Manual Traction with Open Fractures - General Open Fractures

[DarthQWave]

Ok, stupid questions incoming from new EMT. I understand the importance of realigning deformed extremities, but my understanding on the exacts of some situations elude me - obviously baring that almost every situation will be different. So i'm just looking for some general guidelines.

Lets say you have open Tib/Fib fracture as the only injury/complaint/finding. (make up a funny story Minimal bleeding, cms intact - best case scenario to you. You and your partner attempt manual traction and the bones slip back into alignment. You splint the injury and everything is fine all the way to transfer of care.

But what if it's not? Using that same tib/fib example, along with most other open long bone fractures, what if as you are applying traction the bones do slip back into place, but they are now in such a way that they are cutting/damaging surrounding tissue? - Almost like a traction splint that you just "release tension" on after all that work. The PT screams in pain, you are obviously doing more harm then good, bleeding is increasing in severity. Do you stop traction and splint in place? What about open fractures where the entire foot lets say, is only holding on by thin muscle, skin and fat? - Do I just kinda "put it back" and splint in some form or another in place?!?

Anyone see what i'm talking about here? If anyone has any common sense/experience/knowledge towards this topic please help!

 

[Summit]

1. A. For a femur, what are the indications and contraindications for traction splint?
B. Do you apply manual traction first?
C. When do you "release tension"? What are the indications for that?

2. A OK, now tell me what the indications are for manual traction on an open tib fib?
B. Now explain the difference between traction into position and manual traction?
C. When do you precede hand stable with a TIP and when do you not?

 

[DarthQWave]

1. A. For a femur, what are the indications and contraindications for traction splint?
B. Do you apply manual traction first?
C. When do you "release tension"? What are the indications for that?

2. A OK, now tell me what the indications are for manual traction on an open tib fib?
B. Now explain the difference between traction into position and manual traction?
C. When do you precede hand stable with a TIP and when do you not?

I think you got a little confused, I am not saying you are to "release tension" on a traction splint - I was only equating that to pulling manual traction on an open long bone (not femur) fracture, and then letting go once the bone is realigned - obviously we are not holding traction on a long bone fracture all the way to the operating room. However, wouldn't that be pretty much the same thing? - The same as in getting someone with a femur fracture (with indications) secured into a traction splint and then just loosening up the straps and cranks? - Obviously something we would never do.

So in the case of an open long bone fracture, lets say radius/ulna this time, we pull manual traction and the bones are realigned. So then no manual traction is being held, what is to stop those bones from sliding on top of one another and causing further harm? -That is the essence of my question. Is manual traction to realign open fractures worth the additional trauma it may cause?

All that said here are the answers to your questions to the best of my ability. They may spur more questions from me -

1:

A. Painful, swollen, deformed, isolated mid-thigh injury with no other leg injury - contraindications would be anything other than those conditions. (While we are at it, it was never explained to me if a traction splint could be used an open femur fracture - could you explain that to me? I imagine it would fall under the indication of deformed if it was isolated, however i'm not sure.)

B. If I remember correctly, the femur injury only has to be stabilized before using the traction splint. All traction can be applied by the traction splint.

C. You would never release tension on the traction splint, again I think that was just lost in translation. At least we as ems field workers never would.

2:

A. Indications for manual traction, as I understand it on ANY long bone fracture, is deformity, inability to fit into splinting material, angulation or loss of distal cms. (Is that what you are implying? That we never apply traction on anything open in the first place?)

B. Manual traction is the act of manually applying force to straighten the angulated/deformed extremity prior to splinting. Traction into position is a term I've never heard - i'm imagining it would imply that the injury is now in correct anatomic position after result of applying manual traction?

C.TIP?

 

[Summit]

I think you got a little confused, I am not saying you are to "release tension" on a traction splint - I was only equating that to pulling manual traction on an open long bone (not femur) fracture, and then letting go once the bone is realigned - obviously we are not holding traction on a long bone fracture all the way to the operating room. However, wouldn't that be pretty much the same thing? - The same as in getting someone with a femur fracture (with indications) secured into a traction splint and then just loosening up the straps and cranks? - Obviously something we would never do.

You are describing Traction Into Position (TIP) which is not the equivalent of applying manual traction to an isolated midshaft femur preceding mechanical traction (splint). A femur you are going to give up to 15# of traction (because we have precise ability to measure ). TIP is going to be the absolute minimum force applied (slowly) to realign towards anatomical position in order to restore CMS, facilitate splinting, and hopefully reduce pain.

So in the case of an open long bone fracture, lets say radius/ulna this time, we pull manual traction and the bones are realigned. So then no manual traction is being held, what is to stop those bones from sliding on top of one another and causing further harm?

The muscles of, say, the forearm, are not going to be anywhere near as powerful as the thigh. But, there are still possibly sharp ends of bone hanging out.

So is it worth it? Remember, you are performing TIP because there is CMS compromise or because you are unable to adequately stabilize the fracture in its current position. You are NOT applying TIP to all long bone fractures as a matter of course because you can cause trauma during the procedure .

While we are at it, it was never explained to me if a traction splint could be used an open femur fracture - could you explain that to me? I imagine it would fall under the indication of deformed if it was isolated, however i'm not sure.)

Defer to your protocols here as this is a controversial topic. Traction on an open femur is controversial and some device manufacturers list it as a contraindication, due to risk of wound contamination. However, I think that's bunk as any open fx is getting debrided in the OR anyway. Of course, there is the question of whether you believe that traction splints are useful in the first place, which I'm not entirely convinced they are.

B. If I remember correctly, the femur injury only has to be stabilized before using the traction splint. All traction can be applied by the traction splint.

Yes. You may optionally apply manual traction while setting up the traction splint as resources allow. (Don't let go!)