IntroductionThe femur is the largest long bone

in the human body (see Figure 1). Formost of us it is also the strongest, ableto withstand forces from all mannerof trauma that would easily breakother bones. The femur is also sur-rounded by some of the biggestmuscle masses in the body. Thesemuscles are held at bay by thestrength of the femur. Think oftremendous rubber bands strung andstretched over a large wooden rod - ifthe rod is broken, the bands collapse.In the human, this collapse would

result in severe muscle spasms. Forthis reason it is important to realizethe tremendous forces required tobreak a femur in most people. Notsurprisingly, car crashes are thenumber one cause of femur fractures.

To treat prehospital femur fractures(see Figure 2), traction splints weredeveloped and have been aroundsince at least 1875 when Hugh OwenThomas developed the eponymous

“Thomas Half Ring.” The half ringdevice would go on to be the splint ofchoice for these injuries for ahundred years.

In the latter half of the 20th centurya splint based on the half ring princi-ple was developed by Glen Hare.Hare’s splint streamlined the applica-tion process and eliminated much ofthe improvised nature of it. Since the1980s the Hare (as I will simply referto it), became the standard in EMS anda staple in EMT training programs.

Femur Fractures and Traction Splints

by Douglas Havilandby Douglas Haviland

The Gold Cross CONTINUING EDUCATION SERIESThe Gold Cross CONTINUING EDUCATION SERIES

After reading this article, the EMT willbe able to:

• Recognize the extreme traumaticforces involved in the fracture of apatient’s femur.

• Understand the basic principles ofbipolar and non-bipolar tractionsplints.

• Display a working knowledge of howthe Hare and Sager traction splintsare applied.

• Express the contraindications of usefor both types of splints.

• Indicate alternative methods ofloading and transporting a patientwith a traction splint applied.

After reading this article, the EMT willbe able to:

• Recognize the extreme traumaticforces involved in the fracture of apatient’s femur.

• Understand the basic principles ofbipolar and non-bipolar tractionsplints.

• Display a working knowledge of howthe Hare and Sager traction splintsare applied.

• Express the contraindications of usefor both types of splints.

• Indicate alternative methods ofloading and transporting a patientwith a traction splint applied.

EMT ObjectivesEMT ObjectivesFigure 1:

Femur Bones - Illus. 1879 Femur Bones - Illus. 1879

Figure 2:

Mid-Shaft Femur Fracture Mid-Shaft Femur Fracture

9 Spring 2018

-continues on page 10

In the last 25 years another device,developed by Joseph Sager, was intro-duced and has garnered a following.Sager’s splint uses different principlesthan the Hare and is considered bymany to be simpler to apply and –according to the manufacturer – hasother key benefits.

While many agen-cies have adopted theSager, the Hare stylebipolar splint remainsthe dominate trac-tion splint in use atthis time. While Iwill freely refer tothe Hare devicethroughout this piece, it is impor-tant that EMTs understand there areother manufacturers selling devicesthat are, for the sake of brevity, essen-tially clones of the Hare. I will refer tothese as brand “X” bipolar devices.These lower-cost traction splints will,by and large, duplicate nearly everyaspect of the Hare. However, be awarethat there will be one or two signifi-cant points of difference that mayrequire attention. Among these maybe the locking collets, the kickstandand the ratchet.

Other non-bipolar competitorshave also introduced traction splints,including the Kendrick KTD (yes, thesame Kendrick of KED fame) and theFaretec CT-6. In this review we willfocus on the Hare and more closelyexamine the fine points of the Sager.We will not cover the Kendrick or theFaretec.

As noted, Hare devices are alsoreferred to as bipolar splints while theSager is known as a unipolar splint.Do not confuse the term bipolar withbilateral (as in both femurs broken).Information in this article was devel-

oped from various sources, includingfirst-hand experience and manufac-turers’ instructions. What this articledoes not do is take the place of hands-on practice with your equipment!

Most of the controversies sur-rounding traction splinting concernhow rarely most EMS agencies aretasked to apply it . It goes withoutsaying that certain agencies will apply

traction on a fairly regularbasis (facilities hosting

m o t o r c y c l e

m o t o c ro s sfor example), but many(if not most) EMTs have neverapplied one in an actual emergencysetting. With this lack of practicecome rusty skills. Many EMTs are allbut clueless when faced with theirfirst mid-shaft femur fracture, espe-cially if they’ve been out of EMT basictraining for some time. Because ofthese issues some EMS experts arequestioning the value of continuingto teach Hare and to continuecarrying them on ambulances.Additionally, there are many mis-conceptions and old wives’ talesassociated with it.

Indications To Apply And Benefits of Traction

Traction splints are applied toisolated “mid-shaft” femur frac-tures (see note below on Sager typesplint). Typical femur fractureswill present in distinct ways. Thelimb will be shortened and

rotated outward (see Photo 1). Therewill be a bulge at the point of thebreak pointing to its location (i.e.,mid-shaft, proximal or distal). Femursdo break in both the distal and proxi-mal locations, although the latter(proximal) are more typically identi-fied as “hip fractures.”

The patient will experienceextreme pain with any femur break.The leading benefit of the tractiondevice is reducing that pain by inter-rupting the muscle spasms and pre-venting any further movement of thelimb that will cause additionaldamage (and pain!).

Hare traction application typi-cally involves two EMSproviders trained in the skillwho share various responsi-

bilities. If a third EMT isavailable, he/she should tend

to additional patient assessment, careand transport considerations, whichmay become complicated (see below).

Contraindications Of TractionTraction devices are contraindi-

cated for the following conditions:• Any Threat To Life! Patient

unconscious (unable to protectairway), or havingdifficulty breathing

or life-threateningbleeding.

• Any OtherInjury on theaffected limb, includ-ing the knee, ankle orfoot.

• An Open Femur(bone ends exposed),sometimes referredto as a “compoundfracture” (see Figure 3).

• Hip Fracture .The presence of hipinstability rules out

the traction splint. An unstable hipwould not provide a proper base toapply traction and is also indicative ofpossible life-threatening internalbleeding. Secure patient to a longboard and transport to the closesttrauma center.

• Bilateral Femur Fractures. Thisapplies to the Hare type (bipolar)splint. If your ambulance carries a

CEU Article: Traction Splints-continued from page 9

While many agencieshave adopted the Sager(unipolar), the Hare style

(bipolar) remains thedominant traction splint

in use at this time.

While many agencieshave adopted the Sager(unipolar), the Hare style

(bipolar) remains thedominant traction splint

in use at this time.

Photo 1:

Limb Rotated Outward Limb Rotated Outward

Figure 3:

Open FemurOpen Femur

The Hare Traction Splint

10 Spring 2018

bilateral Sager model it is possible tosplint both legs.

• Significant Mult i SystemTrauma affecting head, trunk, armsetc.

• No Splint, including a tractionsplint, should be considered unlessthe complete limb is exposed. In thiscase both limbs should be exposed toensure there is no other injury to theopposed limb.

Given the intrusive nature of boththe Hare and Sager splints - clothingbelow the waist should be removed,including boots, shoes, socks, pantsand skirts. Underwear can be left inplace. The patient’s crotch can becovered for modesty with a sheet afterthe splint is applied. Since applica-tion of a traction splint is best doneprior to moving the patient, respond-ing EMTs will have to weigh patientmodesty against the severity of injuryin the public arena. As with manyemergency medical procedures,EMTs may be forced to make toughchoices. On occasion, modesty willhave to take a back seat.

Caution: If helicopter air transportis considered, the Hare device whenapplied will present difficulty in mostair medical situations due to spaceconsiderations.

Transport ConsiderationsOnce the splint is applied to the

patient the best patient movementoption is to use a long backboard.However, in many situations thetypical six-foot board will not be longenough to support the end of theHare kickstand. It may be necessary tofield-engineer a solution in order tomake the board longer. Options

include extending the board with aKED, short board or board splints.

Given the now-extended overalllength of your patient, you may findthat loading the cot as normal createsa problem: closing the rear doors ofthe ambulance! Rarely does patientcare so directly come into conflictwith the transport vehicle itself. Youmay find that since you extended thebackboard and have several inches ormore hanging off the end of the cot,that the rear loading doors will make

contact with board, the splint andeven the patient. This is a problemespecially prevalent in van style, Type1 ambulances. The easiest solution issimple: load the patient, on the back-board backwards on the cot! Placingthe patient’s head in proximity to therear doors, the extended end with thesplint now faces the front of thepatient compartment, and usuallyoverhangs the “captain’s chair” (theseat typically at the patient’s head).

CEU Article: Traction Splints-continued from page 10

11Spring 2018

-continues on page 12

Contraindications forapplying a traction splint

include: any threat tolife, another injury onthe affected limb, an

open or bilateral femurfractures, and significant

multi-system trauma.

Contraindications forapplying a traction splint

include: any threat tolife, another injury onthe affected limb, an

open or bilateral femurfractures, and significant

multi-system trauma.

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Ambulances usually have ampleroom toward the front and will allowfor overhang of the now-extendedbackboard.

Always keep in mind you’re treatingthe entire patient, not just an isolatedfemur break. While an injured femurcan become a distracting experienceboth for the patient and the EMScrew, remember that the patient’s A-B-Cs always take precedence over thebreak.

Traction Pull: On Hare type splintsthe traction pull is determined by theprovider who is manually pulling thetraction. The mechanical pull shouldequal the EMS provider pull. Onlythe provider pulling traction candetermine this. It should be furthernoted that with Hare splints themechanism to adjust traction (theratchet), will – when the EMT pullingtraction is properly positioned (oneknee down, one knee up, patient’sinjured leg in-between) – end upplaced squarely between the EMT’slegs and within an inch or so of theEMT’s crotch.

This is no time for EMS crew mem-bers to become overly concernedwith personal modesty or harassmentissues. If the skill is practiced regu-larly as proscribed, all crew members,male and female, will come to termswith the interpersonal work environ-ment and the required professional-ism to complete the task. While it isuncomfortable for many EMS per-sonnel to have such close contact withone another, keep in mind yourpatient is in far more dire straits and iscounting on you to do the rightthings. Also, training should be doneas it is expected to be performed inthe field. Saying: “I would do it differ-

ently if it was a real patient” doesn’tcut it; practice as you would beexpected to perform it!

Many EMTs will simply not be ableto complete the tasks required in theposition of pulling traction due tofitness or prior injury themselves.The position requires enough agilityto be in the proper position on theground, and enough strength to pullthe required force for minutes at atime! If the person pulling manualtraction releases, the broken boneends will most likely collide. You canimagine the pain and suffering thatwill cause the patient! Always remem-ber to Do No Harm! Pulling tractionwithout completing the splint is tan-tamount to reinjuring the patient.

As a riding EMS crew, membersshould ensure that all equipment ischecked at least daily. Traction splintsshould be checked to see not onlythat all straps and the ankle hitch arepresent in the bag, but that the entiresplint is assembled and ready for use.(While riding with an orga-nization to which I wasnew, I was doing a rigcheck and checking thevarious splints includingthe Hare. The splint hadbeen checked for months –if not years – by ridingEMS crew members assimply being “on the rig.”That is, ambulance checksheets piled in the logbook noted with a checkmark that the splint waspresent. However, when Ichecked and opened the

bag, I was aghast to find that whileeverything was in the bag and wasindeed present, none of it was assem-bled! Each of the four Velcro cradleswas neatly shrink-wrapped in itsfactory-shipped packaging. None ofthem were in place on the Hare frame.The ratcheting mechanism and thekickstand were firmly secure in theirshipping positions. Obviously, if ithad taken an emergency to discoverthis situation, patient care would havebeen delayed considerably while thecrew tried to piece together the splint.

Furthermore, if the device hadnever been assembled, it most cer-tainly had never been tested or drilledupon. Just because a medical device isnew in the package doesn’t guaranteeit works. Remember the acronym forthe meaning of the word “NEW” –Never, Ever, Worked!

Also, it is a very common occur-rence for ankle hitches to go missing.(They are often discarded as trash bythe hospital operating room staff.) Forthis reason it is important for allEMTs to know how to make an anklehitch from a common cravat. In fact,from my years in the classroom andseveral thousand practice applica-tions, I’ve noted the properly-appliedcravat hitch is often more effectiveand comfortable than the commercialhitch (See Sidebar, page 15).

CEU Article: Traction Splints-continued from page 11

It is important for allproviders to know how to

make an ankle hitchfrom a common cravat.

It is important for allproviders to know how to

make an ankle hitchfrom a common cravat.

Photo 2:

Adjustable ColletsAdjustable Collets

Photo 3:

Securing The Ischial StrapSecuring The Ischial Strap

12 Spring 2018

Traction splints should bechecked to see not onlythat all straps and theankle hitch are present in the bag, but that the

entire splint is assembledand ready for use.

Traction splints should bechecked to see not onlythat all straps and theankle hitch are present in the bag, but that the

entire splint is assembledand ready for use.

Several cravats should be keptwith the traction splint and their useshould be practiced. One infamousincident involved a femur break onthe boardwalk in a shore commu-nity. As noted above, the ambulancewas not checked prior to the call andthe ankle hitch was missing.Between the two responding EMTsand two paramedics on scene, noone remembered how to make acravat hitch! As the story unfoldsanother responding police officerhappened to be an EMT instructor.All the EMS responders wereembarrassed to have a law enforce-ment officer show them up on-scene(and since it was on the boardwalk acrowd had gathered to witness theentire humiliating drama unfold)!

Note on ALS: An isolated femurbreak (i .e. , with no associatedtrauma) should fall under the realmof BLS provider skills. As notedabove, however, complicatingfactors can quickly change an iso-lated break into a much differentscenario. Depending on local ALSprotocols, the paramedics may havethe option to provide morphine oranother analgesic to the patient forpain management. Obviously thiswould be a paramedic directedoption.

PMS (pulse, motor & sensory)should be checked before and afterapplication of the splint. Duringextended transport the distal pulseshould be rechecked. If the pulsewas present before the splint wasapplied, but lost after application,this is not criteria to remove thesplint! Instead note the change andcontinue to recheck. Also, it shouldbe obvious that in order to checkPMS properly, the foot must be com-pletely exposed. There is no optionto allow footwear, socks or hosiery toremain in place. The feet also needto be examined for associated injury.A foot or ankle injury, as notedabove, would preclude tractionsplitting.

Hare Application: application ofthe Hare is taught differentlydepending on local protocols. Basics

of the application include oneresponder providing stabilization tothe affected limb (not traction, butsimple firm stabilization). Thesecond responder will measure thedevice on the unaffected leg(remember the legs will now be dif-ferent lengths; we are trying toapproximate the pre-injury length).

Any Hare style splint will have twoadjustable “collets” that when spuneither clockwise or counter-clock-wise will loosen, allowing adjust-ment of the splint length (see Photo 2,previous page). Splints will be storedfully collapsed in their bag. It ’svitally important that the collets bechecked frequently and that theywere not “cranked down” overzeal-ously when put away. I’ve personally

seen collets so tight they required alarge plier to break loose! Again thiswould spell near disaster in an actualapplication on-scene. Properlyworking collets will lock firmly withjust a snug twist that doesn’t requireundue force.

After checking PMS (see above) andapplying the ankle hitch, the second

rescuer pulls traction. No tractionshould be pulled until all equip-ment is prepared, measured andready for application. No manualtraction is applied until everythingis ready. When prepped correctlyapplication should take no morethan a few minutes (with practice).

After placing the splint properlythe first strap applied is always theuppermost ischial strap; this pro-vides a secure anchor point for theentire splint (see Photo 3, previous page).The ischial strap rides “high & tight”to the patient’s body in the creasewhere the leg meets the trunk. The“rubber” bumper or stop at the mostsuperior end of the Hare should bepressing firmly into the patient’s asscheek. Once again, this is a poten-tially uncomfortable manipulationon the part of the EMT and patient.However, it’s critical that this rubber

CEU Article: Traction Splints-continued from page 12

13 Spring 2018

-continues on page 14

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After checking pulse,motor and sensory,

and applying the anklehitch, the second

rescuer pulls traction.

After checking pulse,motor and sensory,

and applying the anklehitch, the second

rescuer pulls traction.

Figure 4:

Proximal Femur BreaksProximal Femur Breaks

14 Spring 2018

stopper be placed properlyto prevent unin-tended shifting ofthe splint later on,shifting that willcompromise trac-tion. If the ischialstrap is applied cor-rectly it will tend toapply uncomfortablepressure on thefemoral artery, forthis reason paddingshould be providedand genitals shouldbe adjusted asrequired.

Next , mechanical traction isapplied, up to the point that the EMTpulling traction indicates it hasequaled his or her pull. As notedbeyond the basics above, details mayvary depending on local protocols.

Sager Splint Notes: It should benoted that Sager claims that theirsplint can be used on a proximalfemur break (see Figure 4, previous page),unlike the Hare. In fact, Sager claimsthat the splint can be used in up to93% of all femur breaks! The manu-facturer claims the splint is moreeffective than bipolar splints becausethe latter splints tend to apply trac-tion in a unnatural angle. Many whohave never seen a Sager splintapplied are amazed at the relativeease of application (see Figure 5).

For star ters, the Sager can beapplied by only one provider; com-mon Hare splints require a minimum

of two providers.Also, in a typical

a p p l i c a t i o nthe Sager will

not “hang”that far off the end of

the foot, eliminat-ing the overalllength issuesnoted above (see

Photo 4).The Sager uses a

weight-based schemeof traction with a scale inthe splint. Sager recom-

mends traction be applied upto 10% of patient body weightfor single application. Bilateralapplication requires double thetraction, or 20% of body weight.Sager splints incorporate around or sliding scale (depend-ing on model), similar to afishing scale. The scales are cal-ibrated in both pounds andkilograms.

Sager claims one splint covers fromfour years old through adult. Theyalso offer an “ infant” model, al-though infant femur breaks are rare.

Another significant differencebetween the two types of splints(Sager vs. Hare) is that the Sager rec-ommends wrapping the Velcrobands over the area of the break. InHare application it is emphasized tonever place the Velcro cradlesdirectly over the area of the sus-pected break . In either splint theVelcro serves to prevent fur thermovement and ease pain. The Sageralso includes a “pinion” strap for thefeet (see Photo 5). The pinion serves toprevent rotation of the feet.

Blood Loss And ShockAlways remember a single femur

break can account for up to a liter ormore of blood loss (1000 ml - 1500ml). Remember, this could be internal

blood loss into the enclosed, confinedspace within the leg, so bleeding willnot be obvious. Each break in a pelviscan lose as much as 50 0 ml (per

Sager recommends traction be applied up to

10% of patient bodyweight for single

application, and 20% for double application.

Sager recommends traction be applied up to

10% of patient bodyweight for single

application, and 20% for double application.

CEU Article: Traction Splints-continued from page 13

Photo 4:

The Sager Traction Splint - AppliedThe Sager Traction Splint - Applied

Photo 5:

Sager Pinion StrapSager Pinion Strap

The Sager Traction Splint

Figure 5:

Applying The Sager SplintApplying The Sager Splint

A single femur break can account for up to aliter or more of blood

loss (1000 ml - 1500 ml).

A single femur break can account for up to aliter or more of blood

loss (1000 ml - 1500 ml).

-continues on page 15

15 Spring 2018

break), again not external. Combiningthose numbers you can see how apatient who has suffered significant

lower extremity trauma can quicklydeteriorate into a shock condition.Always be alert to the signs of im-pending shock, which could include achange in mental status, and/orincreased heart and breath rates.Remember, cyanosis (blue cast to theskin) is always a late sign.

A curious fact about femur breaks isthat there is actually an inherited con-dition called osteogenesis imperfecta. Thiscondition can lead to making femurs,above all bones, susceptible to breaks!The condition is rare; fewer than20,000 cases are diagnosed in the USevery year. One young female sufferedseven femur breaks as a small child!Because a child suffering a femur breakcan lead to suspicion of abuse issues inthe home, in this case the parents wereheld under a cloud of suspicion until itwas determined she indeed did sufferfrom osteogenesis imperfecta.

Conclusion Traction splinting provides definite

benefits for patients who have experi-enced a femur fracture. To make themost of whichever device your squadcarries, it’s important that you under-stand its application rules and relateddetails. Just because you don’t use thesplint frequently is no excuse; younever know what your next call will be.There is no substitute for regularhands-on drills with your splints.

Douglas Haviland has been involved inemergency services since 198 0 and a fullEMT instructor since 2005. He teaches forJersey Shore University Medical Center -Hackensack Meridian. He also trains newinstructors in AHA CPR.

A rare, inherited condition – called

osteogenesis imperfecta– can lead to making

femurs, above all bones,susceptible to breaks.

A rare, inherited condition – called

osteogenesis imperfecta– can lead to making

femurs, above all bones,susceptible to breaks.

CEU Article: Traction Splints-continued from page 14 Making An Ankle Hitch From A Simple Cravat

Start with a new cravat out of thepackage. Several folds will resultin a long flat band. Lay it flat andsmooth out the folds.

Bring the longer rightside portionup withoutpulling on the remainder.

Bring the moving portion aroundthe bottom of the arch of the footand back to its origin. Tuck thisportion under the original bandand bring it back to the bottom,meeting the other tail. Using bothhands – and with equal pull –remove all slack from the hitch.

The rescuer’s finger indicates theproper location for the Hare “S”hook to pass through, as shownin this photo and the next one.

Final hitch as attached to theHare “S” hook.

With the leg exposed, place thecravat under the hollow of theankle. Cravat is proportioned withone-third left and two-thirds right.This is how you start your hitch.

1

3

5

7

8 9

2

Flip your longer “moving” rightportion over the top and bring theshorter left portion straight up;the moving portion is wrappedaround forming a simple half hitch.

4

The hitch is now complete. Finishit with a “square knot” (left overright, right over left). Under no cir-cumstances use a bowknot; theknot is the only thing between asuccessful traction splint andfailure. The only dependable knotto hold under actual field condi-tions is a square knot.

6

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