Controversies in Traction Splinting

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Myles Webb
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1 Controversies in Traction Splinting Katie Dolbec, MD Department of Surgery Division of Emergency Medicine University of Vermont Medical Center October 19, 2018

2 Disclosures I have nothing to disclose.

4 History of Traction Splinting 1860: John Hilton designed first traction splint 1875: modified by Hugh Owen Thomas designed strictly for in-hospital use

$History of Traction Splinting 1915: Thomas leg splint adopted by French & British armies As is well known, the mortality in Great Britain from compound fractures of the femur in 1916 was 80 per cent.$

5 History of Traction Splinting 1915: Thomas leg splint adopted by French & British armies As is well known, the mortality in Great Britain from compound fractures of the femur in 1916 was 80 per cent. This was reduced coincident with the advent of the Thomas treatment until it reached 7.3 per cent in 1918, a wonderful achievement accomplished by the use of the appliances so admirably described by Meurice Sinclair in this great little book.

6 Types of Traction Splints Thomas Hare Sager Kendrick CT-6 Donway Slishman

7 History of Traction Splinting 2009 Equipment for Ambulances document American College of Surgeons Committee on Trauma American College of Emergency Physicians Traction splint for adult and pediatric patients recommended for all prehospital ambulances

9 Anatomy

10 Physiology The femur is by most measures the longest and strongest bone in the human body The adult thigh can hold 1-3 liters of blood

11 How often is the femur fractured? Incidence of 10/100,000 person years Kids and old people

13 Evidence for Traction Splinting? Slim No RCTs

14 Benefits of Traction Splinting Pain relief Protect soft tissue and nerves from injury from jagged bone ends?minimize bleeding?reduce incidence of fat emboli

15 Does Traction Add Anything? Aren t these all the same benefits of splinting in general?

16 Some Evidence of Benefit Hoppe S, et al. Early versus delayed application of Thomas splints in patients with isolated femur shaft fractures: The benefits quantified. Level I Trauma Center Jan Dec 2012 Isolated femur shaft fractures 106 patients Early splinted (pre-hospital) vs. late splinted (post-xray) Early splinted had decreased need for blood transfusion and lower rate of pulmonary complications

17 But Rosenberg et al, Ann Em Med 1982 Single closed fractures of the femur in children were not responsible for significant hemorrhage resulting in shock

18 Hazards of Traction Splinting

20 Hazards of Traction Splinting Space limitations in rigs/helicopters

21 Contraindications to Traction Osteoporosis Fragile skin Concomitant proximal or distal fractures (hip, pelvis, knee, ankle) Large soft tissue deformity/partial amputation

22 Hazards of Traction Splinting Space limitations in rigs/helicopters How do you know the injury is mid shaft or that there aren t other injuries proximal or distal Can cause nerve damage, other bone injury, skin damage, compartment syndrome May increase bleeding in some cases

23 And What About Penetrating Trauma or Open Fractures? Is this a contraindication to traction? How many of you were taught not to draw contaminated bone ends back into the wound?

24 Hazards of Traction Splinting Space limitations in rigs/helicopters How do you know the injury is mid shaft or that there aren t other injuries proximal or distal Can cause nerve damage, other bone injury, skin damage, compartment syndrome May increase bleeding in some cases Rare use

25 So How Often Are They Placed? Abarbanell, N 2001: Large urban setting 12 months 4,513 reports 16 mid-thigh injuries 5 felt by paramedics to be mid-shaft femur 2 traction splints placed (remainder splinted in other ways)

26 So How Often Are They Placed? Runcie H, Greene M. 2015: Mountain rescue in England and Wales Incidence of 9.3 suspected femur fractures on scene per year 13% of suspected femur fractures treated with traction

27 And How Do We Do Placing Them? Daugherty MC, et al. Children Level 1 pediatric trauma center Jan 1, 2000 Dec 31, 2007 Used x-rays to confirm good placement 435 patients with femur fracture 118 had a traction splint (115 were Hare) 66% improperly placed 52% too low 18% too high 10% leg rotation 7% too large 9% eccentric placement 4% contraindication 15% had more than 1 category of placement error

32 Hazards of Traction Splinting Space limitations in rigs/helicopters How do you know the injury is mid shaft or that there aren t other injuries proximal or distal Can cause nerve damage, other bone injury, skin damage, compartment syndrome May increase bleeding in some cases Rare use No evidence of effectiveness or change in outcome Time

34 Possible alternatives Plain old splinting without traction Strap to other leg Long board Box splint Posterior rigid splint Vacuum splint

36 References Abarbanell NR. Prehospital midthigh trauma and traction splint use: recommendations for treatment protocols. Am J Emerg Med. Vol 19, Iss 2 (2001): Agrawal Y, Karwa J, Shah N, Clayson A. Traction Splint: to use or not to use. The Journal of Perioperative Practice. Vol 19, Iss 9 (Sept 2009): Daugherty MC, Mehlman CT, Moody S, LeMaster T, Falcone RA. Significant Rate of Misuse of the Hare Traction Splint for Children with Femoral Shaft Fractures. Journal of Emergency Nursing. Vol 39, Iss 1 (Jan 2013): Gandy, WE and Grayson S. Sacred Cows: The Traction Splint. EMS World; Vol. 43, Iss. 8 (Aug 2014):

37 References Hoppe S, et al. Early versus delayed application of Thomas splints in patients with isolated femur fractures: The benefits quantified. Injury. Vol 46, Iss 12 (Dec 2015): Kwon YH and Kahwaji CI. EMS, Traction Splint. StatPearls [Internet]. Jan Runcie H and Greene M. Femoral Traction Splints in Mountain Rescue Prehospital Care: To Use or Not to Use? That is the Question. Wilderness & Environmental Medicine; Vol. 26, Iss. 3 (2015): Sinclair M. The Thomas Splint and its Modification in the Treatment of Fractures. American Journal of the Medical Sciences. Vol 175, Iss 2 (Feb 1928): 274.

1 Chapter 29 Orthopaedic Injuries Principles of Splinting 2 Types of Muscles. Striated Skeletal. Smooth

1 Chapter 29 Orthopaedic Injuries Principles of Splinting 2 Types of Muscles Striated Skeletal Smooth 3 Anatomy and Physiology of the Musculoskeletal System 4 Skeletal System 5 Skeletal System Functions