The Fractured Femur: Acute Emergency Care Treatment

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Paula Carter
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1 /79/ $02.00/0 THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright O The Orthopaedic and Sports Medicine Sections of the American Physical Therapy Association The Fractured Femur: Acute Emergency Care Treatment GEORGE J. DAVIES,* MED, PT, ATC, REMT, CET; GEORGE T. ANAST,? MD The most effective emergency care for a fractured femur is the use of a mechanical type traction splint such as developed by Hare and described herein. After general emergency care guidelines using a well-designed properly applied device will lead to significant decrease in pain, marked decrease in morbidity and mortality, and general improvement in the level of the care of the injured athlete. The study of sports medicine has expanded to include injuries that are peculiar to some sports and common to all active sports. Fractures of long bones comprise only a small portion of general sports medicine problems, but constitute a rather large portion of certain of the active sports, such as: skiing, water skiing, bob sledding, and horseback riding. In all of these latter activities the participant is moving at a relatively high velocity where opportunities for falls or misadventure are common. Fractures of the femur are encountered relatively infrequently in general sports medicine. This is fortunate since this injury is extremely serious and is attended by a very substantial morbidity and occasional mortality. It, therefore, behooves all those involved in sports medicine to be familiar with the safest and most effective ways of managing fractures of the femur. Since this is an uncommon injury, similar principles of management and techniques of application for other longer bone fractures would be similar; e.g., management of tibia1 shaft fractures. Fixation splints or so-called coaptation splints have been used for many years to immobilize broken bones and adjacent joints. However, fixation splints have only minimal effect in relieving muscle spasm and immobilizing the fractured ends that cause overriding of the bone ends with concommitant soft tissue damage. - * Acting Chairperson and Assistant Professor of Physical Therapy. Staff Athletic Trainer. Staff. La Crosse Exercise Program, University of Wisconsin-La Crosse, La Cross. WI t Orthopaedic Surgeon, Lakeland Orthopaedic Associates. Ltd.; Woodruff. WI and Medical Director of the Office of Emergency Medical Services of the Wisconsin State Division of Health. 53 In handling long bone fractures, particularly the femur, the development of the traction splint by Sir Hugh Owan Thomas represented an extremely significant contribution to fracture care. Over the years, the use of the traction splint has become accepted as the method of choice for management of femoral shaft fractures. It is a compliment to Hugh Owan Thomas that his initial design has needed minor adaptations to simplify its use and has been little improved upon over approximately the last 100 years. Proper application of a modern day mechanical traction splint applied by adequately trained personnel increases the comfort of the patient, minimizes serious complications (permanent crippling), and eases the transportation of the injured patients to a very substantial extent. GENERAL ACUTE EMERGENCYCARE GUIDELINES Individuals responsible for emergency medical care, including athletic trainers and emergency medical technicians, must consider all the factors surrounding an injury. The femur is the longest, strongest bone in the body and to break such a bone requires extreme force. Consequently, the same force that served to break the femur may have resulted in other injuries to the patient and therefore a systematic physical examination is imperative. Initially, the patient's airway, breathing, circulation, and vital signs must be checked, stabilized, and monitored. If possible, a history should be obtained in which the mechanism of injury is determined. Subjective complaints on the part of

$A quick, handsmon, objective ex- Individuals sustaining a femoral fracture ordiamination should then be performed.$

2 54 DAVIES AND ANAST Vol. 1, No. 1 the patient must be evaluated. "Listen to the Clinical Presentation (Signs and Symptoms) patient! He is telling you the diagnosis," said Sir william osier. A quick, handsmon, objective ex- Individuals sustaining a femoral fracture ordiamination should then be performed. it is imper- narily experience severe Pain and shock-like ative that the examiner run his hands over all Symptoms may develop due to the decrease in parts of the body and test all joints to determine the pressure as a consequence Of the if additional injuries are involved. After the his- hemorrhaging, pain, and discomfort. The foot tory and rapid complete physical examination of may be turned Outward as a consequence Of the the patient, one is in a position to make an fracture and the action of the surrounding musassessment of the patient's problems and insticulature. The injured limb may be shortened due tute a treatment or management plan with appro- Overlapping Of ends and muscular priate disposition of the patient. spasm. The proximal fragment tends to be some- During the course of any initial examination, it what flexed as a of spasm of the is wise to remove or cut away clothing that iliopsoas (Fig- '1. obstructs the view of the injured area, an open Evaluation of the patient with a fractured femur wound is present, it must be thoroughly evalu- seldom involves difficulty in making a proper ated and treated. ~ i l ~ comparison t ~ ~ of ~ obser- l assessment and impression. In individuals with vation for swelling and discoloration can be per- a large heavily muscled thigh, the impression formed to determine if there is a significant may sometimes be in doubt. If the fracture is at change in one extremity. the proximal end, substantial difficulty may be T~ perform a proper examination it may be involved in making the assessment. Minimally necessary at times to move the patient to a displaced or undisplaced fractures in the region limited extent. Failure to perform a proper examination may lead to a missed assessment and more problems than anticipated. It is suggested that the patient should not be moved unduly and that substantial precaution be taken as the examination proceeds. When making an assessment, the fact that the patient can move the injured part does not mean absence of a fracture. Getting the patient to move may just cause additional harm and pain. Unnecessary, purposeless movement of a patient is ill-advised at any time. When evaluating all musculoskeletal injuries, the examination should be carefully and systematically performed. The condition appearing minimal to the untrained observer may in reality have disabling or dangerous potential. As far as fractures are concerned, speed and rapidity of treatment are not important as far as the future of the fracture. Fractures require appropriate handling, slow deliberate management, and proper transportation for a satisfactory outcome. Initial care often determines the future course of the injury and determines -whether the patient will suffer a normal period of morbidity followed by satisfactory recovery or a lifetime of disability as a consequence of excessive zeal. The old concept in emergency care of "grab and run" is obviously unsafe and outmoded; the indicated action today is "stabilize Fig. 1. Characteristic outward rotation and shortened posiand transport". tion of a fractured femur.

Summer 1 9 79 FRACTURED FEMUR 55 of the hip may show no deformity of the extremity and the patient may be able to move the extremity and even stand on it.

3 Summer FRACTURED FEMUR 55 of the hip may show no deformity of the extremity and the patient may be able to move the extremity and even stand on it. Therefore, the index of suspicion must remain high to avoid being misled by variations in the clinical picture. Before applying any traction splint, after the assessment of a fracture is made, one should assess the status of the circulation and status of the nerves in the affected extremity (Fig. 2). coolness of the skin is common and not necessarily of importance. Discoloration of the skin likewise tends to be misleading. The presence or absence of a pulse is important. Absent pulses below the level of the fracture are highly significant findings and should be reported. Numbness or inability to move the extremity below the fracture may indicate involvement of associated nerves. Involvement of vessels or nerves are indications for more rapid management of the patient. Whether the fracture is open (the skin is broken at the site of the fracture) or closed, may affect the management. If the fracture has an open wound associated with it, pressure dressings should be applied before the splint is applied. Application of the Traction Splint The objectives of traction splint application immediately after a femoral fracture are to relieve muscle spasm, decrease pain, prevent overriding of the fragments, and allow easy transportation. If possible, the splint should be applied at the scene of the accident. Additional benefits of splinting are: 1) the possibility of injury to skin and soft tissue is decreased, and 2) that damage to nerves and blood vessels is decreased. Since traction splints have certain peculiarities and risks associated with their use, the Red Cross' recommends that only persons with specific training should attempt to use these devices. If the extremity is severely angulated in a grossly distorted shape, it should be gently brought into general anatomical alignment before application of the splint. A good deal of discussion has occurred as to whether or not the fracture should be moved. The authors believe it is generally understood that little or no harm results from gentle realignment of the limb. The patient may suffer temporary pain and discomfort but will ordinarily be greatly relieved if the limb is brought into general anatomical alignment. Use of the traction splint as originally designed by Hugh Owan Thomas required considerable skill, particularly in the application of the ankle cuff and traction mechanism. Fortunately, a modern adaptation of the splint designed by Glenn Hare of Leucadia, California, eased the application of the splint and substantially simplified the training of those intended to use it (Fig. 3). Fig. 2. Palpation of posterior tibialis pulse (primary blood supply to the foot) distal to the fracture. Fig. 3. Hare traction splint.

56 DAVIES AND ANAST Vol. 1, No. 1 Application of the splint is straight forward. However, care must be taken that it is the proper length and that the ankle hitch mechanism is properly applied.

4 56 DAVIES AND ANAST Vol. 1, No. 1 Application of the splint is straight forward. However, care must be taken that it is the proper length and that the ankle hitch mechanism is properly applied. Also the amount of traction applied must be monitored. Generally with the Hare traction splint if the knurled ring applying traction through the nylon webbing is tightened only by hand to "finger tightness," it is impossible to apply excessive traction to the extremity. If one is concerned about the amount of traction, a small spring scale can be interposed between the rings of the ankle hitch and the hook of the traction web. In this case no more than 15 Ib of traction should be applied. In no case should mechanical leverage be applied to tighten down the knurled ring to a great extent. Generally it should be tightened down to comfort and until the extremity is brought into approximately normal position. The splint should be applied in the following Fig. 4. Fig. 7. Fig. 5. Fig. 8. Fig. 6. Fig. 9.

Summer 1 9 79 FRACTURED FEMUR 57 systematic manner. 1) The proper length of the splint should be measured on the uninvolved side. (Fig.

5 Summer FRACTURED FEMUR 57 systematic manner. 1) The proper length of the splint should be measured on the uninvolved side. (Fig. 4) It should extend approximately 6-8 in beyond the foot of the uninvolved side (Fig. 5). 2) The ankle cuff should be placed around the foot and ankle so the rings meet in the center of the plantar surface of the foot (Fig. 6). 3) One of the trained personnel grasps the involved extremity at the ankle and the lower leg to sup- port the extremity (Fig. 7) and begins to apply manual traction (Fig. 8). 4) Manual traction is applied to straighten the extremity (Fig. 9). If resistance is met, the manual traction is discontinued and the extremity is "splinted as it is". 5) The traction splint is placed beneath the victim's leg with the ischial ring resting snugly against the ischial tuberosity (Figs. 10 and 11 ). 6) The proximal thigh strap is then secured to stabilize Fig. 10. Fig. 13. Fig. 11. Fia Fig. 12. Fig. 15.

6 58 DAVlES AND ANAST Vol. 1, No. I Fig. 16. Fig. 17. the extremity (Fig. 12). 7) The traction strap is attached to the three rings on the ankle cuff (Figs. 13 and 14). 8) The traction rachet is then tightened to the point where it is equal to the manual traction being applied along with the patient's subjective relief of symptoms (which are frequently quite dramatic) (Fig. 15 and 16). 9) The traction rachet is secured. The velcro straps are then applied circumferentially around Fig. 18. Fig. 19. tain the bone ends in a satisfactory position for transport. However, as the pain and spasm decreases, the traction may be temporarily lost. Therefore, it may be necessary to periodically readjust or tighten the ankle hitch to maintain the proper traction. Also, a tendency for the ischial ring to slip out from under the ischium may cause loss of traction. The authors thank James A. Gould for his photographic assist- the extremity provide additional Two ance, Ms. Lori Galstad and Shellie Backlund for serving as the straps are applied proximally to the knee and models, and Mrs. Lillian Smith for typing the manuscript. two are applied distally to the knee (Fig. 17). 10) The extremity is secured in the traction splint REFERENCES: (Figs. 18 and 19). 1. American National Red Cross. Advanced First Aid and Erner- If properly applied, the traction splint will main- gency Care. New York. Doubleday and Company. Inc.. p 184

LESSON ASSIGNMENT. After completing this lesson, you should be able to:

LESSON ASSIGNMENT. After completing this lesson, you should be able to: LESSON ASSIGNMENT LESSON 3 Traction Splints. LESSON ASSIGNMENT Paragraphs 3-1 through 3-5. LESSON OBJECTIVES After completing this lesson, you should be able to: 3-1. Identify the purpose of a traction