Splinting
fractured femurs: Then and now
For femur fractures, using a splint that applies consistent traction has several benefits. First, a traction splint stretches out the powerful muscles of the thigh (and the surrounding fascia), which compresses blood vessels embedded in the muscles and holds the bone ends in place. This helps reduce bleeding. Second, it prevents the broken bone ends from driving further into the surrounding soft tissue, which helps ease the pain. Third, in conjunction with supporting bands around the leg, the traction splint tends to align the broken bone ends within the limb.
When pain and bleeding are diminished, there's less risk of the patient going into shock. Credited with saving many lives, traction splinting is an important technique for anyone dealing with injuries from wilderness and athletic activities to master. This article reviews the different devices for traction splinting (commercial and improvised), and compares their pros and cons.
HISTORY OF TRACTION SPLINTING
The first practical traction splint was designed by a British orthopedic surgeon, Hugh Owen Thomas, in 1875. Thomas came from a family of Welsh bonesetters, who passed down their secrets from father to son. 1 He offered his splint to the French army during the Franco-Prussian War, but they did not adopt it, and it remained almost unknown outside his own practice until World War I. 2
In 1915, Sir Robert Jones (nephew and onetime apprentice of Thomas) introduced the device to the British and French armies. He called it the Thomas leg splint, and by 1918 it had reduced mortality in military femur fractures from 80 percent to about 7 percent. 3 Because almost all femur fractures in battle (usually from bullet and shrapnel wounds) were open, the Thomas splint saved lives mostly by controlling bleeding.
Even in a closed femur fracture, however, the patient can lose more than a liter of blood internally, so traction splinting is still important. The Thomas splint was made from a 3/8" steel rod bent to fit on either side of the leg, with a V-notch in the cross piece beyond the foot. The upper ends of the rod were attached to a padded ring, which had to be slid up the leg until it was braced against the perineum and buttocks. This ring made the splint awkward to apply to a fractured leg, so it was soon modified into the Keller-Blake hinged half-ring splint (which can be improvised from two ski poles, with the interlaced wrist straps replacing the half-ring). The half-ring is eased under the crease of the buttocks, and secured by an attached strap that goes over the top of the thigh. A variation on the Thomas splint was also developed for arm fractures (the Murray-Jones hinged arm splint). 4
A cravat bandage was used for the ankle hitch--and still is by many patrollers if they are improvising a traction splint, or if a commercial ankle hitch will not fit over the ski boot. The traditional way to apply traction, after connecting the ankle hitch to the V-notch of the cross piece with the tails of the cravat, was the Spanish windlass: Insert a stick between the cravat tails, twist the stick to increase tension, then lash or tape the stick to the splint. However, the leg tended to twist in the opposite direction, and if your hand slipped you could lose the traction, causing more pain and damage.
To avoid these problems, many rescuers used an improvised pulley system in which they would pass a cord back and forth a few times between the cross piece and the ankle hitch, pull on the cord until they achieved enough traction, and then tie the cord. The more times they went back and forth with the cord before pulling, the greater the mechanical advantage. Modern commercial traction splints also apply traction by pulling (with a cord, strap, or ratcheting device) rather than the twisting movement of the Spanish windlass.
Several people tried to improve the half-ring splint by adding attachments and accessories to it. In the late 1960s, then-ambulance attendant and policeman Glenn Hare developed a nylon ankle harness and ratchet that could be fitted onto the end of a half-ring splint. After Hare and his brother started their own company, Dyna Med, their improvements evolved into the Hare Traction Splint, which is still used today. 5 A Hare splint applies traction with a ratcheted cylinder mounted on the end of the splint. Cranking the cylinder winds up a strap attached to the ankle hitch.
In 1972, Joseph Sager and Dr. Anthony Borschneck developed an alternative traction splint, the Sager, 6 which they patented and began marketing in North America in the early 1980s. 7 The Sager splint, which is placed on the inner side of the leg, has a padded cross-piece that presses against the ischial tuberosity for counter-traction. The ischial tuberosities are bulges on the rings of the pelvis that form the floor of the abdominal cavity and support the body's weight in a sitting position. Since they are medial to the hip socket, putting pressure on them does not displace the proximal end of a fractured femur, even if the fracture is to the femur neck or close to the proximal end of the shaft.
If a commercial Sager splint is not available, for example in a backcountry setting, a similar device can be improvised with a pole, using one of the patient's shoes as the cross piece and socket for the pole (though this would not work with a massive ski boot). Then you'd attach a loop to the other end of the pole and use the same cord pulley system as with the Thomas splint. 8
In 1986, Richard Kendrick introduced another alternative design, the Kendrick Traction Device (KTD), which was much lighter and more compact. The stabilizing rod resembles a segmented aluminum tent pole, and the KTD fits into a socket on the groin strap. (Kendrick also invented the Kendrick Extrication Device [KED] in 1979, a sort of reinforced corset that immobilizes the cervical spine.) Like the Sager, the KTD can be fitted without lifting the leg, but the splint goes on the outside. A piece of webbing (connected to the ankle hitch) loops over a plastic horn at the foot end of the splint, and traction is applied by pulling on a strap. A device similar to a KTD can be improvised by placing a long pole on the outer side of the leg, securing it to a groin strap, and applying traction with a cord pulley system.
A newer traction splint, the Faretec CT-6 is similar to the KTD, but has a carbon fiber pole rather than aluminum. Traction is applied by pulling a cord that runs through a ratcheted pulley, giving a 4:1 mechanical advantage.
An even lighter traction splint was developed by Dr. Sam Slishman. The device, patented under the name Adjustable Support, is a hollow Black Diamond collapsible pole with an inner cord that is looped through a system of pins, which creates a pulley mechanism with a mechanical advantage of 4:1. Like the KTD and CT-6, the Slishman splint goes on the outside of the leg, and connects to a groin strap and ankle hitch, which can be improvised or purchased with the splint. So you can use this splint as one of your two ski poles, since you can improvise the groin strap and ankle hitch from cravats or webbing. One other benefit of the Slishman splint is that it pushes on the ankle hitch connection and does not extend past the foot, which makes it easier to load the patient into a toboggan or helicopter.
WHEN TO USE TRACTION
Emergency care textbooks recommend traction splints only for midshaft femur fractures (meaning the middle third of the bone), and not for distal or proximal femur fractures. If applied to a distal femur fracture near the knee, a traction splint could twist the bone end enough to injure the popliteal artery or nerve. With proximal fractures, splints that use ischial pads, such as the Hare, lever the proximal end of a fractured femur upward when the padded half-ring is placed under the thigh.
Splints that do not use an ischial pad, such as the Sager, KTD, Faretec CT-6, and Slishman would not cause this problem because they do not place anything under the thigh except straps or cravats. Manufacturers of splints that do not use ischial pads may recommend their products for use with proximal shaft fractures as well as midshaft fractures. Most proximal fractures, however, are hip fractures in the elderly population (who often have osteoporosis), not wilderness or athletic injuries.
COMPARING TRACTION SPLINTS
The modified Thomas splint, Hare, and improvised splint with two ski poles all require that the leg of a supine patient be lifted before they can be applied; and it would be very awkward to secure these splints to a patient in any other position. Sager, KTD, CT-6, and Slishman splints, however, can easily be applied without lifting the patient's leg. They also help care providers avoid another problem that results from lifting the patient's leg--when the person applying the ankle hitch must work around the hands of the person supporting the injured leg, who, in turn has to maintain manual traction until it is replaced with mechanical traction.
Because the ischial pad bar on the Hare splint is only slightly curved, it actually puts more pressure on the proximal end of a fractured femur than the Thomas splint, whose half-ring comes up enough so that it presses on the ischial tuberosity for countertraction.
A Sager splint can be applied to a patient who is prone or on his or her side as well as supine, provided the legs and body are straight. Traction is applied by extending the sliding inner shaft, which pulls a cable passing over a spring-loaded tension gauge. This has three advantages: First, it enables you to apply measured traction; second, the spring helps maintain traction as resistance is reduced by the relaxation of the thigh muscles. Third, because there is only one metal rod, the Sager presents less interference in lateral-view x-rays than the Hare, which means the fracture can be seen more clearly.
The slender shafts of the KTD and CT-6 also tend to create less interference when a tractioned leg is x-rayed. These splints are much lighter and more compact than a Sager or Hare, so it's likely that these will be the ones used by wilderness rescuers who must carry everything in their packs. Trained rescuers can apply traction with the KTD,CT-6, or Sager within a minute or two. Thomas splints and improvised splints, however, take considerably longer to set up and apply, so it is important to apply manual traction if someone is available to do it. But put the ankle hitch on first (if possible), so as to avoid having to work around the hands of the person applying manual traction, or risk losing traction as that person changes his or her grip.
CONCLUSION
Traction splinting can dramatically reduce pain, blood loss, and tissue damage in femur fractures. It has always been an important skill for alpine ski patrollers, though there are limitations with the older devices such as the Thomas and Hare splints. More recent designs, however, have overcome these limitations; and the availability of lightweight or improvised traction splints puts this potentially life-saving technique within the reach of nordic patrollers, as well as other wilderness rescuers.
ENDNOTES
1 Williams H, "Hugh Owen Thomas," in Doctors Differ (Springfield: Charles C. Thomas, 1946).
2 Frederick Watson, The Life of Sir Robert Jones (London: Hodder & Stoughton Ltd., 1934).
3 Sinclair M, The Thomas Splint and its Modifications in the Treatment of Fractures , Preface by Sir Robert Jones (London: Oxford University Press, 1927).
4 American Red Cross First Aid Textbook, revised (Philadelphia: The Blakiston Company, 1937).
5 Thom Dick, "Good Hare Day: Taming that Wild Traction Splint" JEMS 29 (4):16, April 2004.
6 Anthony Borschneck and M.A.Wayne, "Sager Emergency Traction Splint: A New Splinting Device for Lower Limb Fractures," The EMT Journal 4, no. 1 (March 1980): 42-47.
7 Anthony Borschneck, in personal letter to the author, April 15, 2004.
8 Steve Donelan, Wilderness Emergency Care . American Safety & Health Institute, 2001.
Improvised traction splint with two ski poles
Photos & more information about commercial traction splints
Faretec traction splints: http://www.faretec.com/
Kendrick traction splints: http://www.epandr.com/products/traction/KTD.htm
Slishman traction splint: http://www.geocities.com/slishmansplint/
Sager traction splint: http://www.sagersplints.com/