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Thomas Spint – how to apply

Invented by a Welshman ‘Hugh Owen Thomas’, the introduction of this simple device in World War 1 went on to reduce the mortality of #femurs from 80% to 16%.

The Kit

  • Measuring Tape
  • Thomas splint – Adult or Paediatric (depending on size)
  • Hoop – Sizing guide can be found here
  • Slings
  • Hoop Pad
  • Skin Traction – Adult or Paediatric
  • Padding rolls x 2
  • Bandages (wide) x 2
  • Tape
  • Scissors
  • Tongue Depressors x 2

Printable application guide

Measuring

Measure the Inside Leg (unbroken leg) and add 30cm/12inch (to give room for the traction)

Adjusting Splint

Adjust length to the above measurement. ensuring the Hoop is at an angle with the lateral (outside leg) higher than the medial (inside leg).

Set up

  • Apply the hoop Pad (to reduce pressure and secure to tight)
  • Apply the 4 slings (lowest should be 40cm from base)
  • Apply padding along slings
  • Creat a small padding for behind the knee

Application

  • Ensure Adequate analgesia (this hurts) – typically Opiates and entonox
    • Femoral nerve block may be helpful (however, this is variable due to the innovation of the femur and reduces the more distal the fracture)
  • Check Genitals not trapped – by the hoop
  • Apply skin traction & and bandage from ankle to thigh
  • Secure the tight Clip – remembering to put the padding under the clip and velcro round

The Knot

1. take the strings and pass one over and one under the sides of the frame.

2. secure tightly with a Reef Knot

3. pass strings down (one over and one under) around the base, bringing them back over the Reef Knot and  back around the base. This makes a pulley system.

4. Tension the pulley system and tie-off using a bow

5. Pass the tongue depressors (2 tongue depressors tapped together), twist the tongue depressors to achieve the required tension, and lock off against the side.

 

Bandage & Elevate

  • Bandage the leg to the sling using the bandage – to keep secure
  • Place a pillow or blankets under the splint to elevate the heel – To prevent pressure sores

Purple Glove Syndrome – Case

Is a rare complication of I.V. Phenytoin, which presents with a triad of: Pain, Oedema & Discolouration, typically in the hand.

In our case a child presented in status epilepticus, having received rectal diazepam from the ambulance crew, then 0.1mg/kg lorazepam in the ED, followed by 20mg/kg I.V. Phenytoin over 30 min, via a 24g cannula in back of the hand.

After intubation the patients thumb, index and middle fingers were all noted to be purple. Radial pulse was weak however, we saw good flow on ultrasound doppler in the ED. The patient had no cardiovascular Hx or FHx.

 

What the literature says

Mechanism (poorly understood)

  • Phenytoin is highly Alkaline and may induce vasoconstriction and thrombus, resulting in  leakage into the extravascular tissue.
  • Phenytoin may precipitated when it mixes with acidic blood (More common in status patients rather than prophylaxis)
  • I.V. Canulation may cause small tears promoting extravasation (In our case the cannula required repositioning on insertion)

Prevention

  • Phenytoin infusion rate should be the lesser of 1-3mg/kg/min OR under 50mg/min (In our case the infusion rate was 22mg/min, less than 1mg/kg/min)
  • Smaller hand veins should be avoided (As in our case, most reports in literature involve the use of hand veins)
  • Use 20G cannula or larger (This is ideal for adults and older children)
  • Ensure filter used with phenytoin infusions

Stages

  1. Dark purple – Pale blue discolouration occurs around or distal to injection site 2-12hrs after administration. (In our case approx 30 min)
  2. Discolouration and Oedema progresses around site and into fingers, hand and forearm over the next 12-16 hours
  3. Healing, starts at the periphery  moving towards the injection site – most patients have a full recovery over 72hrs (few cases of necrosis requiring amputation have been reported

Treating

  • Stop giving phenytoin
  • Dry Warm Heat (moist heat my contribute to skin breakdown)
  • Elevate
  • Analgesia
  • Regular neuromuscular assessments
  • Avoid Cold (this will worsen the vasoconstriction)
  • GTN patches have also been used in several of the cases but efficacy is unknown

Learning Points

  • Avoid Hand veins for I.V. Phenytoin (this seems to be a contributing factor form the evidence, be it due to small size or more frequent injury of the vein though need to reposition?)
  • Avoid Cannulas that required repositioning (increase chance of leaking)
  • Use a big cannula (easier said than done in a fitting child)

 

References