Splinting: Long Bone, Joint and Traction Splints

Suspected femoral shaft fracture: a static or traction splint is an accepted choice, and traction is used only after you have excluded a distal femur fracture, knee joint disruption, and ipsilateral leg or pelvic fracture.

A splint keeps a suspected fracture or dislocation still. Less movement means less pain, and that matters before transport. For a suspected femoral shaft fracture, the NAEMSP 2025 statement accepts either a static splint or a traction splint.

How It Works

• Static splint: a rigid or padded device that holds the limb where you find it. Fewer risks than traction, and less technique to master.
• Traction splint: pulls along the length of the thigh, anchored by an ischial pad and an ankle attachment. It brings contraindications and technical demands that a static splint does not.
• Pain control: the splint goes with analgesia. The NAEMSP statement asks EMS to give it whenever it is within scope and available.
• Shock needs a search, not a dismissal: Mitchnik 2022 (an Israeli military registry) reported that femur fracture was rarely the sole cause of shock. Open femur fractures in shock did bleed into the thigh, and that bleeding was hard to control. Look for other bleeding, control what you find, and treat the shock.

Where It Fits

Pick the splint once the trauma assessment and the exclusion checks are done. Traction does not replace control of external bleeding, and it does not replace care for an airway, breathing or circulation problem.

Indications

• Suspected femoral shaft fracture with pain, deformity or abnormal movement (static or traction splint)
• Other suspected long bone or joint injury where splinting reduces movement and pain (per local protocol)
• Traction only: midshaft femur fracture after the exclusion checks below are complete

Absolute Contraindications

• Traction: suspected distal femur fracture
• Traction: knee joint disruption
• Traction: co-morbid ipsilateral lower-leg fracture or pelvic fracture
• Traction: hip or proximal femur injury (device IFU and protocol)
• Traction: ankle or foot injury on the affected limb, where the ankle hitch cannot be applied (device IFU and protocol)
• Traction: partial amputation or avulsion with the limb held by marginal tissue (device IFU and protocol)

The first three items are the NAEMSP 2025 exclusions. Hip, ankle or foot, and partial amputation come from device instructions and common EMS teaching, and the NAEMSP statement does not list them. Check them against your agency's device.

Relative Contraindications & Cautions

• Shock: By the Mitchnik 2022 definition (SBP ≤90 mmHg and/or HR ≥130/min), a femur fracture with shock calls for finding and controlling other bleeding. Shock alone is not a reason to skip the exclusion checks or to apply traction.
• Knee injury: a lateral knee injury may come with a suspected femur fracture. Case reports describe peroneal nerve palsy after traction
• Open fracture with exposed bone: some agency protocols list this as a contraindication to traction. Traction can pull contaminated bone back into the wound. Unless your protocol directs traction, use a static splint. Control bleeding and cover the wound first (see Step-by-Step)
• Unreliable assessment: if you cannot reliably assess the fracture level, knee, hip, ankle or pelvis, use a static splint

Consider an Alternative

A static splint is the fallback when traction is excluded or cannot be applied safely. The NAEMSP statement says regional anesthesia may have a role, but only with appropriately trained EMS clinicians.

Abort / Stop Criteria

• Loss of distal pulse, sensation or motor function after splinting: release the traction or loosen the splint, then reassess
• Bleeding that continues through the splint or dressing: control it first and reassess shock

Team Roles During the Procedure

• Operator: runs the exclusion checks and applies the splint
• Limb holder: keeps the limb steady during application and any traction change
• Analgesia and monitor: gives analgesia and watches vitals and perfusion
• Recorder: records times, neurovascular findings, analgesia and the destination

Equipment

Sizing

Size the device to the patient, then check it against the uninjured leg. Follow the device instructions. You will find pediatric sizing and weight bands on Equipment Sizing.

Patient Positioning & Preparation

Expose the limb so you can see the injury, then pad it before the device goes on. Keep the patient on a stable surface.

These doses are typical adult and pediatric references. Check them against local protocol and the current drug labeling. Doses vary by protocol; follow local protocols and medical direction.

Non-opioid analgesics such as acetaminophen may be part of your protocol for minor injuries. Before any NSAID, check bleeding risk and hemodynamics.

Non-drug options exist too. The 2021 paramedic pain systematic review found auricular acupressure, TENS and fascia iliaca compartment block effective. Paramedics could use them. Only use them where your protocol and training allow.

Phase 1: Prepare

1. Assess the whole patient: Find all bleeding and other injuries before choosing a splint.
2. Screen for traction exclusions: Check the distal femur, knee, hip, ipsilateral leg, ankle, foot and pelvis, and look for partial amputation. If any is suspected, do not apply traction.
3. Start analgesia and access: Give analgesia per protocol and secure IV or IO access.
4. Record baseline neurovascular status: Document pulse, sensation and motor function of the limb.

Phase 2: Perform

5. Choose the device: Use a static splint if any traction exclusion is present, cannot be ruled out, or traction cannot be applied safely. An open fracture with exposed bone is also a reason for a static splint unless your protocol directs traction.
6. Pad the limb: Pad bony points and the splint edges before applying the device. For an open fracture, cover the wound with a sterile dressing and do not push exposed bone back; give antibiotics per local protocol. Exposed bone favors a static splint unless your protocol directs traction.
7. Apply a static splint: Apply in the position found and secure the joints on each side of the injury per device instructions.
8. Apply a traction splint (if chosen): Place the ischial pad, attach the ankle hitch and apply traction in steps per device instructions.
9. Stop at the endpoint: Stop at the protocol endpoint. Endpoints vary between agencies; do not over-traction.

Phase 3: Confirm & Secure

10. Re-check neurovascular status: Document distal pulse, sensation and motor function after splinting (see Confirmation & Monitoring).
11. Secure and reassess pain: Confirm straps and padding, and reassess pain after analgesia.
12. Plan the destination: Transport to a major trauma center if CDC/ACS 2021 field triage criteria are met, or per local trauma triage protocol.

Alternative Technique: Other Long Bone and Joint Splints

Think of these as protocol-level teaching points. The NAEMSP 2025 abstract addresses femur fractures and nothing else.

• Immobilize the joints above and below the suspected injury, using the device and protocol you have.
• Pulseless or severely angulated limb: per local protocol, one gentle attempt to realign toward the anatomic position. Stop for pain, resistance or a new change in perfusion, splint in the position found, and notify medical direction and the receiving trauma center.
• Forearm, wrist or hand: rigid or vacuum splint with the joints above and below immobilized.
• Humerus, clavicle or shoulder: sling and swathe per protocol; do not lift the arm to pad the axilla.
• Pelvis or hip: pelvic binder per protocol (see the Pelvic Binder page); do not use traction for a hip or pelvic injury.
• Knee, hip or elbow dislocation with a pulseless limb: treat it as an emergency and get the patient out fast. Attempt realignment only as your protocol directs. A knee dislocation can injure the popliteal artery.
• Ankle or lower leg: splint the foot in the position found, and re-check pulse, sensation and motor after each move.

Primary Confirmation

Document distal pulse, sensation and motor function before and after splinting, and after every move. A stable limb in the splint with unchanged neurovascular findings is the objective check that it worked.

Secondary Confirmation

• Pain score lower after analgesia and splinting
• Limb stays in the splint position without slipping
• No new bleeding through the padding

Expected Findings

Ongoing Monitoring

• Repeat pulse, sensation and motor checks after every move and at protocol intervals
• Vitals and perfusion monitoring, especially with femur fractures
• Analgesia response and sedation level after each dose

Pediatrics

• The NAEMSP 2025 statement covers immobilization and analgesia for suspected femur fractures. It applies to adult and pediatric patients
• Fentanyl pediatric IV/IO dose is 1 mcg/kg (max initial 100 mcg); intranasal dosing is in the medication table; see the fentanyl page for weight-based dosing
• Device sizing and weight bands: Equipment Sizing; dosing: Weight-Based Dosing
• Pediatric traction indications and sizing have not been verified in a retrieved source. Follow local protocol
• Pad well. Size the device with the length-based tape in your protocol
• A non-ambulatory child with a femur fracture and a history that does not fit the injury: consider non-accidental trauma, and follow your child-protection protocol

Older Adults

• A hip fracture may show shortening and external rotation. Do not use traction for a hip injury
• Anticoagulated patients may bleed more. Look for other bleeding
• Fragile skin: pad under straps and at the ischial and ankle contact points

Pregnancy

• Past about 20 weeks, tilt the patient to the left to limit aortocaval compression
• Keep straps and padding off the abdomen. Check fetal status per protocol, and document it

Bariatric

• If your agency stocks a longer or bariatric-rated device, use it. Standard straps may not fit

Physiologically Difficult

• Shock: look for other bleeding before you blame the femur fracture
• Multiple injuries: the traction exclusions still apply when a pelvic or lower-leg fracture comes with the femur fracture

The older adult, pregnancy, bariatric and most pediatric points are protocol-level teaching. No retrieved primary source backs them. Confirm them with local protocol and medical direction.

Immediate Aftercare

Once the splint is on, and before the patient moves, re-check neurovascular status and the analgesia response.

Ongoing Maintenance

• Re-check straps and padding after every move
• Watch the skin under the straps and at the ischial and ankle contact points for pressure injury
• Re-check for compartment syndrome: pain out of proportion, tense swelling, pallor, pulselessness

Transport Considerations

• Triage to a major trauma center per the 2021 CDC/ACS National Guideline for the Field Triage of Injured Patients, or local trauma triage protocol. Suspected fractures of two or more proximal long bones, or a suspected pelvic fracture, are high-risk criteria. A single femur fracture alone is not
• Air-based EMS may be the right call in select circumstances
• Reassess pulse, sensation and motor function after every move and on the way

Pearls

• Static is a full option: the NAEMSP statement does not make traction mandatory for midshaft femur fractures
• Exclude first: screen for distal femur, knee, ipsilateral leg and pelvic injury before you reach for traction
• Shock needs a search: femur fracture is rarely the only cause of shock. It can still hide substantial thigh blood loss. In Mitchnik 2022, open fractures bled hardest. Find it and control it
• Analgesia belongs with splinting: give it per protocol

Common Pitfalls

• Traction applied before anyone checked the knee and pelvis → examine both first, and use a static splint if it stays unclear
• Shock blamed on the femur → look for other bleeding and control it
• Traction used to hold a patient too unstable to move → splint, control the bleeding, then move
• Pain relief taken as success → re-check pulse, sensation and motor

Skill Maintenance

• Practice device application as often as your agency sets. The NAEMSP statement flags skill decay as a concern for infrequent traction use
• Rehearse the exclusion checks in a scenario that ends in a static splint
• Debrief after each application: exclusion checks, endpoint, neurovascular findings
• Check device expiry and sizing during equipment checks