0000-0000/79/0001-0053$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 In handling long bone fractures, particularly
include injuries that are peculiar to some sports the femur, the development of the traction splint
and common to all active sports. Fractures of by Sir Hugh Owan Thomas represented an ex-
long bones comprise only a small portion of tremely significant contribution to fracture care.
general sports medicine problems, but constitute Over the years, the use of the traction splint has
a rather large portion of certain of the active become accepted as the method of choice for
sports, such as: skiing, water skiing, bob sled- management of femoral shaft fractures. It is a
ding, and horseback riding. In all of these latter compliment to Hugh Owan Thomas that his initial
activities the participant is moving at a relatively design has needed minor adaptations to simplify
high velocity where opportunities for falls or mis- its use and has been little improved upon over
adventure are common. approximately the last 100 years.
Fractures of the femur are encountered rela- Proper application of a modern day mechani-
tively infrequently in general sports medicine. cal traction splint applied by adequately trained
This is fortunate since this injury is extremely personnel increases the comfort of the patient,
serious and is attended by a very substantial minimizes serious complications (permanent
morbidity and occasional mortality. It, therefore, crippling), and eases the transportation of the
behooves all those involved in sports medicine injured patients to a very substantial extent.
to be familiar with the safest and most effective
ways of managing fractures of the femur. Since GENERAL ACUTE EMERGENCYCARE
this is an uncommon injury, similar principles of GUIDELINES
management and techniques of application for
other longer bone fractures would be similar; Individuals responsible for emergency medical
e.g., management of tibia1 shaft fractures. care, including athletic trainers and emergency
Fixation splints or so-called coaptation splints medical technicians, must consider all the fac-
have been used for many years to immobilize tors surrounding an injury. The femur is the
broken bones and adjacent joints. However, fix- longest, strongest bone in the body and to break
ation splints have only minimal effect in relieving such a bone requires extreme force. Conse-
muscle spasm and immobilizing the fractured quently, the same force that served to break the
ends that cause overriding of the bone ends with femur may have resulted in other injuries to the
concommitant soft tissue damage. patient and therefore a systematic physical ex-
amination is imperative.
- Initially, the patient's airway, breathing, circu-
* Acting Chairperson and Assistant Professor of Physical Therapy. lation, and vital signs must be checked, stabi-
Staff Athletic Trainer. Staff. La Crosse Exercise Program, University
of Wisconsin-La Crosse, La Cross. WI 54601. lized, and monitored. If possible, a history should
t Orthopaedic Surgeon, Lakeland Orthopaedic Associates. Ltd.; be obtained in which the mechanism of injury is
Woodruff. WI and Medical Director of the Office of Emergency Med-
ical Services of the Wisconsin State Division of Health. determined. Subjective complaints on the part of
53
 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 ordi-
amination 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 mus-
assessment of the patient's problems and insti- culature. 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
t ~ ~ of
ated and treated. ~ i l ~comparison ~ 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 ex-
amination 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 ex-
amination 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 pa-
tient is ill-advised at any time.
When evaluating all musculoskeletal injuries,
the examination should be carefully and system-
atically performed. The condition appearing min-
imal 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 ap-
propriate handling, slow deliberate manage-
ment, and proper transportation for a satisfac-
tory 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 exces-
sive zeal. The old concept in emergency care of
"grab and run" is obviously unsafe and out-
moded; the indicated action today is "stabilize Fig. 1. Characteristic outward rotation and shortened posi-
and transport". tion of a fractured femur.
Summer 19 79 FRACTURED FEMUR 55

of the hip may show no deformity of the extremity risks associated with their use, the Red Cross'
and the patient may be able to move the extrem- recommends that only persons with specific
ity and even stand on it. Therefore, the index of training should attempt to use these devices.
suspicion must remain high to avoid being misled If the extremity is severely angulated in a
by variations in the clinical picture. grossly distorted shape, it should be gently
Before applying any traction splint, after the brought into general anatomical alignment be-
assessment of a fracture is made, one should fore application of the splint. A good deal of
assess the status of the circulation and status of discussion has occurred as to whether or not the
the nerves in the affected extremity (Fig. 2). fracture should be moved. The authors believe
coolness of the skin is common and not neces- it is generally understood that little or no harm
sarily of importance. Discoloration of the skin results from gentle realignment of the limb. The
likewise tends to be misleading. The presence or patient may suffer temporary pain and discom-
absence of a pulse is important. Absent pulses fort but will ordinarily be greatly relieved if the
below the level of the fracture are highly signifi- limb is brought into general anatomical align-
cant findings and should be reported. Numbness ment.
or inability to move the extremity below the frac- Use of the traction splint as originally designed
ture may indicate involvement of associated by Hugh Owan Thomas required considerable
nerves. Involvement of vessels or nerves are skill, particularly in the application of the ankle
indications for more rapid management of the cuff and traction mechanism. Fortunately, a
patient. modern adaptation of the splint designed by
Whether the fracture is open (the skin is bro- Glenn Hare of Leucadia, California, eased the
ken at the site of the fracture) or closed, may application of the splint and substantially simpli-
affect the management. If the fracture has an fied the training of those intended to use it (Fig.
open wound associated with it, pressure dress- 3).
ings should be applied before the splint is ap-
plied.
Application of the Traction Splint
The objectives of traction splint application
immediately after a femoral fracture are to relieve
muscle spasm, decrease pain, prevent overrid-
ing of the fragments, and allow easy transporta-
tion. 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

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. a small spring scale can be interposed between
However, care must be taken that it is the proper the rings of the ankle hitch and the hook of the
length and that the ankle hitch mechanism is traction web. In this case no more than 15 Ib of
properly applied. Also the amount of traction traction should be applied. In no case should
applied must be monitored. Generally with the mechanical leverage be applied to tighten down
Hare traction splint if the knurled ring applying the knurled ring to a great extent. Generally it
traction through the nylon webbing is tightened should be tightened down to comfort and until
only by hand to "finger tightness," it is impos- the extremity is brought into approximately nor-
sible to apply excessive traction to the extremity. mal position.
If one is concerned about the amount of traction, 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 port the extremity (Fig. 7) and begins to apply
splint should be measured on the uninvolved manual traction (Fig. 8). 4 ) Manual traction is
side. (Fig. 4) It should extend approximately 6- applied to straighten the extremity (Fig. 9). If
8 in beyond the foot of the uninvolved side (Fig. resistance is met, the manual traction is discon-
5). 2) The ankle cuff should be placed around tinued and the extremity is "splinted as it is". 5)
the foot and ankle so the rings meet in the center The traction splint is placed beneath the victim's
of the plantar surface of the foot (Fig. 6). 3) One leg with the ischial ring resting snugly against
of the trained personnel grasps the involved the ischial tuberosity (Figs. 10 and 11). 6) The
extremity at the ankle and the lower leg to sup- proximal thigh strap is then secured to stabilize

Fig. 10. Fig. 13.

Fig. 11.
- 14
Fia.

Fig. 12. Fig. 15.

 58 DAVlES AND ANAST Vol. 1 , No. I

Fig. 18.
Fig. 16.

Fig. 19.
Fig. 17.

the extremity (Fig. 12). 7)The traction strap is tain the bone ends in a satisfactory position for
attached to the three rings on the ankle cuff transport. However, as the pain and spasm de-
(Figs. 13 and 14). 8)The traction rachet is then creases, the traction may be temporarily lost.
tightened to the point where it is equal to the Therefore, it may be necessary to periodically
manual traction being applied along with the readjust or tighten the ankle hitch to maintain
patient's subjective relief of symptoms (which the proper traction. Also, a tendency for the
are frequently quite dramatic) (Fig. 15 and 16). ischial ring to slip out from under the ischium
9) The traction rachet is secured. The velcro may cause loss of traction.
straps are then applied circumferentially around
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