International Journal of Orthopaedic and Trauma Nursing 29 (2018) 54e57
Contents lists available at ScienceDirect
International Journal of Orthopaedic and Trauma Nursing
journal homepage: http://www.journals.elsevier.com/international-
journal-of-orthopaedic-and-trauma-nursing
Practice development in orthopaedics and trauma
The principles of traction and the application of lower limb skin
traction
Wendy Duperouzel a, *, Beverley Gray b, Julie Santy-Tomlinson c
a
ANZONA (Australian and New Zealand Orthopaedic Nurses' Association), PO Box 560, Kwinana, 6966, Western Australia, Australia
b
IHSCS, Princess Elizabeth Hospital, Guernsey
c
University of Manchester, United Kingdom
Introduction
Traction remains a feature of the treatment and management of
orthopaedic and trauma conditions in both children and adults.
However, it is one of many treatment modalities in the modern
management of orthopaedic and trauma conditions and is, there-
fore, used less frequently now than it was in the past. This presents
a risk that the practitioner may not be as skilled in application and
care of traction as would have been the case a few decades ago
when traction was the mainstay of fracture care. This article is the
first in a series that aims to provide the practitioner with an un-
derstanding of the principles of traction. The history of traction is
discussed by Flynn (2018). The aim of the present paper is to pro-
vide an overview of the principles of traction, along with detailed
guidance for the application of skin traction to the lower limb and
the subsequent care of the patient.
The principles of traction
Traction is the application of a pulling force, with the purpose of
one or more of the following:

To prevent or reduce muscle spasm

To immobilise/rest/control movement of a joint or part of the
body

To reduce, re-align and/or to immobilise a fracture or dislocation
and to maintain alignment

To elevate a limb to reduce swelling.
There are five main methods of applying traction (see box 1).
Some of the most common terminology relating to traction and its
application is defined in Table 1.
Preparation for application of skin traction
Skin traction is applied to enable a pulling force to be exerted on
* Corresponding author.
E-mail address: w.duperouzel@gmail.com (W. Duperouzel).
https://doi.org/10.1016/j.ijotn.2017.10.004
1878-1241/© 2017 Published by Elsevier Ltd.
the affected body part via the soft tissues. Extensions/tapes are
applied and secured to the skin on both the lateral and medial
aspects of the limb (RCN, 2015). It forms the basis for other traction
applications such as Hamilton Russell and Gallows (or Bryant's)
traction and can be used with a Thomas' Splint. Skin traction is also
used in Dunlop's traction of the arm for supracondylar fractures of
the humerus in children.
Commercial skin traction kits are available with either adhesive
or non-adhesive materials. These kits consist of skin extensions
attached to a spreader plate with foam padding and a cord to attach
the traction to a splint and/or weight. The adhesive traction is used
less frequently because of the danger of skin damage and allergic
reactions and it should never be used in patients who have known
allergies to adhesive plaster or have fragile skin. Before any skin
traction is applied, it is vital to inspect the patient's skin and
ascertain if there are any allergies. If there are abrasions, lacera-
tions, open wounds, rashes or superficial infections, skin traction
may be contraindicated. Skin traction may also be contraindicated
for patients with varicose veins, neurological or vascular disorders,
diabetes and/or fragile skin.
In preparation for the application of the skin traction, all the
equipment needed should be available and at the bedside. The
practitioner applying the traction must check in the patient records
which limb is indicated for the application of traction. It is good
practice to review the radiological images to identify the location,
type and degree of fracture/dislocation. Full explanation of the
procedure including the rationale for the traction should be given
to the patient and any others present and patient consent should be
assured.
Prior to application, it is important to ensure the patient has
adequate analgesia prescribed and administered including docu-
mented pain assessment and evaluation of effectiveness of pain
management. The practitioner should perform a neurovascular
status check of both limbs for baseline observations including
checking of the dorsalis pedis and posterior tibialis pulses of the
foot and ankle and document the findings (Shields and Clarke,
2011). Traction should only be applied by practitioners who are
competent to do so and have sufficient experience (RCN, 2015).
 W. Duperouzel et al. / International Journal of Orthopaedic and Trauma Nursing 29 (2018) 54e57 55

Box 1
Principal methods of applying traction (Jester et al., 2011)
Manual traction: applying the pull manually with the hands.
Skin traction: applying the force over a large area of skin/
soft tissue to transmit traction to the bone.
Skeletal traction: applying the force directly to the bone
through metal pins inserted through the bone.
Two additional methods for skin and skeletal traction:
Fixed Traction: the pull is between two fixed points.
Balanced or sliding traction: the pull is exerted by a pull
between hanging weights and the patient's own body
weight.
Application of traction and skin traction
This section will provide an overview of the main principles of
application of traction, using skin traction as an example (See
Fig. 1). Protection of the bony prominences is provided by padding
the head of the fibula (at the lateral knee area) to prevent pressure
of the common peroneal nerve (pressure on this can cause foot
drop) and around both lateral and medial malleoli at the ankle (see
Fig. 1.1 to 1.3). The Achilles tendon should also be exposed to allow
observation and be free from pressure as it is prone to injury from
the bandaging.
An assistant should support the limb in neutral alignment and
apply gentle manual traction whilst the practitioner applies the
skin extensions (See Fig. 1). The spreader plate/bar should be
positioned distal to the sole of the foot, about 4 fingers width away,
to allow space for the patient to be able to dorsi flex and plantar flex
their foot. There should be adequate foam padding at the ankle to
protect the medial and lateral malleoli (see Fig. 1.3) as these are also
prone to pressure injury. The skin extensions should be applied to
the medial and lateral aspects of the limb ensuring there are no
wrinkles or bumps that may cause pressure. The lateral extension
should lie parallel to, but slightly below the medial extension to
minimise external rotation of the limb.
If adhesive skin traction is used then the backing paper is
removed at this time, gradually working up the leg and smoothing
the adhesive tape at the same time. To prevent the development of
blisters, the skin traction needs to be applied without folds or
creases in the adhesive material and the covering bandage should

Table 1
Common traction terminology glossary of terms

Balkan beam Horizontal beams that run over the top of the bed and are attached to vertical beams which facilitate the suspension/application
of traction
Bohler stirrup A metal ‘stirrup’ shaped apparatus that attaches to a skeletal pin as a traction force connector, prevents rotational pull; screws
enable the stirrup to be secured to a pin
Braun frame A metal frame used for elevation of the lower limb with the knee in flexion that may also support traction; it rests on the bed
with slings/bandages applied before use
Calico or canvas slings Slings used to support the leg in a splint or traction to facilitate protection and positioning of limbs; stretch fabrics should not be
used as these will not maintain the correct alignment and position of the limb
Padding/Gamgee Padding used under the limb and, often, at fracture sites to alter or maintain alignment or position; padding is usually cotton
wool with gauze.
Dunlop's traction Skin traction to forearm with counter traction applied by sling over upper arm; used for supracondylar fractures especially in
children and young adults
Gallows traction Also known as Bryant's traction. Bilateral skin traction is applied to both femora using extensions and an overhead frame
attached to the cot; for children and babies under 2 years with fractures of the shaft femur or developmental dysplasia of hip.
Counter traction is applied through the weight of the child's body so the buttocks must be suspended off the bed.
Hamilton Russell (or modified Hamilton Balanced traction, affecting a long axis pull to the femur, using vertical and longitudinal traction (resultant pull is determined by
Russel) Traction pulley position); using 2 separate cords and pulleys with weights and can be used with skin or skeletal traction. Often used to
treat acetabular and femoral shaft fractures.
Knots Used to secure traction cords: the most common are the slip, clove, half hitch, reef knots.
Octopus suspension Eight ‘legs’ of elastic with cog wheels and pulleys to be applied to a Thomas' splint and then suspend from a Balkan beam
Pearson knee flexion piece/attachment A metal extension for a Thomas' splint that allows for flexion and controlled mobilisation of knee without disturbing alignment
of the fracture (slings are needed to support limb).
Perkins' traction Skeletal traction using 2 individual cords and no external splintage to allow early active leg movements e.g. used for fractured
femur/tibia using a split bed
Pin covers Used to cover pin ends to protect patients and staff from injury; usually metal covers
Pulleys Single, double, triple pulleys are used to allow cords to run freely. They are clamped onto beams to support traction cord in line
of pull and reduce friction. Additional pulleys in a traction system can be used to change the direction of the cord and weight,
but have a resultant increasing effect on the amount of pull/traction.
Pugh's Skin traction to both legs (as described in this article), attached to bar at end of bed or cot. Used for many orthopaedic conditions
and injuries including Perthes Disease, developmental dysplasia of the hip (DDH), and Slipped Upper Femoral Epiphysis (SUFE).
Skeletal pin: Steinmann/Denham pin Small diameter metal rod inserted through long bone to allow attachment of skeletal traction.
Steinmann ¼ smooth shaft, pointed ends
Denham ¼ offset screw thread mid shaft, pointed end/blunt end
Skin extensions Strips of foam or adhesive strapping applied to limbs for application of skin traction as described in this article. Can be adhesive
or non-adhesive.
Spreader bar or plate/coat hanger Used at the end of skin traction extensions to spread the weight between the two sides of skin traction, facilitating traction force
and providing attachment for the cord and attached weights
Thomas' splint/Thomas bed splint/ A metal splint with a padded groin ring used to immobilise the limb e.g. for femoral fractures. Enables application of the traction
force
Traction cord/rope For attachment & suspension of weights, must not fray, should run freely through pulleys and be non slip when knotted.
‘U’ loop A metal ‘u’ shaped loop that attaches to a tibial skeletal pin to facilitate alignment of femoral fractures; used with Bohler stirrup
in modified Hamilton Russell Traction
Weights and holders Traction weights come as single pounds or kilograms and sit on the base of a holder which is attached to the traction cord.
Several weights can be added to the holder to increase or decrease the amount of traction. In some regions water bags are used
instead of metal traction weights.
Windlass Often using one or more wooden spatulas placed between cords at distal end of skin extension used within a Thomas' splint.
The windlass is rotated to wind the traction cord around it to increase or reduces traction force
56 W. Duperouzel et al. / International Journal of Orthopaedic and Trauma Nursing 29 (2018) 54e57

1. Record the baseline neurovascular status

of the limb
2. Check all skin areas thoroughly prior to
application of skin extensions
3. Pad the head of the fibula with an adhesive
foam square (to prevent foot drop from
Figure 1.1 Position of the head of the fibula
damage to the peroneal nerve) (figs 1.1.
and 1.2)
4. Have an assistant apply gentle manual
traction to the limb
5. Place the spreader bar/plate far enough
away from the sole of the foot to allow plan-
tar/dorsi flexion (fig 1.3)
6. Ensure that the foam padding covers both
lateral and medial malleoli to protect bony Figure 1.2 Padding over the head of the fibula
prominences from pressure
7. If the traction kit is adhesive, remove the
backing paper gradually and apply the
extensions to each side of the leg. Ensure
there are no wrinkles or bumps. The same
for non-adhesive traction but the extensions
ned to be held in place by the bandage
(see 9 below)
8. The lateral extension should lie parallel to, Figure 1.3 Application of foam padding to both malleoli
and position of spreader bar
but slightly below, the medial extension to
minimise external rotation
9. Commence a firm bandage at the ankle
from 2 cm above both malleoli up to the
tibial tuberosity at the knee
10. Leave the knee un-bandaged to prevent
knee stiffness and allow for flexion and
extension of the joint. Make sure the
bandage is not too tight, especially at the
Figure 1.4 Application of bandage to secure extensions
knee over the popliteal nerve and artery
which lie just behind the knee
11. Above the knee (if required), commence a
spiral bandage to 2 cm above the fracture
site (except for Hamilton Russell Traction)
12. Leave the head of the fibula free and the
Achilles tendon exposed (Fig. 1.5)
13. Reassess and document the neurovascular
Figure 1.5 Completion of Bandage and reassessment
status of the limb. of neurovasular status

Fig. 1. Application of adhesive and non-adhesive extensions for skin traction

Adapted from: Duperouzel (2015).
 W. Duperouzel et al. / International Journal of Orthopaedic and Trauma Nursing 29 (2018) 54e57
be non-elastic. Should a crease be inevitable, due to the contour of
the limb, the creased area should be lifted, carefully partially slit
transversally and the edges overlapped. If the skin traction is to be
used with a Thomas’ splint (e.g. for a mid-shaft femoral fracture),
the skin extensions should continue up the lower limb to approx-
imately 2 cm proximally above the fracture site. If the skin traction
is to be incorporated into Hamilton Russell traction (e.g. for prox-
imal femoral fracture) then the skin extensions should not continue
above the tibial tuberosity.
Once the skin extensions are in position, bandaging is used to
secure them. If non-adhesive traction is used, the extension tapes
will not be secure without the bandaging. Bandaging of a limb
should always be applied distally to proximally. Bandaging of lower
limb skin traction should begin with two turns of the bandage at
about 2 cm above the malleoli to anchor the bandage at the ankle.
Bandages should be applied working from the inside (medial) to
the outside (lateral) of the limb, as this encourages the limb to lie in
external rotation; a preferable resting position for the knee and hip.
The Achilles tendon should be left exposed and the anchor turns of
the bandage at the ankle should be firm but not so constrictive they
exert excess pressure. The bandage should be applied in a straight
spiral or a ‘figure of eight’ up to the tibial tuberosity, ensuring it is
firm but not tight, particularly over the malleoli, anterior margin of
the tibia and the head of fibula (see Fig. 1.4). Thin padding should be
applied to the anterior margin of the tibia to protect it from pres-
sure if the patient has thin or fragile skin. The knee should be left
un-bandaged to prevent knee stiffness. If the skin extensions
continue above the knee, apply the bandaging to 2 cm above the
position of the fracture (see Fig. 1.4 and 1.5).
To apply sliding/balanced traction, the traction cord attached to
the spreader plate is threaded through a pulley secured to a beam
across the foot of the bed frame. The pulley should allow for free
and smooth running of the traction cord across its barrel whilst the
cord itself should be of non-fraying and non-slip material. The
traction cord is then attached to a set of weights in order to provide
the pulling force. The weight to be used should be prescribed by a
Doctor and no weights removed or added without direct instruc-
tion. The weights should hang freely and not touch the floor or
parts of the bed as this reduces the applied pulling force. Do not
allow weights to hang over any part of the patient. Consideration of
skin traction with a Thomas’ splint will be considered in a subse-
quent article in this series.
Ongoing care of the patient with skin traction

The care of the patient with skin traction is similar to that for all
patients with traction: The leg should be rested in a foam leg
trough to provide comfort and ensure pressure relief by raising
the heel off the bed whilst ensuring there is no pressure on the
Achilles tendon from the edge of the foam trough. Pillows may
be used instead of a trough but are less supportive.

A good resting position for the knee is in about 15 of flexion and
this should be achieved if possible.

Bed clothing should be adjusted appropriately to maintain the
patient's dignity and comfort whilst not impeding the traction
apparatus.
57

Elevation of the foot of the bed will provide counter traction
where there is balanced/sliding traction (with pulleys and
weights) at the end of the bed. The anatomical alignment of the
patient in bed should be checked once the traction system is
completely applied and secured to ensure the pull through the
affected limb is as desired.

Re-assessment of the patient's neurovascular status should be
performed and documented immediately following application
and thereafter at least twice daily, or when care is performed in
which the patient's position has been changed.

Ongoing nursing care should include demonstration and
encouragement of suitable exercises within the confines of the
traction, to be undertaken hourly during waking hours. Deep
breathing, upper limb strengthening and plantar/dorsi flexion of
the foot exercises are recommended if the patient is able to co-
operate. These will help to clear the respiratory tract, maintain
some upper limb muscle tone and help in lower limb muscle
movement which aids venous return for the prevention of deep
venous thrombosis.

Ongoing neurovascular observations must be documented and
pain assessment performed with adequate pain relief adminis-
tered as prescribed.

Care of the skin of the limb should take place twice daily
including assessment of the skin for any areas of breakdown or
pressure and the limb should be washed and re-bandaged as
indicated previously.

In addition to the nursing care of the patient that is provided,
the complete traction system should be checked at least 4
hourly or as often as the patient's condition requires. This is to
ensure the apparatus is secure, clean, dry and dust free to allow
for safe delivery of the traction pull as well as for best practice in
infection control.
Conclusion
Practitioners have a professional responsibility to develop and
maintain their knowledge and skills to ensure safe, effective care.
The application of traction and the care of the patient in traction
involve relatively advanced skills that are easily lost if not used
often. This article has outlined some of the main principles of
traction and the terminology used as well as the application of
lower limb skin traction and subsequent care of the patient. Or-
thopaedic practitioners need to maintain skills in these areas and it
is hoped that this article, and others focusing on traction, will assist
in this.
References
Duperouzel, W., 2015. Adult Lower Limb Traction (Unpublished).
Flynn, S., 2018. History of traction. Int. J. Orthop. Trauma Nurs. https://doi.org/
10.1016/j.ijotn.2017.08.003.
Jester, R., Santy, J., Rogers, J., 2011. Oxford Handbook of Orthopaedic and Trauma
Nursing.
Royal College of Nursing, 2015. Traction: Principles and Application. RCN Guidance.
RCN, London. https://my.rcn.org.uk/__data/assets/pdf_file/0004/608971/
RCNguidance_traction_WEB_2.pdf.
Shields, C., Clarke, S., 2011. Neurovascular observations and documentation for
children within accident and emergency: a critical review. Int. J. Orthop. Trauma
Nurs. 15 (1), 3e10.