Preoperative position splint versus skin traction in patients with hip
fracture: An experimental study
Betul Tosun
a,*, Ozlem Aslan
b, Servet Tunay
caGulhane Training and Research Hospital, Department of Quality Management, Ankara, Turkey bUfuk University, School of Nursing, Department of Fundamentals of Nursing, Ankara, Turkey cOrtadogu Hospital, Department of Orthopedics and Traumatology, Ankara, Turkey
a r t i c l e i n f o
Article history: Received 22 June 2017 Accepted 27 July 2017 Keywords: Comfort Hip fracture Nursing care Pain Patient satisfactiona b s t r a c t
Aim: The aim of the study was to compare the effects of a preoperative position splint and skin traction on pain, comfort, complications, and satisfaction with the treatment and care for patients with hip fracture.
Method: This randomized trial was conducted with a total of 68 patients with hip fracture in a tertiary care hospital in Turkey. Preoperatively, a position splint was applied to the patients in the intervention group (n¼ 34) and skin traction was applied to patients (n ¼ 34) in the control group. Outcomes studied were pain, comfort, satisfaction and complications.
Results: Mann-Whitney U Test showed a significant difference between the position splint group and skin traction group regarding pain severity after the application (p< .05). A significant difference was demonstrated between the two groups concerning comfort levels after the application (p< .05). The position splint group was significantly more satisfied with the treatment and care than the control group in the later period after the application (p< .05). The number of preoperative complications in the po-sition splint group was significantly fewer than that of the skin traction group in the preoperative period (p< .05).
Conclusion: Preoperative position splint application in patients with hip fracture relieved pain and complications and increased comfort and satisfaction with treatment and care.
© 2017 Elsevier Ltd. All rights reserved.
Introduction
Hip fracture causes functional disability and negatively affects quality of life in older people and is an important health problem with high morbidity and mortality rates (McLaughlin et al., 2006). Worldwide, approximately 1.6 million hip fractures occur in older people each year, and it is estimated that the incidence will increase by 310% in men and by 240% in women (equivalent to 4.5e6.3 million hip fractures) by the year 2050 because of the aging global population (Maher et al., 2012; Endo et al., 2013). Most patients (24e75%) cannot return home because of the morbidity after hip fracture and must stay in hospital or transfer to nursing homes (McLaughlin et al., 2006; Maher et al., 2012). Lengthy hospitaliza-tion leads to intense use of medical treatment, nursing care,
surgical and rehabilitation services. The intense use of these ser-vices is a budgetary burden for individuals, families and institutions (Rapp et al., 2010). Pain and immobilization negatively affect the comfort of patients with hip fracture. Being confined to bed for a long time may lead to many complications including; pressure ul-cers, infections, thromboembolism, pulmonary problems, delirium, nerve damage and constipation (Beaupre et al., 2005; Foster, 2006; Maher et al., 2012, 2013; Draper and Scott, 1997). Nurses play a key role in maintaining the health of patients, alleviating pain, enhancing comfort, and avoiding complications using evidence-based nursing care interventions (Wunderlich, 2013; Maher et al., 2013; Harvey et al., 2013).
Literature review
Hip fractures are classified as intracapsular or extracapsular fractures (seeTable 1.). When the hip fracture occurs, movement at the fracture site can cause pain, make reduction difficult and in-crease complications such as avascular necrosis and nerve damage
* Corresponding author.
E-mail addresses:tosunbetul@gmail.com(B. Tosun),oozlem.aslan@gmail.com
(O. Aslan),stunay@yahoo.com(S. Tunay).
Contents lists available atScienceDirect
International Journal of Orthopaedic and Trauma Nursing
j o u r n a l h o m e p a g e : h t t p : / / w w w . j o u r n a l s . e l s e v i e r . c o m / i n t e r n a t i o n a l-j o u r n a l - o f - o r t h o p a e d i c - a n d - t r a u m a - n u r s i n g
https://doi.org/10.1016/j.ijotn.2017.07.002
(Handoll et al., 2011). Surgery must be performed as soon as possible to minimize the risk of complications (Koval and Cooley, 2005; Beaupre et al., 2005). However, surgery can be delayed due to other health problems that must be managed, especially in older patients, or due to medical system-related reasons. In these cases, patients are bedridden until the surgery in Turkey, as in several other countries (Lucki et al., 2012; Endo et al., 2013; Saygı et al., 2010; Resch et al., 2005). Pain, discomfort and possible long-term complications can be exacerbated due to this delay (Beaupre et al., 2005; Foster, 2006; Saygı et al., 2010). To prevent complica-tions, maintain comfort and reduce pain, the affected hip joint must be immobilized in a proper position, and suitable treatment and nursing care should be delivered (Resch et al., 2005; Koval and Cooley, 2005; Maher et al., 2012).
Skin traction is still routinely used to immobilize the hip during the preoperative period in many countries, including Turkey (Yip et al., 2002; Endo et al., 2013; Saygı et al., 2010; Irajpour et al., 2012). There are studies comparing skin traction and various immobilization methods such as splints and pillows (Resch et al., 2005; Saygı et al., 2010; Irajpour et al., 2012; Endo et al., 2013). In many studies no significant difference in pain severity and comfort has been found (Rosen et al., 2001; Resch et al., 2005; Irajpour et al., 2012; Endo et al., 2013) and the complications are more frequent in skin traction groups (Saygı et al., 2010; Endo et al., 2013). Many undesired effects of skin traction have been reported including; skin damage, pressure ulcers, ischemia, nerve injury, allergic re-actions, discomfort and dependency (Foster, 2006; Handoll et al., 2011; Endo et al., 2013).
Position splints, which maintain the limb in the correct anatomical position, can used for immobilization (Irajpour et al., 2012). This splint was designed for the foot but it also prevents rotation of the hip and thigh. After application, the position splint may be detached easily and quickly if required (Demir, 2011; Wunderlich, 2013). Position splint is an alternative method of maintaining immobilization and reducing pain and can make the waiting period more comfortable (Irajpour et al., 2012). The posi-tion splint was used in an observaposi-tional study of patients with hip fracture to achieve immobilization of the affected hip as part of conservative treatment (Dash et al., 2015). In one case report, the splint was used for a patient with a lesser trochanter fracture and contralateral undisplaced inferior pubic rami fracture for six weeks to provide pain relief and enhance comfort (Singh et al., 2015). In another study of patients with femoral shaft, acetabular and un-stable pelvic fractures, the effects of long-leg splinting and skeletal traction for preoperative fracture stabilization were compared and it was shown that the skeletal traction group patients experienced less pain and better function of the knee (Bumpass et al., 2015).
Systematic reviews of randomized controlled trials comparing methods of mobilization (skin traction, pillows, bandages with/ without weight) for patients with hip fracture discuss multiple limitations in research studies, particularly those resulting from inadequate allocation concealment and incomplete outcome assessment (Mak et al., 2010; Handoll et al., 2011). One review indicated a lack of benefit of preoperative skin traction for hip fractures (Handoll et al., 2011). Despite this lack of provable benefit,
in developing countries skin traction continues to be widely used as a routine treatment (Endo et al., 2013). Additionally, there has been no evidence concerning the effect of the position splint in patients with hip fractures before surgery.
Method Aim
There were two main motives for our study: a) the need for an updated, well-designed, prospective, randomized controlled study to relieve pain and; b) the need to prevent complications and in-crease comfort and‘satisfaction with treatment and care’ (STC) in patients with hip fracture and the need for evidence to change routine clinical practice. We aimed to compare the effects of pre-operative position splint and skin traction on pain, comfort, com-plications, and STC in patients with hip fracture. The hypotheses of this study were; 1) Position splints would relieve the pain and complications in patients with hip fracture in the preoperative period and; 2) Position splints would increase comfort and STC in patients with hip fracture in the preoperative period.
Study design
The study (clinical trials registration number: NCT02287571) was a prospective randomized trial.
Participants
The study population consisted of patients with hip fracture who were referred to the Orthopedic and Traumatology Unit in a Training and Research Hospital in Ankara, Turkey between March 2013 and April 2014. The inclusion criteria were; being an inpatient with hip fracture planned for surgery, being 50 years or older, being able to speak and write in Turkish, not having any communication barriers due to cognitive problems (dementia or delirium), not having con-servative treatment or an old fracture, not having any intervention prior to the research nurses' assessment and volunteering to participate in the study. In routine practice, skin traction is used for proximal femur fractures also known as‘hip fracture’. A total of 89 hip fracture patients were hospitalized during the study period. Fifteen patients were not included in the sample; n¼ 2 patients were less than 50 years old, n¼ 1 patient was not able to speak Turkish, n¼ 7 patients were not assessed and randomized by the researcher before the application or patients came to the orthopedic and trau-matology clinic with skin traction, n¼ 2 patients had dementia, n ¼ 1 patient's hip fracture occurred 6 months ago, n¼ 3 patients were allocated to conservative treatment and discharged from hospital.
Seventy-four patients who met the eligibility criteria were randomized. In the skin traction group (n¼ 38), three patients died before surgery, and one patient developed delirium. Thus, 34 pa-tients completed the study in the control group. In the position splint group (n¼ 36), one patient died before surgery, and one patient developed delirium. Thus, 34 patientsfinished the study in the intervention group. (Fig. 1).
Table 1
Proximal Femur Fractures classification according anatomical position. (Aksu and Isiklar, 2008).
Hip Fracture Type Hip Fracture Anatomical Position _Intracapsular
Hip Fracture
Femoral head fracture This fracture affects the ball section of the femur.
Femoral neck fracture This type of fracture occurs in the femur in the 1 or 2 inches distal to the femoral head. Extracapsular Hip
Fractures
Intertrochanteric fracture in the proximal femur
An intertrochanteric hip fracture occurs between trochanters.
Subtrochanteric fracture A Subtrochanteric hip fracture occurs in the area 1 or 2 inches distal to the femoral trochanters.
Intervention
All patients who were admitted to the orthopedic and trauma-tology unit with hip fracture were met by the research nurse within thefirst hour, and invited to participate in the research. After the eligibility criteria were assessed, the initial assessments were completed, and the participants were randomized into two groups (Fig. 1). A position splint was applied to the intervention group patients by the research nurse under the supervision of an ortho-pedic surgeon to achieve a neutral position and to provide a barrier for the bed linen with soft padding and enough space at the heel. A removable‘T’ band was placed on the base of the position splint to prevent rotation. Three different sizes of position splint were applied depending on the patients' shoe size. No weight was used in this group. Routine care was given to the control group. Skin traction was applied to the control group by the research nurse under the supervision of an orthopedic surgeon. The affected limb was elevated by a clinic nurse and the research nurse applied the traction strapping kit, consisting of a rigid sole plate and two ad-hesive strips, one on each side of the leg, and an elastic bandage was applied. A cord was attached to the sole plate at one end and to the weight at the other and was run through the pulley over the end of the bed. For the skin traction weight (min: 2.5 kg, max: 4.5 kg) up to 5e10% of the patient's weight was used (Murray, 2010; Demir, 2011).
Pneumatic beds were used to prevent pressure ulcers in patients in both groups as a routine procedure. The analgesic procedure was the same in both groups. After admission, Tramadol HCL 1 mg/kg was given intramuscularly, and every 8 h until the end of thefirst 24 h of hospitalization; then diclofenac sodium 3 75 mg was prescribed by physicians as needed on the following days. Anal-gesics administered were recorded.
Sample size
Sample size was calculated under supervision of a biostatistician using the“DSS Research Tool Kit Sample Size Calculator Program”. Based on the literature and clinical experience with hip fractures, a sample size of 34 patients with hip fracture in both groups (total 68 patients with hip fracture) was calculated to be adequate. For a 10 cm Visual Analog Scale, standard deviation was estimated to be 1.5 cm (Handoll et al., 2011; Irajpour et al., 2012), and the difference in the severity of pain between groups was estimated to be 0.6 cm (Saygı et al., 2010; Handoll et al., 2011). A confidence interval of 0.95% was selected for the study with a power of 0.80%.
Randomization
Participants who met the inclusion criteria were randomly allocated to either the skin traction group or the position splint group using the block randomization method in which the number of patients and probabilities are equal in the two blocks (Kanık et al., 2011).
Data collection
Before randomization and application, data on patient charac-teristics were collected and initial assessments for pain, comfort and risk of pressure ulcer were performed using the Visual Analog Scale (VAS) and Braden Scale. After application, the research nurse assessed pain and comfort using the VAS at three time points at 15 minutes, at 1 h, and at 2 h, which were all considered as the acute period.
Daily assessments were performed for pain and STC using the VAS, and comfort using the Immobilization Comfort Questionnaire
(ICQ) on the following morning and until the operation, which were considered to be in the late period. In the late period, pain severity was measured at three time points (at 08:00, at 12:00, and at 17:00) every day. Comfort and satisfaction were assessed once a day at 17:00. In the late period, patients were followed up for seven days. Pressure ulcers and other preoperative complications (urinary tract infections, pulmonary complications, adhesive plaster allergy, bleeding in the fractured joint and constipations) were assessed on a daily basis, at 17:00, until the operation. The data on allergic re-actions, changes in skin color, edema, and pressure ulcers were collected using the Skin Assessment Form. Clinical records, including the laboratory test results, were obtained from the pa-tients’ files to determine the complications.
Measures
The Pain Intensity, Comfort and Patient Satisfaction Visual Analogue Scale (VAS) was used to measure the intensity of pain, comfort and patient satisfaction with care. The VAS is a valid and reliable scale, which is widely used worldwide (Kersten et al., 2012). VAS is a measurement instrument used to measure a char-acteristic or attitude ranging across a continuum of values that cannot easily be directly measured (Kersten et al., 2012; Gould et al., 2001). The ‘two-edge’ definition (no pain/comfort, high level pain/comfort) is written on a 10 cm line. The patients were asked to mark their status at the appropriate point on the line. The point that the patients marked on the VAS represented their quantitative pain severity. The meanings of the pain scores are; mild pain is less than 3.4 cm, moderate pain is 3.5cme7.4 cm, and severe pain is greater than 7.5 cm (Boonstra et al., 2014). The Braden Scale (Bergstrom et al., 1987) was used to assess a patient's risk of developing a pressure ulcer. The total score, which is calculated by the sum of the scores of 6 sub-dimensions, is between 6 and 23. According to the total score, there is no risk if it is more than 18, low risk if it is 15e17, moderate risk if it is 13e14, and high risk if it is 12 or less. In patients who are 75 years or older, there is low risk if the total score is 15e18. The Braden Scale was used to determine the pressure ulcer risk before position splint or skin traction applica-tion in thefirst 24 h after admission.
Immobilization comfort
The Immobilization Comfort Questionnaire (ICQ) was used to assess the comfort level of patients during the immobilization period. The ICQ was adapted from Kolcaba's General Comfort Questionnaire. A validity and reliability study was performed (Hogan-Miller et al., 1995) in immobilized patients after coronary angiography. The validity and reliability study of the Turkish version of the ICQ was performed byTosun et al. (2015). The ICQ is a Likert-type tool that provides a score between 1 and 6 for each item (from“strongly disagree” to “strongly agree”). There are items that have negative meanings that are coded inversely. The scores from all items are summed, and a total score is obtained for the entire questionnaire. The total score ranges between 20 and 120. High scores indicate a high degree of comfort. The Cronbach's alpha coefficient was 0.89 in this study.
The skin assessment
The Skin Assessment Form, with drawings of the front and back of the body, was developed by the researcher, based on the litera-ture, to record anyfindings concerning the skin, including pressure ulcers, allergies, changes in skin color and edema (Resch et al., 2005; Saygı et al., 2010; Handoll et al., 2011; Endo et al., 2013). Data on any alterations in the skin, region or grade of ulcer were
collected. Grading was classified according to the European Pres-sure Ulcer Advisory Panel (EPUAP) and the American National Pressure Ulcer Advisory Panel (NPUAP) guidelines. The grades are; Unclassified Grade, Grade I, Grade II, Grade III, and Grade IV (NPUAP e EPUAP, 2009).
Ethical considerations
The study was approved by the Clinical Research Ethics Board at an authorized hospital affiliated with the Turkish Ministry of Health. (Ethical Committee Approval Number: B.10.4.ISM.4.06.68.49/242). The study (clinical trials registration number: NCT02287571) was a prospective randomized trial. Written informed consent was obtained from each patient who met the inclusion criteria to participate in the study. The research conforms to the provisions of the Declaration of Helsinki in 1995 patients were informed that participating in this study was on a voluntary basis and that they were free to leave the study at any time.
Data analysis
SPSS for Windows Version 15.0 was used to analyze the data. The Kolmogorov-Smirnov test was used to determine normality. Descriptive statistics were used to describe patient characteristics. Pearson Chi-Square test, Mann-Whitney U test, and Student's t-test were used to analyze the differences between groups concerning the patient characteristics. The Mann- Whitney U test was used to explore the differences between groups concerning pain, comfort scores, STC scores, operation duration, the mean number of daily preoperative analgesic doses, and total length of hospitalization. The Pearson Chi-Square test was employed to analyze the differ-ences between groups regarding preoperative complications. As the significance level (p < .05) was accepted.
Results Study sample
Of those enrolled in the study, 73.5% of the patients had inter-trochanteric and subinter-trochanteric fractures, while 26.5% had femoral neck fractures and there were no femoral head fractures. The characteristics of the participants (n¼ 68) are shown inTable 2. At the beginning of the study, the characteristics of the participants in the two groups were similar in terms of gender (p¼ .808), marital status (p¼ .223), education (p ¼ .779), chronic disease presence (p¼ .642), antithrombotic medicine use (p ¼ .625), pres-sure ulcer risk (p¼ .272), age (p ¼ .077), body mass index (p¼ .750), mean operation duration (p ¼ .780), mean time passed since admission to hospital (p¼ .775), mean length of preoperative hospitalization (p¼ .731), mean daily analgesic dose (p ¼ .251), and mean total hospitalization duration (p¼ .222). Additionally, there was no significant difference between the groups regarding the mean VAS pain scores (p¼ .663) and VAS comfort scores (p ¼ .823) before application of the splint or traction (Table 3andFig. 2). Pain, comfort and STC scores using the VAS
During the acute period after application, the mean VAS pain scores of the skin traction group were significantly higher than those of the skin traction group (p¼ .001 at 15 min.; p < .001 at 1 h, and p< .001 at 2 h). During the late period, the mean VAS pain scores of the skin traction group were significantly higher than those of the position splint group for three days after admission and on the 5th day (p< .001 on the 1st day; p ¼ .001 on the 2nd day;
p¼ .012 on the 3rd day; p ¼ .008 on the 5th day). No significant difference was found between the groups regarding the mean VAS pain scores on the 4th, 6th and 7th days (respectively, p¼ .069; p¼ .926; p ¼ .450) (Fig. 2).
The mean VAS comfort score of the position splint group was significantly higher than that of the skin traction group (p ¼ .001 at 15 min; p< .001 at 1 h; p < .001 at 2 h).
The mean STC scores of the position splint group were signi fi-cantly higher than those of the skin traction group in the late period (p< .001 on the first day; p < .001 on the 2nd day; p ¼ .001 on the 3rd day; p¼ .015 on the 4th day; p ¼ .012 on the 6th day; p ¼ .053 on the 7th day). No significant difference was found between the groups on the 5th day (p¼ .260) (Fig. 3).
Immobilization comfort scores using the ICQ in the late period The mean ICQ scores of the position splint patients were significantly higher than those of the skin traction patients for seven days after application (p< .001 on the 1st day; p < .001 on the 2nd day; p< .001 on the 3rd day; p ¼ .015 on the 4th day; p ¼ .007 on the 5th day; p¼ .029 on the 6th day; p ¼ .027 on the 7th day) (Table 3).
Preoperative complications
Preoperative complications occurred in 32.4% (n¼ 11) of the skin traction patients and 8.8% (n¼ 3) of the position splint pa-tients. There were significantly more complications in the skin traction group than in the position splint group (p¼ .016). The most frequent complications were constipation (n¼ 4 in the skin trac-tion group, n¼ 3 in the position splint group), pressure ulcers (n¼ 6 in the skin traction group, n ¼ 1 in the position splint group) and adhesive plaster allergy (n¼ 4 in the skin traction group). Additional preoperative complications included pulmonary com-plications (n¼ 2 in the skin traction group, n ¼ 2 in the position splint group), urinary tract infections (n¼ 2 in the skin traction group, n¼ 1 in the position splint group) and bleeding in the fractured joint (n¼ 1 in the skin traction group). As a frequent preoperative complication in the entire sample,“Grade II” pressure ulcers were observed on the toes of two patients and on the coccyx of two patients, and“Grade I” pressure ulcers were observed on the coccyx of two patients in the skin traction group. A“Grade II” pressure ulcer was reported on the coccyx of one of the position splint patients.
Discussion
In contrast to the position splint, the legs can be moved frequently during the skin traction application procedure, and the procedure of skin traction application takes more time, which in-creases pain and makes it a relatively difficult and disturbing practice for patients (Rosen et al., 2001; Brink et al., 2005; Endo et al., 2013). In our study, the position splint decreased the pain more in patients with hip fracture in the acute period and less se-vere pain was measured in the late period in the position splint group. However, in the late period, pain severity in both groups was low and was not of clinical importance, suggesting that the position splint was successful in the acute period. Similar to our results, one study reports that, on thefirst day after immobilization, the pain severity of the skin traction group was significantly higher than that of the group in which a pillow was used and more patients found skin traction a painful procedure (Rosen et al., 2001). This difference may be a result of more successful stabilization with the position splint which provides a painless and more comfortable position. In our study, position splint patients were more
comfortable in the acute period. No study has directly focused on the comfort of the patient with hip fracture, but a few studies have made an implicit claim. One study supports our result that a special pillow designed to provide 30 degrees offlexion and mild external rotation of the hip was more comfortable for patients with hip fracture compared to the skin traction and ordinary pillow (Resch et al., 2005). Also, ICQ results showed that the position splint group was more comfortable during the late period. The lower
comfort levels of skin traction patients may have occurred because patients could not easily move in bed. It is suggested that skin traction can cause fear and anxiety, make patients feel dependent on others, and cause pain. There is no study measuring the comfort of patients with hip fracture using the ICQ with which to compare our findings. Measuring the satisfaction level of patients is very important for improving service quality and factors in the level of satisfaction include but are not limited to, comfort, duration of stay
Table 2
Sociodemographic characteristics of skin traction and position splint group (N¼ 68).
Characteristic Skin traction (n¼ 34) Position splint (n¼ 34) Test Value p
n (%) n (%) Gender Male 15 (44.1) 16 (47.1) 0.590a .808 Female 19 (55.9) 18 (52.9) Maritial status Married 21 (61.8) 16 (47.1) 1.482a .330 Not married 13 (38.2) 18 (52.9) Education status
Secondary school or less 26 (76.5) 25 (73.5) 0.078a .779
High school or more 8 (23.5) 9 (26.5)
Chronic disease
Yes 32 (94.1) 31 (91.2) 0.216a .642
No 2 (5.9) 3 (8.8)
Antithrombotic drug use
Yes 14 (41.2) 16 (47.1) 0.239a .625
No 20 (58.8) 18 (52.9)
Risk of pressure ulser according to Braden Scale
Low risk 27 79.4 23 (67.6) 1.209a .272
_Intermediate or high risk 7 20.6 11 (32.4) M (SD) Range M (SD) Range
Age (year) 76.0 (10.0) 54e92 80.0 (8.0) 56e97 1.799b .077
BMI (kg/m2) 25.5 (4.5) 16.2e34.5 25.1 (6.4) 16.3e42.9 0.319b .750
Time passed for entering the hospital (hour) 6.7 (11.1) 0.17e48 5.3 (7.0) 0.5e25 0.286c .775
Length of preoperative hospitalization (day) 4.8 (2.8) 1.10e17.75 5.3 (3.6) 1.2e19.7 0.343c .731
Operation duration (hour) 2.5 (1.1) 1.2e7.0 2.3 (0.5) 1.5e4.1 0.280c .780
Hospitalization duration (day) 13.5 (10.0) 3.8e64.0 11.3 (5.0) 3.2e32.0 1.220c .222
Number of preoperative analgesic doses for per day 1.0 (0.4) 0.1e1.9 0.9 (0.4) 0.5e2.2 1.147c .251
aPearson Chi-Square (x2). b Student t-Test (t). c Mann-Whitney U test (z).
Table 3
Comparision of the means comfort scores of position splint group and skin traction group.
Measurement Time Position Splint Skin Traction Test Value (z)c p
VASd VASd n M (SD) n M (SD) B.A.a 34 2.05 (1.57) 34 2.05 (1.80) 0.224 .823 15 min. A.A.b 34 4.14 (1.55) 34 2.67 (1.90) 3.228 .001* 1st hour A.A.b 34 5.95 (1.55) 34 3.41 (1.67) 5.256 <.001* 2nd h A.A.b 34 6.55 (1.85) 34 3.61 (1.84) 5.844 <.001* (ICQ)e (ICQ)e M (SD) M (SD) 1st day 34 90.8 (9.5) 34 60.7 (13.5) 6.259 <.001* 2nd day 30 84.5 (10.4) 29 60.7 (11.1) 5.825 <.001* 3rd day 23 81.1 (13.8) 22 61.2 (15.8) 3.883 <.001* 4th day 19 82.0 (15.6) 18 59.6 (11.9) 4.004 <.001* 5th day 11 78.3 (16.9) 13 57.7 (6.4) 2.681 .007* 6th day 5 79.7 (15.3) 9 64.2 (4.9) 2.202 .028* 7th day 4 82.3 (11.9) 7 59.6 (7.9) 2.211 .027*
*p .05 was established as the significance level. aBefore the Application(B.A.).
b After the Application (A.A.). c Mann Whitney U Test (z). d Visual Analog Scale(comfort). e Immobilization Comfort Questionnaire.
in clinic, wait duration, supportive care, response to treatment, and communication between patients and healthcare professionals (Ozer and Çakıl, 2007; Eti Aslan et al., 2007; Husted et al., 2008; Koç et al., 2012). In our study, the position splint group was more satisfied with treatment and care and the satisfaction tended to get worse as the preoperative duration of the stay lengthened. In case of a surgical delay for any reason, the expectations of the patients to have surgery may have led to a decrease in the perception of satisfaction. There is no study regarding the STC of patients with hip fracture. However, in a previous study, the reduction in the duration of hospital stay was associated with improvement in the satisfaction of the patients who underwent hip or knee surgeries (Husted et al., 2008).
In our study, more preoperative complications occurred in skin traction patients. The leading complications were pressure ulcers and plaster allergies which are similar to thefindings of previous studies (Resch et al., 2005; Jerre et al., 2000; Endo et al., 2013). On the other hand, in Draper and Scott's study (1997), 22 different pressure points of the patients were observed daily until the sev-enth day, and no difference was found between the general scores of the traction and no traction groups.
Limitations
Pain, comfort, and STC can be affected by each other and the environment provided by institutions; the current study was con-ducted in only one center, so the standard therapy and care prac-tices for the patients were unique to our institution.
Conclusion
As a conclusion of our study, position splints were responsible for better outcomes in patients with hip fracture in the preopera-tive period and these splints relieved the pain severity and com-plications and promoted the patients’ comfort and satisfaction, thus confirming our research hypothesis. With these advantages, the preoperative position splint can be used in patients with hip fracture instead of skin traction.
Ethical statement
The study“Preoperative position splint versus skin traction in patients with hip fracture: An experimental study” was approved by the Clinical Research Ethics Board at an authorized hospital affiliated with the Turkish Ministry of Health (Ethical Committee Approval Number: B.10.4.ISM.4.06.68.49/242). Permission to perform the research was granted by the Chief of the Orthopedics and Traumatology Clinic in GMMAH. The study (clinical trials registration number: NCT02287571) was a prospective randomized trial. Written informed consent was obtained from each patient who met the inclusion criteria to participate in the study. The research conforms to the provisions of the Declaration of Helsinki in 1995 In addition, all participants gave an informed consent for the research before volunteering and the anonymity was preserved. The manuscript had been edited and certificated by American Journal Expert.
Conflicts of interest
There are no conflicts of interest for the authors of this manuscript.
Funding
Nofinancial support. Author contributions
All authors meet at least one of the following criteria (suggested by the ICMJE: fromhttp://www.icmje.org/ethical_1author.html):
1) substantial contributions to conception and design, acquisi-tion of data, or analysis and interpretaacquisi-tion of data; 2) drafting the article or revising it critically for important intellectual content; and 3)final approval of the version to be published.
Betul TOSUN: 1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3)final approval of the version to be published.
Ozlem ASLAN: 2) drafting the article or revising it critically for important intellectual content; and 3)final approval of the version to be published; and 3)final approval of the version to be pub-lished. Servet TUNAY: 1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; 3)final approval of the version to be published. References
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