# Manual traction



## Topher38 (Feb 12, 2008)

Hey guys I went to a call the other day, The patient (17 year old male) had fallen riding a bike and broke his arm. The arm was deformed slightly distal to the elbow, there was a pulse, it was weak. Cap refill was a around 3 seconds. I was 3rd or 4th on scene so I let the guys who had made patient contact first take care of it. He had no other injuries and they splinted and off he went in the ambulance. So on the way home I was thinking about how it would have been handled if his arm had some cyanosis and a more delayed cap refill. Re-aligning?

Has anyone actually used manual traction to re-align a wrist (radius, ulna)? 

Howd the patient feel after wards? 

If so why and how did it go?

Have any examples (calls) to give? 

If your wondering why im posting this Its not that I dont know what to do but I would like to hear some stories and get some input. Plus splinting can be very creative so Im listening intently (<--spelt right?)

Thanks fellaz.


----------



## rgnoon (Feb 12, 2008)

Manual traction of a closed radial/ulnar frac:
  On the Street - definitely not.
  A day out in the Daks - i'd give it a thought.


----------



## Ridryder911 (Feb 12, 2008)

Most splinting I perform, I use manually traction. Unless grossly angulated and need to "splint as lies", most extremities will not splint in traditional splints without alignment. 

In regards to impeded circulation I will attempt twice and that's it. Obviously it is caused by factors that I cannot control in the field setting. The problem is no longer the fracture rather the absence of circulation. 

Patients are usually in severe pain, and sometimes the decreased pulses actually give paresthesia and decreased sensation. 

Of course patients patients will that the circulation return. Feel better? Not always, remember the fracture is still there with the swelling and damaged surrounding tissue. 

Examples, too numerous to discuss as an individual case. However; I did have one that I knew I had return pulses because of return bleeding. 

R/r 911


----------



## Paramajik (Feb 12, 2008)

*manual traction...*

I dont believe that manual traction is warranted on every fx.  Some times that i would consider traction:
1.  Only if you are going to manipulate it in an attempt to reduce the Fx in  
     the presence deteriorated neurovascular function.

2.  If angulation is severe enough to disallow appropriate packaging and
    transport.

There are several resons that I tend to splint as found.  We in EMS tend to have that thought that we have to do something... anything.  Sometimes leaving well enough alone is actually... doing something.  many studies have found that merely IMMOBILIZING, ice & elevation decrease edema and further tissue destruction.  Thereby, decreasing rehabilitation time that allows the pt to return to being financially productive sooner.  EMS positively effected another life.

Thats not to say that I wouldn't STABILIZE the fx site before and during splint application.  I realize its nomenclature.  There is a dramtic difference between stabilization and traction.

Just some thoughts...


----------



## Ridryder911 (Feb 12, 2008)

I agree, after re-reading my posts, I usually do very little. A simple splint can be applied without issue. I should had been more clear. Most fractures are well guarded and protected by the patient without major intervention. 

R/r 911


----------



## Ridryder911 (Feb 12, 2008)

I agree, after re-reading my posts, I usually do very little. A simple splint can be applied without issue. I should had been more clear. Most fractures are well guarded and protected by the patient without major intervention. 
I was discussing major fractures with obvious displacement and potential vascular compromise
R/r 911


----------



## Paramajik (Feb 12, 2008)

*Potential vascular compromise*

Could it not be said that all fx's have potential vascular compromise?  And, in light of that, we should manipulate every fx.

Rather, what is the clinical presentation of vascular compromise?  A capillary refill of 3 secs?  A mottled, cyanotic, cold portion distal to the fx site?  We're not really splitting hairs here. 

What is the Standard of Care for manipulation of fx'd extremities?

I think it's prudent to say... if distal neurovascuar function is not severely compromised, immobilize the extremity as you find it.  After all, re-implantation can be achieved at ~8 hours post-insult.

Not being a jerk.  Just stimulationg conversation.


----------



## certguy (Feb 13, 2008)

For an average call , why are you even considering manual traction if you don't have a long transport time ? Let the docs with the x ray machines handle that . Angulated fx can be easily splinted with SAM , ladder , or cardboard splints , or possibly anatomically . Hare or Saeger splints can be used for mid shaft closed femurs . Check neuros before and after and apply ice to control swelling and pain .


----------



## Topher38 (Feb 13, 2008)

Paramajik said:


> Not being a jerk.  Just stimulationg conversation.




No I know, This is the conversation I wanted to see. =] Because diffrent people have diffrent prefrences, so I was curious to hear some.


----------



## rescuepoppy (Feb 13, 2008)

The way most peole work in modern times why would you want to try manual traction.  You are almost always a short transport from a hospital where they have X-Ray and can see where the bone eneds are. The only way I would consider ths is if you are way out in the boonies.  First rule of E.M.S. is still do no harm.


----------



## Ridryder911 (Feb 13, 2008)

Paramajik said:


> I think it's prudent to say... if distal neurovascuar function is not severely compromised, immobilize the extremity as you find it.  After all, re-implantation can be achieved at ~8 hours post-insult.
> .


Much rather attempt to have the limb possibly be saved than to simply re-adjust it  (takes about 10 seconds) As well, how many re-implantation saves actually were successful? The curriculum is pretty clear if there is a compromise of no circulation to attempt to revive it. Then splint.


----------



## Code 3 (Feb 13, 2008)

Topher38 said:


> Has anyone actually used manual traction to re-align a wrist (radius, ulna)?



My protocols only allow me to realign angulated *long bone* fractures that present with neurovascular compromise (BHO). Therefore, the wrist alignment is a negative.

ALS can reduce any angulated long bone fractures with or without neurovascular compromise (SO).


----------



## Paramajik (Feb 14, 2008)

*No circulation*

Thanks Red for re-iterating my point.  Severe neurovascular compromise wou ld be consistent with findings of "no circulation".  The comment that i made about re-implantion was to simply illustrate a point.  The data that i have read regarding successful re-implantation shows success rates of between 60-78%.

:excl:Amazingly, I have seen anything related to simple management of musculoskeletal injuries.  We tend to forget about ice & elevation.  Lets not forget, decrease/control post-injury edema = decreasing rehabilitation time.  Its not really the lights & siren EMS that we hope for, but it has a true positive effect on the patients that we care for.


----------



## NJN (Feb 14, 2008)

I've been riding observer for about 8 months now and never have encountered a call where manual traction was needed, let alone any type of fracture (excluding c-spine, and except one call) to any bone. (I realize some of my MVA pts. could have had poss. rib fractures but they were boarded etc.) The only fracture call i have been on was the first call i ever responded to, (5 y/o F, fract. on playground at school) the school nurse packaged her up before we got there. I do realize that i am still fairly new hence my name, but even in my fairly busy town i would have thought that i would have had more fractures (not including c-spine).


----------



## cfrench (Feb 14, 2008)

'For the most part' When dealing with long bone fractures, I generally splint as found (assuming distal CSM's are intact). If the extremity is significantly angulated, I often will straighten using gentle traction for pt comfort. It just makes life easier and often cause decrease in pain during the transport. In these cases, premedicating with NOX works pretty good. NOX is easier to use than IV meds in this case. There is no great rush so it is better to take the time to make the transport more comfortable for the patient. Obviously we are using cold packs as well.
FWIW, IMHO, YMMV


----------



## evantheEMT (Oct 27, 2014)

I would use manual traction if only someone doesnt have a pulse in the extremity.


----------



## OnceAnEMT (Oct 27, 2014)

Protocols here don't allow for any attempt of reduction, CMS or no CMS, save for manual traction of the femur when you're going to use the KTD. 

That said, I am a little confused as to why there is so much clamor for traction of the forearm. I understand this is a scenario where CMS is compromised, but still. 

1. CMS is compromised when tourniquets are tied, and we are seeing full recovery for up to 8 hours of application. 

2. Manual traction is all sorts of contraindicated of a tibia or fibula fracture. Why would the radius and ulna be different? That said, do you plan on holding that traction?

3. Unless you are also doing conscious sedation, I couldn't imagine the pain of reduction of a fracture to the shaft of the humerus. You're going to put a kiddo through that? 

4. Are you able to tell the difference between a distal humerus or proximal radial or ulnar fracture and a dislocation at the elbow, in the field? (The answer is no, and attempted reduction of a fracture here when you suspected a dislocation, specifically in Pedis, will cause more damage)

All of that typed out, I realized this was a necro thread (been wondering why we've seen so much of Rid lately... heh. Back then we didn't know tourniquets could be kept on for 8 hours. Hell, I didn't even know if I had facial hair back then.)


----------



## RedAirplane (Nov 10, 2014)

I'm actually confused about this whole thing about traction. In my EMR (first responder) class I was taught to "splint in the position found."

In my EMT class, I was instead told to leave joints as found unless distal CSM was absent, in which case try to realign gently to restore CSM. For non-joint musculoskeletal injuries-- forearm, tib/fib, etc, return to the anatomical position and then splint.

This seems a bit different than what is said above. When do you "leave it in the position found" and when do you "realign to anatomical position?"

(Also, if you are in a first responder role without traction splint and you suspect a femur fracture, should you take manual traction until help arrives, or should that only happen prior to applying the traction splint?)


----------



## OnceAnEMT (Nov 10, 2014)

Ishan said:


> I'm actually confused about this whole thing about traction. In my EMR (first responder) class I was taught to "splint in the position found."
> 
> In my EMT class, I was instead told to leave joints as found unless distal CSM was absent, in which case try to realign gently to restore CSM. For non-joint musculoskeletal injuries-- forearm, tib/fib, etc, return to the anatomical position and then splint.
> 
> This seems a bit different than what is said above. When do you "leave it in the position found" and when do you "realign to anatomical position?"



It unfortunately seems to vary by protocol. I personally believe in "play it as it lies". That said, a majority of the time the patient is guarding the injury in the perfect position anyway. Ie, holding their fractured forearm up to their chest or their arm at their side. So much more damage can be caused by grossly moving it yourself. If we are talking SAR and we are in a cave and that arm that is stuck behind your head is between you being in the cave and you being not in the cave, well, you may feel some discomfort in a few seconds. But that's a different ball game. 



Ishan said:


> (Also, if you are in a first responder role without traction splint and you suspect a femur fracture, should you take manual traction until help arrives, or should that only happen prior to applying the traction splint?)



This is a very good question, and actually became apparent to me in a SAR drill a few weeks ago. Pt was being managed by searchers who first found her, I showed up as the medical provider, and determined that the shock she was experiencing (and deteriorating further into) was hopefully due to the suspected femur fracture. With the KTD still in a bag a mile away en route, I had one of the teammembers maintain manual traction. Took about 20 minutes before the KTD could be applied, but the traction was the "fix". What did I learn from this? Well, to start I went and learned how to jerry-rig a traction device out of a few things I always carry. Second, you do what you have to do. Traction was the last thing I could do with my very limited resources, so I had it done. As a first responder in the city, hopefully you don't have to have someone hold traction for so long. The important part is, once you have it, you can't release it. Kind of like not allowing a cold injury to re-freeze after warming. I don't suggest traction or reduction of any sort unless it is truly indicated (ie, they present with 3 hips and deteriorating vital signs). Otherwise you risk making a bad situation worse.


----------



## Handsome Robb (Nov 11, 2014)

Traction actually isn't contraindicated in tib/fib fractures.

We do conscious sedation on standing orders so pain management isn't an issue. We can attempt to realign fractures with compromised circulation AND >15 minutes to the ER however can only attempt twice.


----------



## Tigger (Nov 11, 2014)

Yup, if traction is required for extrication or for compromised circulation they get loaded up with fentanyl and valium (now ketamine) and an attempt is made. If unsuccessful we are supposed to call in. 

We are also now doing anterior shoulder dislocations on standing orders.


----------



## ERDoc (Nov 12, 2014)

Does anyone have hematoma blocks in the protocols?  It seems like this would be a good alternative if you don't have the ability to sedate/medicate.


----------



## Av8or007 (Nov 12, 2014)

ERDoc said:


> Does anyone have hematoma blocks in the protocols?  It seems like this would be a good alternative if you don't have the ability to sedate/medicate.




Good idea. This could even be taught to ILS providers who usually cannot give opioids. AFAIK this is a safe procedure with few contraindications. Lidocaine used for LA is very safe as well.


----------



## TransportJockey (Nov 12, 2014)

ERDoc said:


> Does anyone have hematoma blocks in the protocols?  It seems like this would be a good alternative if you don't have the ability to sedate/medicate.


We can do digital and.regional blocks on standing orders. Actually did a digital block last tour for a crushed hand that was allergic to nearly all narcotics.


----------



## ERDoc (Nov 13, 2014)

I find it interesting that this isn't allowed more.  Depending on where you are doing it, there are very few complications and can bring almost immediate relief, even if you don't plan on doing a reduction.


----------

