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BRIEF REPORT
Improvised Traction Splints: A Wilderness Medicine
Tool or Hindrance?
Lori Weichenthal, MD; Susanne Spano, MD; Brian Horan, DO; Jacob Miss, MD
From the Department of Emergency Medicine, UCSF-Fresno Medical Education Program, Fresno, CA (Drs Weichenthal, Spano, and
Horan); and the University of California, San Francisco, San Francisco, CA (Dr Miss).
Objectives.—To investigate whether a traction splint made from improvised materials is as effica-
cious as commercially available devices in terms of traction provided and perceived comfort and
stability.
Methods.—This was a prospective randomized crossover study utilizing 10 healthy, uninjured
volunteers. The subjects were randomized to be placed in 4 different traction devices, in differing order,
each for 30 minutes. Three of the traction splints are commercially available: The HARE, Sager, and
Faretech CT-EMS. The fourth traction device was an improvised splint made as described in Medicine
for the Backcountry: A Practical Guide to Wilderness First Aid. At the end of 30 minutes the pounds
of force created by each device was measured. The volunteers were also asked at that time to
subjectively report the comfort and stability of the splint separately on a scale from 1 to 10.
Results.—All traction splints performed similarly with regard to the primary outcome measure of
mean pounds of traction created at the end of 30 minutes of application with results ranging from 10.4
to 13.3 pounds. There was little difference reported by participants in regard to stability or comfort
between the 4 traction devices.
Conclusions.—In this small pilot study, an improvised traction splint was not inferior to commer-
cially available devices. Further research in needed in this area.
Key words: backcountry, traction splint, wilderness medicine, prehospital
Introduction
In wilderness and austere environments far from defini-
tive medical care, a femur fracture is a potentially life-
threatening injury. Long bone fractures can cause signif-
icant blood loss, and the high force mechanisms
associated with such injuries frequently result in multi-
system trauma. Femur fractures in remote settings also
can require significant resources to stabilize, package,
and evacuate the patient.
First developed for treatment of mid-shaft femur frac-
tures in 1860 by Hilton and further refined by Thomas,
traction splints gained recognition in World War I when
they were reported to decrease mortality from 80% to
15.6%.
1
Since 1961, the American College of Surgeons
(ACS) has mandated that all ambulances in the United
States carry traction splint devices.
2
This recommendation currently is jointly endorsed by
the ACS and the American College of Emergency Phy-
sicians. This practice has carried over to wilderness and
remote settings, with the construction and placement of
improvised traction splints being promoted in most wil-
derness medicine textbooks.
Despite the fact that traction splint placement is con-
sidered the standard of care, there are no definitive stud-
ies demonstrating efficacy or decreased morbidity or
mortality from their prehospital application. Similarly,
there is no research supporting use of improvised splints
in the wilderness. The potential benefits of traction
splints are thought to include decreased pain and amount
of potential bleeding space in the thigh; stabilization and
realignment of the fractured bony ends; and diminished
soft tissue injury including progression to an open frac-
ture.
3
Recent authors have questioned the utility of trac-
tion splints in the prehospital setting, citing occurrences
Corresponding author: Lori Weichenthal, MD, Department of Emer-
gency Medicine, UCSF-Fresno Medical Education Program, 155 N.
Fresno Street, Suite 206, Fresno, CA 93701 (e-mail: lweichenthal@
fresno.ucsf.edu).
WILDERNESS & ENVIRONMENTAL MEDICINE, 23, 61– 64 (2012)
of inappropriate application, skin ulcerations, peroneal
nerve injuries, and increased on-scene time for emer-
gency medical services (EMS) crews with subsequent
delay to definitive care.
1,4,5
The Wilderness Medicine
Society’s most recent Practice Guidelines for Wilderness
Emergency Care in 2006 even stated, “a traction splint is
no more efficacious than a good packaging technique.”
6
Clearly, there is controversy regarding the risks and
benefits of the use of traction splints in the prehospital
setting, and the debate regarding the use of these devices
is not well supported on either side by recent research.
Improvised traction splints in the wilderness setting take
some knowledge and time to create and should only be
used if they can be shown to be efficacious.
The goal of this pilot study is to investigate whether a
traction splint made from improvised materials is not
inferior to commercially available devices in terms of
traction provided and perceived comfort and stability.
Methods
This was a prospective randomized crossover study us-
ing 10 healthy, uninjured volunteers. Subjects were re-
cruited using e-mail and posted notices to employees and
residents at Community Regional Medical Center and
the University of California, San Francisco—Fresno
Medical Education and Research Center. Only individu-
als older than 18 years of age, who self-reported being in
good health and who were capable of signing informed
consent, were eligible to participate in the study. Once
the 10 selected subjects were educated on the specifics of
the study and had signed the consent form, they were
randomly assigned to be placed in 4 different traction
devices, in differing order, each for 30 minutes. Traction
splints were consistently placed on the same leg within
subject testing. Three of the traction splints are commer-
cially available: the Hare, Sager, and Faretech CT-EMS.
The Hare and Sager traction splints are frequently used
in urban and rural prehospital settings and in the emer-
gency department. The Faretech CT-EMS is a more
lightweight device designed for use in remote settings
including search and rescue and ski patrol. The fourth
traction device was an improvised splint made as de-
scribed in Medicine for the Backcountry: A Practical
Guide to Wilderness First Aid.
7
Creation of this splint
involved using a strip of something long and soft to tie
around the ankle with a loop at the sole of the foot,
securing a shaft that is at least 1 foot longer than the
injured leg to the patient’s upper thigh with a strap of
material that is well padded, and using a piece of rope or
cord to make a trucker’s hitch that is pulled from the loop
at the sole of the foot and the end of the shaft until
traction is achieved.
7
For our study, we used a 1-inch
webbing for the foot strap, a 4-foot (1.22 m) stick as a
shaft, and a 1-inch webbing for the leg strap with a
Prusik knot with cord at each end. A similar cord was
used to create traction.
Three of the commercial traction splints were applied to
the volunteers by one of the principal investigators follow-
ing the instructions provided by the manufacturers of the
devices.
8 –10
The improvised traction splint was constructed
and applied by the same investigator for consistency in
application. All subjects were monitored through the study
period and were instructed to notify an investigator at any
time if a traction device became too uncomfortable, at
which time the splint would be removed.
At the end of 30 minutes, an inline Lewis N Clark
BZ200 digital scale (Balanzza, Miami, FL) was placed
on each traction splint to measure the pounds of force
created by each device. The volunteers were also asked
at that time to subjectively report the comfort and sta-
bility of the splint separately on a scale from 1 to 10. For
comfort, 1 was equal to nothing noticeable on the leg,
and 10 was the rating for the splint being unbearable. The
scale for stability ranged from 1, meaning no added
stability, to 10 representing complete immobilization of
the leg. Subjects were also asked to report any perceived
side effects such as pain or paresthesia.
All collected data were entered into an Excel (Mi-
crosoft Corp, Redmond, WA) spreadsheet, where mean
and standard deviation were calculated. This information
was then imported to SAS (SAS Institute Inc, Cary, NC),
where means were compared and 95% confidence inter-
vals were determined.
This study was approved by the Community Regional
Medical Center institutional review board.
Results
The mean age of the 10 study participants was 27 years,
and there were 5 women and 5 men. The mean weight of
the participants was 72.7 kg (160 pounds). All traction
splints performed similarly with regard to the primary
outcome measure of mean pounds of traction created at
the end of 30 minutes of application, with results ranging
from 10.4 to 13.3 pounds. The mean pounds of traction
created for each device with the 95 % confidence inter-
vals listed in parentheses were Hare traction, mean of
13.3 (2.56); Sager splint, mean of 10.8 (3.33); Faretech
CT-EMS, mean of 10.4 (2.85); and improvised splint,
mean of 11.6 (3.77). There was little difference reported
by participants in regard to stability or comfort among
the 4 traction devices (Figures 1 and 2, respectively).
The majority of side effects reported by volunteers
occurred with the Faretech CT-EMS (8 of 10 subjects)
followed by the Sager splint (7 of 10 subjects). The
62 Weichenthal et al
least number was reported with the improvised splint
(2 of 10). The 3 most commonly reported side effects
were pain in the ankle, pain in the hip, and numbness
in the foot. No side effect was so severe that the
subject requested early removal of a traction device.
Discussion
Our study suggests that an improvised traction splint is
not inferior when compared with 3 commercially avail-
able traction devices in healthy and uninjured volunteers,
both in regard to measured pounds of traction created
and with respect to subjective evaluations of stability and
comfort.
Guidelines for the application of traction splints recom-
mend applying a force equal to 10% of the body weight of
the patient not exceeding 15 pounds. A recent study of the
Hare traction splint showed that 30 minutes after applica-
tion only half of the initial traction force remained.
4
At 30
minutes in our study, all of the splints tested had an applied
traction of at least 10 pounds or 7.4% of the mean volunteer
body weight. These results were achieved while also scor-
ing good subjective evaluations of stability and comfort
with limited reported side effects.
LIMITATIONS
This study is a first step at looking at the efficacy of
improvised traction splints in the wilderness setting. Its
results are limited by the small size of the study, the use
of healthy, uninjured volunteers, and the fact that the
commercially available devices that the improvised
splint is being compared with have not been well vali-
dated. Further limitations include that these devices were
not subject to the prehospital and wilderness environ-
ments of long carries and transfers that might reveal
instabilities of these devices not recognized in the more
controlled environment of this study.
Further areas that need to be investigated include eluci-
dating the role of commercially available traction splints in
the wilderness, rural, and urban prehospital settings; com-
paring improvised traction splints with good packaging
techniques in the wilderness setting; evaluation of the sta-
bility of these devices in long transports and transfers; and
further clarification of the potential side effects of these
devices, especially during long transports.
Conclusions
In this small pilot study, improvised traction splints were
not inferior to commercially available devices. Further re-
0.
0
1
2
3
4
5
6
7
8
9
10
*Stabil
a
97 (5.73 - 7.6
7
Hare
ity rang was ba
s
scale from 1-10 (
7
)
1.02 (6.
S
a
s
ed on the parci
p
1isnoaddedst
58 - 8.62)
a
ger
p
ants percepon
o
ability and 10 be
1.21 (5.19 - 7
.
Faretech CT-
E
o
f stability aer
3
ing complete im
.
61)
0.83
(
E
MS I
m
3
0 minutes of tra
c
mobilizaon of yo
(
6.17 - 7.83)
m
provised
c
on based on
ur leg).
Figure 1. Subjective stability rating for traction devices on a scale of 0 –10 (mean is graphed with bar representing 95% confidence interval).
Improvised Traction Splints 63
search is needed in this area including, but not limited to,
how these devices hold up during prolonged transport and
transfer scenarios that are common to wilderness settings.
References
1. Bledsoe B, Barnes D. Traction splint. An EMS relic?
JEMS. 2004;29:64 – 69.
2. American College of Surgeons Committee on Trauma: Minimal
equipment for ambulances. ACS Bull. 1961;46:136–137.
3. Mänsson A, Rüter A, Vikström T. Femoral shaft fractures
and the prehospital use of traction splints. Scand J Trauma
Resusc Emerg Med. 2006;14:26 –29.
4. Sturdee SW, Templeton PA, Dahabreh Z, Cullen E, Gian-
noudis PV. Femoral fractures in children, is early interven-
tional treatment beneficial? Injury. 2007;38:937–944.
5. Wood SP, Vrahas M, Wedel SK. Femur fracture immobi-
lization with traction splints in multisystem trauma pa-
tients. Prehosp Emerg Care. 2003;7:241–243.
6. Forgey WW, ed. Wilderness Medical Society: Practice
Guidelines for Wilderness Emergency Care. 5th ed. Guil-
ford, CT: The Globe Pequot Press; 2006:31.
7. Tilton B, Hubbell F. Fractures, In: Tilton B, Hubbell F,
eds. Medicine for the Backcountry: A Practical Guide to
Wilderness First Aid. 3rd ed. Guilford, CT: The Globe
Pequot Press; 1999:96 –99.
8. Dyna Med Hare traction splint. Skills procedures manual.
Lexington, KY: Galls Inc; 2002.
9. Sager traction splint. Instructor manual. Redding, CA;
Minto Research and Development Inc; 1998.
10. Faretec CT-EMS traction splint. User manual. Painesville,
OH; Faretech Inc; 2009.
0.8
4
0
1
2
3
4
5
6
7
8
9
10
*Comfo
r
scale fro
4
(2.66 - 4.34)
Hare
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t was based on t
h
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1-10 (1 is as
0.79 (3.7
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g
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m
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er
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e
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o
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ust come off no
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.73 (2.67 - 4.
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aretech CT-E
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e leg and 10 bei
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2.05 (
2
M
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t
es of tracon ba
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ng unbearable, th
2
.65 - 6.75)
p
rovised
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ed on a
e splint
Figure 2. Subjective comfort rating on a scale of 1–10 (mean is graphed with bar representing 95% confidence interval).
64 Weichenthal et al