Page 60 - Journal of Special Operations Medicine - Summer 2014

Table 4 Self-Reported Post-Testing Survey Results battlefield death. However, the treatment of femoral
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fractures—once a major emphasis of battlefield care—
Mean Response
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(Likert Value Range 1–5) has received scant attention. Reference to orthopedic
Post-Testing Survey care in the CoTCCC Guidelines is simply to “splint frac-
Question CT-6 KTD RS STS
tures and recheck pulse” in the Tactical Field Care phase
Confidence of proper 4.23 3.89 3.45 4.34 and to reassess in Tactical Evacuation Care. 1
application
Best treatment for 3.70 3.34 3.70 3.98 Despite their long history of use in both military and
femoral fracture civilian prehospital care, surprisingly little recent out-
Best designed for 4.21 3.60 1.79 4.25 comes data are available on the use of traction splints.
dismounted carry Most of the literature comes from World War I, where
Overall most a considerable degree of the decreased mortality from
appropriate for 3.92 3.15 1.94 4.17 femoral fracture is credited to the deployment of the
battlefield use Thomas splint into the European theater. Estimates
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of femoral fracture incidence as comprising 1.7% of
Quotes on the KTD included: “I like the light weight wounded, a proportion similar to today, do not convey
and ease of use. I would prefer if all the parts came at- scale when those casualty counts were routinely mea-
tached to prevent loss”; “This splint is not very durable sured in tens of thousands. So many femoral fractures
and feels like it would break under heavy movement and were encountered by the Allies during the war that a
usage”; “The colored pull tabs and straps make remem- special hospital in Bastogne was dedicated to femoral
bering the steps easy, but the splint does not seem to be fractures. Over 5000 femoral fracture casualties were
durable enough for a combat setting.” treated in the last 9 months of the war by the British
Army alone. In 1916, famed British military surgeon
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Quotes on the RS included: “This splint does an outstand- Colonel Sir Henry Gray calculated the mortality rate
ing job with traction and immobilization. However, size, of femoral fracture as roughly 80%. The primary field
weight, and the requirement to have assistance with ap- treatment at the time was the Liston splint, a wooden
plication remove its relevance from the battlefield”; “This board device in use with the British for almost a century
is too bulky and heavy. In combat/emergency situations it by that time. This device was considered easy to apply,
takes too much time to assemble and place on the patient. and its effect is comparable to rigid splinting methods
I would not want to have this as a deployment item”; “The used today.
size and weight of this device hinders combat effectiveness.
Simply just not practical for dismounted operations.” The Thomas splint was invented by Welsh physician and
bone-setter Hugh Owen Thomas in 1875 for the treat-
Quotes on the STS included: “Considering the nature ment of tuberculosis of the knee. It had a full-ring ischial
of a GSW/IED blast, this traction splint is applicable to pad and used cravats in a clove hitch around the ankle
multiple battlefield injuries”; “Very easy, self-contained, (later a special attachment to the combat boot’s sole
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could almost do it one handed if needed. If not supplied, I was developed) to pull traction on the femur. Thomas’
would buy my own for down range”; “This is lightweight, nephew and former apprentice, Sir Robert Jones, be-
sturdy, and easy to apply with minimal training. It is col- came consultant orthopedic surgeon to the British Army
lapsible into a small footprint which aids in portability in 1914. He soon advocated the splint’s use for fractures
and availability.” Advantages and disadvantages of each of middle and lower thirds of the femur, knee, and upper
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splint noted by participants are summarized in Table 5. tibia. Introduction to the combat zone was slow, and it
was not until 1917 that the Thomas splint was officially
distributed as the standard. Sir Henry Gray reported
Discussion during one battle in spring 1917 that the Thomas splint
was used near-universally for femoral fracture and the
Battlefield Experience With Traction Splinting mortality at casualty clearing stations had dropped to
On the modern battlefield, TCCC interventions focus- 15.6% of 1009 cases. Another review of 3141 patients
ing on the predominant causes of battlefield preventable indicates a 14% mortality following the intervention of
mortality—airway obstruction, external hemorrhage, the Thomas splint. Physicians at the special femur frac-
and tension pneumothorax—have saved numerous ture hospital in Bastogne noted a drop in mortality from
lives. As these “low hanging fruit” decrease in inci- 13% in 1916 to 7% in 1918. While it is certain that
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dence due to improved care, attention must also turn to the Thomas splint played a large role in saving lives,
lesser contributors in order to minimize morbidity and it must be noted the introduction of motorized ambu-
mortality. Junctional and pelvic hemorrhage has received lances, casualty clearing stations, and other concurrent
much attention as of late due to their association with advances cloud the effect.

50 Journal of Special Operations Medicine Volume 14, Edition 2/Summer 2014