Ethical legal special footwear, and braces to return mobility to disabled patients.

Orthopedics uses the techniques of

physical medicine and rehabilitation and occupational therapy in addition to those of traditional medicine
and surgery.

Historical Background of Orthopedic Nursing

The word ‘orthopedics’ was derived from the Greek words; orthos meaning straight or free of History of the Philippine Orthopedic Center
deformity and pais meaning child. POC started in February 9, 1945 by PCAU General Hospital. The US Army established the hospital
in Mandaluyong, Rizal. It was then called as Mandaluyong Emergency Hospital. Its main purpose is to
Orthopedics also called orthopedic surgery medical specialty concerned with the preservation help take care of the civilian casualties of war. But its function was not only as emergency basis seeing
and restoration of function of the skeletal system and its associated structures, i.e., spinal and other not only victims of wars but also all cases.
bones, joints, and muscles.
In May 1945, the hospital was turned over to the Phil. Government. In August 1945, the Bureau
Nicolas Andry, a professor of medicine at the University of Paris published a textbook in of Health took over and only fracture cases and bone joint condition remained.
Orthopedics in 1741 concerning the following;
1. Maintaining a straight child The hospital kept functioning during those difficult years and it is attributed to the skill, ingenuity,
2. Straightening a deformed child dedication and foresight of the staff lead by Dr. Jose V. delos Santos.
3. Finding new ways to straighten deformed child
The hospital finally transferred to its present site in Quezon City.
In 1728-1793, John Hunter contributed to the advancement of understanding fractures and
other musculo-skeletal injuries. Review of Structure and Function of the Musculo-skeletal System

Orthopedics began in the 18th century with the pioneering efforts of Jean André Venet, who I The Bones
established an institute in Switzerland for the treatment of crippled children's skeletal deformities.
A. The human skeleton consist of two main division:
In 1834-1891, Hugh Owen Thomas, an Englishman specialized in the treatment of chronic joint 1. Axial – body upright structure
disease, fractures and dislocations. a) Skull b) vertebral column c) ribs
2. Appendicular – the body appendages
In 1867-1948, Agnes Hunt, referred to as the Florence of Nightingale of Orthopedic Center in a) Arms b) hips c) legs
Great Britain.
B. Four major bone type
The efforts of Sir Robert Jones and the massive casualties of World War I led to the founding of 1. Long bones - length exceeds breadth and thickness
many orthopedic training centers in the early 20th century. 2. Short bones - equal in main dimensions
3. Flat bones – primary made up of cancellous bone tissue
In 1840, William Little established the Royal Orthopedic Infirmary in Great Britain. 4. Irregular bones
In 1857, Anthonius Methyson of Holland described the plaster bandage.
In 1866, the New York Orthopedic Dispensary was formed. C. Long Bones:
1. Structure
A vastly increased knowledge of muscular functions and of the growth and development of bone a) Diaphysis – shaft provides strength resist bending
was gained in the 19th century. Significant advances at this time were the new operation of tenotomy b) Metaphysis – flared portion between diaphysis and epiphysis
(the cutting of tendons, which made correcting deformities easier), the surgical correction of clubfoot, c) Epiphysis – end
the invention of the Thomas splint (which provided better support for fractures of long bones in the - Primary cancellous bone
limbs), and the introduction of quick-setting plaster of Paris for use in orthopedic bandages. - Assist with bone development
d) Epiphyseal plate/line – between metaphysis and epiphysis
Modern orthopedics has extended beyond the treatment of fractures, broken bones, strained - Cartilage growth in length of diaphysis and metaphysis
muscles, torn ligaments and tendons, and other traumatic injuries to deal with a wide range of acquired e) Periosteum – connective tissue covering bone
and congenital skeletal deformities and with the effects of degenerative diseases such as osteoarthritis. - continues at the end of bone with joint capsule but does not
A specialty that originally depended on the use of heavy braces and splints, orthopedics now utilizes bone cover articular cartilage
grafts and artificial plastic joints for the hip and other bones damaged by disease, as well artificial limbs 2. Blood supply

1
 3 Basic Joint Types
a) Nutrient artery – tunnel in the diaphysis of long bone
1. Fibrous – composed of fibrous tissue, tightly, connecting the articular surfaces of two bones
b) Periosteal vessels – supply compmact bones with nutrients
c) Metaphyseal and epiphyseal vessels – supply the spongy bone and 2 types
narrow of the epiphysis
a) sutures – permits no movement
D. Functions
1. Provides framework for the body
b) syndesmosis – permits minimal movement between bones
2. Serves as lever for skeletal muscles
3. Protects vital organs such as the brain, heart and lungs
2. Cartilagenous joints connect two bones with cartilage, allowing only slight movement.
4. Stores calcium and release it to the blood stream according to the body
requirement
5. Manufactures new blood cells in the red bone marrow 3. Synovial joints, the most common joint type, have the most complex structure and permit
maximum mobility. These joints include the following
II Cartilage
a) joint capsule
1) Fibrocartilage – greatest tensile strength
- occurs in the intervertebral dics and in the symphysis pubis b) synovial membrane
2) Elastic cartilage – possesses firmness and elasticity
- occurs in the external air and in the Eustachian tube c) articular cartilage
3) Hyaline cartilage – cushions most of the joints to help soften any impact
- firm yet flexible d) synovial cavity
- occurs also in the part of the nasal system, larynx, trachea and in
the bronchial ring FRACTURES

III Ligaments and Tendons A. Fracture is a break in the continuity of the bone. In adults this break is usually complete in that the
Ligaments – strong cords of fibrous tissue periosteum and the cortical tissue on both sides are completely severed.
- joint capsule provides the primary connection between the bones, but
ligament bind the joints more firmly In pathology, a break in a bone, caused by stress. Certain normal and pathological conditions may
predispose bones to fracture. Children have relatively weak bones because of incomplete calcification,
Tendons – firm cords of fibrous tissue that extend from the muscle to the periosteum and older adults, especially women past menopause, develop osteoporosis, a weakening of bone
- connects muscle to each other to other tissue concomitant with aging. Pathological conditions involving the skeleton, most commonly the spread of
cancer to bones, may also cause weak bones. In such cases very minor stresses may produce a fracture.
IV Skeletal muscle Other factors, such as general health, nutrition, and heredity, also have effects on the liability of bones
to fracture and their ability to heal.
a. Muscles can be long and tapered, short and blunt, triangular, quadrilateral or irregular.
b. Muscle fiber arrangement varies
An incomplete break or greenstick fracture is mere common in children. Bone broken is bent but securely
1. In some muscles, the fiber runs parallel to the muscles long axis
hinged at one side.
2. In others, the fibers are oblique and bipennate like the feather of a quill pin
3. Fibers curve cut from a narrow attachment at the muscles and to form a triangle
A complete fracture occurs when periosteum and cortical tissue completely severed on both sides of
c. Main functions
bone.
1. Prime mover – directly brings about a desired motion
2. Antagonist – muscles that directly opposes the movement under consideration
3. Fixation – generally stabilizes a joint or its part thereby maintaining position while B. Fracture bone fragments are labeled according to relationship to the cortex of the body.
prime mover acts
1. distal – away from
V Joints
2
 2. proximal – here to d. Fixation devices
a. Internal fixation devices
C. Causes of fracture b. External fixation devices

1. In normal bones, fracture occurs when more stress is placed upon a bone that is able to absorb CARE OF PATIENT IN CAST
such as:
Plaster Cast – is temporary immobilization device, which is made of gypsum sulfate, rendered
a) Direct blow or crushing form anhydrous by calcification when mixed with water swells and forms into hard cement.

FUNCTIONS
b) Twisting force (torsion a severe twisting of a broken bone at a side different from where
1. To immobilize
the force was actually applied.
2. To prevent or correct deformity
3. To support, maintain and protect realigned bone
c) Powerful contractions – highly developed muscles contract so violently that muscles
4. To promote healing and early weight bearing
tear from bone sometimes pulling a small piece of bone with it.
* Cast can be applied to the extremities, to the trunk and to the extremity and trunk as in spicas.
d) Fatigue and stress bone breaks after repeated stress It can be applied to encase the whole area where it should be applied or it can be applied as a splint
or mold.
2. Bones weakened by a disease or tumors and subject to pathological fractures
*Complications of cast
Classification of fractures 1. Neurovascular compromise
2. Incorrect fracture alignment
Broad classification 3. Cast syndrome, superior mesenteric artery
a. Occurs with body cast
1. Open fracture b. Traction on superior mesenteric artery causes decrease in blood supply to bowel
c. Signs and symptoms, abdominal pain, nausea and vomiting
2. Closed fracture 4. Compartment syndrome – is a condition in which increases pressure within limited space,
compromises circulation and function of the tissue within that space.

Principles of Fracture Treatment Principle in application of plaster cast

A. Reduction or realignment of bone fragments
B. Maintenance or realignment by immobilization 1. A cast is applied with padding first
C. Restoration of function Padding materials include the following – wadding sheet, roll cotton, stockinet felt.
It can be applied as a combination like stockinet and wadding sheet.
A. Reduction 2. Apply it to the joint above and joint below the injured part.
1. Closed reduction – is accompanied by application of plaster cast after the fracture4 3. Apply it in circular motion and mold it as you do the procedure by the palm.
have been aligned with or without the use of anesthesia, to include the joint above 4. Support it with the palm
and below the fracture line.
Contraindications of plaster cast application
2. Open reduction – immobilization is done by nails, screws, pins, wires or rods which 1. Pregnancy
are inserted with or without plates. Such devices stay in the patient indefinitely unless 2. Skin diseases
they produce symptoms after healing takes place.
For Circular Cast Application
B. Immobilization
The most important phase in obtaining the union of fracture fragments. 1. Check for doctor’s orders
a. Cast 2. Inform and prepare the patient for the procedure.
b. Traction
c. Brace
3
 Explain to the patient and his relatives the need for placing the affected part of the body cast. 1. Age of the patient
Show an illustration of the type of cast to be applied to help them visualize HOW IT IS and 2. Part of the e body affected
WHAT IT IS. 3. The degree of injury the affection of the part
They are also made aware of the approximate duration for the body to remain in cast, the
limitation and the discomfort arising from immobilization less boredom and frustrating. *During the entire period that the patient is in cast, the nurse responsibility is focused on the following:
If possible, a good cleaning bath and shampoo be given to the patient. The affected part be a. Neurovascular check
cleansed thoroughly with soap and water or with detergent and dried. If there is a wound dress b. Preservation of the efficiency of the cast
it accordingly. c. Maintenance and promotion of the integrity of the system of the body
3. Ready all things needed for the application. d. Maintenance of the cleanliness of the cast
4. Position the extremity (by the doctor)
5. Apply padding including the joints above and below the fracture line with thicker pads on the A. Neurovascular checks
bony prominences
6. Soak the plaster cast into a bucket with water; leave it undisturbed until bubble ceases, one In all casted patient, COLOR, MOTION, TEMPERATURE AND SENSATION OF TOES/FINGERS should
after the other. be observed every 30minutes for several hours. After cast application, longer if there is edema, and then
7. Grasp both ends, when bubbles cease, towards the center without squeezing it. regularly every 3 hours.
8. Free the end of the cast and hand it to operator. Circulatory impairment results in symptoms of coldness, edema, cyanosis, pain and finally numbness
9. Apply cast in CIRCULAR MOTION until the whole area is covered and mold it during the process in the toes or fingers. The blanching sign will indicate whether or not there is an adequate circulation.
of application by the palm. When the nail of the thumb or great toes is compressed and immediately released, the color should go
10. Support the cast while applying. from white to pink with the same speed/. If not, the circulation is slow and the toes or fingers need closer
11. Handle the cast with care. observation.
Patients in arm or leg casts should be able to move and feel each toe or finger, because the same
Moving patients or transferring with wet cast must be avoided as much as possible. If this is nerve does not innervate each other. All toes and fingers should be checked.
necessary, care must be taken to maintain the integrity of the cast.
Nerve Function Test
The excess plaster cast is trimmed by means of a trimming knife. Cast spilled on the skin is
easily removed by wiping it with a damp cloth. Nerve Action by the nurse Action by the patient
- Test for Sensory Function - Test for Motor Function
To hasten drying of the cast, several ways can be used
1. Exposure to open air or electric fan Radial Prick web part between thumb Hyperextend the thumb
2. Exposure to heat lamp and index finger
3. Placing the patient in a warm room
Median Prick distal surface of index Oppose thumb and little
Care should be taken in protecting the patient form rapid drying of the cast, as this will result to a dry finger finger flex wrist
outer layer while the inner layer remains wet. Complaints of discomfort should be investigated and
appropriate measures be given to bring comfort. Ulna Prick distal end of the small Abduct all fingers
finger
Patients in body cast or spica cast is turned every 4-6 hours to promote even drying of the cast.
Peroneal Prick lateral surface of the great toes Dorsiflex ankle second toe
Finishing touches on the dried cast. extend toes

Edges that are extremely rough should be trimmed and smoothened very slightly with a knife. Tibial Prick medial and lateral surface Plantar flex ankle and
of sole of foot flex toes
Rough edges can be covered with adhesive petals, especially if there is no stockinet underneath the
plaster and wadding sheet. Psychological Implications and Going Home In Cast

Care of the Patient in Cast To relieve patients’ apprehension and anxieties that crowd their minds with their cast on, the nurse
The duration of keeping the body or part of it in cast is at least 1 month. Though, it varies among can help the [patient make a start toward resolving some of the problems by helping them become to
patients. Factors that influence the duration are remain as independent as possible.
4
 Instruction regarding cast care need to be received and patient can be reminded that frequent rest e. motor weakness or paralysis
periods for the entire body are necessary. Discussing plans with the patient before discharge will make 3. Infections, tissue necrosis due to skin breakdown
the transition from the hospital to another facility much smoother and add to her peace of mind. a. drainage through casts
b. sudden, unexplained rise in temperature
What to observe/remarks c. hot spot felt on cast over the lesion
d. pressure on the groins, knee, ankle and metatarsals
Cast of the upper extremities
1. Signs of impaired circulation/circulation of fingers such as Spica Casts
a. cyanosis of the skin 1. Signs of respiratory distress
b. coldness of the skin 2. Signs of cast syndrome
c. loss of function a. Prolonged nausea
d. numbness b. Repeated vomiting
e. pulselessness of the extremity c. Distention
f. severe pain d. Vague abdominal pain
g. marked swelling e. Absence of bowel sounds
2. Nerve damage due to pressure on the nerve as it passes over bony prominences 3. Pressure on the jaws, ears, face, clavicle area, anterior superior iliac crest, groin, buttocks, and
a. pain increasing in persistence above the knee.
b. anesthesia 4. Urinary and bowel disturbances
c. feeling of deep pressure 5. Signs of plaster cast
d. paresthesia a. itchiness/burning sensation
e. motor weakness and paralysis b. severe pain
3. Infections, tissue necrosis due to skin breakdown c. rise in the body temperature
a. musty, unpleasant odor over the cast or edges of the cast d. disturb sleep
b. drainage through cast or windows e. night cries among babies
c. sudden unexplained rise in temperature f. restlessness
d. hot spot felt on cast over lesion 6. Signs of infections and tissue necrosis
4. Pressure on the elbows, axilla, wrists, metacarpals and iliac crest
Turning Patient In Cast
Remarks
1. Avoid insertions of foreign bodies in cast Turning casted trunk and lower extremities must be done carefully. The Patient must be lifted and
2. Avoid soiling of the cast not rolled or dumped. Support should be provided to the encased part and the whole body.
3. Report signs of cracks and weakness of the cast
4. Maintain proper alignment of casted extremity The first changing of the patients’ position is dependent on the condition of the cast and the body
5. Proper support of the cast area involved. The first turning usually is to dry the posterior surface of the cast as well as to provide
comfort and protect against respiratory complications.
Cast of the Lower Extremities
1. Observe for impaired circulation as manifested by There should be no attempt to turn the patient alone if one estimates that one is physically unable
a. Cyanosis or bluish discoloration of the skin without the patient’s assistance.
b. coldness of sensation
c. loss of function of the affected extremity Turning Patient in Hip Spica 1 - 1 ½
d. numbness
e. absence of pulse A. Supine to lateral
f. marked swelling With 2-3 members working together the patient is gently pulled toward the unaffected side. Member
2. Nerve damage due to pressure on the nerve as it passes over bony prominences remains on this side to give the patient the sense of security while the other member moves to the
a. increasing persistent localized pain opposite side of the bed where the affected leg is to arrange the pillow along the entire length of the
b. numbness in the extremity casted leg and back.
c. feeling of deep pressure
d. paresthesia
5
B. Supine to prone PRINCIPLES OF TRACTION
1. MAINTAIN THE ESTABLISHED LINE OF PULL
One member places his hands on the patient shoulder and hips, while the other support the thighs Weights should hang freely, not hitting the bed or resting on the floor. The position of the weights
and extremities. The member of the opposite side pulls the shoulder and thighs as the patient is gently should be rechecked if the level of the bed is altered.
teased on his front. After the patient has been turned, observe the following points:
a. Toes should not dips against the mattress AVOID
b. Body section of the cast plaster should not press the back, chest and abdomen 1. Bumping against the weights when walking near the bed.
c. Heels should be maintained in correct angulations and should be allowed to extend 2. Allowing the weights to sway.
beyond the mattress Both movements can cause pain for the patient in traction. It is preferred that the weights
should not hang over the patient, if necessary, the nurse should tape the weights so they will not
Placing Patient in Bedpan fall on the patient.
In bowel or bladder elimination, the buttocks should be lower than the head and toward the breast.
This can be achieved by: 2. PREVENT FRICTION
Traction rope should rest in the groove of the pulley and move easily. The rope should not be
a. Elevating the head part slightly and placing a small pillow under the back of the patient. frayed. The nurse should TIE securely knots in the traction rope and tape the rope ends. The rope knots
should not lodge against the pulley because this will interfere with the line of pull. For the same reason,
b. Placing a folded cloth on the posterior aspect of the bedpan. This will absorb moisture and the nurse should ensure that the pulley, spreader bar and footplate do not rest against the foot of the
this prevents spoiling the cast. bed.
Adult patients are usually placed in their good side first. The bedpan is placed so that the
buttocks are on the posterior section of the bedpan. Pillows, blankets are then arranged 3. MAINTAIN COUNTER TRACTION
to support the legs and back so that there will no be back flow. To provide traction, the nurse must ensure that counter traction is maintained. If the weight of the
If patient can support himself by lifting with the aid of the overhead trapeze, the bedpan patient body is to provide the counter traction, HIS BODY should not interfere with the DIRECTION OF
is slipped under the buttocks. PULL. For instance, the feet of the patient in BUCK traction should not touch the foot of the bed, or if the
Bladder and bowel elimination in children with hip spica if placed in headboard frame is patient is in cervical traction, his head should not touch the head of the bed.
not difficult if the bedpan is kept constantly in the spica under the buttocks.
4. MAINTAIN CORRECT BODY ALIGNMENT
Instrument for Cast Removal The patient should have correct BODY alignment while lying centered in the bed. The nurse must
1. Cast cutter (manual electric) ensure that the patient does not angle his body or lean off the side of the bed because the line of traction
2. Spreader pull would then be changed or interrupted.
3. Trimming knife
4. Bandage scissors Types of Traction
5. Plaster sears
1. SKIN TRACTION
Points to Remember Skin traction is accomplished by weights that pull on tape, sponge rubber or plastic materials
1. After the cast is removed, support the part with pillow maintaining the same position that attached to the skin. TRACTION on the SKIN, TRANSMITS traction to the musculoskeletal structures.
existed in the cast. Forms
2. Move the extremity gently. 1. Buck Extension
3. Observe the skin for any abrasions and plaster sore. A form of skin traction in which the pull is exerted in one plane when partial or
4. Wash skin with mild soap followed by application of oil or lanolin. temporary immobilization is desirable. In Buck’s extension, strips of adhesive, moleskin
or perforated flex foam are applied smoothly to each side of the affected extremity and
TRACTION attached to a spreader block at the foot. The extremity is wrapped with elastic bandage
Traction is the application of a pulling force to a part of the body. It is used to align and immobilize to improve adherence of the tape to the skin and prevent slipping. A traction rope is
fractured bones, to relieve muscle spasms and to correct flexion contractures, deformities and attached to the spreader block then over the pulley, thence to a weight hung over the
dislocations. side of the bed.
For traction to be effective, there must be also a pull in the OPPOSITE DIRECTION (COUNTER 2. Russell’s Traction
TRACTION) by using the body or by elevating part of the bed toward the traction. Russell traction when properly applied in good mechanical
working efficiency is a comfortable device for the patient.
The equipment required is not elaborated. A single section of
6
 common Balkan frame can be attached to the bed with overhead
bar directly above the injured limb. Four pulleys are used. These
pulleys are arranged so that one is on the overhead bar at a level
directly above the tubercle of the tibia of the fractured leg, another
is attached to the footplate and two are attached to a crossbar at
the foot of the bed and are placed at about the level of the
mattress. A hammock which is used from the knee sling and
traction tapes form the BASIS OF TRACTION.
Important points in the nursing care of patient in Russell Traction
1. The knee sling should be smooth and its edges must not cause pressure on the
soft tissue over the peroneal nerve.
2. The heel of the foot in traction should just clear the bed.
Firm pillows should support the thigh and the calf along the
entire length, leaving the heel free of the bed.
3. The popliteal space must be watched for ridging and skin denudation. Elevation of
the backrest is permitted and few difficulties are encountered in giving nursing
care because the fractured leg is not at the mercy of the gravity and will not be
altered in position.
4. Encourage active dorsiflexion and plantar flexion of the feet.
Important features
1. A piece of felt should be inserted between the sling and the patient’s skin to
prevent wrinkling of the sling under the popliteal area. This will assist in
eliminating pressure sores that sometimes form at this point.
2. The heel should clear the bed. The ideal position for the heels of the patient in
Russell traction is that of a person standing with his heels four inches apart.
Abduction is to be avoided.
3. Two pillows are usually placed under the limb in traction. One under the thigh to
maintain the desired angle and the other under the calf down and including the
Achilles tendon.
2. SKELETAL TRACTION
Method of traction used most frequently in the treatment of fracture of the femur, humerus and the
tibia. The traction is applied directly to the bones by use of a metal pin or wire (Kirschnerwire, Steimann
pin), inserted into and through a bone distal to the fracture. Usually the skin is made under local
anesthesia. The pin or wire is sterilized with all the aseptic precaution of an operation. Following insertion
of pins, the wound is covered with a small gauze squares. If the wire or pin extends back to the caliper,
a cork placed over the end of the pin prevents the tearing of lines and other more serious accidents.
Skeletal traction is applied by weights and pulleys as described for skin traction. The Thomas Splint
with the Pearson attachment is usually used with skeletal traction in fractures of the femur. It may be
used with skin traction and other balanced suspension apparatus. Because upward traction is required
for these fractures, the patient is placed on a fracture bed.
Inasmuch as fracture occurs under varying circumstances and involves individuals of different ages,
weights and body builds, NO TWO FRACTURES ARE ALIKE and every fractured patient require individual
treatment. By same token, traction may be modified in many ways to meet a variety of special
7
requirements, as exemplified by so called “BALANCED SUSPENSION TRACTION” and the “RUNNING
TRACTION”.
3. MANUAL TRACTION
Means the application of traction to a part of the body by the hands of the operator. When assisting
with the application of traction or a cast, the nurse may be asked to apply a manual traction. This calls a
firm smooth grip on the extremity and the avoidance of sudden jerking movements.
BALANCED SUSPENSION
Balanced suspension traction is used primarily for femoral fractures in adults by means of the Thomas
splint with a Pearson attachment. Balanced suspension provides counter traction by its own system of
weights and pulleys. Therefore when the patient lifts, the splint should also lift so that traction is
maintained.
The Thomas splint has a sling that supports the thigh. The nurse should check for irritation from the
ring to the groin, inner thigh and ischium. The Pearson attachment is connected to the splint by the knee
and supports the calf in a position parallel to and above the bed. A Steimann pin or Kirschner wire is
inserted through the distal end of the femur or through the proximal or distal end of the tibia.
The nurse teaches the patient and family that the traction’s main purpose is to provide sling, this
allows the leg to rest comfortably and provides freedom to move without disrupting traction pull or
alignment.
By using the overhead trapeze, the patient can lift the shoulders and upper body. This movement
allows for change of linen from the top to the bottom of the bed. Similarly, the nurse can apply lotion to
the patient’s back because the individual is not allowed to turn for back care.
UPPER EXTREMITY TRACTION
Skin/Skeletal
Sidearm traction is used to immobilized fracture of the humerus and may be applied either a skin or
skeletal traction. There is outward pull on the upper arm and an upward pull on the forearm. For this
reason, two separate set-ups of adhesive strips and elastic bone wraps are needed. In addition, if skeletal
traction is used, a Kirschnerwire is usually inserted trough the olecranon.
If the traction equipment is attached to the bed frame under the mattress, elevating the head of the
bed will not disrupt the traction pull. However, if the frame is attached so that it moves when the bed
position changes, the nurse should keep the head of the bed flat. Placing a folded blanket under the
mattress near the traction frame can provide COUNTER TRACTION.
Skeletal
Overhead 90-90 traction, there is an upward pull on the upper arm, which is at a 90degree to the body.
The elbow is flexed at a 90degree that the forearm is suspended in a sling and rest above and across the
body. Weight is attached to the sling and to the Kirschner wire that is usually inserted through the
olecranon.
Because the arm is elevated, the patient should have less edema. This will be the case as long as the
nurse ensures the patient keeps the involved hand supported in the sling and does not allow it to hang
freely.
CERVICAL TRACTION
Skin Cervical Halter
Skin traction is frequently used for patients with sprains or strains to the cervical spine and ruptured
cervical discs. It is applied to the cervical spine by a halter with straps that go under the chin and around
the head of the base of the skull. After the halter is placed, the spreader bar and attached weights are
connected. The patient may have small pillow under his head and should rest the back against the bed.
Because cervical traction is usually ordered intermittently for a specified period, the nurse should teach
the patient how to remove and reapply it. This information is especially important for the patient because
there may be the need to remove the halter if vomiting or choking occurs. Any severe headache or pain
in the area of the traction should be reported.
Skeletal Cervical Tong
Skeletal traction to the cervical spine is used to immobilize and reduce fractures of the cervical spine that
may injure the spinal cord. This type of traction is always continuous and is applied by Gardner, Vinki or
crutchfield tongs inserted into the skull.
There should be little bleeding after the first 24hours should be reported. If the tongs loosened or slip
out, emergency measures include immobilizing the patient’s head with sandbags and notifying the
physician immediately.
With the skeletal traction to the cervical spine, there is a straight line of pull and the head of the bed
may be elevated 6 inches to provide counter traction. An overhead trapeze must not be used with either
skin or skeletal traction because it is use could strain the individual’s neck.
The physician determines the degree of stability of the spine and writes
specific orders for the patient to turn. If turning is allowed, the nurse should use
the “LOGROLLING”. Technique that is, the patient is rolled as a unit so that the
spine stays aligned and is not twisted.
PELVIC TRACTION
Types
1. Pelvic belt is primarily for relief of lower back pain to the lumbar spine
whereas the pelvic sling is used to treat a pelvic fracture.
Pelvic belt traction is applied to the lumbar spine by a pelvic belt with straps attached to
weights. It is used to reduce muscle spasms and in the conservative management of low back pain
and herniated lumbar disc. This traction may be ordered for intermittent periods. However, patient’s
cooperation is crucial to success.
The nurse should place the patient in William’s position, in which both the hips and knees are
flexed at a 30degree angle and the head of the bed is slightly elevated. This position relieves pressure
from the lower back by decreasing the lumbar curve. It also provides counter traction. If traction
increases pain to the back or legs, the nurse should report this to the physician.
2. Pelvic sling
It is used continuously to stabilize and immobilize fractures of the pelvis. A
large canvas sling attached to weights suspends the patient’s buttocks just off
the bed. The pelvic sling may also be used to compress the entire pelvis (by
applying pressure along each side), if there is a pelvic ring separation.
Compression is achieved when the physician repositions the rods from the
attachment edges of the sling to grooves that are closer together toward the
patient’s midline.
8
Strict immobilization is required to maintain the traction force. The nurse
should give back care every 4 hours by sliding her hands between the sling
and the patient’s back. However, it is difficult to reach the buttocks for skin
care and bathing and the patient may generally uncomfortable. For these
reasons an external fixator may be inserted into each iliac crest to stabilize
unstable fractures of the pelvis. External fixation can reduce the patient’s pain,
allow for his early ambulation and facilitate nursing care.
NURSING PRIORITIES FOR PATIENTS IN TRACTION
1. Frequently inspection of the fracture dressing in the first 24hours after application. A bandage
that appears loose when applied may in a very few hours cause constriction which if not relieved
may lead to gangrene of the extremity.
2. Dressing is applied in such a way as to leave the tips of the fingers and toes exposed. Any
cyanosis, loss of temperature, tingling sensation in these parts should warn the nurse that the
dressings are too tight. If the condition is caused by a single turn of the bandage, the turn may
be divided with scissors, but it is usually advisable to notify the surgeon.
3. After the first 24 hours, the fracture dressing should be inspected at least 3-4 times daily.
Evidences of constriction should be noted and pressure points checked – heel on the bedclothes
resting on toes.
4. It is also important to ask the patient if there are any painful areas.
5. If traction is in used, the apparatus should be checked to see the ropes are in the wheel of the
groove of the pulleys that the supporting apparatus is free of the pulleys, that the weights hang
freely and that the patient has not slipped down in the bed.
6. The foot must be in natural position; rotation outward or inward should be reported. FOOT
DROP is to be avoided and the patient’s foot must be maintained in the neutral position
supported by appropriate orthopedic devices. The rope sometimes frays; therefore, it too must
be inspected at least daily.
7. Weights are necessary to provide constant force and may be ordinary metal traction weights or
bags of water, hot or cold. It is especially important that the knots on the traction rope be tied
securely. Enough weight is applied at first to overcome shortening tendency of the injured limb,
but is gradually lessened as the fracture becomes more fixed. Weights should never be removed
from a patient with fracture unless a life-threatening situation arises. Weight and pulley is
applied to secure constant corrective extension.
8. WHEN THERE IS PULL IN ONE DIRECTION, THERE MUST BE AN EQUAL PULL IN THE OPPOSITE
DIRECTION. Counter traction is supplied by either the patient’s body and friction against the
bed (fracture of the upper extremity) or by elevating the foot of the bed (fracture of the lower
extremity).
9.When traction frames are used, a trapeze may be suspended overhead within easy reach of the
patient. This apparatus is of great help in assisting the patient to move in bed and on and off
the bedpans.
NURSING CARE OF PATIENT IN TRACTION
Nursing principles and implications
The purposes of traction regardless how it is achieved are
1. To reduce and to immobilize a fracture
2. To lessen or to eliminate muscle spasms
3. To prevent fracture deformity
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