CLINICAL ORTHOPAEDICS

Understanding the
principles of traction
P i

SM x'\ i
cr.
&

;/ .v

f A k:......

m ■Si. ,r*
% .
iWWH
Dave Nichol RGN, ONC, BA, As the use oftraction has declined in recent years, nurs­ The force involved in traction is described in
DipEd, FETC, is a Nurse Tutor, es’ skills in this area have consequently decreased. Stan­ relation to Newtons third law of motion, where­
Mid Trent College of Nursing dards of care for patients in traction might now be by it is said that for every action there must be
and Midwifery, Queen’s Medical called into question. This article attempts to redress this an equal and opposite reaction. Within the con­
Centre, Nottingham. imbalance by describing the principles Ixhind safe and text of nursing it has been stated that (3): In
effective traction. order to pull an object in one direction there
This article has been subject to must be an equal counter-thrust in the opposite
clouble-blind review. Modem trends in orthopaedic treatment and care direction.’ This adequately describes both fixed
have led to an overall reduction in the use of trac­ and balanced traction.
tion, both skin and skeletal. Nursing skills in Similarities between fixed and balanced traction
this area have diminished accordingly and nurs­ Both fixed and balanced traction can be skin or
es, therefore, are increasingly turning to theory skeletal in form. Confusion can arise when skin
to supplement their lack of practical expertise. traction and skeletal traction are seen as differ­
However, theoretical sources are not always reli­ ent classifications (2) and, therefore, not com­
able and examples of illustrations can be found patible or comparable.
showing balanced traction without the required The difference lies in their purpose. Skin trac­
KEY WORDS counter-traction (1). tion is used for short periods of time or when a
Traction has been used for more than 3,000 small amount of weight is required, for exam­
► ORTHOPAEDICS
years (2) to maintain fracture alignment, relieve ple, to reduce pain prior to hip surgery. Skeletal
► FRACTURES
pain and decrease muscular spasm. It can pro­ traction can be used for long periods of time, or
► NURSING CARE
mote exercise or rest in an injured or diseased when a large amount of weight is required, per­
These key uvrds correspond with entries in the
RCN Nursing Bibliography. part of the body (2), and can also help in the haps to reduce a fractured femur.
relief of pressure. Hamilton Russell traction (Figs, la, lb), for
Downloaded from RCNi.com by ${individualUser.displayName} on Aug 28, 2016. For personal use only. No other uses without permission.
August 9A'olurne 9/Number 46/1995 Nursing Standard 25
Copyright © 2016 RCNi Ltd. All rights reserved.
 CLINICAL ORTHOPAEDICS
example, comes under the classification of bal­
Fig. 1a. Balanced skin traction - Hamilton Russell method. anced traction yet can be in the form of skin or
skeletal, depending upon the requirements.
Differences between fixed and balanced traction
There is, however, an essential distinction
between fixed traction and balanced traction.
Both use one direct pull against another, but bal­
anced traction relies upon the patients own body
weight to produce the necessary counter-traction.
5lbs Fixed traction, on the other hand, generates its
force between two fixed points (Fig. 2).
10lbs

5lbs Safe and secure system

In balanced traction (Figs, la, lb, 3-5), the degree
5lbs
of counter-traction can lie increased by further ele­
pillow
vating the foot of the bed in leg traction, or the
head of the lied in cervical traction. If this is per­
5lbs
formed then the traction weights need to be
increased accordingly. Balanced traction, in skin
or skeletal form, is by far the most commonly
used type today. Nurses need not be confused
Fig. 1b. Balanced skeletal traction - Hamilton Russell method. when suspension systems, frequently seen in con­
junction with a Thomas splint, are incorporated
in balanced traction. The weights and pulleys that
suspend the limb and splints form no part of the
traction itself, but serve simply to support the
limb and apparatus. An understanding of the
above principles is essential in the maintenance
of a safe and secure system (4).
Hamilton Russell traction Another example of
balanced traction that causes much confusion is
20lbs
the Hamilton Russell method (Figs, la, lb).
Here, one set of weights and apparatus applies
the necessary traction and supports the lower
limb. Stewart and Hallett (5) have described the
principle of the parallelogram of forces with a
pillow resultant pull in the line of the femoral shaft, but
this idea is sometimes difficult to grasp. To
10lbs
enable a greater understanding of the principles
of Hamilton Russell traction the comparison of
a barge on a canal can be used (Fig. 6).
On each of the canal banks ropes are placed
Fig. 2. Fixed skin traction.
from the front of the barge. This means the ropes
are at right angles to each other. If a person, on
each bank, pulls his or her rope using equal
strength and in the same line of the rope, the
result is that the barge will move up the middle
of the canal. This is Hamilton Russell traction.
To demonstrate the principle a transparent dia­
gram can be placed over the canal diagram (Fig.
7). In practice, however, the pull in this type of
traction (Figs, la, 1 b) is doubled, due to the par­
allel configuration at the foot of the apparatus,
although some pull is lost through pulley fric­
tion. This is just one of the many types of bal­
anced traction that are available (5-7).
Perkins traction Perkins traction (Fig. 3), a
variety of balanced traction seen in the treat­
ment of femoral shaft fractures, operates with­
out the need for external splintage. It is a recent
alternative to the Thomas splint (8) but a Had-
field or Perkins bed is required, as is the use of

26 Nursing Standard Augustfrom

Downloaded 9A'olumc 9/Number 96/1995
RCNi.com by ${individualUser.displayName}
on Aug 28, 2016. For personal use only. No other uses without permission.
Copyright © 2016 RCNi Ltd. All rights reserved.
 CLINICAL ORTHOPAEDICS
Simonis low friction swivels (5). associated problems of pressure in the groin area.
The advantages of this system have been Perkins traction is also versatile; weights do
demonstrated by Buxton (9) and include early not have to be evenly distributed on both sides,
active knee movement, an excellent range of thereby enabling the correction of any valgus or
movement, the promotion of bony union and, varus deformity. The cords, too, do not neces­
compared to studies using other methods of sarily need to be attached to the same extension
traction (10), fewer serious complications. By bar, thus correcting any internal or external rota­
dispensing with the Thomas splint, there are no tion of the limb.
Fig. 3. Balanced skeletal traction - Perkins method.
The bed and mattress have removable lower
halves. This enables traction to be maintained
while knee flexion exercises are performed. The
degree of flexion obtained by this method has
been shown to be greater than any amount
obtained using the traditional Thomas splint (9).
The use of Simonis swivels helps diminish the
amount of skeletal pin movement and, as a
result, the amount of overall pin site infection
and discharge (11). However, if bones are osteo­
porotic this adds to the problem of pin loosen­
ing. Another useful skeletal traction technique
is that of‘double denham pinning' (12, 13),

I whereby the traction load is distributed between

the two clamped parallel pins.
In the initial stages of nursing care following
application of Perkins traction, the pillow or
trough supporting the fracture site requires more
manual support, for example, to allow the
patient to use a bedpan. If extra support is not
Fig. 4. Balanced skin traction.
provided ‘sagging’ at this level can occur.
Tire aim in Perkins traction is not only for ear­
ly ambulation of the knee but also early appli­
cation of functional/cast bracing. This reduces
the length of time spent in hospital, giving bet­
ter results, both physically and psychologically
(14). It also decreases the risk of deep vein
thrombosis development through prolonged
limb immobility and bed rest (15).
Fixed traction As indicated earlier, fixed traction
is used less frequently than balanced traction. It
is traction between two fixed points and usual­
ly only seen in conjunction with a Thomas splint
(Fig. 2). The two fixed points are the ring of a
Thomas splint and the opposite end of the splint
(Fig. 2, inset). As previously stated, traction may
Fig. 5. Balanced skeletal traction.
be in the form of skin or skeletal and here it is
W//7Zi> exerted using an attachment of cord. This cord
is tied to the distal end of the Thomas splint and
traction is increased by means of twisting a
‘Spanish windlass’ (or wooden dowelling). The
result is that the fracture can be moved between
those two points to allow any deformity or dis­
placement to be corrected.

Risk of discomfort and sores

The problem, however, lies in the fact that the
greater the traction, the greater the pressure on
the fixed points. One of those points beneath the
ring of the Thomas splint is the ischial tuberos­
ity of the pelvis and, therefore, any increased
pressure in the groin increases the risk of dis­
comfort and pressure sores. To relieve this pres­
sure a separate cord is also tied to the distal end
Downloaded from RCNi.com by ${individualUser.displayName} on Aug 28, 2016. For personal use only. No other uses without permission.
August 9A’olume 9/Number 96/1995 Nursing Standard 27
Copyright © 2016 RCNi Ltd. All rights reserved.
 CLINICAL ORTHOPAEDICS
of the splint and a weight is attached to this cord. the actual fixed traction.
This weight is designed to relieve pressure in the There has been some confusion when this
groin and, theoretically, has no bearing on the traction is sometimes referred to as combined
fracture site. In practice, however, it does have fixed and balanced/sliding traction. Therefore, in
some added effect but the main effect is through the interests of simplicity and understanding, it
is better to see tractions within the two classifi­
Fig. 6. Using the analogy of a canal barge to demonstrate the cations of fixed and balanced and not a combi­
Hamilton Russell method. nation of these. What is important is to
equal pull ♦ understand the principles.
General advice Examples of inappropriate prac­
tices can be seen in orthopaedic wards today:
knots tied in the middle of traction cord; slings
.0® made from non-adhesive and adhesive felr (with
0®
the paper backing still attached); balanced trac­
tion without elevation for counter-traction; pul­
leys that are of the wrong type, or no pulleys
■ u_ where pulleys should be.
equal
pull
O®sQ,® Fighting complacency
These examples should preclude complacency in
x'O® nurses’ attitudes towards traction. Knots should
c®.0® never be seen in the middle of traction cord.
Makeshift slings should not be used as their fail­
ure could compromise the patient’s treatment
Fig. 7. Balanced skeletal traction - Hamilton Russell method - and recovery. Weight and cords should lie care­
merged with the barge analogy. fully adjusted at the outset and continually re­
evaluated, to ensure a free-running mechanism.

equal pull
k
- A ’double’ or ’triple’ pulley should not lie used
for a single cord. If a pulley is required, for exam­
ple, with Hamilton Russell traction, then use
one, and if a patient is nursed in balanced trac­
'' tion, then counter-traction (elevation) is required.
Nursing care of patients in traction should
respect and complement the principles of its
operation. There is an abundance of literature
1 ^____ /] that adequately covers the general nursing care
(1, 2,4, 6, 16, 17) and, more specifically, the care
2— - of pin sites (13, 18-21).
, - "' ' equal pull Conclusion Problems will continue as the use of

5 I traction continues to diminish. It is important

that these problems are recognised and high­
lighted in an effort to improve and maintain the
standard of care of patients in traction. It is to be
hoped that this discussion can be the first step
on the road to such improvement •

References 36-39. system for fragile bones. Injury. 1984. 18. Wallis S. An agenda to promote
1. Osborne LJ, DiGiacomo I. 7. Howard M, Corbo-Pelaia SA. 15, 280-281. self-care, nursing care of skeletal pin
Traction: a review with nursing Psychological after effects of halo 13. Nichol D. Preventing infection. sites. Professional Nurse. 1991. 6, 12,
diagnoses and interventions. traction. American Journal of Nursing. Nursing Times. 1993. 89, 13, 78-80. 715-719.
Orthopaedic Nursing. 1987. 6,4, 1982. 82, 12, 1839-1843. 14. Short J, Upadhyay S. Does simple 19- Rees M. Does nursing
13-18. 8. Perkins G. The Ruminations of an traction and functional bracing affect intervention affect the outcome of
2. Styrcula L. Traction basics, part Orthopaedic Surgeon. London, the outcome of a fractured femur as skeletal pin reaction in clients with
one. Orthopaedic Nursing. 1994. 13,2, Butterworth. 1970. compared with the Thomas splint skeletal traction and external fixation:
71-74. 9. Buxton RA. The use of Perkins’ method. Physiotherapy. 1984. 70, 9, a literature review. Orthopaedic Bare
3. Footncr A. Orthopaedic Nursing. traction in the treatment of femoral 350-354. Bones. 1993. Autumn, 20.
Second edition. London, Bailliere shaft fractures. Joumal of Bone and 15. Carroll P. Deep venous 20. Walton-Jones P. Effects of pin
Tindall. 1992. Joint Surgery. 1981. 63-B, 362. thrombosis: implications for care on pin reactions in adults with
4. Davis P. The principles of traction. 10. Anderson RL. Conservative orthopaedic nursing. Orthopaedic extremity fracture treated with
Nursing. 1989. 3, 34, 6. management of fractures of the Nursing. 1993. 12, 13, 33-41. skeletal traction and external fixation.
5. Stewart JDM, Hallett JP. Traction femur. Journal of Bone andJoint 16. Heywood Jones I. Making sense Orthopaedic Nursing. 1988. 7,4,
and Orthopaedic Appliances. Second Surgery. 1967. 49-A, 1371-1375. of...traction. Nursing Times. 1990. 86, 29-33.
edition. Churchill 11. Charnley J. ’The Closed Treatment 23, 39-41. 21. Walton-Jones P. Clinical
Livingstone. 1983. of Common Fractures. Edinburgh, 17. Taylor I. Ward Manual of standards in skeletal traction pin site
6. Smith C. Nursing the patient in Churchill Livingstone. 1972. Orthopaedic Traction. Melbourne, care. Orthopaedic Nursing. 1991. 10, 2,
traction. Nursing Times. 1984. 80, 16, 12. Smith D. An improved traction Churchill Livingstone. 1987. 12-16.

28 Nursing Downloaded
Standard Augustfrom RCNi.com
9/Volume 9/Number by ${individualUser.displayName} on Aug 28, 2016. For personal use only. No other uses without permission.
46/1995
Copyright © 2016 RCNi Ltd. All rights reserved.