Authors of section

Authors

Theerachai Apivatthakakul, Jong-Keon Oh

Executive Editor

Michael Baumgaertner

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Skin traction

1. General considerations

Disadvantages of prolonged skin traction

  • Inadequate pain relief
  • Loosening
  • Constriction
  • Friction with skin necrosis

Traction configurations

Straight skin traction is achieved with weight over the end of the bed.

Straight skin traction with weight over the end of the bed for preliminary treatment of femoral fractures

If skin traction is likely to be used for more than 24 hours, greater patient comfort and better control of the fracture can be achieved using balanced skin traction (Hamilton-Russell), which allows for a slightly flexed knee and hip and elevation of the extremity.

This configuration of traction and leg support also can be adjusted to control femoral rotation by directing the upward support medially or laterally.

Balanced skin traction (Hamilton-Russell) of proximal femoral fractures with a mobile Balkan beam frame allowing for a slightly flexed knee and hip and elevation of the extremity

2. Application of skin-traction kit

This photograph shows a commercially available skin-traction kit.

Commercially available skin-traction kit for treatment of femoral fractures

A simple skin-traction kit can be made easily with:

  • Roll of nonelastic adhesive strapping (approximately 3 inches, 8 cm, wide)
  • Foam padding for the malleolar region
  • Wooden spacer block (suitably drilled for cord attachment)
Simple skin-traction kit for treatment of femoral fractures

Before applying the adhesive traction strip, paint the skin with friar’s balsam (tincture of benzoin) or equivalent.

Skin preparation with tincture of benzoin before application of skin-traction kit to the lower leg

Apply the strip to the lower leg from the level of the knee to the supramalleolar region.

Apply the strapping to the inner side of the leg, then unroll it a little further to allow placement of the spacer and the foam. Then apply it to the outer side of the leg.

It is important to ensure that the wooden spacer lies transversely, ie, parallel to the sole of the foot.

Application of skin-traction kit to the lower leg

To prevent the development of blisters, the skin traction needs to be applied without folds or creases in the adhesive material, and the covering bandage should be nonelastic.

Should a crease be inevitable due to the contour of the limb, the creased area should be lifted and partially slit transversally, and the edges overlapped.

Creased area of adhesive bandage should be lifted and partially slit transversally, and the edges overlapped.

Once the adhesive strip is satisfactorily in place, ensuring that the padded lower section overlies the malleoli, an inelastic bandage is carefully wrapped around the limb from just above the malleoli to the top of the strip.

Inelastic bandage wrapping around the limb from just above the malleoli to the top of the skin-traction strip

Apply the overlying bandages spirally, overlapping by half.

Inelastic bandage wrapping around the limb from just above the malleoli to the top of the skin-traction strip, applying overlying bandages spirally, overlapping by half

3. Positioning of the lower extremity

As the proximal fragment position can not be influenced, use traction to align the distal extremity to align the fracture. Typically, this requires mild flexion, abduction, and slight external rotation.

4. Straight skin traction

With straight skin traction, add padding under the patient’s calf to keep the heel from pressing on the bed beneath it.

Note: With any longitudinal traction, the surface of the bed should be tilted, eg, with blocks at the foot of the bed or in Trendelenburg, to counteract the tendency for the traction weights to pull the patient down the bed. With the tilted bed, the weight of the patient acts as countertraction.
Straight skin traction with weight over the end of the bed for preliminary treatment of femoral fractures

5. Balanced skin traction

To apply balanced skin traction, a dedicated orthopedic bed or a standard bed in combination with a mobile Balkan beam frame is needed.

Place a padded sling behind the slightly flexed knee and apply skin traction to the lower leg. The traction cord and pulley system are shown here.

The principle of the parallelogram of forces determines that the upward pull of the sling and the longitudinal pull of the skin traction create a resulting force in the line of the femur, as illustrated.

This configuration of traction and leg support can also be adjusted to control femoral rotation by moving the overhead bar medially (internal rotation) or laterally (external rotation).

Balanced skin traction (Hamilton-Russell) of proximal femoral fractures with a mobile Balkan beam frame allowing for a slightly flexed knee and hip and elevation of the extremity

A simpler alternative to this technique involves two separate systems:

  • A sling suspended from the overhead frame or supported with a rope and pulley counterweight to provide an upward force, which lifts the leg off the bed
  • Longitudinal (distal) traction applied with skin or skeletal technique

The resulting vector force, as illustrated, is oblique (the vector sum of the upward and distal forces applied by the two weights).

Balanced skin traction (Hamilton-Russell) of proximal femoral fractures with a mobile Balkan beam frame allowing for a slightly flexed knee and hip and elevation of the extremity with two separate pulley systems

6. Assessment of reduction

After traction has been set up, take an x-ray to check for acceptable fracture alignment.

Readjust as necessary.

7. Mobilization in bed

Assisted active mobilization and chest physiotherapy should start from the first day.

With the aid of a trapeze bar, as shown, patients can lift themself, and the traction system allows mobilization of the knee.

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