Femur fractures, especially those that occur in a wilderness setting, typically result from high force trauma and require prolonged treatment via traction and splinting. Subsequent blood loss from an untreated femur injury can be as high as 1.5 liters and result in patient mortality as high as 54 percent. Wilderness medicine courses often review the long term management of such injuries through improvised femur traction and splinting. This case review discusses the use of improvised traction for a patient who sustained a comminuted femur fracture as a result of a high speed motor vehicle accident. More traditional backcountry traction techniques were used to manage the patient during his emergency department stay. In this case the treatment techniques were taken from the wilderness, modified, and brought indoors.

When I started teaching wilderness medicine there was a rather distinct line in my head about the boundaries between wilderness and urban settings. One mile or one hour, right? Over the years however that distinction has become rather blurry. My urban training finds its way to the wilderness, and more often than not my wilderness training finds its way to the urban setting, be it inside the hospital or in the back of an ambulance. It matters not the setting but only the process by which I problem-solve, and it is this that often raises the eyebrows of my urban colleagues. By learning to be without traditional equipment in a backcountry setting, one is often encouraged to use other supplies, often not medical at all, in new and innovative ways. It is of course this improvisation which is really one of the hallmarks of wilderness medicine. This case review is of the use of improvised traction for a patient who sustained a comminuted femur fracture as a result of a high speed motor vehicle accident.

For anyone who has worked the night shift in an emergency department, you understand the ebb and flow of adrenaline that occurs within its walls. You learn to relish it, loathe it, and otherwise be drawn to it. As emergency providers we go from the noncritical and mundane to the emergent and morose in seconds, often between bites of dinner. It was nearing midnight of this particular shift and the department was busy as usual, with not an empty bed, when we received a trauma notification. A motor vehicle traveling at a high rate of speed had rear-ended another that was stopped just out of sight around a bend in the road. There was heavy damage to both cars. The driver of the rear car, our soon to be patient, was a young, extremely fit man in his late 20s who had sustained at the very least an obvious right femur fracture. The deformity and bruising in the thigh coupled with the spasm of his quadriceps muscle and severe pain made it quite obvious. His leg was placed in traction using a HareĀ® traction device by prehospital personnel. With any change in tension or movement of the device his pain became excruciating. Through the radio patch we could hear his discomfort as he yelped with each bump down the road. The trauma team was notified and we awaited his arrival.

The incidence of femur fractures is reported as 10 per 100,000 person-years.1 The incidence is highest in two age categories: those less than 20 years of age and in the elderly greater than 75 years old.2 There exists great potential for multi-system trauma given the significant amount of force typically needed to fracture a femur. The emergent nature of an isolated femur fracture is great given the potential for significant blood loss, which is often reported as between 1 and 1.5 liters3, the high risk for vascular and tissue damage within the thigh compartment, and the often vast levels of patient discomfort. Mortality in the setting of femur fractures is said to range from 20-54 percent.4

Femur traction was first described in 1860 by John Hilton. This early traction device was further developed in the 1870's by British physician Hugh Thomas and in 1917 it gained widespread use as part of combat medicine in WWI. Though official documentation from that era is scant femur traction is said to have reduced mortality by as much as 64 percent in soldiers with femur fractures.5 It is surprising that in the age of evidence based medicine rigorous analysis of the efficacy of femur traction in the setting of patient outcomes has yet to be completed. Proponents of femur traction tend to cite treatment of the aforementioned sequela while dissenters often voice improper application, side effects such as palsy and distal blood flow disruption, and lack of any real proof of efficacy.

As the patient arrived at our emergency department we found him to be conscious and alert despite early and high doses of narcotics that had been used by the transporting paramedics. Any adjustment or loosening of the Hare® traction device sent his quadriceps muscle into immediate spasm and he screamed in pain. It quickly became clear that traction was crucial to his pain control. We rapidly began administering aliquots of morphine and fentanyl, and eventually switched to ketamine hoping that the dissociative properties would benefit this young man as much as those for pain control. Relief, however, continued to be short-lived, and he would end up writhing in pain the second traction was adjusted or diminished.

Improvised traction

The prefabricated traction device was eventually removed by the provider team for the sake of imaging. The patient begged me to maintain ongoing traction as his primary nursing caregiver and I did so manually for nearly thirty minutes. Intermittently, I required a colleague to take over so that I could medicate the patient for his pain and check on my other patients. It became clear to me that he would require ongoing traction. Unfortunately, the previously used, prefabricated device had been retrieved by the EMS unit who delivered him and our own in unit device was out of service. As a result, I decided that creativity was in order and I would improvise a traction device. I had done it countless times with ski poles, sticks, and paddles, but I was without even these adjuncts in our emergency department. Initially I fashioned an improvised ankle hitch out of a triangular bandage (though eventually used a prefabricated ankle strap) and tied a piece of cord to it with an attached overhand loop as a handle. This gave me greater flexibility in my positioning while pulling traction as I no longer had to physically grip his ankle. I eventually decided to try and mimic the typical Bucks traction that would ultimately be applied to his leg that evening so that I could free myself of constant pulling. To do so, I tied a cardiac monitor to the end of the cord and gently hung it over the edge of the bed. While not perfect with regard to direction of pull the weight was sufficient to prevent continued spasm of his quad and his pain remained under control.

Pinned Femur

Throughout his Emergency Department stay this setup was adjusted to fit his needs. While in CT I was able to fashion a truckers hitch off the end of the examination table on which he was lying. The patient was then able to adjust his own traction as he had a foundation from which to pull against. This allowed me to leave the exam room during imaging but still maintain ongoing and reliable traction.

Hours after his initial presentation improvised femur traction was finally released in preparation for Bucks traction. Surprisingly, his quadriceps resumed its spasm and I once again resumed manual traction until the tibial pin was placed and hitched to a more traditional weighted traction system. This night, wilderness improvisation techniques proved beneficial despite being in a city more densely populated with well-funded, academic medical institutions than many countries have in total.

Posted on May 12, 2015



References
  1. Weiss RJ, Montgomery SM, Al Dabbagh Z, Jansson KA.National data of 6409 Swedish inpatients with femoral shaft fractures: stable incidence between 1998 and 2004. Injury 2009; 40(3): 304-308. doi: 10.1016/j.injury.2008.07.017.
  2. Hedlund R, Lindgren U.Epidemiology of diaphyseal femoral fracture. Acta Orthop Scand 1986; 57(5): 423-7. PMID: 3811886.
  3. Lieurance R, Benjamin JB, Rappaport WD. Blood loss and transfusion in patients with isolated femur fractures. J Orthop Trauma 1992; 6(2): 175-179.
  4. Mansson E, Ruter A, Vikstrom T. Femoral shaft fractures and the prehospital use of traction splints. Scand J Trauma Resusc Emerg Med 2006; 14(26).
  5. Gray HMW: The Early Treatment of War Wounds. H Frowde, Hodder and Stoughton: London, 1919.

Photos taken by the author and hence property thereof. Permission granted to reproduce as part of this submission only.


PearceBrad Boehringer is a critical care flight nurse/paramedic that has taught for the wilderness medicine school SOLO, based in Conway, NH, for many years. His backcountry experience has included stints as an Outward Bound instructor, international high altitude mountain guide, ski patroller, and search and rescue volunteer. He has worked EMS in various regions that include rural New Hampshire and the greater Boston area. He is currently on a Fulbright Grant in Finland teaching nursing education through simulation at Laurea University of Applied Science. Upon his return to the U.S., he will continue to work as a flight nurse/paramedic for LifeFlight of Maine and also in the Brigham and Women's Hospital emergency department.