Commercial Splints to Immobilize Femur Fractures

This article accompanies “A Field Guide to Splinting,” part of the special supplement Combating the Hidden Dangers of Shock in Trauma, sponsored by North American Rescue, LifeFlow by 410 Medical, and QinFlow.

Sager Splint

In the early 1970s, Joseph Sager and Anthony Borshneck, MD, developed the Sager splint. Rather than steel rods positioned on either side of the fractured limb, the Sager sits between a patient’s legs and applies traction from the ankle, with counterpressure directed onto the ischial tuberosity (see Figure 1).

Hare-type splints are problematic when used for proximal femur fractures because the ischial pad may rest directly under the fracture, acting as a fulcrum. The Sager splint solves this problem and may be used for any type of femur fracture without concern for fracture location. The Sager also enables traction for bilateral femur fractures.

In addition, the Sager offers the ability to measure the actual traction applied. Because of this feature it is now commonly stated that optimal traction is roughly 10%–15% of a patient’s body weight (though this estimate may need modification with today’s expanding waistlines).¹ To measure traction force, earlier versions of the splint offered a traction dial, which extended past the foot like the Thomas and Hare. But the most recent Sager is nearly flush with the foot, making it much easier to fit in any type of basket, helicopter, or ambulance.

The utility and importance of traction quantification, however, remains debatable. Caregivers today monitor pain, perfusion, skin pressure points, and stability far more closely than numerical traction metrics. For those of us who live by “treat the patient, not the numbers,” the traction gauge is superfluous.

The Sager splint is sold in pediatric and adult versions.

Kendrick Traction Device and Monopole Splints

While the Sager was the first monopole splint, the KTD, invented by firefighter Rick Kendrick in 1986, was the first to move the monopole from medial to lateral leg.¹ For emergency physicians this greatly improved the ease of rolling a patient, performing a rectal examination, and inserting a Foley catheter. Made from aluminum rather than steel, it was the first to claim “relative radiolucency.” It was also the first traction splint to fit every size patient from pediatric to adult (see Figure 2).¹

But the KTD is most notable because it was a major leap in portability. Collapsible and weighing less than 20 oz, the KTD is easily stored in any pack or vehicle. Bilateral traction isn’t possible with the KTD, but for those who want to be prepared for such medical calamities, the price of 2 KTDs remains significantly less than a Sager. The KTD was a major advance in traction splinting and remains one of the best-selling traction splints to date.

Since the KTD patents expired, a variety of similar lateral monopole splints have come to market that are worthy of mention.

CT-6 Military and CT-EMS Traction Splints

The CT-6, made by Faretec, is the most notable KTD-like splint, largely because it’s currently in use by the US military. It features a pulley system with 4:1 advantage rather than a simple 1:1 cinch strap. Faretec also makes an orange-and-black EMS version (see Figures 3 and 4).

Both are made from carbon fiber. Whether carbon fiber is an actual advantage remains debatable because aluminum bends, while carbon fiber cracks. The pulley system is a definite advance (see Figure 5).¹ 

Interestingly, while 4:1 traction is the theoretical mechanical advantage, the experimental traction provided is still less than 1:1. For 40 lbs of force, the output traction is less than 35 lbs. And for the KTD the output is less than 10 lbs. Never underestimate friction!

The CT-6 also offers a single ankle hitch, which fits everything from small limbs to large boots, while the KTD requires a separate boot hitch.

CT-7 Leg Traction Splint

Faretec launched the CT-7, its improvement to the CT-6, in 2019 (see Figure 6). It no longer extends past the foot and now utilizes a screw mechanism to apply traction. This provides enormous mechanical advantage, but at the cost of application time. Roughly 30 turns of the screw are required for 2 in of extension (see Figure 7).

ITD (Improved Traction Device)

Built by Emergency Products + Research, the ITD offers a stronger cinch mechanism than the KTD but with no mechanical advantage. Like the CT-6 the pole sections are made of carbon fiber, and it offers a padded groin strap. The midleg straps are also labeled. The carbon fiber material is 10 times stronger and lighter than the aluminum pole currently used and does not conduct heat away from or transfer cold to the patient, as an aluminum pole will (see Figure 8).

OTD (Optimum Traction Device)

Made by the same company as the ITD, EP+R, the OTD and the KTD are virtually equivalent (see Figure 9).

Tactical Traction Splint (TTS)

North American Rescue has built a black KTD-like splint, the Tactical Traction Splint (TTS), which also features labeled midleg straps. It’s designed for use on patients with suspected midshaft femur fractures. Its durable container is made of 500-denier Cordura with a robust MOLLE system for easy attachment. The compact storage system allows for rapid and reliable deployment in tactical and prehospital settings (see Figure 10).

Slishman Traction Splint (STS)

In 2007 the current version of the STS was developed by Sam Slishman, MD, but it was only made available in the US by Rescue Essentials in 2012. Like the KTD and its relatives, it’s a compact lateral monopole splint. Like other lateral monopole splints, it fits all sizes from pediatrics to adults. There are several major advantages offered by the STS (see Figure 11).

• No extension past the foot—This is particularly important for tall patients and tight transports in elevators, basket stretchers, helicopters, and ambulances.
• Proximal traction—Other splints require the rescuer to apply traction distal to the foot. Proximal traction permits rescuers to remain closer to the patient’s head. It also makes traction readjustment easier in tight spaces like helicopters. And it has the side benefit that a cooperative and coherent patient can adjust traction to their own fractured femur to find the position of greatest comfort. Psychologically this is an enormous advantage because patients can control their own pain. With all other splints, the rescuer-patient interaction goes something like, “As traction is applied to your leg, you may feel discomfort, but eventually you will feel better.” With the STS, the dynamic shifts to, “Let’s apply traction together until you feel maximum pain relief.” It’s very different.
• Useful despite lower leg trauma—All other traction splints require an intact lower leg to apply traction. For patients with dislocated ankles, tibia fractures, knee sprains, or foot amputations, traction splinting can be impossible. Because the STS ankle hitch may be applied proximal to the calf or even patella, femur traction is still possible. In addition to the above distinctions, the STS weighs less than 25 oz, packs compactly, and permits patient rolling, rectal exam, Foley catheter insertion, and is relatively radiolucent, which means it’s transparent to an x-ray (see Figure 12).

Because it’s more rigid than KTD-like splints, the STS requires no midleg straps to maintain traction, though one is provided for rotational stability. For KTD-like splints, the midleg straps keep the splint itself from bowing. The STS is far more rigid, with negligible bowing.

Traction in the STS is delivered by an internal pulley mechanism, which offers traction comparable to the CT-6. The input force vs. output traction has been tested using more than 80 lbs of input force (see Figure 13).

The 2 data sets represent the difference in traction output, depending on which end of the splint is held fixed. Traction applied to a patient, therefore, is somewhere in between, because both the distal and proximal ends of the splint move in actual use.

Slishman Traction Split–Compact (STS–C)

In March 2020 the STS–C was launched by Rescue Essentials and targeted to medics for whom pack size and weight are critically important. The weight is less than 13 oz and pack length less than 13 in (see Figure 14).

Aside from its size, there are several main differences compared with the STS:

• The distal strap is well padded and designed for application proximal to the calf or patella for adults. For shorter adults or children, however, it can still be applied at the ankle (see Figure 15).
• The outer pole is held in place by a single spring button after extension. This speeds application by eliminating a thumb screw.
• Traction is still applied proximally from the hip. However, the lock mechanism utilizes a v-cleat. This also speeds application by eliminating the second thumb screw.
• Mechanical advantage is roughly two-thirds that of the STS.
• Rotational stability is provided by a pressure wrap, which is included within the carry bag. The wrap is applied around the feet, eliminating the need to lift the legs for midleg strap application.

Other Notable Traction Splints

Donway Pneumatic Traction Splint—The Donway splint is found mainly in Great Britain, Australia, and New Zealand. It most closely resembles the Hare, with 2 telescoping poles and distal traction from the ankle. It’s made in pediatric and adult versions (see Figure 16).

Traction is delivered pneumatically rather than mechanically. Groin padding is improved compared to the Hare, and traction can be monitored numerically through a pressure gauge (see Figure 17).

For whatever reason, the Donway splint never found its way into US markets. Given recent advances in splinting, the prognosis for the Donway seems poor.

Level One Trauma Splint (LOTS)—The Level One Trauma Splint (LOTS) from Tac Med Operator is unusual because it employs a carbon fiber rod positioned posterior to the injured leg. It also utilizes a material wrap with Velcro straps to completely splint the leg. Traction is applied from the foot, and like the KTD the LOTS utilizes a 1:1 cinch strap. It’s meant to be useful for splinting other types of fractures and is sold with a pelvic binder as well (see Figure 18).

For splinting any limb injury, the LOTS is an exceptional product because it delivers rigid long-axis and formable off-axis form-fitting immobilization. But for traction it suffers because of the added time for application and because it limits access to the injured limb.

Reel Articulating Splint—Perhaps the strongest, most “bombproof” splint to date, the Reel splint from Reel Research is also the most expensive. A variant of the Hare splint, the Reel features numerous points of adjustable articulation, enabling adjustable position-of-injury splinting for arms, legs, and knees (see Figure 19).

Fear of exacerbating injuries made the existence of the Reel splint possible years ago, and it was used extensively by the military for position-of-function immobilization. But today prehospital providers are more empowered and encouraged to align injuries on scene for transport, thereby greatly diminishing the need for the Reel.

Like the Hare, the Reel features 2 articulating parallel poles, a ratchet mechanism, numerous midleg straps, and handles to facilitate lifting. It is also, however, quite bulky and radio-opaque.

Reel Splint Hybrid System—Reel Research also offers a Reel Splint Hybrid System. This version has a unique twist. A pair of snap-ring twist “quick disconnect” sleeves are positioned at the distal end of the splint and allow the Reel’s exclusive traction ratchet to be inserted. With the immobilizer component in the straight and neutral position, the ratchet can then be connected. In this traction configuration there are 2 vitally important developments incorporated into the splint’s design (see Figure 20).

Reference

1. Rescue Essentials. Femoral traction: Evolution, engineering, and systems. Accessed April 3, 2022. www.rescue-essentials.com/femoral-traction-evolution-engineering-and-systems/

Sam Scheinberg, MD, is an orthopedic surgery specialist in Portland, Oregon, and has more than 60 years of experience in the medical field. He graduated from the University of Tennessee College of Medicine in 1965. He invented the SAM Splint during his tenure as an orthopedic resident at the University of Louisville in Kentucky. He and his wife, Cherrie, cofounded SAM Medical nearly 40 years ago to provide innovative practical solutions for the “feet on the street” in the prehospital world.