Traction splints – Indications, Contraindications

Traction splints are widely used for the immobilization of fractures of the lower limb. There is a brevity of evidence-based research on their efficacy. We present a case of skin complication following traction splint for spiral fracture of the femur. It is prudent to identify patients at higher risk of developing complications of immobilization. In circumstances where delays are inevitable, the indication and appropriateness of the continuation of traction splint should be re-evaluated.

Indications of Traction splints

A suspected or obvious isolated fracture of the midshaft femur is an indication for traction splint. If there are other fractures in the foot or ankle traction may not be effective, because traction splints require support on strap sites to be able to apply traction.[rx][rx][rx]

• Lateral malleolus fracture
• Medial malleolus fracture
• Posterior malleolus fracture
• Bimalleolar fracture
• Trimalleolar fracture
• Tibiotalar dislocation or subluxation
• Ankle fracture-dislocation
• Temporary stabilization of acute fractures, sprains, or strains before further evaluation or definitive operative management
• Immobilization of a suspected occult fracture (such as a scaphoid fracture)
• Severe soft tissue injuries requiring immobilization and protection from further injury
• Definitive management of specific stable fracture patterns
• Peripheral neuropathy requiring extremity protection
• Partial immobilization for minor soft tissue injuries
• Treatment of joint instability, including dislocation

Contraindications of Traction splints

• Fractures of ankle or foot
• Partial amputation or avulsion with bone separation while only marginal tissue connects the distal limb
• Situations in which caution must be exercised include the presence of thermal or electrical burns, open fractures, grossly contaminated wounds, and significant soft tissue swelling.
• Injuries that violate the skin or open wounds. Antibiotic administration should be considered for these patients depending on the severity of the lesion.[rx] These patients also require additional soft tissue care, which may necessitate tissue debridement and skin closure before splint application.
• Injuries that result in sensory or neurologic deficits. The complications of splint placement such as compartment syndrome, pressure injuries, or malreduction may go unnoticed if the patient has a concurrent nerve injury. These patients should undergo evaluation by a surgeon before splint application as neurologic findings may be a sign of a surgical emergency.
• Injuries to the vasculature require special attention by vascular surgeons, as these may require urgent operative intervention. Furthermore, evaluation of the vasculature is essential both before and after splint application, as the reduction of some fractures may result in acute arterial injury or obstruction if trapped between the fracture fragments.
• Patients with peripheral vascular disease or neuropathy. Special care should be taken when applying lower extremity splints in these patients since their baseline sensation may be altered. These patients have difficulty detecting pressure sores, skin irritation, and possible vascular compromise.

Splint Types

Commonly used tractions are Thomas, Hare, Sager, Kendrick, CT-6, Donway, and Slishman traction splints. We will discuss the most common Traction splints: Hare, Sager

Hare Traction Splints

In the 1960s, Glen Hare developed Hare traction splint, modifying full ring Thomas splint into half-ring splint by incorporating a ratchet mechanism with additional length adjustment mechanisms and improving the ischial pad. It maintained bipolar traction with two steel rods on both sides of the limb. Most importantly, the Hare traction splint was more compact, easy, and effective for a femur fracture. The Hare splint is not effective with proximal femur shaft fracture because the ischial pad may rest directly under the fracture. An adult unit is not adjustable for pediatric patients. Below is a simplified application guide.

• Stabilize the injured leg.
• Position the splint against the uninjured leg to adjust the length.
• Place splint under the patient’s leg and place the ischial pad against the ischial tuberosity.
• Adjust splint to length, then attach ischial strap over the groin and thigh.
• Apply the ankle hitch to the patient.
• Apply gentle but firm traction until the injured leg length is approximately equal to the uninjured leg length.
• Secure the remaining velcro straps around the leg.
• Reassess neurovascular function.

Sager Traction Splints

In the 1970s, Joseph Sager and Dr. Anthony Borshneck developed the Sager splint. Sager traction is unipolar traction. One steel rod sits between a patient’s legs and applies traction from the ankle with counter pressure directed onto the ischial tuberosity. Sager splint sits between the leg against the ischial tuberosity, so it is more effective for proximal femur fracture than hare splint. Also, one Sager splint can be used for a bilateral femur fracture. However, there is an increased risk of damage to the genitalia as the splint can move from the initial ischial tuberosity placement during transport. Sager traction splint can measure the actual traction applied on the gauge. The optimal traction is roughly 10% to 15% of a patient’s body weight.

• Position the splint between the patient’s legs, resting the saddle against the ischial tuberosity.
• Attach the strap to the thigh.
• Secure the ankle strap tight.
• Gently extend the inner shaft until the desired amount of traction, approximately 10% of the patient’s body weight.
• Adjust the thigh/leg/foot strap.
• Reassess neurovascular function.

After initial evaluation in the hospital, it is appropriate to transition the patient to skin traction, commonly referred to as “Bucks Traction,” or skeletal traction if necessary.  Bucks traction has the advantage that it requires no incision and is far less traumatic for the patient, but is limited in the amount of weight that is safe without causing skin breakdown. Any form of skin traction, whether Bucks traction or with traction splints, has the risk of overlying soft tissue damage.  The amount of weight and traction applied to the skin should never result in wounds or soft tissue damage, for which the clinician must be vigilant.[rx][rx][rx]

References