# To traction splint or not to traction splint?



## Summit (Nov 26, 2012)

When I last researched this topic 7 years ago, WMS seemed quite split on whether we ought to traction splint. Then the 2006 WMS Practice Guidelines stated:

"A traction splint is no more efficacious than a good packaging technique. Immobilizing the fractured extremity to the uninjured leg with adequate padding. When long transport is anticipated, place padding behind the knee to create 5-10%" flexion for comfort (Forgey, p. 31).

Brief rationale is given such as cooling the patient, necrosis, pressure points... so where are we now in 2012 since WMS hasn't updated their guidelines? Does any newer research bear this out? Is there a travel time to the ED after which this kicks in? 4 hours? Obviously, if you aren't going to traction splint, you aren't going to put manual traction in place. Articles to read? Thoughts?


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## mycrofft (Nov 27, 2012)

*Same edition of changes including latest CPR*

Journal "CIRCULATION" (AHA), 2010  

http://circ.ahajournals.org/content/122/16_suppl_2/S582.full

This is under "first aid" but the science ought to carry over.

Straightening an Angulated FractureFA-602A, FA-602B
Consensus on Science
One LOE 4 prehospital study187 and 6 LOE 5 hospital studies and reviews188–193 showed no evidence that straightening of an angulated suspected long bone fracture shortens healing time or reduces pain prior to permanent fixation. One LOE 4194 study showed reduced pain with splinting without straightening. One LOE 5195 study on cadavers suggested that straightening angulated fractures decreases compartment size and might increase compartment pressure. One LOE 5 study196 showed no evidence that traction splints could have prevented any hemodynamic compromise in isolated long bone leg fractures in children.

Treatment Recommendation
In general, there should be no attempt to manipulate a suspected extremity fracture.

Knowledge Gaps
In the first aid setting, what are the benefits/risks of realigning long bones that are angulated and presumed to be fractured? Does travel time to a definitive healthcare facility make a difference? Does the application of traction reduce blood loss?

Stabilizing Suspected Extremity FractureFA-605A
Consensus on Science
There are no published studies that evaluate the change in pain or functional recovery when a first aid provider stabilizes a suspected extremity fracture.

Treatment Recommendation
There is no evidence for or against manual stabilization or splinting for a suspected extremity fracture by first aid providers.

Knowledge Gaps
Is there any benefit in terms of pain reduction or healing if first aid providers stabilize a suspected fracture? Is there any harm in stabilizing a suspected fracture as a first aid maneuver? Does distance from a definitive healthcare facility make a difference in effectiveness of stabilization?
==============

That said, the guy we tractioned with a frankly fx'ed femur ("3F"?) reported pain relief at once, without drugs, but that's an anecdote and he had a 3/4 mile trip to the ED on base.


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## Chris07 (Nov 27, 2012)

Although not the same organization, Wilderness Medical Associates (WMA) does not really recommend (but nor do they discourage) the use of traction splints in remote environments. Their reasoning mostly stem from:

1. Its difficult to maintain the needed level of traction over an extended period of time.
2. Traction splints are large/bulky and can hinder packaging/evacuating a patient.
3. Prolonged pressure on the ankle and other pressure points of a traction splint can cause ischemia/infarction of the tissue in that area.

Traction splints are a pain (in my opinion) to improvise and have limited benefit. Padding  between the legs and splinting it to the other leg (assuming you don't have a bilateral fx) is your best bet. The person's going to need to be carried out anyway.

 traction splinting has really fallen out of favor even in urban EMS. I have never used one, and I've even asked two 8+ year vets. 1 has used it twice, and the other has never used it. 

Anyway, I'll see if I can dig something up from WMA regarding traction splinting.


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## Chris07 (Nov 27, 2012)

A blog post by Dr. David Johnson, MD (medical director of WMA)

Tractions Splints in Wilderness Medicine


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## Akulahawk (Nov 27, 2012)

Over the years, I have done many refreshers where we had to do traction splinting. They do have their place, however, I'm not going to use one unless all the patient has is a midshaft femoral fracture. Otherwise I'm probably just going to either be real careful with it, or more likely consider the legs appropriately splinted when I placed the patient on a spine board. After all, a long spine board is nothing more than a big splint!

Like anything else, you just have to know when to use it.


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## Summit (Nov 27, 2012)

Chris I read Dr Johnson's thoughts and generally agreed.

I also found this from ICAR http://www.ikar-cisa.org/ikar-cisa/documents/2011/ikar20111013000773.pdf


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## zmedic (Nov 27, 2012)

mycrofft; said:
			
		

> Journal "CIRCULATION" (AHA), 2010
> 
> http://circ.ahajournals.org/content/122/16_suppl_2/S582.full
> 
> ...



These studies are talking about all long bone fractures, ie humerus, tibia etc. Not just femur. So it isn't really looking at what the question is, which is if traction on femur fractures reduces mortality.


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## Veneficus (Nov 27, 2012)

Having some insight into austere medical treatments, I can tell you traction is totally impractical. 

It may work good when you are laying around somewhere, but one you start to evac it is going to cause way more problems than it is worth.

Complicating this is the inability to splint the femur without external fixation. (which if you have the capability works great for all bone fractures. You just have to go a little heavy on the pain meds and keep some flexion.

Go simple and go home. No need to rig up fancy gizmos. Rig up the fastest way back to civilization. 

Without an xray or obvious deformity you will be hard pressed to identify a commuted fracture which I discovered just a few days ago is not very amiable to splinting. 

in fact, on the commuted tib/fib, the external sam splint caused more harm than good and despite the best efforts of providers, had to be removed twice to preserve neurovascular function. External fixation with pillow splint was the temporary solution along with lots of morhpine and a touch of midazolam and phenergan for flavor.

The real solution was orthosurg back in civilization.


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## Summit (Nov 27, 2012)

Veneficus said:


> Having some insight into austere medical treatments, I can tell you traction is totally impractical.
> 
> It may work good when you are laying around somewhere, but one you start to evac it is going to cause way more problems than it is worth.
> 
> ...



Indeed, my biggest worry was always this: how am I as a field provider to know the nature of the femur fracture AND the absence of contraindicating (and very likely) additional injuries that may not grossly present on physical assessment and the symptoms of which may be masked by the femur fracture? Would it be with my magical MRI eyes?

I am essentially ALWAYS going to show up with a full body vacuum splint and a litter. In a 4 or 14 hour transport, it isn't the extra 2 or 5 minutes it will take me to put on a KTD or improvise something that worries me. Should I do it? Is it good for the patient? It always struck me as, "yes" only a tiny fraction of the time that would be hard or impossible to distinguish from many of the "no."


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## Veneficus (Nov 27, 2012)

Summit said:


> Indeed, my biggest worry was always this: how am I as a field provider to know the nature of the femur fracture AND the absence of contraindicating (and very likely) additional injuries that may not grossly present on physical assessment and the symptoms of which may be masked by the femur fracture? Would it be with my magical MRI eyes?
> 
> 
> 
> ...


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## Luno (Nov 29, 2012)

Veneficus, I'm gonna have to take this shot, since the opportunities are so rare when there is a hole in your arguements...  


> Anytime you have bone deformity you have injury to every tissue between the outside of the body and the bone.


Have you considered spiral fractures of the femur prior to a fall?


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## Veneficus (Nov 29, 2012)

Luno said:


> Veneficus, I'm gonna have to take this shot, since the opportunities are so rare when there is a hole in your arguements...
> 
> Have you considered spiral fractures of the femur prior to a fall?



No, I considered only extrinsic trauma when I said that.

Good Catch.

edit: nor did I consider pathological fractures from CA, Mets, osteoporosis, osteomalacia, or osteomyelitis.


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## Luno (Nov 29, 2012)

Damn it man... CA was going to be my next point...


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## Veneficus (Nov 29, 2012)

Luno said:


> Damn it man... CA was going to be my next point...



Can't make it too easy on you...

Work harder.


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## Luno (Nov 29, 2012)

Hahaha, well played, as also having a little insight into austere/remote, I'm going to have to look into this a little further, there is remarkably little information for or against.  The reason that I called you out on spirals is that we were seeing such a run of spirals prior to falls and the subsequent miss of femur fx prehospital that we spent a good amount of time looking into the mechanics of the injury.  This does bring up a very interesting point about prehospital femur splinting, and whether or not it falls into the "well it couldn't really hurt them," or evidentary based medicine.  Interestingly enough though, pre-traction splint invention femur fx provided up to 80% mortality, but I haven't researched enough about the why.  Good call though on the compartment vs. exanguination arguement with a closed femur fx, since it should only provide enough space to hold 1 liter of blood, +/- depending on patient.


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## Veneficus (Nov 29, 2012)

Luno said:


> Interestingly enough though, pre-traction splint invention femur fx provided up to 80% mortality, but I haven't researched enough about the why.



Is this a prehospital number or overall mortality?

It sounds like there must be many confounding factors. I have seen dozens of femur Fxs and I can't honestly say a traction or lack of it had anything to do with the final outcome. 



Luno said:


> Good call though on the compartment vs. exanguination arguement with a closed femur fx, since it should only provide enough space to hold 1 liter of blood, +/- depending on patient.



This is actually an interesting dichotomy. 

the American College of Surgeons ATLS course still lists longbone compartments as one of the 5 locations of life threatening blood loss. 

Since the proximal lower extremity commutes with both the distal part and the pelvis, I am not read to call BS on the mortality. The blood may originate from the proximal extremity but does not mean it is contained there. 

As for compartment syndrome, the distal lower extremity is the most likely site of it, but is definately a possibility in any closed space. (including the abd and thorax in some conditions)


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## mycrofft (Nov 29, 2012)

zmedic said:


> These studies are talking about all long bone fractures, ie humerus, tibia etc. Not just femur. So it isn't really looking at what the question is, which is if traction on femur fractures reduces mortality.



These aren't studies, they are _pronunciamentos_.







Entries one and two pretty well nail it in my book. The only loophole is this was written about first aid; however, they did not specify the means to straighten the fracture, and the science seems to be multilevel.


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## mycrofft (Nov 29, 2012)

I am stumped as to how traction can _*cause*_ mortality, other than the AHA _Circulation_ article mentioning that some folks feel flexing the fractured extremity can cause the potential compartment to expand, ths allowing further bleeding into it. 

I'd vote for *contributing factors* (is that the same as confounders?), such as the second one I saw: sixteen story fall onto pt's feet upright, femurs fxed and jammed into pelvis, C-1 jammed into occiput, etc etc. Healthy femurs don't break easily and can be used as some sort of indicator of the force absorbed by the pt; also, I never heard of a fx healthy femur due to "stepping in a hole" and resulting in a spiral fx; in fact, I never heard of a spiraled femur. It's usually mechanical force which if strong enough to snap the thighbone, is strong enough to squish everything in between and often open it up.


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## Veneficus (Nov 30, 2012)

mycrofft said:


> I'd vote for *contributing factors* (is that the same as confounders?),



In a manner of speaking.

A confounder is an unaccounted for variable in a research study.


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## mycrofft (Nov 30, 2012)

So the contributors could confound the study results. Confound it!

(I knew, but I let it slide).


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## Luno (Nov 30, 2012)

*You would think... *



mycrofft said:


> in fact, I never heard of a spiraled femur. It's usually mechanical force which if strong enough to snap the thighbone, is strong enough to squish everything in between and often open it up.



Interestingly enough, it's not necessarily high energy mechanical force (impact).  I have to dig into my research which is on another computer, but spiral femur fx are quite common abuse injuries with in the infant/toddler age group, and are relatively common in skiers.  The femur as a bone is protected from impact by muscle, however it is very brittle and doesn't withstand rotational force very well.  If I remember correctly, and I have to double check my research, to spiral fracture a femur, all it takes is 103 ft/lbs of torque, and .5 degrees of rotation.  As a side note, alot of the high energy trauma (direct impact) are not open as far as I've seen personally, having worked on several...


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## mycrofft (Nov 30, 2012)

I didn't work around skiers (eastern Nebraska, go figure), and both fx's I personally treated had near-emergence of the bone end. (One fell as above, the other ran full running in the dark the dark into a thigh-hig steel railing painted black) .

Spiral fx of the femur in child or infant (not totally ossified) abuse?

And skiers...I imagine if the femur goes like that, associated structures are going to be jacked as well? (knee, hip acetabulum).


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## zmedic (Nov 30, 2012)

I was ski patrol for 9 years, all the spiral fractures I saw on skiers were of the tibia. The only femur fractures I've seen on skiers were from hitting something like a tree. Not saying it's not possible, but especially with modern bindings its very rare to have spiral fractures in general, femurs especially.


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## mycrofft (Dec 1, 2012)

*Something's wrong with a website about femur fx*

http://femurfractureguide.com/fracturetypes.php

They state skiing accidents cause spiral fx of femurs and are the most common form. They also say it can be a sign of child abuse. 
THEN they go on to say comminuted fx's are very common in car accidents; I will bet you a doughnut there are more MVA's by a wide margin versus skiing accidents or child abuse cases resulting in a femur fx.

Quote about comminuted fx:
"The comminuted femur fracture is a break in which there are three or more fragments of the femur resulting from tremendous pressure. These are very common in car accidents. Comminuted femur fractures can be especially difficult to treat, as the fragments can make things complicated for the doctor".Sounds like a layperson or maybe a trolling lawyer?

They solicit people's stories, have a blank FAQ. :nosoupfortroll:


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## Luno (Dec 1, 2012)

*You would think...*



zmedic said:


> I was ski patrol for 9 years, all the spiral fractures I saw on skiers were of the tibia. The only femur fractures I've seen on skiers were from hitting something like a tree. Not saying it's not possible, but especially with modern bindings its very rare to have spiral fractures in general, femurs especially.



We spent the time to evaluate this, and due to the mechanism of injury, modern ski bindings are pooly suited to avoid this injury.  Especially since it is primarily a slow speed injury with rotation over the outside edge of the ski with a flexed knee, but the flex is less than 90 degrees.  Granted, the correct snow condition, especially given east vs. west coast snow, moisture composition, location on trail, skier experience level, and release of properly adjusted dins.  The reason for our more indepth look at this was more than 5 spiral femurs in a couple of weeks, confirmed by x-ray. 

Also, the femur is great at withstanding direct impact, but is remarkably similar to chalk with regards to withstanding rotational forces...


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## mycrofft (Dec 1, 2012)

Not real rotationally ductile, eh?

Any reason for such a cluster of that variety of fx? Recent weather hx maybe? Or just a lotta skiing newbies? Or "hotdogging" (now called "extreme") skiing?

EDIT: emedicine website article.
About traction as definitive tx :
"Treatment of femoral shaft fractures has undergone significant evolution over the past century. Until the recent past, the definitive method for treating femoral shaft fractures was traction or splinting. Before the evolution of modern aggressive fracture treatment and techniques, these injuries were often disabling or fatal. Traction as a treatment option has many drawbacks, including poor control of the length and alignment of the fractured bone, development of pulmonary insufficiency, deep vein thrombosis, and joint stiffness due to supine positioning.
The femur is very vascular and fractures can result in significant blood loss into the thigh. Up to 40% of isolated fractures may require transfusion, as such injuries can result in loss of up to 3 units of blood.[3] This factor is significant, especially in elderly patients who have less cardiac reserve". (Emphasis mine).

And it goes on.
http://emedicine.medscape.com/article/90779-overview

EDIT2: GREAT ARTICLE IF MAYBE A LITTLE DATED (1991):

http://books.google.com/books?id=IdhI0peNJCUC&pg=PA156&lpg=PA156&dq=spiral+femur+fractures+skiing&source=bl&ots=L50NYcaOEL&sig=0cgN75RRYvFJg8mAr47R6SN9yYo&hl=en&sa=X&ei=3Iq6UO6LLu3OigKvj4GICA&sqi=2&ved=0CGQQ6AEwBw#v=onepage&q=spiral%20femur%20fractures%20skiing&f=false


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## mycrofft (Dec 1, 2012)

EDIT2: GREAT ARTICLE IF MAYBE A LITTLE DATED (1991):

http://books.google.com/books?id=IdhI0peNJCUC&pg=PA156&lpg=PA156&dq=spiral+femur+fractures+skiing&source=bl&ots=L50NYcaOEL&sig=0cgN75RRYvFJg8mAr47R6SN9yYo&hl=en&sa=X&ei=3Iq6UO6LLu3OigKvj4GICA&sqi=2&ved=0CGQQ6AEwBw#v=onepage&q=spiral%20femur%20fractures%20skiing&f=false

I liked the description of the lower leg, planted in the snow, acting like a wrench handle to effectively transmit torsional motion to the femur.


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## zmedic (Dec 1, 2012)

Luno; said:
			
		

> ]We spent the time to evaluate this, and due to the mechanism of injury, modern ski bindings are pooly suited to avoid this injury.  Especially since it is primarily a slow speed injury with rotation over the outside edge of the ski with a flexed knee, but the flex is less than 90 degrees.  Granted, the correct snow condition, especially given east vs. west coast snow, moisture composition, location on trail, skier experience level, and release of properly adjusted dins.  The reason for our more indepth look at this was more than 5 spiral femurs in a couple of weeks, confirmed by x-ray.
> 
> Also, the femur is great at withstanding direct impact, but is remarkably similar to chalk with regards to withstanding rotational forces...



I hear what you are saying, the mechanism makes sense. But still pretty rare in most places in the county. I see you are from WA, you have a lot of patients who have been skiing "sierra cement?" I have a suspicion that spring/ glacier skiing in some places like washington produces much more of these injuries than in other places like VT/NH or CO where there is less heavy slush skiing.


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## Luno (Dec 2, 2012)

@Mycrofft, while reading the study, it is direct contrast to what we've seen, primarily beginner skiers, and does call into question the binding.  It makes one key assumption that the rotational force upon the tibia is equal to the rotational force upon the femur, which in the incidents that we observed, is not the case.  The bent knee and body's rotation over the outside of the ski causes forces to be distributed a little differently.  Here is what we did as we were first looking at this just as a physical experiment to see if our conclusions were even possible, standing with your feet approximately shoulder width apart, your knees bent approximately between 15 and 40 degrees, take your left foot, cross it and plant it in front of you, and over a  line formed by your right foot.  The further past that line that your left foot goes, and if your knee angle is correct you will begin to feel the pressure build at your right hip, specifically applying rotational force to your femur.  It's wild, but you have to try it to believe it...   We can get into the release of bindings and DINs in another post...


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## mycrofft (Dec 2, 2012)

I think skiing style and maybe bindings have changed since 1991? Global warming changed the snow?

I'm convinced and converted about spiral fx's, I wonder if there are equiv situations other than skiing? 

And, no, I'm not even trying to do that unless you pick up my medical bills and carry me around on your back!

I sent a link to the 1991 article to MtRescue, but his park uses mostly inner tubes.


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## MediMike (Dec 7, 2012)

Danger! Anecdotal! 

Had a 180lb 4th grader playing tetherball, leg planted, swung at the ball, spun around on the planted leg. Spiral femur fx.

Ok that's all


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## mycrofft (Dec 30, 2012)

Good one.

I just remembered my THIRD femur fx. Nebraska football player out after curfew, struck by car that stopped on impact, ran a block home and got into bed. THEN had increasing pain and unable to get out of bed. Still clothed, too. Afraid of Coach Osborne benching him.


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## Summit (Mar 31, 2013)

Bump for further discussion


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