Traction Splint

Part of First Aid

A broken femur is one of the most dangerous fractures you can sustain — the powerful thigh muscles pull the bone ends apart and can cause fatal internal bleeding. A traction splint counteracts that force and can save a life.

Why the Femur Is Different

The femur (thighbone) is the largest, strongest bone in the human body. Breaking it requires massive force — a fall from height, a crush injury, a vehicle impact. What makes femur fractures uniquely dangerous is the muscle response.

The quadriceps (front of thigh) and hamstrings (back of thigh) are among the most powerful muscles in the body. When the femur breaks, these muscles spasm and contract involuntarily, pulling the broken bone ends past each other. This causes three life-threatening problems:

1. Internal bleeding. The overlapping bone ends tear through muscle tissue and blood vessels in the thigh. A closed femur fracture can bleed 1-2 liters into the thigh compartment — enough to cause hemorrhagic shock and death
2. Nerve and vessel damage. The femoral artery and nerve run alongside the femur. Displaced bone ends can sever these structures
3. Pain-induced shock. The pain from a femur fracture with uncorrected muscle spasm is extreme and contributes to cardiovascular collapse

A standard rigid splint (see Rigid Splints) immobilizes the fracture but does nothing about muscle spasm. A traction splint applies a continuous pulling force to the leg that counteracts the muscle contraction, separates the overlapping bone ends, and restores the thigh to its normal length. This reduces bleeding, relieves pain dramatically, and can be the difference between the patient living and dying.

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When to Use a Traction Splint

Apply a traction splint when:

• There is a suspected mid-shaft femur fracture (pain, deformity, and/or shortening of the thigh between the hip and the knee)
• The injured leg appears shorter than the uninjured leg (measured from hip bone to heel)
• The thigh is swollen and rigid from internal bleeding and muscle spasm

Do NOT apply a traction splint when:

• The fracture is near the hip joint or near the knee joint (traction pulls the joint apart rather than aligning the bone)
• There is also a fracture of the lower leg on the same side (traction transmitted through the knee can displace the lower fracture)
• There is a dislocated hip or knee
• The foot or ankle on the injured side is severely injured (the ankle is the anchor point for traction — an injured ankle cannot tolerate this)

Warning

A traction splint is an advanced technique. Done incorrectly, it can worsen the injury. But for an isolated mid-shaft femur fracture, NOT applying traction may result in death from blood loss or shock. If you meet the criteria above, the benefits outweigh the risks.

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Anatomy of an Improvised Traction Splint

A traction splint has four components:

1. The frame — a rigid pole or board that runs along the outer side of the leg, from the hip down past the foot. Must extend at least 30 cm beyond the sole of the foot
2. The ischial pad — padding at the top of the splint that rests against the ischial tuberosity (the bony part of the pelvis you sit on). This is the anchor point — traction pulls the leg against this pad
3. The ankle hitch — a figure-eight or stirrup strap around the ankle/foot that transmits the traction force to the leg
4. The windlass — a stick used to twist a cord or strap to apply progressive traction force

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Building an Improvised Traction Splint

Materials Needed

Component	Material	Specifications
Frame pole	Straight, strong branch, board, or metal pole	At least 30 cm longer than the patient’s leg (hip to foot), 4-6 cm diameter
Cross-bar	Short stick or board	15-20 cm long, lashed perpendicular to the bottom of the frame pole
Ischial pad	Rolled towel, folded clothing, padding	Large enough to distribute pressure across the buttock/groin crease
Ankle hitch	Cloth strips, belt, cravat	Two strips, each at least 60 cm long and 5 cm wide
Windlass stick	Any stick	15-20 cm long, pencil-thickness or larger
Ties	Cloth strips, belts, cordage	At least 5-6 ties to secure the leg to the frame
Padding	Cloth, moss, clothing	Line the entire inner surface of the frame

Step-by-Step Construction

Step 1 — Prepare the frame. Cut or find a rigid pole/board at least 30 cm longer than the patient’s full leg (measure from the hip to the foot on the uninjured side, then add 30 cm). Lash a short crossbar perpendicular to the bottom end of the frame — this is the traction anchor. The crossbar should extend equally on both sides of the frame pole, creating a T-shape.

Step 2 — Prepare the ischial pad. Roll a towel, jacket, or other padding into a firm cylinder approximately 15 cm long and 8-10 cm in diameter. Attach it firmly to the top end of the frame, perpendicular to the pole, so it will rest in the groin crease against the ischial tuberosity when the splint is positioned.

Step 3 — Prepare the ankle hitch. Take two cloth strips, each approximately 60 cm long. Place one strip on each side of the ankle, crossing them under the sole of the foot and over the top of the foot in a figure-eight pattern. This creates a stirrup that distributes traction force around the ankle without putting all the pressure on one point.

Alternatively, use a single broad strap (belt or cravat) passed under the foot and brought up on each side. Pad the ankle bones (malleoli) before applying the hitch — these are pressure-sensitive and will develop sores quickly under traction.

Step 4 — Position the frame. Place the frame along the outer side of the injured leg. The ischial pad should press firmly into the groin crease at the top. The crossbar at the bottom should extend well past the sole of the foot.

Warning

The ischial pad must rest against the ischial tuberosity (sit bone), NOT against the femoral artery or genitalia. Position it in the crease between the thigh and the pelvis, pressing against bone. Incorrect placement can compress the femoral artery and cut off blood supply to the entire leg.

Step 5 — Secure the frame to the leg. Using cloth strips or belts, tie the frame to the thigh and lower leg at 4-5 points. Do NOT tie directly over the fracture site. Pad between the ties and the skin.

Tie points:

• Upper thigh (just below the ischial pad)
• Lower thigh (above the knee, well below the fracture)
• Below the knee
• Mid-calf
• Above the ankle (below the ankle hitch)

Step 6 — Attach the ankle hitch to the crossbar. Run the tails of the ankle hitch straps down to the crossbar at the bottom of the frame. Tie them loosely to the crossbar for now — you will tension them in the next step.

Step 7 — Apply traction. This is the critical step. Traction should be applied slowly and progressively.

1. Tie a length of cord from the ankle hitch tails to the crossbar, leaving enough slack to insert a windlass stick
2. Insert the windlass stick between the cord strands
3. Begin twisting the windlass slowly — each twist shortens the cord, pulling the foot toward the bottom of the frame while the ischial pad anchors the pelvis
4. Apply traction until the injured leg is approximately the same length as the uninjured leg. Measure from the front of the hip (anterior superior iliac spine) to the heel on both sides
5. The patient should report significant pain relief as traction is applied — this confirms correct technique
6. Secure the windlass by tying it to the frame so it cannot unwind

How much traction force:

• Apply approximately 10% of the patient’s body weight. For a 80 kg person, roughly 8 kg (18 lbs) of force
• In practice, increase traction until the patient reports pain relief and the leg lengths approximately match
• Do NOT over-traction. Excessive force can damage the ankle, knee, or hip joint. If the patient reports increasing pain (especially at the ankle or knee), reduce traction

Step 8 — Secure and stabilize.

• Bind the injured leg to the uninjured leg at the knees and ankles for additional lateral stability
• Place padding between the knees and between the ankles
• Recheck all ties and circulation

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Post-Application Monitoring

Check every 30 minutes:

• Circulation in the foot: pulse at posterior tibial artery (behind the inner ankle bone), sensation in toes, ability to wiggle toes
• Ankle hitch: is it cutting into the skin? Is padding still in place?
• Traction: has the windlass loosened? Is the leg still at correct length?
• Ischial pad: has it shifted? Is it still on the sit bone, not on soft tissue?
• Ties: have any become too tight as swelling progresses?

Signs that something is wrong:

• Loss of pulse in the foot — loosen ankle hitch, recheck ischial pad position
• Increasing pain at the ankle — add more padding, reduce traction slightly
• Skin pallor or blue discoloration of toes — circulation compromised, loosen ties
• Numbness spreading up the leg — nerve compression, reposition and loosen

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Transport Considerations

A patient with a femur fracture cannot walk. They require a stretcher or other transport. The traction splint must remain in place during transport.

• The splint extends past the foot — account for extra length when building a stretcher or loading into a vehicle
• Keep the leg elevated slightly if possible to reduce swelling
• The windlass must be secured so that jostling during transport does not allow it to unwind
• Assign someone to monitor the splint during transport — checking circulation, traction tension, and pad position

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Expected Outcomes

With proper traction splinting:

• Pain decreases significantly within minutes of applying traction
• Internal bleeding slows as the bone ends separate and the thigh compartment is decompressed
• The leg returns to approximately normal length and alignment
• Healing time for a femur fracture is 12-16 weeks with continued immobilization

Without traction:

• Continued muscle spasm drives bone ends through soft tissue
• Internal bleeding of 1-2 liters is common; some cases bleed more
• Hemorrhagic shock develops within hours
• If the patient survives, the femur heals shortened, causing permanent limping and disability

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Key Takeaways

• Femur fractures are life-threatening due to massive internal bleeding caused by muscle spasm pulling bone ends apart — a traction splint counteracts this force
• The four components are: rigid frame, ischial pad (anchored on the sit bone), ankle hitch (figure-eight around the ankle), and windlass (twisting stick to apply tension)
• Apply approximately 10% of body weight as traction force, increasing until the patient reports pain relief and leg lengths match
• Never apply traction if the fracture is near the hip or knee joint, or if there is a concurrent lower leg fracture on the same side
• Monitor circulation in the foot every 30 minutes — the ankle hitch and traction force can compromise blood flow if not properly padded and tensioned