The purpose of this guideline is to provide guidance about scoliosis traction on the Stryker Frame at Great Ormond Street Hospital (GOSH).
The Stryker Turning Frame is a traction bed used to treat patients following spinal surgery, trauma, or neurosurgery (Rationale 1 and 2). Diagnosis, clinical examination and x-rays determine the duration of traction. These guidelines should be read in conjunction with the traction guidelines.
Scoliosis traction - care of the child
Contact the spinal liaison sister (via the Orthopaedic Ward or switchboard) to arrange the use of the frame.
The spinal liaison sister will contact the biomedical engineers who maintain and store the Stryker frame in between use.
Gather the following equipment:
Preparation of the child and family
Explain the need/rationale for the use of the Stryker Turning Frame (Rationale 5, 6 and 7).
Demonstrate turning of the frame. The child may wish to practice in the frame (Rationale 5, 6 and 7).
The nurse may wish to practice in the frame, before demonstrating this to the child and family (Rationale 8).
Record a set of baseline Neurovascular observations pre-operatively, and before the traction is applied (Rationale 9 and 10).
Can the child move their toes and foot:
- Assess plantar flexion and inversion of foot (active/passive) (Rationale 11).
- Assess sensation of plantar surface of foot (web space under toes) (Rationale 12).
- Assess dorsiflexion of foot and extension of toes (active/passive) (Rationale 13).
- Assess sensation of dorsal surface of foot (web space between first toe (big toe) and second toe) (Rationale 14).
- Assess pain – ask the child to locate and describe it.
Can the child move their fingers and hand:
- Assess abduction of fourth and little finger (active/passive) (Rationale 15).
- Assess sensation of fat pad – tip of little finger (Rationale 16).
- Assess range of dorsiflexion of wrist (active/passive) and extension of fingers (Rationale 17).
- Assess sensation of web space between thumb and index finger (Rationale 18).
- Assess opposition of thumb and index finger (Rationale 19).
- Assess sensation of surface of index finger (Rationale 20).
- Assess pain – ask the child to locate and describe it.
- Peripheral pulses (in arm – brachial, radial, ulna and digital pulses; in leg – femoral, popliteal, posterior tibial, and dorsalis pedis).
- Capillary refill (normal is less than two seconds).
- Skin colour, skin temperature and skin turgor.
- Check for any numbness, tingling or reduced sensation in the extremity.
Always compare the affected limb, with the unaffected limb on each occasion and document.
Any abnormalities must be reported to the medical staff immediately.
Record any specific observations as specified in the postoperative notes.
Record neurovascular observations. The frequency of recording is determined by the child’s clinical condition and any specific postoperative instructions (Rationale 21 and 22).
Medical staff must be informed of any neuro vascular deterioration immediately (Rationale 23).
The child must be reviewed daily by the spinal or orthopaedic Registrar (Rationale 24 and 25).
The registrar must torque (tighten) the halo to the correct tension (inches/pound) using the adjustable torque screwdriver (Rationale 26).
The torque of the pins needs to be re-checked during the course of the treatment (Rationale 27).
The traction weight must be prescribed by the spinal surgeon and documented in the child’s’ notes (Rationale 28 and 29).
The spinal consultant determines the traction weight by X-rays, neurological function and the absence of pain (Rationale 30).
Ensure the weights hang freely and the knots are secure. (Rationale 31).
Cords should be checked daily for fraying (Rationale 32).
Ensure the stirrups are not putting pressure on the skin, superficial nerves, or bony prominences. Pay particular attention to the malleoli, the dorsum of the foot, head of fibula and the popliteal area (back of the knee) (Rationale 33).
It is important that baseline neurovascular observations are recorded and regular monitoring of neurovascular status is carried out (Davis P & Barr L 1999, Styrcula L 1994b) (Rationale 34).
Ensure both legs are receiving equal traction to ensure there is an equal pull on the spine. (Rationale 35 and 36).
The traction pull is maintained continuously throughout the duration of the traction period (Rationale 37).
Please refer to guidelines on traction care.
The child must be turned every two hours (Rationale 38).
Pressure area care is of the utmost importance (NICE 2001, RCN 2002).
Pin sites should be observed on each shift (Rationale 39).
If the pin sites are clean and dry they should be left untouched (Rationale 40).
If pins show signs of oozing or infection inform medical staff, swab and clean with normal saline. There is no reliable evidence to support any of the solutions currently used to clean/dress pinsites (RCN 2002).
The child is able to resume oral fluids and diet once bowel sounds are heard (Rationale 41).
The child’s intake and output should be recorded accurately and monitored (Rationale 42).
Offer regular small amounts of food and drink.
Encourage the child to eat and drink slowly (Rationale 43).
Encourage the child to find which position (either prone or supine) is most comfortable for them when eating or drinking (Rationale 44).
Consider the use of drinking straws, and non-spill cups (Rationale 45).
Liaise with the dietitian (Rationale 46).
A balanced diet will promote bone healing.
A fibre rich diet will help prevent constipation (BOA/RCN [SON]/AOT).
Ensure the child is well hydrated (Rationale 47).
Monitor urine output and record urinalysis.
Ensure prompt treatment of a urinary tract infection (Whaley LF & Wong DL 1994).
The child may have a catheter in situ if they have undergone surgery, in the initial post-operative period (Rationale 48 and 49).
If the child does not have a catheter, a slipper bedpan or urinary bottle are used for elimination (Rationale 50).
Provide age and developmental stage appropriate toys and activities (Rationale 51).
Involve the play therapist and the schoolteacher if applicable.
Encourage visits from family and friends.
Ensure the child has a carer present or access to and the ability to use a call bell (Rationale 52).
Washing and dressing is carried out whilst the child is on the frame and can be coordinated with the turning of the frame (Rationale 53).
Hair washing is carried out whilst the child is lying supine (Rationale 54).
A hair-washing tray is used (Rationale 55).
Comb/brush the hair gently (Rationale 56, 57, 58 and 59).
Clothing and underwear may need to be adapted (for example poppers or Velcro in place of the seams) (Rationale 60).
Postoperative care: patient safety
Read Turning Frame Operation Instructions before operating the Stryker Turning Frame (Stryker UK Ltd 2002a, Stryker Medical 2002b).
Ensure the manual pertains to the model of frame you have.
Be aware of the maximum allowable weight for the frame (Stryker UK Ltd 2002a, Stryker Medical 2002b) (Rationale 61 and 62).
Pay particular attention to the safety features of the frame as detailed in the Turning Frame Operation Instructions (for example, security pin, knurled nut) (Stryker UK Ltd 2002a, Stryker Medical 2002b) (Rationale 63).
The brakes should be on at all times, except when transporting the child (Stryker UK Ltd 2002a, Stryker Medical 2002b) (Rationale 61 and 62).
It is recommended that at least two people are required for the turning of the frame, one to remove the security pin and observe the child, the airway, any tubes/lines and one to do the turning (Rationale 62 and 63).
The turn should be completed in one smooth movement at a moderate speed (Rationale 64).
Record neurovascular observations (Rationale 65).
Removal of the traction and frame
Diagnosis, clinical examination and X-rays determine the duration of traction.
The halo and all traction pins are removed in theatre (Rationale 66).
The child is transported to theatre on the Stryker frame. In specific cases, the consultant may elect to have the child transferred onto a theatre trolley to transport the child from the ward to the operating theatre.
Rationale 1: Traction aids straightening of the spine.
Rationale 2: The Stryker Turning Frame is designed for total patient care and comfort, if traction and / or frequent turning of the child is required during extended recovery (Stryker UK Ltd 2002a and 2002b).
Rationale 3: Halo size is dependent on head circumference. Refer to the manufacturer's sizing chart – currently PMT Halo System Components Sizing Chart.
Rationale 4: The Halo sizing chart is kept on the Orthopaedic Ward.
Rationale 5: To prepare the child and family.
Rationale 6: To aid compliance with treatment.
Rationale 7: To obtain "consent."
Rationale 8: To familiarise themselves with the frame and to ensure staff competence.
Rationale 9: To determine a baseline of what is "normal" for the child.
Rationale 10: To allow comparison of neurovascular status pre and post application of traction and the Stryker frame.
Rationale 11: To determine tibial nerve function.
Rationale 12: To determine tibial nerve sensory distribution.
Rationale 13: To determine peroneal nerve function. Pressure on the peroneal nerve, where it passes the neck of the fibula, may cause foot drop. Weakness in dorsiflexion and inversion may indicate common peroneal nerve damage.
Rationale 14: To determine peroneal nerve sensory distribution.
Rationale 15: To determine ulnar nerve function.
Rationale 16: To determine ulnar nerve sensory distribution.
Rationale 17: To determine radial nerve function.
Rationale 18: To determine radial nerve sensory distribution
Rationale 19: To determine median nerve function
Rationale 20: To determine median nerve sensory distribution (BOA / RCN [SON] / AOT; Broughton 1997; Footner 1992)
Rationale 21: To monitor the child’s neuro vascular status.
Rationale 22: To compare pre and post application of traction and the Stryker frame.
Rationale 23: To identify any deterioration in neurovascular status promptly.
Rationale 24: Children in hospital are reviewed by medical staff at least once every 24 hours.
Rationale 25: To assess progress of the child and determine treatment plan.
Rationale 26: The Spinal Consultant determines the initial torque. This is based on the age and weight of the child.
Rationale 27: To prevent loosening of the pins which may lead to a reduction in traction (Fleming et al 2000).
Rationale 28: To ensure the correct traction weight is prescribed.
Rationale 29: To maintain accurate documentation.
Rationale 30: To ensure neurovascular status is not compromised (please refer to neurovascular observations).
Rationale 31: To maintain the efficiency of the traction system (Davis & Barr 1999; Styrcula 1994a).
Rationale 32: When the cord passes over the pulleys it is prone to fraying, which may reduce the efficiency of the traction system, or the cord may snap (Davis & Barr 1999).
Rationale 33: Traction can easily compromise the skin.
Rationale 34: To maintain accurate documentation and to ensure that potential problems are identified at an early stage.
Rationale 35: To maintain symmetry.
Rationale 36: To prevent pelvic obliquity, which may lead to spinal mal-alignment.
Rationale 37: To maintain the efficiency of the traction.
Rationale 38: To avoid the development of decubitus ulceration/pressure ulcers (RCN 2001).
Rationale 39: To identify problems at an early stage (RCN 2002).
Rationale 40: Tampering with pin sites excessively can lead to infection (Hill & Tucker 1997).
Rationale 41: The intestines may have been handled during surgery, which temporarily interrupts normal bowel function.
Rationale 42: The child may experience loss of appetite from being less active, or if they are constipated.
Rationale 43: To ensure intake is sufficient to promote healing.
Rationale 44: When the child is on the Stryker frame they are lying in one of two positions, prone or supine.
Rationale 45: It is difficult to eat and drink when lying prone or supine.
Rationale 46: A diet rich in protein and minerals (calcium, phosphates, sodium, potassium) and vitamins A and D are necessary for callus formation and muscle repair.
Rationale 47: Kidney stones and renal calculi, although uncommon in children, remain a potential risk for children in traction, particularly if combined with urinary stasis.
Rationale 48: For elimination of urine.
Rationale 49: For the accurate measurement of urine in order to record and maintain an accurate fluid balance.
Rationale 50: The child is nursed in one of two positions on the Stryker frame, either prone or supine.
Rationale 51: The child’s psychological, social, emotional, and spiritual needs must be addressed, along with their physical needs.
Rationale 52: To alert nursing staff.
Rationale 53: This allows the child to have a complete wash on one stage.
Rationale 54: This allows the child to lie flat on the frame.
Rationale 55: The water collects in the tray and can be drained off.
Rationale 56: To keep the hair tangle free.
Rationale 57: To prevent the hair becoming matted and forming a hard mass.
Rationale 58: To remove any blood that dries onto the hair.
Rationale 59: This allows assessment of the occipital area and reduces the risk of pressure ulcer development (BOA / RCN [SON] / AOT).
Rationale 60: So that this can be put on and removed easily with the traction in situ.
Rationale 61: To ensure the child's safety.
Rationale 62: To ensure the staff safety.
Rationale 63: To ensure the child's safety during turning.
Rationale 64: Children report feeling more secure when the frame is turned at a moderate speed in one smooth movement.
Rationale 65: To ensure integrity of the neurovascular system following turning of the frame and repositioning of the patient/traction (Davis & Barr 1999).
Rationale 66: To ensure the child’s comfort and safety and compliance with the procedure.
British Orthopaedic Association (BOA) (2006) Casting Techniques Course Compartment Syndrome Handout. London, British Orthopaedic Association, Royal College Of Nursing/Society Of Orthopaedic And Trauma Nursing Association Of Orthopaedic Technicians (BOA / RCN [SON] / AOT )
Broughton NS (1997) A Textbook of Paediatric Orthopaedics. London, WB Saunders
Davis P, Barr L (1999) Principles of Traction. Journal of Orthopaedic Nursing 1(3): 222-227.
Fleming BC, Krag MH, Huston DR, Sugihara S (2000) Pin loosening in a halo-vest orthosis: a biomechanical study. Spine 25 (11): 1325-31.
Footner A (1992) Orthopaedic Nursing. London, Balliere Tindall
Hill RA, Tucker SK (1997) Leg lengthening and bone transport in children. Br J Hosp Med 57 (8): 399-404.
National Institute for Clinical Excellence (NICE) (2001) Pressure Ulcer Risk Management and Prevention Inherited Clinical Guideline B. London, NICE
Royal College of Nursing (2002) A Traction Manual. London, Royal College of Nursing.
Royal College of Nursing (2001) Pressure Ulcer Risk Assessment and Prevention. London, Royal College of Nursing.
Stryker Medical (2002b) (2002) 965 Spinal SurgiBed Operations and Maintenance Manual. UK, Stryker Medical.
Stryker UK Ltd (2002a) (2002) Stryker Assembly, Operation Instructions - 124 Wedge Turning Frame and 965 Spinal SurgiBed. UK, Stryker Medical.
Styrcula L (1994) Traction basics: Part I. Orthop Nurs 13 (2): 71-4.
Styrcula L (1994) Traction basics: Part II. Traction equipment. Orthop Nurs 13 (3): 55-9.
Whaley LF and Wong DL (1994) Nursing Care of Infants and Children (5th edition). New York, CV Mosby
Document control information
Lucy Howlett, Spinal Clinical Nurse Specialist, Orthopaedics
Kathy Bridgwater, Practice Educator, Orthopaedics
Lucy Howlett, Spinal Clinical Nurse Specialist, Orthopaedics
Clinical Practice Committee
First introduced: 19 May 2004
Date approved: 7 June 2011
Review schedule: Two years
Next review: 7 June 2013
Document version: 2.0
Replaces version: 1.0