What is the recommended protocol for applying skin traction to a patient?

Skin Traction Protocol

Skin traction should generally be avoided as routine practice for hip fractures in adults, as current evidence does not support its use for pain relief, fracture alignment, or complication prevention, and it carries significant risks of skin damage and pressure ulcers. 1, 2

When Skin Traction May Be Considered

If skin traction is applied despite limited evidence supporting its use, the following protocol should be followed:

Pre-Application Assessment

• Evaluate skin integrity carefully before application, as elderly patients with hip fractures are at high risk for skin complications 3
• Assess cardiovascular status and chronic illnesses, as these increase risk of complications 3
• Check for contraindications including compromised peripheral blood supply, severe coagulation dysfunction, or pre-existing skin damage 4
• Document baseline skin condition at the planned traction site 3

Application Technique

• Ensure the skin is clean and dry before applying any adhesive materials 5
• Apply traction to the affected limb using appropriate adhesive strapping or foam-backed materials 6
• Maintain proper alignment of the limb during application 6
• Use minimal weight (typically 2-5 pounds) sufficient only for comfort, not for fracture reduction 6
• Avoid excessive tension that could compromise skin perfusion 4

Monitoring and Complications

Critical warning: Deep skin slough can occur during or immediately after surgery in patients who have had skin traction applied, with full-thickness skin loss involving subcutaneous tissue necrosis. 3

• Inspect skin every 2-4 hours for signs of pressure damage, particularly at adhesive contact points 3, 2
• Monitor for erythema, blanching, or early breakdown of skin integrity 3
• Assess neurovascular status regularly to detect circulatory compromise 6
• Evaluate pain levels, noting that any benefit appears limited to 24-60 hours post-application 2
• Check for adhesive-related skin damage, which is a documented disadvantage of this technique 2

Nursing Care Considerations

• Hygiene care is more difficult with traction in place, requiring careful planning 1
• VTE prophylaxis must be maintained despite traction application 1
• Pressure ulcer prevention protocols should be intensified, as traction increases risk 1
• Pain management should not rely on traction alone, as evidence for pain relief is inconsistent 2

When to Remove Traction

• Remove immediately if skin breakdown occurs 3
• Discontinue if surgery is delayed beyond 48-60 hours, as any potential benefit diminishes 2
• Remove if patient experiences increased discomfort or complications 2

Important Caveats

Do not confuse skin traction with other techniques: Skin traction for fracture management is completely different from the Z-track technique used for intramuscular injections or the skin lift technique used for subcutaneous insulin injections. 7, 5 These are distinct procedures with different indications and should never be conflated.

The evidence strongly suggests that routine preoperative skin traction for hip fractures should be discouraged, as it does not improve outcomes and increases complications, particularly in elderly patients with cardiovascular disease. 1, 2 The main documented advantage (possible pain reduction between 24-60 hours) is outweighed by the significant risk of skin damage and pressure ulcers. 2