Traction splints

[Guest guest]

Has the day of the traction splint come and gone?

How long has it been since you applied a traction splint in the field?

Is traction splinting standard of care?

What is the best version of the traction splint?

Gene G.

[Guest guest]

In a message dated 11/12/2006 5:55:20 PM Central Standard Time,

wegandy1938@... writes:

Has the day of the traction splint come and gone?

How long has it been since you applied a traction splint in the field?

Is traction splinting standard of care?

What is the best version of the traction splint?

Gene G.

having 'grown up' with everything from the Ring Splint (the one with

the full ring around the thigh, needing a dozen or more cravats and a chunk of

broomstick to put on) to the Kendrick Traction Splint,. I'm in favor of

either the Kendrick or the Sager, as they are so much easier to put on than the

type splints (including the HARE), and much easier to adjust to a

length where the patient will fit into the back of the ambulance or helo.

I've used them mostly in the past 20 years as transport adjuncts for

isolated femur fractures being transported to a facility with a Real Live

Orthopod

available....averaging about 1 every two years.

The type splints should not be used on patients with lower leg or

pelvic fractures, where the Sager and Kendrick splints MAY be useful in some

cases of unstable femur fractures with limited pelvic injuries where reasonable

femur splinting can not be managed by the use of a long spine board and a

board splint between the legs.

ck

S. Krin, DO FAAFP

[Guest guest]

Funny you should mention Traction Splints, haven't seen one used or used one

in 15 years, then POW, 2 in one month. I'll be interested to hear

everyone's opinions, as I'm on the fence on their use, but as a " style " I

tend to like the HARE's best (if I have to choose).

Traction splints

Has the day of the traction splint come and gone?

How long has it been since you applied a traction splint in the field?

Is traction splinting standard of care?

What is the best version of the traction splint?

Gene G.

[Guest guest]

Thoughts about varioius models of traction splints:

Let's take the Hare and its imitators. OK, the Hare imitated the ,

but changed it in a way that made it a less valuable device.

The Hare, because of its configuration, will cause angulation of the femur

unless it is elevated enough to bring the femur into a straight line. The

" stand " that is provided does not do that. If you look at a lateral x-ray of

the

femur with a Hare on it, you will generally see that the femur is bent at an

angle.

The other problem I see is that the Hare must extend out 12-15 inches from

the foot of the patient, and in some trucks, the door won't close with the Hare

in place unless you move the patient. Take a 6'5 " patient with a Hare on,

and you may be unable to close the doors.

Also many helo air evac units will not accommodate it. If the service is

running a 206A, forget it. The patient will not fit into the compartment with

the Hare on.

So there are significant problems with the Hare.

It takes two people to apply it, and it takes more time than I want to spend

at the scene doing something that is of dubious value.

Sagers and Kendricks are much quicker and easier to apply, and they don't

angulate the fracture.

But are any of them needed?

The answer seems to be, in most circumstances, no.

The isolated midshaft femur fx in a stable patient may warrant a traction

splint for pain relief. I can see that. But the best pain relief is

fentanyl,

and without any evidence that application of the traction splint affects

patient outcome, I would opt for analgesia, immobilization using the long board,

and rapid transport.

It does seem to me that the traction splint is another medieval device whose

time has come and gone.

Your opinions may differ, so let's hear them.

Gene G.

[Guest guest]

Taction splints are still used quite frequently in our 'neck of the woods'. We

are a small rural department and have applied traction splints on 11 femur

fractures over the last 12 months. I also work for one of the largest Fire/EMS

departments in the US and we also use them when indicated.

McEntire-Hunter

lmchunter@...

Home: (979)922-1543

Mobile: (979)848-6666

[Guest guest]

I would say that the HARE traction splint would still be the best hands down.

With the incidents around the panhandle with ranch accidents I believe one is

used about once a week. I would say that those who do not use them would not do

so because of improper training.

Just my thoughts.

wegandy1938@... wrote:

Has the day of the traction splint come and gone?

How long has it been since you applied a traction splint in the field?

Is traction splinting standard of care?

What is the best version of the traction splint?

Gene G.

[Guest guest]

I see them used on occaision...usually on isolated injuries more than

multi-system trauma...we use SAGER....happen to feel they are the best...and

very quick and easy to apply....

Dudley

Traction splints

Has the day of the traction splint come and gone?

How long has it been since you applied a traction splint in the field?

Is traction splinting standard of care?

What is the best version of the traction splint?

Gene G.

[Guest guest]

I think the Hare traction splint should go the way of the air splint. I can

remember using a Hare style traction splint 3 times in over 30 years of

being in EMS. I have used a Sager splint a few times. I with Dr Krin give me

a Sager or KED style splint.

Bernie Stafford EMTP

_____

From: texasems-l [mailto:texasems-l ] On

Behalf Of wegandy1938@...

Sent: Sunday, November 12, 2006 5:46 PM

To: texasems-l ; Paramedicine

Subject: Traction splints

Has the day of the traction splint come and gone?

How long has it been since you applied a traction splint in the field?

Is traction splinting standard of care?

What is the best version of the traction splint?

Gene G.

[Guest guest]

Slug: The Traction Splint

Hed: The Traction Splint

Dek: An EMS relic?

By E. Bledsoe, DO, FACEP, & Donn , LP

Words: 1680

Traction splints have been a part of our equipment inventory for as long as

EMS has existed. Application of the traction splint is one of the most

fundamental of EMT skills. The purpose: immobilize femur fractures through

traction. Its application is believed to reduce hemorrhage, reduce secondary

tissue damage and reduce pain. But does the traction splint make a

significant impact on patient care in the modern EMS era or has it become an

EMS relic? Now that I have your attention, let's move on.

Historical review

Hilton introduced the first traction splint for lower extremity

fractures in 1860. In the 1870s, Hilton's splint was refined by noted

British surgeon and bone setter Hugh O. . This later version of the

splint came to be known as the splint and was widely used for

treatment of femur fractures.

During World War I, Sir suggested use of the

splint for the management of acute femoral fractures.[ii] During World War

I, the advent of trench warfare resulted in a marked increase in the number

of open femur fractures from gunshots and jagged shell fragments. Because of

this new style of warfare, military surgeons saw a stark increase in

mortality secondary to these injuries. The surgeons obviously had to change

their strategy for managing these injuries, and ' splint seemed like

the perfect tool.

The splint was introduced into military medical practice

as a method of treating obvious femur fractures in 1916. Following

widespread usage of the splint to treat these injuries, a significant

decrease in mortality from femur fractures was reported. However, the degree

to which mortality decreased is open to conjecture. Various percentages in

improved mortality secondary to use of the traction splint were anecdotally

reported-a phenomenon that became known as the " Splint boast. "

However, in a report, noted World War I surgeon and British Colonel Sir

Henry Gray reported that the mortality from femur fractures dropped from 80%

in 1916 to 15.6% in 1917 after the splint was used for 1,009 cases in

a particular battle.[iii] Although the splint was introduced

for the treatment of femur fractures, it seemed intuitive to several

physicians that it would be useful for initial immobilization of femur

fractures in the prehospital setting. Because of this, the American College

of Surgeons Committee on Trauma included the traction splint in its document

Essential Equipment for Ambulances in the early 1970s, and it remains a

mandated piece of equipment today.[iv]

How does it work?

Regardless of the type or manufacturer, the femur traction splint consists

of a frame that extends from the proximal thigh to an area distal to the

heel. The splint has a padded portion that fits against the ischial

tuberosity, which serves as the anatomical fixation point. The proximal

portion of the splint may be a ring that encircles the proximal thigh, a

partial ring or simply a padded bar. A traction device is located on the

distal part of the splint. The traction device can be a commercial

ratchet-type mechanism or a simple windlass and triangular bandage twisted

to take up slack and create distal traction of the femur. The thigh and leg

are usually supported by several soft and/or elastic supports.

The femur is the largest bone in the body and can cause

significant blood loss and tissue damage when fractured. The blood loss

comes from the fracture site itself and from surrounding tissues that are

damaged by the sharp bone ends. Blood losses of up to 2-4 units (1,000-2,000

mL) of blood have been reported with femur fractures.

The theory behind the traction splint is that it reduces

potential blood loss by applying traction to the leg, thus separating and

aligning the fracture segments. This serves to keep the thigh at its normal

length and also retains the thigh at a relatively normal circumference-thus

decreasing the potential space for blood loss.1

How often does the traction splint enhance EMS care?

In present EMS practice, the femur traction splint is indicated only for

isolated fractures of the femur.[v],[vi] It is contraindicated for:

* Pelvic fractures;

* Hip injuries with gross displacement;

* Any significant injury to the knee; and

* Avulsion or amputation of the ankle and foot.[vii]

With a single indication and numerous contraindications, how

often is the traction splint actually used in prehospital care? Researchers

looked at the incidence of traction splint usage in the city of ton,

Ill. (population 73,200 in 8.5 square miles), for a one-year period in 1999.

They reviewed 4,513 run reports and found 16 patients with mid-thigh trauma.

Of these 16 patients, 11 had minor trauma and five had clinical findings

suspicious for femoral shaft fractures.

Of the five patients with findings suspicious for femur

fractures, paramedics attempted traction splint application in three. One of

the patients who did not receive a traction splint had a possible hip

injury, making the splint contraindicated. The fifth patient that also did

not receive the traction splint was pain-free when paramedics arrived and

was simply transported in a position of comfort without incident.

Of the three cases where the EMS personnel attempted application

of the traction splint, only two were successful. The third patient was an

82-year-old woman who had mid-thigh trauma after a fall. When the crew

applied the splint and applied traction, it resulted in severe pain for the

patient and the splint was subsequently removed. A rigid splint was then

placed on this patient and she was transported without incident.

Thus, in this study group, only 0.11% of patients (1/11th of one

percent) had clinical findings suggestive of a femoral shaft fracture, and

only 0.07% met criteria for using the splint. Stated another way, only 7 of

10,000 patients in the study group had indications for traction splint

application. The author of this study concluded, " traction splints as

essential ambulance equipment may be unnecessary. " [viii]

Are traction splints safe?

As a rule, traction splints are safe when used according to the criteria

presented above. However, several recent studies have detailed complications

associated with EMS use and misuse of the traction splint. Researchers in

Buffalo, N.Y., recently described two patients who developed peroneal nerve

palsies following inappropriate application of traction splints. The Buffalo

study demonstrated how traction splints can aggravate certain soft tissue

lower extremity injuries.[ix]

The peroneal nerve (also called the fibular nerve) crosses over

the knee and is vulnerable to injury near the knee. Application of a

traction splint can cause the head of the fibula to be displaced laterally,

stretching or tearing this nerve.

This problem is made worse when there's an injury affecting the

integrity of the knee. One of the patients in the Buffalo study had a

traction splint () applied because of lower thigh pain and swelling.

By the time the patient arrived in the radiology department he was unable to

move his foot and great toe and had numbness on the bottom of his foot.

X-rays were negative and orthopedic consultation revealed a severe knee

sprain. The splint was removed and his peroneal nerve palsy eventually

cleared.

The second patient also received a traction splint after EMTs

suspected a distal femur fracture after a fall. At the ED, the patient also

exhibited peroneal nerve palsy. X-rays of the affected leg were negative and

the patient's nerve palsy slowly cleared after removal of the splint.

A Pennsylvania study detailed the case of a 22-year-old man who

fell 40 feet from a rooftop party and briefly lost consciousness. EMS was

called and found the man to be hemodynamically unstable, but without any

neurological or vascular deficits. IV therapy was initiated, a traction

splint was applied for an obvious thigh deformity and the patient was

transported to a trauma center. There he was found to have multiple injuries

(left pneumothorax, liver hematoma and multiple fractures). X-rays revealed

a comminuted left mid-shaft femur fracture and a comminuted left calcaneus

fracture.

The patient remained in the traction splint for six hours, at

which time he was found to have numbness and coldness of his left foot. The

left foot was severely swollen, and the pulses in the foot were absent,

indicating a compartment syndrome. The traction splint was removed and the

patient was taken to the operating room where the compartment syndrome was

surgically decompressed. Vascular surgeons had to surgically remove clots

from the posterior tibial artery and dorsalis pedis artery to restore blood

supply to the foot. The patient later required skin grafting to cover the

wounds from surgical decompression of the foot.[x]

A recent prospective study of 40 patients with multi-system

trauma who had a traction splint applied found that 38% of patients had the

traction splint applied despite the fact that its usage was contraindicated

by other injuries.[xi]

These studies clearly illustrate that inappropriate use of a

traction splint can cause injury or aggravate existing injury and in the

overall scheme of things, the indications for using a traction splint in the

prehospital setting are quite limited. Therefore, it's appropriate to ask,

is it prudent to stock the traction splint on ambulances and rescue vehicles

when it is so infrequently used? Most femur fractures are accompanied by

other injuries that may contraindicate use of the traction splint. Of the

remaining isolated femur fractures, most can be adequately treated through

immobilization with a rigid or adjustable splint or on a long spine board or

a vacuum splint/mattress. For systems that still carry medical anti-shock

trousers (MAST), isolated femur fractures are one of those few remaining

indications in which the MAST may be indicated.

Summary

Traction splints have been used in EMS for more than 40 years. However, they

were originally designed for the treatment of femur fractures-not temporary

stabilization. Multi-system trauma and other injuries make usage of the

traction splint contraindicated for many femur fractures. Thus, with the

relatively low usage of the traction splint, it may be time to revisit

guidelines that require traction splints on every ambulance and rescue

vehicle. They may be, in essence, an EMS relic we may want to part with.

Bledsoe, DO, FACEP, EMT-P, is an emergency physician in Texas. He can

be contacted at bbledsoe@....

Donn , LP, is a paramedic in Texas who works off the Ivory Coast as a

paramedic in the petroleum industry. He can be contacted at

donn@....

References

1 Henry BJ, Vrahas MS. The Splint. Questionable Boast of an

Indispensable Tool. American Journal of Orthopedics. 25(9):602-604.1996

2 R. Treatment of acute fractures of the thigh. British Medical

Journal. 11:1086-1087. 1914.

3 Gray HMW. The Early Treatment of War Wounds. London: H Frowde, Hodder and

Stoughton. 1919.

4 American College of Surgeons, American College of Emergency Physicians.

Equipment for Ambulances. 2000 (available at

http://www.facs.org/trauma/publications/ambulance.pdf).

5 JE. Basic Trauma Life Support, Fourth Edition. Upper Saddle

River, NJ. Brady Publishing/Pearson Education (p. 193-195). 2000.

6 JD. Femur fractures: complications and treatments of traumatic

femoral shaft fractures. Journal of Emergency Medical Services. 28(4):82-83.

2003.

7 McSwain NE, et al. Prehospital Trauma Life Support, Revised Fifth Edition,

St. Louis, MO. Mosby (p. 285). 2003.

8 Abarbanell NR. Prehospital midthigh trauma and traction splint use:

Recommendations for treatment protocols. American Journal of Emergency

Medicine. 19:137-140. 2001.

9 Mihalko WM, Rohrbacher B, McGrath B. Transient peroneal nerve palsies from

injuries placed in traction splints. American Journal of Emergency Medicine.

17:160-162. 1999.

10 AD, Kelikan AS. splint, calcaneus fracture, and compartment

syndrome of the foot: a case report. Journal of Trauma. 44:205-208. 1998.

11 Wood SP, Vrahas M, Wedel SK. Femur fracture immobilization with traction

splints in multisystem trauma patients. Prehospital Emergency Care.

7:241-243. 2003.

_____

[Guest guest]

I haven't used one in a while. But then again I haven't had a

patient that required one in quite some time. My thoughts on

traction splints is use one you are comfortable with but that is

just me. If you aren't proficient with the type you have...get it

out and practice!

But that is just my thoughts.

> Has the day of the traction splint come and gone?

>

> How long has it been since you applied a traction splint in the

field?

>

> Is traction splinting standard of care?

>

> What is the best version of the traction splint?

>

> Gene G.

>

>

[Guest guest]

In a message dated 11/12/2006 5:54:43 P.M. Central Standard Time,

wegandy1938@... writes:

Has the day of the traction splint come and gone?

Not quite ready to hang it up just like having multiple tools for airway

management a tool is a tool is a tool applied right it's a great tool applied

wrong it's crap.

How long has it been since you applied a traction splint in the field?

Certified since 1981 I've never put one on in the field actually.

Is traction splinting standard of care?

TRICK QUESTION! You have taught me that SOC is defined by a jury in a trial

and is not what MOST of us think of it as. In that respect (the way most of us

think in the case of an insolated femur fracture then yes, I'd say it is but

again SOC is a misunderstood concept by the majority of EMS folks as we have

discussed in the past.

What is the best version of the traction splint?

I am partial to the Sager for it's ability to do bilateral traction but

again I've never once had to apply it, and frankly how many times will you see

isolated femurs times 2? In the USAF based service I worked in we had both the

Sager and the Hare, and that was a problem since none of my CIV EMT's had

been trained on the Sager, and most of the USAF EMT's had only played with the

Hare since at that time the USAF seemed to favor the Sager. Then they ship us

the Kendrick version that folded and the IDMT types LOVED that one since it

fit in a field pack but we never deployed it while I was there.

In another thread on another list many moons ago we discussed this same

topic and one guy from the metro Atlanta area claimed to have put on " 100's of

Hares " in his system in 5 years. No one could understand why he saw so many

isolated closed femur fractures.

Most people waste too much time playing with traction splints in my view

especially in multi system traumas where your transport time to a trauma care

facility is short like the systems I worked in, in New jersey and Pennsylvania.

LNM

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

LNMolino@...

(Cell Phone)

(Home Phone)

(IFW/TFW/FSS Office)

(IFW/TFW/FSS Fax)

" A Texan with a Jersey Attitude "

" Great minds discuss ideas; Average minds discuss events; Small minds

discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962)

The comments contained in this E-mail are the opinions of the author and the

author alone. I in no way ever intend to speak for any person or

organization that I am in any way whatsoever involved or associated with unless

I

specifically state that I am doing so. Further this E-mail is intended only for

its

stated recipient and may contain private and or confidential materials

retransmission is strictly prohibited unless placed in the public domain by the

original author.

[Guest guest]

How would you say that the HARE would angulate the fracture anymore than any

other splint?

If properly applied the splint would or should not angulate but should support

the leg with elevation also designed to lessen the blood flow to the area. Is

this not what we need to be doing?

After reading the article by Dr. Bledsoe it would appear that we could get the

same effect with the MAST trousers as we could with the traction splint. I

would also have to change my opinion that possibly the traction splint is a

device that should find a place for " long term treatment " of the femur fracture

and not for EMS use.

As far as spending time placing the device on the patient, if properly trained

(with continued practice) a team should be able to place the unit on a patient

(if the need is there) with minimal time spent. We are there to care for the

patient and " do no harm " .

As with any treatment we may not always use a particular treament, but why do

we need to limit our resources if and when our patients need them?

Danny L.

Owner/NREMT-P

PETSAR INC.

(Panhandle Emergency Training Services And Response)

Office

Fax

[Guest guest]

The old Hare did cause alignment problems. I have seen the xrays to support it.

I think that the new Hare design may have taken care of it. We do not use the

Hare so have not kept up with it. Best splint ever made was the half

ring. Did the job and didn't cost an arm and a Leg. We no long use that one

either. Not high tech enough to suit the crews. However, now that we have

equipment flying away never to be seen again, we may go back to two sticks tied

together.

Henry

Re: Traction splints

How would you say that the HARE would angulate the fracture anymore than any

other splint?

If properly applied the splint would or should not angulate but should support

the leg with elevation also designed to lessen the blood flow to the area. Is

this not what we need to be doing?

After reading the article by Dr. Bledsoe it would appear that we could get the

same effect with the MAST trousers as we could with the traction splint. I would

also have to change my opinion that possibly the traction splint is a device

that should find a place for " long term treatment " of the femur fracture and not

for EMS use.

As far as spending time placing the device on the patient, if properly trained

(with continued practice) a team should be able to place the unit on a patient

(if the need is there) with minimal time spent. We are there to care for the

patient and " do no harm " .

As with any treatment we may not always use a particular treament, but why do

we need to limit our resources if and when our patients need them?

Danny L.

Owner/NREMT-P

PETSAR INC.

(Panhandle Emergency Training Services And Response)

Office

Fax

[Guest guest]

Danny,

It's quite simple. The way the Hare is designed, because of the butt bar,

it elevates the proximal end of the femur. The leg is not in anatomical

position. With the Sager and Kendrick, the leg IS in anatomical position and

in a

straight line with the splint is applied.

But I still ask the question, is this standard of care? And what evidence

exists to support the use of the traction splint in any event?

Gene

>

> How would you say that the HARE would angulate the fracture anymore than any

> other splint?

>

> If properly applied the splint would or should not angulate but should

> support the leg with elevation also designed to lessen the blood flow to the

area.

> Is this not what we need to be doing?

>

> After reading the article by Dr. Bledsoe it would appear that we could get

> the same effect with the MAST trousers as we could with the traction splint. I

> would also have to change my opinion that possibly the traction splint is a

> device that should find a place for " long term treatment " of the femur

> fracture and not for EMS use.

>

> As far as spending time placing the device on the patient, if properly

> trained (with continued practice) a team should be able to place the unit on a

> patient (if the need is there) with minimal time spent. We are there to care

for

> the patient and " do no harm " .

>

> As with any treatment we may not always use a particular treament, but why

> do we need to limit our resources if and when our patients need them?

>

> Danny L.

> Owner/NREMT-

> PETSAR INC.

> (Panhandle Emergency Training Services And Response)

> Office

> Fax

>

>

[Guest guest]

Henry,

I guess I haven't seen the new Hare design. How is it different from the

old one? Like you, I have seen the xrays to support the angulation. I wish I

had one of them to post.

You're right about the Half Ring. The best ever designed.

And you're also right about crews wanting sexy equipment. I still make my

students learn to do the Half Ring and make the ankle hitch out of a

cravat.

Gene

>

> The old Hare did cause alignment problems. I have seen the xrays to support

> it. I think that the new Hare design may have taken care of it. We do not use

> the Hare so have not kept up with it. Best splint ever made was the

> half ring. Did the job and didn't cost an arm and a Leg. We no long use that

> one either. Not high tech enough to suit the crews. However, now that we have

> equipment flying away never to be seen again, we may go back to two sticks

> tied together.

>

> Henry

> Re: Traction splints

>

> How would you say that the HARE would angulate the fracture anymore than any

> other splint?

>

> If properly applied the splint would or should not angulate but should

> support the leg with elevation also designed to lessen the blood flow to the

area.

> Is this not what we need to be doing?

>

> After reading the article by Dr. Bledsoe it would appear that we could get

> the same effect with the MAST trousers as we could with the traction splint. I

> would also have to change my opinion that possibly the traction splint is a

> device that should find a place for " long term treatment " of the femur

> fracture and not for EMS use.

>

> As far as spending time placing the device on the patient, if properly

> trained (with continued practice) a team should be able to place the unit on a

> patient (if the need is there) with minimal time spent. We are there to care

for

> the patient and " do no harm " .

>

> As with any treatment we may not always use a particular treament, but why

> do we need to limit our resources if and when our patients need them?

>

> Danny L.

> Owner/NREMT-

> PETSAR INC.

> (Panhandle Emergency Training Services And Response)

> Office

> Fax

>

>

[Guest guest]

In a message dated 11/13/2006 9:22:46 P.M. Central Standard Time,

wegandy1938@... writes:

I still make my

students learn to do the Half Ring and make the ankle hitch out of a

cravat.

Ya know gene it's guys like you that make it really easy for a Medic student

to use bad language at the bar after class oh yea and make decent Medics out

of them in the end.

I once had a student ask me " why do you always make us work outside of the

box? " my stock answer was that patients don't come in boxes!

Keep being they%* & %%^ and $ & ^^ & %* & % and ^ & %^ & %*\, etc. Gene!

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

LNMolino@...

(Cell Phone)

(Home Phone)

(IFW/TFW/FSS Office)

(IFW/TFW/FSS Fax)

" A Texan with a Jersey Attitude "

" Great minds discuss ideas; Average minds discuss events; Small minds

discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962)

The comments contained in this E-mail are the opinions of the author and the

author alone. I in no way ever intend to speak for any person or

organization that I am in any way whatsoever involved or associated with unless

I

specifically state that I am doing so. Further this E-mail is intended only for

its

stated recipient and may contain private and or confidential materials

retransmission is strictly prohibited unless placed in the public domain by the

original author.

[Guest guest]

In a message dated 11/13/2006 8:44:02 P.M. Central Standard Time,

wegandy1938@... writes:

And what evidence exists to support the use of the traction splint in any

event?

Anecdotally, (God that ought to bring out some vultures) in the

inter-facility world I've sen it applied in a community ED setting on a stable

non

multi-systems trauma patient where the pain relief alone would make it a

benefit.

The kid in question that comes to my mind had a tree that was being felled

slap him sorta sideways and he had the proverbial non multi-systems trauma

single point fracture of the mid shaft of the femur. he was NOT traction

splinted

(I have no idea why as I was not there) in the field but we were asked to

bring in a traction splint when we were called too move him. I was the

Supervisor on that night and thought that this was odd so I " ' ed " the call

(it's good to be the King at times) and when we got in there they had the ortho

guys in place already looking at his x-rays etc. The Dr. that would be doing

the cutting on this kid at the other facility (university hospital setting)

wanted him in a traction splint for the transport. He asked US to put it on as

he stated " I put one on in residency 10 years ago and never since " , the kid

had pain med's on board but even with that his pain relief was notable once

traction was applied.

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

LNMolino@...

(Cell Phone)

(Home Phone)

(IFW/TFW/FSS Office)

(IFW/TFW/FSS Fax)

" A Texan with a Jersey Attitude "

" Great minds discuss ideas; Average minds discuss events; Small minds

discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962)

The comments contained in this E-mail are the opinions of the author and the

author alone. I in no way ever intend to speak for any person or

organization that I am in any way whatsoever involved or associated with unless

I

specifically state that I am doing so. Further this E-mail is intended only for

its

stated recipient and may contain private and or confidential materials

retransmission is strictly prohibited unless placed in the public domain by the

original author.

[Guest guest]

One could well argue that the lack of efficacy behind the traction splint

would not make it a standard of care-only a treatment option. If you are to

carry a mechanical splint, then the REEL splint by far is the best splint

for the dollar. It will pull traction on femurs but also manage

tibia/fibular fracture and all three long-bone fractures of the leg as well

as knee injuries. The device is used by the military and we have discussed

it for the Special Forces and is popular in tactical settings. I have one

here at home and have played with it. Very impressive.

http://www.splints.com/

I have no financial interest in the device.

BEB

_____

From: texasems-l [mailto:texasems-l ] On

Behalf Of wegandy1938@...

Sent: Monday, November 13, 2006 8:41 PM

To: petsardlj@...; texasems-l

Subject: Re: Traction splints

Danny,

It's quite simple. The way the Hare is designed, because of the butt bar,

it elevates the proximal end of the femur. The leg is not in anatomical

position. With the Sager and Kendrick, the leg IS in anatomical position and

in a

straight line with the splint is applied.

But I still ask the question, is this standard of care? And what evidence

exists to support the use of the traction splint in any event?

Gene

In a message dated 11/13/06 9:04:32 AM, petsardlj@sbcglobal

<mailto:petsardlj%40sbcglobal.net> .net writes:

>

> How would you say that the HARE would angulate the fracture anymore than

any

> other splint?

>

> If properly applied the splint would or should not angulate but should

> support the leg with elevation also designed to lessen the blood flow to

the area.

> Is this not what we need to be doing?

>

> After reading the article by Dr. Bledsoe it would appear that we could get

> the same effect with the MAST trousers as we could with the traction

splint. I

> would also have to change my opinion that possibly the traction splint is

a

> device that should find a place for " long term treatment " of the femur

> fracture and not for EMS use.

>

> As far as spending time placing the device on the patient, if properly

> trained (with continued practice) a team should be able to place the unit

on a

> patient (if the need is there) with minimal time spent. We are there to

care for

> the patient and " do no harm " .

>

> As with any treatment we may not always use a particular treament, but why

> do we need to limit our resources if and when our patients need them?

>

> Danny L.

> Owner/NREMT-

> PETSAR INC.

> (Panhandle Emergency Training Services And Response)

> Office

> Fax

>

>

[Guest guest]

You go Gene...my EMT instructor did the same thing...always said " If you can put

the Half Ring on...you can use ANY traction splint " because it was all

about the concept...and she was right....

Dudley

Re: Traction splints

Henry,

I guess I haven't seen the new Hare design. How is it different from the

old one? Like you, I have seen the xrays to support the angulation. I wish I

had one of them to post.

You're right about the Half Ring. The best ever designed.

And you're also right about crews wanting sexy equipment. I still make my

students learn to do the Half Ring and make the ankle hitch out of a

cravat.

Gene

>

> The old Hare did cause alignment problems. I have seen the xrays to support

> it. I think that the new Hare design may have taken care of it. We do not use

> the Hare so have not kept up with it. Best splint ever made was the

> half ring. Did the job and didn't cost an arm and a Leg. We no long use that

> one either. Not high tech enough to suit the crews. However, now that we have

> equipment flying away never to be seen again, we may go back to two sticks

> tied together.

>

> Henry

> Re: Traction splints

>

> How would you say that the HARE would angulate the fracture anymore than any

> other splint?

>

> If properly applied the splint would or should not angulate but should

> support the leg with elevation also designed to lessen the blood flow to the

area.

> Is this not what we need to be doing?

>

> After reading the article by Dr. Bledsoe it would appear that we could get

> the same effect with the MAST trousers as we could with the traction splint. I

> would also have to change my opinion that possibly the traction splint is a

> device that should find a place for " long term treatment " of the femur

> fracture and not for EMS use.

>

> As far as spending time placing the device on the patient, if properly

> trained (with continued practice) a team should be able to place the unit on a

> patient (if the need is there) with minimal time spent. We are there to care

for

> the patient and " do no harm " .

>

> As with any treatment we may not always use a particular treament, but why

> do we need to limit our resources if and when our patients need them?

>

> Danny L.

> Owner/NREMT-

> PETSAR INC.

> (Panhandle Emergency Training Services And Response)

> Office

> Fax

>

>

[Guest guest]

In a message dated 11/13/2006 11:24:08 P.M. Central Standard Time,

THEDUDMAN@... writes:

it was all about the concept

same can be said for the " Vest Type extrication Device " and other things in

EMS. Hence the need for A & P and a bit of physics in EMS training.

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

LNMolino@...

(Cell Phone)

(Home Phone)

(IFW/TFW/FSS Office)

(IFW/TFW/FSS Fax)

" A Texan with a Jersey Attitude "

" Great minds discuss ideas; Average minds discuss events; Small minds

discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962)

The comments contained in this E-mail are the opinions of the author and the

author alone. I in no way ever intend to speak for any person or

organization that I am in any way whatsoever involved or associated with unless

I

specifically state that I am doing so. Further this E-mail is intended only for

its

stated recipient and may contain private and or confidential materials

retransmission is strictly prohibited unless placed in the public domain by the

original author.

[Guest guest]

Is that something that should happen, or happened once?

Where are the other traction splints any better? No angulation?

Where are they anchored?

On any traction splint I have seen they are anchored at the same place.

On the angulation is this a problem with injury to the patient or is it a

problem with initial placement by EMT's not paying attention to how they apply

it?

The Sager and Kendrick do not elevate the extemity. Is this not a problem

with basic first aid? Elevation slows bleeding, which is a problem with femur

fractures. Is that not why we apply a traction splint, to reduce the injury,

prevent further blood loss, and lessen our patients pain?

Help me here. Am I off track?

wegandy1938@... wrote:

Danny,

It's quite simple. The way the Hare is designed, because of the butt bar,

it elevates the proximal end of the femur. The leg is not in anatomical

position. With the Sager and Kendrick, the leg IS in anatomical position and in

a

straight line with the splint is applied.

But I still ask the question, is this standard of care? And what evidence

exists to support the use of the traction splint in any event?

Gene

>

> How would you say that the HARE would angulate the fracture anymore than any

> other splint?

>

> If properly applied the splint would or should not angulate but should

> support the leg with elevation also designed to lessen the blood flow to the

area.

> Is this not what we need to be doing?

>

> After reading the article by Dr. Bledsoe it would appear that we could get

> the same effect with the MAST trousers as we could with the traction splint. I

> would also have to change my opinion that possibly the traction splint is a

> device that should find a place for " long term treatment " of the femur

> fracture and not for EMS use.

>

> As far as spending time placing the device on the patient, if properly

> trained (with continued practice) a team should be able to place the unit on a

> patient (if the need is there) with minimal time spent. We are there to care

for

> the patient and " do no harm " .

>

> As with any treatment we may not always use a particular treament, but why

> do we need to limit our resources if and when our patients need them?

>

> Danny L.

> Owner/NREMT-

> PETSAR INC.

> (Panhandle Emergency Training Services And Response)

> Office

> Fax

>

>

[Guest guest]

Check this out...I know it is Sager's site....but it is the easiest place to see

the pictures of what we are talking about.

Dudley

http://www.sagersplints.com/pages/skeletal.html

Re: Traction splints

Is that something that should happen, or happened once?

Where are the other traction splints any better? No angulation?

Where are they anchored?

On any traction splint I have seen they are anchored at the same place.

On the angulation is this a problem with injury to the patient or is it a

problem with initial placement by EMT's not paying attention to how they apply

it?

The Sager and Kendrick do not elevate the extemity. Is this not a problem with

basic first aid? Elevation slows bleeding, which is a problem with femur

fractures. Is that not why we apply a traction splint, to reduce the injury,

prevent further blood loss, and lessen our patients pain?

Help me here. Am I off track?

wegandy1938@... wrote:

Danny,

It's quite simple. The way the Hare is designed, because of the butt bar,

it elevates the proximal end of the femur. The leg is not in anatomical

position. With the Sager and Kendrick, the leg IS in anatomical position and in

a

straight line with the splint is applied.

But I still ask the question, is this standard of care? And what evidence

exists to support the use of the traction splint in any event?

Gene

>

> How would you say that the HARE would angulate the fracture anymore than any

> other splint?

>

> If properly applied the splint would or should not angulate but should

> support the leg with elevation also designed to lessen the blood flow to the

area.

> Is this not what we need to be doing?

>

> After reading the article by Dr. Bledsoe it would appear that we could get

> the same effect with the MAST trousers as we could with the traction splint. I

> would also have to change my opinion that possibly the traction splint is a

> device that should find a place for " long term treatment " of the femur

> fracture and not for EMS use.

>

> As far as spending time placing the device on the patient, if properly

> trained (with continued practice) a team should be able to place the unit on a

> patient (if the need is there) with minimal time spent. We are there to care

for

> the patient and " do no harm " .

>

> As with any treatment we may not always use a particular treament, but why

> do we need to limit our resources if and when our patients need them?

>

> Danny L.

> Owner/NREMT-

> PETSAR INC.

> (Panhandle Emergency Training Services And Response)

> Office

> Fax

>

>

[Guest guest]

What are your thoughts on the use of traction splints on children?

" Bledsoe, DO " wrote:

Slug: The Traction Splint

Hed: The Traction Splint

Dek: An EMS relic?

By E. Bledsoe, DO, FACEP, & Donn , LP

Words: 1680

Traction splints have been a part of our equipment inventory for as long as

EMS has existed. Application of the traction splint is one of the most

fundamental of EMT skills. The purpose: immobilize femur fractures through

traction. Its application is believed to reduce hemorrhage, reduce secondary

tissue damage and reduce pain. But does the traction splint make a

significant impact on patient care in the modern EMS era or has it become an

EMS relic? Now that I have your attention, let's move on.

Historical review

Hilton introduced the first traction splint for lower extremity

fractures in 1860. In the 1870s, Hilton's splint was refined by noted

British surgeon and bone setter Hugh O. . This later version of the

splint came to be known as the splint and was widely used for

treatment of femur fractures.

During World War I, Sir suggested use of the

splint for the management of acute femoral fractures.[ii] During World War

I, the advent of trench warfare resulted in a marked increase in the number

of open femur fractures from gunshots and jagged shell fragments. Because of

this new style of warfare, military surgeons saw a stark increase in

mortality secondary to these injuries. The surgeons obviously had to change

their strategy for managing these injuries, and ' splint seemed like

the perfect tool.

The splint was introduced into military medical practice

as a method of treating obvious femur fractures in 1916. Following

widespread usage of the splint to treat these injuries, a significant

decrease in mortality from femur fractures was reported. However, the degree

to which mortality decreased is open to conjecture. Various percentages in

improved mortality secondary to use of the traction splint were anecdotally

reported-a phenomenon that became known as the " Splint boast. "

However, in a report, noted World War I surgeon and British Colonel Sir

Henry Gray reported that the mortality from femur fractures dropped from 80%

in 1916 to 15.6% in 1917 after the splint was used for 1,009 cases in

a particular battle.[iii] Although the splint was introduced

for the treatment of femur fractures, it seemed intuitive to several

physicians that it would be useful for initial immobilization of femur

fractures in the prehospital setting. Because of this, the American College

of Surgeons Committee on Trauma included the traction splint in its document

Essential Equipment for Ambulances in the early 1970s, and it remains a

mandated piece of equipment today.[iv]

How does it work?

Regardless of the type or manufacturer, the femur traction splint consists

of a frame that extends from the proximal thigh to an area distal to the

heel. The splint has a padded portion that fits against the ischial

tuberosity, which serves as the anatomical fixation point. The proximal

portion of the splint may be a ring that encircles the proximal thigh, a

partial ring or simply a padded bar. A traction device is located on the

distal part of the splint. The traction device can be a commercial

ratchet-type mechanism or a simple windlass and triangular bandage twisted

to take up slack and create distal traction of the femur. The thigh and leg

are usually supported by several soft and/or elastic supports.

The femur is the largest bone in the body and can cause

significant blood loss and tissue damage when fractured. The blood loss

comes from the fracture site itself and from surrounding tissues that are

damaged by the sharp bone ends. Blood losses of up to 2-4 units (1,000-2,000

mL) of blood have been reported with femur fractures.

The theory behind the traction splint is that it reduces

potential blood loss by applying traction to the leg, thus separating and

aligning the fracture segments. This serves to keep the thigh at its normal

length and also retains the thigh at a relatively normal circumference-thus

decreasing the potential space for blood loss.1

How often does the traction splint enhance EMS care?

In present EMS practice, the femur traction splint is indicated only for

isolated fractures of the femur.[v],[vi] It is contraindicated for:

* Pelvic fractures;

* Hip injuries with gross displacement;

* Any significant injury to the knee; and

* Avulsion or amputation of the ankle and foot.[vii]

With a single indication and numerous contraindications, how

often is the traction splint actually used in prehospital care? Researchers

looked at the incidence of traction splint usage in the city of ton,

Ill. (population 73,200 in 8.5 square miles), for a one-year period in 1999.

They reviewed 4,513 run reports and found 16 patients with mid-thigh trauma.

Of these 16 patients, 11 had minor trauma and five had clinical findings

suspicious for femoral shaft fractures.

Of the five patients with findings suspicious for femur

fractures, paramedics attempted traction splint application in three. One of

the patients who did not receive a traction splint had a possible hip

injury, making the splint contraindicated. The fifth patient that also did

not receive the traction splint was pain-free when paramedics arrived and

was simply transported in a position of comfort without incident.

Of the three cases where the EMS personnel attempted application

of the traction splint, only two were successful. The third patient was an

82-year-old woman who had mid-thigh trauma after a fall. When the crew

applied the splint and applied traction, it resulted in severe pain for the

patient and the splint was subsequently removed. A rigid splint was then

placed on this patient and she was transported without incident.

Thus, in this study group, only 0.11% of patients (1/11th of one

percent) had clinical findings suggestive of a femoral shaft fracture, and

only 0.07% met criteria for using the splint. Stated another way, only 7 of

10,000 patients in the study group had indications for traction splint

application. The author of this study concluded, " traction splints as

essential ambulance equipment may be unnecessary. " [viii]

Are traction splints safe?

As a rule, traction splints are safe when used according to the criteria

presented above. However, several recent studies have detailed complications

associated with EMS use and misuse of the traction splint. Researchers in

Buffalo, N.Y., recently described two patients who developed peroneal nerve

palsies following inappropriate application of traction splints. The Buffalo

study demonstrated how traction splints can aggravate certain soft tissue

lower extremity injuries.[ix]

The peroneal nerve (also called the fibular nerve) crosses over

the knee and is vulnerable to injury near the knee. Application of a

traction splint can cause the head of the fibula to be displaced laterally,

stretching or tearing this nerve.

This problem is made worse when there's an injury affecting the

integrity of the knee. One of the patients in the Buffalo study had a

traction splint () applied because of lower thigh pain and swelling.

By the time the patient arrived in the radiology department he was unable to

move his foot and great toe and had numbness on the bottom of his foot.

X-rays were negative and orthopedic consultation revealed a severe knee

sprain. The splint was removed and his peroneal nerve palsy eventually

cleared.

The second patient also received a traction splint after EMTs

suspected a distal femur fracture after a fall. At the ED, the patient also

exhibited peroneal nerve palsy. X-rays of the affected leg were negative and

the patient's nerve palsy slowly cleared after removal of the splint.

A Pennsylvania study detailed the case of a 22-year-old man who

fell 40 feet from a rooftop party and briefly lost consciousness. EMS was

called and found the man to be hemodynamically unstable, but without any

neurological or vascular deficits. IV therapy was initiated, a traction

splint was applied for an obvious thigh deformity and the patient was

transported to a trauma center. There he was found to have multiple injuries

(left pneumothorax, liver hematoma and multiple fractures). X-rays revealed

a comminuted left mid-shaft femur fracture and a comminuted left calcaneus

fracture.

The patient remained in the traction splint for six hours, at

which time he was found to have numbness and coldness of his left foot. The

left foot was severely swollen, and the pulses in the foot were absent,

indicating a compartment syndrome. The traction splint was removed and the

patient was taken to the operating room where the compartment syndrome was

surgically decompressed. Vascular surgeons had to surgically remove clots

from the posterior tibial artery and dorsalis pedis artery to restore blood

supply to the foot. The patient later required skin grafting to cover the

wounds from surgical decompression of the foot.[x]

A recent prospective study of 40 patients with multi-system

trauma who had a traction splint applied found that 38% of patients had the

traction splint applied despite the fact that its usage was contraindicated

by other injuries.[xi]

These studies clearly illustrate that inappropriate use of a

traction splint can cause injury or aggravate existing injury and in the

overall scheme of things, the indications for using a traction splint in the

prehospital setting are quite limited. Therefore, it's appropriate to ask,

is it prudent to stock the traction splint on ambulances and rescue vehicles

when it is so infrequently used? Most femur fractures are accompanied by

other injuries that may contraindicate use of the traction splint. Of the

remaining isolated femur fractures, most can be adequately treated through

immobilization with a rigid or adjustable splint or on a long spine board or

a vacuum splint/mattress. For systems that still carry medical anti-shock

trousers (MAST), isolated femur fractures are one of those few remaining

indications in which the MAST may be indicated.

Summary

Traction splints have been used in EMS for more than 40 years. However, they

were originally designed for the treatment of femur fractures-not temporary

stabilization. Multi-system trauma and other injuries make usage of the

traction splint contraindicated for many femur fractures. Thus, with the

relatively low usage of the traction splint, it may be time to revisit

guidelines that require traction splints on every ambulance and rescue

vehicle. They may be, in essence, an EMS relic we may want to part with.

Bledsoe, DO, FACEP, EMT-P, is an emergency physician in Texas. He can

be contacted at bbledsoe@....

Donn , LP, is a paramedic in Texas who works off the Ivory Coast as a

paramedic in the petroleum industry. He can be contacted at

donn@....

References

1 Henry BJ, Vrahas MS. The Splint. Questionable Boast of an

Indispensable Tool. American Journal of Orthopedics. 25(9):602-604.1996

2 R. Treatment of acute fractures of the thigh. British Medical

Journal. 11:1086-1087. 1914.

3 Gray HMW. The Early Treatment of War Wounds. London: H Frowde, Hodder and

Stoughton. 1919.

4 American College of Surgeons, American College of Emergency Physicians.

Equipment for Ambulances. 2000 (available at

http://www.facs.org/trauma/publications/ambulance.pdf).

5 JE. Basic Trauma Life Support, Fourth Edition. Upper Saddle

River, NJ. Brady Publishing/Pearson Education (p. 193-195). 2000.

6 JD. Femur fractures: complications and treatments of traumatic

femoral shaft fractures. Journal of Emergency Medical Services. 28(4):82-83.

2003.

7 McSwain NE, et al. Prehospital Trauma Life Support, Revised Fifth Edition,

St. Louis, MO. Mosby (p. 285). 2003.

8 Abarbanell NR. Prehospital midthigh trauma and traction splint use:

Recommendations for treatment protocols. American Journal of Emergency

Medicine. 19:137-140. 2001.

9 Mihalko WM, Rohrbacher B, McGrath B. Transient peroneal nerve palsies from

injuries placed in traction splints. American Journal of Emergency Medicine.

17:160-162. 1999.

10 AD, Kelikan AS. splint, calcaneus fracture, and compartment

syndrome of the foot: a case report. Journal of Trauma. 44:205-208. 1998.

11 Wood SP, Vrahas M, Wedel SK. Femur fracture immobilization with traction

splints in multisystem trauma patients. Prehospital Emergency Care.

7:241-243. 2003.

_____