Splinting a Midshaft Femoral Fracture
Splint the fractured femur in the position found using rigid splinting or long backboard immobilization, prioritizing immediate transport to definitive care over traction splint application. 1
Initial Assessment and Life-Threatening Concerns
Before splinting, immediately assess for:
Severe bleeding: Femoral fractures can cause life-threatening blood loss exceeding one liter due to disruption of cancellous bone and periosteum 1. If severe external bleeding is present, control hemorrhage first using direct pressure or tourniquet application before splinting 1
Vascular compromise: Check if the extremity is blue, purple, or pale, which indicates poor perfusion requiring immediate emergency activation 1. Assess ankle-brachial index if possible; ABI <0.9 suggests vascular injury requiring CT angiography 1
Open fracture: If bone is protruding through skin or an open wound is present, cover with a clean dressing to reduce contamination risk before splinting 1
Splinting Technique
Immobilize the femur in the position found rather than attempting reduction 1. The 2024 American Heart Association/Red Cross guidelines explicitly state it is reasonable to treat deformed fractures in the position found unless straightening is necessary to facilitate transport 1.
Acceptable Splinting Methods:
- Long backboard immobilization with padding 2
- Rigid splinting using padded boards extending from hip to ankle 2
- Position of comfort with adequate padding and support 2
Traction Splint Considerations:
While historically used, traction splints are not essential for prehospital femoral fracture care 3, 2. A study of 4,513 EMS runs found traction splints were successfully applied in only 0.04% of total patients, with no adverse outcomes when long backboard immobilization or rigid splinting was used instead 2. Traction splints are contraindicated in multisystem trauma, pelvic fractures, hip injuries, and penetrating trauma 3, 4.
Pain Management
- Administer IV analgesia if IV access is available, though this occurs in only 22% of cases in prehospital settings 4
- Avoid excessive manipulation during splinting, as extracapsular femoral fractures cause considerable pain due to periosteal disruption 1
Transport Priority
Activate emergency response immediately and transport to a trauma center 1. Splinting serves primarily to reduce pain, prevent further injury, and facilitate transport—not as definitive treatment 1. Definitive surgical stabilization should occur within 24-48 hours of admission for optimal outcomes 1.
Critical Pitfalls to Avoid
- Do not delay transport attempting complex traction splint application 3, 2
- Do not attempt fracture reduction unless absolutely necessary for transport 1
- Do not overlook hemorrhage control—femoral fractures can cause severe internal bleeding even without external wounds 1
- Do not miss vascular compromise—pale or pulseless extremities require immediate surgical consultation 1