and Dave, 1995). Bucks Traction: Bucks Traction is a balanced skin traction exerting a pull in one plane to the lower

limb via skin extensions (Taylor, 1987; Styrcula, 1994; Osmond, 1999 and Redemann, 2002). It was named after Gurdon Buck who in 1861 published his experience with the treatment of twenty-one cases of fractured femur (Peltier, 1968: 1610). Bucks Traction is used as a short-term measure were light traction forces are required to immobilize hip fractures before surgery and reduce muscle spasms (Styrcula, 1994d and Redemann, 2002). It can also be used for hip dislocations, hip and knee contractures, non-displaced fracture of the acetabulum and bilaterally for the reduction of lower back pain (Taylor, 1987 and Styrcula, 1994d) although these uses are rarely seen today. The patient is put in a supine position with the legs straight in the natural position, which is slight abduction (Taylor, 1987 and Styrcula, 1994d). A boot or wrap is then applied and the traction force is exerted in line with the long axis of the leg via a rope attached to the footplate of the boot/extension passing over a pulley at the end of the bed connecting to a weight (Taylor, 1987; Styrcula, 1994d and Osmond, 1999). The pulley has no effect on the traction force but acts to change the direction of the pull in order to work with gravity (Taylor, 1987 and Osmond, Josephine A. Kruse Learning Contract 51999). Countertraction is achieved by elevating the foot of the bed to a level that prevents the patient being dragged of the bed. To optimise patient comfort it is important to have balance between the traction force and countertraction force. If the bed needs to be elevated too high to prevent the patient being pulled of the bed the weight might be too heavy and needs to be reviewed (Dave, 1995 and Osmond, 1999). These days Bucks traction is used mostly in the elderly (Styrcula, 1994d: 61) and controversy exist over its effectiveness. Many studies found the proposed benefits to be untrue (Finsen, Borset, Buvik and Hauke,

1992; Anderson, Harper, Connolly and 1993 and Rosen, et al, 2001) but as long as orthopaedic surgeons request their patients to be put into traction nurses will need to know how to apply it correctly and how to care for these patients so as to at least not do any harm. To set up Bucks traction the following equipment is needed: A traction bed end with a pulley A Notac non-adhesive traction kit containing one skin extension of vented foam with a spreader plate, traction cord and a retaining bandage A weight bag Role of tape Josephine A. Kruse Learning Contract 6For the application two people are needed. The footboard of the bed needs to be removed and the traction frame put in its place. The waterbag needs to be filled according to the prescribed weight and the traction rope at the spreader should be secured. The patient should be in supine position with the legs extended in slight abduction (Taylor, 1987: 27). If the leg is internally or externally rotated as a result of the hip fracture it should not be overly manipulated to achieve the anatomical position as this can cause neurovascular damage (Styrcula, 1994d: 61). Before putting on the skin traction the patients neurovascular status should be assessed to gain baseline data (Taylor, 1987 and Styrcula, 1994b). One person should now hold the affected leg supporting the heel and applying steady manual traction. The foam extension will be fitted around the leg with the extra foam on the malleoli, leaving enough room between the sole of the foot and the spreader plate to put three fingers beside each other and the lateral part of the extension lying slightly below the medial to prevent external rotation (Taylor, 1987 and Styrcula, 1994d). The second person

now bandages over the extension in a figure eight style from the outside to the inside to again prevent external rotation. The malleoli, the head of the fibula and the popliteal fossa should be avoided (Appendix 1), as these are pressure pointsareas were superficial nerves pass along the skin (Taylor, 1987; Styrcula, 1994b and Osmond, 1999). The end of the bandage will be secured with tape. The traction cord will be passed over the pulley in line with the foot (ensuring the pulley is in the right position) and the water-filled weight bag is attached using a Slip knot (Appendix 2). The end of the traction cord should be taped and finally the foot of the bed should be elevated to provide countertraction (Taylor, 1987; Styrcula, 1994b and Osmond, 1999). Nursing Care for the patient in Bucks traction has to take into account the numerous adverse effects fractures and the resulting impaired mobility have on the patient in general. With traction a few more potential problems can be added to the list. Impaired skin integrity is one of the obvious problems, especially in the elderly that have to be in traction for a long time (Redmann, 2002:315). The skin should be Josephine A. Kruse Learning Contract 7inspected before application of the extensions and any bony prominences need to be padded (Taylor, 1987; Styrcula, 1994d; Rosen et al, 2001 and Redemann, 2002). Too much weight can lead to tissue damage and the traction consequently needs to be removed once per shift to check the integrity of the skin (Taylor, 1987; Styrcula, 1994d and Redemann, 2002). Patients should be encouraged to move themselves around the bed using the Monkey Bar and it is suggested to have the side rail of the bed up to assist in movement (Taylor, 1987; Styrcula, 1994 and Redemann, 2002). Altered tissue perfusion, the danger of deep vein thrombosis (DVT) or pulmonary

embolism (PE) is another common problem (Taylor, 1987; Styrcula, 1994d; Osmond, 1999; Rosen et al, 2001 and Redemann, 2002). Deep breathing and ankle pump exercises as well as the use of TEDS stockings and anticoagulant therapy are ways to prevent this (Taylor, 1987; Styrcula, 1994d; Rosen et al, 2001 and Redemann, 2002). Calves should be inspected for tenderness, unusual warmth and redness (Carroll, 1993 and Bright and Gorgi, 1994) and any signs of dyspnea and tachypnea can indicate a PE (Smeltzer and Bare, 1996 and Turpie, Chin and Gregory, 2002). There is also a high risk for peripheral dysfunction such as compartment syndrome or nerve paralysis. Neurovascular checks and assessment of movement should be done before applying traction then hourly for the first twenty-four hours and if all is well four-hourly there after (Taylor, 1987; Styrcula, 1994b and Kunkler, 1999). Although traction is said to relieve pain and muscle spasms it might not be enough and pain management is therefore another important part of the nursing care. Pain can be assessed using the 1-10 scale (McCaffery and Pasero, 2001 and Redemann, 2002) and patients should be encouraged to take analgesia before pain becomes severe. Education with regards to addiction fears and risk of constipation need to be provided (Redemann, 2002:316). As with all immobilised patients there is a high risk for constipation not only as a result of the immobility but also by its combination with analgesia intake and for traction Josephine A. Kruse Learning Contract 8patients especially the challenge of getting onto a pan, coupled with the embarrassment at having to open your bowels in bed (Taylor, 1987; Winney, 1998 and Redemann, 2002). The use of fracture pans, provision of privacy, high fluid intake, roughage in the diet and if needed aperients can all help in promoting normal

bowel elimination (Winney, 1998 and Redemann, 2002). Impaired gas exchange is a difficulty putting the client in traction at risk for respiratory problems. The recumbent/semirecumbent position these patients are confined to does not allow for full movement of the diaphragm causing small tidal and large residual volumes (Redemann, 2002:317). To prevent problems frequent repositioning elevation of the bed head whenever possible combined with coughing and deep breathing exercises and the use of a spirometer can all assist to maintain a good gas exchange (Smeltzer and Bare, 1996 and Redemann, 2002). Knowledge deficit and the need for patient education do always apply but especially for the patient in traction and their families as the whole set-up can look very frightening (Taylor, 1987 and Styrcula, 1994b). High risk for injury is especially relevant to the patient in traction as incorrect management can cause considerable discomfort (Taylor, 1987 and Redemann, 2002). The traction must be inspected throughout the shift to ensure the line of pull is maintained, all clamps are tightened and there are no fraying ropes or unsecured knots that could endanger the patient. Ropes must move freely over the pulleys, the line of traction should be maintained at all times. Neither weights nor ropes should touch the bed or sheets. A pillow should not be put under the effected leg and when moving the patient the weight should not be removed. When undoing the skin extensions once per shift manual traction needs to be applied. Josephine A. Kruse Learning Contract 9Josephine A. Kruse Learning Contract 10 In summary caring for the patient in traction is very much the same as caring for any orthopaedic patient in addition to some points that are unique to traction. This paper will the close with a short list of the most important points of nursing care related to the set-up and care of the patient in traction:

Points to Remember: Dos of Traction Check skin and traction apparatus once per shift Elevate the foot of the bed to ensure countertraction Maintain line of pull Use only braided cord (3-4 mm thick) Secure knots with tape Use only traction bandage Check the four Ps Supply manual traction when re-bandaging extensions Donts of Traction: Over manipulate the leg Reuse cord Bandage over the malleoli or head of the fibula Have knots in the middle of the cord Have weight or ropes touch bedclothes, part of the bed or the floor Put a pillow under the effected leg Take traction off during movement