How a Traction Injury Expert Witness Reviewed Missed Skin Checks and Pressure Wound Escalation

When traction is applied without a care plan, pressure injuries can follow

A frail, elderly patient was admitted following a fall at home and placed in skin traction while clinicians debated surgical versus conservative management. Several days into the admission, nursing staff discovered a blister beneath the bandaging used to anchor the traction. Despite this, the traction was reapplied without escalation, leading to deterioration and the development of a full-thickness, necrotic pressure wound over the patient's achilles.

An Apex traction injury expert witness was instructed to review the quality of care delivered during this admission. The expert concluded there were multiple, serious breaches of duty, including a failure to initiate a traction-specific care plan, inadequate inspection of the limb under traction, and missed opportunities to escalate a pressure-related injury.

What the traction injury expert witness found fell below acceptable standards

Throughout the admission period, the expert identified systemic nursing failings that contributed to the avoidable injury:

• A Waterlow score was calculated appropriately on the ward, identifying the patient as very high risk

• However, no pressure ulcer care plan or SSKIN bundle was initiated at the time

• There was no documented care plan relating to traction despite known risks in elderly patients

• Nursing notes did not show routine daily skin inspections as expected under national guidance

• A blister discovered beneath the traction bandages was not escalated to senior medical staff

• The traction was simply reapplied, and the injury deteriorated into necrosis

“When traction is used in elderly, frail patients, a robust care plan is not optional, it’s essential. This wound could have been prevented with basic daily inspection and collaborative escalation.”— Apex Traction Injury Expert Witness

What a traction injury expert witness expects in elderly orthopaedic admissions

In complex cases involving skin traction, best nursing practice demands:

1. A specific traction care plan including skin inspection frequency

2. Daily checks of the skin beneath and surrounding bandages

3. Early referral to the Tissue Viability Nurse (TVN) upon detection of skin changes

4. Escalation to medical teams before reapplying traction to injured skin

5. Full documentation of the wound trajectory, including body maps and dressing changes

   
   

In this case, none of the above standards were followed until the injury had already progressed. The expert confirmed that the wound was device-related, and the deterioration likely would not have occurred had staff responded appropriately to the first signs of skin breakdown.

Why collaboration between nurses and doctors is critical in traction management

The review also found no documented communication between nurses and the orthopaedic team regarding the blister. The wound was only recognised as necrotic after a delayed TVN referral and continued use of the traction device. Handover to the next hospital also failed to include accurate wound details, delaying the response from the receiving team.

The expert concluded that these failings collectively contributed to the progression of a preventable wound and rendered the case indefensible from a nursing perspective.