Page 20 - Journal of Special Operations Medicine - Fall 2016

local anesthesia. No electrical power was required. Figure 3 Image showing 550 paracord being used to lash the
The extremity was flexed at the hip and blankets were disposable pin driver from an external fixation set, allowing
placed under the knee. A medial incision was made 3cm for a swivel arm that does not interfere with the knee.
3,4
above the medial epicondyle. This location avoids un-
intended injury to the femoral artery more proximally,
or the intercondylar notch of the knee joint more dis-
tally. Care was taken in the dissection to avoid injury to
the saphenous vein. A 5mm threaded Steinmann pin or
transfixing pin from an external fixator set was placed
using a pin driver (depending on availability, a hand
drill or a nonsterile power drill may also be used). The
pin was placed horizontal to the ground, and perpendic-
ular to the knee joint, rather than perpendicular to the
femoral shaft (Figure 2). A plain radiograph confirmed
placement but was not required.

Figure 2 Anterior-posterior radiograph demonstrating
correct placement approximately 3cm cephalad to the medial
epicondyle. This confirmatory radiograph is not required but
is included for instructional purposes. Figure 4 Image showing a hole cut out of an inverted sharps
container, allowing for foot placement. This construct was
reinforced with casting tape.

Note that the pin was placed in a medial to lateral direction and is
perpendicular to the knee joint rather than perpendicular to the long
axis of the femur itself.

Placing the femoral pin on traction requires some in-
genuity in the austere environment. We used 550 para-
chute cord (paracord) to lash the disposable pin driver Discussion
to the pin while allowing room for swivel motion about
the knee (Figure 3). Using more of the 550 paracord, we The principles of initial fracture management in an aus-
suspended gymnasium free weights over a pulley impro- tere setting include fracture stabilization, pain control,
vised from an inverted plastic container, with space cut prevention of infection, and prevention of further injury.
out for the foot (Figure 4). Placing the leg in 90°-90° Stabilization of femur fractures in an austere environ-
traction, with the hip flexed and the knee bent compen- ment where advanced medical care is available is facili-
sated for angulation of the proximal segments seen in tated by an arsenal of techniques ranging from splinting
the subtrochanteric femur fracture. devices to external fixation. However, these standard
strategies are often inadequate for peritrochanteric fe-
Generally, 1kg of weight should be placed for every mur fractures.
10kg of body weight. For an adult, 80kg man, this
would equal 8kg, or about 18lb. A range of 7kg to 9kg Hare traction splints or similar devices are bulky and
(15–20lb) is generally appropriate in adults and should often unavailable, and their application confers risk of
not exceed 13kg (30lb). Keeping the cord short enough significant skin breakdown, especially with prolonged
that the weight is not supported by the litter will aid in evacuation. These traction devices are contraindicated
transport (Figure 5). Alternative configurations, based for proximal femur fractures if concomitant ipsilateral
on available equipment and supplies, are possible. 5 knee or tibial injury is present. External fixation is of

2 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2016