CASTS AND TRACTIONS

I. Introduction The management of musculoskeletal injuries and disorders frequently involve the use of cast and traction. Patient education is essential for optimal outcomes. Nursing care is very essential to maximize the effectiveness of these treatment modalities and to prevent potential complications associated with the management. Patient with Cast A. Definition of cast A cast is a rigid device that immobilizes the affected body part while allowing the other body parts to move. It also allows early mobility and reduces pain (Ignatavicius, 2006). B. Purpose Generally, cast permit mobilization of the patient while restricting movement of a body part. Specific purposes include: To immobilize a reduced fracture. To correct a deformity To apply uniform pressure to underlying soft tissue To support and stabilize weakened joints C. Types of cast 1. Arm cast a. Short arm cast CHARACTERISTIC: Extends from below the elbow to and including part of the hand. USE: Stable fractures of the wrist (metacarpals, carpals, distal radius). b. Long arm cast CHARACTERISTIC: Includes the upper arm to and including part of the hand. USE: unstable fractures of the wrist, distal humerus, radius or ulna. c. Hanging arm cast CHARACTERISTIC: Same as LAC but heavier with added loop at the forearm. USE: Fractures of the humerus that cannot be aligned by LAC (light traction is possible while the client is in bed or by an attached strap that extends around the neck.) d. Thumb spica cast CHARACTERISTIC: Similar to SAC but with the thumb casted in abduction. USE: Fractures of the thumb. e. Shoulder spica cast CHARACTERISTIC: the shoulder is casted in abduction with the elbow flexed. USE: unstable factures of the shoulder girdle or humerus; dislocation of the shoulder 2. Leg cast a. Short leg cast CHARACTERISTIC: From below the knee to the base of the toes. USE: Fractures of the ankle, metatarsals, or foot. b. Long leg cast CHARACTERISTIC: From the mid-upper thigh to the base of the toes. USE: Unstable fractures of the tibia, fibula or ankle. c. Walking cast

CHARACTERISTIC: a walking device in the bottom of SLC or LLC. USE: Same for SLC or LLC. d. Leg cylinder cast CHARACTERISTIC: Similar to SLC, but the ankle and the foot are not casted. USE: Stable fractures of the tibia, fibula, or knee. e. Long-leg cylinder cast CHARACTERISTIC: Similar to LLC but the ankle and the foot are not casted. USE: Stable fractures of the distal femur, proximal tibia or knee. 3. Body or spica cast a. Hip spica CHARACTERISTIC: Extends from below the nipple line down the affected leg (single), down the leg and half of the unaffected leg (11/2), or down both legs (double) USE: Dislocation of the hip; pelvic or hip injuries. b. Rissers cast CHARACTERISTIC: the body jacket extends from the shoulders to beyond the iliac crest and the hips, with a large opening over the anterior chest. USE: Scoliosis; thoracic spinal fractures. c. Halo cast CHARACTERISTIC: the body jacket contains a hollow brace. USE: Fractures of the cervical spine. Nursing care and management of patient with cast 1. Assessment a. Neurovascular assessment Assessment of the neurovascular status includes the following: Color, warmth, pulses distal to the cast, capillary refill. Movement of distal fingers to toes, awareness of light touch distal to the cast and changes in sensation. Encourage the patient to report tingling sensation. Pulse, color and warmth should be assessed by comparison with the unaffected extremity. Neurovascular assessment should be performed every 30 minutes for 4 hours after cast or splint application and then every 3-4 hours. b. Assessment of pain Careful assessment of pain should be completed regularly, and the client should be encouraged to verbalize the degree of pain. Inadequate analgesic effects should be reported promptly to the surgeon because an increased dosage or change in medication might be needed. Unrelieved pain my also be a classic symptom of compartment syndrome; therefore any complaint of pain should be given full attention. Be especially alert to complaints of progressive pain or pain out of proportion to the injury or treatment. c. Assessment of cast The skin around the cast edges should be observed for damage or swelling. Also assess the cast itself. Hot spots-areas that feel warmer-may indicate tissue necrosis or infection. Wet spots may indicate may indicate wound drainage or bleeding. An older cast may develop a sour smell because of perspiration or normal sloughing of outer skin layers. Musty, offensive odors may indicate tissue necrosis or infection. Notify physician because the cast might be needed to change.

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d. Assessment of complications COMPARTMENT SYNDROME Assessment for compartment syndrome should be done for the first week after injury. Traumatic injury and treatment such as closed reduction usually produces swelling which progresses for the 1st 12-24 hours after injury. The greatest swelling is likely to be experienced in the 1st 24-48 hours. Mild swelling is expected; however, moderate or severe swelling associated with pain or discoloration is abnormal. Excessive swelling constricts the enclosed tissue and may predispose for compartment syndrome. The affected extremity should be compared regularly with uninjured extremity and current findings should also be compared with baseline assessment data. Manifestations of compartment syndrome can begin as early as 30 minutes after ischemic injury which include pain or pain thatis out of proportion to the injury. 2. Nursing care specific to the type of cast a. Arm cast The patient whose arm is immobilized in a cast must adjust to the many routine tasks. The unaffected arm must assume all the upper extremity activities. The nurse, in consultation with an occupational therapist, suggests devices designed to aid one-handed activities. The patient may experience fatigue due to modified activities and weight of cast. Frequent rest periods are necessary. To control swelling, the immobilized arm is elevated. When the patient is lying down, the arm is elevated so that each joint is higher than the preceding proximal join (ex. Elbow higher than the shoulder, hand higher than the elbow.) A sling may be used when the patient ambulates. To prevent pressure on the cervical spinal nerves, the sling should support the distributed weight over a large area and not on the back of the neck. The nurse encourages the patient to remove the arm from the sling and elevate it frequently. Circulatory disturbances in the hand may become apparent with signs of cyanosis, swelling, and an inability to move the fingers. One serious effect of impaired circulation in the arm is Volkmanns Contracture, a specific type of compartment syndrome. Contracture of the fingers and wrist occurs as the result of obstructed arterial blood flow to the forearm and the hand. The patient is unable to extend the fingers, describes abnormal sensation (pain on passive stretch), and exhibits signs of diminished circulation in the hand. Permanent damage develos within a few hours if action is not taken. This serious complication can be prevented with nursing surveillance and proper care. Neurovascular checks must be done frequently. Compartment syndrome is managed in part by bivalving the cast to release the constricting cast and dressing. A fasciotomy may be necessary to improve vascular status (Smeltzer, 2008). b. Leg cast The application of a leg cast imposes a degree of immobility on the patient. The cast may be a short-leg cast, or a long leg cast. The fresh cast must be handled in a manner that will not denting or disruption of the cast.

The patients leg must be supported on pillows to heart level to control swelling, and ice packs should be prescribed over the fracture site for 1-2 days. The patient is taught to elevate the casted leg when seated. The patient should also assume a recumbent position several times in a day with the casted leg elevated to promote venous return and control swelling. The nurse assesses circulation by observing the color, temperature and capillary refill of the exposed toes. Nerve function is assessed by observing the patients ability to move the toes and by asking sensations in the foot. Numbness, tingling, and burning may be caused by peroneal nerve injury from pressure at the head of the fibula. When the cast is hard and dry the nurse and the physical therapist teach the patient how to transfer and ambulate safely with assistive devices such as walker or crutches. The gait to be used depends on the on whether the patient is permitted to bear weight. A cast boot, worn over the casted foot, provides broad, nonskid walking surface (Brunner, 2008). c. Body or spica cast Cast that encase the trunk (body cast) and portions of one or two extremities (spica cast) require special nursing strategies. Body cast are used o immobilize the spine. Hip spica cast are used for some femoral fractures and after some hip joint surgeries, and shoulder spica cast are used for some humeral neck fractures. Nursing responsibilities include preparing and positioning the patient, assisting with skin care and hygiene, and monitoring for cast syndrome, which occurs as a result o psychological and physiologic responses to confinement to a cast. Explaining the procedure helps reduce the patients apprehension about being encased in a large cast. The nurse reassures the patient that several people will provide care during the application, that support for the injured area will be adequate, and that care providers will be as gentle as possible. Medications for pain relief and relaxation administered before the procedure enable the patient to cooperate during the application of the cast. Cracking or denting of the cast is prevented by supporting the patient on a firm mattress and with flexible, water-proof pillows until the cast dries. The nurse positions the pillows next to each other, because spaces between pillows allow the damp cats to sag, become weak and possibly break. A pillow is not placed under the head and the shoulders of a patient in a body cast while the cast is drying because doing so causes pressure on the chest. The nurse turns the patient as a unit towards the uninjured side every 2 hours to relieve pressure and to allow the cast to dry. It is important to avoid twisting the patients body within the cats. Sufficient personnel (at least 3), are needed when the patient is turned so that the fresh cast can be adequately supported with the palms of the hands at vulnerable points (ex, joints) to prevent cracking. The nurse encourages the patient to assist in the repositioning, if not contraindicated, by the use of the trapeze or bed rail. A stabilizing abduction bar incorporated into the spica cast should never be used as a turning device. The nurse adjusts the pillows to provide support without creating areas of pressure. The nurse urns the patient to a prone position, twice daily if tolerated, o provide postural drainage of the bronchial tree and o relieve pressure on the back. A small pillow under the abdomen enhances comfort. The nurse can either place a pillow lengthwise under the

dorsa of the feet or allow the toes to hang over the edge of the bed to prevent the toes from being forced into the mattress. The nurse inspects the skin around the edges of the cast frequently for signs of irritation. The nurse can inspect for some of the skin under the cast by pulling the skin taut and using a flashlight. The skin can be bathed and massaged by reaching under the cast edges with the fingers. The perineal opening must be large enough for hygienic care. To protect the cats from soiling, the nurse can insert clean, dry, plastic sheeting under the dry cast and over the cast edge before elimination by the patient. Usually, fracture bedpans are easier to use than regular bedpans for patients with a hip spica cast. Patients immobilized in large cast may develop cast syndrome that may include psychological and physiologic manifestations. The psychological component is similar to that of a claustrophobic reaction. The patient exhibits an acute anxiety reaction characterized y behavioral changes and autonomic responses like increased RR, diaphoresis, dilated pupils, increased HR, elevated BP. The nurses need to identify the anxiety reaction and provide an environment to which the patient may feel secure. The physiologic cast syndrome responses are associated with immobility in a body cast. With decreased physical activity, gastrointestinal motility decreases, intestinal gases accumulate, intestinal pressure increases, and ileus may occur. The patient exhibits abdominal distension, abdominal discomfort and N/V. as with other instances of adynamic ileus, the patient is treated conservatively with decompression (NGT connected to suction) and IV fluid therapy until GI motility is restored. If the cast restricts the abdomen, the abdominal window must be enlarged. After the ileus resolves and the bowel sounds resumes, the patient gradually resumes an oral diet. Rarely, the distension places traction on the superior mesenteric artery, reducing the blood supply to the bowel. The bowel may become gangrenous, which requires surgical intervention. The nurse monitors the patient in a large body cast for potential cast syndrome, noting bowel sounds every 4-8 hours, and report distension, N/V to the physician. The patient with a body/spica cast is often cared for in the home. The nurse teaches the family members how to care for the patient, which includes providing hygienic, and skin care, ensuring proper positioning, preventing complications and recognizing symptoms that should be reported to the health care provider (Brunner, 2008). Guidelines for applying cast NURSING ACTIONS RATIONALE Support extremity or body part o be casted. Minimizes movement; maintains reduction and alignment; increases comfort. Position and maintain part to be casted in Facilitates casting; reduces incidence of position indicated by the physician during complications. casting procedure. Drape patient. Avoids undue exposure; protects other parts from contact with casting material. Wash and dry part to be casted. Reduces incidence of skin breakdown. Place knitted material over part to be Protects skin from casting material. casted Protects skin from pressure. Folds over edges of cast when finishing Apply in smooth nonconstrictive 3.

manner. Allow additional material. Wrap soft, nonwoven roll padding smoothly and evenly around part. Use additional padding around bony prominences to protect superficial nerves. Apply plaster or nonplaster material evenly on body part. Choose appropriated width bandage. Overlap preceding turn by half the width of the bandage Use continuous motion, maintaining constant contact with the body part. Use additional casting material at joints and at points of anticipated cast stress. Finish cast Smooth edges Trim and reshape with cast knif or cuter. Remove particles of casting materials from the skin. Support cast hardening Handle hardening cast with palms of the hands. Support cast on firm smooth surface. Do not rest cast on hard surfaces or on sharp edges. Avoid pressure on cast. Promote drying of cast. Leave cast uncovered and exposed to air. Turn patient every 2 hours supporting major joints. Fan may be used to increase airflow and speed drying. 4.

application, creates smooth, padded edge; protects skin from abrasion. Protects skin from pressure of cast. Protects skin at bony prominences. Protects superficial nerves. Creates smooth, solid, well-contoured cast. Facilitates smooth application. Creates smooth solid immobilizing cast. Shapes cast properly for adequate support. Strengthens cast.

Protects skin from abrasion. Allows full ROM of adjacent joints.

Prevents particles from loosening and sliding underneath the cast. Casting materials begin to harden in minutes. Maximum hardness of nonplaster cast occurs in minutes. Maximum hardness of nonplaster cast occurs with drying (24-72 hours). Avoids denting of cast and development of pressure areas. Facilitates drying.

Guidelines for removing cast NURSING ACTIONS RATIONALE Inform the patient about the procedure. Facilitates cooperation and reduces fear about the procedure. Reassure the patient that the electric saw or Reduces anxiety. cutter will not cut the skin. Wear eye protection. Protects eyes from flying cast particles.

Bivalve cast using a series of alternating pressures and linear movements of blade along the line to be cut. Cut padding with scissors. Support body part as it is removed from the cast. Gently wash and dry area that has been immobilized. Apply emollient lotion. Teach the patient to avoid scratching or rubbing the skin. Collaborate with physical therapist to teach patient o resume active use of body part gradually within the guidelines of prescribed treatment regimen. Teach patient to control swelling by elevating the extremity or using elastic bandage if prescribed. 5.

Cuts cast in half. Avoids burning sensation from prolonged contact of oscillating blade with padding. Releases all of the casting materials. Reduces stresses on body part that hes been immobilized. Removes dad skin that has accumulated during immobilization. Keep skin supple. Prevents skin breakdown. Prevents weakened part from excessive stress. Progressive exercise reduces stiffness, and restores muscle strength and function. Facilitates circulation and controls fluid pooling.

B. Purpose Reduce, realign, and promote healing of fractured bones. Decrease muscle spasms that may accompany fractures or follow surgical reduction. Prevent tissue damage trough immobilization. Prevent or treat deformities. Rest an inflamed, diseased or painful joint. Reduce and treat dislocations and subluxations. Prevent the development of contractures. Reduce muscle spasms associated with low back pain or cervical whiplash. Expand a joint space during arthroscopy or before major joint reconstruction.

Nursing Implications for client with cast

NURSING RESPONSIBILITIES Perform frequent neurovascular assessments Palpate the cast for hot spots that may indicate the presence of underlying infection. Report any drainage to physician promptly CLIENT AND FAMILY TEACHING Do not place ant objects in the cast. If the cast is made of plaster, keep it dry. If he cast is made up of fiber glass, dry it with blow drier on the cool setting if it becomes wet. Assess the injured extremity for coolness, changes in color, increased pain, increased swelling, and/or loss of sensation. Use a blow dryer on the cool setting to relieve itching by blowing cool air into the cast. If a sling is used, it should distribute the weight of the cast evenly around the neck. Dont roll the sling; this can impair circulation to the neck. If crutches are used, arrange for physical therapist to teach correct crutch walking. When the cast is removed at follow up appointments for skin assessments, an oscillating cast remover will be used. A guard prevents the cast remover from penetrating past the depth of the cast, so it will not cut the client. It I noisy and the client will feel vibration. The client may wish to wash and thoroughly dry the extremity before reapplication of cast.

C. Types of traction 1. Skin a. Bucks Used for many conditions affecting hip, femur, knee or back. It is generally used for surgery immobilization and stabilization of fractured hips or fractures of the femoral shaft. It can be unilateral or bilateral. It may also be used to correct knee and hip joint contractures. b. Russells Used for fractures of femur or hip. c. Bryants Used for fractures of the femur, fractures in small children, and stabilization of hip joint in children under 2 years or 30 lb in weight. d. Pelvic belt or girdle Used for sciatica, muscle spasms at the lower back, and minor fracture of the lower sine. e. Pelvic sling Used for pelvic fractures to provide compression for a separated pelvic girdle. 2. Circumferential: head halter Used for soft-tissue disorders and degenerative isk disease of the cervical spine. It is not commonly used for unstable fractures of the cervical spine. 3. Skeletal a. Overhead arm Commonly used for immobilization of fractures and dislocations of the upper arm or shoulder. b. Lateral arm Commonly used in immobilization of fractures and dislocations of the upper arm and shoulder. c. Balanced suspension Used for injury or fracture of the femoral shaft of the femur, acetabulum, hip, tibia, or any combination of these. D. Principles of effective traction Whenever traction is applied, countertraction must be used to achieve effective traction. Countertraction is the force acting in the opposite direction. Usually, the patients body weight and bed position adjustments supply the needed countertraction (Brunner, 2008).

III. Patient with traction A. Definition of traction Traction is the application of a pulling force to a part of the body to provide reduction, alignment, and rest (Brunner, 2008; Ignatavicius, 2006).

The following are additional principles to follow when caring for patient in traction: Traction must be continuous to be effective in reducing and immobilizing fractures. Skeletal traction is never interrupted. Weights are not removed unless intermittents traction is prescribed. Any factor that might reduce the effective pull or alter its resultant line of pull must be eliminated. o The patient must be in good body alignment in the center of the bed when traction is applied. o Ropes must not be obstructed. o Weights must not hang freely and not rest on the bed or floor. o Knots on the rope or the footplate must not touch the pulley of the foot of th bed. E. Nursing care and management of patient with traction 1. Assessment He nurse must consider the psychological and physiological impact of musculoskeletal problem, traction device, and immobility. Traction restricts moilty and independence. The equipment often looks threatening, and its application can be frightening. Confusion, disorientation, and behavioral problems mat develop I patients who are confined in a limited space for an extended time, therefore, the nurse must assess and monitor the patients anxiety level and psychological responses to traction. It is important to evaluate the body part to be placed in traction and its neurovascular status and compare it to the unaffected extremity. The nurse also assesses skin integrity along with body system functioning for baseline data. Ongoing assessment is indicated for the patient in traction. Immobility-related complications may include pressure ulcers, atelectasis, and pneumonia, and constipation, loss of appetite, urinary stasis, UTI, and venous thromboemboli formation. 2. Nursing care specific to the type of traction a. Skin Skin traction is used to control muscle spasms and to immobilize an area before surgery. The amount of weight applied must not exceed the tolerance of the skin. No more than 23.5 kg of traction can be used on an extremity. Pelvic traction is usually 4.5-9 g depending on the weight of the patient. Before traction is applied, the nurse inspects for abrasions and circulatory disturbances. The skin and the circulation must be in healthy condition to tolerate the traction. If traction is applied in the extremity, the extremity should be clean and dry before the foam boot or traction is applied. NURSING INTERVENTIONS Ensuring Effective Traction It is important to avoid wrinkling and slipping of the traction bandage and to maintain countertraction. Proper position must be maintained to keep the leg in a neutral position. To prevent bony fragments from moving against one another, the patient should not turn from side to side; however, the patient may shift position slightly with assistance. Monitoring and Managing Potential Complications

SKIN BREAKDOWN During initial assessment, the nurse identifies fragile or sensitive skin. The nurse also monitors the status of the skin in contact with the tape or foam to ensure that shearing forces are avoided. The nurse performs the following procedures: Removes the foam boots to inspect the skin, the ankle and the Achilles tendon three times a day. A second nurse is needed to support the extremity during the inspection and skin care. Palpates the area of the traction tapes daily to detect underlying tenderness. Provide back care at least every 2 hours to prevent ulcers. The patient must remain in supine position may be at risk for complication. NERVE DAMAGE Skin traction can place pressure on peripheral nerves. When traction is applied to the lower extremity, care must be taken to avoid pressure on the peripheral nerves at the point at which it passes around the neck of the fibula just below the knee. Pressure at this point can cause footdrop. The nurse questions the patient about sensation and asks the patient to kove the toes and foot. Dorsiflexion of the foot demonstrates function of the peroneal nerve. Weakness of dorsiflexion or foot movement or and inversion of the foot might indicate pressure on the common peroneal nerve. Plantar flexion demonstrates function of the tibial nerve. The following are important points to keep in mind when caring for a patient in traction: Regularly assess sensation and motion. Immediately investigate any complaint of a burning sensation or impaired motor function. Promptly report altered sensation or impaired motor function. CIRCULATORY IMPAIRMENT After skin traction is applied, the nurse assesses circulation of the foot or hand within 1530 minutes and then every 1-2 hours Circulatory assessment consists of the following: Peripheral pulses, color, papillary refill, and temperature of the fingers or toes. Unilateral calf tenderness, warmth, redness and swelling. The nurse also encourages the patient to perform active foot exercises every hour when awake. b. Skeletal Skeletal traction is applied directly to the bone. This method of traction is applied occasionally to treat fractures of the femur, the tibia, and the cervical spine. Skeletal traction frequently uses 7-12 kg to achieve therapeutic effect. NURSING INTERVENTIONS Maintaining Effective Traction When skeletal traction is used, the nurse checks the traction apparatus o see that the ropes are in the wheel grooves of the pulleys, that the ropes are not frayed, that the weights hang freely, and that the knots in the rope are tired securely.

Maintaining Positioning The nurse must maintain alignment of the patients body in traction as prescribed to promote an effective line of pull. The nurse positions the patients foot to avoid footdrop (plantar flexion), inward rotation (inversion). The patients may be supported in a neutral position by orthopedic devices. Preventing Skin Breakdown The patients elbows frequently become sore and nerve injury may occur if the patient repositions by pushing on the elbow. In addition, patients frequently push on the heel of the unaffected leg when they raise themselves. This digging of the heel into the matress may injure the tissues. Therefore the nurse should protect the elbows and heels and inspect them for pressure ulcers. Specific pressure points are assessed for redness and skin breakdown. Areas that are particularly vulnerable may include . if the patient cant do ischial tuberosity, popliteal space, Achilles tendon and heel. If the patient is not permitted to turn on one side or the other, the nurse must make an extra effort to provide back care and to keep the bed dry and free of crumbs and wrinkles. The patient can assist by holding the overhead trapeze and raising the hips off the bed. If the patient cant do this, the nurse can push down on the mattress with one hand to relieve pressure on the back and bony prominences and to provide for some shifting of weight. For change of bed linen, the patient raises the torso while the nurses on both sides of the bed roll down and replace the upper mattress sheet. Then, as the patient raises the buttocks off the mattress, the nurses slide the sheets under the buttocks. Finally, the nurses replace the lower section of the bed linens while the patient rests on the back. Sheets and blankets should be placed so as not to obstruct traction. Monitoring Neurovascular Status The nurse assesses the neurovascular status of the immobilized extremity at least every hour initially and then every 4 hours. The nurse instructs the patient to report any changes in sensation or movement immediately so that they can be promptly evaluated. The nurse encourages the patient to do active flexion-extension ankle exercises and isometric contraction of calf muscles 10 times an hour while awake to decrease venous stasis. In addition, elastic stockings, compression devices, and anticoagulant therapy may be prescribed to help prevent thrombus formation. Prompt recognition of a developing neurovascular problem is essential so that corrective measures can be instituted promptly. Providing Pin Site Care The wound at the pin site requires attention. The goal is to avoid infection and development of osteomyelitis. For the 1st 48 hours after insertion, the site is covered with a sterile absorbent non-stick dressing and rolled gauze. After this time, a loose cover dressing or no dressing is recommended. It is usually done 2-3 times a day. Frequency must be increased when there are signs of infection. Chlorhexidine solution is the most prescribed cleansing solution; however, water and saline are alternate sources. The nurse must inspect the pin sites for reaction and infection. Signs of infection might include redness, warmth, serous and slightly sanguineous drainage at the site. Signs subside after 72 hours. Minor infection may readily be treated with antibiotics whereas

infection that results from systemic manifestations may additionally warrant pin removal until infection resolves. When pins are mechanically stable, about 48-72 hours after, weekly pi site care is recommended. Crusting may occur at the pin site and should remain undisturbed unless there are concomitant signs of infection. Crusts provide a normal protective barrier and their removal may disturb healing tissue and make it more vulnerable to infection. The patient should be taught to perform pin site care prior to discharge from the hospital and should be provided with written follow-up instructions that include the signs and symptoms of infection. The patient is permitted to take a shower 5-10 days of pin insertion and is encouraged to leave the pins open to water flow. The sites are dried with a clean towel and left open to air. Promoting Exercise Patient exercises, within the therapeutic limits f traction, assists in maintaining muscle strength and one in promoting circulation. Active exercises include pulling up on the trapeze, flexing an extending the feet, and ROM and weight resistance exercises for noninvolved joints. Isometric exercises of the immobilized extremity are important for maintaining strength in major ambulatory muscles, without exercise, the patient will loose muscle mass and strength and rehabilitation will be greatly prolonged. 3. Nursing implications for patients with traction

In skeletal traction, never remove the weights. In skin traction, remove weights only when intermittent skin traction has been ordered to alleviate muscle spasm. For traction to be successful, a countertraction is necessary. In most instances, the countertraction is the clients weight. Therefore, dont wedge the clients foot or place it flush with the foot or place it flush with the foot-board in place. Maintain the line of pull: o Center the client on bed. o Ensure that weights hang feely and dont touch the floor. Ensure that nothing is lying on or obstructing the ropes. Dont allow the knots at the end of the rope to come into contact with the pulley. If a problem is detected, contact physician to assist in repositioning. The area of the fracture must be stabilized when the client is repositioned. In skin traction: o Frequently assess skin for evidence of pressure, shearing, or pending breakdown. o Protect pressure sites with padding and protective dressings as indicated. In skeletal traction: o Frequent skin assessment should include pin care per hospital policy. o Report signs of infection at the pin sites, such as redness, drainage, and increased tenderness, to the physician. o The client may require more frequent analgesic administration. Perform neurovascular assessment frequently. Assess for common complications of immobility including formation of pressure ulcers, formation of renal calculi, deep vein thrombosis, pneumonia, paralytic ileus and loss of appetite.

Instruct the client and the family about the type and purpose of traction.