The Sager splint applies counter-traction against the ischial tuberosity medial to the shaft of the femur.

PHOTOS COURTESY MINTO RESEARCH & DEVELOPMENT INC.

This splint applies counter-traction to the ischial tuberosity from below the femur shaft, which can cause movement of the bone ends. JEMS | AUGUST 2004

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AN EMS RELIC?
T

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

strategy for managing these injuries, and the Thomas splint seemed like the perfect tool. The Thomas splint was introduced into military medical practice as a method of treating obvious femur fractures in 1916. Following widespread usage of the Thomas splint, 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 reporteda phenomenon that became known as the Thomas splint boast. However, in a report, renowned World War I surgeon and British Colonel Sir Henry Gray noted that the mortality from femoral fractures dropped from 80% in 1916 to 15.6% in 1917 after the Thomas splint was used for 1,009 cases in a particular battle.3 Although the Thomas splint was introduced for the treatment of femoral fractures, it seemed intuitive to several physicians that it would be useful for initial immobilization of femoral 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.4
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raction 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 femoral fractures through traction. Application of the traction splint is believed to reduce hemorrhage, secondary tissue damage and pain. But does it 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, lets move on.

Historical review
John Hilton introduced the first traction splint for lower extremity fractures in 1860. In the 1870s, Hiltons splint was refined by noted British surgeon and bone setter Hugh O. Thomas. This later version of the splint came to be known as the Thomas splint and was widely used for treatment of femoral fractures.1 During World War I, Sir Robert Jones suggested using the Thomas splint to manage acute femoral fractures.2 The advent of trench warfare had 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 sharp increase in mortality secondary to these injuries. The surgeons obviously had to change their

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TRACTION SPLINT
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 the 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 fractures can cause significant blood loss and tissue damage. The blood loss results from the fracture itself and from surrounding tissues damaged by sharp bone ends. Losses of up to 24 units (1,0002,000 mL) of blood have been reported with femoral fractures. The theory behind the traction splint is that it reduces potential blood loss by separating and aligning the fracture segments through traction. This serves to keep the thigh at its normal length and relatively normal circumferencethus decreasing the potential space for blood loss.1 Of the three cases in which 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 due to a fall. When the crew applied the splint and 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, two of 4,513 patients had indications for traction splint application. Stated another way, 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. The author of this study concluded, Traction splints as essential ambulance equipment may be unnecessary.8

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.9 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 an injury affects the integrity of the knee. One of the patients in the Buffalo study had a (Thomas) traction splint applied because of lower thigh pain and swelling. By the time the patient arrived in the radiology department, he could not move his foot or 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 due to a fall. At the ED, the patient also exhibited peroneal nerve palsy. X-rays of the affected leg were negative, and the patients nerve palsy slowly cleared after removal of the splint. A Pennsylvania study

How often does the traction splint enhance EMS care?

In present EMS practice, the traction splint is indicated only for isolated fractures of the femur.5,6 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.7 With a single indication and numerous contraindications, how often is the traction splint actually used in prehospital care? Researchers studied the incidence of traction splint usage in Evanston, 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 patient who did not receive a traction splint had a possible hip injury, a contraindication. The other patient who did not receive the traction splint was pain-free when paramedics arrived and was simply transported in a position of comfort without incident.

PHOTOS JOE HEIGHTMAN

Traction is maintained as the splint is placed under the patient.

Traction is applied and Velcro straps are secured.

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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 hemodynamically unstable, but without any neurological or vascular deficits. IV therapy was initiated, and a traction splint was applied for an obvious thigh deformity. The patient was transported to a trauma center, where 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 removed clots from the posterior tibial artery and dorsalis pedis artery to restore blood supply to the foot. The patient later required skin grafts to cover the wounds from surgical decompression of the foot.10 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.11 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 limited. Therefore, its appropriate to ask, is it prudent to stock the traction splint on ambulances and rescue vehicles when it is so infrequently used? Most femoral fractures are accompanied by other injuries that may contraindicate use of the traction splint. Of the remaining isolated femoral 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 femoral fractures are one of those few remaining indications in which the MAST may be indicated.

4. American College of Surgeons, American College of Emergency Physicians: Equipment for Ambulances. 2000. www.facs.org/trauma/publications/ambulance.pdf 5. Campbell JE: Basic Trauma Life Support, 4th ed. Brady Publishing/Pearson Education: Upper Saddle River, N.J., pp. 193195, 2000. 6. Clark JD: Femur fractures: complications and treatments of traumatic femoral shaft fractures. JEMS. 28(4):8283, 2003. 7. McSwain, et al: Basic and Advanced Prehospital Trauma Life Support, revised reprint 5th ed. Mosby: St. Louis, p. 285, 2003. 8. Abarbanell NR: Prehospital midthigh trauma and traction splint use: Recommendations for treatment protocols. American Journal of Emergency Medicine. 19:137140, 2001. 9. Mihalko WM, Rohrbacher B, McGrath B: Transient peroneal nerve palsies from injuries placed in traction splints. American Journal of Emergency Medicine. 17:160162, 1999. 10. Watson AD, Kelikan AS: Thomas splint, calcaneus fracture, and compartment syndrome of the foot: A case report. Journal of Trauma. 44:205208, 1998. 11. Wood SP, Vrahas M, Wedel SK: Femur fracture immobilization with traction splints in multisystem trauma patients. Prehospital Emergency Care. 7:241243, 2003.

TRACTION SPLINT IN EMS: FUNDAMENTAL CARE Dont Jump the Gun

By Lawrence H. Brown & Elizabeth A. Criss
he article by Bledsoe and Barnes is sure to raise a few eyebrows among EMS professionals throughout the worldand well it should. As the authors point out, traction splinting has been a fundamental component of EMS care since the very beginning of the discipline. It is important, though, to read the article carefully and to pay close attention to what the authors are saying. Bledsoe and Barnes are not advocating the abandonment of traction splints; theyre questioning whether traction splinting is a necessary EMS intervention. There is a difference. Bledsoe and Barnes are absolutely correct: Very little science went into the original decision to include traction splinting in the EMS scope of practice. Anecdotal case reports and descriptive case series can never carry the same weight as well-designed, prospective, comparative studies. In the early days of EMS, however, there was no good science upon which to base decisions about what skills to include and exclude from the standard of care. Physicians and other leaders had to make the best decisions they could on the basis of the information available at the time. The fact that early decisions had to be made in the absence of good science should not be upsetting; what should be upsetting is that more than 30 years later we still havent conducted scientifically sound research on most of the EMS scope of practice. At the same time, the absence of strong studies proving the effectiveness of any given intervention does not necessarily mean that intervention is not important. Traction splinting is only one of dozens, if not hundreds, of EMS interventions that have never been subjected to rigorous evaluation. Indeed, if we removed every EMS device and suspended every EMS intervention that has yet to be scientifically proven there would be very little left for EMS to do. The papers that Bledsoe and Barnes cite describing adverse effects

Summary
Traction splints have been used in EMS for more than 40 years. However, they were originally designed for the treatment of femoral fracturesnot temporary stabilization. Multi-system trauma and other injuries contraindicate traction splint usage for many femoral 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.
Bryan Bledsoe, DO, FACEP, EMT-P, is an emergency physician in Texas. He can be contacted at bbledsoe@earthlink.net. Donn Barnes, LP, works off the Ivory Coast as a paramedic in the petroleum industry. He can be contacted at donn@phudpucker.com.

References
1. Henry BJ, Vrahas MS: The Thomas splint: Questionable boast of an indispensable tool. American Journal of Orthopedics. 25(9):602604, 1996. 2. Jones R: Treatment of acute fractures of the thigh. British Medical Journal. 11:10861087, 1914. 3. Gray HMW: The Early Treatment of War Wounds. H Frowde, Hodder and Stoughton: London, 1919.

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associated with traction splinting are worrisome. The science behind these anecdotal case reports and descriptive case series, however, is no more sound than the science that got traction splints placed on EMS vehicles in the first place. These reports raise questions; they do not give answers. It is perfectly appropriate to raise questions. Bledsoe and Barnes should be applauded for pointing out the lack of science supporting, and the anecdotal evidence questioning, traction splints. We should not, however, change our current practices simply because someone has raised a question about them. We should answer the question. We must do the researchwell-designed, prospective, comparative researchto evaluate the efficacy of prehospital traction splinting. And then we must do the research to address whatever questions Bledsoe, Barnes and anyone else raises next.
Lawrence Brown and Liz Criss are regular contributors to the JEMS Research Review column, and both serve on the board of advisors for the Prehospital Care Research Forum.

Proper Splint Design & Application Are the Keys

By Anthony G. Borschneck, MD, co-creator of the Sager Emergency Traction Splint

D questions the value and efficacy of traction splinting of fractured

r. Bryan Bledsoes and Donn Barnes thought-provoking article

femurs in todays prehospital setting. However, before we rush to condemn traction splints as an EMS relic we must first evaluate three key issues: 1) the leading cause of complications using todays traction splints; 2) the incidence of femoral fractures within the United States, as well as the value of having equipment on board to treat them; and 3) the necessary control of blood loss and pain management. I will elaborate: 1) The leading cause of complications using todays traction splints: The contraindications of traction splinting noted by Bledsoe and Barnes are: pelvic fractures, hip injuries with gross displacement, knee injuries, and avulsion and amputation of the foot. Fractures/dislocations of the hip are also included. I would suggest that proximal third fracture of the femur with gross displacement is not a contraindication and requires some qualification.1 Not all traction splints are the same. Almost all traction splints with the exception of the Sager splintapply counter-traction to the ischial tuberosity from below the shaft of the femur (see p. 64). The original Thomas full-ring and half-ring splints applied counter-traction on the ischial tuberosity medial to the shaft of the femur.2 The bottom of the ring was well below the femoral shaft and did not impinge on it (see top of p. 65). People should not assume that todays modified half-ring (ischial bar/pad type) splints have the exact design specifications and functionality of the original Thomas half-ring splint. They dont. In thin, young, small patients and some adults, the proximal pad/bar of many of todays half-ring splints may push up against the shaft of the femur in order to apply a non-slip perch against the ischial tuberosity. Tightening of the thigh strap to prevent slippage off the ischial tuberosity may enhance distortion at the fracture site.

If you look at a lateral projection of a supine human pelvis and femur, youll note that the ischial tuberosity and the shaft of the femur are on the same plane. The ischial tuberosity projects no more than one-half to one inch (1 or 2 cm) below the level of the femur.3 In proximal third fractures, these splints may cause injury to the sciatic nerve and its branches, popliteal and peroneal, as well as blood vessels and tissue. A review of the various models of ischial pad splints still in use today show pad elevations of 1.75 inches, 2.5 inches and 3.5 inches. The same elevations exist in pediatric models. These elevation ranges are inconsistent with the pediatric anatomy of most toddlers, pre-schoolers and other young school-age children of small stature. Counter-traction groin straps on some models pull laterally and may constrict blood flow to the femoral artery and vein in the proximal anterior thigh if excessive traction force is applied. Similar action of the strap below the thigh may cause injury to the sciatic nerve and its branches as well. Sager Emergency Traction Splints were designed to apply countertraction against the ischial tuberosity medial to the shaft of the femur in a manner consistent with the original Thomas full and half-ring splints. Simon and Koenigsknecht note in Emergency Orthopedics: The Extremities, the [Sager] splint does not have a half-ring posteriorly, which eliminates any pressure on the sciatic nerve and most importantly eliminates the angulation of the fracture site, which occurs with half-ring splints.4 By design, Sager splints provide anatomically correct, straight inline traction and immobilization. There is minimum movement of the injured limb during application, and the Sager figure 8 strap restricts distal rotation. The Sager Model S304 (Sager Form III Bilateral) features containment within the body silhouette; it does not extend beyond the patients heels and thus eliminates transport complications in helicopters, fixed-wing aircraft and van-type ambulances. Sager splints provide gentle, quantifiable traction that is dynamic in nature. As such, Sager splints were designed to permit graded reduction of the traction force as the muscle spasm decreases and the leg length increases.5 The Sager traction handle/scale enables first responders to set and document the traction force applied. Minto recommends a traction force of an estimated 10% of the patients body weight with a maximum of 15 lbs. of traction force (for single fractures). Only rarely will more traction be required.6 An unpublished retrospective study of 53 patients with lower limb fractures recorded at one hospital during a five-year period indicated a single case of cool foot below the ankle harness. However, the physician reported normal dorsalis pedis and posterior tibial pulses. Two cases of unrelieved pain were also recorded. The average time in traction for all patients was 2.56 hours. No other splint complications were reported. Because the bulk of these injuries occurred in rural areas, transportation times were long.7 Another study, conducted in 2002 and involving 183 volunteer EMTs, paramedics and instructors, demonstrated that an attempt to manually pull 15 lbs. of traction resulted in a wide range of traction force, from 3.5 lbs. to 111 lbs. The group average was two and onehalf times the recommended amountat a force of 37.99 lbs.8 Misuse of traction splints is suggestive of educational deficits; much

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more emphasis should be placed on traction splint design as well the indications and contraindications regarding the use of traction splints. 2) The incidence of femoral fractures in the United States: Bledsoes and Barness questioning of the necessity or limited use of traction splints is based primarily on three studies. The Abarbanell (Evanston) study was limited to a single-year evaluation of femoral fractures treated with Hare and Ferno Trac splints.1,9 Both of these splints are indicated only for use in mid-shaft femoral fractures.1,10 The two other studies referenced do not specify which traction splints were used (the Watson and Kelikian study identifies the splint only as a Thomas splint).1,10,11 Sager splints are indicated for treatment in proximal third and mid-shaft femoral fractures and as such, have a much wider range of application and use. Therefore, much broader, long-term and more inclu- 1957 ARC First Aid book instructions for use of cravats with the Thomas half-ring splint. sive studies are needed before an accurate saving abilities may not be as dramatic as many authors have sugevaluation of the usage of traction splints can be made. With respect to the incidence of femoral fractures within the gested, it still has a place in the acute setting of femoral fractures, United States, it should be noted that a 1997 estimate of the total when applied appropriately and continued until definitive treatment number of femoral fractures was 474,551 patients. Of these, only 9% can be attained Thus continued use of traction splints in acute (41,012) were mid-shaft fractures, and 84% (399,484) were proximal management of femoral shaft fractures seems appropriate.18 third fractures.12 Recognizing the potential for hypovolemic shock to accompany a The actual reportage of incidences involving femoral fractures for femoral fracture, minimizing blood loss with prompt traction and imthe year 2002 was 438,496. Given these figures, the value of having mobilization, and providing effective pain management and relief a traction splint onboard to treat femoral fractures should not be so should continue to be the standard of care. If prehospital personnel have a greater understanding of anatomy easily discounted nor underestimated.13 and select appropriate equipment, the incidence of treatment compli3) Control of blood loss & pain management: Its important for prehospital personnel to recognize that the main functions and cations with traction splints would be greatly reduced. In an effort to objectives of traction splinting are to: 1) align the fractures, 2) provide ensure safe, complication-free treatment of patients with fractured fesecure immobilization, 3) control spasm, 4) control and reduce blood murs, Minto Research & Development Inc. provides training videos, loss, 5) provide pain relief, 6) prevent further injury to blood vessels, application posters, user handbooks and instructors manuals with nerves and tissue, and 7) lower the incidence of clinical fat embolism. exams.19 In femoral fractures, especially if the fracture is in the proximal end, traction splinting is the best-known prehospital treatment for immo- Anthony Borschneck, MD, is vice president of Medical Research for Minto Research & Development Inc. (Redding, Calif.). He is an emergency physibilization of the joints above and below the fracture site. When a patient suffers a fractured femur, the amount of pain felt by cian (ret.) with more than 35 years experience treating femoral fractures. the patient is in part related to the amount of muscle in spasm, as well Dr. Borschneck co-developed the Sager Emergency Traction Splint. For more as the degree of spasm. This is why a fractured femur typically results information on Sager Emergency Traction Splints, contact Minto Research & Development Inc. at 800/642-6468, via e-mail at MINTORD@aol.com in much more pain than a fractured humerus. The application of traction on the muscle tires and pulls it out of or online at www.sagersplints.com. Sager is a registered trademark of Minto spasm, consequently relieving much of the patients pain. It also re- Research & Development Inc. stores the cylindrical shape of the leg and, in the process, increases tisReferences sue pressure within the thigh, which inhibits further blood loss. 1. Bledsoe B, Barnes D: The traction splint: An EMS relic? JEMS. Traction splinting also aides in shock prevention, and, therefore, its 29(8):6469, 2004. 2. Borschneck AG, Wayne M: Sager Emergency Traction Splint: A new use as a treatment option should not be denied to patients. splinting device for lower limb fractures. The EMT Journal. 4(1):4247, In The Thomas splint: Questionable boast of an indispensable tool, Henry and Vrahas note, Although the Thomas splints life1980.

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3. Merrill V: Atlas of Roentgenographic Position and Standard Radiologic Procedures, 3rd ed., Mosby, p. 189. 4. Simon RR, Koenigsknecht SJ: Emergency Orthopedics: The Extremities, 3rd ed. Appleton & Lange: Norfolk, Conn., p. 8, 1995. 5. Borschneck AG: Why Traction? JEMS. 10(7):45, 1985. 6. AAOS: Emergency Care and Transportation of the Sick and Injured, 8th ed. Jones & Bartlett Publishers: Sudbury, Mass., p. 653, 2002. 7. Retrospective study of 53 cases of fractures of the long bones of the lower limb treated with Sager Emergency Traction Splints, January 1973 to June 1978, Chilliwack General Hospital, Chilliwack, B.C., Canada. 8. Borschneck AG, Spotts C: Traction force challenge. Emergency Medical Services Magazine. 31(5):7274, 2002. 9. Abarbanell NR: Prehospital midthigh trauma and traction splint use: Recommendations for treatment protocols. American Journal of Emergency Medicine. 19:137140, 2001. 10. Wood SP, Virahas M, Wedel SK: Femur fracture immobilization with traction splints in multi-system patients. Prehospital Emergency Care. 7(2):241243, 2003. 11. Watson AD, Kelikian AS: Thomas splint, calcaneus fracture, and compartment syndrome of the foot: A case report. The Journal of Trauma: Injury, Infection, and Critical Care. 44(1):205208, 1998. 12. Confidential QMPDC Work Project: Projected Potential US Femur Fracture Hospital Admission, ICD9 Data Files. 13. Knowledge Enterprise Inc., No. 1510, p. 2, Inpatient fractures 19992002, ICD9 codes 820.00-820.09, 821.00-821.39. 14. Jones R: Treatment of acute fractures of the thigh. British Medical Journal. 11:10861087, 1914. 15. Sinclair M: The Thomas Splint and Its Modifications in the Treatment of Fractures. Oxford University Press, p. 152, 1927. 16. Jones RS: Notes on Military Orthopedics. Cassell & Company Ltd., pp. 112121, 1917. 17. Kendrick DB: Blood program in World War II (Supplemented by Experiences in the Korean War), In Historical Note Blood Transfusions in World War One. Office of the Surgeon General, Department of the Army: Washington D.C., pp. 59, 1112, 1989. 18. Henry BJ, Vrahas MS: The Thomas splint: Questionable boast of an indispensable tool. American Journal of Orthopedics. 25(9):604, 1996. 19. Instructor Manual & Portfolio. Minto Research & Development Inc.: Redding, Calif.

Military Use: SOP

By Richard S. Wiegert, SFC, NREMT-P, Advanced Training Branch (BNCOC); Joaquin R. Soliza, SFC, NREMT-I, Dept. of Combat Medic Training; Juan M. Almonte, SSG, NREMT; Ernest J. Barner, SSG, NREMT; Nathan M. Chipman, SSG, NREMT, 82d Airborne Division*; Renan Cortez, SGT, NREMT, 1st Infantry Division; Jacques C. Hope, SGT, NREMT, 3rd Infantry Division*
raction splints remain a universal part of medical equipment sets (MES) in most U.S. Army evacuation vehicles, from ground ambulances (both wheeled and tracked) to aircraft. Traction splints, like any durables in the MES (KED, litters, straps, spine boards, etc.) are usually exchanged at an ambulance exchange point (AXP) or landing zone (LZ) when an aircraft picks up the patient.

3
The U.S. military utilizes the REEL Splint System for traction splinting and immobilizing angulated knee injuries. The process: 1) traction applied; 2) ischial strap padded and secured; 3) straps secured; and 4) patient logrolled onto backboard.

Training
Battlefield care operates under the tenets of Tactical Combat Casualty Care (TCCC), emphasizing the total continuum of care in an operational environment. TCCC is broken down into three phases of care: 1) Care under fireCare rendered by the medic at the scene of injury while under direct, effective hostile fire. Things to consider: First, the medic is limited to what they carry in a leg pack and aid bag on their back. Second, hemorrhage control and getting the patient under cover are the key objectives at this phase of care.

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2) Tactical field careThe care rendered by the medic once they are no longer under direct, effective hostile fire or when an injury occurs but there is no hostile fire. 3) Casualty evacuation care (CASEVAC)The care rendered once the casualty has been picked up by vehicle, aircraft or boat. Combat medics are taught traction splinting in the EMT portion of their entry-level medic training (91W). Traction splinting is trained and tested to NREMT and DOT standards. It is also part of sustainment training in most Army medical units training plans.

Operational
Because the traction splint is part of the MES in most evacuation platforms, it is usually applied at the AXP during patient exchange. Patients with indications for traction may arrive at the AXP with the extremity immobilized, often in field-expedient fashion (e.g., anatomical splinting, cravats/wraps). If time and situation allow traction splinting at the AXP, it is often done (when indicated) at this level of care. The Bledsoe article mentions patients who have developed palsies from compression, or in the case of the patient left in the splint for six hours, a cold, vascular-compromised extremity. A few perspectives from the military address these complications: In operational environments, evacuation times and methods (e.g., ground vs. air) are often governed by the current mission situation. Patients can be in the evacuation chain from minutes to (potentially) several hours. Given this, we assert and stress the importance of the ongoing exam. Medics are drilled in checking distal PMS before and after splinting, and during evacuation to avoid complications. Army ground evacuation vehicles are designed to negotiate nearly any terrain and a patient in traction and on a spine board may potentially have an uncomfortable, rough ride. Civilian EMS courses and NREMT testing emphasize securing splint to spine board. However, this is difficult at times in the field. Therefore, in the military, the splinted leg is often supported or suspended separate from the backboard to prevent injury aggravation. Traction splinting is a tool used by Army medical personnel as a way to stabilize obvious femur fractures in an operational environment. Although isolated femur fractures are rare, traction splints are still carried in most Army evacuation vehicles. Army medics continue to be trained in traction splinting, with emphasis on the CASEVAC phase of Tactical Combat Casualty Care. Ultimately, the unit medical officer (MD/DO/PA) will guide protocol on application and/or removal of existing splints for traction application. *Units served with during Operation Enduring Freedom/Iraqi Freedom. Note: The Chief, Academic Division, Department of Combat Medic Training, authorized the operational feedback provided. It does not represent the position of the Department of Combat Medic Training, AMEDD Center & School or the U.S. Army.

by Galls in England. Its called the Slishman splint. Because of this history, my perspective on Dr. Bledsoes article is certain to be very biased. This is unavoidable. Patients who suffer this injury are typically miserable. Some present unconscious due to multitrauma. But the large majority that Ive seen are wide awake and in agony. Pain causes the large quadriceps to contract, forcing sharp femur fragments into surrounding tissue, causing further discomfort. This feedback loop results in excruciating pain. By providing traction to the spastic quad, this painful experience can be significantly alleviated. An additional reason to apply traction is to limit bleeding within the thigh. For me, the question is not whether traction limits pain and helps patients, but how to best apply traction. A perfect traction splint is one that can be applied quickly with minimal training, requires minimal manipulation of the injured limb during application, permits modification of traction for patients awake and capable and causes few complications, such as peroneal nerve or vascular injury. Ill conclude with the topic of complications. It boils down to our comfort with sins of commission vs. those of omission. Should we not apply splints to every femoral fracture for fear that someone may suffer a peroneal nerve palsy, venous thrombus, pressure sore or other problem due to splint application? Such complications as pain, further tissue trauma from fracture fragments, conversion of fractures from closed to open and, perhaps, exsanguination may also result from not applying traction splints. But it is more difficult to lay blame for not taking any action. If it is my leg, I want a traction splint.

Questioning Commended
By Sam Scheinberg, MD, The Seaburg Co. Inc.

O tionship with any femoral traction splints. I would like to commend Bledsoe and Barnes on their willingness to question established benefits. Its exactly that kind of thinking and courage that has produced many of the major advances in the health-care field. The fact that one community experienced a low incidence of femoral fractures has little meaning. I practiced orthopedics in an equally small community and at one point treated eight femoral shaft fractures in three separate hospitals. Is this normal? Of course not, but it does illustrate that types of trauma can vary according to many factors, including speed limits and road conditions. Bledsoe and Barnes cite complications regarding the improper use of femoral traction splints and make specific reference to a lengthy use of six hours. I can state only that the improper use of any device (e.g., drying your hair in a microwave oven) could lead to serious complications. Recognizing that blood loss, vascular and neurological complications and morbidity can vary according to fracture type, transport time, provider skills, immobilization techniques, age, pre-injury health status and associated injuries, I believe the overriding reason for prehospital femoral traction (excluding the wilderness setting) is for pain relief. During my 30 years as an orthopedic surgeon, I have witnessed the dramatic pain relief provided by femoral traction splints and significant increase in pain when these devices were removed. Therefore, I can only hope such a device is applied to me or my family members if we are ever so unfortunate to suffer such a terrible injury. JEMS
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ur company does not manufacture, sell or have any financial rela-

Sins of Commission vs. Sins of Omission

By Sam Slishman, MD, ED physician & traction splint developer
m an emergency physician at the University of New Mexico. Six years ago I developed a lightweight, easy-to-apply, multi-use traction splint. It is now manufactured in Italy by Gipron and distributed

| AUGUST 2004 | JEMS

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