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Femur Fractures
Objectives:
Upon completion of this article you will be able to:
1.
2.
3.
4.
5.
6.

Describe common terms associated with femur fractures and the different types of femur fractures.
Discuss the mechanism of injury relating to femur fractures.
Explain the assessment of a patient with femur fractures.
Describe the signs and symptoms of femur fractures.
Discuss emergency tools and equipment needed to stabilize femur fractures.
Describe treatment methods for femur fractures.

Scenario
It is 1700 hours, and you and your partner are attempting to eat
dinner at a local restaurant, when suddenly you hear squealing
tires and then a loud crash right outside the restaurant. All of a
sudden a woman comes running inside yelling, Call 911! Call
911! You and your partner rush to the woman who states that a
young man on a motorcycle had just ran a red light and was struck
by a car. You quickly advise your dispatch of the accident and
request police assistance while your partner goes to the
ambulance to retrieve your equipment. Both you and your partner
move quickly to the scene and find that the police have already
arrived and have secured the crash scene. You find the motorcycle rider, a 19-year-old man wearing an apparently
undamaged motorcycle helmet lying five feet from his motorcycle; you notice that the motorcycle has damage on the
left side where it was apparently struck by a car. You approach the patient and find that he is alert and oriented to time,
place, event, and person. You also note that his airway, breathing and circulation appear to be intact. However he is
complaining of severe pain to his upper left leg. You quickly glance over the patient looking for any obvious
life-threatening injuries; when none are noted, you expose the patients legs, utilizing all body substance isolation (BSI)
protocols. Once the patients leg is exposed, you notice an obvious deformity and swelling in the area of the mid-shaft
of the left femur. You also find that the patients left leg appears to be shorter than his right. You know from your
training that the patient has probably suffered a femoral shaft fracture and that these fractures are very dangerous and
potentially life-threatening if not treated, but what is your next step? What other considerations should you take into
account? How do you stabilize or treat the injury?
Femoral fractures if not treated quickly, are a potentially life-threatening injury. Even when treated properly, they are a
painful, traumatic experience that are potentially crippling for the patient and require the utmost care from the
emergency responder. This discussion will assist you in identifying common terms, anatomy, types, and mechanisms of
injury indications as well as emergency equipment that is needed to treat and stabilize femoral fractures.
Basic Anatomy of the Human Femur
The human femur is also known as the thigh bone. It is positioned between the pelvis
where it forms to make the hip joint at the pelvis and the bones of the lower leg and joins
with the tibia and fibula to form the knee joint. The femur is the largest, longest, and
strongest bone (when an average human jumps, the femur withstands a force of half a ton)
within the human body,1 thus normally requires great force to fracture. Superiorly, the
femur is identified by the head, the greater trochanter and the lesser trochanter, the shaft
connect, and the superior and inferior ends. The femur is identified inferiorly by the lateral
and medial condyles as well as the patellar surface.

2,3,4

Types of Femur Fractures and Risks Associated with Them

Common terms associated with all fractures are simple fractures, comminuted fractures,
open fractures, closed fractures, and pathological and stress fractures.5
Femur fractures are classified by the location of the fracture on the bone itself. While you as
an emergency responder will not classify the type of femur fracture that your patient has
suffered, an understanding of the types will aid in your assessment and treatment of your
patient. Types of femur fractures superiorly to inferiorly are proximal fractures and femoral
shaft fractures. Proximal fractures include hip fractures-dislocations, 6 femoral neck
fractures, and intertrochanteric fractures. These proximal fractures result in almost a 20
percent mortality rate in the elderly; this is due in large part to loss of blood. Shaft
fractures include fractures to the distal portion of the femur.7
Hip fractures and dislocations, although not commonly thought of as femur injuries are in
reality fractures and dislocations of the proximal femur. These injuries are commonly seen

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Common Terms
Associated with
Femur Fractures

Adduction vs.
Abduction: Adduction
refers to the motion
toward midline of the
body, while abduction
refers to motion away
from the midline. An
example of this is when
a person raises his or
her arm it would be
considered abduction,
but when it is lowered
it would be considered
adduction.
Anterior vs. Posterior:
Anterior is a term used
to describe the front

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with the elderly as a result of falls and bone degeneration. However, these types of injuries
occur in every age group. Posterior dislocations of the hip may be caused by a motor
vehicle occupants knee striking a dashboard during an automobile crash. The impact
between the occupants patella and the dashboard causes the femur to be driven
posteriorly, with enough force to result in a (hip) femur dislocation. Hip fractures and
dislocations may be either posterior or anterior, with posterior being more common. Of
particular note with this type of injury is the close proximity of the sciatic nerve; this nerve
controls all of the muscular activity of the lower leg as well as sensation of the entire leg.
Injury to this nerve may result in complete or partial paralysis of the leg.4,6,8
Femoral neck fractures fall into the category of proximal femur fractures and are among the
most common injuries to the femur and are at times called hip fractures, even though it is
actually the femur that is fractured and not the pelvis. Femoral neck fractures occur
commonly with the elderly and are largely a result of falls and bone degeneration. This type
of fracture is also commonly found with high impact collisions such as automobile crashes,
much like explained in the preceding paragraph with a dislocation. Subcapital fractures are
fractures of the neck of the femur where the femur joins the head. Femoral neck fractures
are commonly classified using the Garden Classification System. This system identifies four
classifications:
Garden I - Incomplete fracture of the femoral neck; this fracture is stable.
Garden II - Complete fracture of the femoral neck; although complete, it is stable.
Garden III - Complete fracture with impaction of the femoral head; the femoral shaft
is externally moved or rotated. This form of fracture may be stable or unstable.
Garden IV - The femoral neck is moved superiorly migrated relative to the femoral
head; this form of fracture is highly unstable.1

Image courtesy of The University of Glasgow

Intertrochanteric fractures involve either the greater or lesser femoral trochanters or both.
This form of fracture is classified as either intertrochanteric or subtrochanteric. The
intertrochanteric fracture is the most common and is further classified according to the
involvement of the lesser and greater trochanter.
Femoral shaft fractures may occur on any part of the shaft between the trochanters and the
condyles. A large amount of force is required to produce fractures of the shaft of the femur.
These fractures tend to be unstable due to spasms of the thigh muscles as they attempt to
splint the fractured bone fragments. This splinting may also cause an open wound as the
fractured femoral ends protrude through the skin, or the superficial femoral artery may be
injured with complex fractures of the distal femur. This may result in a blood loss of
between 500 to 1,000 mL and more. A loss of this amount of blood may result in
hemorrhagic shock if left uncontrolled and should be treated as an emergency.

Mechanisms of Injury Relating to Femur Fractures

Injuries to any part of the femur is a result of a large amount of force (kinetic energy) being

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portion of the body,

while posterior
describes the back
portion of the body. For
example, the sternum
is on the anterior
aspect of the body,
while the cervical spine
is on the posterior
portion.
Closed vs. Open
Fracture: A closed
fracture is when the
epidermis is not broken
or when the bone is not
protruding through the
skin. An open fracture
involves the bone
protruding through the
skin.
CMS: Memory aid used
to check extremities,
Circulation, Movement
and Sensation.
Circulation refers to
skin color of the
extremity and how it
compares to the
others. Is it pale or
cyanotic? Is the pulse
present in all
extremities and are
they equal? Movement
is the patients ability
to move his or her toes
or fingers. Sensation
refers to whether the
patient has normal
feeling in each
extremity. Can the
patient feel gentle
squeezes in each
extremity equally?
Crepitus: The sound of
two fractured bone
ends rubbing together,
often described as
crackling.
DCAP-BTLS: Memory
aid; the letters of which
stand for Deformities,
Contusions, Abrasions,
Punctures/penetrations,
Burns, Tenderness,
Lacerations, and
Swelling.
Dislocation vs.
Fracture: Both
dislocations and
fractures involve the

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applied to a relatively small area. Such force produces a significant mechanism of injury.
Keeping this in mind you should remain alert for other serious traumatic life-threatening
injuries. We will review what some of the significant mechanisms of injuries are and when
they should be suspected. Significant mechanisms of injuries should be suspected whenever
there are:
Obvious deformities to any portion of the body.
Penetrating trauma that includes gunshot and/or stab wounds.
Blunt trauma, such as unrestrained occupants during a motor vehicle collision (MVC)
at any speed.
Death within the passenger compartment of the vehicle.
Motor vehicle extrication time greater that 20 minutes with heavy equipment.
A MVC with intrusion into the passengers compartment that includes rollovers and
ejections from the vehicle at any speed.
Any pedestrian struck by an automobile.
All motorcycle collisions.
Any falls from greater than three times the patients height, or over 20 feet in height
for adults and 10 feet in height for children.
Bicycle accidents involving children as well as recreation vehicle accidents, such as jet
skis and snowmobiles.
Fractures of the femur generally result from one of four traumatic mechanisms of injury or
forces. These forces include direct blows to a bone, which occurs when a force is applied
directly to the bone itself. An example is of a motorcycle rider, as with our scenario in the
opening section of this topic, whose left leg (femur) was struck by the other vehicles front
end resulting in a fracture to the femoral shaft. Injuries of this nature may be incurred by
bicyclists as well as pedestrians when struck by an automobile. Yet another example would
be when a rider of a motorcycle, Jet Ski, or bicycle is ejected over the handlebars. At that
moment, the patients feet or lower legs will not move with his or her body, resulting in the
upper leg (femur) striking the handlebars and causing a fracture as the riders upper torso
moves forward and the lower extremities do not. This causes the handlebars to act as a
fulcrum resulting in an extreme amount of force being applied to the riders body, normally
the femoral area.
Next there are indirect blows to a bone which commonly occurs when one bone or a portion
of the body is impacted by an object. A common example is a fall or a jump in excess of 20
feet for an adult. Commonly a person will jump or fall and then land on the heels of his or
her feet, causing the bones of the lower legs to transmit the force up into the femur, which
in turn may cause a proximal fracture of the femur or dislocation.
Twisting is another injury which occurs when a patients leg or body is stopped in one
position; however the other portion of the body continues to move. This may result from an
automobile collision or sports-related injuries. They commonly result in posterior
dislocations. An example of twisting would be in the case of a football player. As the player
rushes forward his leg is entrapped, by the crush of bodies, yet his upper body continues to
move. If the amount of force is great enough, an injury will result.
Finally, a high energy impact injury can result in a proximal fracture of the femur or
dislocation fall. An example is an occupants knee striking the automobiles dash during a
crash, causing fracture to the femur. It should be noted that many times an elderly patient
may suffer a proximal femoral fracture as a result of a minor fall; this is in large part due to
osteoporosis.
Arrival and Assessment
We now are aware of some of the common mechanisms of injury of femur fractures and
therefore as we are responding to a scene, prior to arrival we should remain prepared for
them. Upon arrival, we must ensure that the scene is safe and the patient is stable. First
survey the scene, ensuring that the scene is safe to enter. Remember that your teams
safety is most important. If you become injured or incapacitated, you will be unable to
assist your patient. If needed, take steps to reduce or mitigate the hazards present. Ensure
that you have all of the required equipment available, including BSI equipment. Now begin
to survey the scene and ask yourself these questions:
How many patients are there?
Can I see the mechanism of injury? If so, how severe is it?
Are there enough emergency responders on scene or do I need more?
Do I have the proper equipment? Is it enough?

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musculoskeletal
system; however, they
are two distinctly
different injuries. A
fracture actually
involves the breaking
of a bone or bones, as
a result of an outside
force. A dislocation is a
disruption of a joint,
usually injuring the
ligaments as well as
loss of bone-to-bone
contact. A combination
of a fracture-dislocation
is possible as well.
Displaced vs.
Nondisplaced Fractures:
A displaced fracture
occurs when there is an
actual deformity, or
distortion of the
fractured limb; this
may result in either a
change in the length of
the limb or a rotation
of the affected limb or
both. A nondisplaced
fracture is when the
bones do not move;
normally this is seen
with hairline fractures.
Lateral vs. Medial: The
term lateral is used to
describe parts of the
body that are farther
from the midline (an
imaginary line that
runs centrally down the
human body), whereas
medial is a term that is
used to describe
something that is closer
to the midline of the
body.
Pathological and Stress
Fractures: Pathologic
fractures occur when
normal stress is placed
on an abnormal bone.
This condition is due to
an underlying
abnormality of the
bone, usually either a
tumor, or a metastatic
disease. Similar to a
pathological fracture, a
stress fracture occurs
when repeated stress is
placed on a bone,
causing the bone to
weaken and develop a

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After conducting the scene size up, move to your patient and begin your initial assessment.
Start with the basics first: simultaneously check the patients airway, breathing, and
circulation (ABCs), as well as the patients level of consciousness (LOC).
If the airway is compromised, open the airway, but if you suspect a serious mechanism of
injury, take spinal stabilization precautions until medically cleared. Therefore, should you
need to manually open the patients airway, utilize the jaw thrust method ensuring that C
spine precautions are used. In terms of breathing, what is the patients approximate rate of
respiration? Remember the average adults respiratory rate is 12-20 breaths per minute,
while newborns take in 30-60 breaths per minute. Are the patients respirations bilaterally
equal in depth? What is the patients respiratory pattern? Are there any abnormal
respiratory issues present or developing? Some of these include tachypnea, bradypnea, and
apnea. Any abnormal respiratory pattern may be an indication of a potential head injury or
other life-threatening condition. If the patients respiratory rate is eight breaths per minute
or less and is inadequate, provide supplemental oxygen via bag valve mask with reservoir
at 15 liters per minute (lpm) of oxygen at 24 breaths per minute. If respiratory rate is
greater than eight breaths per minute and the breathing is adequate, consider 15 lpm of
oxygen via a non-rebreather mask.
Check for circulation by palpating the carotid pulse. Once located, what is the rate?
Remember that the average adults pulse rate is 60-100 beats per minute, while a
newborns pulse rate is 100-180 beats per minute. Is it tachycardic (fast) or bradycardic
(slow)? What is the quality of the pulse? Is it strong, weak, or thready? Is the patients
pulse rate regular, irregular, or bounding? Assess the patients skin temperature: is it warm,
cold, or clammy to the touch? Assess the patients skin color: is it cyanotic (bluish), flushed
(red), or ashen (grayish)? Inspect the patient for visible bleeding; should you locate any
bleeding, attempt to control it. If you are unable to control the bleeding, remain alert for
indications of the onset of hypovolemic shock. Determine the need to load and go or
additional assistance such as Advanced Life Support (ALS) if not equipped or emergency air
transport. What is the patients level of consciousness? Is he or she alert and oriented to
person, place, time, and event? Assess your patients level of consciousness (LOC) utilizing
the AVPU memory aid (Alert, alert to Verbal stimuli, alert to Painful stimuli, Unresponsive).
Should your patients LOC be altered, reconsider your transport priority.
Signs and Symptoms of Femur Fractures
Now that you have assessed the patients ABCs and LOC, lets look at the patient. We begin
with the rapid trauma assessment (RTA). Pay particular attention to areas where trauma
may have been focused, however do not focus on the most dramatic injury, many times the
most obvious/dramatic injury is not the most life-threatening. Remember the goal of the
rapid trauma assessment is to locate and identify all potentially life-threatening conditions.
If at any time throughout the assessment, you come across a life-threatening injury,
stabilize it and then continue with the assessment. Additionally, if during the assessment,
the patients mental status deteriorates or you are unable to stabilize the patient, expedite
transport and/or request ALS support. For the purpose of this article, we will assume that
you have performed the RTA and have found that no significant injuries were sustained to
the patients upper body. We will therefore begin our assessment in the pelvic region.
Assess the pelvis for DCAP-BTLS and crepitus. Expose the pelvic area; if possible, be
considerate of the patients privacy. Visualize the pelvic area for any obvious signs of injury
and deformities to include the hip joint. Note the presence of priapism; if observed, suspect
a lower spinal cord injury. If the patient is conscious, ask if he or she feels pain in the pelvic
area. If none is noted, evaluate the pelvic ring for stability by gently pressing medially
(towards the center). DO NOT ROCK, on the pelvic ring (Iliac crest). Then gently compress
the pelvis (symphyis pubis) posteriorly. If movement is felt, suspect a pelvic fracture and
stabilize the pelvic area immediately utilizing a pneumatic anti-shock garment (PASG). Be
alert for uncontrolled hemorrhaging, which may result in up to 2,000 mL of blood loss.
Additionally, remember that the genitals of both males and females are very vascular and
an injury to the area may result in rapid blood loss. Apply dressings as needed. Reconsider
the need for rapid transport or additional assistance.

hairline fracture.
Proximal vs. Distal:
When something is said
to be proximal in
regards to the human
body it is closer to the
trunk of the body.
Distal is a term that is
used to describe an
aspect of an extremity
that is closer to the
free end of the
extremity. For
example, the femur is
proximal to the patella,
while the fibula is distal
to both the femur and
the patella.
Simple vs.
Comminuted Fracture:
A simple fracture is
when there is a single
fracture and the bone is
broken into two pieces.
A comminuted fracture
is when there are
multiple fractures and
there are more than
two bone fragments at
the fracture site.
Superior vs. Inferior:
When these terms are
used to describe the
human body they are
used in regards to the
head and feet. When
something is said to be
on the superior aspect
of something it is
describing the portion
of the object that is
closest to the head. On
the contrary, when
something is said to be
on the inferior aspect of
something it is
describing the portion
of the object that is
closer to the feet. An
example of this is the
greater trochanter is on
the superior aspect of
the femur, while the
lateral condoyle is on
the inferior aspect.

While inspecting the pelvic area be alert for proximal femur fractures as well as both
posterior and anterior dislocations of the femur. Remember to keep in the mind the six Ps:
Pain - Is the area tender to the touch?
Pallor - Is the patients skin color abnormal? Is the capillary refill altered distal to the potential injury site?
Paralysis - Can the patient move the suspect injured limb?
Paresthesia - Is the affected limb numb or tingling?

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Pressure - Does the patient feel tension or pressure within the injured limb?
Pulse - Is the distal pulse absent or diminished?
Patients that have suffered either a proximal femur fracture or dislocation will present with bruising and swelling within
the area of the injury. Patients will not be able to stand or walk and will report severe pain in and around the hip region.
Patients with a femur fracture will attempt to resist any movement to the injured area. Those patients that have
sustained a proximal femur fracture may present with the injured limb appearing to be somewhat shorter than the
non-injured limb or with a visible deformity. Patients that have suffered a proximal femur fracture will normally present
with their injured limb positioned straight out, and rotated away from the body. Elderly patients that have suffered a
proximal femoral fracture may present with referred knee pain.
The most common dislocation is the posterior dislocation. Patients that have suffered a posterior dislocation generally
present with their knee drawn in medially (towards their chest) and over the opposite thigh and their thigh rotated
slightly medially over the top of the opposite thigh. At times you may be able to palpate the femoral head within the
muscles of the buttocks. Similar to patients that have suffered a proximal femur fracture, patients that suffer an
anterior dislocation will normally present with their injured limb positioned straight out and rotated away from the
body. It may be difficult to determine if the sustained injury is a fracture or dislocation.7,8,9,10
Now that we have cleared the pelvic/hip area we will move on to the limbs themselves. Again, as an overview of the
RTA process, we will briefly discuss how to assess the extremities for DCAP-BTLS, CMS, and crepitus. Expose all
extremities; inspect all four extremities for obvious injuries, to include amputations, and obvious fractures. Check distal
pulses in all extremities and capillary refill in both the fingernails and toenails. Inspect the color and temperature of
each extremity. The lack of distal pulse, capillary refill 2 seconds or greater, and coolness or ashen skin color indicates
loss of perfusion to that extremity. Evaluate the cause, and attempt to correct it. Should the cause be a fracture, splint
the fracture quickly in an attempt to restore circulation. However, if the extremity has good perfusions and the fracture
is not life-threatening, do not attempt to splint the fracture at this time. Check for medical alert bracelets to attempt to
identify prior medical conditions that may affect treatment. (Note: double check the neck and upper chest to ensure
that you did not miss a medical alert necklace). If the patient is alert and oriented attempt to determine if motor
function and sensitivity is intact. Motor function may be evaluated by asking the patient to slightly squeeze your fingers
or by pushing down lightly with their feet. If weakness is only on one side, suspect brain injury due to a stroke, head
injury or spinal cord injury. Sensitivity may be evaluated by gently squeezing the fingers and toes and inquiring if the
patient was able to feel the pressure. If the patient is unable to move his or her extremities and/or not feel the
sensation, suspect a spinal injury.
If the patient has both lower and upper extremity fractures, treat the lower extremity fracture first, due to possibility of
rapid blood loss. Reevaluate your transport priority and the need for additional assistance. While conducting this phase
of the RTA, you should remain alert for indications like femoral shaft fractures, which may occur at any place along the
femoral shaft between the hip and knee joints. Femoral shaft fractures are normally the result of severe traumatic force
being applied as a result of an enormous amount of kinetic energy being displaced, such as in an automobile crash or
falls from a significant height.2,8 Patients with this injury commonly present with severe pain and the inability to stand
or walk, bruising and swelling within the area of the injury, the injured limb being significantly shorter that than the
uninjured limb, and severe deformities being present as the thigh muscles spasm in an attempt to stabilize the fracture.
A significant amount of these injuries, roughly 17 percent, result in open fractures, with bone fragments protruding
through the skin. 11 In addition to these indications, there is commonly a significant loss of up to 1,200 ml of blood; this
will increase with open femoral fractures. There may be severe angulations or rotations at the fracture location.
Emergency Tools and Equipment Need to Stabilize a Femur Fracture
You have identified the presence of a fracture of the femur, so lets discuss some emergency tools and equipment used
to stabilize/treat femoral injuries. Remember to follow all local protocols when required.
Pneumatic Anti-Shock Garment (PASG) - This item is used to prevent or minimize hypovolemic shock, but as always
follow your local protocols. It does so by forcing the circuiting blood to remain in the upper body where the vital organs
are located. This garment also controls massive life-threatening blood loss of the lower extremities. A secondary
function of the PASG is to use it as a means of a stabilization method and control internal bleeding for fractures of the
pelvis and proximal femur as well as acting as an air splint by stabilizing the fracture site. Contradictions for use of the
PASG include pregnancy, chronic pulmonary edema and acute heart failure, and groin injuries, as well as severe head
injuries and short transport times (under 30 minutes). Inflate the lower portions of the garment before the upper ones.
Inflate all compartments when stabilizing a patient with a pelvic injury unless otherwise contraindicated. 12 When using
this garment, ensure that all local procedures are followed. It should be noted that once the PASG is in place only a
medical doctor may remove it; this is due to the possible rapid and large blood shift away from the torso area, resulting
a rapid decrease in the patients blood pressure.
Traction splints are commonly used to stabilize femur fractures and work by holding the broken
bones immobile and applying pressure along its length, allowing the bone ends to return to a
normal position. The purpose is to greatly reduce the pain of trauma from femoral fractures.
Traction splints are a near standard piece of equipment on most modern ambulances and are

Pneumatic
Anti-Shock

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commonly used by all first responders. While it is possible to pull traction manually, it is
difficult to maintain at a constant rate for any period of time, due to the emergency responder
becoming exhausted or distracted. Therefore, it is much more beneficial to all involved to use
a commercially available traction splint. There four basic types of commercially available
traction splints are: the Thomas Half-Ring, the Hare Traction Splint, the Sager, and the KTD. All
four use the same basic principles of traction. One end of the splint is strapped to the hip, and
pushes upward against the pelvic bone, while the other end is attached by a strap around the
ankle. At this point traction is pulled utilizing a mechanical device much like a ratchet; once the
required level of traction is achieved, secure the limb to the splint as well as the uninjured limb
and then check for neurovascular status. These devices are contraindicated with pelvic
fractures as well as injuries to the knee and lower leg. Below are examples of two of the most
common types of traction splints used in the pre-hospital setting. It should be noted that
traction splints require two rescuers in order to be properly placed into action.
Trauma Pelvic Orthotic Devices (T-POD) are utilized in the prehsopital initial treatment to
stabilize a suspected pelvic fracture. The fabric belt that is wrapped around the patient is
designed to help decrease blood loss and aid in pain control. The T-POD is a temporary device
until definitive treatment can be accomplished.

Garment (PASG)

The use of PASG is

very controversial,
to say the least, and
indeed its use has
been discontinued in
a majority of EMS
systems. EMS
providers should
follow their local
protocols regarding
the use of this
device.

Treatment Methods for Femur Fractures

We will begin our discussion of possible femoral injury treatment working from the proximal end of the femur to the
distal aspect. If you locate any significant/life-threatening bleeding or fractured bone ends protruding through the skin
(open femur fracture), ensure that you dress the wound and control the bleeding prior to proceeding. Remember to
follow all local protocols when required.
It may be difficult to determine whether the patient has suffered an actual proximal femoral fracture or an anterior
femoral dislocation. If you are unsure as to which injury was sustained by the patient, treat as an anterior femoral
dislocation. At this point you will proceed in one of two ways depending on your findings.
If you suspect a proximal hip fracture, check for CMS function in the injured limb. If you find adequate CMS functions
distally, you need to stabilize the fracture site. (Note: if CMS is not present distally to the injury, it is imperative that
you realign the limb quickly. If at any time CMS is lost, evaluate the cause and realign the limb). Next ensure that the
limb is aligned properly; if it is not aligned, do so manually, by placing one hand on the lower aspect of the injured
limbs heel and the other on the upper aspect of the foot (the top), pull down on the leg firmly and gently move it back
into its correct anatomical position. Once the limb is in place, check CMS once again ensuring that it has not been
compromised. You will now maintain manual traction while your partner prepares a traction splint. If using a traction
splint similar to the Hare Traction Splint, your partner will measure the splint against the uninjured limb, ensuring
proper sizing. Once sized, the splint is then put into place by moving it under the injured leg as the leg is lifted slightly,
while ensuring that manual traction is maintained. Once properly positioned, attach the superior traction splint strap,
sometimes called a thigh strap or inguinal strap, firmly. Next attach the ankle strap to the patients ankle and begin to
tighten the ratchet device to obtain traction. (While mechanical traction is being applied, ensure that manual traction
remains in place, until mechanical traction overtakes manual traction). Stop once the limb is secured and the patients
pain level has decreased. Once in place, ensure that the remaining straps are secured and check CMS again.
Hare Traction Splint Procedure13
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.

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Upon recognizing the injury, Rescuer One should stabilize leg in the position found.
Rescuer Two will then expose the injured leg.
Assess neurological function distal to injury site.
Assess circulatory function distal to injury site.
Rescuer Two should prepare traction splint.
Position splint against uninjured leg.
Place the ischial pad against the iliac crest.
Adjust splint to length, extending the splint so that the bend is even with the heel of the foot.
Tighten locking collars.
Open and position the Velcro straps along the splint.
Release the ratchet, extending the entire length of the traction strap.
Place the splint next to the injured leg.
Rescuer Two should apply the ankle hitch to the patient.
Rescuer Two should apply gentle but firm traction.
Rescuer One will now move the splint into position.
The splint should be firmly seated against the ischial tuberosity.
Rescuer One secures the pubic strap.
The strap is brought over the groin and high over the thigh and secured.
Rescuer One attaches the ankle hitch to the traction strap.
The traction strap is taken in, applying mechanical traction until the pain and muscle spasms are relieved.
Maintain manual traction until the mechanical traction takes over.

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Traction can be stopped when the injured leg is approximately the same length as the uninjured leg.
Secure the remaining Velcro straps around the leg.
Reevaluate all of the straps.
When splint is properly applied, the patients foot should be upright.
Reassess circulatory and neurological function distal to injury site.
Compare to original findings and note any changes.
Transport patient on firm surface, such as a long spine board, so that the splint is supported.

If you are using a traction splint similar to the Sager Traction Splint, your partner will
place the splint medially to the injured limb, with the T-shaped padded end against
How much traction should I
the pubic bone. Next your partner will secure the ankle straps to the patients ankle.
apply when using a Sager
(Remember while your partner is placing the traction splint, you must maintain
Splint?
manual traction). Once the ankle straps are properly in place, your partner will slowly
pull out the inner shaft to achieve the amount of traction desired, while observing the
amount registered on the Traction Scale. It is suggested to use 10% of the patients
Apply the amount of traction
body weight per fractured femur up to 15 pounds. Once in place, ensure that the
recommended by your medical
remaining straps are secured and check CMS again.8,9,10
director, or that required by
protocol.
Now that the traction splint has been applied, apply the pneumatic anti-shock
garment (PASG) to aid in stabilizing the fracture site. First position the PASG on the
For adults, the American
ground, open it, and place the patient on top of the garment. Next secure the legs
Academy of Orthopedic
and abdominal area using the Velcro straps. Now open the valves and begin to inflate
Surgeons recommends gentle
the leg sections first, followed by the abdominal section unless contradicted. Inflate
traction to a maximum of 15
pounds per fractured femur 30
the PASG until Velcro snaps or you are able to make an indentation in the garment.8
Monitor CMS in the patients feet as well as blood pressure, ensuring that neither one pounds for a bilateral fracture.
is compromised. Make sure that inflation is stopped once the patients systolic blood
pressure is greater than 100 mm Hg.
If you suspect an anterior hip dislocation or are unsure, do not attempt to realign the limb, but check for CMS function
in the injured limb. (If CMS is not present distally to the injury, consider upgrading the patients priority). Next carefully
position the patient on a long spinal board, maintaining the injured limb in the position found. Once on the spinal board,
place pillows and blankets around the injured limb, supporting it as well as securing it in place. You should secure the
patient in place and transport. Remember to check CMS en route to the hospital and monitor the patients vital signs.
If your patient has suffered a femoral shaft fracture, check for CMS function in the injured limb. If you find adequate
CMS functions distally, you need to stabilize the fracture site. (If CMS is not present distally to the injury, it is
imperative that you realign the limb quickly. If at any time CMS is lost evaluate the cause and realign the limb). Next
ensure that the limb is aligned properly; if it is not aligned, do so manually, by placing one hand on the lower aspect of
the injured limbs heel and the other on the upper aspect of the foot (the top), pull down on the leg firmly and gently
moving it back into its correct anatomical position. Once the limb is in place, check CMS again ensuring that it has not
been compromised. You will now maintain manual traction while, your partner prepares a traction splint. Once the
traction splint is applied check CMS again, If satisfied, package for transport.8,9,10
At times you may be faced with a situation in which you have a patient with a proximal femoral fracture or a femoral
shaft fracture and do not have a traction splint available, there are multiple patients, the patient has suffered injuries so
severe that you are unable to utilize a traction splint (such as an amputation distally to the femur), or the patient is so
unstable that you must transport immediately and are unable to apply the traction splint in the field. So what do you
do? Simply do what you can. All of us remember basic splinting from our training classes. This injury can be treated in
the same manner; although not as effective or as preferred, it will work in a crisis. First check for CMS functions distally
to the injury. (If CMS is not present distally to the injury, it is imperative that you realign the limb quickly; if at any
time CMS is lost, evaluate the cause and realign the limb). You will need to stabilize the fracture site. Next ensure that
the limb is aligned properly; if it is not aligned, do so manually, by placing one hand on the lower aspect of the injured
limbs heel and the other on the upper aspect of the foot (the top), pull down on the leg firmly and gently moving it
back into its correct anatomical position. Once the limb is in place, maintain; check CMS once again ensuring that it has
not been compromised. You will now maintain manual traction while your partner places a long padded rigid splint (if
necessary, any long, stiff object will work) on either side of the injured limb and secure it in place. At this point, you
should be able to release traction and assist your partner in securing the injured limb to the uninjured one. Once you
have secured both limbs together, move the patient to a long spinal board and transport.
During transport you should continually monitor CMS on the injured limb as well as the vital signs to include the
patients blood pressure, this is especially important with patients where PASG has been applied. Remain alert to
increased pain reported by the patient or reduced CMS in the injured limb.

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Scenario Conclusion
From your training you realize that you must perform a Rapid Trauma Assessment to ensure that there are no other
life-threatening injuries present. When none are found, you move back to the suspected fracture. After ensuring that
the CMS on the patients injured limb is intact, you place one hand on the lower aspect of the injured limbs heel and the
other on the upper aspect of the foot (the top), pull down on the leg firmly and gently reposition the injured limb into its
correct anatomical position. Your partner places a traction splint on the injured leg, and as he or she begins to pull
mechanical traction, you are able to release your hold and assist. You and your partner decide to utilize the PASG to be
safe, and position the patient on the garment. You begin to inflate the PASG and tell your partner to monitor the
patients blood pressure, ensuring that the patients systolic blood pressure does not go above 100 mm Hg. You know
that you have inflated the PASG enough when the Velcro snaps and you are able to make an indentation in the
garment. Once you are satisfied you and your partner position the patient on a long spinal board and prepare for
transport. While en route to the hospital, the patient begins to complain of increasing pain in the injured leg. You know
that the bones are becoming destabilized and you need to readjust the tension of the traction splint. Once completed,
the patient advises that his pain has lessened. You arrive at the emergency room and transfer care to the staff. You
later learn that the motorcyclist did in fact suffer a left mid-shaft femur fracture and underwent surgery to stabilize the
injury.
Author Robert Provost, Copyright CE Solutions. All Rights Reserved.

References:
1. Femur in the Medical Dictionary, Thesaurus and Encyclopedia." Medical Dictionary. Web. 30 Nov. 2011.
http://medical-dictionary.thefreedictionary.com/femur.
2. Femur Fracture | Broken Femur." About Orthopedics. Web. 30 Nov. 2011. http://orthopedics.about.com
/od/brokenbones/a/femur.htm.
3. Browner, Bruce D. Skeletal Trauma. Philadelphia, PA: W.B. Saunders, 2002
4. NHRG - Basic Anatomy." The North Herts Radiology Group. Web. 30 Nov. 2011.
http://www.northhertsradiologygroup.co.uk/anatomy.html.
5. University of Michigan Healy Systems. Femur Fracture: What Is a Femur Fracture. July 25, 2011.
http://www.med.umich.edu/1libr/sma/sma_femurfra_sma.htm.
6. Paul J Evans PA-C and McGory, Brian J MD. Maine Joint Replacement Institute. Fractures of the Proximal Femur.
July 31, 2011. http://www.orthoassociates.com/hipfx.htm
7. Pathologic Fracture (Femur)." Dr. Amilcare Gentili's Radiology Education Publications on the Internet" Web. 30
Nov. 2011. http://www.gentili.net/fracture1.asp?ID=87
8. Bruce, Browner et al. Emergency Care of the Sick and Injured 7th ed. Jones and Bartlett Publishers, Sudbury, MA.
Pg 671-676.
9. Bledsoe, B et al: Paramedic Care. Principles and Practice, Trauma Emergencies. Pearson Education Inc, Upper
Saddle River, NJ 2001. Pg 247-248.
10. LeSage, Paul, et al: EMS Field Guide, Basic and Intermediate Version. InforMed, Lake Oswego, Oregon 1998. Pg
17.
11. Winquist RA, Hansen ST Jr., Clawson DK. Closed Intramedullary Nailing of Femoral Fractures: A Report of 520
Cases. J Bone Joint Surg Am, 1984. Pg 66:529-539.
12. Emergency Care and Transportation of the Sick and Injured. Jones & Bartlett Pub, 2008
13. Hare Traction Splint Skill Procedure User Guide, Accessed October 27, 2011. http://www.haretractionsplint.com

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