Traction and Saager splint Contraindication

[island emt]

A definite reason to use a traction splint & manual manipulation is when their is a loss of pulses distal to the injury site caused by impingement of the femoral artery. Open or closed you need to attempt to restore circulation to the limb.

In the old days we were taught to always splint a compound femur in position so as to not bring the dirt & germs back into the leg tissue.

In reality it does make sense to reduce it as these pt's are all going to the or for surgical repair anyway.

[fakingpatience]

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?

Midshaft femur fracture

What are contraindications for a traction splint?

ANY other leg injuries that could be made worse w/ the pulling force, ie. other fx, knee injury, ligament injury, pelvis injury. I don't remember if open fx was a contraindication, but I know completly severed bone is a contraindication (So pretty much if the skin/ muscle/ ligaments is the only thing keeping the leg from being amputated). If the outside bone is very dirty, I would attempt to clean it first by flushing it with normal saline

What is a compound fracture?

Open fx

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

Dirt getting back in? Risk of bone being completely broken/ snapped in half

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

loss of pedal pulses/ cms

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

Good to think about the traction splint, since it is one we use so rarely (I have never used it) It is aways good to mental go over it again.

On the same note, would to try and realign any other fx? I was taught yes, 1 try, unless you feel resistance, but some people here say no, never try.

[AnthonyM83]

Doc, I haven't gotten to visualize nerves and vessels in vivo but how likely is it that the Sharp bone edges can cause damage as its reduced. It just seems like there's a lot displaced in a fracture and lot that the bone edges can rub against.

Additionally another reason to reduce it is to decrease space for possible lacerated vessels to bleed into.

[DwayneEMTP]

Yeah FP, thanks for filling in the blanks..

And for me the loss of distal pulses is a huge issue. Life before limb, but we're going to save the friggin' limb if we can!

Thanks for playing all...

OP, did this help to answer your questions?

Dwayne

[uglyEMT]

No problem Dwayne. Im glad that your challenging me to think!

After seeing your comments I did some thinking. You are correct I jumped the gun and shot gunned my answers. For that I am sorry. I should have thought through it more and been more complete in my answers. I also reviewed my protocols and SOPs.

Indication for use of splint:

Closed femur fracture (suspected) in which PMS distal to the injury site is comprimised.

Contraindication(s):

Open femur fracture, hip fracture (suspected), knee injury, lower leg injury, ankle injury, possible amputation.

Compound fractures are more commonly known as Open Fractures in todays literature.

As per my protocols and SOPs (standard operating procedures) any open femur fracture is contraindicated for use of the traction splint. I am to splint the leg in place, if possible secure fractured leg to the other leg and transfer per log roll onto long spine board. OK thats what I follow, but here is my take on it after reviewing some literature from Doctor Bledsoe and others. Being a femur fracture is going to be surgically operated on the risk of infection is there but can be reduced with irrigation of the wound site and bone. Also antibiotics can be administered to help prevent infection. Thus the use of the traction splint would be benificial to any femur fracture because it would reduce spasm thus pain and also by attempting to get the leg to its normal length you reduce the void in which the bleed is allowed to flow thus reducing blood loss and possibly preventing hypovolumic shock. Again though even though this will probably by the protocol in the future in my area it is not now so I will follow my draconian one until I am told otherwise.

Dwayne you are correct when I missed a big reason to manipulate the leg. It would be if my intial assement found absent distal PMS. I would want to manipulate the leg to regain distal PMS and either use the traction splint or hard splint to maintain the PMS. After application reevaluate my PMS and also reevaluate while in route to maintain distal PMS.

Hopefully my new answers are a little more thorough and follow along with others thinking. Again as my one response said I stay within my protocols even though in my head I know different.

[DwayneEMTP]

Great posts all!

Hopefully walking through scenarios makes it easier for you to imagine using these tools, and allows you to see the reasons for or against so that you can make your own more rational decisions and not always be a slave to the opinions of others.

And Ugly, good on you for reviewing your answers. My goal in these things is to try and get you to look at these questions the way that you would look at them if you were on scene...with only the logic and knowledge that is in your head. You're really brave about doing that, most of the rest of us need some practice.

Pulses...in these types of injuries once we've done our basic life saving things, airway, O2, IVs, etc, it all comes down to pulses and reassessment, right?

Great job all..

Dwayne

[uglyEMT]

Pulses...in these types of injuries once we've done our basic life saving things, airway, O2, IVs, etc, it all comes down to pulses and reassessment, right?

Great job all..

Dwayne

I always check my PMS anytime I am doing an intervention then reevaluate. On bumpy roads (we have a few here) after particularly heavy ones I will instantly recheck. On the highways or smooth roads I will check every 5 minutes.

I learned the hard way a few days out of school from an ED Doc chewing me out because I made a bandage too tight on a splint and didn't recheck my PMS. Thankfully nothing happened because of it but it was the mere fact of being chewed out in front of my crew that made me never make that mistake again.

[Richard B the EMT]

I learned the hard way a few days out of school from an ED Doc chewing me out because I made a bandage too tight on a splint and didn't recheck my PMS. Thankfully nothing happened because of it but it was the mere fact of being chewed out in front of my crew that made me never make that mistake again.

Sounds like a rookie mistake, by someone who at the time WAS a rookie. However, a partial fail to the ER Doctor, due to personal experiences, I don't recall so much whatever the lesson, just that I got humiliated in public.

Before I get attacked due to that, just know, everyone, I hate being humiliated in public, no matter what the subject, or the person doing the humiliation. I view public humiliation by anyone in a supervisory position as a form of legal bullying. Let's discuss that, if at all, in another string, please. I've hijacked this one too long already.

[megadancer91]

Thanks for all the replies everyone! I guess it is still across the board huh? I know that if I work where I am currently in school my local protocols do not allow use of either splint on an open fracture. Our teacher likes to ask us "How much blood can you lose from a femur fracture" and the answer is "all of it," so i just assumed that you endangered arteries and other blood vessels by pulling the bone back into place.

As for pulses, I am being taught to ONLY try to realign deformities if there is loss of pulses, and to stop if there is resistance... that whole do no harm deal. Our teachers ALWAY drill PMS check into our heads too... I have forgotten so many times during drills... I sure hope I will stop forgetting soon!!!

Thanks again for the answers!

Smiles,

Meg

[ERDoc]

Doc, I haven't gotten to visualize nerves and vessels in vivo but how likely is it that the Sharp bone edges can cause damage as its reduced. It just seems like there's a lot displaced in a fracture and lot that the bone edges can rub against.

Additionally another reason to reduce it is to decrease space for possible lacerated vessels to bleed into.

Anthony, I'm not sure if this was directed at me but I'll answer any way. When you are reducing the fx you are moving in the opposite direction of the sharp edges. Think of a broken glass bottle that you are holding from the mouth. Rub the glass bottle along your skin with the sharp edges going forward and you will cut your skin. Now, pull the bottle from the mouth and you will not cut yourself because the sharp edges are moving in the wrong direction. This is the same thing that you are doing when you reduce a fracture. I hope you can visualize what I am describing.