# compound/femur



## MCROP (Aug 27, 2010)

What would be the best way to deal with a compound fracture of the femur?


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## JPINFV (Aug 27, 2010)

Splint in place unless distal pulse/motor/sensation is affected. I would urge providers to never reduce an open fracture if it can be avoided because osteomyelitis is not fun.


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## MasterIntubator (Aug 27, 2010)

I have read some recent studies somewhere saying that using a traction splint is no more harmful in an isolated femur Fx vs an isolated open femur fracture.  

I can't recall the exact source, but it was both online and a new textbook ( Brady maybe? ).  It had military reference as well.

Anyone else read about that?


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## Akulahawk (Aug 27, 2010)

Splint in place if possible, and if able, provide pain relief. Pain may increase if/when autospliting begins to occur. The quads and hamstrings can be quite powerful, and difficult to overcome if you're having to provide traction to relieve pain.

If you DO decide to provide traction splinting, document the heck out of it. They're going to want to know that there really was an open Fx because the risk of infection is much higher than if the skin remained intact.


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## adamjh3 (Aug 27, 2010)

Akulahawk said:


> Splint in place if possible, and if able, provide pain relief. Pain may increase if/when autospliting begins to occur. The quads and hamstrings can be quite powerful, and difficult to overcome if you're having to provide traction to relieve pain.
> 
> If you DO decide to provide traction splinting, document the heck out of it. They're going to want to know that there really was an open Fx because the risk of infection is much higher than if the skin remained intact.



Aren't we NOT supposed to traction splint compound femur Fxs? That would leave a piece of bone "floating" giving a greater chance of it to shift and cause further injury, no?


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## JPINFV (Aug 27, 2010)

Ok... I might have prematurely rang that warnng bell. Here's what Up-To-Date has for midshaft femur fractures.



> Little clinical evidence exists to support the use of traction in the preoperative management of midshaft femur fractures. Nevertheless, many orthopedic surgeons advocate immobilizing well-aligned fractures, with or without neurovascular injury, in a skin traction device [2,28,29]. Those who support the use of traction claim that it reduces patient discomfort, improves fracture alignment, and may resolve problems with arterial flow. A systematic review of studies of traction for proximal femur (ie, hip) fractures found no clear benefit; comparable studies have yet to be performed in midshaft femur fractures. (See "Hip fractures in adults", section on 'Initial management'.)
> 
> Skin traction splints can be used for both closed and open fractures of the femoral shaft. Hare or Thomas traction splints are most commonly used. The device is attached to the ankle at one end and secured against the pelvis at the other. Traction is applied by pulling the ankle distally while the proximal end braces the pelvis to prevent it from moving, thereby enabling distraction of the femoral fracture fragments.


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## CAOX3 (Aug 27, 2010)

JPINFV said:


> Splint in place unless distal pulse/motor/sensation is affected. I would urge providers to never reduce an open fracture if it can be avoided because osteomyelitis is not fun.



I agree with this, infection and the possibility of internal bleeding caused by reducing an open fracture isnt going to benefit anyone.


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## Akulahawk (Aug 27, 2010)

adamjh3 said:


> Aren't we NOT supposed to traction splint compound femur Fxs? That would leave a piece of bone "floating" giving a greater chance of it to shift and cause further injury, no?


If the Fx has the bone still sticking out of the skin, traction splinting can be done, but you want to make sure that you document what you found before you apply traction. Either way, the patient is going to get antibiotics in an attempt to reduce the chance of allowing an infection to take hold. Also, if you do apply traction, you're going to have to apply a considerable force. The reason is that since the quads and hamstrings will contract, and this can cause the broken bits of the femur to grind against other bony fragments or dig into the musculature - both cause pain. 

As the article that JP posted suggests, there is little benefit to using a traction splint in a hip (femoral neck) fracture. In my experience, and in the experience of an Orthopedic Surgeon that I have had a chance to work with, mid-shaft femur fractures do benefit from traction splinting precisely because of the improvement in patient comfort. Being that most of those Fx's will be repaired surgically anyway, there won't be much clinical benefit to prehospital traction splinting of mid-shaft femur Fx, except for perhaps blood flow improvement, if it's compromised. 

Much of the info in the article was "new" stuff about 12-15 years ago. It is nice to know that info hasn't changed much since then.


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## MasterIntubator (Aug 27, 2010)

I would have to venture that there would be no more increased risk to infection than what is already there, and prone to come from what they may get from the hospital..  Nothing in the studies support it, but.... nosocomial infections from hospitals are well documented.

I suppose... see what your protocols say, and what your medical director advises.  We use it in all isolated femur fractures.


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## Akulahawk (Aug 27, 2010)

CAOX3 said:


> I agree with this, infection and the possibility of internal bleeding caused by reducing an open fracture isnt going to benefit anyone.


Infection is the biggest concern. Internal bleeding is a concern to me, but a remote one, but that can be managed, and with increased tension put on the musculature, you're going to see a decrease in bleeding as smaller capillary beds, arterioles, and such will have some tamponade effect. You're also going to see a slight decrease in the cavity volume after the reduction.

Being that the bony end(s) are already outside the body, they are already considered contaminated, so antibiotics will likely be given empirically.


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## JPINFV (Aug 27, 2010)

Quick note, I would post a link, but Up-To-Date is a subscription service, so if you have access to it you could easily get the full article and if you don't then...


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## Akulahawk (Aug 27, 2010)

Unfortunately for me, I do not have access to the "Up-To-Date" service. Ortho injury, among other things, was my bread-and-butter for several years. You could say that was my specialty, until I got into EMS.


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## adamjh3 (Aug 27, 2010)

Akulahawk said:


> If the Fx has the bone still sticking out of the skin, traction splinting can be done, but you want to make sure that you document what you found before you apply traction. Either way, the patient is going to get antibiotics in an attempt to reduce the chance of allowing an infection to take hold. Also, if you do apply traction, you're going to have to apply a considerable force. The reason is that since the quads and hamstrings will contract, and this can cause the broken bits of the femur to grind against other bony fragments or dig into the musculature - both cause pain.
> 
> As the article that JP posted suggests, there is little benefit to using a traction splint in a hip (femoral neck) fracture. In my experience, and in the experience of an Orthopedic Surgeon that I have had a chance to work with, mid-shaft femur fractures do benefit from traction splinting precisely because of the improvement in patient comfort. Being that most of those Fx's will be repaired surgically anyway, there won't be much clinical benefit to prehospital traction splinting of mid-shaft femur Fx, except for perhaps blood flow improvement, if it's compromised.
> 
> Much of the info in the article was "new" stuff about 12-15 years ago. It is nice to know that info hasn't changed much since then.



Thanks for clearing that up, I'll have to check my protocols to make sure that isn't where I heard that one is not supposed to traction splint a compund femur Fx.


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## Too Old To Work (Aug 27, 2010)

There's not a lot of science to support using a traction splint with an open or closed Femur Fx. Isolated mid shaft Femur Fx are fairly rare since someone who sustains enough trauma to cause a Fx to the biggest bone in the body probably has other significant injuries as well. 

The infection thing is pretty much a myth too. Anyone who has any sort of open injury is going to get a broad spectrum anti biotic pretty quickly, especially if they are going to the OR. You don't think that all those knives and bullets are sterilized before they are used, do you? 

Sadly, much of what we do in EMS is based on past practice, myth, and anecdote. 

Remember that the plural of war story is not data.


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## Akulahawk (Aug 27, 2010)

Too Old To Work said:


> There's not a lot of science to support using a traction splint with an open or closed Femur Fx. Isolated mid shaft Femur Fx are fairly rare since someone who sustains enough trauma to cause a Fx to the biggest bone in the body probably has other significant injuries as well.
> 
> The infection thing is pretty much a myth too. Anyone who has any sort of open injury is going to get a broad spectrum anti biotic pretty quickly, especially if they are going to the OR. You don't think that all those knives and bullets are sterilized before they are used, do you?
> 
> ...


Too True.


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## reaper (Aug 27, 2010)

The number one reason for traction splinting is pain relief! Take it from someone that has multiple Femur fx's, it is a night and day difference with traction. I will take traction over Morphine, any day!


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## adamjh3 (Aug 27, 2010)

reaper said:


> The number one reason for traction splinting is pain relief! Take it from someone that has multiple Femur fx's, it is a night and day difference with traction. I will take traction over Morphine, any day!



But if you can have both... h34r:


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## Aprz (Aug 28, 2010)

Too Old To Work said:


> You don't think that all those knives and bullets are sterilized before they are used, do you?


Slight tangent regarding infectious control, but I thought bullets heat-up significantly that infenction isn't a problem because of the bullet itself being sterile or not before being shot, but rather it being an open wound. Just what I thought.


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## JPINFV (Aug 28, 2010)

Too Old To Work said:


> You don't think that all those knives and bullets are sterilized before they are used, do you?



No, however the environment surrounding someone getting shot or stabbed and someone having an open fracture is more than slightly different. Punctures (be it stabs or bullet holes) don't stick into the ground when someone falls. Similarly, while bullets might not be sterile, I'd argue that they're generally pretty clean. Dirty bullets jam guns, which is a lesson the French learned the hard way with the Chauchat during WW1.


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## firetender (Aug 28, 2010)

*Just curious...*

Is the Hare Traction splint in use anymore, I didn't see it mentioned.


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## CAOX3 (Aug 28, 2010)

firetender said:


> Is the Hare Traction splint in use anymore, I didn't see it mentioned.



It is.


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## reaper (Aug 28, 2010)

firetender said:


> Is the Hare Traction splint in use anymore, I didn't see it mentioned.



It is mainly all I use. I only use a Sager if there is space issues.


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## Too Old To Work (Aug 28, 2010)

JPINFV said:


> No, however the environment surrounding someone getting shot or stabbed and someone having an open fracture is more than slightly different. Punctures (be it stabs or bullet holes) don't stick into the ground when someone falls. Similarly, while bullets might not be sterile, I'd argue that they're generally pretty clean. Dirty bullets jam guns, which is a lesson the French learned the hard way with the Chauchat during WW1.



Bacteria are pretty small. When I say dirty, I mean in the bacterial sense, not dirt clinging to the rounds themselves. If it's an open Fx, it's likely to get surgical debridement before being fixed. From my observation, every patient that goes to the OR gets a broad spectrum antibiotic before hand. 



Aprz said:


> Slight tangent regarding infectious control, but I thought bullets heat-up significantly that infenction isn't a problem because of the bullet itself being sterile or not before being shot, but rather it being an open wound. Just what I thought.



Bullets tend to drive debris, such as clothing, into the wound, hence the wound is contaminated. Knives don't do that, but they are pretty dirty as a rule. Either way, all patients with open wounds will get antibiotics before the trip to the OR.


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## JPINFV (Aug 28, 2010)

Too Old To Work said:


> Bacteria are pretty small. When I say dirty, I mean in the bacterial sense, not dirt clinging to the rounds themselves.



I'm willing to bet that if you cultured a bullet before being fired and culture the ground that the ground is going to have more bacteria than the head of a bullet before being fired. It's not that the bullet has been sterilized, it's just that it neither has the elements really needed for bacterial life nor is it really exposed to bacteria in the first place.


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## Too Old To Work (Aug 28, 2010)

JPINFV said:


> I'm willing to bet that if you cultured a bullet before being fired and culture the ground that the ground is going to have more bacteria than the head of a bullet before being fired. It's not that the bullet has been sterilized, it's just that it neither has the elements really needed for bacterial life nor is it really exposed to bacteria in the first place.



It's exposed to bacteria, if from nothing else, the hand that loaded it. The wound becomes contaminated not from the bullet itself (usually), but from the clothes and other debris that are pushed into the wound. 

My point was that worrying about sterility from open injuries isn't really a concern.  Open wounds are by definition going to have some degree of contamination no matter what the cause.


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