“What’s that mailbox say?” You ask your partner, “14338 Hansen Road? Good, we’re here. Your partner calls “on scene” to dispatch as you pull into the gravel driveway of the farmhouse you’re responding to. It’s set some distance from the road, but as you pull up you’re met by two teenagers who are waving you towards the gate to a field. You stop and ask them where they’re directing you.
“He’s out in the field!” They both exclaim at once. You ask the older of the two what’s going on. “Our dad was trying out our new dirt bike and he fell! He’s about a quarter of a mile out in the pasture! He’s hurt real bad! We think his leg’s broke! He’s yelling a lot. You’ve got to go help him!”
Judging by the amount of rain your area has had in the last few weeks, the dirt lane out into the pasture doesn’t look all that friendly for your ambulance to travel down. Luckily, the guys from the station are following you in Utility 984 which is a 4-wheel-drive pickup truck. They arrive shortly after you get out of the ambulance and pull out the gear you need. You take a backboard, the c-collar bag, your trauma kit, the drug box, and on a whim you dust off the traction splint and take it with you. As the utility unit pulls up, you throw all of your gear in the back and ask them to give you a lift down to the patient.
After about a 3 minute ride you find the patient, an adult male in his late 40s. He’s lying in a kind of fetal position on his left side holding onto his right thigh very tightly with both hands. He’s pale, cool, and diaphoretic and even though he’s trying to be brave for his sons, you can tell that he is in extreme amounts of pain. You introduce yourself to the patient and ask him what happened while your partner attempts to protect his c-spine. He seems to be conscious and alert but has trouble getting the words out. Through the story told by him and his sons, you find that he was turning sharply on the new dirt bike and had stuck out his leg to help him keep his balance. Apparently he must have caught something with his foot because he felt a terrible pain in his thigh and flew off of the bike at a fairly high rate of speed. On assessment, you find a few superficial abrasions to the patient’s arms and one on his forehead, but no other injury other than to his obviously deformed leg. You ease the patient to a supine position and can see that the leg is shortened and rotated. Then you expose the patient and see that his right thigh is swollen to about twice the size of the left one. He has no pain to palpation to his head, neck, back, chest, abdomen, pelvis, arms, left leg, or right ankle… but that deformed, shortened, rotated, and swollen left thigh suggests a mid-shaft femur fracture, and a painful looking one at that.
Since you’re working a paramedic truck, you have your partner pop in a large bore IV line while you get out the drug box. The patient’s going to need a line anyway as people can lose a huge amount of their total blood volume into their thigh without spilling a drop externally and he could probably use some pain control before you move him. You choose to give him 50mcg of Fentanyl and have the rest drawn up to give him after you see his tolerance to the medication. While you’re doing this, you‘re thinking about how lucky you are that you remembered to grab the traction splint. You’re also desperately hoping that you remember how to put it on. It’s been… a while since you put one on a patient last and you think you were sick that last skills review day where you were supposed to practice it. Your partner wasn’t however and you put the patient on the traction splint together. Once you pull the traction, you see the relief spread over your patient’s face as the bone is pulled back into alignment and his muscles stop spasming. His pain drops markedly and his blood pressure is actually up a bit since you last took it. You give him a repeat dose of Fentanyl to prepare him for the bumpy ride back in the pickup truck and package him the rest of the way on the long-board for spinal precautions.
The femur is one of the strongest bones in the body and is said to be able to withstand forces of up to 15-30 times a person’s body weight before breaking. It does this because it is surrounded and supported by the powerful muscles within the thigh that contract around it to provide reinforcement. Femurs are connected proximally to the pelvis through the femoral neck or acetabulum, and are connected distally at the knee joint. When the femur is fractured, the muscles of the thigh spasm and contract, pulling the jagged ends of the newly fractured femur past each other, shortening the leg and causing great pain and damage to the internal tissue as the bones lacerate and damage the structures around it. The damage from an improperly splinted femur fracture can be worse than the injury from the trauma taken to break the bone in the initial injury. In fact, due to its proximity to the femoral artery and vein, a patient can completely exsanguinate from an isolated femur fracture. It is of vital importance to stabilize and realign a femur fracture as soon as possible after an injury in order to prevent further damage and potential other complications.
Traction splints are required by law to be carried in most ambulances in the United States. They come in three popular varieties, the Kendrick Traction Device, The Hare Traction Splint, and the Sager Splint. All of them are designed to perform the same function for a wide cross section of patients however their design and application vary greatly. They serve to pull distal force along the leg to lengthen it back to its normal length. The traction applied by the splint pulls the femur back into normal alignment and the splint then serves to immobilize the leg. The traction and immobilization stop the muscle spasms and realign the bone, preventing further injury and greatly reducing pain. It is amazing the first time a provider sees a traction splint being properly applied to a femur fracture and realizes the amount of immediate pain relief the splint provides. While EMS providers don’t tend to use traction splints very often, once they do they consider them to be extremely valuable pieces of equipment.
A traction splint is indicated for a mid-shaft femur fracture with no pelvic involvement and no injury distal to the femur on the involved leg. Mid-shaft femur fractures present with a history of an injury from a specific force, such as the story above or from a front-end vehicle accident, but can also occur from incidents of lower energy transfer. Femur fractures will be present with shortened, rotated extremities with swollen, painful thighs in the affected leg. Be sure to check distal pulses before and after application of the splint.
Get to know your traction splint and pull it out to play with it every so often. When you need it, you’ll *really* need it and it’s good to know how to use it. Your patients will thank you.