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540 THE JOURNAL OF BONE AND JOINT SURGERY
HISTORICAL NOTE
The Thomas splint
ITS ORIGINS AND USE IN TRAUMA
P. M. Robinson,
M. J. O’Meara
From Trafford
General Hospital,
Manchester, England
P. M. Robinson,
MBChb(Hons), B MedSci,
MRCS(Eng), Specialist
Registrar, Trauma and
Orthopaedics
Department of Orthopaedics
Trafford General Hospital,
Moorside Road, Manchester
M41 5SL, UK.
M. J. O’Meara, MB ChB,
BSc(Hons), Dip, IMC, RCSEd,
Specialist Registrar,
Anaesthetics
Academic Department of
Traumatology
Institute of Research and
Developments, Birmingham
Resear ch Park, Vi ncent Driv e,
Birmingham B15 2SQ, UK.
Correspondence should be sent
to Mr P. M. Robinson; e-mail:
paulrobinson230979@yahoo.
co.uk
©2009 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.91B4.
21962 $2.00
J Bone Joint Surg [Br]
2009;91-B:540-3.
The Thomas splint is a common piece of equipment in emergency departments and
orthopaedic units in hospitals worldwide. Its basic design has changed little since its first
description by Hugh Owen Thomas was published in 1875. We have reviewed the origins of
the Thomas splint as a means of correction of deformities of the lower limb and its
evolution through both World Wars into an essential item for the management of trauma of
the lower limb.
The Thomas splint is considered to be an
essential piece of equipment in emergency and
orthopaedic units in hospitals worldwide. Its
basic design has changed little in the 133 years
since its description by Hugh Owen Thomas in
his book Diseases of the hip, knee and ankle
joints with their deformities, treated by a new
and efficient method.1 The popularity and suc-
cess of the Thomas splint can be attributed to
the simplicity of its design, the ease of use and
its effectiveness in immobilising fractures of
the lower limb, reducing the morbidity and
mortality from these injuries. This article
examines the origins of the Thomas splint as a
means of correction of deformities of the lower
limb and looks at its evolution through the
World Wars in the management of trauma to
the lower limb.
Hugh Owen Thomas
Hugh Owen Thomas (1834 to 1891) (Fig. 1)
was from a family of Welsh bone-setters,
descended from the survivor of a shipwreck off
the coast of Anglesey in North Wales in 1745.
The family tradition of bone-setting was passed
down from father to son over three generations.
His father, Evan Thomas, left Wales at the age
of 19 years and settled in Liverpool where he set
up a practice for the treatment of fractures and
of bone and joint diseases.2 He was not a quali-
fied medical practitioner and his unorthodox
methods of treatment, although widely success-
ful, had many critics and opponents. He saw the
advantages of formal medical education and
resolved to send all five of his sons to medical
school, where they all subsequently qualified.
Hugh Owen Thomas was born in Bodedern
in Anglesey, where he spent much of his
childhood because of ill health. At the age of 17
years he served a four-year apprenticeship with
his uncle, Dr Owen Roberts of St Asaph. He
studied medicine from 1855 to 1857 at the Uni-
versity of Edinburgh and subsequently trans-
ferred to University College, London, where he
completed his studies. He qualified as a member
of the Royal College of Surgeons in 1857, at the
age of 23 years. He then spent a period in
France where he studied in Paris.3 After this he
joined his father in his Liverpool practice for a
short time before setting up as a general practi-
tioner in the deprived areas of Victorian Liver-
pool. Instinctively, he specialised in the study
and treatment of injuries and diseases of the
locomotor system, particularly tuberculosis.4
He had an extremely busy practice, treating
among others injured dock workers and seafar-
ers whose injuries might have been sustained
weeks or months earlier while at sea. His
methods were based on the family tradition of
bone-setting, to which he brought his own
astute observations and his knowledge of ortho-
dox medicine and surgery. He was a strong
believer in the natural ability of the body for
recovery, accordingly advocating the use of rest
as a means of treatment. Rest was to be
“enforced that the patient’s ordinary move-
ments will not materially jar the joint, uninter-
rupted, even momentarily, so as not to arrest or
delay the progress to cure, and prolonged to
secure beyond relapse the resolution of the dis-
ease”.1 He achieved this by complete immobili-
sation of the diseased part in one of his many
ingeniously designed splints or “machines”.1
His success meant that his practice grew rapidly
and in 1866 he was forced to relocate to larger
premises at 11 Nelson Street, Liverpool, which
THE THOMAS SPLINT 541
VOL. 91-B, No. 4, APRIL 2009
consisted of two waiting rooms, four consulting rooms, a
surgery and a workshop in which his splints and appliances
were produced, individually fitted for each patient, with the
aid of a blacksmith and a leather-worker.
The Thomas splint
The earliest splint was first used in 1865 for treating dis-
eases of the knee such as tuberculosis by prolonged rest and
immobilisation,1 and only later for the management of frac-
tures of the lower limb. It consisted of a proximal oval ring
padded with boiler felt and leather, which fitted around the
groin, using the ischial tuberosity as a fixed point (Fig. 2).
This ring was attached by two iron rods to a smaller ring
below. The inner rod was attached to the proximal ring at
an angle of 45°, with padding this angle increased to 55°.
An apron of leather was stretched across the two bars to
support the limb. Strapping was applied to the leg and trac-
tion was gained by tying this to the cross-bar at the distal
end of the splint.
The addition of a patten to the distal ring and to the shoe
of the sound limb allowed the patient to walk in the splint
(Fig. 3). The simplicity of the design was not accidental
since Thomas recognised that his appliances should be
affordable enough to allow treatment of even the poorest of
patients in locations away from the wealthy charitable
medical institutions found in large towns and cities at that
time. He commented that his splint “will enable any sur-
geon to treat his cases at home, with no more mechanical
assistance than can be rendered by the village blacksmith
and saddler, and the poorer class of sufferers will, at a small
cost, be assisted as effectually as the wealthier classes”.1
It was in the treatment of fractures of the lower limb,
particularly of the femur, that the Thomas splint became
best known. Its introduction into wider practice owes much
to Sir Robert Jones, the nephew of Hugh Owen Thomas,
who went to live with his uncle at the age of 16 years,
became his pupil and pursued a medical career. In 1888
Robert Jones was appointed surgeon to the Manchester
ship canal project where he set up the first accident service
Fig. 1
A picture of Hugh Owen Thomas from Mend-
ers of the maimed by Keith3 (1919) by permis-
sion of Oxford University Press.
Diagram of the original Thomas knee splint.
From Diseases of the hip, knee and ankle
joints, with their deformities, treated by a new
and efficient method by Thomas (1876).1
Fig. 2
Diagram illustrating how the
addition of a patten beneath the
shoe of the sound limb enabled
the patient to mobilise in the
splint. From Disease of the hip,
knee and ankle joints, with their
deformities, treated by a new
and efficient method by Thomas
(1876).1
Fig. 3
542 P. M. ROBINSON, M. J. O’MEARA
THE JOURNAL OF BONE AND JOINT SURGERY
in order to treat the numerous casualties which resulted.
His ideas on the organisation of trauma care and the treat-
ment of fractures were way ahead of their time. As a result
of his success he was appointed consultant orthopaedic sur-
geon to the British army during the First World War. In a
letter to the British Medical Journal published in December
1914, he advocated the use of the splint in fractures of the
middle and lower thirds of the femur, knee and upper tibia.5
He recognised its superiority in reducing and immobilising
fractures, allowing easy surgical access for debridement of
compound injuries and providing a simple means for trans-
porting patients comfortably. It was his introduction of the
Thomas splint to the Western front which brought recogni-
tion to the appliance, but unfortunately it was not supplied
routinely to army medical teams until 1917.
At the beginning of the First World War the management
of femoral fractures, which were usually compound ballistic
injuries, was such that most soldiers with these injuries died.
The existing methods of splintage of fractures were inade-
quate and the initial treatment of casualties was often greatly
delayed. Many figures are quoted for the reduction in mor-
tality from open fractures of the femur following the intro-
duction of the Thomas splint. The sources of those figures
are not always clear.6 However, in his book, The early treat-
ment of war wounds, the distinguished First World War mil-
itary surgeon Sir Henry Gray stated that during one
particular battle in spring 1917, when the Thomas splint was
used for nearly all femoral fractures, the death rate at the
casualty clearing stations was 15.6% in 1009 cases.7 This
was a notable reduction in mortality from earlier in the war,
when Gray estimated that the death rate from gunshot frac-
ture of the thigh was 80%.7 Some military surgeons had pre-
viously suggested that more lives would be saved if
amputation was carried out in all cases of femoral fracture.
However, only 17.2% of patients required amputation in the
particular battle quoted by Gray.7
The drastic reduction in morbidity and mortality may not
have been solely due to the use of the Thomas splint, since
methods of evacuation and treatment had also improved,
although the splint undoubtedly played a huge role.8 Te a m s
of three stretcher bearers, who were themselves often mor-
tally wounded, were required to apply the splint swiftly to
casualties lying in ‘no-man’s land’, under enemy fire and at
night. To prepare for this task they were trained to apply the
splint blind-fold by numbers.9 To increase speed of use in the
field the limb was placed in the splint without removal of
clothes or boots (Fig. 4) and traction was applied by a clove
hitch over the boot or a special clip into the heel of the boot,
known as Tapson’s sole clip.
One disadvantage of the use of a clove hitch in this way
was the risk of ischaemia of the foot if traction was applied
too vigorously or for too long. In order to increase comfort
during transport the splint was suspended clear of the
stretcher by the application of suspension bars (Fig. 4). Later,
a knee flexion piece was added to allow adequate definitive
treatment of more distal femoral fractures by the splint.
The Thomas splint proved to be extremely versatile and
a smaller modified version was also used for immobilising
fractures of the humerus and of the forearm around the
elbow, with the arm held in extension7 (Fig. 5).
In North Africa during the Second World War the
Thomas splint began to be used in a different form by the
British and Australian forces. Casualties were evacuated
from forward field hospitals by ambulance, travelling over
rough desert terrain. Even with the damaged limb immobi-
lised in a Thomas splint jolting and jarring of the limb still
occurred, making these long journeys agonising for the
injured soldiers. The solution to this problem was to place
the limb in traction in the Thomas splint as normal, apply
padding, and then wrap the splint and limb in plaster-of-
Paris. This achieved excellent immobilisation and allowed
the casualties to be transported more comfortably. There
Fig. 4
Diagram showing the casualty on a stretcher with a Thomas splint applied over the boot and clothing. This demonstrates
how the splint was suspended from proximal and distal bars to improve comfort (from Early treatment of war wounds by
Gray7 (1919) by permission of Oxford University Press).
THE THOMAS SPLINT 543
VOL. 91-B, No. 4, APRIL 2009
were several different arrangements of this modification,
which became known as the ‘Tobruk splint’, named after
the siege of Tobruk in 1941.10 It was favoured by British
surgeons over the plaster-of-Paris spica because it was
quicker to apply and required less plaster and water, two
resources which were in short supply in North Africa. This
splint is still used today in the treatment of some femoral
fractures in children.
The Thomas splint has also continued to prove its value
in armed conflict. It has found an extended use in the mod-
ern treatment of battlefield injury, proving useful in the
management of open and closed fractures of the femur in
casualties who could not be moved for political or logistical
reasons. The report of the Royal Army Medical Corps on
the first ten days of the 2003 Gulf conflict found the
Thomas splint to be an essential tool, particularly in the
management of ballistic injuries.11 It is of advantage when
treating fractures which are complicated by open soft-tissue
injuries since the wounds can be reviewed on a daily basis
and managed accordingly. This would not be the case if the
leg were fully enclosed in a cast.
The fundamental principles of the Thomas splint which
are that it is non-invasive, easily applied and has few com-
plications, make it useful in settings other than in hospital.
Pre-hospital practitioners often have to deal with patients
with open or closed femoral fractures. These patients
require splintage to prevent haemorrhage, to allow
analgesia and to facilitate transport. Various splints which
allow traction have evolved from the original design.12 The
splint remains an essential itemin the initial management of
fractures of the shaft of the femur which owes much to the
ingenuity and simplicity of the original design.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
References
1. Thomas HO. Diseases of the hip, knee and ankle joints with their deformities:
treated by a new and efficient method. Liverpool: T. Dobb & Co, 1876.
2. Jones AR. Hugh Owen Thomas. J Bone Joint Surg [Br] 1948;30-B:547-50.
3. Keith A. Menders of the maimed. London: Henry Frowde and Hodder and Stoughton,
1919.
4. Jones A R. The influence of Hugh Owen Thomas on the evolution of the treatment of
skeletal tuberculosis. J Bone Joint Surg [Br] 1953;35-B:309-19.
5. Jones R. Treatment of fractures of the thigh. BMJ 1914;11:1086-7.
6. Henry BJ, Vrahas MS. The Thomas splint: questionable boast of an indispensable
tool. Am J Orthop 1996;25:602-4.
7. Gray HMW. The early treatment of war wounds. London: Henry Frowde and Hodder
and Stoughton, 1919.
8. Kirkup J. Fracture care of friend and foe during World War I. ANZ J Surg
2003;73:453-9.
9. Ellis H. The Thomas splint. J Perioper Pract 2007;17:38-9.
10. Dunc an T, Stoat M. War surgery and medicine. http://www.nzetc.org/tm/scholarly/
tei-WH2Surg.html (date last accessed 15 June 2008).
11. Rowlands TK, Clasper J. The Thomas splint: a necessary tool in the management
of battlefield injuries. J R Army Med Corps 2003;149:291-3.
12. Abarbanell NR. Prehospital mid thigh trauma and traction splint use: recommenda-
tions for treatment protocols. Am J Emerg Med 2001;19:137-40.
Fig. 5
Diagram showing the
modified Thomas splint
used for treating frac-
tures of the upper limb,
(from Early treatment of
war wounds by Gray7
(1919) by permission of
Oxford University Press).
