Page 62 - Journal of Special Operations Medicine - Summer 2014

following 3 days of Thomas splint use with a tight adhe- of femoral nerve block anesthesia in all cases and the fact
sive skin bandage while she awaited definitive surgery. traction by Thomas splint was used as definitive care on
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admission regardless of the splint originally applied.
A review of 115 children seen in a pediatric trauma
center with a Hare splint applied in the prehospital set- Recent studies focusing on pain control alone are also
ting noted that 66% were misapplied when viewed on inadequate in examining the primary outcome of trac-
radiography. Due to these pressures asserting lack of tion splinting on the battlefield—reducing hemorrhage.
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recent evidence, the latest “Equipment for Ground Am- Traction is hypothesized to reduce hemorrhage in a
bulances” policy statement by the American College of closed fracture by creating a smaller elliptical area sur-
Surgeons Committee on Trauma and others lists femoral rounding the fracture site, which would hold less blood
traction splints as merely optional for civilian EMS. 27 than the roughly spherical area expected before trac-
tion. Traction stabilization helps prevent movement of
Contemporary Military Considerations the jagged fractured bone ends, thereby minimizing soft
While few disagree that traction splinting is an effective tissue damage, decreasing the risk of vascular injury,
treatment for femoral fracture, controversy exists in the and preventing the conversion of a closed to an open
civilian sector over whether this treatment can be de- fracture. This concern is almost nonexistent in the ci-
6
layed during the projected “Golden Hour” or less that vilian setting, where transport to a waiting ambulance
exists as patients move from the prehospital phase of mere feet away is the most likely scenario.
care to that of the hospital. While rigid splinting alone
may be adequate in the short-term of civilian EMS or However, the risk for further injury in a casualty car-
even be extrapolated to the current medical evacuation ried a long distance by litter through rough terrain to an
system, this conclusion does not carry over to when bat- evacuation vehicle is just as real today as it was on the
tlefield casualties may be delayed transport to definitive battlefields of France in 1917. Reduction of open frac-
care for many hours or days. It is essential to under- tures caused by a gunshot wound was a primary impe-
stand the mortality benefit seen with the Thomas splint tus for Thomas splint use in World War I. The Thomas
in World War I was observed by comparison with what splint served to decrease the risk of infection from leav-
was essentially a rigid splinting technique. ing bone ends exposed in the austere environment and
to better control hemorrhage from the wound. In gen-
Obviously, in a complicated trauma patient with a short eral, it is recommended today to also irrigate the wound
transport time, care providers should focus on immediate of an open fracture and to give prehospital antibiotics.
life threats with the critical TCCC interventions like tour- It is also expected that realignment of the fracture will
niquets and cricothyrotomy. However, as the military, decrease the incidence of fat embolism. Unfortunately, it
and its Special Operations Forces in particular, adapts has proved difficult to evaluate these hypotheses in the
to fighting in a less-developed operational environment, civilian setting, and the data available in the military set-
the concept of “Prolonged Field Care” has surfaced. No ting remain much the same as it was prior to the recent
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longer may first responders expect immediate evacua- conflicts. Notably, Royal Army Medical Corps surgeons
tion of the wounded to surgical care within the “Golden with the 202 Field Hospital reported successful use of
Hour.” Combat medics and corpsmen may be required to the Thomas splint for treatment of seven casualties with
manage the critically injured for indefinite periods, much femoral fractures in the first week of Operation Iraqi
like their counterparts in America’s previous wars. Freedom and strongly advocated for continued use.
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While much of the data from World War I are almost
In a prospective study of 64 patients with femoral frac- 100 years old, the benefit of traction splinting for battle-
ture randomized to either traction or simple/rigid splint- field femoral fracture remains unequivocal.
ing in an Iranian EMS system, there was no significant
difference between groups in pain level immediately after Against the backdrop of controversy over the necessity
application. However, pain was significantly decreased in of prehospital traction splinting as a general principle,
those with traction splints compared with simple splint- the Department of Defense’s selection of traction splints
ing at 1, 6, and 12 hours post application. The authors for field use has not been previously based on rigorous
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of that report attributed this late-appearing difference scientific review. One group from San Francisco’s am-
in pain control to increasing contraction of the thigh bulance service in the early 1980s reported 11 femoral
muscles that was overcome with the application of trac- fractures (among other injuries) treated with the RS,
tion but left unabated in those assigned to simple splints concluding it to as superior to the Thomas splint as a
alone. The authors of an Australian retrospective study of matter of subjective provider preference. A single ar-
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95 pediatric patients with isolated femoral fracture came ticle in the literature has compared multiple traction
to similar conclusions regarding the short-term benefit splints sold commercially to civilian first responders.
of traction splinting on pain control. However, this ar- This article compared the Hare, Sager, a civilian pack-
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ticle’s conclusion was limited by the early administration aged variant of the CT-6, and an improvised technique

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