Authors of section

Authors

Peter V Giannoudis, Hans Christoph Pape, Michael Schütz

Executive Editors

Chris Colton, Rick Buckley

Open all credits

Temporary Thomas splint

1. General considerations

Thomas’ splint

Temporary stabilization of femoral shaft fractures can be achieved using the Thomas’s splint apparatus. It can also be used for transportation of patients. This can provide adequate fracture stability and pain relief until definitive stabilization is carried out.
If this method of treatment is chosen the appropriate size of the Thomas’s splint has to be selected.

Femoral shaft Thomas's splint - general considerations

Prolonged temporary treatment

If prolonged temporary treatment is envisaged, consider other methods of treatment (external fixator) to avoid soft-tissue complications (pressure sores, skin blistering under adhesive strip.)

Medical treatment

During immobilization, pharmaceutical thromboembolic prophylaxis is desirable.
Non-steroidal anti-inflammatory medication should be avoided due to reported adverse effects on fracture healing.

Thomas’s splint with children

In older children it can be used as a definitive method of treatment (for a period of four to six weeks). In younger children, the presence of the ring can displace a short proximal fragment.

Definitive treatment

In cases where there are contraindications to surgery and/or socio-economic issues do not permit fracture fixation, Thomas’s splint traction can be used as the definitive method of treatment.

Teaching video

AO teaching video: Application of the Thomas splint

2. Positioning

The patient should lie down on his or her back.

Femoral shaft Thomas's splint – Patient positioning

3. Size and length of the Thomas’s splint

Circumference

To begin, the circumference of the thigh is measured to establish the size of the inner circumference of the ring of the Thomas‘s splint.

Here the circumference of the thigh is measured as sixty centimeters.

Size and length of the Thomas’s splint

When choosing the Thomas‘s splint to be used, four centimeters should be added to the measurement to allow for swelling.

In this example, a splint with an inner circumference of sixty-four centimeters is selected.

Size and length of the Thomas’s splint

Length

The length of the patient’s leg is measured, and twenty centimeters are added to establish the length of the Thomas‘s splint.

Size and length of the Thomas’s splint

4. Preparation

Tinc Benz Co

Tinc Benz Co is used on the skin of the leg to improve the adhesion of the adhesive traction strip.

Preparation of the Thomas's splint

On the medial side, beginning at the groin, Tinc benz co is applied down to the ankle.

Preparation of the Thomas's splint

The adhesive also is spread on the lateral side from the greater trochanter down to the ankle.

Preparation of the Thomas's splint

Application of adhesive traction strip

The adhesive traction assembly will now be applied. It is important that the material does not stretch lengthwise.

Thomas's splint – Application of adhesive traction strip

The lower part of the strip is padded, to prevent pressure sores forming over the medial and lateral malleoli.

Thomas's splint – Application of adhesive traction strip

The backing is removed, and the adhesive strip is applied on the medial side, reaching proximally up to the groin.

Thomas's splint – Application of adhesive traction strip

On the lateral side, the backing is removed, and the adhesive strip is applied as far as the greater trochanter. Care is taken to verify that there are no wrinkles in the strip, as they can lead to pressure sores.

Thomas's splint – Application of adhesive traction strip

Bandage

Starting four finger-breadths above the ankle joint, a circular crêpe bandage is wound proximally, with moderate tension, towards the groin.

Again, it is crucial that there be no wrinkles in the bandage.

Thomas's splint – Bandage

A second, proximal bandage ensures that the adhesive strip is secured as far as the groin.

Thomas's splint – Application of bandage

5. Application of Thomas’s splint

Passing the splint over the leg

The Thomas‘s splint is applied by passing it over the patient’s leg, upwards, to the groin.

Application of Thomas’s splint

Limb support

Either the Thomas’s splint is fitted with slings to support the limb prior to passing it over the leg, or a Kramer wire, which must be very well-padded, to prevent pressure sores, is placed under the patient’s leg.

Proximally the support extends to the ring of the splint.

Application of Thomas’s splint – Limb support

If a Kramer wire support is used, it should be bent slightly under the patient’s knee.

Application of Thomas’s splint – Limb support

The Kramer wire must be further bent to the angle of the heel, in order to prevent pressure sores under the heel.

Application of Thomas’s splint

Secure leg and Thomas's splint

Flannelette bandage slings are used to support the leg on the Thomas‘s splint, whilst also providing support to the Kramer wire.

To complete the bandaging proximally it is passed over the ring of the Thomas‘s splint, under the Kramer wire, around the Thomas‘s splint, back under the Kramer wire, and is secured on the lateral side with a reef knot.

Application of Thomas’s splint

The second and third flannelette slings are applied in the same manner.

The second bandage is located behind the knee.

Application of Thomas’s splint

The third bandage is located just above the ankle, posterior to the Achilles tendon.

Application of Thomas’s splint

Traction

Traction is applied to the fractured femur by tightly tying the cord at the end of the traction strip assembly to the distal end of the Thomas‘s splint.

Application of Thomas’s splint - Traction

6. T-pulley installation

The T-pulley does not exert traction, but it suspends the patient’s leg dynamically to allow the patient to use a bed pan, to be bathed, etc.

T-pulley installation for Thomas's splint

The T-pulley is fixed in place.

It is suspended by tying the cord securely to the top.

The cord is passed over a proximal pulley of the traction frame, downwards and under the top T-pulley, then it goes upwards, over a second more proximal frame pulley.

T-pulley installation for Thomas's splint

The cord is passed distally, over the remaining frame pulleys …

T-pulley installation for Thomas's splint

… and sufficient weights are attached to suspend the patient’s leg.

T-pulley installation for Thomas's splint

Retightening of splint

Additional traction may be applied by re-tightening and knotting the traction cord at the distal end of the Thomas’s splint.

T-pulley installation for Thomas's splint

7. Re-tightening of splint

Additional traction may be applied by re-tightening and knotting the traction cord at the distal end of the Thomas’s splint.

Re-tightening of Thomas's splint

8. Reduction

The hands may be used to reduce the femoral fracture.

Reduction

9. Final splint adjustments

Counter traction

It should be noted that tightening the distal end of the traction cord forces the ring of the Thomas‘s splint proximally, possibly risking pressure sores at the groin.

To prevent this proximal displacement, counter traction with weights is applied to the end of the Thomas‘s splint, as shown here.

Final Thomas's splint adjustments – counter traction

Eight kilograms are generally sufficient for an adult patient, with less weight used for a younger person.

Final Thomas's splint adjustments – counter traction

Elevation of foot of the bed

The weights at the distal end of the splint will cause the patient to tend to slip gradually towards the foot of the bed.

To prevent this, the foot of the bed is elevated, so that the weight of the patient balances the weight at the distal end.

Final splint adjustments

Pressure points

A finger is passed around between the ring of the Thomas‘s splint and the groin to verify that there are no pressure points.

Final splint adjustments

If pressure points are found, then the tension in the traction cord tied to the Thomas‘s splint should be relaxed a little.

Final splint adjustments

10. Completed Thomas’s splint

The application of the Thomas's splint …

Completed Thomas’s splint

… is now complete.

Completed Thomas’s splint

11. Aftertreatment for a definitive treatment by Thomas's splint

For aftercare and rehabilitation following nonoperative treatment please refer to your local protocol.