# Closed mid shaft  femur fracture



## Jacedc (May 25, 2012)

Would you put on the sager or hair traction splint on a patient before or after back boarding them?


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## DesertMedic66 (May 25, 2012)

Either or. As long as the patients legs aren't strapped to the board yet you are fine.


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## Jacedc (May 25, 2012)

Sweet thank you for answering!


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## medichopeful (May 25, 2012)

Debate over backboarding aside, I would say traction splint before (if, that is, the person lets you touch their leg!).  Part of backboarding, remember, is securing the legs, which you would need the splint on to do correctly in a femur scenario.  Also, the sooner you get the femur "realigned," the better.


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## Hunter (May 25, 2012)

medichopeful said:


> Debate over backboarding aside, I would say traction splint before (if, that is, the person lets you touch their leg!).  Part of backboarding, remember, is securing the legs, which you would need the splint on to do correctly in a femur scenario.  Also, the sooner you get the femur "realigned," the better.



This.

Your patient would probably be better with the leg splinted first, while it might hurt like hell while you're realigning it once it is secured with propper traction your patient will probably be much happier.


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## Veneficus (May 25, 2012)

I would not use the splint.

I would put the leg in traction.

It can be done with Kling and not all the metal crap.


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## Anjel (May 25, 2012)

I was always taught to do it first. 

In hopes it will releive some pain as you are rolling them around.


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## zmedic (May 25, 2012)

Veneficus said:


> I would not use the splint.
> 
> I would put the leg in traction.
> 
> It can be done with Kling and not all the metal crap.



I don't think improvising a traction splint is in most peoples standard of care. If you carry a traction splint and are trained to use it, why re-invent the wheel?


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## Veneficus (May 25, 2012)

zmedic said:


> I don't think improvising a traction splint is in most peoples standard of care. If you carry a traction splint and are trained to use it, why re-invent the wheel?



So you don't have to take it off for an x-ray?

So the patient can fit in the truck the way they were intended to?

So you don't have to leave the device at the hospital? (more for the hospital that doesn't want to store EMS crap) 

So the hospital staff can maintain traction without having to figure out the EMS specific device while waiting for ortho?

Just a couple of reasons I guess.

No need to buy, carry, maintain, or improvise making said gagets work.

Simple is better. I didn't realize specific commercial devices constituted a standard of care anywhere.

Afterall, what is the difference between a KED, An Oregon Vest, and short board? Other than the company you are giving your money to?

I am sure a company like physio control woul just love if somebody decided that a LP 15 was specified as the standard of care and not simply "EKG monitor." Probably a few other companies out there wouldn't mind either.


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## mycrofft (May 25, 2012)

But learn how to "improvise" so you don't have to learn how to when there's an injured pt at your side. 

Also, fractured midshaft femur can bleed a lot (will traction improve bleeding from the femur itself? Veneficus?) and the bone ends can endanger some very major vessels. AS WELL as causing truly excruciating pain which can lead to or worsen shock.

By the way, it is Hare traction splint, not "hair". Sounds like a truly weird improvisation, using hair...


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## Veneficus (May 25, 2012)

mycrofft said:


> (will traction improve bleeding from the femur itself? Veneficus?)



Theorhetically, yes, reducing the space it is bleeding from and into should permit faster clotting.

Realistically, I do not think it would be clinically significant.

Edit: significant for the purpose of controlling an existing hemorrhage from the bone.


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## EMT John (May 25, 2012)

I've been a big fan of the sager and the KTD since i did ski patrol, just because they are both compact and you don't need to worry about them fitting in the helicopter. I think the Hare is an outdated device but since people don't like change we haven't switched. Sager and Hare are about the same price but sager is half the weight and size. KTD is a 1/3 of the cost and tiny piece of equipment at 20oz. 

I've always splinted before back boarding but that's just how I was trained. Seems like less movement if you do it that way.


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## mycrofft (May 25, 2012)

Anyone know how many lbs tension is required ?
(I know, it's sort of a trick question, as it will vary due to how long the  muscle has been in spasm, how large the pt is, how muscular, etc). But generally, are we talking more than say fifteen lbs?*

NATO used to have, besides olive drab Hare splints, a long device shaved like a deep shallow "V" with the six inches of the "apex" turned down 90degrees and an underling ring to fit against the ischial tuberosity. The expectation was you would use triangular bandages or whatever to secure the splint at three or four points, then tie something  around the booted foot to create a 'Spanish windlass" between the boot/foot and the bent"V". I think they also used to make a device to add to the traditional D ring stretcher (litter) but you needed to fasten the pt to the litter or it just dragged the pt towards the foot end eventually.




*QUOTE:

"The amount of traction applied is proportionate to the patient’s body weight. For a single-sided fracture, traction equal to 10 percent of the body weight up to 15 pounds is applied. For bilateral fractures, 10 percent of the body weight is applied per limb, up to a total of 30 pounds of traction."

(so I guessed pretty right, thinking about one leg.)  

SOURCE:
http://www.fireengineering.com/arti...ce-ems/back-to-basics-traction-splinting.html

Good article.


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## nwhitney (May 25, 2012)

I was taught 10% of body weight up to 15lbs.  

As far as splinting before or after boarding I would say it depends.  If there are other life threats going on then board and go and apply traction in the rig if able.  This is what I was taught and it is what some LO's here prefer.


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## Tigger (May 25, 2012)

Veneficus said:


> I would not use the splint.
> 
> I would put the leg in traction.
> 
> It can be done with Kling and not all the metal crap.



Considering that transport to the hospital is likely going to be the most painful experience for the patient after the actual injury, I would like to do more for them than some kling. I can think of a few ways to improvise a traction devise, but none of them are nearly as effective as a purpose built splint. And if I can't get ALS in any reasonable amount of time, the splint is about it for pain control.

There are many more hands in the ED than on scene and while I understand that getting the splint off is a pain, it is certainly possible to do with relatively little pain if everyone communicates and works smoothly.


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## mycrofft (May 26, 2012)

HOw about a ,long spine board with a leg traction device built in?
Ferno-Washington, you listening?


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## zmedic (May 26, 2012)

I trust most of my EMTs much more in their ability to put on a commercial traction splint than to rig up something. 

Most splints fit in the ambulance. Otherwise how do those EMTs keep brining patients to my ER in traction splints. 

We can see the fracture just fine even with a Sager or Hare on.

You can do whatever you want, but I think most rookie EMTs/medics reading this board are just going to get themselves into trouble if they start improvising traction splints rather than use what they are carrying.


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## mycrofft (May 26, 2012)

...and need to be practicing with. Practice not only refreshes skills but it makes sure the splint is present and in good condition.


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## Veneficus (May 26, 2012)

zmedic said:


> I trust most of my EMTs much more in their ability to put on a commercial traction splint than to rig up something.
> 
> Most splints fit in the ambulance. Otherwise how do those EMTs keep brining patients to my ER in traction splints.
> 
> ...



It has been my experience that when using the Hare, that you have to put the pt in the ambulance "backwards" in order to get the door to close when using the Hare. 

What is worse is when you get to x-ray and there is no traction and you can see overriding bone with the splint improperly applied in order to get it in the ambulance.

I don't think it is so much "rigging" as using normal body mechanics, but you are right, it is probably beyond the basic EMT training. I would be willing to bet though if I showed you how to do it, you would be sold.

Anatomy is a wonderful thing to understand.


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## Veneficus (May 26, 2012)

Tigger said:


> Considering that transport to the hospital is likely going to be the most painful experience for the patient after the actual injury, I would like to do more for them than some kling. I can think of a few ways to improvise a traction devise, but none of them are nearly as effective as a purpose built splint. And if I can't get ALS in any reasonable amount of time, the splint is about it for pain control.
> 
> There are many more hands in the ED than on scene and while I understand that getting the splint off is a pain, it is certainly possible to do with relatively little pain if everyone communicates and works smoothly.



Do you hold manual traction before/during applying your splint?

The commercial devices just make it a hands free maneuver, so does the kling. You don't need any rods or other improvised stuff. JUst something to hold the traction to free your hands.

In fairness you do need something to tie the kling to, and I have found the backboard handles or the cot to work just fine.


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## the_negro_puppy (May 26, 2012)

Here an x-ray of a patient I had a little while ago. A donway traction splint was used, fitted correctly. Midshaft femur.







What your opinion of this x-ray? Insufficient traction?


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## mycrofft (May 27, 2012)

I'm no radiologist, but if it was immobilized and the pt experienced some relief, then it was sufficient. The field traction splints are not curative, as with all field splints they are for transport.

Are there protocols to overcome the spasm associated with such an injury? Benzo or a paralytic? I remember in the ER we wold hit them with a pretty good Valium dose before finally restoring a recalcitrant dislocated shoulder. Femoral fx must be much much harder.


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## Handsome Robb (May 27, 2012)

mycrofft said:


> I'm no radiologist, but if it was immobilized and the pt experienced some relief, then it was sufficient. The field traction splints are not curative, as with all field splints they are for transport.
> 
> Are there protocols to overcome the spasm associated with such an injury? Benzo or a paralytic? I remember in the ER we wold hit them with a pretty good Valium dose before finally restoring a recalcitrant dislocated shoulder. Femoral fx must be much much harder.



Agreed.

I can twist my protocol for versed to make it fit the situation. It's pretty open-ended. 

I've never used traction splints. Not that I don't like them, just never had an isolated mid-shaft femur. Always had pelvic, hip or tib/fib involved as well. 

Last one I came close to maxing out on my fentanyl protocol and also gave her a bit of versed. She was pretty happy by the time we got to the ER. 3 oblique fractures to the femur...ouch. This was the third time she ahd fractured that femur as well. Hip replacements and a poor diet did grandma wrong.


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## the_negro_puppy (May 27, 2012)

With this patient he was a young healthy male who failed to land a motorbike jump in a field. No other injuries. I believe we had given 2 x 5mg IV morphine before we started setting up for the splint, still in pain. I then gave him penthrane/methoxyflurane inhaler and the pain virtually 'went away' as he said lol. Traction was applied with pt receiving further IV morph enroute. Tx time approx 30 mins, we stopped on the way to pick up another medic who gave 2 x 1mg IV Midazolam, to assist with analgesia/controlling spasms. total of 25mg Morph was given.


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## mycrofft (May 27, 2012)

The one we could save was due to running in the dark and colliding with a black-painted railing full tilt no hesitation and no guarding.

Another one fell almost sixteen stories feet first. Not, as you say, isolated.


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## Handsome Robb (May 27, 2012)

mycrofft said:


> The one we could save was due to running in the dark and colliding with a black-painted railing full tilt no hesitation and no guarding.



Ouch.



> Another one fell almost sixteen stories feet first. Not, as you say, isolated.




Double ouch. 

And still living? I hope not.


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## mycrofft (May 27, 2012)

The fall victim stepped onto a counterweighted lift (parallel ropes with a board suspended between) not designed for people in a grain elevator. The counterweight was off. He tried to stop with his hands on the ropes (tore off skin), landed upright. Fx feet, ankles/tib fib,  thighs, acetabular-femoral joints, T spine, and drove C spine into base of skull. Tough guy, lived another day in ICU.

Blackdog, USA toyed with nitrous oxide for field analgesia back in the late Seventies/nineteen eighty. Simultaneously and coincidentally, there was a wave of campus nitrous parties where I was working, a couple of kids went out dorm windows when they leaned back on window screens.


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## Handsome Robb (May 28, 2012)

mycrofft said:


> The fall victim stepped onto a counterweighted lift (parallel ropes with a board suspended between) not designed for people in a grain elevator. The counterweight was off. He tried to stop with his hands on the ropes (tore off skin), landed upright. Fx feet, ankles/tib fib,  thighs, acetabular-femoral joints, T spine, and drove C spine into base of skull. Tough guy, lived another day in ICU.
> 
> Blackdog, USA toyed with nitrous oxide for field analgesia back in the late Seventies/nineteen eighty. Simultaneously and coincidentally, there was a wave of campus nitrous parties where I was working, a couple of kids went out dorm windows when they leaned back on window screens.



Now that's impressive. Bummer for him, but impressive.


We have nitrous setups, they recently were just taken off the truck. ILS special events crews still use them and our ALS ski patrol uses it. 

I love nitrous, it works brilliantly for getting someone out of a jacket without having to cut it off and they don't even notice the IV stick if we decide to use narcotics.


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## wigwag (May 29, 2012)

For those EMT students out there, better look at your practical exam sheets.  For testing purposes, they usually like for you to immobilize before boarding.


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## Tigger (May 29, 2012)

wigwag said:


> For those EMT students out there, better look at your practical exam sheets.  For testing purposes, they usually like for you to immobilize before boarding.



If the patient is reasonably stable and both the traction splint and spinal motion restriction are required I see no reason why you would not put the splint on first. The splint eases pain and limits further movement, both of which are going to occur during any sort of log roll.


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## AnthonyM83 (May 30, 2012)

Veneficus said:


> I don't think it is so much "rigging" as using normal body mechanics, but you are right, it is probably beyond the basic EMT training. I would be willing to bet though if I showed you how to do it, you would be sold.
> 
> Anatomy is a wonderful thing to understand.


 Sure is! But social tact is also a wonderful thing to understand. As written, this post (and many others) have a condescending underlying tone to them. There's something that yells "ego". And this is coming from someone who doesn't always have the nicest sugar coated posts, either. That of course is a personal opinion.

Back to the topic, though. I've never had a problem closing the doors of the ambulance with a traction splint. We just move the backboard far enough up on the bench so a bit is hanging over the edge or resting on "captain's chair" or some put patient backwards on board. Also, locally trauma centers seem "decently" familiar with the Hare and Sager, and actually use both themselves from their own equipment room. I'm told it's an ATLS skill (?).


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## Doczilla (May 30, 2012)

Ortho doc showed me a way to rig up traction using a giant ace bandage or two, after using manual traction and securing to the other leg. It turned out later to be pretty decent, but then again I didn't have a fancy traction splint (read: no way to get resupply from a UH-60) . Simple, and easy. 

I've had good results with femoral nerve blocks for these types of tricky patients that didn't nessesarily need RSI yet pain meds were a slippery slope based on their  cocominant injuries and overall condition. This of course, is out of the question in the states for most of us. 

Works like a charm for tourniquet pain too.


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## Veneficus (May 30, 2012)

AnthonyM83 said:


> Sure is! But social tact is also a wonderful thing to understand. As written, this post (and many others) have a condescending underlying tone to them. There's something that yells "ego". And this is coming from someone who doesn't always have the nicest sugar coated posts, either. That of course is a personal opinion.



It is probably best if I don't reply to this.  I might say how I really feel.



AnthonyM83 said:


> Back to the topic, though. I've never had a problem closing the doors of the ambulance with a traction splint. We just move the backboard far enough up on the bench so a bit is hanging over the edge or resting on "captain's chair" or some put patient backwards on board. Also, locally trauma centers seem "decently" familiar with the Hare and Sager, and actually use both themselves from their own equipment room. I'm told it's an ATLS skill (?).



It is an ATLS skill. It is usually not given as much attention as the surgical skills though. More of a "by the way this is a teraction splint and this is how it works."


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## Doczilla (May 30, 2012)

Oh yeah, forgot to mention good point on the bone bleeding. A lot of people don't factor that in.


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## mycrofft (May 31, 2012)

wigwag said:


> For those EMT students out there, better look at your practical exam sheets.  For testing purposes, they usually like for you to immobilize before boarding.



Goingn to be hard to put a traction splint on someone in the back seat of a rollovered Honda Fit or old (pre-198's) VW Bug.


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## AnthonyM83 (May 31, 2012)

Which exam sheet are you referring to? 
Don't recall reference to backboarding or cspine on the NREMT traction splint sheet except for the final steps of securing to backboard...


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## zmedic (May 31, 2012)

mycrofft said:


> Goingn to be hard to put a traction splint on someone in the back seat of a rollovered Honda Fit or old (pre-198's) VW Bug.



The poster said "for testing purposes." In most testing scenarios the patient is just lying on the ground in front of you. They usually aren't inside of an actual car. So if the patient is just lying there with a femur fracture, put the traction splint on before backboarding.


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## Doczilla (May 31, 2012)

Ooh, now that you poked your head in, Doc, have you ever tried a femoral block?


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## mycrofft (May 31, 2012)

zmedic, agreed.


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