# Thomas Splint Application

## Overview

This module describes how to apply a Thomas splint to immobilise a suspected fractured femur prior to diagnostic imaging, and to reduce pain, blood loss, and the risk of fat embolism and pulmonary complications.

## Indications

1. Suspected femur fracture

## Contraindications

1. None

## Patient information & consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“I suspect you have broken your thigh bone. I’m going to straighten your leg and apply a special splint until I can get an X-ray of your leg to confirm the diagnosis. Having the splint on may seem uncomfortable, but because it reduces movement of the broken bone, it will actually reduce your pain and prevent the broken fragments from damaging surrounding tissue.”

### What can my patient expect?

“I’m going to wrap your leg in a bandage, place it in a metal splint, and apply traction to the end of the splint to slightly separate the ends of your broken thigh bone, preventing them from rubbing against each other. This is usually uncomfortable but you will feel much better once the splint is on.”

### What is my patient’s role?

“Let me know if it becomes too painful. Try not to move around too much while we put on the splint.”

## Preparation

An assistant is needed for this procedure.

### Documentation

1. Patient notes

### Equipment

1. Equipment for analgesia/sedation

2. Thomas splint

3. Stockinette (or bandage if this is not available)

4. Two elastic bandages

5. Skin traction device

6. Pillow to elevate leg

## Site & Positioning

The patient should be supine. The affected leg will usually tend to be shortened and externally rotated. Applying a Thomas splint will help to internally rotate the affected leg to a neutral position.

## Procedure

Follow medical asepsis without gloves.

1. Perform hand hygiene.

2. Give analgesia or sedation as required.

3. Test the patient’s

   neurovascular status
   neurovascular status

   Look at the colour, capillary refill, and ask the patient about sensation and if the toes can be moved.

   .

4. Wrap the length of the Thomas splint with stockinette or bandages.

5. Place the patient’s foot in the stirrup of the skin traction device, with the malleoli covered with the foam padding. Leave 10 cm of space between the sole of the foot and the stirrup beneath it. Unroll the long ends up either side of the leg to the hip. Confirm that there is no knot where the two rope ends exit the stirrup of the traction device.

6. Ask your assistant to lift and hold traction on the leg. Starting above the malleoli, wrap an elastic bandage with 50% overlap around the leg all the way to the upper thigh to secure the skin traction device.

7. Slide the Thomas splint under the leg, all the way up to the groin until the ring abuts the ischial tuberosity posteriorly. Your assistant should maintain traction. The longest part of the splint should be at the hip, with the shorter part in the groin.

8. Gently internally rotate the foot if it is externally rotated.

9. Wind the outer string of the skin traction device over and under the outer side of the Thomas splint, and the inner string under and over the inner side of the Thomas splint.

10. Tie a

    reef knot
    reef knot

    between the two strings.

11. Wind the strings around the bottom of the Thomas splint and around the reef knot a few times to create a pulley. Pull to apply traction to the leg.

12. Knot the strings around the bottom of the Thomas splint, maintaining the traction you created.

13. Elevate the leg with a pillow under the splint. The heel should be free in the air.

14. Confirm that there is no risk of pressure sores by checking potential pressure points (proximal ring in perineum, heel, etc).

15. Test the patient’s

    neurovascular status
    neurovascular status

    Look at the colour, capillary refill, and ask the patient about sensation and if the toes can be moved.

    .

16. Send the patient for imaging and refer to orthopaedic surgery for definitive treatment.

## Troubleshooting

The patient is complaining of pain in the gluteal area.

This may be more uncomfortable for the patient than a well-reduced fracture itself. Augment the padding on the ring and try to position the patient more comfortably with pillows. Ensure the patient has adequate analgesia. Check that the scrotal and labial tissues have not been impinged.

## Risks

1. Pressure ulcers & infected wounds under the splint/heel

2. Compromised neurovascular status and loss of limb

3. Fat embolism

4. Blood loss due to fracture

## References

1. Held M. Orthopaedics for Primary Health Care. Available from: https://www.ortho.capetown/primary-care-orthopaedics

2. Video: https://www.youtube.com/watch?v=nI2FkT7Jmxc&ab_channel=UCTOrthopaedicsDept