Traction and Saager splint Contraindication

[megadancer91]

Hi all!

I was going over some scenarios with a fellow student and we came across one that involved a compound femur fracture. We both said we would use some sort of splint (Sam, pillow, or whatever available) because of the fact that it was an open fracture. However the treatment the scenario gave was to apply a traction splint... My teachers have told us time and time again that we CANNOT use saagers or traction splints on open fractures...

SO now I am extremely confused about whether or not a compound fracture is a contraindication or not.

Let me know what you have been taught or if you are positive one way or the other!

Smiles,

Meg

[entity]

Hi all!

I was going over some scenarios with a fellow student and we came across one that involved a compound femur fracture. We both said we would use some sort of splint (Sam, pillow, or whatever available) because of the fact that it was an open fracture. However the treatment the scenario gave was to apply a traction splint... My teachers have told us time and time again that we CANNOT use saagers or traction splints on open fractures...

SO now I am extremely confused about whether or not a compound fracture is a contraindication or not.

Let me know what you have been taught or if you are positive one way or the other!

Smiles,

Meg

You're not from Centennial College by chance are you?

Our instructor let us know the exact same thing - compound fractures are not to be tractioned.. on the flip side, I can also recall being told that if you have an open fracture but the bone naturally popped back into place, you can use a sager..

I don't have a definitive answer though.. but I found this a bit helpful..

http://www.sagersplints.com/pages/why3.html

[AnthonyM83]

Depends on local protocols. Both theories are accepted

[DwayneEMTP]

Instead of a definitive answer, or going to protocols, lets see if we can walk through it and decide for ourselves what the best course of action would be, and why, OK?

What is the indication for a traction splint?

What are contraindications for a traction splint?

What is a compound fracture?

Why would you NOT want to use a traction splint with exposed bone ends?

Why might you choose to ignore the issues with reducing a fracture with exposed bone ends?

I'm asking those of you that know the answers to let those that are learning do their thing here, and for you not to spoil it for them. Please feel free to help, but not solve. Thanks.

Dwayne

Note, I found the list below on accident and thought that some might find it interesting and useful.

Different types of bone fractures: -

• Open Fracture : An open fracture is a fracture where the broken bone is exposed. That is dangerous because of increased chances of infection.
• Closed Fracture : A closed fracture is a fracture where the bone is broken, but the skin is intact.
• Simple fracture : The fracture occurs along one line, splitting the bone into two pieces.
• Multi-fragmentary fracture : In this the bone splits into multiple pieces.
• Compression Fracture : A compression fracture is a closed fracture that occurs when two or more bones are forced against each other. It commonly occurs to the bones of the spine and may be caused by falling into a standing or sitting position, or a result of advanced osteoporosis.
• Avulsion Fracture : An avulsion fracture is a closed fracture where a piece of bone is broken off by a sudden, forceful contraction of a muscle. This type of fracture is common in athletes and can occur when muscles are not properly stretched before activity. This fracture can also because of an injury.
• Impacted Fracture : An impacted fracture is similar to a compression fracture, yet it occurs within the same bone. It is a closed fracture which occurs when pressure is applied to both ends of the bone, causing it to split into two fragments that jam into each other. This type of fracture is common in car accidents and falls.
• Stress Fracture : It is a common overuse injury. It is most often seen in athletes who run and jump on hard surfaces such as runners, ballet dancers and basketball players.
• Compression fracture of the spine : It is common in individuals with osteoporosis. Often no identifiable injury causes it. This results in significant pain and disability.
• Rib fractures : If you experience pain while breathing you probably have a rib fracture. In this condition you also have tenderness and shallow breathing.
• Complete Fracture : in this the bone fragments separate completely.
• Incomplete Fracture : in this the bone fragments are still partially joined.
• Linear Fracture : in this the fracture is parallel to the bone's long axis.
• Transverse Fracture : in this the fracture is at a right angle to the bone's long axis.
• Oblique Fracture : in this the fracture is diagonal to a bone's long axis.
• Spiral Fracture : in this at least one part of the bone has been twisted.
• Comminuted Fracture : in this the fracture results in several fragments.
• Compacted Fracture : in this the fracture is caused when bone fragments are driven into each other.

http://www.buzzle.co...-fractures.html

[P_Instructor]

Interesting.....Was the compound fx angulated? Were the bone ends exposed? Usually (insert your opinion of this), traction/sager splints are utilized for non-severe angulated mid-shaft femur fractures only. If the bone ends have already been reduced, how are you to know. Your primary objective for these devices are elongating the fracture site as not to create more damage with the sharp bone ends. Also, they (supposedly) reduce pain from nerve ending irritation. Ha. Many can do this with proper splinting with other devices, and pain medication (if authorized). I can think of only one time that I had an isolated mid-shaft closed femur fracture where we used the traction splint. The majority of my cases were splint in place, and not compromise the distal circulation. If the bone ends are exposed, by reducing the fracture in line, you will also cause more tissue and possible nerve/vascular damage as the bone ends align. Open/exposed, probably not by me, open/non-exposed, depends on many other factors found with assessment.

[uglyEMT]

Instead of a definitive answer, or going to protocols, lets see if we can walk through it and decide for ourselves what the best course of action would be, and why, OK?

What is the indication for a traction splint?

Femur fracture that has not punctured the skin

What are contraindications for a traction splint?

Any femur fracture that has broken the skin

What is a compound fracture?

A fracture in which the bone has broken completely and pierced the skin

Why would you NOT want to use a traction splint with exposed bone ends?

With the bone ends exposed (pierced the skin) the risk on infection is great. Due to the amount of blood loss from a femur fracture the risk on a blood infection is hightened. Pain to the patient from the bone ends hitting each other while tightening the traction goes against our ethos of do no harm.

Why might you choose to ignore the issues with reducing a fracture with exposed bone ends?

I can't think of any. Why risk the patient further injury by traction and possible infection. Then by splinting in place and possibly getting pain meds on board (Im BLS so its outside my SOP for pain meds)

I'm asking those of you that know the answers to let those that are learning do their thing here, and for you not to spoil it for them. Please feel free to help, but not solve. Thanks.

Dwayne

I dont know if I broke that rule LOL by answering but hopefully it can get a discussion going. Dwayne great way of going about this, instead of copy and pasting rule books or instruction sheets get the people thing as to WHY this should or should not be done. The more we learn the physiology behind what we do the better we understand why we do it. I think thats where the paramedic program excells beyond the basic, physiology, to me it should be taught in basic and expanded upon as you get higher certs. To many algorythem folks out there, need more critical thinkers.

[ERDoc]

We had a similar thread a few years ago (I didn't try searching for it). The term compound fx is no longer used. It is an open fracture if it breaks through the skin. We can debate points on both sides but the reality is, there is no evidence to back it up. I did a pubmed search specifically for Hare traction and Sager traction. The only article I could find was from 1979. In the hospital, femur fxs are treated with traction, usually with an intermedullary nail put through the distal femur. I did find a study comparing intermedullary nails vs external skeletal traction and they seem to offer the same results.

So, if traction works in the hospital, why wouldn't it work in the prehospital environment? A femur fx will cause spasms of the surrounding musculature, so if you can put it back into an anatomic position and decrease the spasms, making your pt feel better, why would you not do that? Any damage from a fracture is going to come from the original injury, not the reduction. You are putting the bone back where it is supposed to be so it will not harm the pt. As for infection, any open fx is going to the OR for a washout and a femur fx will require fixation so this really isn't a concern. I'm not saying to allow a large amount of dirt to enter the wound. If it is dirty, irrigate before splinting. The only contraindications I could find, which come from the Sager website, are a pelvic fx and a fx near the knee. The pelvic fx is pretty obvious. As for the injury near the knee, apparently with the force vectors involved with the splint, the distal femur could be rotated anteriorly and the sharp ends can injure popliteal artery and nerve.

[DwayneEMTP]

I knew that you'd be one of the first to jump in here Ugly! But I think you answered some questions too fast. I'm glad that you like critical thinking, because I'm going to be critical of some of your answers and ask that you allow others to do the same before you jump back in to recover... :-)

Warning! Some of the answers below are intuitive to me and based on my own line of logic mixed with myriads of sources that I can no longer even remember. I can't direct you to the answers in 'the book', or the studies that they came from, so all should be considered, as always, at least partially if not completely in error and fair game for attack and critique.

...Femur fracture that has not punctured the skin

Really? I'll bet that if I check your book I'll find a different, more specific indication. I know I will if I check the traction splint docs.

...Any femur fracture that has broken the skin

Uh oh, again a little quick on the draw.That is the only absolute or relative contraindication? I'm thrashing you a bit on this brother because I'm willing to bet you know these answers off of the top of your head yet posted without completely thinking the questions through. But that is why we're here, right? To develop more, better habits?

...A fracture in which the bone has broken completely and pierced the skin

As below, this is more commonly known as an Open Fracture now. Though the medical literature is still full of Compound Fractures. Any idea why the fall out of favor with CF Doc?

...With the bone ends exposed (pierced the skin) the risk on infection is great. Due to the amount of blood loss from a femur fracture the risk on a blood infection is hightened. Pain to the patient from the bone ends hitting each other while tightening the traction goes against our ethos of do no harm.

Excellent answer. The risk of infection increases when you bring the dirty bone ends back into the tissue, but the tissue isn't likely very clean anyway, right? You can sort of guide the bone halves externally when pulling them back through the skin to keep them from banging terribly, and you haven't, in my opinion, violated your ethics when the temporary pain will result in longer term comfort as well as decreased morbidity.

...I can't think of any. Why risk the patient further injury by traction and possible infection. Then by splinting in place and possibly getting pain meds on board (Im BLS so its outside my SOP for pain meds)

There is one significant assessment finding here that would absolutely cause me to continue manipulating this leg, meaning traction as opposed to leaving it in place. And this should absolutely be at the very front of your mind with this pt for BLS providers. Not talking about pain, though that would probably do it. Something more important. Can you think of what it would be?

...I dont know if I broke that rule LOL by answering but hopefully it can get a discussion going.

You didn't, and you did, at least with me.

...Dwayne great way of going about this, instead of copy and pasting rule books or instruction sheets get the people thing as to WHY this should or should not be done. The more we learn the physiology behind what we do the better we understand why we do it. I think thats where the paramedic program excells beyond the basic, physiology, to me it should be taught in basic and expanded upon as you get higher certs. To many algorythem folks out there, need more critical thinkers.

I agree completely. When I was going through medic school pharmacology was just kicking my ass. I've never excelled at memorizing large amounts of data, and had never had the occasion to improve that skill before that time. What I found was that I just couldn't do it! But one day, in these very forums, someone mentioned context hooks, which you've maybe noticed became a favorite phrase of mine. So instead of trying to memorize them I began to imagine the pt that I would use a drug on, what would that pt look like, what kind of things would they say,what would happen if I gave it despite their contraindication, what happened if I gave too much? Too little? Combined it with another drug with different effects? And soon my little pea brain began to make pictures I could see of the different systems effected, and how they were effected, what happened when I misdosed, or boneheaded it in some way. It works really well to me to this day.

Thanks for playing brother. Give the guys and gals a few hours to 'one up you' before you reply, ok? You can take it... :-)

Dwayne

[Happiness]

In my training as old as it is we were always told only to use the Sagar for mid Tib/Fib closed fractures. To be honest this is an area that I never really gave alot of thought to, just did what I was told.

I have had one open femur fracture and that was only a few months ago. 19 yr old riding his dirt bike, he hit a rock and slammed onto another rock. He tried to get up but down he went. Before we got there is riding buddy had removed his riding boot and checked for pedals. When we finally got him off the beach into the ambulance and I got his cloths cut off (about 5min tops had my vff with me)I noticed one little drop of blood on his thigh, I looked harder and there was no open fracture to be seen, I then looked at the size of his thigh and it was three times the size of the other one. As it turned out after the xrays he did have an open fracture, the part of bone that actually went through the skin was the size of needle and it had gone through the skin and maybe while I was packaging him up it went back inside.(if that makes any sense)

So even though I am not allowed to use this piece of equipment for a open fractured femur or any other fractured femur I don't think I would. And here is my reasoning why, #1 in this case anyways he is on a beach lots and lots of dirt as with other scenes it could be a potential infection entry point and #2 with the thigh strap it the swelling is going to cause a blood flow issue and potential necrosis.

I have seen higher level medics us the sagar on hip and femur fractures but it was a bit of a pain to get all the straps and the tension to work properly.

To the original poster When you have a question like this try to think outside of the box, do a good rule in, rule out for potential risks and benifits and take Dwaynes advise (he is a smart cookie) and you should do fine.

[Richard B the EMT]

In my training as old as it is we were always told only to use the Sagar for mid Tib/Fib closed fractures. To be honest this is an area that I never really gave alot of thought to, just did what I was told.

Wow, are our trainings and protocols different. Here in NY State, whatever type or brand traction splint, CONTRA-Indicated to use for fx leg if possible tib-fib involvement. Devices supposed to only be used for Femur fx. Admit I keep hearing debate if contra-indicated when "open" femur fx, due to possibility of infection, other side of the coin is to use, and have antibiotics for possible infection ready at the receiving hospital.