STRONG RECOMMENDATION Overall, there were two high quality (Endo 2013, Rosen 2001) and six moderate studies (Needoff 1993, Resch 1998, Resch 2005, Saygi 2010, Tosun 2018, Yip 2002) addressing preoperative traction. Since 2012, one high (Endo 2013) and one moderate quality study (Tosun 2018) investigated preoperative traction. Tosun (2018) found that a position splint resulted in significant difference in immobilization comfort score (30.1/100) and pain compared to traction, whereas Endo found no differences in pain. Tosun (2018) also found that preoperative traction resulted in more pre-operative complications (constipation, pressure ulcers, adhesive plaster allergy, urinary tract infections, pulmonary complications, bleeding in the fractured joint) than a position splint applied for 1 day preoperatively, whereas, Endo found no significant differences in complications between traction and no traction. These results are consistent with prior evidence and strengthen the body of evidence indicating that there are no benefits of preoperative traction. The recommendation reflects that there are some instances in which traction may be required (e.g., specific cases with peri-trochanteric fractures), however, in most cases pre-operative traction should not be used.
Benefits/Harms of Implementation
There are no known harms of implementing this recommendation. However, research is lacking regarding the potential harm of pre-operative traction as a form of tethering, which could trigger delirium, particularly in patients with dementia.
Outcome Importance
Complications, comfort, and pain are important outcomes related to hip fracture.
Cost Effectiveness/Resource Utilization
Not using preoperative traction may decrease cost/resource utilization compared to bedrest with positioning for comfort using pillows.
Acceptability
Use of alternatives to preoperative traction appeared to be acceptable to patients (Endo 2013, Tosun 2018).
Feasibility
Positioning with pillows is feasible.
Future Research
Future research regarding preoperative modalities to minimize patient pain should be continued to be investigated, including use of a position splint. Research should address possibility of delirium as a complication of pre-operative traction use.
- Endo, J., Yamaguchi, S., Saito, M., Itabashi, T., Kita, K., Koizumi, W., Kawaguchi, Y., Asaka, T., Saegusa, O. Efficacy of preoperative skin traction for hip fractures: a single-institution prospective randomized controlled trial of skin traction versus no traction. Journal of Orthopaedic Science 2013; 2: 250-5
- Needoff, M., Radford, P., Langstaff, R. Preoperative traction for hip fractures in the elderly: a clinical trial. Injury 1993; 5: 317-8
- Resch, S., Bjärnetoft, B., Thorngren, K. G. Preoperative skin traction or pillow nursing in hip fractures: a prospective, randomized study in 123 patients. Disability & Rehabilitation 2005; 18: 1191-5
- Resch, S., Thorngren, K. G. Preoperative traction for hip fracture: a randomized comparison between skin and skeletal traction in 78 patients. Acta Orthop Scand 1998; 3: 277-9
- Rosen, J. E., Chen, F. S., Hiebert, R., Koval, K. J. Efficacy of preoperative skin traction in hip fracture patients: a prospective, randomized study. Journal of Orthopaedic Trauma 2001; 2: 81-5
- Saygi, B., Ozkan, K., Eceviz, E., Tetik, C., Sen, C. Skin traction and placebo effect in the preoperative pain control of patients with collum and intertrochanteric femur fractures. Bull NYU Hosp Jt Dis 2010; 1: 15-7
- Tosun, B., Aslan, O., Tunay, S. Preoperative position splint versus skin traction in patients with hip fracture: An experimental study. International Journal of Orthopaedic and Trauma Nursing 2018; 0: 8-15
- Yip, D. K., Chan, C. F., Chiu, P. K., Wong, J. W., Kong, J. K. Why are we still using pre-operative skin traction for hip fractures?. International Orthopaedics 2002; 6: 361-4