2 TRACTION SPLINTING IN LIMB FRACTURES – A VITAL MANOEUVRE in fractured femur treatment.
The aim of this short paper is to highlight the need for early application of traction splints in the management of femoral shaft fractures. Over the last four weeks I have been consulted as a Vascular Surgeon, to review three patients with femoral shaft fractures, in whom absent pulses had been noted below the groin. The first patient reviewed in the Emergency Department of a tertiary referral hospital, had sustained a combination of chest, abdominal and right leg injuries.
The acute management of the patient had been appropriate but during the secondary survey, the obviously angulated and externally rotated pulseless right leg, caused a lot of consternation in the attending staff, who asked for a vascular surgical review. Prompt application of a Hare traction splint resulted in brisk restoration of popliteal and pedal pulses. Failure of both Ambulance and Emergency Department staff to identify the need for this device in the management of a simple femoral shaft fracture was interesting.
Two further cases presented within a week to Liverpool Hospital Emergency Department. In the first instance, a male motorcyclist had sustained a simple transverse fracture of the femoral shaft at the junction of the middle and distal third. This had resulted in leg shortening and external rotation of the distal leg. Emergency Department staff, concerned at the absence of pulses, were arranging for radiography and Doppler studies. A consultation to the Vascular Surgical Service was also requested. Prompt application of a Hare traction splint was all that was necessary to realign the femoral shaft and restore the pulses, avoiding unnecessary radiography or vascular studies. The final case again involved a male motorcyclist who had sustained a transverse fracture of the distal left femur with slight comminution. A transverse laceration of the popliteal fossa had resulted in degloving to the level of the gastrocnemius muscle of the distal portion of the wound. The leg was obviously deformed, the thigh shortened and grossly swollen. Two x-rays were performed to confirm the bony injury which was quite clinically apparent (Figure 2). Nothing had been done to restore the pulse deficit below the left groin. In this case, again, the application of a Hare traction splint resulted in prompt restoration of pulses during the interval prior to placement of a Denham tibial pin in the Operating Theatre.
In all three scenarios, staff with at least moderate exposure to general principles of trauma management, failed to identify the need for application of a traction splint to restore pulses in the presence of a femoral shaft fracture. In part, their concerns related to the pain that movement of the leg would produce. Systemic analgesia with intravenous Morphine or inhaled nitrous oxide and reassurance and explanation, will usually allow the placement of traction splints. Patients usually experience significant relief from pain promptly after the leg is restored to normal alignment.
The decision to x-ray prior to realignment, was made on one occasion in this trio of patients. In some ways this is analogous to x-raying a tension pneumothorax or dislocated ankle before treating these life or limb threatening conditions. The need for application of the traction splint has higher priority than the need to image the bony deformity, which can be done with greater patient comfort and less threat to the limb, after application of the traction splint. The final observation was of the lack of familiarity of attending medical staff from two teaching hospitals with the traction devices which are available to them in their respective emergency departments.
These three cases highlight the need for general awareness of first aid principles in the management of femoral shaft fractures and of the need for attending staff to be practised in the application of simple traction splints.
John Crozier, Vascular Surgeon, Lecturer in Surgery Liverpool Hospital, LIVERPOOL