Traction splint: to use or not to use.
The Thomas splint is surely the best known appliance in orthopaedic and trauma surgery (Ellis 2007). Despite the advancement in operative technique, patients are often required to be temporarily treated in an immobilisation splint to be stabilized medically or for other reasons. The technique of immobilisation has evolved from mere immobilisation to traction splint using skin or skeletal traction. Currently, traction splints (TS) are widely used in the prehospital setting for immobilisation of femoral fractures. The indication often extended beyond an isolated mid-shaft fracture of femur to include all types. This exposes patients to all the potential risks of immobilisation along with specific risks due to the technique (Wood et al 2003). The risks and morbidity of immobilization are often not recognised or are ignored (Halanski & Noonan 2008). In the current climate of medicolegal awareness, knowledge of the potential problems associated with immobilisation and insight into preventing them are beneficial both to the patient and the surgeon. It is hence important to inform patients and their carers of the risks associated with the splintage. Above all, there is brevity of evidence-based research on the efficacy of TS for femur immobilisation, either as an isolated injury or in combination with other orthopaedic injuries (Wood et al 2003). We present a case of skin complication following traction splintage and review the literature on the same.
A 74 year old lady slipped on a slippery surface while on a holiday. She sustained a short spiral fracture of the shaft of left femur. She did not have any distal neurovascular deficit and was hemodynamically stable. After initial resuscitation, her leg was immobilised on a Thomas splint complemented by an adhesive skin bandage on balanced traction and she was admitted for definitive surgery. Skeletal traction with a distal femoral or proximal tibial Denham pin was not used. However, due to the volume of trauma cases on the trauma list, her operation was delayed for three days. On removal of the splint, it was noted that she had developed a pressure ulcer on the popliteal region with a necrotic surface (Figure 1).
[FIGURE 1 OMITTED]
She underwent intramedullary nailing from which she made satisfactory progress. The wound was dressed regularly with nonadhesive and adsorbent dressings. She was finally discharged for outpatient follow-up after 28 days of hospital stay. On subsequent review, her wound had healed with some scarring and the fracture uniting. She was mobilising full weight bearing.
The traction splint was introduced for the first time in 1860 by John Hilton. However it was only in 1870s when Hugh O Thomas (1834-1891) devised his modification to solve the problem of efficient immobilisation of the lower limb, both in the treatment of fractures, especially of the femoral shaft, and in treatment of chronic bone and joint diseases, in particular tuberculosis of the knee (Thomas 1876). It wasn't until the First World War (19141918) when Sir Robert Jones (1858 1933), Thomas' nephew, introduced it on the western front and showed it to reduce the mortality of compound fractures of the femur from 80% to 7.3% (Ellis 2007). Over the past century, despite this evidence being challenged, the traction splint has received recognition as essential kit in the management of injuries to long bones in the lower extremity. The indications of its usage have been extended to allow immobilisation of the limb through the traction, while still allowing access to the limb wounds (Henry & Vrahas 1996).
There is a paucity of evidence in the literature with regards to the indications, techniques and materials available to use for preparing the splint. Jones (1912) advocated its use to be extended for fractures of the middle and lower thirds of the femur, knee and upper tibia. The Thomas splint immobilises the limb with or without traction, aiding transfer of patient or the limb without undue movements at the fracture and hence limiting continued injury to the soft tissue (Mueller 1970). It allows access to the wounds and hence contributes to improved outcome. Various improvements with the use of the Thomas splint have evolved over the years. Improved slings were designed by Thomas (1968), which were made from Coutille--as used in corset manufacture. Its shape supposedly adapts itself easily to all the usual adult sizes of the splint and is reversible to suit the right or the left side. Alternative slings in use were plaster-of-paris, which was not very popular due to its potential risk of causing pressure ulcers. Elastic stockinet was not firm enough to support the position of a recent fracture accurately, and leather was costly to fabricate and difficult to clean adequately.
Injuries to the pelvis, knee, tibia and fibula have been listed as contraindications for its use in many orthopaedic and emergency medical services literature (ACS 1997, Watson & Kelikian 1998, Brinker & Miller 1999, Mihalko et al. 1999, Wood et al. 2003). Furthermore, the use of TS in children and the elderly requires further investigation. The presence of osteoporosis, arthritis, vascular disease, neuropathy and long-term steroids may complicate TS use (Wood et al 2003).
Sporadic reports of various complications resulting from use of TS or similar traction splinting devices include peroneal nerve palsies, ligamentous laxity, compartment syndrome, vascular compromise, urethral injuries and pain (Corea 1992, Watson & Kelikian 1998, Brinker & Miller 1999, Mihalko et al. 1999). Prolonged application of the TS may also result in skin breakdown. It is prudent to identify patients at higher risk of developing complications of immobilisation. They are patients who have difficulty in communicating effectively, including the very young, developmentally delayed patients or the obtunded or comatose patients; patients who have decreased sensation due to injury locally or to the spinal cord, peripheral neuropathy or following regional anaesthesia (Ragnarsson & Sell 1981, Sobel & Lyden 1991, Guyton 2005). The other group of patients in the similar group are the frail and elderly patients who have thin skin which yields easily to minor trauma due to ageing or due to being on steroids. TS use may result in skin damage to the foot, ankle, buttocks or perineum. Excessively tight fastening may result in diminished circulation to the distal extremity. The patient described here has depicted certain contraindications for its use and technique--ie the patient was an elderly, frail lady with thin skin and a tightly applied skin adhesive bandage. Stretching of the peripheral nerves with resultant neurovascular sequelae, may also occur with excessive traction. Areas of increased pressure lead to foci of decreased perfusion, resulting in pressure sores (Halanski & Noonan 2008). There is underreporting of these complications.
Patients should be comfortable after immediate immobilisation and hence any complaints of increased pain or neurovascular change while being splinted should be evaluated in a timely manner by a member of the medical team. The lady on TS complained of discomfort on several occasions while awaiting surgery but was reassured that her symptoms were probably due to the fracture itself. It is now well understood that elderly patients with fractures involving the proximal femur have a higher morbidity and mortality with delayed surgery. Every effort must be made to reduce the time to surgery in this group of patients as well and early mobilisation is to be encouraged. In circumstances where delays are inevitable, the indication and appropriateness of continuation of traction splint should be re-evaluated. It has been observed that application of the Thomas splint is a dying art (Figure 2 for Splint application instructions) and hence there is marked apprehension among colleagues in its application. We describe here a standard technique for its application (With permission: Ossur, Manchester 2009, www.ossur.co.uk).
There is little evidence that use of the traction splint is more efficacious than simple rigid well padded splints, pillow splints, or, in the emergency department and transport settings, a Jones's bandage (Wood et al 2003). When contraindications to traction splint use exist, in the light of the limited research support for their use these devices should be avoided. Prolonged use should be monitored to avoid skin complications.
Figure 2. Thomas Splint fitting instructions (With permission from Ossur, Manchester, 2009, www.ossur.co.uk) 1. Patient Measurement--Measure the patient's uninjured leg for both inside leg and thigh dimensions. Select the splint and hoop size to suit. The design of the hoop and wrap assembly naturally allows adjustment to cater for swelling. [ILLUSTRATION OMITTED] 2. Splint Adjustment--Having selected the Thomas splint, adjust the length to suit the inside leg measurement ensuring that both sides are adjusted to the same length. Length increments in both inches and centimetres are marked on the sides of the outer tubes and the small cap head screw acts as an indicator of length. Following this, attach the hoop by inserting both rods into the housings on each end of the outer tubes. Having inserted the rods to their maximum penetration ensuring that both have 'clicked' positively into position, the splint can then be adjusted to suit either right or left leg application by extending the appropriate side to obtain an angle of approx 20 to 30 degrees. Once again ensuring that a positive 'click' is heard confirming correct positioning. [ILLUSTRATION OMITTED] 3. Splint Preparation--From the traction kit, select the fabric slings provided and starting from the top drape each one in turn over the outer tubes to form a trough, securing each on the underside with the (Velcro[R]) closure until a length commensurate to that of the leg is achieved. Eight slings are provided, four large and four medium. It may be beneficial to tether the first sling to the hoop wrap with a couple of strips of Velcro[R] hook from the pack provided. [ILLUSTRATION OMITTED] 4. Splint Preparation (continued)--From the traction kit, select the two packs of gamgee padding. The longest piece should be placed along the full length of splint directly on top of the slings and trimmed in size to suit. The smaller piece of gamgee is to be folded into a pad and positioned to act as fulcrum behind the knee to keep it in slight flexion. [ILLUSTRATION OMITTED] 5. Positioning of leg in the Splint--Having applied the skin traction, the leg can now be placed onto the prepared splint. The hoop with wrap attached should reach the ischial tuberosity and the strap adjusted to allow the buckle to be fastened comfortably around the leg. With this completed, the foot should automatically find its position relative to the end of the splint, allowing room for the traction system to be completed using normal conventions and finally tying the cords to the end of the splint. A windlass is provided for use in taking up slack. [ILLUSTRATION OMITTED] 6. Securing leg into the splint--After the traction cords have been attached, the splint can be raised temporarily on a pillow whilst the leg is bandaged using the crepe bandages supplied. The gamgee pad can be positioned as described in instruction 4. Following this final bandaging procedure the splint with leg encased can be supported by any one of a number of overhead 'pulley and cord' systems. Cord eyes, four in total, positioned at either end of both side supports can be used for attaching the pulley cords. For extra support, the cord should be entered through the cord eye and under the rod that holds the cord eye. Special attention should be paid to slings and padding on and around both the Achilles and heel areas in order to guard against impending pressure sores. [ILLUSTRATION OMITTED]
American College of Surgeons 1997 Advanced Trauma Life Support for Doctors: Student course manual Chicago, IL
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Correspondence address: Mr Yuvraj Agrawal, Department of Trauma and Orthopaedics North Manchester General Hospital, Delaunays Road, Manchester, M8 5RB. Email: firstname.lastname@example.org
Mr Yuvraj Agrawal
Specialist Registrar in Trauma and Orthopaedics, North Manchester General Hospital, Manchester
Dr Jyoti Karwa
SHO in Accident and Emergency, North Manchester General Hospital, Manchester
Mr Nikhil Shah
FRCS (Tr & Orth) MCh (Orth) MS (Orth) DNB
Consultant Trauma and Orthopaedic Surgeon, North Manchester General Hospital, Manchester
Mr Anthony Clayson
FRCS (Tr & Orth)
Consultant Trauma and Orthopaedic Surgeon, North Manchester General Hospital, Manchester
Provenance and Peer review: Unsolicited contribution; Peer reviewed.
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|Title Annotation:||CLINICAL FEATURE|
|Author:||Agrawal, Yuvraj; Karwa, Jyoti; Shah, Nikhil; Clayson, Anthony|
|Publication:||Journal of Perioperative Practice|
|Article Type:||Case study|
|Date:||Sep 1, 2009|
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