Abstract
Introduction
Methods
Results
Conclusion
Keywords
Introduction
Rationale
Current practice
Nederland, A. Landelijk protocol ambulancezorg. 2016 1-12-2021; Available from: https://www.ambulancezorg.nl/static/upload/raw/5bb07881-6bc2-40aa-a307-5946758e1b43/20160801_LPA8_1_definitief_drukproef_wm_bv.pdf.
NASEMSO. National model EMS clinical guidelines version 2.0. 2017 1-12-2021]; Available from: https://www.ems.gov/pdf/advancing-ems-systems/Provider-Resources/National-Model-EMS-Clinical-Guidelines-September-2017.pdf.
Tasmania, A. Clinical practice guidelines for paramedics & intensive care paramedics. 2012 1-12-2021]; Available from: https://www.dhhs.tas.gov.au/__data/assets/pdf_file/0018/107334/A00_-_Ambulance_Tasmania_Clinical_Practice_Guidelines_for_Paramedics_and....pdf
Victoria, A. Clinical practice guidelines. 2019 1-12-2021]; Available from: https://www.ambulance.vic.gov.au/paramedics/clinical-practice-guidelines/.
Service, Q.A. Clinical practice procedures: trauma/orthopaedic splinting – CT-EMS femoral traction. 2022 30-1-2022]; Available from: https://www.ambulance.qld.gov.au/docs/clinical/cpp/CPP_Orthopaedic%20splinting_CT%20EMS.pdf.
Unfallchirurgie, D.G.f. Polytrauma /Schwerverletzten-behandlung. 2016 1-12-2021]; https://www.dgu-online.de/leitlinien/leitlinien-der-dgu/aktuelle-leitlinien-der-dgu.html & https://www.awmf.org/leitlinien/detail/ll/012-019.html].
(NAEMT), N.A.o.E.M.T. TCCC-MP/AC Guidelines and curriculum. 2019 1-12-2021]; Available from: https://www.naemt.org/education/naemt-tccc/tccc-mp-guidelines-and-curriculum.
Objectives
Methods
Search strategy and data collection
Howick, I.G., P.; Greenhalgh, T.; Heneghan, C.; Liberati, A.; Moschetti, I.; Phillips, B.; Thornton, H.; Goddard, O.; Hodgkinson, M. The Oxford 2011 levels of evidence. 2011 1-12-2019]; Available from: https://www.cebm.net/wp-content/uploads/2014/06/CEBM-Levels-of-Evidence-2.1.pdf.
Database | EMbase | CINAHL | Cochrane | PubMed |
---|---|---|---|---|
Search Strategy | ((Exp femur/ AND (exp fracture/ or closed fracture reduction/ or exp fracture healing/)) or exp femur fracture/ or ((femoral.ti,ab,kw. OR femur.ti,ab,kw.) AND fracture*.ti,ab,kw.)) AND (exp traction therapy/ OR traction*.ti,ab,kw. OR exp splint/ OR splint*.ti,ab,kw. OR exp femur fracture/th) AND (exp emergency health service/ OR First Aid/ OR exp patient transport/ OR Ambulance*.ti,ab,kw. OR Paramedic*.ti,ab,kw. OR HEMS.ti,ab,kw. OR Emergency cent*.ti,ab,kw. OR First aid.ti,ab,kw. OR emergency department*.ti,ab,kw. OR pre-hospital.ti,ab,kw. OR prehospital.ti,ab,kw.) | S1 (MH "Femur+") S2 (MH "Fractures+") S3 (MH "Fracture Healing") S4 (MH "Orthopedic Fixation Devices") OR (MH "External Fixators+") S5 (MH "Femoral Fractures+") S6 TI (((femoral OR femur) AND fracture*))) OR AB (((femoral OR femur) AND fracture*))) S7 S2 OR S3 OR S4 S8 S1 AND S7 S9 S5 OR S6 OR S8 S10 (MH "Traction") S11 (MH "Splints") S12 TI (traction* OR splint*) OR AB (traction* OR splint*) S13 S10 OR S11 OR S12 S14 S9 AND S13 | #1 MeSH descriptor: [Femoral Fractures] explode all trees #2 MeSH descriptor: [Femur] explode all trees #3 MeSH descriptor: [Fractures, Bone] explode all trees #4 MeSH descriptor: [Closed Fracture Reduction] explode all tree #5 MeSH descriptor: [Fracture Healing] explode all trees #6 #3 or #4 or #5 #7 #2 and #6 #8 (Femoral or femur) and fracture*:ti,ab,kw (Word variations have been searched) #9 #1 or #7 or #8 #10 MeSH descriptor: [Traction] explode all trees #11 MeSH descriptor: [Splints] explode all trees #12 splint* or traction*:ti,ab,kw (Word variations have been searched) #13 #10 or #11 or #12 #14 #9 and #13 | (("Femur"[Mesh] AND ("Fractures, Bone"[Mesh] OR "Closed Fracture Reduction"[Mesh] OR "Fracture Healing"[Mesh])) OR "Femoral Fractures"[Mesh] OR ((femoral[tiab] OR femur[tiab]) AND fracture*[tiab])) AND ("Traction"[Mesh] OR traction*[tiab] OR "Splints"[Mesh] OR splint*[tiab] OR Femoral fractures/therapy[Mesh]) AND ("Emergency Medical Services"[Mesh] OR "First Aid"[Mesh] OR "Transportation of Patients"[Mesh] OR Ambulance*[tiab] OR Paramedic*[tiab] OR HEMS[tiab] OR Emergency cent*[tiab] OR First aid[tiab] OR emergency department*[tiab] OR pre-hospital[tiab] OR prehospital[tiab]) |
Hits (N) | 146 | 403 | 110 | 589 |
Bledsoe 2004 | Runcie 2014 | Borschneck 2004 | Nackenson 2017 | Irajpour 2012 | Scheinberg 2004 | Wood 2004 | Martin 2004 | Wood 2003 | Bumpass 2015 | Chu 2003 | Hoppe 2015 | Trunkey 2004 | Spanp 2014 | Campagne 2020 | Gozna 2004 | Abarbanell 2001 | Rowlands 2003 | Wieger 2004 | Haddox 2004 | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
A clearly stated aim | 1 | 1 | 2 | 2 | 2 | N/A | N/A | N/A | 1 | 2 | 2 | 2 | N/A | 2 | 2 | N/A | 2 | 1 | N/A | N/A |
Inclusion of consecutive patients | 0 | 1 | 0 | 2 | 2 | N/A | N/A | N/A | 1 | 2 | 2 | 1 | N/A | 1 | 2 | N/A | 1 | 0 | N/A | N/A |
Prospective collection of data | 0 | 2 | 0 | 1 | 2 | N/A | N/A | N/A | 2 | 2 | 2 | 2 | N/A | 1 | 2 | N/A | 1 | N/A | N/A | N/A |
Endpoints appropriate to the aim of the study (intention to treat) | 0 | 0 | 0 | 1 | 2 | N/A | N/A | N/A | 0 | 2 | 1 | 2 | N/A | 2 | 2 | N/A | 2 | N/A | N/A | N/A |
Unbiased assessment of the study endpoint (blinding) | N/A | N/A | 0 | 0 | 0 | N/A | N/A | N/A | 0 | 0 | N/A | N/A | N/A | 0 | 0 | N/A | N/A | N/A | N/A | N/A |
Follow-up period appropriate to the aim of the study | N/A | N/A | N/A | N/A | 1 | N/A | N/A | N/A | 2 | 2 | 0 | 0 | N/A | 1 | 2 | N/A | 1 | N/A | N/A | N/A |
Loss to follow-up <5% | N/A | N/A | N/A | N/A | 0 | N/A | N/A | N/A | 0 | 1 | 0 | 0 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
Prospective calculation of the study size | N/A | N/A | N/A | N/A | 0 | N/A | N/A | N/A | 0 | 2 | 0 | 0 | N/A | 0 | 0 | N/A | 0 | N/A | N/A | N/A |
An adequate control group | N/A | N/A | N/A | 1 | 2 | N/A | N/A | N/A | N/A | 2 | N/A | 1 | N/A | 1 | 2 | N/A | N/A | N/A | N/A | N/A |
Contemporary groups | N/A | N/A | N/A | 2 | 2 | N/A | N/A | N/A | N/A | 2 | N/A | 2 | N/A | 1 | 1 | N/A | N/A | N/A | N/A | N/A |
Baseline equivalence of groups | N/A | N/A | N/A | N/A | 2 | N/A | N/A | N/A | N/A | 1 | N/A | 2 | N/A | 2 | 1 | N/A | 0 | N/A | N/A | N/A |
Adequate statistical analyses (CI; RR) | N/A | N/A | N/A | 2 | 1 | N/A | N/A | N/A | 0 | 2 | 0 | 2 | N/A | 2 | 2 | N/A | 0 | N/A | N/A | N/A |
Total | 1 | 4 | 2 | 11 | 16 | N/A | N/A | N/A | 6 | 20 | 7 | 14 | N/A | 13 | 16 | N/A | 7 | 1 | N/A | N/A |
Results

Reference | Study type | Level of evidence | Number of subjects | Outcome measures | Conclusion |
---|---|---|---|---|---|
[3] Bledsoe | Review/position paper | V | N/A | N/A | Relatively low usage of TS demands revisited guidelines for ambulance and rescue vehicles |
Runcie | Retrospective | III | N/A | Establish incidence rates of femoral fractures in mountain rescue Investigate attitude towards TS Review literature for evidence on TS Test hypothesis that application of TS reduces mortality and morbidity in patients with femoral fractures | Femoral fractures are rare in mountain rescue TS may be no more effective than other methods of splinting in prehospital care No evidence was identified that supports the hypothesis that TS reduces mortality and morbidity |
[10] Borschneck | Position paper | V | N/A | N/A | Continued use of TS in acute management of femoral shaft fractures seems appropriate |
[12] Nackenson | Retrospective | III | 170 | Application of TS in blunt versus penetrating injuries Use of analgesia | Only 30% of patients with midshaft femur fracture where immobilized using a TS No association was found between TS utilization and morphine administration |
[25] Irajpour | Experimental prospective cohort | III | 32 | Pain intensity between simple and traction splint groups | Significant reduction in pain 1, 6 and 12 h after traction splinting |
[26] Howick, I.G., P.; Greenhalgh, T.; Heneghan, C.; Liberati, A.; Moschetti, I.; Phillips, B.; Thornton, H.; Goddard, O.; Hodgkinson, M. The Oxford 2011 levels of evidence. 2011 1-12-2019]; Available from: https://www.cebm.net/wp-content/uploads/2014/06/CEBM-Levels-of-Evidence-2.1.pdf. Scheinberg | Position paper | V | N/A | N/A | Overriding reason for TS application is pain relief. |
[27] Wood | Position paper | V | N/A | N/A | In the setting of poly trauma a rigid splint and opioid analgesia provide adequate reduction in pain and blood loss while minimizing complication risks. |
Martin | Position paper | V | N/A | N/A | TS can be a much-needed field therapy for pain management and stabilization, but lack of relevant and critically unbiased studies |
[29] Wood | Prospective follow-up | III | 828 | Identify patients with TS in place for femur fracture immobilization Identify injuries patients with injuries that can complicate and/or contraindicate TS use | Of 828 multisystem trauma patients 40 (4.8%) were identified having as having a TS in place for femur fracture Complicating and contraindicating injuries were found in 15 out of 40 (38%) patients No current evidence-based research demonstrating the efficacy of TS or comparing the outcomes of TS versus traditional rigid splints |
Bumpass | Prospective cohort trial | III | 33 | VAS scores pre immobilization, during application and post immobilization in splint group versus skeletal traction group | Traction pin placement led to less discomfort during application compared with splint placement. No significant difference was seen in post immobilization pain scores |
[31] Chu | Retrospective | III | 95 | Establish a consensus opinion on best ED practice with regard to TS application in children with femoral fractures Hypovolemic shock and pain scores | Timing of TS did not appear to be associated with hypovolemic shock or neurovascular complications in isolated pediatric femoral shaft fractures Main priority is pain relief preferably via femoral block and titrating analgesia |
[32] Hoppe | Retrospective | III | 106 | Blood transfusion and analgesic requirements in early versus delayed TS groups | Blood transfusion and pulmonary complications significantly lower in early splinted group No differences in analgesic requirements between early versus delayed TS groups |
[33] Trunkey | Position paper | V | N/A | N/A | Acute management of femoral shaft fractures with a TS is appropriate. A TS will control hemorrhage, particularly in a closed fracture by reducing the volume of the potential space. It would be appropriate for a multi-institutional RCT to be carried out. |
[34] Spano | Retrospective | III | 579 | MortalityH Hospital length of stay Units of blood transfused Complications | No difference in complications or mortality in patients receiving prehospital TS versus those who did not Patients who had a prehospital TS placed had fewer units of blood transfused in the first 24 h and shorter hospital LOS However, these patients had a lower ISS and thus were not as sick as the no traction group |
[35] Campagne | Retrospective | III | 218 | Mortality Hospital length of stay Units of blood transfused Complications | TS can lower hospital length of stay. |
[36] Gozna | Position paper | V | N/A | N/A | Re-evaluate the cost-effectiveness and efficacy of the types of splints currently used. Due to substantial risk of developing fat embolism syndrome patients with femoral fractures should be properly and safely splinted. |
[41] Abarbanell | Retrospective | III | 16 | Use of/need of TS | Position of comfort may constitute an acceptable course of care TS as essential ambulance equipment may be unnecessary |
[42] Rowlands | Case report | IV | 7 | N/A | TS remains to play an important role in military femoral trauma Application of TS allows early evacuation to a base hospital for internal fixation |
[43] Wiegert | Position paper | V | N/A | N/A | TS is a tool used by Army medical personnel Unit medical officer will guide protocol on application and/or removal |
[7] Haddox | Position paper | V | N/A | N/A | Only indication is a suspected closed, isolated, mid-shaft femur fracture. Better and more training required. Future research to be conducted with hospitals and EMS services that have responsibility for ski resorts. |
Author and year of publication | Reason for exclusion | ||||
---|---|---|---|---|---|
Not meeting PICO | Not concerning effects on pain | Not concerning effects on blood loss | Using TS as definitive treatment | Summary | |
Canning 2003 | X | X | X | Letter to editor about infection risk in open femoral fractures | |
Daugherty 2013 | X | X | X | Retrospective study to assess the rate of misapplication of the Hare traction device among femoral shaft fractures in pediatric patients | |
Mansson 2006 | X | Retrospective analysis of the incidence and prevalence of femoral fractures. Prospective study to determine the force of traction exerted by TSs over time. | |||
Short 1984 | X | X | X | Prospective study comparing simple traction and cast bracing with the Thomas’ Splint in terms of time spent in traction, hospital length of stay and return to work |
Effect on pain | Author | Conclusion | Level of evidence & study type | No of subjects | P-value | Added value |
---|---|---|---|---|---|---|
Bumpass | no difference in post immobilization scores | III prospective cohort | 71 | 0,12 | ||
Irajpour | significant reduction 1, 6 and 12 hrs after application of TS | III prospective cohort | 32 | 0,02 | ||
Chu | pain relief preferably via block or IV | III retrospective | 95 | N/A | ||
Nackenson | no association TS and analgesia use | III retrospective | 159 | 0,678 | ||
Hoppe | no difference early and delayed application | III retrospective | 106 | 0,41 | ||
Wood | regular splinting and IV analgesia provide also adequate relief | V position paper | N/A | N/A | ||
Borschneck | TS decreases muscle spasm and therefore pain | V position paper | N/A | N/A | ||
Slishman | same reasoning as Borschneck | V position paper | N/A | N/A | ||
Scheinberg | reduction when TS applied | V position paper | N/A | N/A | ||
Martin | TS much needed field therapy for pain relief | V position paper | N/A | N/A | ||
Effect on blood loss | ||||||
Hoppe | lower requirements for blood transfusion in early splinted group | III retrospective | 106 | 0,04 | ||
Spano/Campagne | fewer blood units needed first 24 hrs when prehospital TS was placed | III retrospective | 579 | 0,001 | ||
Campagne | lower hospital length of stay | III retrospective | 218 | 0,05 | ||
Borschneck | TS will control hemorrhage by reducing volume of potential space | V position paper | N/A | N/A | ||
Trunkey | same reasoning as Borschneck | V position paper | N/A | N/A | ||
Effect on complications | ||||||
Wood | in multiple-trauma patients, injuries that can complicate traction splint use are common | III prospective follow-up | 40 | N/A | ||
Hoppe | lower rate of pulmonary complications in the early-splinted group | III retrospective | 106 | 0,08 | ||
Spano | no difference in complications or mortality in patients receiving prehospital TS | III retrospective | 579 | 0,09 | ||
Campagne | no difference in complications or mortality in patients receiving prehospital TS | III retrospective | 218 | 0.771 | ||
Gozna | due to substantial risk of developing fat embolism patients should be properly TS | V position paper | N/A | N/A | ||
Runchie | no reduction in mortality and morbidity, TS no more effective than other methods of splinting prehospitally | III retrospective | N/A | N/A | ||
Necessity | ||||||
Runcie | literature evidence suggests that traction splints may be no more beneficial than simple splints | II review | 5 | N/A | ||
Abarbanell | TS as essential ambulance equipment may be unnecessary | III retrospective | 16 | N/A | ||
Chu | timing of TS was not associated with shock or complications. Necessity of TS is questioned | III retrospective | 95 | N/A | ||
Rowlands | TS remains to play an important role in military trauma. | IV case-report | 7 | N/A | ||
Bledsoe | considering the relatively low usage of the TS, it is time to revisit guidelines that require TS | V position paper | N/A | N/A | ||
Borschneck | due to incidence numbers the value of having a TS on board should not be easily underestimated | V position paper | N/A | N/A | ||
Haddox | no removal before good research has been performed | V position paper | N/A | N/A | ||
Wiegert | TS is a tool. Application to be decided by medical officer | V position paper | N/A | N/A |
Effect on pain
Effect on blood loss
Secondary outcomes
Complications
Necessity
Discussion
Zorg, L.N.A. Landelijke traumaregistratie. 2021 1-12-2021; Available from: https://www.lnaz.nl/trauma/landelijke-traumaregistratie.
Zorg, L.N.A. Landelijke traumaregistratie. 2021 1-12-2021; Available from: https://www.lnaz.nl/trauma/landelijke-traumaregistratie.
Nederland, A. AZN Tabellenboek. 2018 1-12-2021]; Available from: https://www.ambulancezorg.nl/static/upload/raw/dd0f3beb-7bed-45d3-a7b6-b5e51493726c/AZN+tabellenboek+2018+-+tabellen%2C+grafieken+en+kaarten+-+071019.pdf.
Zorg, L.N.A. Landelijke traumaregistratie. 2021 1-12-2021; Available from: https://www.lnaz.nl/trauma/landelijke-traumaregistratie.
Nederland, A. AZN Tabellenboek. 2018 1-12-2021]; Available from: https://www.ambulancezorg.nl/static/upload/raw/dd0f3beb-7bed-45d3-a7b6-b5e51493726c/AZN+tabellenboek+2018+-+tabellen%2C+grafieken+en+kaarten+-+071019.pdf.
Oost, A.Z.R. Trends in de vraag naar acute zorg in Acute Zorgregio Oost in de periode 2014-2017. 2021 1-12-2021; Available from: https://acutezorgregiooost.nl/wp-content/uploads/2019/07/Rapport-Trends-Acute-Zorgregio-Oost-2015-2018.pdf.
Strengths and limitations
Conclusion
Funding
Declaration of Competing Interest
References
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