Journal of Orthopaedic Nursing (2006) 10, 138–143

www.elsevierhealth.com/journals/joon

Journal ofOrthopaedic Nursing

A brief review of the effects of preoperative skintraction on hip fractures

Kelly Foster DN, RNA (Staff Nurse)*

Chapel Allerton Hospital, Chapel Town Road, Leeds, LS7 4SA

Summary The use of preoperative skin traction is still reported today as a treat-ment for hip fractures whilst awaiting surgery at many hospitals. The main rationalefor its continued use is pain relief for the injured patient. It has also been suggestedthat traction prior to surgery maintains the position of the fracture, thereby makingreduction of the fracture easier when operating. However, there are also disadvan-tages to its use, primarily concerning the development of pressure sores and thepotential damage traction equipment can cause to skin. The studies reviewed con-cluded that preoperative traction was not successful as an analgesic tool, nor did itcontribute to the development of pressure sores. No evidence showed that tractionaided fracture reduction or the healing time after surgery. The use of preoperativeskin traction should therefore not be used routinely as a therapeutic intervention forhip fractures before surgery.

�c 2006 Elsevier Ltd. All rights reserved.

KEYWORDSTraction(skin/skeletal);Hip fractures;Preoperative treatment

1d

Editor’s commentsTo begin to get to grips with the evidence relating to perennial orthopaedic nursing care issues such as traction for hip fractures isdaunting for many. This study is a personal perspective based on a brief review of the research to date. PD

Introduction

Hip fractures present a major challenge to healthand social services, placing considerable strain onresources in orthopaedic and geriatric care provi-

361-3111/$ - see front matter �c 2006 Elsevier Ltd. All rights reseroi:10.1016/j.joon.2006.06.002

* Tel.: +44 113 2049160.E-mail address: kellyfossy@yahoo.co.uk.

sion (Fisher and Mowatt, 1997; Hollingworthet al., 1995). The elderly population accounts forapproximately 310,000 fractures a year in the UK,with hip fractures costing hospitals £288millionalone (Hollingworth et al., 1995; Woolf and Akes-son, 2003). This does not include the needs for ex-tended social care and the services required for hipfracture patients to return to their homes indepen-dently. Elderly patients sustaining hip fractures ac-

ved.

A brief review of the effects of preoperative skin traction on hip fractures 139

counts for a significant proportion of trauma pa-tients entering hospitals and Hollingworth et al.(1995) predict that, unless treatment patternschange, or the incidence of falls decline, hipfractures will continue to give rise to costs in theregion of 360 million by 2011. As the elderly popu-lation continues to increase in number this does notappear to be an unrealistic estimation.

Although great emphasis must be placed uponthe rehabilitation of hip fracture patients, focuson the importance of preoperative treatmentsshould also be considered. Early stages of the pa-tient’s care pathway need to be examined to in-crease understanding of how this care potentiallyinfluences future management and rehabilitationof the patient. The use of traction was once a com-mon method of treating patients with hip fractures,however, as new surgical techniques evolved its usehas been resigned to preoperative management(Draper and Scott, 1998). Whilst acknowledgingthat the priority for hip fracture patients is opera-tive treatment within the first 24 h of admission toreduce mortality and morbidity (Parker and Pryor,1992; Rogers et al., 1995; Zuckerman et al., 1995)many authors report that skin traction still remainsa therapeutic intervention for patients whilstawaiting surgery (Jerre et al., 2000; Parker andHandoll, 2005; Rosen et al., 2001).

Traction is applied when a pulling force to an in-jured or diseased part of the body is implementedwhilst counter traction pulls in the opposite direc-tion (Davis, 1989). In theory this technique repli-cates the actions of the surgeon in reducing thefracture (Draper and Scott, 1997). Potential advan-tages include pain relief, preventing further dis-placement of the fracture and maintaining orimproving alignment so reduction of the fractureis easier when operated on (Anderson et al.,1993; Harvey, 1998; Needof et al., 1993). However,the use of traction can also create complications,especially those related to immobility and bedrest. For example, Jerre et al. (2000) found thatnursing staff felt patient care, such as pressure re-lief, was compromised due to the traction equip-ment surrounding patients. Also, in addition tothe cardiovascular, pulmonary, neurologic, renaland gastrointestinal systems being at risk (Harvey,1998; Mellett, 1998), difficulties directly related tothe application of skin traction need to be consid-ered. Rosen et al. (2001) warns that skin tractionis not a benign treatment, with adverse effectsincluding mechanical shearing of the skin, blister-ing, reduced arterial supply and venous drainage,and nerve compression (Anders and Ornellas,1997; Anderson et al., 1993; Styrcula, 1994a,b;Yip et al., 2002).

Literature search

The review presents an analysis of the use of pre-operative skin traction for elderly patients withhip fractures. The term hip fracture includes intra-capsular (femur neck) and extracapsular (trochan-teric and subtrochanteric) fractures of theproximal femur, with the mean age of patients usu-ally ranging from 78 years to 81 years old (Parkerand Handoll, 2005). The primary methods of skintraction identified were Hamilton Russell tractionor use of a traction boot. Databases CINHAL andMEDLINE were used to obtain research papersfocusing on preoperative skin traction in hip frac-tures. Cross-referencing of papers was also imple-mented to ensure most papers relating to thisarea of care were found. No dates were excludedfrom the search and search criteria encompassedthe terms ‘traction (skin/skeletal) use of, hip frac-tures and timing, preoperative traction’. Nineresearch papers were found, including a Cochranereview, which focused upon the use of preopera-tive traction in hip fracture patients, while otherarticles obtained commented upon the use of pre-operative traction and its rationale.

Findings

Main areas found related to whether traction re-lieved pain, eased reduction of a fracture whenoperated on or if traction contributed to increasedpressure sore risk. Each of these issues will beexamined and discussed in turn.

Pain relief

One rationale for using preoperative traction isthat it reduces pain. By overcoming the effects ofmuscle spasm that inevitably coincides with the in-jury, traction is thought to promote comfort (Davisand Barr, 1999; Royal College of Nursing, 2002).However, due to the subjective nature of pain,objective assessment is problematic (Rosen et al.,2001). This is further complicated by the high inci-dence of senile dementia within those that sustainhip fractures (Grimley Evans et al., 1979; Woodet al., 1992). In an attempt to rectify these vari-ables the majority of studies used the visual ana-logue scale, a valid method of pain assessment.Researchers also implemented assessments on sub-jects’ mental state to ensure equivalence withinsample groups, excluding those with cognitiveimpairment. The latter was also conducted to en-sure that informed consent was provided fromparticipants.

140 K. Foster

Finsen et al. (1992) examined the use of preop-erative traction. Patients were randomised togroups using skin, skeletal or no traction. They re-ported that patients receiving skeletal tractionwere administered a higher number of analgesics.However, when examining the type of pain medica-tion provided it is evident that this group actuallyreceived less opiates than the group with no trac-tion, which would suggest that patients with skele-tal traction in place were in less pain than thosewith no traction. This discrepancy could compro-mise the conclusion Finsen et al. (1992) made thatpreoperative traction should not be used routinely,as the need for analgesia was no higher within thegroup that had no traction. Although this is correctin relation to paracetamol and codeine, the intakeof opiates within this group is actually greater.Nevertheless, Finsen et al. (1992) do acknowledgethat comparison of central and peripheral analge-sia is a limitation within the study. Also in Finsenet al.’s (1992) study no valid assessment tool wasimplemented to monitor patient’s pain levels. In-stead, the assumption was made that the amountof analgesia administered was a sufficient guidein examining the experience of pain.

Resch and Thorhgren (1998), in their comparisonof skin or skeletal traction, used the visual ana-logue scale and participant’s analgesic intake todetermine pain levels. Results showed that thosein skeletal traction required fewer doses of painmedication. Although this did not prove to be ofany clinical importance, further investigationfound that there was a decline in the subjectiveexperience of pain both after the administrationof analgesia and the application of either skin orskeletal traction, suggesting that traction reducespreoperative pain. Unfortunately, as Resch andThorhgren (1998) did not allocate a group to a notreatment intervention, it is difficult to draw anyfirm conclusions on whether to treat patients withtraction from their study.

Jerre et al. (2000) presented two groups, onereceiving skin traction and the other no interven-tion at all. By assessing pain scores every 4 h overa 12-hour period results showed no significant dif-ferences in supplementary analgesia provided orpain scores recorded. Anderson et al. (1993) alsoexamined Hamilton Russell skin traction in rela-tion to its potential pain relieving properties andrevealed that pain scores were no different be-tween patients who were assigned to skin tractionor those that were nursed with their limb free inbed. However, no information is provided regard-ing the type of pain medication given, andwhether this was comparable for both groups ofpatients.

Stromqvist et al. (1988) have suggested an alter-native to the application of traction, stating thatby placing a patient’s leg in the position of semi-flexion and lateral rotation pain will be alleviatedjust as effectively as it provides the lowest intra-capsular pressure. Similarly, Needof et al. (1993)used patients whom had no traction with a support-ing pillow, placing the injured limb in flexion,abduction and external rotation, and compared itto those with skin traction. They found no differ-ence between the pain scores of those in skin trac-tion and those using a pillow, despite an increasedintake of analgesia by the traction group for thefirst 24 h. However, assessment of pain scores wereonly taken on a morning, which is unrealistic to en-sure accurate measurement of a person’s painrelating to a traumatic injury.

Comparison of skin traction and the use of a pillowhas also been investigated by Rosen et al. (2001) andYip et al. (2002). Pain levels and analgesic intakewere recorded by Rosen et al. (2001) immediatelybefore the choice of intervention, 15 min later andthen on subsequent mornings until theatre. Resultsdemonstrated the group using the pillow experi-enced lower pain scores than the traction groupthe morning after admission. Interestingly, Rosenet al. (2001) reported that pain scores did not corre-late with the amount of analgesia provided, asexpressions of pain were lower regardless of howfrequently patients received pain medication. Itmay also indicate that the interventionwas a greaterfactor than medication for the reduction of pain.However, Yip et al. (2002) found that, although painscores on the evening of admission and first morningafter injurywere increased in thosewith no traction,subsequent dayswere no different in relation to painlevels between the groups with skin traction andthose using a pillow for comfort.

The only study to differentiate between pain atrest, and pain on movement between patients withtraction and those without was Draper and Scott(1997). They found that pain scores, and doses ofanalgesia received, were not significantly differentbetween groups upon movement. Nonetheless,pain scores at rest showed that those in traction re-ported less pain on the first day after injury, butthis did not continue into the second day postin-jury. However, Draper and Scott (1997) did reporta reduced sample size at this time due to patientsbeing operated on, therefore a larger sample size isneeded to fully determine pain levels for patientsmore than 1 day postinjury. Unfortunately, Draperand Scott’s (1997) sample is not comparable. Byincluding participants with cognitive impairment,those having a lower mental function only in thegroup with no traction, Draper and Scott’s (1997)

A brief review of the effects of preoperative skin traction on hip fractures 141

results could be greatly flawed, as patients withlow mental test scores maybe less likely to reportpain. Although they attempted to rectify this withstatistical analysis, Parker and Handoll (2005) ques-tion the validity of this research.

Pressure sore risk

Another area of significance is the potential corre-lation between preoperative traction and thedevelopment of pressure sores. Studies investigat-ing this hypothesised that traction would predis-pose a patient to developing ulceration due tothe restrictions traction apparatus applies to themovement of the patient and the care providedby nursing staff. This is further compounded bythe fact that many hip fracture patients may havealso been lying, undiscovered, for long periods oftime before being presented to A&E, and thenplaced on trolleys with minimal pressure relievingqualities (Fisher and Mowatt, 1997).

Anderson et al. (1993), Draper and Scott(1997) and Jerre et al. (2000) all considered thethreat of pressure sore development within theirpopulation of participants and reported thesefindings. Information regarding this subject wasprovided by personal communication to the Coch-rane Review from Needof et al. (1993) and Yipet al. (2002), who declared that there were nosignificant differences between patients with skintraction and those when nursed without. How-ever, no data is accounted for within their publi-cations, therefore analysis of research design andvalidity of assessment tools could not be under-taken. Anderson et al. (1993) also confirmed thatthere were no differences between groups stud-ied, but all patients developed a grade one pres-sure sore whilst in hospital. Jerre et al. (2000)stated that five of the participants in tractionexperienced grade one ulceration preoperatively,whereas the group with no traction did not sufferthis complication.

The only study that deviated from expectationwas Draper and Scott (1997). They provided a com-prehensive report upon the assessment of pressuresores, accounting for a total of 46,958 pressuresore observations throughout their study. Informa-tion was provided regarding the assessment tooland the body areas assessed for skin deterioration.They revealed that overall scores showed no dis-tinction between groups with traction and thosewithout. However, on further examination it wasfound that scores of individual body areas sug-gested that the traction group were actually lesslikely to incur injury to the heel on the oppositeside to the fracture. Draper and Scott (1997) spec-

ulate the reason for this is because the tractionapparatus provides suspension for some of the pa-tient’s weight, therefore making it easier to moveup the bed. They also acknowledge that the lownumber of pressure sores may be due to frequentpressure checks for research purposes, and there-fore may not truly reflect practice.

Skin damage directly caused from the tractionequipment has also been commented upon in anumber of papers. Shabat et al. (2002) followed10 patients who developed severe skin slough asa result of skin traction. Unfortunately, no infor-mation is provided in relation to how often theskin traction was removed to clean the underlyingskin or the frequency of skin assessment whilsttraction was in use. Shabat et al. (2002, p. 110)simply state that skin slough was detected on re-moval of the skin traction device before surgerywas performed in five of the patients, whilst skindamage was discovered immediately after surgeryin two patients and the final three patients in thepostoperative period. The RCN (2002) state thatbandages must be reduced daily and skin inspec-tion implemented. Rosen et al. (2001) reportedtwo participants suffering from blisters, with onepatient experiencing sensory changes of the foot;this was relieved by adjustment of the tractionboot that was in place.

Fracture reduction

As well as considering the immediate implicationsof traction for nursing care, one must also considerwhether preoperative traction has any effect onthe outcomes of surgery, and rehabilitation poten-tial thereafter. Anderson et al. (1993) gained theopinion of a surgeon in determining whether frac-ture reduction was easier in those that had previ-ously been attached to traction or not, findingthat there was no difference between groups. Fin-sen et al. (1992) found that preoperative fracturereduction was faster in those without traction,but like Needof et al. (1993) and Yip et al.(2002), noted that the duration of operation wassimilar for each group of participants.

Rather than examining the reduction time andease of surgery, Jerre et al. (2000) evaluated thequality of the fracture reduction, but found no dis-parity between sample groups with skin tractionand no traction. The mean hospital stay was com-parable (Anderson et al., 1993), along with thehealing rate 4 months later (Jerre et al., 2000).This would therefore indicate that preoperativeskin traction does not aid fracture reduction, orsubsequently improve the recovery of the patientin terms of healing time.

142 K. Foster

Discussion

The use of traction has never disappeared, and de-spite a previous decline, observations of practicesuggest its subsequent increase. Although from theresearch presented, the consensus is that preopera-tive traction is an ineffective intervention for reduc-ing pain or easing fracture reduction, and althoughthere is no indication that traction predisposes thedevelopment of pressure sores, one could always ar-gue that the restrictions placed upon patient mobil-ity from traction is a greater risk than not having itthere at all. However, the author believes that dueto themethodological discrepancies and inadequatepresentation of data in some studies, no firm conclu-sions can be made relating to this topic. Investiga-tion into why traction may not be effective is alsorequired. For example, Draper and Scott (1996)found that nursing staff had inadequate knowledgeof the principles of traction and its implementation,therefore potentially compromising care.

In agreement with Parker and Handoll (2005)other issues need to be addressed to determinewhether traction may be an advantage, such aswhether traction is beneficial for different typesof hip fracture. Attention should also focus uponwhen patient’s pain is at its highest, and whethertraction may be beneficial for particular timeperiods only. Education in relation to the issueshighlighted is essential to ensure the health profes-sional’s care provision is based upon the interest ofthe patient and not merely upon traditional prac-tices. However, and perhaps most importantly, thesubjective experience of the patient in tractionneeds to be heard (Parker and Handoll, 2005). Beingsurrounded by traction equipment can be frighten-ing as well as isolating. It is essential that the nursingstaff understand the intricacies of traction and it’srationale, not only so that expert care is provided,but also to ensure that the focus of care is thepatient and their experiences, and not the imposingtraction apparatus that surrounds them (Harvey,1998). The author believes further investigation isrequired into the potential benefits of preoperativetraction, rather than instigating a ban upon its use.Healthcare professionals are also encouraged tolisten to the wishes of the patient, and what eachindividual feels is beneficial to them in relation tothe application of traction apparatus (Love, 2000).

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