CLINICAL FEATURE

KEYWORDS Traction splint / Thomas splint / Complications

Provenance and Peer review: Unsolicited contribution; Peer reviewed.

Traction splint:
to use or not to use
by Yuvraj Agrawal, Jyoti Karwa, Nikhil Shah and Anthony Clayson
Correspondence address: Mr Yuvraj Agrawal, Department of Trauma and Orthopaedics North Manchester General Hospital, Delaunays Road, Manchester, M8 5RB.
Email: yuvraj_90@yahoo.com

Traction splints are widely used for immobilisation of fractures of the lower limb. There is brevity
of evidence-based research on their efficacy. We present a case of skin complication following
traction splint for spiral fracture of femur. It is prudent to identify patients at higher risk of
developing complications of immobilisation. In circumstances where delays are inevitable, the
indication and appropriateness of continuation of traction splint should be re-evaluated.

Introduction Case report a pressure ulcer on the popliteal region with

a necrotic surface (Figure 1).
The Thomas splint is surely the best known A 74 year old lady slipped on a slippery
appliance in orthopaedic and trauma surface while on a holiday. She sustained a She underwent intramedullary nailing from
surgery (Ellis 2007). Despite the short spiral fracture of the shaft of left which she made satisfactory progress. The
advancement in operative technique, femur. She did not have any distal wound was dressed regularly with non-
patients are often required to be temporarily neurovascular deficit and was adhesive and adsorbent dressings. She was
treated in an immobilisation splint to be hemodynamically stable. After initial finally discharged for outpatient follow-up
stabilized medically or for other reasons. resuscitation, her leg was immobilised on a after 28 days of hospital stay.
The technique of immobilisation has evolved Thomas splint complemented by an On subsequent review, her wound had
from mere immobilisation to traction splint adhesive skin bandage on balanced traction healed with some scarring and the fracture
using skin or skeletal traction. Currently, and she was admitted for definitive surgery. uniting. She was mobilising full weight
traction splints (TS) are widely used in the Skeletal traction with a distal femoral or bearing.
prehospital setting for immobilisation of proximal tibial Denham pin was not used.
femoral fractures. The indication often However, due to the volume of trauma cases
Discussion
extended beyond an isolated mid-shaft on the trauma list, her operation was
fracture of femur to include all types. This delayed for three days. On removal of the The traction splint was introduced for the
exposes patients to all the potential risks of splint, it was noted that she had developed first time in 1860 by John Hilton. However it
immobilisation along with specific risks due
to the technique (Wood et al 2003). The
risks and morbidity of immobilization are
often not recognised or are ignored
(Halanski & Noonan 2008). In the current
climate of medicolegal awareness,
knowledge of the potential problems
associated with immobilisation and insight
into preventing them are beneficial both to
the patient and the surgeon. It is hence
important to inform patients and their
carers of the risks associated with the
splintage. Above all, there is brevity of
evidence-based research on the efficacy of
TS for femur immobilisation, either as an
isolated injury or in combination with other
orthopaedic injuries (Wood et al 2003). We
present a case of skin complication
following traction splintage and review the
literature on the same.
Figure 1. Picture showing the pressure sore in the popliteal region of size 8 x 1.5 cms.

September 2009 / Volume 19 / Issue 9 / ISSN 1467-1026 295

CLINICAL FEATURE

Traction splint: to use or not to use

Continued

was only in 1870s when Hugh O Thomas
(1834 – 1891) devised his modification to
solve the problem of efficient
immobilisation of the lower limb, both in the
treatment of fractures, especially of the
femoral shaft, and in treatment of chronic
bone and joint diseases, in particular
tuberculosis of the knee (Thomas 1876). It
wasn’t until the First World War (1914-
1918) when Sir Robert Jones (1858 –
1933), Thomas’ nephew, introduced it on
the western front and showed it to reduce
the mortality of compound fractures of the
femur from 80% to 7.3% (Ellis 2007). Over
the past century, despite this evidence
being challenged, the traction splint has
received recognition as essential kit in the
management of injuries to long bones in the
lower extremity. The indications of its usage
have been extended to allow immobilisation
of the limb through the traction, while still
allowing access to the limb wounds (Henry
& Vrahas 1996).
There is a paucity of evidence in the
literature with regards to the indications,
techniques and materials available to use
for preparing the splint. Jones (1912)
advocated its use to be extended for
fractures of the middle and lower thirds of
the femur, knee and upper tibia. The
Thomas splint immobilises the limb with or
without traction, aiding transfer of patient or
the limb without undue movements at the
fracture and hence limiting continued injury
to the soft tissue (Mueller 1970). It allows
access to the wounds and hence
contributes to improved outcome. Various
improvements with the use of the Thomas
splint have evolved over the years. Improved
slings were designed by Thomas (1968),
which were made from Coutille - as used in
corset manufacture. Its shape supposedly
adapts itself easily to all the usual adult
sizes of the splint and is reversible to suit
the right or the left side. Alternative slings in
use were plaster-of-paris, which was not
very popular due to its potential risk of
causing pressure ulcers. Elastic stockinet
was not firm enough to support the position
of a recent fracture accurately, and leather
was costly to fabricate and difficult to clean
adequately.
Injuries to the pelvis, knee, tibia and fibula
have been listed as contraindications for its
use in many orthopaedic and emergency
medical services literature (ACS 1997,
Watson & Kelikian 1998, Brinker & Miller
1999, Mihalko et al. 1999, Wood et al.
2003). Furthermore, the use of TS in
children and the elderly requires further
investigation. The presence of osteoporosis,
arthritis, vascular disease, neuropathy and
long-term steroids may complicate TS use
(Wood et al 2003).
Sporadic reports of various complications
resulting from use of TS or similar traction
splinting devices include peroneal nerve
palsies, ligamentous laxity, compartment
syndrome, vascular compromise, urethral
injuries and pain (Corea 1992, Watson &
Kelikian 1998, Brinker & Miller 1999,
Mihalko et al. 1999). Prolonged application
of the TS may also result in skin breakdown.
It is prudent to identify patients at higher
risk of developing complications of
immobilisation. They are patients who have
difficulty in communicating effectively,
including the very young, developmentally
delayed patients or the obtunded or
comatose patients; patients who have
decreased sensation due to injury locally or
to the spinal cord, peripheral neuropathy or
following regional anaesthesia (Ragnarsson
& Sell 1981, Sobel & Lyden 1991, Guyton
2005). The other group of patients in the
similar group are the frail and elderly
patients who have thin skin which yields
easily to minor trauma due to ageing or due
to being on steroids. TS use may result in
skin damage to the foot, ankle, buttocks or
perineum. Excessively tight fastening may
result in diminished circulation to the distal
extremity. The patient described here has
depicted certain contraindications for its
use and technique – ie the patient was an
elderly, frail lady with thin skin and a tightly
applied skin adhesive bandage. Stretching
of the peripheral nerves with resultant
neurovascular sequelae, may also occur
with excessive traction. Areas of increased
pressure lead to foci of decreased
perfusion, resulting in pressure sores
(Halanski & Noonan 2008). There is under-
reporting of these complications.
Patients should be comfortable after
immediate immobilisation and hence any
complaints of increased pain or
neurovascular change while being splinted
should be evaluated in a timely manner by a
member of the medical team. The lady on
TS complained of discomfort on several
occasions while awaiting surgery but was
reassured that her symptoms were probably
due to the fracture itself. It is now well
understood that elderly patients with
fractures involving the proximal femur have
a higher morbidity and mortality with
delayed surgery. Every effort must be made
to reduce the time to surgery in this group of
patients as well and early mobilisation is to
be encouraged. In circumstances where
delays are inevitable, the indication and
appropriateness of continuation of traction
splint should be re-evaluated. It has been
observed that application of the Thomas
splint is a dying art (Figure 2 for Splint
application instructions) and hence there is
marked apprehension among colleagues in
its application. We describe here a standard
technique for its application (With
permission: Össur, Manchester 2009,
www.ossur.co.uk).
Conclusion
There is little evidence that use of the
traction splint is more efficacious than
simple rigid well padded splints, pillow
splints, or, in the emergency department
and transport settings, a Jones’s bandage
(Wood et al 2003). When contraindications
to traction splint use exist, in the light of the
limited research support for their use these
devices should be avoided. Prolonged use
should be monitored to avoid skin
complications.

296 September 2009 / Volume 19 / Issue 9 / ISSN 1467-1026


Excessively tight fastening may result
in diminished circulation to the distal extremity
1. Patient Measurement - Measure the patient’s uninjured leg for both
inside leg and thigh dimensions. Select the splint and hoop size to suit.
The design of the hoop and wrap assembly naturally allows adjustment to
cater for swelling.
2. Splint Adjustment - Having selected the Thomas splint, adjust the
length to suit the inside leg measurement ensuring that both sides are
adjusted to the same length. Length increments in both inches and
centimetres are marked on the sides of the outer tubes and the small cap
head screw acts as an indicator of length. Following this, attach the hoop
by inserting both rods into the housings on each end of the outer tubes.
Having inserted the rods to their maximum penetration ensuring that both
have ‘clicked’ positively into position, the splint can then be adjusted to
suit either right or left leg application by extending the appropriate side to
obtain an angle of approx 20 to 30 degrees. Once again ensuring that a
positive ‘click’ is heard confirming correct positioning.
3. Splint Preparation - From the traction kit, select the fabric slings
provided and starting from the top drape each one in turn over the outer
tubes to form a trough, securing each on the underside with the
(Velcro®) closure until a length commensurate to that of the leg is
achieved. Eight slings are provided, four large and four medium. It may
be beneficial to tether the first sling to the hoop wrap with a couple of
strips of Velcro® hook from the pack provided.
Figure 2. Thomas Splint fitting instructions (With permission from Össur, Manchester, 2009, www.ossur.co.uk)
September 2009 / Volume 19 / Issue 9 / ISSN 1467-1026
CLINICAL FEATURE
4. Splint Preparation (continued) - From the traction kit, select the two
packs of gamgee padding. The longest piece should be placed along the
full length of splint directly on top of the slings and trimmed in size to suit.
The smaller piece of gamgee is to be folded into a pad and positioned to
act as fulcrum behind the knee to keep it in slight flexion.
5. Positioning of leg in the Splint - Having applied the skin traction, the
leg can now be placed onto the prepared splint. The hoop with wrap
attached should reach the ischial tuberosity and the strap adjusted to
allow the buckle to be fastened comfortably around the leg. With this
completed, the foot should automatically find its position relative to the
end of the splint, allowing room for the traction system to be completed
using normal conventions and finally tying the cords to the end of the
splint. A windlass is provided for use in taking up slack.
6. Securing leg into the splint - After the traction cords have been
attached, the splint can be raised temporarily on a pillow whilst the leg is
bandaged using the crepe bandages supplied. The gamgee pad can be
positioned as described in instruction 4. Following this final bandaging
procedure the splint with leg encased can be supported by any one of a
number of overhead ‘pulley and cord’ systems. Cord eyes, four in total,
positioned at either end of both side supports can be used for attaching
the pulley cords. For extra support, the cord should be entered through the
cord eye and under the rod that holds the cord eye. Special attention
should be paid to slings and padding on and around both the Achilles and
heel areas in order to guard against impending pressure sores.
297
CLINICAL FEATURE

Traction splint: to use or not to use

Continued

References
American College of Surgeons 1997 Advanced
Trauma Life Support for Doctors: Student
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Brinker M, Miller M 1999 Fundamentals of
Orthopaedics New York, NY, W B Saunders
Corea JR, Ibrahim AW, Hegazi M 1992 The
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Guyton GP 2005 An analysis of iatrogenic
complications from the total contact cast Foot &
Ankle International 26 903-907
Halanski M, Noonan KJ 2008 Cast and splint
immobilization: complications Journal of the
American Academy of Orthopaedic Surgeons
16 (1) 30-40
Henry BJ, Vrahas MS 1996 The Thomas splint:
Questionable boast of an indispensable tool
American Journal of Orthopaedics 25 602-604
Jones R 1912 Treatment of fractures of the thigh
British Medical Journal 11 1086-7
Ragnarsson KT, Sell GH 1981 Lower extremity
fractures after spinal cord injury: A retrospective
study Archives of Physical Medicine and
Rehabilitation 62 418-423
Sobel M, Lyden JP 1991 Long bone fracture in a
spinal-cord injured patient: Complication of
treatment. A case report and review of literature
Journal of Trauma 31 1440-1444
Thomas HM 1968 Improved sling for the Thomas
splint British Medical Journal 3 (5611) 181
Thomas HO 1876 Diseases of the Hip, Knee
and Ankle Joints with their Deformities: treated
by a new and efficient method Liverpool, T Dobb & Co
Watson AD, Kelikian AS 1998 Thomas splint,
calcaneus fracture, and compartment syndrome of
the foot: a case report Journal of Trauma 44
205-208
Wood SP, Vrahas M, Wedel S 2003 Femur fracture
immobilization with traction splints in multisystem
trauma patients Prehospital Emergency Care 6
(2) 241-243
About the authors
Mr Yuvraj Agrawal
MRCS
Specialist Registrar in Trauma and Orthopaedics,
North Manchester General Hospital, Manchester
Dr Jyoti Karwa
MB BS
SHO in Accident and Emergency, North
Manchester General Hospital, Manchester
Mr Nikhil Shah
FRCS (Tr & Orth) MCh (Orth) MS (Orth) DNB
Consultant Trauma and Orthopaedic Surgeon,
North Manchester General Hospital, Manchester
Mr Anthony Clayson
FRCS (Tr & Orth)
Consultant Trauma and Orthopaedic Surgeon,
North Manchester General Hospital, Manchester

Mihalko WM, Rohrbacher B, McGrath B 1999

Members can search all issues of the BJPN/JPP
Transient peroneal nerve palsies from injuries
published since 1998 and download articles free of
placed in traction splints American Journal of
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Emergency Medicine 17 160-162 Access is also available to non-members who pay a
Mueller ME, Allgower M, Schneider R, Willenegger H small fee for each article download.
1970 Manual of Osteosynthesis New York,
Springer Verlag

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