Thomas Splint Research Articles

Clinical Tip: Development of an Ankle Distraction Device Compatible With MRI and Radiography

Measurements of cartilage thickness in human ankles are important in evaluating the development of osteoarthritis, particularly following articular fractures. Unlike the knee, cartilage in the ankle is relatively thin (on the order of 1.5 mm), so it is difficult to image clearly using either MRI or CT techniques. Part of the problem is the lack of separation between the surfaces of the tibial and talar cartilage, making it essentially impossible to determine their respective thicknesses. Ankle distraction has been achieved in the operating room by applying tension to the foot using a windlass attached to the operating table, while the patient’s upper body is restrained by straps. Trauma units use devices like the Hare Traction splint, which applies force to the foot while bracing against the posterior ischium, to temporarily distract fractures of the femur. Neither of these systems is suitable for use with MRI, and significant modifications would be required to use them during CT scans. We have built a novel device that distracts the ankle (as well as the knee) using a specially modified brace above the knee to grip the distal surfaces of the thigh musculature where it narrows above the knee as anchor points (Figure 1) and a screw to apply tension to the foot strap. The distance between the tensioning mechanism and the brace is adjustable for patient size. The parts of the distractor adjacent to the ankle are radiolucent and the entire device is compatible with the MR and CT environments (Figure 2). In use, the device has been found to be minimally uncomfortable for the patient. Fig 1 Arrows indicate anchor points for the knee brace on the musculature of the distal thigh. Fig 2 The distractor in place on a subject leg To facilitate application of consistent tension to the ankle, a simple proving ring-based gauge made entirely of plastic was added to the system (Figure 3). It is placed in the load train between the tensioning screw and the ankle strap. As the force increases, the circular ring distorts and the rack attached to one side of the hoop moves relative to the pinion on the other. This action turns the attached calibrated scale, and the force is read against a mark on the rim of the hoop. Figure 3 The tension gauge is connected between the foot strap (left) and the tensioning screw (right). The gauge ensures that consistent loads are applied to the ankle and allows the technician to monitor any slippage that would cause the force to diminish. As a matter of patient safety, forces are not allowed to exceed 30 pounds (130N). Using the device, we have greatly improved the quality of our MRI scans. Distraction of the ankle joint introduces enough separation between the cartilage surfaces for accurate segmentation of the digitized image for finite element modeling, as well as for direct visual analysis (Figure 4). CT scans also benefit from use of the device (Figure 5). Figure 4 Coronal plane MRI scans showing distraction of the ankle mortise. Anatomical (left), and distracted (right). Figure 5 Sagittal plane CT scans showing distraction between the tibia and talus. Anatomical (left), and distracted (right).

The use of traction splint in the management of phalangeal fractures of the hand

The use of skin traction splintage is established in the treatment of phalangeal fractures of the fingers. We report our experience with this technique. Fifty patients with 53 different types of closed displaced proximal and middle phalangeal fractures were included in a 4-year study period. Satisfactory radiological reduction was obtained by 48 traction splints applied (90.56%) while five cases required operative intervention (9.44%). The mean duration of traction splint application was 21 days (range 14–28 days). The mean duration of the physiotherapy required after removal of the traction splint was 19 days (range 5–51 days). The mean follow-up period was 39.2 days (range 14–365 days). Out of the 48 traction splints used, full range of movement was obtained in 45 fingers (93.75%). We recommend the use of this technique, as it is a simple, quick, inexpensive, and noninvasive procedure with excellent results.

Wilderness medicine

Wilderness medicine

A small trial of the nursing care of patients immobilised with a Thomas splint

Thomas splints are often used to immobilise patients who have a fractured femur. Skin ulceration may occur in the area under and around a Thomas splint causing considerable discomfort to the patient. The aim of this study was to identify factors that may affect the occurrence of ulceration in patients immobilised with a Thomas splint and specifically to investigate different frequencies of pressure care in preventing skin changes associated with ulceration. The effects of other factors including the patient’s weight, leg circumference, type of fracture, traction ring size and traction weight on the incidence of skin changes were also investigated. Data were collected from 33 children in three different hospitals. Results suggest that the duration between pressure care may be reduced from 2 to 6 h (possibly 4 h). Thus reducing the risks associated with movement of the fractured leg.

Traction splinting of femoral shaft fractures in a paediatric emergency department: time is of the essence?

To describe the use of traction splinting in children with femoral shaft fracture and to determine if timing of traction splinting application effects outcome. A retrospective descriptive study conducted over a five and a half year period (1 January 1996 to 1 July 2001) on children presenting with femoral shaft fracture to a Paediatric trauma centre. Data were collected on all children with a radiological diagnosis of fracture to the femoral shaft. Evidence for hypovolaemic shock and neurovascular compromise was sought. The administration of parenteral analgesia and whether a validated pain scale was employed to monitor pain relief was documented. The use of traction splint or other leg splint device before arrival in the ED and subsequent changes to splinting in hospital were noted. Times to perform radiographic examination and femoral nerve block were also recorded. Ninety-five (95) patients met the study inclusion criteria with 66.3% having some form of immobilization and 70% administered parenteral analgesia in the pre-hospital setting. In only 7.3% of patients was a Thomas splint traction applied within 2 h of arrival. Adverse clinical outcome was not reported in any patient regardless of time to application of Thomas splint traction. The application of Thomas splint traction in the ED resulted in a significant delay in the performance of diagnostic radiographs and femoral nerve block. The timing of traction splinting is not associated with poor outcome in isolated paediatric femoral shaft fracture provided effective analgesia has been administered in a timely fashion.

A review of emergency equipment carried and procedures performed by UK front line paramedics

Objectives: To assess which items of resuscitation equipment are carried on United Kingdom (UK) front line ambulances and what procedures paramedics are able to perform. To compare these findings with those of a previous survey in 1997. Method: Postal survey to the chief executives of all the UK ambulance services and direct comparison with the data from 1997. Results: Nasopharyngeal airway usage (NPA) has increased (21–55%) and the laryngeal mask airway (LMA) (from 10 to 26%). No services employ the Combitube. 94% of services use a Hudson type trauma mask (increase of 17%). One service no longer allows its paramedics to deliver 12–15 l of oxygen. 68% of trust paramedics can perform needle thoracocentesis (increase of 35%). No paramedics perform chest drain insertion. All services have 14G intravenous cannulae available and 45% carry the intraosseous needle (increase of 30%). No services employ the MAST suit. There is an increase by 29% in the use of crystalloids and a decrease in the use of colloids of 22%. 23% of fluid resuscitation protocols are based upon the principles of hypotensive resuscitation. Spinal boards and extrication devices are used by 97% of services. The use of inflatable splints has decreased (38–23%). There has been a minor increase in the use of traction splints to 74% of services. The use of Entonox is universal. Nalbuphine (Nubain) is the most widely used opiod. The use of morphine/diamorphine has doubled to 10% with a further 26% to introduce their use. 29% of services have equipped some vehicles with automatic external defibrillators. Conclusions: The equipment available to UK paramedics and procedures that they may perform continues to expand. There are still variations in the basic management of airway, breathing and circulation care and only some services are keeping up to date with current medical thinking, for example the increasing use of crystalloids and hypotensive resuscitation. It remains to be seen whether the widespread use of Nalbuphine as a first line analgesic may decrease as the use of natural strong opiates becomes more widespread.

Foundation lecture. Fracture care of friend and foe during World War I.

In the early years of trench warfare, compound lower limb fractures caused by gunshot missiles prompted the -questioning of traditional splintage techniques and established evacuation methods. These prejudiced recovery and delayed surgery, often by many days, causing a high mortality rate especially for open femoral fractures. Importantly, battle weaponry was modified by differences in climate and terrain in Mesopotamia, Gallipoli, the Alps and the Northern European plain, to manifest differences in wound pathology. In Flanders, the static situation limited simple bullet wounds and launched a high percentage of jagged shell -fragment injuries complicated by tissue destruction, in-driven clothing and metal contaminated with mud, lethal bacteria and spores. From no-mans-land, soldiers with arm fractures scrambled back unaided, with tibial fractures they might hobble between two comrades, but with femoral fractures they were helpless unless stretcher bearers arrived. Often they did not, or only after a lull in fighting, by which time death from blood loss or exposure supervened. Even on a stretcher, poor fracture immobilization and long arduous carries added to shock and mortality. Remedies to these deficiencies and observations by Australasian, Austrian, British, Canadian, French, German, South African and American surgeons are noted. Trained to treat bullet wounds in open terrain, many military medical organizations were slow to adjust to the novel challenges associated with trench warfare. However, from 1917 well-trained stretcher bearers, efficient application of the Thomas splint, better control of haemorrhage and more rapid evacuation with motorized ambulances reduced deaths, amputation rates and long-term disability significantly.

F EMUR F RACTURE I MMOBILIZATION WITH T RACTION S PLINTS IN M ULTISYSTEM T RAUMA P ATIENTS

Objective. To evaluate the frequency of concomitant injuries that can complicate and/or contraindicate the use of traction splints (TSs) for femur fracture immobilization (FFI) in a population of multisystem trauma patients. Methods. This was a descriptive, prospective study utilizing a data collection tool to identify patients with multisystem trauma for which a TS was in place for FFI. Patient care records and follow-up diagnoses were reviewed to identify patients with positive femur fracture(s) who concurrently had injuries that can complicate and/or contraindicate TS use. Injuries considered to complicate or contraindicate traction splint use include 1) pelvic injury, 2) patellar fracture or ligamentous knee injury, and 3) tibia/fibula fracture. Results. Forty patients were identified as having a TS in place with an underlying diagnosis of multisystem trauma. All 40 had follow-up diagnosis information available, 39 of which were positive for femur fracture on the side of the extremity on which the splint was placed, or bilaterally. The incidence of complicating and/or contraindicating injuries was 38%. Conclusion. Traction splints are commonly used in the prehospital and transport setting for immobilization of femur fractures. There are limited data available on the benefit of traction splint use for femur fracture in the prehospital or transport environment. This study identified that concomitant injuries that complicate and/or contraindicate traction splint use are common.

Repair of Third Metacarpal Bone Fracture in a Foal Using DCP and Thomas Splint—A Case Report

Sardari, K. and Sharifi, K. 2002. Repair of third metacarpal bone fracture in a foal using DCP and Thomas Splint-A case report. J. Appl. Anim. Res., 22: 177–182. Third metacarpal bone fracture in a 1.5 month thoroughbred foal was diagnosed. The foal was treated by using internal plate fixation with DCP (Dynamic Compression Plate) and Thomas splint. After 60 day postoperatively, the plate was removed and the limb was again immobilized, with Thomas splint. After 5 days the Thomas splint was removed, and plaster cast was applied which was subsequently changed after 6 days and kept for another 6 days. There after, the plaster cast was removed and no external support was provided and foal was left to enjoy himself for normal walking and exercise schedule.

The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery.

Information illustrating the benefits of fracture stabilization after multiple trauma has been gathering for almost a century. At the turn of the last century, the introduction of the Thomas splint clearly demonstrated the importance of skeletal stabilization in the management of these patients. The introduction of standardized surgical treatment for fractures in the early 1950s is considered today as the turning point in the care of the polytraumatized patient. With the knowledge acquired, the application of early operative fixation of fractures in severely injured patients in the 1980s has yielded to the concept of early total care of all fractures. Yet, in distinct patient subgroups with severe thoracic injuries and very high injury severity scores, this concept has been associated with adverse outcomes. Therefore, in a further era that began in the 1990s, a different approach has been favored for these subgroups. It recommends early (initial) temporary stabilization followed by secondary definitive osteosynthesis of major fractures in patients at high risk of developing systemic complications. In the last decade, attempts have been made to determine which patients benefit from early total care and which ones should undergo a secondary definitive approach. This manuscript provides a historical overview on the changing treatment of fractures and summarizes the evolution of "damage control orthopedic surgery."

Prehospital Midthigh Trauma and traction splint use: Recommendations for treatment protocols

The present study was completed to establish an epidemiologic database defining the prehospital occurrence of midthigh trauma/suspected femoral shaft fractures, and the use of/need for traction splints (TS) in hope of developing recommendations for further treatment protocols. On review of 4,513 paramedic run reports for the 12-month period from January 1999 through December 1999, from a low-volume urban emergency medical services (EMS) system, 16 persons (0.35% total patients) presented with midthigh injuries. Data collected included patient chief complaint/injury, mechanism of injury, clinical findings, splint application, additional interventions, iatrogenic complications, patient age, and ambulance field time. Paramedics noted injuries suspicious for femoral shaft fractures in 5 patients (31.25% study patients, 0.11% total patients). TSs were applied successfully only twice (12.50% study patients, 0.04% total patients). Fourteen patients (87.50% study patients) were managed with long backboard immobilization, rigid splinting, and/or patient transportation in a position of comfort. No sequelae as a result of such care occurred. No inappropriate use, point estimate (PE) [(0)/(16) (0.00% to 20.60%)] or unmet need, PE [(0)/(4), 497) (0.00% to 0.08%)] of care was noted. The data presented in this study suggest that given similar EMS system characteristics, prehospital midthigh injuries/suspected femoral shaft fractures occur on an extremely rare basis, and treatment with long backboard immobilization, rigid splinting, and/or patient transportation in a position of comfort may constitute an acceptable course of care. Including TSs as essential ambulance equipment may be unnecessary.

Bedrest alters respiratory muscle strength in patients immobilized due to fractured femurs

Bedrest produces decrements in the functioning of all physiological systems. Physiotherapists treat patients who are managed with Thomas splints following fractured femurs. The patients are generally compartmentally treated as orthopaedic patients. No attention is paid to the status of the respiratory system which can be the cause of morbidity in these patients. Since the ventilatory muscles play a major role in breathing and coughing the purpose of the present study was to determine the effect of a limited period of bedrest on the strength of the inspiratory and expiratory muscles.A sample of convenience consisting of 15 African male patients immobilized by Thomas’ Splint for fractured mid-shaft femurs participated in the study by voluntary consent. All patients had been confined to bed for at least 3 weeks. Maximal inspiratory pressures (PiMAX) and Maximal expiratory pressures (PeMAX) were recorded using a Boehringer Force Meter at functional residual capacity in the semi-recumbent position. The data were normalized and analyzed using the student t-test at the 0.05% level.The results showed a significant reduction in both PiMAX and PeMAX compared to age predicted normal values. The decrease in PeMAX was greater than that of PiMAX.We conclude that respiratory muscle strength decays with bedrest.

Surgical repair of multiple tibial fracture in a Wolf whelf (Canis lupus) by bone plating

Fractures of limbs are common in domestic as well as in wild animals. Fracture reduction, perfect immobilization and postoperative care will decide the success rate in any fracture management in non-infected cases. We present here a successful surgical repair of tibial fracture with bone plating in a Wolf whelf. A eight month old male Wolf pup (Canis lupus) belonging to S.V. Zoological Park, Tirupati was presented to the surgical ward with a complaint of broken right hind limb. The animal was unable to walk and bear weight on right hind limb. Temperature, pulse and respiratory rates were within normal physiological limits. On palpation, swelling, crepitus and pain was observed. At the proximal third of tibial shaft. Radiographic examination revealed complete, multiple fracture of proximal third of right tibial shaft. Fractured bone chips were also noticed (Fig. 1). Based on these findings, it was decided to perform surgery. Triflupromazine hydrochloride @ 2 mg/kg body weight was given intramuscularly as preanaestheti c 15 minutes before surgery. The animal was anaesthetized with 25% solution of Thiopentone sodium @ 25 mg/kg body weight given intravenously. The tibia was approached from medial aspect by incising the skin and separating muscles. After avoiding blood vessels and nerves, proximal and distal fracture segments were isolated. Sharp edges were removed. The two fractured ends were kept in alignment and immobilized and six holed sherman bone plate was applied over it. The screws were snugly fit up to opposite cortex. The plate was kept in position by wires (Fig. 2). Demineralized bone matrix powder was poured at the fractured site to enhance healing and bone formation. Streptopenicillin powder was applied over the operative site after removing blood clots. The muscles were sutured using no.1 chromic catgut by interrupted suture technique. Shin incision was closed using no.1 silk by horizontal mattress suture technique. Tincture benzoin seal was applied to the suture line. Streptopenicillin 0.5 grams and Diclofaenac sodium 2 ml. was given intramuscularly for five post operative days. Modified Thomas splint was applied to the limb for perfect immobilization. The animal made uneventful recovery without any complications.

Management of a metacarpophalangeal joint fracture using a dynamic traction splint and early motion

Dynamic traction and early motion have been used by hand therapists to treat proximal interphalangeal joint fractures with good results. However, metacarpophalangeal joint fractures have been neglected, perhaps because of their relative infrequency. The purpose of this case study is to report the authors' experience using dynamic traction in conjunction with early motion to treat a construction worker who fell from scaffolding and sustained a complex fracture of the left small-finger proximal phalanx with involvement of the metacarpophalangeal joint. Range of motion of the patient's left small finger at discharge from therapy, approximately 22 weeks postoperatively, was as follows: metacarpophalangeal joint, hy-perextension/65 (85° passive flexion); proximal interphalangeal joint, 20/80 (5/90 passively); and distal interphalangeal joint, 0/50 (65° passive flexion). The patient made a successful return to full-time construction work. The results of this case appear to support consideration of the use of dynamic traction and early motion for management of selected metacarpophalangeal joint fractures.

Transient peroneal nerve palsies from injuries placed in traction splints

Two patients thought to have distal femur fractures presented to the emergency department (ED) of a level 1 trauma center with traction splints applied to their lower extremities. Both patients had varying degrees of peroneal nerve palsies. Neither patient sustained a fracture, but both had a lateral collateral ligament injury and one an associated anterior cruciate ligament tear. One patient had a sensory and motor block, while the other had loss of sensation on the dorsum of his foot. After removal of the traction splint both regained peroneal nerve function within 6 hours. Although assessment of ligamentous knee injuries are not a priority in the trauma setting, clinicians should be aware of this possible complication in a patient with a lateral soft tissue injury to the knee who is placed in a traction splint that is not indicated for immobilization of this type of injury.

The dynamic elbow suspension splint

Elevation of the upper extremity after elbow surgery has rarely been advocated and can be difficult to achieve. Usually the extremity is elevated with the elbow at 90° of flexion, so that swelling from the hand drains to the elbow but the elbow remains dependent. Excessive swelling causes discomfort and compromised wound healing, makes early mobilization difficult, and predisposes to joint contracture. We report on a dynamic elbow suspension splint, which is analogous to the Thomas splint used for femoral shaft fractures. The arm is held in full extension with an above-elbow plaster slab and is secured to the Thomas splint with skin traction. The splint is suspended on a Balkan frame at an angle of 60°. We prefer to use the new Zimmer Thomas splint, because it is radiolucent and has self-adhesive sheepskin supports that can be simply applied. It allows the patient to mobilize in bed and is well tolerated by patients and nursing staff. The dynamic elbow suspension splint is a useful adjunct after complex elbow surgery or trauma, because it reduces swelling and maintains the elbow in extension.

Controlled active motion following primary flexor tendon repair: A prospective study over 9 years

One hundred and thirty patients with 339 divided flexor tendons affecting 208 fingers were studied prospectively between 1988 and 1996, to assess a regime of primary flexor tendon suture and active postoperative motion, combined with a modified Kleinert dynamic traction splint. The tendon suture technique used was a high-strength multistrand technique using a modified Kessler core and a Halsted peripheral stitch. The results were influenced by the zone in which the tendon was divided, by the physiotherapy and to a lesser extent by the grade of surgeon operating. Overall results by Strickland criteria were 92% excellent or good, 7% fair and 1% poor. There were 43 complications in 31 patients including five zone 2 ruptures (5.7%) and one further rupture in zone 5. This method of flexor tendon repair requires good physiotherapy and splint-making capability but gives good results with minimal need for further surgery.

Thomas Splint, Calcaneus Fracture, and Compartment Syndrome of the Foot

Thomas Splint, Calcaneus Fracture, and Compartment Syndrome of the Foot

The Mennen plate in periprosthetic hip fractures

We would like to report five patients with periprosthetic hip fractures, treated with a Mennen plate, as we felt there were contraindications to revision surgery in these patients. Their average age was 79.1 years. All patients were uncomfortable in Thomas splint traction and more comfortable after surgery: they required an average of 2 units of blood to be transfused; they were partially weight-bearing with a caliper in an average of 9 weeks, home in an average of 10 weeks, and the average time to clinical or radiological union was 4.8 months. We considered a reasonable level of mobility was regained after surgery and would recommend Mennen plate fixation for periprosthetic fractures in those patients perhaps too frail for revision.

The Proximal Interphalangeal Joint Swing Traction Splint

Conventional PIP joint flexion splints exhibit several shortcomings regarding kinematic and kinetic behavior. A new PIP joint swing traction splint (STS) has been developed to overcome these shortcomings while maintaining the advantage of the ease of use of conventional simple rubber band traction devices. This article defines the advantages of the STS system in terms of physics and also describes the fabrication technique involved.