To traction splint or not to traction splint?

[Summit]

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?

 

[mycrofft]

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.

 

[Chris07]

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.

 

[Chris07]

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

Tractions Splints in Wilderness Medicine

 

[Akulahawk]

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.

 

[Summit]

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

 

[zmedic]

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.

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.

 

[Veneficus]

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.

 

[Summit]

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.

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."

 

[Veneficus]

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?

This is where knowledge of pathophys comes into play.

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

Most of it is going to be soft tissue.

Since the body does a relatively good job of splinting itself, neurovascular injury is more of an exception than a rule.

Obviously on physical exam you will have distal neuro deficits, which may be mild like parasthesia or complete loss of motor/sensation. (The later being very rare)

Bleeding is also likely to be self contained. While technically it is possible to bleed to death in the compartment of a long bone, particularly the lower proximal extremity, the question becomes, if the injury is closed and the bleeding not self contained, what exactly do you plan to do about it?

External compression may work. But if it doesn't, it is going to take a knife. along with some exploration of where the bleeding is coming from.

If the bleeding is contained compartment syndrome may be an issue. That can only be solved with a knife and since it requires only ~ 30 mmhg pressure, you may still have a pulse with it.

But all of this boils down real simple.

Forget all of the fancy bells and whistles and get out of there. Evacuation should take precedent over any temporizing measure, because none of the serious consequences can be addressed in the field without "heroic" measures, which are more likely to fail than succeed.

 

[Luno]

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?

 

[Veneficus]

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.

 

[Luno]

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

 

[Veneficus]

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

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

Work harder.

 

[Luno]

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.

 

[Veneficus]

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.

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)

 

[mycrofft]

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.

 

[mycrofft]

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.

 

[Veneficus]

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.

 

[mycrofft]

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

(I knew, but I let it slide).