Skin traction

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 patients 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

Patients 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 patients 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 patients 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 Childrens Hospital Westmead
Practice Guideline.
Pressure area prevention management clinical practice guideline (2014). Royal Childrens
Hospital.
Split Russells/Bucks Traction (2012). Cincinnati Childrens 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. Wongs Essentials of pediatric nursing.
(8th ed.). (pp 1106-1173). St Louis: Mosby.
Whiteing, N. (2008). Fractures: pathophysiology, treatment and nursing care. Nursing
Standard, 23(2), 49-57.