Skin traction is a type of traction that transmits the force via skin. Traction is a directional pull on the trunk or on an extremity.
The main goals of the use of skin traction are
- Control muscle spasms and pain resulting due to them
- Reduction of the fractures
- Prevention and correction of the deformity.
Skin traction is accomplished by attaching immobilizing devices either to the skin. The other type of traction is the skeletal traction where the pull is directly on the bone by inserting a pin or wire in the bone and using that for the pull.
Skeletal traction is discussed in a separate article.
Uses Skin Traction
Skin traction is used in the treatment of conditions for which only a small amount of pull is required. It is often used for
- Immobilization of extremities after internal fixation of fractures
- For the relief of muscle spasms in low back pain
- For immobilization of septic joints.
Elderly patients are not good candidates for skin attachment, because their skin is fragile and their circulation may already be impaired. Traction with skin attachment is mostly applied to the lower extremity, although it is occasionally indicated for traction to an upper extremity.
Traction and Countertraction Concept
Traction is often applied to part of the body to negate the effect of the forces causing the deformity. To be effective, the traction should act on the deformity and not the whole body. To counter the effect on the whole body we need another force that acts in opposite direction.
This is countertraction.
Let us understand this with an example. Suppose that there is a fracture of the shaft of the femur bone. Shaft femur fracture would produce a deformity because of the pull of the muscles and broken bone. To straighten it one requires to put a pulling force distal to the fracture site. Let us say one holds the foot and pulls the limb so as to correct the deformity. Some of the deformities would be corrected but the force of the pull would also pull the body towards the person who is pulling.
We need to cancel this force to avoid dragging the body. Let us say that another person is holding the shoulders of the person and is able to resist the drag exerted by pull. If he exerts a force equal to the pull, there would be two forces that would act on the body and the body would not move. At the same time, both the forces would also be exerted on the fracture, and therefore correction of the deformity results.
Try to pull a person’s hand. If there is no resistance when you would result in pulling a person toward you. However if a person holds him from the elbow, all your force is transferred to the forearm only. This is another example of traction and countertraction forces,
In orthopedic practice,countertraction may be obtained by altering the angle of the body-weight force in relation to the pull of traction, such as by elevating the foot of the bed with blocks to enable body weight to act as a counterforce.
Countertraction is an important aspect of traction treatment.
The absence of counteraction not only results in ineffective traction but also in the discomfort of the patient.
Types of Skin Traction
There are two kinds of skin tractions
- Adhesive
- Nonadhesive
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 15lb or 6.5 kgs but should be individualized.
The weights, typically weighing five to seven pounds, attach to the skin using tape, straps, or boots. They bring together the fractured bone or dislocated joint so that it may heal correctly.
Traction could be further either fixed type or sliding type. Fixed type traction is in between two fixed points. For example – Thomas splint.
Sliding-type traction uses the patient’s body weight as countertraction.
The types of skin traction can also be classified by the use or region it is used for. Some reactions are named after the inventor who invent them.
Following are the main types of skin traction
- Buck’s Traction
- Thomas Splint
- Hamilton Russel traction
- Bryant’s traction
- Head halter traction [for cervical spine]
Gardner-Wells or Crutchfield tongs are other cervical tractions but use pin placement in the bone and hence are skeletal traction.
A brief of different types of skin traction is given below.
Buck’s SkinTraction
A non-adhesive tape is applied on either side of the injured leg from the knee to just above the ankle. A slack is left from the sole of the foot to above the malleoli to allow foot movements of plantar flexion and dorsiflexion.
The pressure areas like the head of the fibula and malleoli and Achilles tendon are well padded.
A rope attached distally passed over the pulley on the foot edge of the bed and a desirable weight is attached.
However, weight more than 4-5 kgs should not be attached because that will produce more shear on the skin than it can tolerate.
Buck’s traction is commonly used in fractures of the neck femur, fractures of the hip, and soft tissue injury of the hip. Most of the uses of Buck’s traction are now for aligning the limb or controlling the pain in the preoperative period.
Hamilton-Russell Traction
It is a traction system that was initially used in femur fractures but can also be used in acetabular fractures. The set up requires a Balkan with crossbars. The system allows the use of forces in a manner that the resultant force is along the line of the fracture of the femur.
The skin traction is applied distal to the knee. However, it may be preferable to use skeletal traction with Hamilton Russel traction as more weight could be attached.
For skeletal traction, a proximal tibial skeletal pin needs to be inserted.
Bryant’s Traction or Gallow’s Traction
These are almost similar reactions that are used in small children [Age less than 18 months and weight less than 15 kgs in weight] for the treatment of femoral fractures
On a bed, the hips are flexed to 90 degrees and both legs are suspended vertically by skin traction on both the limbs with knees in slight flexion, from the beams above the cot.
The child’s buttocks are raised just off the mattress [should allow free passage of handundernesth].
The traction is removed after 3 weeks and hip spica is applied.
It is not used very commonly now.
Thomas Splint
This was developed by Hugh Owen Thomas for patients of hip tuberculosis and bears his name. It is an example of fixed traction.
It has saved many lives and limbs in the first world war because the use of this splint made transportation of injured patients easier.
It is a long leg splint with a ring that goes up to the groin and a hoop that extends beyond the foot.
It comes in different sizes of rings and lengths and an appropriate size needs to be used. It fixes itself groin with the limb resting on the padded bandages. Skin traction is applied to the affected leg and the traction cord is tied to the extended hoop to create fixed traction..
Head Halter Traction
It is cervical traction where a chin-type stirrup and a balancing pad on occiput are used to transmit force via the attached cord that is tethered weight.
The head end of the bed is raised to provide counter traction.
halter’s traction is used to provide pain relief in cervical spondylosis and for deformity correction in torticollis.
It is also used to provide temporary stabilization in the neck injuries.
Finger Trap Traction
This involves inserting the digits into finger traps and then suspending them onto a stand with the elbow flexed to 90 degrees. A countertraction is given by hanging the weight over the humerus.
It is rarely used now.
Dunlop Traction
A traction system for midshaft or supracondylar humerus fractures in children. Again, it is seldom used now because of better surgical methods available now.
Complications of Skin Traction
Complications often result due to tight wrapping or excessive weight leading to pressure areas. Bony prominences are especially prone.
Following complications are associated with skin traction
- Skin Injury
- Can vary from abrasion to partial-thickness skin loss.
- Nerve injury
- Peroneal nerve and ulnar nerve are most prone
- Pain, paresthesia, and loss of function are early signs
- Compartment Syndrome
- Severe complication
- Caused by a deprivation of blood supply within the compartment
- Contributing factors
- Direct soft tissue injury
- Vascular injury
- Fasciotomy may be indicated if not relieved
- Inadequate Immobilization
These complications demand careful selection of patients and regular inspection.
A rash, abrasion, or open wound is a contra¬indication to skin attachment.
Precautions for Use of Skin Traction
Following things should be taken into account while application of skin traction
- Clean skin thoroughly
- The elastic bandages must be wrapped evenly with gentle, equal pressure exerted
- The bandages should be removed and rewrapped daily and adjusted frequently.
- Inspect the skin daily for signs of skin breakdown.
- Adequately pad areas of bony or soft tissue prominences.
- Maximum weight should not exceed 5 kgs
- Maximum period in traction should be no more than 3 months.
- Daily monitoring of motor and sensory function in the limb
References
- Duperouzel W, Gray B, Santy-Tomlinson J.The principles of traction and the application of lower limb skin traction. Int J Orthop Trauma Nurs. 2018;29:54–57. [Link]
- Davis P, Barr L. Principles of traction.Journal of Orthopaedic Nursing. 1999;3:222–227.
