In the prehospital setting, is a tourniquet appropriate for a closed femur fracture with significant swelling and suspected internal hemorrhage?

Tourniquets Are NOT Appropriate for Closed Femur Fractures with Internal Bleeding

No, a tourniquet is not appropriate for a closed femur fracture with internal bleeding and swelling, as tourniquets are specifically designed for life-threatening external extremity hemorrhage, not internal or closed bleeding. 1

Why Tourniquets Don't Work for Closed Fractures

Mechanism of Action Mismatch

• Tourniquets control external bleeding by occluding blood vessels proximal to an open wound 1
• Internal bleeding from a closed femur fracture occurs within the thigh compartment and bone itself—a tourniquet cannot compress these deep bleeding sources 2
• The bleeding in closed femur fractures originates from fractured bone surfaces, disrupted medullary vessels, and surrounding soft tissue injury that are not amenable to external compression 2, 3

Evidence Against Tourniquet Use in Closed Fractures

• International first aid guidelines explicitly state tourniquets are indicated only for "severe, life-threatening external extremity bleeding" 1
• The American College of Surgeons and American Heart Association recommend tourniquets specifically for amputations, open wounds with foreign bodies, or when direct pressure fails to control external hemorrhage 4
• Tourniquets should only be used when "the site of bleeding is not amenable to use of a tourniquet"—which includes closed injuries 1

Actual Blood Loss in Femur Fractures

The Reality of Femoral Hemorrhage

• Isolated femur shaft fractures rarely cause hemorrhagic shock as the sole injury 2
• In a military trauma registry study, only 8.5% of isolated femur fractures presented with severe shock 2
• When shock occurs with femur fractures, 72.7% had open fractures with external bleeding that was "difficult to control" 2
• In civilian trauma, patients with isolated extra-capsular femur fractures had low transfusion requirements, with most transfusions occurring post-operatively rather than from acute hemorrhage 3

When to Suspect Other Bleeding Sources

• If a patient with a closed femur fracture is in shock, you must investigate for concurrent thoracic (9.9% incidence) or abdominal injuries (26.3% incidence) 2
• The presence of shock with a closed femur fracture should prompt immediate evaluation for other sources of life-threatening hemorrhage 2, 3

Appropriate Prehospital Management

Correct Interventions for Closed Femur Fractures

• Splint the fracture in position to reduce pain and prevent further soft tissue injury during transport 1
• Note that traction splinting is explicitly "not a necessary or required element of prehospital stabilization" and is "often contraindicated" 1
• Avoid attempting to straighten angulated fractures in the prehospital setting 1
• Focus on rapid transport to definitive surgical care rather than prolonged field interventions 2

Fluid Resuscitation Strategy

• Initiate intravenous access and isotonic crystalloid resuscitation if signs of hypovolemia are present 5
• Monitor for signs of shock including tachycardia (HR ≥130 bpm) and hypotension (SBP ≤90 mmHg) 2
• Cardiac output-guided fluid administration improves outcomes in femur fractures 5

Critical Pitfalls to Avoid

Common Errors in Management

• Never apply a tourniquet to a closed extremity injury—it will not control internal bleeding and may worsen ischemic injury 1, 4
• Do not delay transport for extensive field stabilization procedures like traction splinting when the patient shows signs of shock 2
• Do not assume the femur fracture is the cause of shock—aggressively search for other bleeding sources 2, 3
• Avoid repeated manipulation of the fracture site, which can worsen soft tissue injury and bleeding 2

When Tourniquets ARE Appropriate

• Only apply tourniquets for open femur fractures with uncontrolled external thigh bleeding that fails direct pressure 1, 4
• Reserve tourniquet use for "suspected FSF injuries with shock or persistent thigh bleeding" in the context of open wounds 2
• Manufactured tourniquets are superior to improvised devices and should be applied proximal to the bleeding site with documentation of application time 1, 4