i have a question

[daedralarsa]

about splinting
if a Pt has a femur fracture and a tib/fib fracture, would you just splint the whole leg? bc i know you cant pull traction right. maybe its a dumb question...but i just want to be sure

 

[fyrdog]

The only dumb question is the unasked question.

Yes you must splint the whole leg. You can splint each fx and then the whole leg or use one splint as long as it immobilizes both fractures. Don't forget to check for pulses before and after splinting.

 

[akflightmedic]

Great question.

You are correct that it would not be a good idea to pull traction on a tib/fib fx just because there is also a femur fracture.

Let's think for a second of the injury. If there was enough force from the mechanism of injury to fracture a femur (the strongest bone in the body) and also fracture two other bones, do you think this would be their only injury?

Very rarely, will you see an injury this severe and only be isolated to one extremity. When these types of severe injuries occur, splinting the leg will probably be one of your last concerns; more than likely there will be airway issues involved, or other more sever injuries, so of course that is where you priorities will be.

However, if you were to encounter this situation, and splinting the leg were your only issue, there would be no harm in splinting it in a position of comfort or position found; it would all depend on the situation.

 

[firetender]

The odds of someone having a clean break in the femur, tib and fib seem remote to me. The force that it takes to frature the femur would most likely splinter the tibia and fibula, leaving far too many pick up sticks to apply traction to without compromising other tissue, including arteries.

 

[So. IL Medic]

Never ever even think about applying traction to a tib/fib fx even if the break was so clean it was Spic n span clean.

Splint it.

 

[Alexakat]

How about a closed femur fracture with in tact PMS? Would you always apply traction splint?

 

[So. IL Medic]

How about a closed femur fracture with in tact PMS? Would you always apply traction splint?

Easy answer - nope.B)

Had a call once - cow versus farmer. The cow won. It crushed the farmer's leg against a steel gate and left the farmer lying on the ground with an obvious femur fracture. Checked the medial pulse and it was strong, the guy felt me touch his foot and he wiggled his toes slowly. So we splinted the leg in the way we found it. Transported. He was transferred to an ortho center with our splint still in place for the reason you brought up. Don't mess with a good pulse in the fractured extremity - might make things worse with traction. Let the surgeon mess with it.

 

[Ridryder911]

I totally disagree! Closed mid shaft femurs are to be tractioned splinted for a reason. Not having pulses is not the reason for traction!

The reason for traction is to reduce the possibility of muscle contractions, and as well if it is a displaced femur fracture, reducing the possibility of lacerating the femoral artery, veins, nerves etc.

The reason for not traction's splinting femur fractures of the proximal and distal ends are due the amount of traction and location probably does no good, however; there are many EMS that agrees to even apply traction on those type of injuries and even on open ones, hence it is better than having a lacerated femoral artery.

If one ever sees the thigh (quads) have spasms to "guard" a femur fracture, one can appreciate the reason of traction splinting devices.

R/r 911

 

[Guardian]

I totally disagree! Closed mid shaft femurs are to be tractioned splinted for a reason. Not having pulses is not the reason for traction!

The reason for traction is to reduce the possibility of muscle contractions, and as well if it is a displaced femur fracture, reducing the possibility of lacerating the femoral artery, veins, nerves etc.

The reason for not traction's splinting femur fractures of the proximal and distal ends are due the amount of traction and location probably does no good, however; there are many EMS that agrees to even apply traction on those type of injuries and even on open ones, hence it is better than having a lacerated femoral artery.

If one ever sees the thigh (quads) have spasms to "guard" a femur fracture, one can appreciate the reason of traction splinting devices.

R/r 911

I found this out the hard way, a couple of years ago. Great point.

 

[So. IL Medic]

Sorry, Ridryder, but I disagree with your disagreement.

Journal of Emergency Medicine published a study in 2001 that showed that conventional splinting and immobilization was just as effective in the field for femur fx w/ good mcs and they even went as far as to say traction splints didn't have to be a required part of ambulance equipment. Reasons being that the quad spasms occur very quickly after insult if they occur at all and that unnecessarily manouvering the jagged bone ends is as risky or even more risky to increase trauma than aany muscular guarding or spasm movement. They concluded that conventional splinting was acceptable care. I even remember my medic instructor telling us not to play with good pulses, splint and transport.

 

[reaper]

I can tell you from having broken both Femurs that the traction splint is a great device.

Don't look at what a study says, look at what is best for your pt!

Spasms do continue for a long time. They are very painful. You feel almost instant relief of most pain, as soon as the traction is pulled. they are designed to realign the bone, so it is not tearing into the muscle. That my friend is very painful.

My pt's always get a traction splint if they do not have a open fracture (which still can be done), or other fractures of the same leg.

Just a little insight from someone that has felt the pleasures of a traction splint!!!

 

[Guardian]

I can tell you from having broken both Femurs that the traction splint is a great device.

Don't look at what a study says, look at what is best for your pt!

Spasms do continue for a long time. They are very painful. You feel almost instant relief of most pain, as soon as the traction is pulled. they are designed to realign the bone, so it is not tearing into the muscle. That my friend is very painful.

My pt's always get a traction splint if they do not have a open fracture (which still can be done), or other fractures of the same leg.

Just a little insight from someone that has felt the pleasures of a traction splint!!!

Wow, how did you break both femurs? There is a good story here, i know it!

 

[Guardian]

Anecdotally, swelling and further injury seems to be significantly reduced when I apply a traction splint. I’m not sure why, just thought I’d throw that out there. I’m a born again traction splinter.

 

[medicdan]

In all seriousness, how many traction splint-worthy cases have you had? I have asked a lot of people, both in the US and in Israel and nobody seems to have done it in the field. My understanding (and please correct me) is that in cases of femur fracture, there is a high probability of more severe injury-- pelvic/his injury, abd injury, etc, and in the prehospital realm, the blood loss in the femur is minor compared to other possible injuries.
Especially here, they have taken the splints off of many ambulances. The emphasis here is on rapid evacuation/transport, and they forgo just about all treatment in the field.
For the record, I do know of EMTs that have used the splint to stabilize another injury of the leg, taking advantage of the metal frame and velcro, not using the traction mechanism. It seems it is easier to use a traction splint then padded board splint.

 

[Ridryder911]

Sorry, Ridryder, but I disagree with your disagreement.

Journal of Emergency Medicine published a study in 2001 that showed that conventional splinting and immobilization was just as effective in the field for femur fx w/ good mcs and they even went as far as to say traction splints didn't have to be a required part of ambulance equipment. Reasons being that the quad spasms occur very quickly after insult if they occur at all and that unnecessarily manouvering the jagged bone ends is as risky or even more risky to increase trauma than aany muscular guarding or spasm movement. They concluded that conventional splinting was acceptable care. I even remember my medic instructor telling us not to play with good pulses, splint and transport.

Please read this article in full!
http://www.swissrescue.ch/dossier/traction_splint/traction_splint_angl.pdf

That is part of the problem in EMS, most do not really understand on how and to interpret a study or report. Let us review it in more detail.

First, a study should never be interpreted as replacing a medical standard and practice, until several studies and recommendation have been made to replace standards in teaching, curriculums, and standard of practice such as in CPR, ACLS, etc have occurred. These changes are studied from multiple and various studies, not one nor an isolated vague study.

I agree we definitely need to evaluate any and all equipment and treatment we perform, as well as we need to evaluate any studies performed, in great detail. Yes, definitely observe any scientific studies, and as well anecdotal reports.

The study quoted was solely based upon review of paperwork not on evaluation of clinical findings, and it was based upon 16 patients and out of these had minor related injuries. Out of five injuries only three actually had traction devices applied.

So would you want to base your treatment solely based upon this study? Again, this study was not evidenced enough, and obviously not sound enough to cause changes in standards of treatment in all trauma life support courses. As well, no changes have been made in this six year old study.

Again, those that have read my posts, definitely are aware of my position of current findings and the need of doing this. As well, as understanding a thorough knowledge of applying such studies in patient care. I personally would not cite this article in defense of my treatment modality. It is still considered the standard of care in the use and application of traction devices, and until then (unless directed by medical director not to) would be held accountable in treating mid shaft femur fractures. In other words, if laceration of femoral artery, nerve, or undue pain occurred while enroute from movement of bone/bone fragments, could be very litigious.

R/r 911

 

[reaper]

Wow, how did you break both femurs? There is a good story here, i know it!

Motorcycle handle bars!! Young and stupid!



EMTSTUDENT,

I have applied a traction at least 5 times this year alone. All verified by Dr. that it was needed and the correct treatment.

Where do you figure that blood lose is minimal in a Femur fx? I consider 1500cc's a decent amount of blood.

 

[So. IL Medic]

No, I'm saying that applying an absolute to all treatment doesn't always mean the best for the pt and that sometimes doing less is better. Treating a potential problem when a problem does not yet exist can cause a worse one.

 

[So. IL Medic]

I finished reading the article. The first part made good points. The second was an ad for Minto research Inc and Sager. There's a time for each modality of treatment.

 

[BBFDMedic28]

For the person who asked if anyone has applied traction splint in the fiield...I have twice. I have been doing this for five years and only twice have I done this. Both times the pt had strong distal pulses before and after the splint was applied. In reguards to the "use traction splint or splint as is" dispute....we were taught to use it if indicated. so I am going to agree with ridryder.

 

[Ridryder911]

One should not confuse femur traction with other fractures of those of re manipulation and traction to attempt to reestablish pulses. The reason again for traction in femur is for prevention of the jagged edges of the femur and help reduce the muscles contractions.

I have seen multiple femur fractures yearly. Some of those I never place traction splinting due to other time delay and possibility of fracture sites of proximal and distal sites. As well, I have seen several with muscle contractions beginning and soon after the fracture, with the muscles attempting to "guard" the injured leg. It is not unusual that I have given muscle relaxants, and analgesics to reduce this.

I have seen a young person literally die from am isolated femur fracture. The fracture ends lacerated the femoral artery and within 30 minutes the patient had exsanguinated out. So yes, it does occur, as well pin traction is still utilized as some treatment modality in orthopedic care.

Review the current PHTLS/IHTLS and even ATLS standards. I agree, not all femur fractures have to be in traction splints, one has to judge wisely.

R/r 911