When is a prehospital traction splint indicated for an adult or child older than five years with a suspected isolated closed or minimally open femoral shaft fracture and no contraindicating injuries?

When to Use Prehospital Traction Splint

Traction splints are not necessary or required for prehospital stabilization of suspected femoral shaft fractures and are often contraindicated. 1

Primary Recommendation

Use simple non-traction splinting (static splinting) or long backboard immobilization for suspected isolated femoral shaft fractures in the prehospital setting. 1, 2 The evidence strongly supports that traction is not a necessary element of prehospital femoral fracture management, and alternative immobilization methods provide adequate care without the complications associated with traction devices. 1

When Traction Splints Should NOT Be Used

Traction splints are contraindicated or complicated by the following injuries, which occur in approximately 38% of multisystem trauma patients with femoral fractures: 3

• Pelvic fractures or injuries 3
• Knee injuries (patellar fracture or ligamentous injury) 3
• Tibia/fibula fractures 3
• Hip fractures or injuries 1
• Ankle fractures or injuries 3
• Open fractures with significant soft tissue damage 3

The American Academy of Pediatrics explicitly states that femoral splinting materials may include either simple non-traction devices or devices that provide femoral traction, indicating traction is optional rather than mandatory. 1

Acceptable Alternative Management

Long backboard immobilization, rigid splinting, and/or patient transportation in a position of comfort constitute an acceptable course of care for midthigh injuries and suspected femoral shaft fractures. 2 This approach has been shown to result in no adverse sequelae in prehospital care. 2

Key Management Principles:

• Splint the fractured extremity in the position found to reduce pain, prevent further soft tissue injury, and facilitate transport 1, 4
• Provide immediate multimodal analgesia starting with scheduled paracetamol unless contraindicated 4, 5
• Add opioids cautiously, particularly if renal function is unknown 4
• Avoid NSAIDs if renal dysfunction is suspected (present in 40% of trauma patients) 1, 4
• Assess for vascular compromise immediately - if the extremity is blue, purple, or pale, activate emergency response immediately 1
• Cover any open wounds with clean dressing to reduce contamination risk 1

Clinical Context and Evidence Quality

The incidence of midthigh injuries requiring any splinting is extremely rare in EMS systems (0.35% of total patients), with suspected femoral shaft fractures occurring in only 0.11% of all patients. 2 Traction splints were successfully applied in only 0.04% of total patients in one urban EMS system study. 2

The timing of traction splint application is not associated with poor outcomes in isolated pediatric femoral shaft fractures, provided effective analgesia has been administered in a timely fashion. 6 This finding further supports that the critical intervention is pain management rather than traction application.

Critical Pitfalls to Avoid

• Do not delay transport to apply a traction splint when simple immobilization is adequate 2
• Do not apply traction splints in multisystem trauma without first ruling out contraindications 3
• Do not prioritize traction splinting over pain management - early analgesia is more important than the splinting method 6
• Do not assume femoral fractures cause hemorrhagic shock - this premise has been questioned in recent evidence 7

Equipment Considerations

The 2021 joint position statement from the American Academy of Pediatrics explicitly notes that traction is not a necessary or required element of prehospital stabilization of suspected femur fractures. 1 EMS systems may reasonably choose to carry simple non-traction femoral splinting devices rather than traction splints, as the latter may represent unnecessary equipment given their infrequent appropriate use. 2, 8