A Multidisciplinary Improvement Project for Optimizing Prehospital Care of Femur Fractures
Introduction
Femur fractures are common in the United States with an annual incidence of mid-shaft femur fractures approximately 10 per 100,000 person-years, with a bimodal distribution in young adults and the elderly.1 Management of these injuries begins in the prehospital setting, where application of a traction splint has been shown to decrease hemorrhage and pain in patients with isolated mid-shaft femur fractures. Per the Advanced trauma life support: Student course 10th edition manual, splinting of these injuries decreases bleeding by realigning the injured extremity to its native anatomic position, preventing excessive motion at the fracture site and enhancing the tamponade effect of the muscle and fascia.2
While some authors have questioned the use of traction splints in the prehospital setting,3,4 recent data have supported its continued relevance. A retrospective query of a large trauma database of isolated midshaft femur fractures discovered that traction splint placement, whether in the prehospital setting or emergency department, decreases mortality when compared to no traction splint application. The authors also reported that prehospital traction splint placement significantly decreases hospital length of stay days and blood units transfused in first 24 hours with compared to no placement.5 Irajpout et al. showed that prehospital traction splinting had a significant reduction in pain intensity score compared to simple splinting.6 Data regarding compliance of traction splint application in the prehospital setting is limited, however a recent study investigating 170 patients with midshaft femur fractures in the Florida EMS system that showed only 30% application of traction splints when their application was indicated.7
According to New York State’s Collaborative Advanced Life Support Adult and Pediatric Treatment Protocols (CALSTP), an injury indicative of traction splinting is a mid-thigh injury without suspected injury to the pelvis, ipsilateral knee, lower leg, or ankle nor association with amputation or near avulsion.8 These injuries may present as cyanotic, pulseless or severely deformed, and application of a traction splint in the presence of these contraindications may result in worsening neurovascular compromise. A prospective study between 2000-2001 showed that within 828 multisystem trauma patients, 40 patients (4.8%) had a traction splint for immobilization of femoral fracture(s). Out of these patients, the incidence of concomitant, contraindicating injuries to traction splints for femur fractures in multi-trauma patients was approximately 38%, suggesting that contraindications to traction splinting are common.9
Related
- Orthopedic Considerations of the Polytrauma Patient
- EMS Evaluation and Management of Limb-Threatening Knee Injuries
- The Lost Art of Splinting: How to properly immobilize extremities & manage pain
The Performance Improvement Patients Safety (PIPS) program in Kings County Level 1 Adult Trauma Center in Brooklyn, New York, retrospectively reviewed data in our Trauma Registry and revealed low compliance with prehospital application of TS in patients with suspected midshaft femoral fractures. Educational intervention was designed in cooperation with regional EMS leadership and post educational (post interventional) compliance with prehospital application of TS was reevaluated. Institutional Review Board $ Privacy Board provided by FWA#:3624 IORG#:64 IRB#:11521, exemption categories: #45 CFR 46.104(d).
Methods
The Context
All patients with a midshaft femur fractures were identified from the institution’s Trauma registry between January 2016 and June 2021. For all patients with mid-shaft femur fractures, demographics, method of injury and application of traction splint were collected. All patients who were not brought in by EMS were excluded. For each patient with a mid-shaft femur fracture, any indication or contraindication to traction splinting was identified. Outcome data from patients with or without traction splint application was not obtained. No patient with a mid-shaft femur fracture was found to have a traction splint on arrival. Results were presented to the division medical director of the FDNY-EMS in September 2019, following which a multidisciplinary focus group discussed why traction splints were not being placed and how to improve compliance.
The intervention
Our trauma and critical care surgeons presented and discussed these findings, along with case presentations, during required CME that involved paramedics from the surrounding EMS stations in the hospital catchment areas. A six-minute video was played demonstrating the application and indications of the Slishman Traction Splint, which is the sole traction splint in use by FDNY-EMS. After the video, review material that included the State EMT protocol, the NYC regional protocol and the FDNY medical affairs directive for placing traction splints on mid-shaft femur fractures was distributed. The indications and contraindications of traction splints were reviewed and a discussion was held to answer any questions and clarify misconceptions.
Immediately following these discussions, practice skill session groups were formed on the apparatus floor of the hosting EMS station. Each group had approximately three EMS members, a stretcher and an STS splint. Each member rotated in the group and applied the STS splint at least once. At the conclusion of the educational intervention, groups had the opportunity to critique individual technique and review key learning points.
Interventions to Sustain the Change
Practice skill sessions occurred approximately twice a month for two months at all EMS stations that brought patients to our Level 1 Trauma Center. All cases of mid-shaft femur fractures that occurred after the educational intervention, from November 2019 to July 2020 (early post-training group), and July 2020 to June 2021 (late post-training group) were identified from the Trauma registry. The follow-up results were presented, reviewed, and discussed with the Division Medical Director of the FDNY-EMS in July 2020 as a future improvement project.
Statistical Analysis
Chi square analysis was done to compare the rate of appropriate traction splitting in patients with an indication and no contraindications between pre-training, early post-training, and late post-training. All statistical analysis was done utilizing SPSS version 28 (IBM Corp., Armonk, NY, USA) at a significance threshold of p < 0.05.
Results
In the pre-training group, 24 patients with mid-shaft femur fractures were identified, and 16 had contraindications to traction splint placement. However, none of the eight patients with indications and without contraindications with a mid-shaft femur fracture (n = 0) were found to have a traction splint on arrival to the ED. Two patients with a contraindication to traction splinting were also found to have splints not approved for use.
In the early post-training group, 13 patients with mid-shaft femur fractures were identified, none of which had any contraindication to traction splint placement. One of these patients had a history of below knee amputation in the injured extremity, and was excluded from the analysis. Of the remaining 12 patients, a traction splint was placed in 33% (n = 4) of cases Figure 1.
Figure 1: Percentage of mid-shaft femoral fracture patients arriving to the emergency department with appropriate traction splinting in pre-training, and early/late post-training groups. TS = Traction Splint
Additionally, two patients had splints with triangular bandages, and three patients had non-specified splints. In the late post-training group, nine patients had mid-shaft femur fractures without contraindications to traction splitting. A traction splint was placed in 33% (n = 3) cases Figure 1. Two patients had fixation splits.
There was an increased, but nonsignificant, rate of traction splitting between the pre-training group and the overall post-training group (0.0% vs 33.3%; p = 0.061) Table 1.
| Training Groups | Traction Splinting Placed | P-value |
| Comparison 1 | 0.172 | |
| Pre-training | 0 (0.0%) | |
| Early Post-training | 4 (33.3%) | |
| Late Post-training | 3 (33.3%) | |
| Comparison 2 | 0.061 | |
| Pre-training | 0 (0.0%) | |
| Early and Late Post-training | 7 (33.3%) | |
| Comparison 3 | 1.000 | |
| Early Post-training | 4 (33.3%) | |
| Late Post-training | 3 (33.3%) | |
| Comparison 4 | 0.068 | |
| Pre-training | 0 (0.0%) | |
| Early Post-training | 4 (33.3%) | |
| Comparison 5 | 0.072 | |
| Pre-training | 0 (0.0%) | |
| Late Post-training | 3 (33.3%) |
Table 1: Comparison of rate of traction splitting in mid-shaft femur patients with no contraindications within training groups.
Sub-analysis showed a similar trend between the pre-training group, and the early (0% vs 33%; p = 0.068) and late post-training groups (0% vs 33%; p = 0.072) Table 1. There was not a significant difference noted between the early and late-training groups in terms of rate of traction splinting (33.3% vs 33.3%; p = 1.000).
Discussion
Optimized care for mid-shaft femur fractures begins in the prehospital setting with emergency medical services, who have the opportunity to improve patient outcomes with correct application of a traction splint. The widespread use of this efficacious primary survey adjunct has yet to be seen however, as evidenced by the absence of its placement in the original sample. Poor compliance is likely multifactorial; reasons may include the diversity of musculoskeletal trauma presentations, urge for rapid transport, or unfamiliarity of use. A novel educational intervention designed in collaboration with the FDNY-EMS is described to address this opportunity for improvement.
While online training modules as educational interventions have been previously promulgated to improve EMS stroke recognition,this is the first study to assess the effectiveness of an EMS training program to improve the pre-hospital care of trauma patients with mid-thigh femur fractures.10,11 Post intervention traction splinting was shown to increase to 33.3% from 0% in two sample groups of mid-shaft femur fracture patients without contraindications to traction splint application. Splitting post intervention into early and late groups also showed the same 33.3% increase. Notably, 66.7% of the overall post-interventional sample had any splint applied, implying that the intervention may promote increased awareness of all extremity splinting not limited to traction.
While the CALSTP instructs that both EMTs and paramedics may place traction splints when indicated, paramedics have New York state required CME for which this education intervention fulfilled. Though our intervention may have been effective, our sample may have included patients brought in by EMTs who would not have attended the educational intervention. Although our analysis showed that the increased rates of appropriate traction splinting were non-significant statistically, the results are promising and may be underpowered due to small sample size. Thus, further studies with larger sample sizes are warranted.
These findings were similar to Nackenson et al’s 2017 study investigating 170 patients in the Florida EMS system that showed only 30% usage of traction splints. The authors cite possible reasons for this low percentage of utilization to lack of provider comfort and concern for concomitant life-threatening injuries that may prompt immobilization with alternative methods due to need of rapid transport7.
In these situations, in which other life-threatening injuries may prompt rapid transport, several studies suggest that there is an opportunity for traction splinting when indicated. For instance, in their retrospective descriptive study conducted over a five-and-a-half-year period on children presenting with femoral shaft fracture to a pediatric trauma center, Chu et al. showed that adverse clinical outcomes were not reported in any patient regardless of time to application of traction splinting. This suggests that timing of traction splinting is not associated with poor outcomes in isolated pediatric femoral shaft fracture.12
Spaite et al. also set the precedent for on scene efficiency by evaluating the relationship between injury severity, prehospital procedures, and time spent on scene by paramedics for victims of major trauma. They found that more procedures were performed in the field on more severely injured cases, demonstrating that short scene times can be attained without forgoing potentially life-saving interventions.13
Literature examining low-volume EMS systems and wilderness rescue pose that traction splints may be no more effective than other methods of splinting in pre-hospital care and argue for utilization of alternative methods, such as long backboards or rigid splinting over traction splinting in rescue situations.14,15 For lower resource or wilderness areas, several studies have recognized the benefits of using traction splints for femur fractures and have investigated the usage of improvised femur traction splints as possible alternatives to commercially available models.16,17 This may explain the described increased splinting of any type, not limited to traction after the educational intervention.
Conclusion
An opportunity exists to improve the outcome of trauma patients by optimizing prehospital care. Analyzing data of trauma centers, recognizing opportunities for improvement in prehospital setting and furthering EMS crew’s education in cooperation with loco-regional EMS agencies may improve placement of traction splints in the pre-hospital setting for patients with mid-shaft femur fractures.
References
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