Preventing pressure ulcers from paediatric femoral traction: use of an audit cycle to assess a new concise manual and a daily care chart

Abstract

Introduction

Femoral shaft fractures are common in children up to 14 years of age and traction is frequently used during their treatment. A lack of training and unfamiliarity of junior doctors and nursing staff with this treatment modality may lead to unfavourable skin complications, especially in the absence of regular monitoring. We introduced and audited a simple and reproducible way of monitoring these patients.

Methods

An initial audit was conducted of all children with femoral shaft fracture treated in skin traction. A new traction manual and daily care chart were introduced, and a re-audit was performed. A parallel survey regarding skin traction in children was conducted involving 33 hospitals in the United Kingdom.

Results

The initial audit showed three patients (23%) developed grade 2 pressure sores with a mean duration of traction of 8.5 days. A pressure sites check was documented in only 7.7%. A re-audit, after introduction of the traction manual and daily care chart showed a mean duration of traction of 8.4 days and only one patient (12.5%) developed a grade 1 sore. Pressure site monitoring improved significantly with 75% documentation. No daily care chart was used among the 33 centres in the survey and only 27% of centres had access to a manual in the ward.

Conclusions

Introduction of a single-page traction manual and a daily care chart into patient care notes to effectively monitor for pressure areas in children on skin traction helps reduce the incidence of serious skin complications.

Introduction

Femoral shaft fractures are among the most common diaphyseal fractures in children, with an estimated annual incidence of 25 per 100,000 per year for children aged 0–14 years.¹

Treatment options in children include the use of a Pavlik harness, a walking spica cast, a standard spica cast applied immediately or after a period of traction, elastic intramedullary nailing, submuscular plating, external fixation or trochanteric-entry intramedullary nailing.²

Treating femoral fracture in traction in adults and children is well established and several methods for the application of traction have been described over the years.^3–6 However, unlike in adults, skin traction for a prolonged period is still a viable method of treatment in children. Although internal fixation with titanium elastic nails remains the popular method of treatment in older children, prolonged traction is still used in children aged 5 years or less prior to application of a spica cast.⁷

With the decline in the use of skin traction as a method of treatment, current surgical trainees have become less familiar with the application of skin traction. One survey among UK trainees showed that only about 20% were confident in applying a Thomas splint.⁸ Although there is increased awareness about changing patient position to prevent pressure sores, as highlighted in National Institute for Health and Care Excellence (NICE) clinical guidance 179,⁹ there is no specific guidance on how to regularly monitor the skin of patients who are treated in skin traction.

Because knowledge of the technique of application and the pitfalls of poorly applied skin traction is not widespread among medical personnel, it could contribute to increased pressure related skin complications.

We hypothesise that a thorough understanding of the technique of application and proper assessment and skin care using easily accessible guidelines and a daily care chart could prevent traction-related skin complications.

Methods

This study involved three stages in an effort to prove our hypothesis:

• (i) an audit of patients with femoral fracture treated in traction and the incidence of pressure sores;
• (ii) the development of a concise manual and charts which could be filed in the patient notes showing how to apply femoral traction and monitor pressure areas;
• (iii) a re-audit after use of the new manual and daily care charts.

First stage: retrospective clinical audit of pressure sores caused specifically by traction

This audit was conducted to look for the incidence of pressure ulcers in patients with femoral fracture who were treated with skin traction between June and December 2015. Thirteen patients were included in our audit. All patients who had traction for less than 24 hours before surgical fixation or early spica cast application and were treated with casts for minimally displaced distal metaphyseal fractures were excluded. Hospital notes including the nursing records of these patients were reviewed and the data on daily monitoring of the patients for skin changes and neurovascular status, where available, were noted. However, these records were generic and were directed towards well-known sites at risk of pressure sores in any patient and not specifically directed towards areas under the skin traction or skin that was in contact with the traction apparatus.

Second stage: development of a manual on application of femoral traction and a daily care chart

Search for guidelines

We conducted a survey of 33 centres in the UK to obtain guidelines or protocols. Between September and November 2015, telephone interviews and email surveys were conducted with nurses, senior house officers and orthopaedic specialty registrars working at these hospitals. This included 16 major trauma centres and 17 district general hospitals. All hospitals in the sample were treating children with femoral fractures. Only 27% of the respondents said that they had access to a reference manual in the ward for application of femoral traction. None of the centres had any documented daily monitoring system specifically for those patients who were treated in traction.

Prior to formulation of the new manual and daily care chart, a detailed literature search was undertaken of the available medical databases including PubMed and Medline using the MeSH (Medical Subject Headings) words child, paediatric, pediatric, femur, fracture, traction, treatment and guidelines in different combinations. The lack of any published guidelines for application of traction and daily care of children with femoral shaft fractures, who are on traction, confirmed the need for a new simple, easily available and applicable manual and daily care chart.

After reviewing different skin traction application resources^11–13 we designed the Birmingham Paediatric Femoral Fracture Traction Manual and Daily Care Chart.

Manual

The reference manual for the application of skin traction, incorporates diagrams of fixed, sliding and balanced traction systems, and was concise enough to fit one side of A4 paper (Figure 1). The manual has details of equipment needed, diagrams depicting the traction system, as well as a post application checklist. The application of skin traction itself is explained by diagrams¹¹ and applies to both gallows and balanced traction settings.

Figure 1 .

Application of femoral fracture balanced traction illustration and steps

Daily care chart

We also formulated a daily care chart of similar size for specifically monitoring those on femoral traction (Figure 2). The chart is divided into checks for the patient as a whole, the limb in traction and the traction kit. It aims to identify and deal with problems such as pain, constipation, loss of position, loss of alignment, loss of effective traction, skin integrity and neurovascular compromise.

Figure 2 .

Femoral fracture traction daily care chart

Both documents were printed on a single sheet of paper, which had the manual on the front page and the daily care chart checklist on the reverse side. This double-sided A4-sized chart aimed to help both the junior surgical trainee and the nurses in both applying the traction and looking after patients in tractions. The chart could be reviewed during the daily rounds.

Following discussions with senior staff nurses in the orthopaedic ward, and all the consultants in our department, approval was given for a project to check the feasibility of using this new chart as part of patients’ care pathway notes. It was hoped that with standardised application of traction and monitoring, pressure ulcers on the skin could be prevented. The project was also approved by the audit department.

Third stage: re-audit after introduction of the manual and the daily care chart

The new manual and chart were included in the notes of patients who were on traction due to a femoral fracture. A re-audit was undertaken between February and August 2018. The charts were monitored in particular for the incidence of pressure ulcers.

Practice standards in our institution

Children arriving with a femoral shaft fracture in the accident and emergency department of our hospital, which is a level 1 trauma centre, were admitted and fitted with appropriate traction in a dedicated paediatric orthopaedic ward. Those under 2 years of age and those who weighed less than 12kg were fitted with gallows traction. Sliding traction through a Thomas splint was used for the others. The bed was tilted to bring the head end down and weights were attached to the end of the splint through a system of cords and pulleys. This sliding traction offloaded the pressure on the ischial tuberosity from the splint and the body weight provided the counter traction. Some patients arrived with back slabs and others with fixed traction in a modified Thomas splint and these were changed to the systems described above under the cover of analgesics and a femoral nerve block. Patients who needed traction for longer than 24 hours had a suspended balanced traction, through a system of cords, weights and pulleys connecting the Thomas splint to the overhead Balkan beams, to allow more freedom of movement in the injured lower limb.

The nursing notes at our hospital used the European Pressure Ulcer Advisory Panel classification of pressure ulcers to grade any skin lesions (Table 1).¹⁰

Table 1 .

Pressure ulcer classification

Grade 1	Non-blanchable erythema of intact skin	Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin
Grade 2	Blister	Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion or blister
Grade 3	Superficial ulcer	Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
Grade 4	Deep ulcer	Extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures with or without full-thickness skin loss

Results

Results of the initial audit

Thirteen patients ranging in age from 4 months to 15 years were treated with traction lasting more than 24 hours during the 7-month audit period. The mean duration of traction was 8.5 days (range: 2–15 days). Daily check of traction and specific traction-related skin condition was documented in only one patient (7.7%). Others had intermittent entries. Neurovascular status was documented daily in all 13 patients (100%). Generic (non-specific) skin condition was documented daily in 11 patients (85%). In this process, three grade 2 pressure sores related to traction (blister or partial thickness skin loss)¹⁰ were identified (one over Achilles tendon, one over medial femoral condyle and one in the groin); an incidence of 23%.

Results of re-audit after introduction of the manual and the daily care chart

After introduction of the new manual and the daily care chart, a clinical re-audit was conducted to investigate the incidence of pressure sores in patients with femoral fracture who were treated with skin traction between 1 February and 31 August 2018. Eight patients were included in our audit using the criteria applied for the first audit. Two were treated with gallows traction, and six were treated in a Thomas splint with balanced traction. Mean patient age was 2.7 years (range: 1–4 years). Mean duration of traction was 8.4 days (range: 1–14 days). The daily care chart was used in six patients (75%). One patient who was treated with gallows traction for 3 days followed by spica, and another patient who was treated with balanced traction for 2 days before application of hip spica did not have the daily care chart in their notes. However, neither of these patients developed a pressure sore. Neurovascular status was documented daily in all patients (100%). Only one patient developed a grade 1 pressure sore (12.5%). This patient was 3 years old. He was treated in a balanced traction for 11 days followed by application of hip spica. The daily care chart helped to detect the pressure ulcer (at Achilles tendon insertion) at an early stage. It was treated promptly with protective skin dressing and healed completely without complications.

Discussion

Traction is a well-known method for treating femoral fractures in children. In the past, traction was the preferred method of treatment in the majority of children but now it is mostly used as a method of initial stabilisation before definite treatment.^3,7,14–16 With more surgical options available and less use of traction as a definite method of treatment, there is less emphasis on training both nursing staff and doctors on how to set it up and what to look for day to day, as part of maintenance care. Orthopaedic trainees are losing the essential skills to apply skin traction and to look after patients who are treated in traction.⁸ This deskilling of practice may lead to less-favourable outcomes and more complications. This becomes more evident during out-of-hours setting up and application of traction, when more skilled and trained staff are not readily available.

Madhuri et al¹⁴ conducted a meta-analysis on the treatment of fracture femur in children and adolescents. Apart from malunion in the conservative group, serious adverse events were recorded in 40 per 1,000 for the conservatively managed patients. The reported complications included loss of reduction requiring surgery and superficial pin tract infection (skeletal traction pins). However, pressure ulcers on the skin related to traction were not recorded as a complication.¹⁴ It is also possible that in the absence of clear guidelines for daily care, pressure sores were missed or not recorded and highlighted to staff. Moreover, the failure to record and audit traction-related pressure sores may give a false impression that traction does not cause any complications.

Since the introduction of our paediatric femoral fracture traction manual and daily care chart, our staff are able to quickly screen, identify and deal with some of the most common problems related to traction. Common problems include knots being stuck in pulleys, weights being ineffective because they are in contact with the floor and the bed not being tilted. Documentation had improved significantly from 7.7% to 75% in our re-audit, following the introduction of the new document. The incidence of pressure sores had decreased from 23% to 12.5% and the grade of the pressure sore had also decreased, demonstrating earlier detection. The quality and detail of the documentation had also improved significantly. The simple and clear escalation steps mentioned in the chart help staff to efficiently deal with any complication at an early stage. This improves overall patient experience and outcomes. The A4 sheet can be added digitally to patient notes in hospitals that have digital records.

Study limitation

A limitation of this work is that the prospective observational study involved only a small number of patients.

Conclusions

The use of a specifically designed single-sheet document incorporating both a manual and a daily care chart, which can be filed in the patient notes, has shown a significant reduction in the incidence of pressure sores. However, this daily care chart is most useful when combined with continuing education and training of the staff involved in the care of these patients.

We recommend use of Birmingham Paediatric Femoral Fracture Traction Manual and Daily Care Chart for all paediatric patients with a femoral fracture, who are treated in traction for any length of time. It could be combined with a training session for junior doctors at the start of their paediatric orthopaedic placement to learn the techniques of application of skin traction and how to look after patients on traction. Alternatively, this information could be included in junior doctors’ online learning resources.