Category Archives: General

General

Are Femoral Traction Splints Okay In Open Fractures?

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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!

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Figure It Out! The Answer

Several readers emailed the correct answer yesterday. The picture is a child with a bicycle handlebar injury to the epigastrium. The plastic grip over the end of the handlebar has a small hole in the middle leaving the distinctive mark seen in the photo.

Children are more likely to sustain significant injuries from this mechanism because they have little muscle in their abdominal wall, so it can’t protect as well as it does in adults. Everything between the handlebar and the spine gets crushed together, frequently resulting in serious injury.

Possible injuries include:

  • Pancreatic injury / transection
  • Liver laceration (left lobe)
  • Duodenal injury / hematoma
  • Retrohepatic vena cava injury

I’ve listed them in what I believe to be the usual order. The literature varies a bit because there aren’t a lot of series published. In this case, the injury was a pancreatic transection.

Bottom line: Handlebar injuries in children (and to a lesser degree, adults) are a significant marker for serious abdominal injury. CT scan is mandatory to find the diagnosis. Proper management of a pancreatic injury is a good topic for a future post!

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Figure It Out!

Here’s a test of your observational skills and trauma knowledge. This picture tells you everything you need to know. What happened, and what’s the likely diagnosis?

Answer tomorrow!

Source: Private archive. Patient not treated at Regions Hospital

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Best Of: Forensic Nursing

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Forensic Nursing combines nursing science with the investigation of injuries or deaths that involve accidents, abuse, violence or criminal activity. Sexual Assault Nurse Examiners (SANE nurses) are one of the most recognized types of forensic nurses, but they have special training in one type of injury. Forensic nursing programs typically involve a broader set of skills, encompassing some or all of the following:

  • Interpersonal violence, including domestic violence, child and elder abuse/neglect, psychological abuse
  • Forensic mental health
  • Correctional nursing
  • Legal nurse consulting
  • Emergency/trauma services, including auto and pedestrian accidents, traumatic injuries, suicide attempts, work-related injuries, disasters
  • Patient care facility issues, including accidents/injuries/neglect, inappropriate treatments & meds
  • Public health and safety, including environmental hazards, alcohol and drug abuse, food and drug tampering, illegal abortion practices, epidemiology, and organ donation
  • Death investigation, including homicides, suicides, suspicious or accidental deaths, and mass disasters

Forensic nurses find that their additional training improves their basic nursing skills, and allows them to derive greater career satisfaction from helping patient in another rather unique way.

Approximately 37 training programs exist, ranging from certificate programs that require a specific number of hours of training, to degree programs (typically Masters level programs). Many of the certificate programs are available as online training. 

Source: International Association of Forensic Nurses (http://www.iafn.org/)

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