Prehospital Traction Splint for Adult Femoral Shaft Fractures
Direct Recommendation
For adult patients with suspected isolated closed or minimally open femoral shaft fractures and no contraindicating injuries, traction splints are not necessary—simple non-traction splinting or long backboard immobilization provides adequate care and should be used instead. 1
Evidence-Based Rationale
Primary Immobilization Strategy
Static (non-traction) splinting or long backboard immobilization is the preferred method for isolated femoral shaft fractures in the prehospital setting, supported by strong evidence from the American Academy of Pediatrics and American Heart Association. 1, 2
Position-matched splinting should be employed—splint the injured limb in the position found to minimize pain, protect soft tissue, and facilitate transport rather than attempting reduction or applying traction. 1, 2
The American Heart Association specifically recommends prioritizing immediate transport to definitive care over traction splint application, as splinting serves primarily to reduce pain and prevent further injury during transport, not as definitive treatment. 2
Supporting Research Evidence
A 2024 study demonstrated that skeletal traction does not reduce opioid consumption compared to position of comfort, and patients actually consumed more opioids in the emergency department when traction was applied. 3
Epidemiologic data from a 2001 study showed that in actual EMS practice, traction splints were successfully applied in only 0.04% of total patients, with 87.5% of midthigh injuries managed successfully with long backboard immobilization, rigid splinting, or position of comfort without any adverse sequelae. 4
A 2003 study of multisystem trauma patients found that 38% had concomitant injuries that complicate or contraindicate traction splint use, highlighting the limited real-world applicability. 5
Critical Contraindications to Traction Splints
Even when considering traction splint use, the following are absolute contraindications:
- Hip fractures or hip-related injuries (American Academy of Orthopaedic Surgeons) 1
- Pelvic injuries 5
- Patellar fractures or ligamentous knee injuries 5
- Tibia/fibula fractures on the same extremity 5
Essential Pre-Splinting Assessment
Before applying any splint, perform these critical assessments:
Vascular assessment: Check for signs of vascular compromise (blue, purple, or pale extremity appearance)—if present, activate emergency response immediately and transport without delay. 1, 2
Hemorrhage control: Femoral fractures can cause life-threatening blood loss exceeding one liter; control severe external bleeding first using direct pressure or tourniquet application before splinting. 2
Wound protection: Cover any open wounds with a clean dressing to reduce contamination risk before immobilization. 1, 2
Pain Management Considerations
Avoid NSAIDs when renal dysfunction is suspected, as approximately 40% of trauma patients have renal impairment, increasing the risk of NSAID-related nephrotoxicity. 1
Multimodal analgesia should be provided, but excessive manipulation during splinting should be avoided as femoral fractures cause considerable pain due to periosteal disruption. 2
Practical Implementation
EMS systems may opt to carry simple non-traction femoral splinting devices rather than traction splints, given the infrequent appropriate use of traction devices and the high rate of contraindicating injuries in actual practice. 1
The evidence consistently demonstrates that traction splints offer no clinical advantage over simpler immobilization methods, have numerous contraindications that are common in trauma patients, and may actually increase patient discomfort during application. 3, 4, 5