The force required to fracture an adult's femur represents a significant mechanism of injury. Between October 2016 and December 2017, Qatar's national ambulance service, Hamad Medical Corporation Ambulance Service (HMCAS), treated a total of 192 patients with a femoral fracture. HMCAS attends approximately 900 calls per day which, on average, includes two to three major trauma patients.
During World War One (WW1), it was noted that a fractured femur had an unacceptable high mortality rate. This resulted in the widespread introduction of traction splints into military medicine (Rowlands and Clasper, 2003)—a practice that continues to this day and has resulted in traction splints becoming established within civilian prehospital care (Green et al, 2000; Rowlands and Clasper, 2003; Lee and Porter, 2005). This has led to the development of a range of tractions splints over the years, such as the Thomas, Hare, Trac3, Donway and Sager traction splints. The Trac3 traction splint is the device used by HMCAS and is available in both adult and paediatric sizes.
The primary purpose of the traction splint is to reduce pain (Abarbanell, 2001; Lee and Porter, 2005; Irajpour et al, 2012; Nichol and Nelson, 2019) and provide haemorrhage control. Improving the alignment of the fracture leads to an associated reduction in bleeding through the decrease of the virtual compartment space of adjacent damaged soft tissues, subsequently reducing haemorrhage potential (Green et al, 2000; Abarbanell, 2001; Lee and Porter, 2005; Nichol and Nelson, 2019). An additional benefit of fracture alignment is a reduction in risk of further damage to the underlying neurovascular bundle (Green et al, 2000; Lee and Porter, 2005).
Lee and Porter (2005) describe an algorithm for prehospital management of lower limb fractures, which provides guidance on the choice of splintage related to injury pattern. These guidelines continue to recommend the use of traction splints in the treatment of fractured femurs (Lee and Porter, 2005). However, careful patient selection and correct application is a priority to minimise complications (Lee and Porter, 2005). Mihalko et al (1999) has described two case studies of transient peroneal nerve palsies caused by inappropriate application of traction splints, whereas Daugherty et al (2013) reported 66% of traction splints being incorrectly applied in paediatric patients, specifically in the 3–9 year age group (Daugherty et al, 2013).
Importantly, the following injury patterns remain contraindications to the application of a traction splint: pelvic trauma, injuries to the patella, tibial/fibular and ankle fractures (Lee and Porter, 2005; Nichol and Nelson, 2019). The perceived need to apply a traction splint for mid-shaft femur fractures led to an audit targeted at identifying practices around the use of the traction splint in the HMCAS.
Methods
Setting
The HMCAS is the sole national ambulance service in Qatar, operating a two-tier system comprising ambulance paramedics (APs) and critical care paramedics (CCPs). Ambulances are staffed by two APs and respond to all emergency calls in the country. CCPs operate on a rapid response vehicle and are supported by a critical care assistant. CCP units respond to the most critical cases and have an extended scope of practice, which includes rapid sequence induction (RSI) and procedural sedation. CCPs are recruited from abroad, mainly South Africa, the United States, Canada and Australia. All recruited CCPs are degree-qualified and undergo further induction training on arrival to Qatar in order to familiarise themselves with the CCP scope of practice. All APs are degree-educated, mainly in nursing, and undergo an intensive 3-month AP training programme in Qatar.
The AP analgesic formulary includes methoxyflurane, intravenous paracetamol, ketorolac and oral paracetamol and ibuprofen. The CCP formulary includes that of the AP scope, as well as fentanyl, ketamine and midazolam. CCPs have the ability to perform procedural sedation in cases such as the application of a traction splint for a mid-shaft femur fracture.
Design, data capture and analysis
A retrospective descriptive design was employed, involving the review of prehospital patient care records. The Medical Research Center determined this project as ‘Quality Improvement’ and hence does not require Institutional Review Board approval. (Ref: MRC-01-18-153).
A baseline measurement was conducted by retrospectively reviewing the ambulance service's medical records database from 1 October 2016 to 31 December 2016, to include only cases with a recorded provisional diagnosis of femur fracture for all age groups during the study period (n=66). A traction splint was applied in 10 cases (15%) and not used for 56 cases (85%) median pre intervention (16%). In addition to the initial data collection, a pre-intervention survey was conducted to gain an understanding of the staff's perceptions surrounding the use of the traction splint (Table 1). Following completion of this audit process, an action plan was developed and implemented.
| Pre intervention | Post intervention | Pre intervention | Post intervention | ||
|---|---|---|---|---|---|
| 1. I always use a traction splint when transporting a patient with a suspected closed mid-shaft femur fracture | 5. I feel pressured when on scene to move the patient quickly and therefore there is limited time to apply the traction splint. | ||||
| Strongly Disagree | 6% | 7% | Strongly disagree | 2% | 7% |
| Disagree | 4% | 0% | Disagree | 18% | 13% |
| Neutral | 12% | 13% | Neutral | 19% | 7% |
| Agree | 45% | 40% | Agree | 48% | 60% |
| Strongly Agree | 35% | 40% | Strongly agree | 4% | 13% |
| 2. When was the last time you used a traction splint on a patient? | 6. The type/size of ambulance/helicopter prevent the use of the traction splint. | ||||
| Never | 23% | 20% | Strongly disagree | 10% | 0% |
| More than 2 years ago | 15% | 27% | Disagree | 29% | 27% |
| 1–2 years ago | 0% | 20% | Neutral | 13% | 7% |
| Within the last 1 year | 29% | 27% | Agree | 34% | 60% |
| Within the last month | 19% | 7% | Strongly agree | 13% | 7% |
| 3. How comfortable are you in the use of the traction splint? | 7. The size of the patient prevents effective use of the traction splint. | ||||
| Very uncomfortable | 2% | 0% | Strongly disagree | 0% | 0% |
| Uncomfortable | 14% | 20% | Disagree | 8% | 0% |
| Neutral | 10% | 0% | Neutral | 10% | 0% |
| Comfortable | 52% | 46% | Agree | 65% | 80% |
| Very comfortable | 23% | 33% | Strongly agree | 17% | 20% |
| 4. The traction splint is difficult to use. | 8. Utilisation of the traction splint is necessary to decrease pain associated with a closed mid-shaft femur fracture. | ||||
| Strongly disagree | 10% | 7% | Strongly disagree | 0% | 0% |
| Disagree | 43% | 27% | Disagree | 2% | 0% |
| Neutral | 17% | 20% | Neutral | 10% | 0% |
| Agree | 26% | 33% | Agree | 63% | 87% |
| Strongly agree | 4% | 13% | Strongly agree | 25% | 13% |
The action plan involved the development and introduction of a system-wide simulation-based mandatory trauma CPD training programme and was introduced from 1 January 2017 through to 31 March 2017. The core components of the CPD training programme focused on the clinical approach to the trauma patient, identifying immediate life threats, basic and advanced life support, with a dedicated component of the training focused specifically on the recognition and management of femur fractures, the practical application of the traction splint and use of analgesia during the application process. Following completion of the training intervention, the audit process was repeated. The pre-intervention survey was sent out to all trained staff to evaluate the impact of the training on staff's understanding and perceptions of the subject matter. Post-intervention clinical data were collected from 1 April–31 December 2017, and analysed to determine whether or not any improvements had been made.
Results
The introduction of the simulation-based training for all operational paramedics had a positive impact on the management of femur fractures. Post intervention, a total of 69 femur fractures were identified following the review of patient care records. Of the 69 recorded femur fractures, 35 (51%) had a traction splint applied. During the 3-month intervention period, 57 femur fractures were recorded, of which 10 (18%) had a traction splint applied. The use of the traction splint increased significantly in the months following the intervention, from a median of 16% up to 50% post intervention.
The results of the survey indicate that staff are now more comfortable and confident using the traction splint for the management of femur fractures following completion of the trauma CPD training, compared with during the pre-intervention period. Table 1 displays the full results of the staff survey both pre and post intervention.
Discussion
The application of the traction splint is indicated for patients presenting with an isolated mid-shaft femur fracture (Gossman et al, 2018). During this audit period, a total of 192 documented femur fractures were identified, with 55 (28.6%) of these being splinted with a traction splint.
A study conducted by Abarbanell (2001) retrospectively reviewed 4513 prehospital care reports to identify patients with mid-thigh injuries. Of these, only 16 patients (0.35%) presented with mid-thigh injuries, of which only five patients (31.25% study patients, 0.11% total patients) had clinical signs of a femur fracture (Abarbanell, 2001). During the study, the application of a traction splint was only attempted in three cases (18.75% study patients, 0.07% total patients) but was successful in only two cases (12.50% study patients, 0.04% total patients) (Abarbanell, 2001).
However, Nackenson et al (2017) described the use of the traction splint for patients with femur fractures, reporting a traction splint application rate of 30% of patients with femur fractures (Nackenson et al, 2017). Abarbanell (2001) highlights the low prevalence of femur fractures and that the resulting infrequent use of a traction splint may result in staff reluctance to apply the traction splint, opting instead for simple rigid splinting. This is further impacted by the complicated application of the traction splint, which requires at least two rescuers. However, Nackenson et al (2017) indicate that a higher utilisation rate is feasible.
Key to optimising the care of patients with fractured femurs is tailor-made simulation-based training (Johnson et al, 1999; Aggarwal et al, 2010). This is further supported by Abelsson et al (2014) who describe simulation as a positive training and education method for prehospital medical staff, providing opportunities to train in the areas of assessment, treatment, and implementation of procedures and devices under realistic conditions.
Although the present study did not investigate the impact of traction splint application on scene time, the survey suggests that staff do occasionally feel pressured by the scene supervisor to rapidly treat and transport their patient. This may influence ambulance service staff's decision to apply the traction splint.
The type and size of vehicle (helicopter or ground unit) being used to transport a patient, as well as the patient's size, also appear to influence ambulance service staff's decision to apply the traction splint. Hedges et al (1988) suggest that the application of a traction splint prolongs prehospital scene time, although this must be weighed against the benefit of stabilising a long bone that has the potential for catastrophic bleeding during transport.
Although the current study did not differentiate between adults and paediatrics, the studies by Nackenson et al (2017) and Daugherty et al (2013) were used to benchmark a target median of 30% for traction splint application for patients with a documented femur fracture.
Prior to the introduction of the mandatory trauma CPD training, our median was 16%—almost half of our target median. Post training, our median increased significantly to 50%. The number of recorded femur fractures in the months following the trauma CPD training reduced compared with the pre-intervention figures. This may be attributed to ambulance service staff's improved recognition, management and documentation of femur fractures following completion of the trauma CPD training.
Limitations
The main limitations of this study are the design and the sample size. The small number of patients that had a traction splint applied makes it difficult to obtain a large sample size. This would require a study over a much longer period.
The review of the ePCRs and the identification of patients with a femur fracture relied solely on the correct documentation of the treating prehospital care provider, i.e. correctly choosing ‘femur fracture’ from the diagnosis list in the ePCR. The recorded diagnosis of femur fracture does not differentiate between a mid-shaft femur fracture and other types of femur fracture; therefore, this study is unable to determine if cases where a traction splint was required were missed, indicated or applied inappropriately.
Analgesia, which is an important part of the prehospital management of a femur fracture, as well as for the application of a traction splint, was not reviewed in this study.
The survey results imply that less people report the use of a traction splint after the educational intervention. This may be attributed to the disproportionately large number of staff in relation to the low incidence of femur fractures, implying very low exposure of staff to these injuries.
Conclusion
The introduction of the mandatory trauma CPD programme has had a marked impact on ambulance service staff's confidence and ability to identify and manage femur fractures, as well as appropriately applying the traction splint when indicated. Our benchmark target of 30% was exceeded, reaching a median of 50% at the completion of the study.
This study highlights the importance of focused training and the positive impact it can have in addressing areas requiring improvement. It is equally important that the training is continuous and not a one-off event. By making training continuous, it will ensure that staff remain knowledgeable and confident in their abilities, as well as preventing a decline in care and skill fade, especially where low clinical exposure is a factor.
Further research is still needed to describe analgesic practices in association with femur fractures and the application of the traction splint. There is paucity in the literature regarding the potential space for blood loss. Further research in this area would be beneficial.