International Trauma Life Support: Utilization of Traction Splints With Open Femur Fractures

INTERNATIONAL TRAUMA LIFE SUPPORT
UTILIZATION OF TRACTION SPLINTS WITH OPEN FEMUR FRACTURES

The guidelines and references contained in this document are current as of the date of publication
and in no way replace physician medical oversight.
INTRODUCTION
The purpose of this document is to update International Trauma Life Support (ITLS) instructors
and providers of the position of ITLS in regard to the use of traction splints with open femur
fractures.
BACKGROUND
The question of whether it is permissible to use a traction splint to manage an open mid-shaft
femur fracture was posed to the ITLS Editorial Board by an instructor in the organization.
In response a literature review on the topic was performed. No Class 1 evidence was found to
support the use or non-use of this device in the above mentioned clinical situation. Only one
consensus document from the wilderness rescue literature was located.
CONSIDERATIONS
Among the recommended methods for stabilization of mid-shaft femur fractures is the use of a
traction splint. Based on observational studies, with the proper application of traction, the
broken ends of the bone move less, decreasing hemorrhage and patient pain. It should be
stressed that traction splints should not be used in either proximal or distal femur fractures due
to the propensity of the device to cause movement of the hip or knee, increasing the risk of
complications 1.
Among the tenets of field management of fractures is the principle that when there is an open
fracture, the provider should not allow the bone ends to retract back into the open wound
during stabilization, as contaminated material can be carried into the wound, increasing the risk
of infections such as osteomyelitis. The adage has been that open fractures should be “splinted
as they lie”. In the presence of neurovascular compromise, the fracture can be manipulated to
allow for restoration of pulses distal to the fracture.
Utilization of Traction Splints Resource Document © International Trauma Life Support

As the longest and strongest bone in the body, it takes a lot of force to cause a femur fracture.
Thus the presence of a fractured femur suggests a high energy injury and that the patient is at
risk for multiple injuries such as internal bleeding, head injury or additional fractures. Isolated
femur fractures are relatively rare in healthy adults so that a femur fracture is a potential
marker of high force injury. Emphasis is placed on rapid transport of multi-trauma patients,
shortening the time to definitive care. In urban situations with short transport times,
application of traction splints for femur fractures (open or closed) is likely not to impact patient
outcome.
Original use of the traction splint, first popularized by Dr. Thomas during the First World War,
included the use of the device for femur fractures resulting from gunshot wounds, which by
definition are open fractures. This recommendation is carried over to modern day combat
wounds 2,3
Given that all open fractures are contaminated and subject to infection and will need to
undergo wash-out and/or debridement by an orthopedic surgeon, we believe that application
of a traction splint in the austere environment to either open or closed fractures benefits the
patient. Copious irrigation, preferably in route, should be performed prior to reduction to
reduce foreign material in the wound. If available, appropriate antibiotic therapy should be
initiated and the fact that the fracture was open and reduced by EMS personnel must be
conveyed to the receiving facility.
RECOMMENDAITONS
Based on local protocols and clearance, application of a traction splint after stabilization of life
threatening injuries can improve patient comfort and reduce possibility of neurovascular injury
for patients in isolated or austere environments, where transport to definitive care is
substantially delayed.
MEDICAL OVERSIGHT
Medical oversight should review current literature and develop pre-hospital EMS protocols in
regard to appropriate use of traction splints with open femur fractures. Implementation of this
protocol should be monitored and supervised through a quality assurance program.

CONCLUSION
It is the position of ITLS that patients in isolated or austere environments, where transport to
definitive care is substantially delayed, application of a traction splint after stabilization of life
threatening injuries can improve patient comfort and reduce possibility of neurovascular injury.
REFERENCES
1. http://www.haretractionsplint.com/history.htm
2. Melamed E et al, Prehospital Care of Orthopedic Injuries, Prehospital and Disaster

Medicine, 22:21, 2007
3. Rowlands T and Clasper J The Thomas Splint – A Necessary Tool In The Management Of
Battlefield Injuries R Army Med Corps 2003; 149: 291-293
4. Bledsoe, B and Barnes, R Traction Splinting, JEMS August 2004, page 64

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INTERNATIONAL TRAUMA LIFE SUPPORT

UTILIZATION OF TRACTION SPLINTS WITH OPEN FEMUR FRACTURES

Utilization of Traction Splints Resource Document © International Trauma Life Support

Utilization of Traction Splints Resource Document © International Trauma Life Support

2. Melamed E et al, Prehospital Care of Orthopedic Injuries, Prehospital and Disaster

4. Bledsoe, B and Barnes, R Traction Splinting, JEMS August 2004, page 64

Utilization of Traction Splints Resource Document © International Trauma Life Support

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