Tag Archives: splint

Part 2: Metal Splints – Can You CT Scan Through Them?

In my last post, I debunked the myth that using a pre-formed aluminum splint significantly degrades the quality of standard x-rays. But what about a study that provides much more detail, such as CT scan?

CT scan techs have told me that there would be too much artifact using any kind of metal splint. And typically, when imaging an extremity with CT, we are looking at vascular runoff. The vessels are small, and high image quality is extremely important. If the images are bad, then we risk having to give the patient another dose of both radiation and contrast.

As you know, my mantra is question everything! So i scouted around and found some images to share using one of these splints. Look closely for the intimal flap in the image below:

Can’t see it? That’s because it isn’t there! But you certainly could if it were!

Bottom line: A perforated aluminum splint causes absolutely no artifact or image degradation. Do not cause additional injury by removing it prior to imaging, either CT or conventional x-ray. Although your friendly techs, radiologists, and orthopedic surgeons may moan, it won’t hurt their ability to make decisions on the images.

Metal Splints – Can You X-ray Through Them?

Splinting is an important part of the trauma resuscitation process. No patient should leave your trauma resuscitation room without splinting of all major fractures. It reduces pain, bleeding, and soft tissue injury, and can keep a closed fracture from becoming an open one.

But what about imaging? Can’t the splint degrade x-rays and hamper interpretation of the fracture images? Especially those pre-formed aluminum ones with the holes in them? It’s metal, after all.

Some of my orthopedic colleagues insist that the splint be removed in the x-ray department before obtaining images. And who ends up doing it? The poor radiographic tech, who has no training in fracture immobilization and can’t provide additional pain control on their own.

But does it really make a difference? Judge for yourself. Here are some knee images with one of these splints on:

Amazingly, this thin aluminum shows up only faintly. There is minimal impact on interpretation of the tibial plateau. And on the lateral view, the splint is well posterior to bones.

On the tib-fib above, the holes are a little distracting on the AP view, but still allow for good images to be obtained.

Bottom line: In general, splints should not be removed during the imaging process for acute trauma. For most fractures, the images obtained are more than adequate to define the injury and formulate a treatment plan. If the fracture pattern is complex, it may be helpful to temporarily remove it, but this should only be done by a physician who can ensure the fracture site is handled properly. In some cases, CT scan may be more helpful and does not require splint removal. And in all cases, the splint should also be replaced immediately at the end of the study.


Are Femoral Traction Splints Okay In Open Fractures?

Application of traction splints to the femur can be a bit tricky, mostly because of the various indications and contraindications. The company that makes the Hare traction splint gives the sole indication as a suspected femur fracture, and the sole contraindication as an open femur fracture. In my mind, this is a bit too simplistic.

I agree that the traction splint should only be applied on femur fractures, known or suspected. However, there are a few more contraindications:

  • The patient should not have a posterior pelvic fracture. Unfortunately, prehospital providers don’t have xray vision, so they usually can’t tell. If there is any suspicion (pelvic instability, deformity), then don’t use it.
  • The knee joint must be intact. Application of a traction splint across a bad knee will distract the tibia and the femur, potentially causing more injury. Take a good look at the knee. If it’s edematous or discolored, no traction splint.
  • The tibia must not be fractured. As in the previous bullet point, the tibial segments will pull apart before the strong muscles in the thigh allow the femur to reduce.

What about the open fracture scenario? The concern is that contaminated bone will be pulled back into the wound. It’s not really known whether this results in an increased infection rate, but it’s better to be safe and not do it. However, there are two scenarios when applying traction to an open femur fracture is warranted:

  • There is significant bleeding from the wound. Restoring the normal anatomy will create more pressure around the injured tissues and may slow bleeding.
  • The distal pulses are compromised or absent. Most of the time, this is due to kinking of the vessel, not outright damage to it. Pulling it to length may restore normal flow.

Bottom line: Treat traction splints with respect. Keep these tips in mind, but always adhere to your local protocols and procedures first. However, if it’s not covered by them, or you are getting concerned that the patient’s (or their leg’s) wellbeing is at risk, do the right thing!

Thanks to Don Dustin from Mineral County EMS in Colorado for posing this question!

Hare Traction – Putting It On, Taking It Off

Femoral traction devices have been around for a long time. One reader has asked about the timing of removal of these devices after they arrive at the hospital. I learned a number of things while reviewing the literature to answer this question.

Most importantly, there is really only one indication for applying a traction splint to the femur: an isolated, relatively mid-shaft femur fracture. Unfortunately, there are lots of contraindications. They consist of other injuries or fractures that could sustain further damage from traction. Specifically, these include:

  • Pelvic or hip fracture
  • Hip dislocation
  • Knee injury
  • Tib/fib, ankle or foot fracture

I did find one interesting study from 1999 that looked at how useful these splints really were. Of 4,513 EMS runs, only 16 had mid-thigh trauma and 5 of these appeared to have a femur fracture. Splint application was attempted in 3, and only 2 were successful. This was the experience in only one city (Evanston, IL) for one year. However, it mirrors what I see coming into our trauma center.

Unfortunately, when it comes to removal, there are very few guidelines out there. My advice is to have your orthopedic surgeon evaluate as soon as imaging is complete. They can help decide whether converting to some type of definitive traction is necessary, or whether it can be changed to a more conventional splint. In any case, the objective is to minimize the total amount of time in the traction splint to avoid any further injury to other structures.

Reference: Prehospital midthigh rauma and traction splint use: recommendations for treatment protocols. Am J Emerg Med, 19:137-140, 2001.