Sacred Cow Slaughterhouse: The Traction Splint

In this article Gene and Kelly discuss the indications, use and efficacy of one of the oldest devices used in prehospital medicine, the traction splint.

Gene: For as long as Kelly and I have been in EMS, the traction splint has been a required item on ambulances. In the 1950s, when I first became an “ambulance driver” in Texas, the only items of equipment required on an ambulance were a first aid kit and a traction splint. There was no requirement that anybody know how to use either of them.

As we have progressed to changes in concepts of oxygen administration, spinal restriction application, hypothermia and pain management, we still have the mandatory traction splint on our ambulances. Do we really need it?

Kelly: I think we can agree there benefits to splinting, but does that extend to traction splinting? Splinting as a packaging technique can increase a patient’s comfort, protect soft tissue and nerves from injury by jagged bone ends, and perhaps minimize bleeding and reduce the possibility of fat emboli.¹ But the question remains, does traction add any significant benefit? Traction splints take some time to apply properly, and in a patient with multiple injuries, that time might be time better used moving the patient toward the place where their injuries can be treated surgically.

In my 20 years in EMS, the patients I’ve encountered with isolated midshaft femur fractures (and thus indication for a traction splint) can be counted on two hands with fingers left over. And if you’ve ever tried to load a patient with a Hare Traction Splint into a BK 117 helicopter or a type II ambulance, you become intimately familiar with the phrase “space limitations.” When instructions for packaging include the directive, “Load ’em on the stretcher backward,” that is strike one against the prehospital utility of the device.

Gene and I tried to find out whether there is any reliable evidence that traction splints make any difference in ultimate outcomes when they are used. So we tried to find every research article and study ever done on traction splints and evaluate the findings. What we found was lots of opinion and not much definitive research. Ten years ago authors Bryan Bledsoe and Donn Barnes reviewed the literature and concluded that “with the relatively low usage of the traction splint, it may be time to revisit guidelines that require traction splints on every ambulance and rescue vehicle. They may be, in essence, an EMS relic we may want to part with.”² The fact is, there were no definitive studies demonstrating efficacy or decreased morbidity or mortality from prehospital use of traction splints 10 years ago, nor are there any now.³ So our use of traction splints is purely anecdotal.

Gene: My first experience with a traction splint happened on a miserably cold night in north-central Texas. It was sleeting and snowing, the temperature was 10ºF, and the wind was blowing 15–20 miles an hour. We responded to a head-on collision five miles out of town and 30 miles from the nearest Level 3 hospital. We found an 18-year-old female who had been extricated from the wreckage by bystanders. She was lying on the highway without any covering whatsoever.

As we had been taught to do, we cut her clothing off to inspect her injuries. We saw a closed midshaft fracture of her right femur and went to get the traction splint. I remember being really hyped because I had practiced applying it many times, to what I and the deadly serious examiners from Texas health department had deemed perfection. This required slow and steady application of the splint, being careful not to move the leg while measuring the splint, then applying traction in the proper way, carefully sliding the splint under the leg, fashioning the ankle hitch out of a triangular bandage and sliding it under the foot just right so as not to move it, carefully snugging it up, and then pulling traction in a smooth motion without any undue movement of the leg.

My partner and I talked over the steps we were taking just as we’d been taught. Good communication was a factor in passing the skill station. After traction was applied, we slid the splint under the leg and made it snug against the ischial tuberosity, applied the hook to the ankle hitch and applied traction. Then we carefully attached the straps from distal to proximal, making sure none of them covered the site of the fracture. Then we moved the patient to the long board, secured the splinted leg with a triangular bandage, and lifted her onto the cot and into the ambulance. This was a good 15 minutes after we arrived on scene.

Kelly: Not to mention that all this time she was becoming hypothermic. Of course, in those days we thought that hypothermia might actually help trauma patients. That was before we heard about the Triad of Death.

My first application of a traction splint was in a nice, warm nursing home. The splint was an off-brand folding contraption with a ratcheting traction bar, but nobody could figure out how to get it to release. We wound up fashioning a Spanish windlass tied to the end of the splint and pulled traction with that. And just like they taught us in class, our patient experienced significant pain relief once we got the bone ends aligned.

Gene: One thing that we didn’t notice at the time but saw when the first X-rays came back was that the bone was angulated at a 45º angle. This was because the “heel stand” on the splint was not high enough to create a straight plane for the bone. Nobody had told us that—not the “Orange Book” or Nancy Caroline.

Kelly: Our patient fared better than yours, Gene. X-rays showed our patient’s femur was perfectly aligned…with the bone ends about two inches apart. Of course, we had no way of determining if we tore any muscle or endangered her femoral artery in any way, but it bears considering.

Gene: After I graduated from my role as a Red Cross first aid provider, which was all that was required then, and went through EMT and paramedic school, I started thinking about things in terms of whether they really worked. I had grave doubts about the traction splint, so I started reading all the literature I could find. There was very little. But what I did find was this:

The first traction splint was designed by John Hilton in 1860 and later modified by Hugh Owen Thomas, a British orthopedic surgeon in 1875. He invented it purely for in-hospital use for femur fractures, although he was alleged to have presented it to the French army during the Franco-Prussian War, but they did not adopt it. Nobody used it but him, it seems, and never in the field, until 1915 when his nephew, Sir Robert Jones, showed it to the French and British armies. He called it the Thomas leg splint. Most femur fractures in battle were caused by bullet wounds, and the splint supposedly saved lives by controlling bleeding, except that there were no studies documenting this. This splint came to be known as the Thomas half-ring splint, because it had a padded, hinged ring attached to a bent steel rod that is positioned up against the buttocks and the ischial tuberosity. It required the use of bandages to form the leg slings and make the ankle hitch and create a windlass that could be twisted to create traction.⁴

Kelly: One of the larger hospitals in our area still has a Thomas half-ring splint leaning against the wall among all the unclaimed EMS equipment. I found it quite telling that one of our new orthopedic residents didn’t know what it was.

Gene: A search of the literature regarding use of traction splints reveals lots of opinion and not much research. Reasons for using traction splints can be boiled down to these:

• Stabilizing bone ends to avoid further injury to soft tissues from movement;
• Reducing bleeding;
• Relieving pain.

Kelly: Yes, but as I alluded to earlier, all of those supposed benefits apply to splinting in general. Does adding traction to the mix provide any additional benefit? And is pain relief that important an indication when we have effective analgesics like fentanyl and ketamine? As a provider, if I have someone lying on the floor with a broken extremity, I’m going to provide narcotic pain relief before I package them, because the very act of splinting and packaging can be quite painful.

Besides, contraindications and possible complications are many. Patients with osteoporosis are possible contraindications, as are elderly patients with fragile skin. Traction splints should not be used for proximal or distal fractures of the femur, or where there are knee, lower leg, ankle or foot injuries, or in patients with pelvic fractures. It’s a rare patient indeed who sustained enough kinetic energy to fracture the strongest bone in the human body without also damaging those other structures.

Given the fact that we have no X-rays or CTs in ambulances, it can be a challenge to spot a pelvic fracture or occult knee injury. Reported complications have been soft tissue injuries from pressure from the splint, compartment syndrome in the foot resulting in arterial damage and thrombosis, and peroneal nerve damage.^5–7

Gene: There have been few reliable studies comparing outcomes from patients who had traction splints applied to their femur fractures and those who did not. One study done by physicians at the Israel Defense Forces Trauma Branch in 2007 stated the following:

Traction splints still are essential for wartime extremity injuries. Traction splints should be used for isolated femoral fractures and gunshot wounds in victims without concomitant life-threatening injuries. In an open or gunshot fracture, the indication for splinting is even greater, due to the possibility of neurovascular and extensive soft tissue injuries. In the case of pelvic injuries with leg or ankle injuries on the same side, the splint may be applied without traction. The splint was advocated for the rapid transport scenario and delayed transport scenario. In the urban setting, traction splints may not be necessary; simply tying one leg to another may suffice. Tourniquets should not be applied to control hemorrhaging from femoral fractures, since they will fail and may cause further injury.⁸

This study suggests that in urban settings, traction splints may not be necessary, but no comparative studies are cited. The statement that “tourniquets should not be applied to control hemorrhaging from femoral fractures, since they will fail and may cause further injury” seems not to be supported by current understanding.

I had a patient who had an open femur fracture with a laceration of his femoral artery whose life was saved by his coworker who used a rope to make a tourniquet to stop arterial bleeding, which was spurting 15 feet from the patient. The wound was football-size and shaped, and it was filled with coagulated blood. I covered it with a trauma dressing, gave him fentanyl for his pain and left it alone. If I had applied a traction splint, there is no question in my mind it would have caused him to bleed out.

Kelly: And if you had followed your protocol, you would have been subject to a claim for wrongful death because you caused harm and violated the standard of care. It has been said before, “They’re protocols, not suicide pacts.” If you’d been working under a protocol that mandated applying a traction splint to all femur fractures, you would have had to decide which to follow—your protocols or good patient care, and you could have been criticized either way. I am thankful to work for an organization that does not expect blind adherence to protocol, provided documentation supports the medic’s decision.

Gene: The subject of “standard of care” arises often when we debate treatment options. Standard of care is an illusory concept, and in reality we do not decide what it is—ultimately a jury does. We can discuss standard of care from a purely medical standpoint, but the ultimate decision only happens in court. Otherwise we are simply debating the issues among ourselves.

In talking to many colleagues both prehospital and in-hospital, I have found that the traction splint is rarely used today. The issues confronting combat medics and urban medics, while similar in some ways, are different in terms of time from injury to definitive hospital care. Enough force to fracture a femur may well cause other injuries that may take priority over femur fractures. A bleeding liver or spleen will not wait on application of a traction splint.

In 2001 Dr. Neal Abarbanell studied a group of patients in a large urban area to determine the incidence of use of traction splints. Of 4,513 patient reports reviewed for a 12-month period, 16 patients presented with mid-thigh injuries, of which 5 were identified by paramedics as being midshaft femur fractures. Traction splints were applied only twice, with the other patients being managed by long board immobilization or other rigid splints.

Abarbanell concluded that “prehospital mid-thigh trauma is encountered on an extremely rare basis,” and that “long backboard immobilization, rigid splinting, and/or patient transportation in a position of comfort, based on severity of injury, may constitute an acceptable course of care in the treatment of mid-thigh injuries/suspected femoral shaft fractures. Including [traction splints] as essential equipment for ambulances may be unnecessary. Further investigation using randomized treatment protocols and larger populations…is necessary before the findings of this study…can be universally applied to all prehospital situations.⁹

Of course there have been no randomized studies done before or since then in any patient population.

Kelly: Another issue surrounding traction splints is use for open fractures. According to two studies of military injuries, open fractures occur in about 11%–17% of combat casualties and are usually grossly contaminated from bullets and fragments of explosives.^10,11 Prehospital irrigation of such wounds is recommended, but to my knowledge no EMS service has protocols that suggest en-route irrigation of open femoral fracture wounds with saline and IV antibiotics administration, and this is probably not feasible for most services other than remote frontier and wilderness settings. And the authors of that study stated that “splinting, irrigation and wound care should never delay evacuation of a patient with an open fracture and a penetrating torso injury even if stable. Splinting these patients in the field increases on-scene time and endangers their well-being.”

Certainly irrigating the wound in Gene’s patient with the large, gaping open wound would have not been the right thing to do at that moment.

I was taught as an EMT that open fractures were contraindications to traction splints, for fear that drawing contaminated bone ends back into the wound would increase the chance of infection. Given most orthopedists I’ve known, I’d say it’s a pretty solid bet that most patients who require surgical stabilization of fractures will be receiving intravenous antibiotics. I refer you to the old joke about the Orthopedist’s Law of the Heart: “The heart is that organ in the chest whose purpose is to pump Ancef to the bones.”

Gene: I think we can probably agree on these points:

• There have been no randomized studies on the use of traction splints to determine whether they make any differences in overall patient outcomes.
• It is highly unlikely that any such studies will be done, given the extremely low incidence of femur fractures, the many contraindications and possible complications that would exclude many prospective patients, and the cost of such studies.
• Traction splints can reduce pain and discomfort, possibly limit soft tissue and nerve damage, and limit hemorrhage.
• Traction splints can cause nerve damage, soft tissue damage and compartment syndrome in extremities.
• Traction splints may either decrease bleeding or increase it, depending upon individual circumstances—there are no studies that prove this either way.
• For a patient with an isolated midshaft femur fracture and no other apparent injuries, traction splints may be appropriate, but there is no medical evidence to show they would improve the patient’s ultimate outcome.
• Time used applying traction splints on-scene for patients with multiple injures would better be used in transport to the appropriate trauma center.

Kelly: Stephen Wood, et al., concluded that in multiple-trauma patients there are often injuries that complicate or contraindicate traction splints. There is limited medical evidence for their use, and other methods of bone immobilization may be just as good. And when contraindications exist, they should be avoided.³

Intuitively, the need for a traction splint is clear. When a femur breaks, the quadriceps group spasms, causing bone ends to override one another, sawing into delicate vascular and nervous tissue. Common sense would dictate that a device to align those bone ends would be beneficial.

However, let’s consider all the other treatments we used to provide whose benefits were “intuitively obvious,” yet medical research proved them to be ineffective, and in some cases harmful: long spine boards, high-flow oxygen, high-volume fluid administration, and withholding pain medications. It may well be that traction splints need to be added to that list.

Is removing traction splints from ambulances altogether going a step too far? If so, what kind of traction splint works best? The short answer is, we don’t know, but we’d love to hear your opinions. Let us know what you think in the comments or on EMS World’s Facebook page.

References

1. Gerhardt RT, Mabry RL, De Lorenzo RA, Butler FK. Fundamentals of Combat Casualty Care, Ch. 3, www.cs.amedd.army.mil/borden/book/ccc/UCLAchp3.pdf.

2. Bledsoe B, Barnes D. Traction splint. An EMS relic? J Emerg Med Serv, 2004 Aug; 29(8): 64–9.

3. Wood SP, Vrahas M, Wedel SK. Femur fracture immobilization with traction splints in multisystem trauma patients. Prehosp Emerg Care, 2003 Apr–Jun; 7(2): 241–3.

4. Henry BJ, Vrahas MS. The Thomas splint. Questionable boast of an indispensable tool. Am J Orthop (Belle Mead NJ), 1996 Sep; 25(9): 602–4.

5. Agrawal Y, Karwa J, Shah N, Clayson A. Traction splint: to use or not to use. J Perioper Pract, 2009 Sep; 19(9): 295–8.

6. Mihalko WM, Rohrbacher B, McGrath B. Transient peroneal nerve palsies from injuries placed in traction splints. Am J Emerg Med, 1999 Mar; 17(2): 160–2.

7. Watson AD, Kelikian AS. Thomas splint, calcaneus fracture, and compartment syndrome of the foot: a case report. J Trauma, 1998 Jan; 44(1): 205–8.

8. Melamed E, Blumenfeld A, Kalmovich B, Kosashvili Y, Lin G; Israeli Defense Forces Medical Corps Consensus Group on Prehospital Care of Orthopedic Injuries. Prehospital care of orthopedic injuries. Prehosp Disaster Med, 2007 Jan–Feb; 22(1): 22–5.

9. Abarbanell NR. Prehospital midthigh trauma and traction splint use: recommendations for treatment protocols. Am J Emerg Med, 2001 Mar; 19(2): 137–40.

10. Mabry RL, Holcomb JB, Baker AM, et al. United States Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield. J Trauma, 2000 Sep; 49(3): 515–28.

11. Jacob E, Erpelding JM, Murphy KP. A retrospective analysis of open fractures sustained by U.S. military personnel during Operation Just Cause. Mil Med, 1992 Oct; 157(10): 552–6.

William E. “Gene” Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and urban settings and the offshore oil industry. He has testified in court as an expert witness in a number of cases involving EMS providers and lectures on medical/legal aspects of EMS. He lives in Tucson, AZ.

Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a frequent EMS conference speaker and author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between and the popular blog A Day in the Life of an Ambulance Driver.