Skeletal and Skin Traction

ST.
ANTHONY COLLEGE OF ROXAS CITY, INC 2020
Skeletal and Skin Traction

Angela Lopez,SN, Joycie Pamisal, SN, Jonna Casumpang,SN
What is traction?
Traction refers to the practice of slowly and gently pulling on a fractured or dislocated
body part. It’s often done using ropes, pulleys, and weights. These tools help apply
force to the tissues surrounding the damaged area.
The purpose of traction is to guide the body part back into place and hold it
steady. Traction may be used to:
 Stabilize and realign bone fractures, such as a broken arm or leg
 Treat bone deformities caused by certain conditions, such as scoliosis
 Correct stiff and constricted muscles, joints, and tendons
 Stretch the neck and prevent painful muscle spasms
Essential Materials for Traction
1. Firm mattress or a bed board. Facility to elevate the head end and foot end of
the bed.
2. An overhead frame, trapeze, and side rails to shift the position of the patient.
3. Bars, pulleys, weight hangers, skeletal traction apparatus and plaster cast
materials.
Types
Skin Traction Skeletal Traction
Skin Traction
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ST.ANTHONY COLLEGE OF ROXAS CITY, INC 2020
Skin traction is far less invasive than skeletal traction. It involves applying splints,
bandages, or adhesive tapes to the skin directly below the fracture. Once the material
has been applied, weights are fastened to it. The affected body part is then pulled into
the right position using a pulley system attached to the hospital bed.
METHODS OF APPLYING SKIN TRACTION
1. Adhesive Skin Traction
2. Non-adhesive Skin Traction
ADHESIVE SKIN TRACTION
 Adhesive skin traction has been discontinued because the adhesive material used
causes many complications. The maximum weight that can be attached with skin
traction is 6.7 kg but should be individualized.
NON-ADHESIVE SKIN TRACTION
 This consists of lengths of soft, ventilated latex foam rubber, laminated into a
strong cloth backing.
 These are useful in thin and atrophic skin or when there is sensitivity to adhesive
strapping. It is applied in similar fashion as adhesive skin traction
 As the grip is less secure, frequent reapplication may be necessary
 Attached traction weight should not be more than 4.5kg (10 lbs)
Common Skin Traction
 Buck’s Traction
 Hamilton Russell Traction
 Tulloch Brown Traction
 Gallow’s/ Brayant’s Traction
 Modified Brayan’s Traction
Buck’s Traction
• Often used preoperatively for femoral fractures
• Can use tape
• No more than 5 kgs
Hamilton Russell Traction

• Below knee skin traction is applied
• A broad soft sling is placed under the knee
Tulloch Brown Traction
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• Steinman pin through the proximal tibia

• Support legs on slings suspended from light
duralumin U-loop which is slipped over the ends
of Steinman pin
• Attach the Nissen stirrup to the Steinman pin it
enables leg to be suspended and rotation of
movements controlled.
Gallow’s or Bryant’s Traction

• The treatment of fracture shaft femur in children
up to age of 2 yrs.
• Weight of child should be less than 15-18kg. Tie
the traction to the over head beam.
Modified Bryant’s Traction

• Sometimes used as an initial management of
developmental dysplasia of hip (1 yr)
• By three weeks hips should be fully abducted.
Complications of skin traction

• Allergic reaction to adhesive
• Excoriation of skin from slipping of adhesive strapping
• Pressure sores around malleoli & tendoachilles
• Common peroneal nerve palsy
Any fragile
condition of skin Impairment of
circulation-varicose
ulcers, Impending
Dermatitis gangrene.
Abrasion &
Laceration of Marked shortening of
bony fragments
skin where more traction
weight has to be
Contraindications applied
of Skin Traction
Nursing Management
Maintain skin integrity
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 Patient’s 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.
 Positioning at least every 4 hours
 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
Activity
 Patient exercises within the therapeutic limits of the traction, assist in
maintaining muscle strength and tone, and in promoting circulation.
 Non-pharmacological distraction and activity will improve patient comfort.
 The patient is able to move in bed as tolerated for hygiene to be completed.
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 patient’s pain is sufficiently managed and
should be considered prior to pressure area care.
 Assess and document outcomes of pain management strategies employed
Provide client teaching

 Encourage active exercises for unaffected body parts.
 Encourage the use of a trapeze, if indicated.
 Promote deep-breathing exercises hourly
Observations
 Check the patient’s neurovascular observations hourly and record in the medical
record.
 If the bandage is too tight it can cause blood circulation to be slowed.
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 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.
Skeletal Traction
 Skeletal traction involves placing a pin, wire, or screw in the fractured bone.
After one of these devices has been inserted, weights are attached to it so the
bone can be pulled into the correct position. This type of surgery may be done
using a general, spinal, or local anesthetic to keep you from feeling pain during
the procedure.
 Skeletal traction is most commonly used to treat fractures of the femur, or
thighbone. It’s also the preferred method when greater force needs to be applied
to the affected area. The force is directly applied to the bone, which means more
weight can be added with less risk of damaging the surrounding soft tissues.
E QUI P M E N T S
● Steinman pin Denhams pin K wire
Steinman pin
 Are rigid stainless steel pins of varying length, 4 to 6 mm diameter.
 After insertion a special, stirrup (Bohler 1929) is attached to the pin.
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The Bohler stirrup allows the direction of the traction to be changed without turning the
pin in the bone
Denham Pin
 Similar to Steinmans pin except for a short threaded length situated in the center
and held in the introducer.
 It engages the bony cortex and reduces the risk of pin sliding.
 Used in
a) cancellous bones &
b) osteporotic bones
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Kirschner wire
A Kirschner wire (also called a K-wire) is a thin metallic wire or pin that can be used
to stabilize bone fragments. These wires can be drilled through the bone to hold the
fragments in place.
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CAST APPLICATION
MARIBEL D. FUENTES, SN JIMSON ALTOMIA, SN KIETH AMEI FALALIMPA, SN
BSN III OUR LADY OF MIRACULOUS MEDAL
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CAST APPLICATION
INTRODUCTION
CASTS
 Is a rigid external immobilizing device that is molded to contours of the body.
 It can be said to be a shell, frequently made from the plaster or fiberglass,
encasing a limb (or, in some cases, large portions of the body) to stabilize and
hold anatomical structures, most often a fractured bones, in place until healing is
confirmed.
when to use a cast
 A cast is used when the two ends of a fractured boned can be realigned
(reduced) without surgery, which called closed reduction.
 In some cases –if the bone is badly misaligned, sticking through the skin or
broken into the three or more pieces- surgery is necessary to realign the bone.
What are the casts made of?
 plaster or fiberglass.
 Fiberglass is lighter, more durable and more comfortable due to the superior
airflow. It is also easier to take effective x-rays through a fiberglass cast.
 Plaster is less expensive and more easily shaped.
Cast application
• Before casting material is applied (plaster or fiberglass), a "stockinette" is usually

placed on the skin where the cast begins and ends
• After the stockinette is placed, soft cotton padding material (also called cast
padding or Webril) is rolled on.
• Next, the plaster or fiberglass cast material is rolled on while it is still wet.
• The cast will usually begin to feel hard about 10 to 15 minutes after it is put on,
but it takes much longer to be fully dry and hard.
• Be especially careful with a plaster cast for the first 1 to 2 days.
Plaster casts
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•A plaster cast is made from rolls or pieces of dry muslin that have starch or
dextrose and calcium sulfate added.
•When the plaster gets wet, a chemical reaction happens (between the water and
the calcium sulfate) that produces heat and eventually causes the plaster
to set, or get hard, when it dries.
•A person can usually feel the cast getting warm on the skin from this chemical
reaction as it sets.
•The temperature of the water used to wet the plaster affects the rate at which
the cast sets. When colder water is used, it takes longer for the plaster to
set, and a smaller amount of heat is produced from the chemical reaction.
•Plaster casts are usually smooth and white.
Fiberglass casts
•Fiberglass casts are also applied starting from a roll that becomes wet.
•After the roll is wet, it is rolled on to form the cast. Fiberglass casts also
become warm and harden as they dry.
• Fiberglass casts are rough on the outside and look like a weave when dry.
Fiberglass are available in many colors.
How Can You Prevent a Cast From Breaking, and How Do You Keep it Clean
and Dry?
1. Loose cast
2. Protect the cast from water.
3. Fiberglass casts and water.
4. Very wet under cast.
5. Odors in a cast.
6. Don't break a cast
7. Do not put anything inside a cast.
8. Don't trim the rough edges of a cast.
9. Use an arm sling.
10. Do not walk on the cast.
11. Walking boots.
12. Crutches
TYPES OF CASTs
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Cast can be generally divided into four main groups: arm casts, leg casts, cast
braces and body or spica casts.
Upper Extremity Casts
Short arm cast

Is also known as the below-elbow cast. This is a
frequently used circumferential immobilization cast of
the forearm and wrist made of either synthetic material
or plaster of Paris, used as a treatment for some local
fractures and soft tissue injuries.
Long arm cast
Applied from the upper arm to the hand. It is use in

the Upper arm, elbow, or forearm fractures. Also used
to hold the arm or elbow muscles and tendons in place
after surgery
Arm cylinder cast
Applied from the upper arm to the wrist. It is

used to hold the elbow muscles and tendons in
place after a dislocation or surgery .

Shoulder spica cast
 Applied around the trunk of the body to

the shoulder,
 arm, and hand.
 Shoulder dislocations or after surgery on
the shoulder area
Minerva cast
Applied around the neck and trunk of the body. It is use after surgery on the neck or
upper back area.
Lower Extremety Cast
Short leg cast

Applied to the area below the knee to the foot. It is used in the lower leg
fractures, severe ankle sprains and strains, or fractures. Also used to hold the leg or
foot muscles and tendons in place after surgery to allow healing.
Long leg cast
Applied from the upper thigh to the ankle. It is used

In the Knee, or lower leg fractures, knee dislocation or
after surgery on the leg or knee area.
Walking cast
A walking cast helps to immobilize the

movement of the ankle, foot and calf, and
supports the user’s weight while walking.
Cast Brace
Patellar tendon bearing

cast
To immobilize fractures of
the tibial shaft and at the same
time allow the knee to bend.

Body Cast
Unilateral hip spica cast

Applied from the chest to the foot on one
leg. It is used in thigh fractures. Also used to hold
the hip or thigh muscles and tendons in place
after surgery to allow healing.
One and one-half hip spica cast
Applied from the chest to the foot on one leg to the

knee
of the other leg. A bar is placed between both legs to
keep
the hips and legs immobilized. It is used in high
fracture.
Also used to hold the hip or thigh muscles and
tendons in place
after surgery to allow healing.
Bilateral Long
Leg Hip Spica Cast
Applied from the chest to the feet. A bar is

placed between both legs to keep the hips and
legs immobilized. It is used in the Pelvis, hip, or
thigh fractures. Also used to hold the hip or
thigh muscles and tendons in place after
surgery to allow healing.

Short Leg Hip Spica Cast

Applied from the chest to the thighs or knees.
It is used to hold the hip muscles and tendons
in place after surgery to allow healing.
Abduction boot cast

Applied from the upper thighs to the feet. A bar is
placed between both legs to keep the hips and
legs immobilized. It is used to hold the hip
muscles and tendons in place after surgery to
allow healing.
ASSISTIVE DEVICES FOR PATIENTS WITH CASTS INCLUDE
 Crutches
 Walkers (children)
 Wheelchairs Reclining wheelchairs
CAST CARE INSTRUCTIONS
 Patients or parent /guardian should be given written instructions on how

to manage the fracture /cast
 Keep the cast clean and dry

 Check for cracks or breaks in the cast.

 Do not scratch the skin under the cast by inserting objects inside the cast.
 Do not put powders or lotion inside the cast.
 Cover the cast while your child is eating to prevent food spills and crumbs
from entering the cast.
 Prevent small toys or objects from being put inside the cast.
 Encourage your child to move his or her fingers or toes to promote
circulation.
 Do not use the abduction bar on the cast to lift or carry the child.
 Use a diaper or sanitary napkin around the genital area to prevent leakage
or splashing of urine.
 Place toilet paper inside the bedpan to prevent urine from splashing onto
the cast or bed
 In case of itching apply ice packs or place hair dryer (cool air)against one
of the ends to draw air in through it
WHEN TO COME BACK TO THE HOSPITAL
 Cast is too tight

 Develops Fever
 Increased pain
 Increased swelling above or below the cast
 Complaints of numbness or tingling
 Drainage or foul odor from the cast
 Cool or cold fingers or toes
 Can’t move fingers or toes
COMPLICATIONS OF PLASTER
 Due to improper applications :

 Joint stiffness and malposition of limb.
 Plaster blisters and sores.
 Pressure Sores
 Due to plaster allergy :
 Allergic contact dermatitis –
 The skin symptoms of irritation are usually all mild and
Temporary.
 Quaternary ammonium compound
BENZALKONIUM CHLORIDE is the allergen
responsible for plaster of Paris-induced allergic
contact dermatitis
 Purulent dermatitis
 Due To Tight Cast
 Compartment syndrome
 Nerve Palsy
 Circulatory Complications Others
 Gangrene complicating fractures
 Deep vein Thrombosis
 Disuse osteoporosis and renal calculus formation

CONTRAINDICATIONS
✗ Open fractures
✗ Neurovascular compromise
✗ Skin infection or ulcers
✗ Swelling of the limb
✗ Allergy to cast materials
✗ Comminuted fractures
Assessment
Assess the following before and after cast application
 Evaluate the client’s pain, noting severity, nature, exact location, source and
alleviating and exacerbating factors.
 Access neurovascular status.
 Inspect for and document any skin lesions, discoloration, or no removable
foreign material.
 Evaluate the client’s ability to learn essential procedures, such as applying slings
correctly, crutch walking, or using a walker.
 Deficient knowledge related to the treatment regimen
 Acute pain related to the musculoskeletal disorder
 Impaired physical mobility related to the cast
 Self-care deficit: bathing/hygiene, feeding, dressing/grooming due to restricted
mobility
 Impaired skin integrity related to lacerations and abrasions
 Risk for peripheral neurovascular dysfunction and related to physiologic
responses to injury and compression effect of cast
Nursing Management
 Prepare the client for cast application.

 Obtain informed consent if surgery is required.
 Clean the skin of the affected part thoroughly.
 Assist the health care provider during application of the cast as needed.
 After the cast application, provide cast care.
 Support an exposed cast, with the palms of your hands to prevent
indentations.
 Ensure that the stockinet is pulled over rough edges of the cast.
 Elevate the casted extremity above the level of the heart.
 Provide covering and warmth to uncasted areas.
 Expose the fresh plaster cast to circulating air, uncovered, until dry (24 to
72 hours). Expose the fresh synthetic cast until it is completely set (about
20 minutes).
 Instruct the client to avoid wetting the cast. Instruct him to dry a
synthetic cast with a hair dryer on cool setting if it gets wet.
 Initiate pain relief measure if indicated.
 Encourage position changes.
 Elevate the affected body part.
 Provide analgesics as appropriate.
 Observe for signs and symptoms of cast syndrome with clients who are
immobilized in large casts, such as a body or hip spica cast.

 Report abdominal pain and distention, nausea and vomiting, elevated

blood pressure, tachycardia, and tachypnea which are physiologic effects
of cast syndrome.
 Any client who is claustrophobic is at risk for psychological cast syndrome,
which includes acute anxiety and possible irrational behavior.
 Provide nursing care for compartment syndrome, if indicated. Observe for signs
and symptoms and discuss and assist with treatments.
 Notify the health care provider immediately if signs or symptoms of other
neurovascular complications occur.
 Notify the health care provider if “hot spots” occur along the cast; they may
indicate infection under cast.
 Provide client and family teaching.
 Encourage isometric exercises to strengthen muscles covered by the cast.
Promote muscle-strengthening exercises for the upper body if crutches
are to be used.
 Advise the client to promptly report cast breaks and signs and symptoms
of complications (i.e. circulatory compromise, cast syndrome, and hot
spots).
 Warn the client against inserting sharp objects (e.g. coat hanger to
scratch itchy skin under the cast). Instruct him to use a cool air from a
dryer to help alleviate the itch.
 Teach the client appropriate cast care, depending on the type of cast.
 Encourage safety precautions (e.g. avoid walking on wet floors, watch
throw rugs, be careful with stairs).
 Teach the client skin care and muscle-strengthening exercises for the
affected body part after cast removal.
 Encourage mobility and active participation in self-care.
 Reinforce health care provider instructions on the amount of eight bearing
allowed.
AMPUTATION
Juvie Lie F. Ferren, SN

• Amputation is the removal of an extremity by trauma, medical illness or surgery.

As a surgical measure, it is used to control pain or a disease process in the
affected limb, such as malignancy or gangrene.
• In some cases, it is carried out on individuals as a preventative surgery for such

problems. A special case is that of congenital amputation, a congenital disorder,
where fetal limbs have been cut off by constrictive bands.
• In some countries, amputation of the hands, feet or other body parts is, or was
used as a form of punishment for people who committed crimes. Amputation has
also been used as a tactic in war and acts of terrorism; it may also occur as a
war injury.
LEVELS OF AMPUTATION

UPPER LIMB AMPUTATION
-Upper limb amputations tend to be less common than lower limb amputations, but can
affect people of all ages.
• Wrist Disarticulation - Limb is amputated at the level of the wrist
• Transradial (below elbow amputations) - Amputation occurring in the forearm,

from the elbow to the wrist
• Transhumeral (above elbow amputations) - Amputation occurring in the upper

arm from the elbow to the shoulder
• Shoulder Disarticulation - Amputation at the level of the shoulder, with the

shoulder blade remaining. The collarbone may or may not be removed
• Forequarter Amputation - Amputation at the level of the shoulder in which

both the shoulder blade and collar bone are removed

LOWER LIMB AMPUTATION
• Foot Amputations - Amputation of any part of the foot. This includes mid
tarsal amputations, Lisfranc amputation, Boyds amputation & Symes amputation
• Transtibial Amputations (below the knee) - Amputation occurs at any level

from the knee to the ankle
• Knee Disarticulation - Amputation occurs at the level of the knee joint
• Transfemoral Amputations (above knee ) - Amputation occurs at any level

from the hip to knee joint
• Hip Disarticulation - Amputation is at the hip joint with the entire thigh and
lower portion of the leg being removed

CAUSES
Circulatory Disorders
-A circulatory disorder is any disorder or condition that affects
the circulatory system. Circulatory disorders can arise from problems with the
heart, blood vessels or the blood itself. Disorders of the circulatory system generally
result in diminished flow of blood and oxygen supply to the tissues.
• Diabetic vasculopathy
• Sepsis with peripheral necrosis

Neoplasm
-A neoplasm is an abnormal growth of cells, also known as a
tumor. Neoplastic diseases are conditions that cause tumor growth — both benign
and malignant. Benign tumors are noncancerous growths. They usually grow slowly and
can't spread to other tissues. Malignant tumors are cancerous and can grow slowly or
quickly. Bone cancer can begin in any bone in the body, but it most commonly affects
the pelvis or the long bones in the arms and legs.
• Cancerous bone or soft tissue tumor
Trauma
-The longer we live, the more inevitable it is that we will experience trauma. Trauma is
the response to a deeply distressing or disturbing event that overwhelms an individual’s
ability to cope, causes feelings of helplessness, diminishes their sense of self and their
ability to feel the full range of emotions and experiences.
• Traumatic amputation
• Amputation in utero
-Amniotic band syndrome (ABS) is a rare birth defect in which bands of
tissue inside the sac of fluid that surrounds a baby in the womb tangle around
the baby's body causing injury. This happens when there is a rupture in the
inside sac (amnion).

Frostbite
-Frostbite is an injury caused by freezing of the skin and underlying tissues. First your
skin becomes very cold and red, then numb, hard and pale. Frostbite is most common
on the fingers, toes, nose, ears, cheeks and chin. Exposed skin in cold, windy weather
is most vulnerable to frostbite. In some cases, frostbite can have very serious
outcomes. The lack of blood flow and oxygen to the skin can cause the flesh to die,
leading to permanent tissue damage. This may result in the need for amputation of the
affected extremities.
COMPLICATIONS
-Like any type of operation, an amputation carries a risk of complications. It also carries
a risk of additional problems directly related to the loss of a limb. There are a number
of factors that influence the risk of complications from amputation, such as your age,
the type of amputation you've had, and your general health.
• Edema
-Stump edema occurs as a result of trauma and the mishandling of tissues during
surgery. After the amputation, there is an imbalance between fluid transfer across
the capillary membranes and lymphatic reabsorption. This, in combination with
reduced muscle tone and inactivity, can lead to stump edema. The complications
that can arise from stump edema include wound breakdown, pain, reduced mobility
and difficulties with prosthetic fitting. Numerous interventions are used to manage
and prevent post-operative stump edema, including, compression socks, rigid
removable dressings, exercise, wheelchair stump boards.
• Wounds and infection
-Surgical site infection after amputation is common and as well as increasing patient
morbidity, can have negative effects on healing, phantom pain and time to
prosthetic fitting. Risk factors for a stump infection include diabetes mellitus, old age
and smoking, which are all common denominators amongst the amputee population.
The decision to insert a drain and use clips instead of sutures is also associated with
increased infection risk.
• Pain

- Pain is an inevitable consequence of amputation. There are several types of

sensations following an amputation that should be discussed when referring to pain
following amputation. Some of them are extremely painful and terribly unpleasant;
some are simply weird or disconcerting. In one form or another, they are
experienced by most people following an amputation.
• Muscle weakness, contractures, and Joint instability
-After amputation, it is not uncommon for patients to experience pain, muscle
weakness or instability in structures not directly associated with the amputation.
These compensatory structures are the muscles and joints that are required to
perform additional functions post amputation, often resulting in stiffness, spasm or
pain.
ROM exercises should be incorporated to avoid contractures, as well as prone lying
to prevent hip flexion contractures, a sandbag could be placed next to the residuum
to prevent a hip abduction contracture. A sandbag could also be placed on the lower
part of a transtibial residuum when the patient is prone, to prevent hip flexion contractures.
MANAGEMENT
• A rigid cast dressing, removable rigid dressing, or an elastic residual limb
shrinker that covers the residual limb may be used to provide uniform
compression, to support soft tissues, to control pain and edema, and to prevent
joint contractures.
• The rigid dressing is removed several days after surgery for wound inspection
and is then replaced to control edema. However, edema is better controlled with
semi-rigid dressings for certain types of amputation, and may facilitate earlier
ambulation and improved readiness for prosthesis.
• Prosthetic: Referring to a prosthesis, an artificial substitute or replacement of a
part of the body such as a tooth, eye, a facial bone, the palate, a hip, a knee or
another joint, the leg, an arm, etc. A prosthesis is designed for functional or
cosmetic reasons or both. Typical prostheses for joints are the hip, knee, elbow,
ankle, and finger joints. Prosthetic implants can be parts of the joint such as a
• unilateral knee. Joint replacement and arthroplasty mean the same thing. The
word "prosthesis" comes via New Latin from the Greek "prostithenai" meaning
"to add to, or to put in addition." The plural of prosthesis is prostheses.

NURSING INTERVENTION
• Provide stump care on a routine basis: inspect the area, cleanse and dry
thoroughly, and rewrap stump with an elastic bandage or air splint, or apply a
stump shrinker.
Rationale: Provides an opportunity to evaluate healing and note complications
such as infection to the wound site (unless covered by immediate prosthesis).
Wrapping stump controls edema and helps form stump into a conical shape to
facilitate the fitting of the prosthesis.
• Assist with specified ROM exercises for both the affected and unaffected limbs
beginning early in the postoperative stage.
Rationale: Prevents contracture deformities, which can develop rapidly and
could delay prosthesis usage.
• Instruct and assist patient to lie in the prone position as tolerated at least twice a
day with a pillow under the abdomen and lower-extremity stump.
Rationale: Strengthens extensor muscles and prevents flexion contracture of
the hip, which can begin to develop within 24 hours of sustained malpositioning.
• Demonstrate the use of mobility aids like trapeze, crutches, or walker.
Rationale: Facilitates self-care and patient’s independence.
• Assist with ambulation.
Rationale: Reduces the potential for injury. Ambulation after lower-limb
amputation depends on the timing of prosthesis placement.
• Inspect dressings and wound; note characteristics of drainage.

Rationale: Early detection of developing infection provides an opportunity for

timely intervention and prevention of
more serious complications.
• Expose stump to air; wash with mild soap and water after dressings are
discontinued.
Rationale: Maintains cleanliness, minimizes skin contaminants, and promotes
healing of tender and fragile skin.
• Monitor vital signs.
Rationale: Temperature elevation and tachycardia may reflect developing
sepsis.
• Apply anti-embolic and sequential compression hose to the non-operated leg, as
indicated.
Rationale: Enhances venous return, reducing venous pooling and risk of
thrombophlebitis.
• Administer low-dose anticoagulant as indicated.
Rationale: May be useful in preventing thrombus formation without increasing
the risk of postoperative bleeding and hematoma formation.
ASSISTIVE DEVICES
JAM VALLES CORROS,SN

INTRODUCTION
Immobility in hospitalized patients is known to cause functional decline; decline

and complication affecting the respiratory, cardiovascular, gastrointestinal,
integumentary musculoskeletal and renal system. For surgical pt. early ambulation is
the most significant factor in preventing complications. Lack of mobility and ambulation
can be devastating to the older adult when the aging process causes a more rapid
decline in function. Ambulatory provides not only improved physical function, but also
improves emotional and social well-being.
Assistive Devices
■ Assistive devices are basically helpful products that improve a person’s ability to
function independently.
■ They are used by people with disabilities and older adults who want to remain
independent as long as possible
Indications for Ambulatory Assistive Devices

■ Structural deformity, amputation, injury, or disease resulting in decreased ability
of Lower extremities.
■ Muscle weakness or paralysis of the trunk or Lower extremities

■ • Inadequate balance
Commonly used Assistive devices for mobility includes :

■ Cane
■ Walkers
■ Crutches
Cane
Cane is a hand held ambulation device made of wood or aluminum •
■ Three types of canes are commonly used:
1. The standard straight-legged cane;
2. The tripod or crab cane, which has three feet
3. The quad cane, which has four feet and provides the most support
■ The Standard cane should have rubber caps to improve tractions and prevent
slipping.
■ The Standard cane is 91 cm (36 in) long: some aluminum cane can be adjusted
from 56 to 97 cm (22 to 38 in).
■ The length should permit the elbow to be slightly flexed.
■ Client may use either one or two canes, depending on how much support they
require.
CLIENT TEACHING
USING CANE:
- Hold the cane with the hand on the stronger side of the body to provide
maximum support and appropriate body alignment when walking.
- Position the tip of a standard cane ( and the nearest tip of the canes about 15
cm (6 in) in front if the near foot, so that the elbow is slightly flexed.

WHEN MAXIMUM SUPPORT IS REQUIRED

- Move the cane forward about 30 cm (1ft), or a distance that is comfortable while
the body is borne by both legs.
- Then Move the affected (weak) leg forward to the cane while the weight is borne
by the cane and stronger leg.
- Next, move the unaffected (Stronger) leg forward ahead of the cane and weak
leg while the weight is borne by the cane and weak leg
- Repeat the steps. This pattern of moving provides at least to points of support
on the floor at all times.
Safety considerations:
● Ensure proper fitting footwear is used.
● Use rubber tips to prevent the device from slipping.
● Avoid scatter rugs.
● Inspect rubber ends after being outside and remove any gravel.
WALKERS
■ Walkers are mechanical devices for ambulatory clients who need more support
than a cane provices and lack the strength and balance required for crutches.
■ Walkers come in many different shapes and sizes, with devices suited to
individual needs.
a. Standard
b. Four-Wheeled

c. Two-wheeled
STANDARD WALKER
■ Standard Cane is made of polished aluminum. It
has four legs with rubber tips and plastic hand
grips. Many walkers have adjustable legs.
■ The standard walker needs to be picked up to
be used.
■ The client therefore requires partial strength in
both hands and wrist, stronger elbow extensors,
and strong shoulder depressors.
■ The client also needs the ability to bear at least
partial weight on both legs.
FOUR WHEELED WALKER
■ This do not need to picked up to be moves,
but they are less stable than the standard
walking.
■ They are used by clients who are too weak or
unstable to pick up and move the walker with
each step.
■ Some walker have a seat at the back so tat
the client can sit down to rest when desired.
TWO WHEELED WALKER

■ An adaptation of the standard and four-
wheeled walker is one that has two tips and
two wheels.
■ This type provides more stability that the four-
wheeled model yet still permits the client to
keep the walker in contact with the ground all
the time.
■ The legs allow the client to easily push the
walker forward, and the legs without rollers
prevent the walker from rolling way as the
client steps forward.
■ The nurse may need to adjust the height of a client’s walker so that the hand bar
is just below the client’s waist and the client’s elbow are slightly flexed.
■ This position helps the client assume a more normal stance.
■ A walker that is too low causes the client to stoop; one is too high makes the
client to stretch and reach.
CLIENT TEACHING
USING WALKERS
A. WHEN MAXIMUM SUPPORT IS REQUIRED
- Move the walker ahead about 15 cm (6 in) while your body weight is
borne by both legs.
- Then move the right foot up to the walker while your body weight is
borne by the left leg and both arms.
- Next, move the left foot up to the right foot while your body weight is
borne by the right leg and both arms.
B. IF ONE LEG IS WEAKER THAT THE OTHER
- Move the walker and the weak leg ahead together about 15 cm (6 in)
while your weight is borne by the stronger leg.
- Then move the stronger leg ahead while your weight is borne by the
affected leg and both arms.
CRUTCHES
■ Crutches may be a temporary need for some clients and a permanent one for
others. Crutches should enable a client to ambulate independently; therefore, it
is important to learn to use them properly.
■ The most frequent used type of crutches are the underarm crutch, or axillary
crutch with hand bars, and the Lofstrand Crutch which extends only to the
forearm.
■ On the Lofstrand crutch, the metal cuff around the forearm stabilizes the wrists
and thus make walking easier, especially on stairs.

■ The platform, or elbow extensor crutch also has a cuff for the upper arm to
permit forearm weight bearing.
■ All crutches require suction tips, usually made of rubber, which help to prevent
slipping on a floor surface.
■ In crutch walking, the client’s weight is borne by the muscle of the shoulder
girdle and upper extremities.
■ Before beginning crutch walking, exercise that strengthen the upper extremities
arms and hands are recommended.
Measuring Clients for Crutches

■ When nurses measure clients for axillary crutches, it is most important to obtain
the correct length for the crutches and the correct placement of hand piece.
■ There are two methods of measuring the crutch length:
1. The client lies in a supine position and the nurse measures from the anterior
folds of the axilla to the heel of the foot and adds 2.5cm (1in)
2. The client stands erect and position the crutch. The nurse makes the sure the
shoulder rest of the crutch is at least three finger widths, that is 2.5cm to 5 cm (1 to 2
in), below the axilla.
■ To determine the correct placement of the hand bar:
1. The client stands upright and supports the body weight hand grips of the
crutches.
2. The nurse measures the angle of elbow flexion. It should be about 30
degrees. A goniometer may be used to verify the correct angle.
GONIOMETER

CLIENT TEACHING
■ Follow the plan of exercise developed for you to strengthen your arm muscles
before beginning crutch walking
■ Have a health care professional establish the correct length for your crutches and
the correct placement of the hand pieces. Crutches that are too long force your
shoulder upward and make is difficult for you to push your body off the ground.
Crutches that are too short will make you hunch over and develop an improper
stance.
■ The weight of your body should be borne by the arms rather than the axillae
(armpits). Continual pressure on the axillae can injure the radial nerve and
eventually cause crutch palsy, a weakness of the muscle of the forearm, wrist
and hand.
■ Maintain an erect posture as much as possible to prevent strain on muscles and
joints to maintain balance.
■ Each step taken with crutches should be a comfortable distance for you. It is
wise to start with a small rather than a large step.
■ Inspect the crutch tips regularly, and replace them if worn.
■ Keep the crutch tips dry and clean to maintain their surface friction. If the tips
become wet, dry them well before use.
■ Wear a shoe with a low heel that grips the floor. Rubber soles decrease the
changes of slipping. Adjust shoelaces so they cannot come unties or reach the
floor where they might catch on the crutches. Consider shoes with alternative
forms of closure (e.g Velcro), especially if you cannot easily bend to tie laces.
Slip-on shoes are acceptable only if they are snug and the heel does not come
loose when the foot is bent.
Crutch Gaits
■ Crutch gait is the gait of a person assumes on crutches by alternating body
weight on one or both legs and the crutches.

■ Five standard Crutch gaits: Four point gait, Three-point gait, Two point gait,
Swing to gait, Swing-through gait
■ The gait used to depends on the following individual factors: (a) the ability to
take steps (b) the ability to bear weight and keep balance in a standing position
on both legs or only one, and (c) the ability to hold the body erect.
■ Clients also need instruction about how to get into and out of chairs and go up
and down the stairs safely. All of these crutch skills are best taught before the
client is discharged and preferably before the client has surgery.
Crutch Stance (Tripod position)
■ Before crutch walking is attempted, the client needs to learn facts about the
posture and balance.
■ The proper standing position with crutches is called the TRIPOD (TRIANGLE)
POSITION.
■ The crutches are places 15 cm (6in) in front of the feet and out laterally about
15 cm (6in) to create a wide base support.
■ The feet are slightly apart. A tall client requires a wider base than does a short
client.
■ Hips and knees are extended, the back is straight, and the head is held straight
and high.
■ There should be no hunch to the shoulders and thus no weight borne by the
axillae.
■ The elbows are extended sufficiently to allow eight bearing on the hands.
■ If the client is unsteady, the nurse place a gait/transfer belt around the client’s
waist and grasps the belt from above, not below. A fall can be prevented more
effectively if the belt is held from above.
Four-Point Alternate Gait
■ This is the most elementary and safest, providing at least three points of support
all the rime, but is requires coordination.
■ Clients can use it when walking in crowds because it does not require much
space.
■ To use this gait, the client needs to be able to bear weight on both legs.

1. Move the right crutch ahead a suitable distance, such as 15 cm ( 4-6in)

2. Move the left foot forward, preferable to the level of the left crutch.
3. Move to the left crutch forward.
4. move the right foot forward.
Three-point Gait
■ To use this gait, the client must be able
to bear entire body weight on the
unaffected leg.
■ The two crutches and the unaffected leg
bear weight alternately.
1. Move both crutches and the weaker
leg forward.
2. Move the stronger leg forward.
Two-Point Gait
■ This gait is faster than the four-point
gait. It requires more balance because
only two points support the body at one
time; also requires at least partial weight
bearing on each foot.
■ In this gait, arm movement with
crutches are similar movement during
normal walking.
1. Move the left crutch and right foot
forward together.
2. Move the right crutch and left foot
together.
Swing-To Gait
■ This swing gaits are used by clients with
paralysis of legs and hip.

■ Prolonged use of this gaits results in atrophy of the unused muscles.

1. Move both crutches ahead together.
2. Lift body weight by the arms and swing to the crutches.
Swing-Through Gait
■ This gait requires considerable skill, strength,
and coordination.
1. Move both crutches forward together.
2. Lift body weight by the arms and swing
through and beyond the crutches.
Getting into a Chair

■ Chairs that have armrest and are secure
or braces against the wall are essential
for clients using crutches.
1. Stand with the back of the unaffected
leg centered against the chair. The chair helps
the client during the next steps.
2. Transfer the crutches to the hand of
affected side and hold the crutches by the hand
bars. The client grasps the arm of the chair
with the hand on the unaffected side. This
allows the client to support the body weight on
the arms and the unaffected leg.
3. Lean forward, flex the knees and hips,
and lower into the chair.
Getting Up the Chair

■ For this procedure, the nurse instruct the
client to
1. Move forward to the edge of the chair
and place the unaffected leg slightly under the
edge of the chair. This position helps the client

stand up from the chair and achieve balance, because the unaffected leg is supported
against the edge of the chair.
2. Grasp the crutches by the hand bars in the hand on the affected side, and
grasp the arm of the chair by the hand on the unaffected side. The body weight is
placed on the crutches and the hand on the armrest to support the unaffected leg when
the client rises to stand.
3. Push down on the crutches and the chair armrest while elevating the body of
the chair.
4. Assume the tripod position before moving.
Going up Stairs
■ For this procedure, the nurse stands
behind the client and slightly to the
affected side if needed. The nurse
instructs the client to:
1. Assume the tripod position at the bottom
of the stairs.
2. Transfer the body weight to the crutches
and move the unaffected leg onto the
step.
3. Transfer the body weight to the
unaffected leg on the step and move the crutches and affected leg to the step.
The affected leg is always supported by the crutches.
4. Repeat steps 2 and 3 until the client reaches the top of the stairs.
Going Down The Stairs

■ For this procedure, the nurse stands one step
below the client on the affected side if
needed. The nurses instructs the client to:
1. Assume the tripod position at the top of the
stairs.
2. Shift the body weight to the unaffected leg
and move the crutches and affected leg down
onto the next step.
3. Transfer the body weight to the crutches, and
move the unaffected leg to the step. The
affected leg is always supported by the
crutches.
4. Repeat steps 2 and 3 until the client reaches the bottom of the stairs.

Skeletal and Skin Traction

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Skeletal and Skin Traction

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ANTHONY COLLEGE OF ROXAS CITY, INC 2020

Skeletal and Skin Traction

Skin Traction Skeletal Traction

Hamilton Russell Traction

Tulloch Brown Traction

BSN-III OLMM Page 2

• Steinman pin through the proximal tibia

Gallow’s or Bryant’s Traction

Modified Bryant’s Traction

Complications of skin traction

• Excoriation of skin from slipping of adhesive strapping

• Pressure sores around malleoli & tendoachilles

• Common peroneal nerve palsy

BSN-III OLMM Page 3

Pain Assessment and Management

Provide client teaching

 Monitoring of swelling of the femur should also occur to monitor for

● Steinman pin Denhams pin K wire

BSN-III OLMM Page 5

a) cancellous bones &

BSN-III OLMM Page 6

BSN-III OLMM Page 7

MARIBEL D. FUENTES, SN JIMSON ALTOMIA, SN KIETH AMEI FALALIMPA, SN

BSN III OUR LADY OF MIRACULOUS MEDAL

BSN-III OLMM Page 8

What are the casts made of?

• Before casting material is applied (plaster or fiberglass), a "stockinette" is usually

BSN-III OLMM Page 9

BSN-III OLMM Page 10

Upper Extremity Casts

Short arm cast

Long arm cast

Applied from the upper arm to the hand. It is use in

Arm cylinder cast

Applied from the upper arm to the wrist. It is

place after a dislocation or surgery .

BSN-III OLMM Page 11

Shoulder spica cast

 Applied around the trunk of the body to

Lower Extremety Cast

Short leg cast

BSN-III OLMM Page 12

Long leg cast

Applied from the upper thigh to the ankle. It is used

A walking cast helps to immobilize the

Patellar tendon bearing

BSN-III OLMM Page 13

Unilateral hip spica cast

One and one-half hip spica cast

Applied from the chest to the foot on one leg to the

Applied from the chest to the feet. A bar is

BSN-III OLMM Page 14

Short Leg Hip Spica Cast

Abduction boot cast

ASSISTIVE DEVICES FOR PATIENTS WITH CASTS INCLUDE

 Wheelchairs Reclining wheelchairs

CAST CARE INSTRUCTIONS

 Patients or parent /guardian should be given written instructions on how

BSN-III OLMM Page 15

 Check for cracks or breaks in the cast.

WHEN TO COME BACK TO THE HOSPITAL

 Cast is too tight

 Due to improper applications :