BY BARRY S. DASKAL
From the first day of EMT school, most of us can’t wait to get our hands on the equipment. One of the more mysterious and impressive pieces of basic life support (BLS) equipment is the traction splint. Years later, you check for the trusty orange (or blue or green) traction splint bag as a part of your daily inspection. Everything’s in there ready to go. Or is it? When was the last time you took the bag out, opened it, and actually inspected the equipment? Is the ankle hitch there? How many leg straps are there? Most importantly, do you remember how to use the traction splint?
WHY SPLINT?
Splinting skeletal injuries is done when a patient pre-sents with a painful, swollen, deformed extremity, which is generally indicative of a bone fracture. There are two types of splinting: fixed (fixation) and traction. The goals of splinting are to stabilize the injury and prevent further injury from occurring. When applying a splint, regardless of the type or location on the body, you must ensure that the immobilizing device secures not only the fracture site but also the joints above and below the injury. Splinting is not a skill we use often. Many EMS instructors view splinting as one of the most perishable BLS skills, and providers have referred to splinting as a “lost art.”1 No splint is as challenging as the traction splint.
 (1) Make sure you inspect your traction splint and all its parts as part of your routine inspection. (Photos by author.) |
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TRACTION SPLINT
A traction splint is typically used to treat severe midshaft fractures of the femur. The femur is the longest and strongest bone in the human body; the surrounding muscles (quadriceps) are also incredibly strong. When the femur breaks, the surrounding muscles spasm, pulling the bone ends past each other, which results in immense pain, bleeding (internal or external), and muscle and nerve damage. Because of the femur’s proximity to the femoral artery, it is possible to hemorrhage to death from an isolated femur fracture.
INDICATIONS FOR SPLINTING
As stated above, the traction splint is used to treat severe midshaft fractures of the femur. In simple terms, it is to be used only for a painful, swollen, deformed midthigh injury without coexisting lower leg injury.2 Unless you have a bone end sticking out, it’s nearly impossible to make a field conclusion that a femur fracture is midshaft, so let the other indications present guide you. Traction splints are applied only when the fracture is isolated to the femur and there are no other associated traumatic injuries to the leg or pelvis.
 (2) You must apply manual stabilization immediately. Note: The blue tape represents the fracture site. |
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CONTRAINDICATIONS FOR SPLINTING
The contraindications for use of a traction splint include injuries close to the knee or involving the knee itself, hip or pelvic injuries, lower leg or ankle injuries, and any partial amputation or avulsion with bone separation where the distal limb is connected only by marginal tissue.3 Use of a traction splint in the presence of distal fractures or other leg injuries will more likely than not pull apart the distal injury rather than apply traction to the targeted femur fracture.
BACKING UP
The Department of Transportation EMT-Basic curriculum calls for a minimum of four hours of lecture and six hours of hands-on practical skills time on musculoskeletal care. Splinting procedures are included in this section. Six hours is not a whole lot of time to handle all varieties of splinting equipment and learn the many options for musculoskeletal and spinal injury care. Traction splinting alone typically requires 40 to 50 minutes of practice for a single evolution.
CONTROVERSY
There is a tendency for instructors and providers alike to downplay the importance of traction splinting as a useful patient-care tool. There are two reasons this tends to happen.
First, as mentioned previously, the femur is the longest and strongest bone in the body. The leading cause of femur fractures is major trauma. You are much less likely to encounter isolated femur fractures. The force necessary to break a femur generally causes other significant or at least distracting injuries. The use of a long backboard has been emphasized in major trauma situations and is frequently referred to as a “full body splint.” Often, application of a traction splint is considered a distracting waste of time in light of other injuries that require care. This is untrue. In fact, femur fractures by themselves can result in mortality from trauma.
That stabilizing sharp and jagged bone tends to keep it from repeatedly cutting into muscle, nerves, and blood vessels has been well established. Traction splinting is also a major form of pain management. Anyone who has ever looked into the face of a trauma patient with a fractured femur as mechanical traction is applied will never forget the relief that comes over the patient’s face; it is both immense and immediate. This has a secondary effect of decreasing patient movement, since the need to continually seek a more comfortable position is considerably reduced.
Second, controversy has long revolved around the management of open fractures. Femurs are no exception. It was previously believed that traction splinting should be used only on closed fractures of the femur to avoid pulling contaminated bone ends back beneath the surface of the skin. This is clearly not the case. Any open fracture requires surgical debridement in an operating room. Traction splinting will allow you to deliver a live patient to the orthopedic surgical team.
TYPES OF TRACTION SPLINTS
There are several varieties of traction splints on the market. All operate on the same principle: One end of the splint is positioned against the ischial tuberosity and pushes upward against the pelvic bone; the other end is attached to the foot or ankle and is tightened with an opposing force that results in traction. Traction, in turn, stretches contracted muscles and reduces spasm, which reduces pain. It causes better alignment of bone ends, preventing further nerve, vascular, and tissue damage.4
Two main varieties of traction splints are currently available. The first style is essentially a bed that supports the injured leg. It is a two-part lightweight tubular aluminum frame that has a wider diameter on the outside and contains narrower posts inside that telescope down to the distal end and are adjustable based on the length of the patient’s limb. The two posts are joined by web and self-fastening straps that support and secure the leg. At the proximal end, there is an ischial strap that secures around the front and a padded cross bar on the bottom that connects the medial and lateral bars. At the midpoint, there is a locking mechanism that secures the adjusted length. The distal end of the splint has a ratchet with webbing wrapped around it and an “S” ring hook that connects to a separate ankle hitch. This type of splint also has a stand used to elevate the extremity. Traction is applied by ratcheting the webbing at the distal end down until spasms are relieved. This splint is designed only for use on a single-sided (one leg) femur fracture.
The second style is constructed of a singular post with a narrower interior post that telescopes outward toward the patient’s feet. This splint is placed medially, between the legs, and has an ischial strap that secures to the proximal end of the fractured extremity. This device has preattached ankle hitches and can be used on either limb or bilaterally if needed. In the case of bilateral fractures, the ischial strap is secured to the more severely injured leg. The amount of traction applied is proportionate to the patient’s body weight. For a single-sided fracture, traction equal to 10 percent of the body weight up to 15 pounds is applied. For bilateral fractures, 10 percent of the body weight is applied per limb, up to a total of 30 pounds of traction.5
HOW TO APPLY A TRACTION SPLINT
The first step in applying any type of splint is to stabilize the site above and below the fracture and check for distal pulse, motor, and sensory function.
 (3) |
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 (4) Assess pulse and motor sensory function. |
With the bed-type splint, one rescuer manually stabilizes the fracture site while a second rescuer applies an ankle hitch. Once in place, the two rescuers can elevate the leg slightly and simultaneously pull manual traction using the ankle hitch itself. With the medially placed single-post device, elevation of the leg and manual traction are not employed.
The length of the bed-type splint is determined by using the noninjured leg as a reference measurement. Adjust the end of the traction splint so that it is eight to 12 inches longer than the noninjured leg. Slip the traction splint under the patient’s injured leg as the second rescuer elevates the leg and maintains continuous manual traction using the ankle hitch. The ischial ring of the traction splint must be against the bony prominence of the buttocks (ischial tuberosity). The kickstand at the end of the traction splint can be raised once the traction splint is in place. Pad the groin and gently, but securely, apply the ischial strap. (1)
 (5) |
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 (6) The responder applies the ankle hitch. Once you have established mechanical traction, you can release manual stabilization. |
The first rescuer attaches the mechanical traction device to the ankle hitch while the other rescuer continues manual traction. Once mechanical traction exceeds manual pull, manual traction can be released.
Avoid using too much traction, which may overstretch the leg, but use enough traction to maintain limb alignment. With the medially placed device, remember the amount of traction pulled is based on body weight. With either device, limb alignment and relief of discomfort will serve as reasonable endpoints for the degree of traction needed.
 (7) |
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 (8) Applying the splint. |
Secure the leg straps following manufacturer directions. Usually one strap is placed above the ankle hitch, one below the knee, one just above the knee, and one at the top of the thigh just below the ischial strap. As with any splint, never fasten straps directly over the injury site to avoid causing further injury and discomfort.
With the splint secured, reassess distal pulses, motor, and sensory function. To ensure continued traction, it is usually necessary to place the patient on a long spine board. Depending on the size of the patient compartment in your transport vehicle and the height of your patient, you may have to place the patient or the stretcher into the ambulance backward (with the feet pointing forward) to close the doors for transport.
 (9) Mechanical traction is in place. |
Fire/EMS providers constantly strive to deliver the best prehospital patient care. New and innovative equipment continues to appear, much of which is quickly incorporated in the field by progressive agencies. Traction splinting is neither new nor innovative; it is tried and true. It is incumbent on EMS providers to remain familiar and competent with all of the tools in our arsenal.
Endnotes
1. “The lost art of splinting,” Jennifer Cuske, RN, EMT-P, JEMS, July 2008.
2. BLS Trauma Protocol T-5, New York State Department of Health, Bureau of EMS.
3. BLS lecture notes, Nassau County (NY) EMS academy.
4. http://www.sagersplints.com/pages/anatomy.html/.
5. http://www.sagersplints.com/.
Additional Resource
EMT Prehospital Care, 3rd edition. Mosby EMS, http://www.haretractionsplint.com/.
BARRY S. DASKAL is a police officer/aircraft rescue firefighter with the Port Authority of New York & New Jersey Police Department at John F. Kennedy International Airport in New York City. He is also a certified EMT-critical care and clinical lab instructor at the Nassau County (NY) EMS Academy. He previously served as a police officer with the New York City Police Department and as a supervising fire alarm dispatcher with the Fire Department of New York. He has been a volunteer firefighter since 1990 and has served as a captain and training officer. He is a member of the Wantagh Fire Department in Nassau County, New York. He is the creator and host of “The Average Joe Firefighter” podcast on FireEngineering.com.
