Student Corner: The Differences Between Traction Splints

Student Corner is a bimonthly column discussing research projects and interest areas among current EMT and paramedic students. To be featured in this column contact editor@emsworld.com. 

When the longest, heaviest, and strongest bone in the body breaks and your patient screams ceaselessly in pain, what do you do? You reach for that traction splint, of course. 

Currently the two main traction splints that dominate the market are Hare and Sager. Other options include Thomas, Kendrick, Donway, Slishman, and CT-6 splints, but these are not as commonly used. 

So how do we decide which one to reach for? In practice we just grab the one our ambulance happens to carry. In theory, however, the choice is far more interesting.

Hare Traction Splint

The Hare was first developed in the 1960s by introducing a ratchet mechanism into the then-commonly used Thomas splint. Hare uses bipolar traction with bilateral steel rods that flank the limb. It is compact and fits beautifully into the bench seat of an ambulance. However, most ambulances, at least in Los Angeles County, are stocked with only one traction splint. So if you have to treat a bilateral fracture, you’re off by a Hare.

The Hare is applied by 1) placing (or rather diligently shoving) one end under the patient’s ischial tuberosity and strapping it in place; 2) attaching the other end to the patient’s ankle; 3) applying traction; 4) securing the remaining straps; 5) checking circulation/motor/sensory (CMS); and 6) then hoping the shape and mass of your patient’s os coxae and glutes can hold steady tension until you get to the nearest trauma center.

Sager Traction Splint

To improve on this design, the 1970s brought us the Sager. Unlike Hare, Sager applies unipolar traction with one steel rod and is placed between the patient’s legs, rather than posteriorly, thus accommodating both proximal and bilateral femur fractures.

Otherwise, Sager is applied in a similar six-step process to Hare: 1) placement; 2) thigh strap; 3) ankle strap; 4) traction; 5) remaining straps; 6) CMS. With the Sager, however, instead of worrying about your patient’s os coxae and glutes not holding down the splint, you’re concerned about a bump in the road shifting the articulating base and cushion of the splint’s outer shaft onto your patient’s genitalia.

In an ideal world ambulances would carry one Sager and two Hares, allowing EMS providers to decide in the field which one would best fit each trauma patient based on their specific injuries and anatomical build. 

In the Field

As painful as femoral fractures look and sound, they are not difficult to treat. Strap on some Velcro, twist some knobs, and your patient’s pain is relieved. However, there is more to traction splints than meets the eye. 

Recently I was the attendant on a 9-1-1 call for an accident where a 30-year-old male was struck by an SUV while crossing a street at night. One of his many injuries was a unilateral closed mid-femur fracture. So far so good; we carry a Hare on our ambulance. Unfortunately, the patient was about 5’10” and no more than 140 lbs., with little body fat, so that Hare kept sliding up past his ischial tuberosity. Still, with that diligent shoving, we got it securely strapped in place, and just seconds later his pain from that injury was completely gone.

Our patient’s condition was stable. Cool on the outside but fired up on the inside, we arrived at the hospital and presented him to the trauma team. And what did they do? They cut off that Hare and put the patient’s leg into that redheaded stepchild of splints: the cardboard splint! It was a good thing we had our poker faces on; our jaws would have hit the floor.

Cardboard Splints

Yes, both Sager and Hare look impressive and professional, but as the attending physician kindly took the time to explain that night, when it comes to femur fractures, less is more. The traction splints apply continuous tension, which is both unnecessary and could lead to further injury during transport since it prevents the bone from resting in place and can allow for inevitably harmful movement. In the future, he suggested, just apply manual traction, set the bone in place, and stabilize it with towels and cardboard.

Though a cardboard splint looks makeshift and might elicit disapproving comments from bystanders, it will actually mitigate many of the complications associated with both Hare and Sager. It is so compact you can keep a dozen of them on hand in various sizes, easily accommodating bilateral fractures and patients of all ages, shapes, and sizes. Its placement does not depend on the patient’s anatomy for stability, which makes application easier for the medic; nor does it endanger genitalia, which makes the patient a lot less anxious. It even makes the administrative staff happy because the cost is nominal. And research shows there is no significant difference in the resulting condition of patients who have and have not been treated with traction splints prior to hospital arrival. 

Summary

When treating femur fractures in the field, the Hare and Sager are the most commonly used traction splints today. Though their application essentially follows the same process, the two splints apply and hold traction differently. Furthermore, while Hare fits best with unilateral mid-femur fractures, Sager also accommodates both proximal and bilateral ones. 

However, research shows no indication that traction splints lead to fewer complications or decreased mortality rates in patients who present with femoral fractures. Cardboard splints may suffice in their stead.  

Resources

Gossman W, Ginglen JG, Kwon YH, Kahwaji CI. EMS, Traction Splint. National Center for Biotechnology Information, www.ncbi.nlm.nih.gov/books/NBK507842/. 

Spano S, Campagne D, Cagle K, et al. Prehospital Midthigh Trauma and Traction Splint Use: A Retrospective Review of a Trauma Registry. UCSF Fresno Department of Emergency Medicine, www.fresno.ucsf.edu/em/posters/Prehospital%20Midthigh%20Trauma%20and% 20Traction%20Splint%20Use_Poster.pdf. 

Robin Click is a former lawyer and current EMT in Los Angeles.