1. Femoral Shaft Fracture: Initial Assessment and Splinting

Case Context and Assessment Priorities

A 34-year-old cyclist is brought in after a high-energy collision with a vehicle. He is alert, in obvious pain, and holds his right thigh in external rotation with visible swelling and shortening. The working diagnosis is a femoral shaft fracture. The femur is a high-energy bone: it sits adjacent to the femoral artery and nerve, it can bleed 1–1.5 L into the thigh, and its fracture pattern can propagate to the knee or hip. The initial assessment therefore has two jobs that must run in parallel: find and document neurovascular compromise, and immobilize the limb with a traction splint to reduce pain, limit further soft-tissue injury, and control bleeding. This case walks through a structured assessment and splint application, with the documentation that makes the findings defensible.

Step 1 — Primary Survey and Mechanism Check

Begin with the standard primary survey (ABC). Femoral shaft fractures are a classic cause of occult hemorrhagic shock: the thigh can hold a large volume of blood without an obvious external wound. Record mechanism, time of injury, and any anticoagulant use. Then perform a focused limb exam before touching the splint:

  • Inspection: thigh deformity, swelling, skin integrity, open wounds, and the position of the limb (external rotation and shortening suggest proximal or midshaft involvement).
  • Palpation: tenderness, crepitus, and thigh compartment tension. Do not repeatedly manipulate the fracture to "test" it.
  • Distal pulses: dorsalis pedis and posterior tibial, graded and compared with the uninjured side.
  • Neurological status: light touch and two-point discrimination over the dorsal web space (deep peroneal), the sole (tibial), and the lateral foot (sural).
  • Motor: active ankle dorsiflexion and plantarflexion, and great-toe extension.

Document each finding with a timestamp. A pulse that is present but weak, or a new sensory deficit, changes the urgency of reduction and splinting.

Step 2 — Neurovascular Documentation Before and After Splinting

The single most common documentation failure in femoral shaft injury is recording neurovascular status only once. Record it before splint application and after traction is applied, because traction can restore or, if excessive, compromise perfusion. Use a consistent, comparable format so a later clinician can detect change:

ParameterRight (injured)Left (reference)Time
Dorsalis pedis pulse2+2+Pre-splint
Posterior tibial pulse1+2+Pre-splint
Capillary refill<2 s<2 sPre-splint
Light touch, dorsal web spaceIntactIntactPre-splint
Ankle dorsiflexionWeak, painfulFullPre-splint

After traction and splinting, repeat the same fields. If the posterior tibial pulse drops from 1+ to absent, or a new sensory deficit appears, release traction slightly and reassess; persistent deficit requires urgent orthopedic and vascular review.

Step 3 — Applying the Traction Splint

A traction splint (e.g., a Hare or Sager-type device) applies longitudinal pull through the ankle to counteract thigh muscle spasm, reducing overriding of fracture fragments. The sequence matters:

  1. Prepare the device and confirm the ankle strap and traction mechanism function before positioning.
  2. Support the limb with an assistant maintaining gentle manual alignment; do not force rotation.
  3. Fit the proximal ischial pad against the ischial tuberosity, not the perineum, and secure the thigh straps.
  4. Apply the ankle hitch over the heel and dorsum of the foot, avoiding pressure on the Achilles tendon and malleoli.
  5. Apply traction until pain and deformity are reduced — typically 10–15% of body weight as a starting point, titrated to comfort and alignment, not to a fixed number.
  6. Recheck pulses, sensation, and motor immediately, then secure the remaining straps and document the traction force used.
Do not apply a traction splint to a suspected open fracture with gross contamination, a pelvic fracture, or a knee injury that cannot tolerate longitudinal pull without orthopedic input. In those situations, immobilize with a vacuum splint or board and escalate.

Visualizing the Assessment and Splinting Sequence

The diagram below shows the parallel tracks of neurovascular assessment and splint application, and the decision point where post-traction findings determine whether to continue, adjust, or escalate.

Femoral Shaft Fracture: Assessment and Traction Splinting Neurovascular Track Splinting Track Inspect: deformity, swelling, skin Palpate: tenderness, compartment tension Pulses: DP + PT, compare sides Sensation: web space, sole, lateral foot Motor: ankle DF/PF, great-toe extension Record baseline with timestamp Prepare traction splint, check mechanism Assistant supports limb in alignment Ischial pad + thigh straps Ankle hitch over heel and dorsum Apply traction: ~10–15% body weight Titrate to pain relief and alignment Post-traction NV status? Stable → continue, document Changed → adjust traction Absent pulse → escalate

Step 4 — Documentation and Handover

Complete the record with the elements that a receiving team will need: mechanism and time, limb position and deformity, pre- and post-splint neurovascular findings, traction force applied, skin condition under straps, and any change in pain score. A concise handover note might read:

Right femoral shaft fracture, closed, high-energy mechanism (cyclist vs car, 14:20).
Pre-splint: DP 2+, PT 1+, cap refill <2 s, sensation intact, ankle DF weak/painful.
Traction splint applied 14:48, ischial pad seated, ankle hitch over heel, traction ~12% body weight.
Post-splint: DP 2+, PT 2+, sensation intact, pain reduced 8/10 → 4/10.
Skin intact under straps. Plan: analgesia, imaging, orthopedic review.
If the patient's pain does not improve after traction, or if the thigh becomes tense and firm, reassess for compartment syndrome and consider that the traction force may be excessive or the fracture pattern unstable. Document the reassessment rather than simply increasing traction.

Common Pitfalls to Avoid

  • Single neurovascular check: always record before and after splinting; a change is the finding that matters.
  • Ischial pad misplaced: sitting it on the perineum causes pressure injury and nerve compression; seat it on the ischial tuberosity.
  • Fixed traction force: titrate to comfort and alignment; a number alone is not a clinical endpoint.
  • Missing the open fracture: inspect the whole thigh and document any wound before covering it with straps.

The case is complete when the limb is immobilized, the neurovascular status is documented at both time points, and the handover note contains the traction force and the post-splint findings.

← Previous 📖 Contents Next →