Contact our office:

(503) 765-7615
logistics@crisis-medicine.com

Login
Crisis Medicine
  • Training
    • TCCC and TECC Concepts
    • Training for Law Enforcement
    • Training for Fire & EMS
    • Training for Private Citizens
    • Training for EDC
    • Training For Faith Communities
    • Training For Teachers
  • Courses
    • ONLINE TCCC & TECC Courses
    • In-Person Training Calendar
    • Preview Course
    • Course Overview By Skills
    • Student Reviews
  • Company
    • About Crisis Medicine
    • Agency Pricing
    • Contact
    • CM in the Media
    • Disclosures – None
    • Lessons Learned in Blood
    • Frequently Asked Questions
  • Learn
    • New
    • Quick Tips
    • MARCH
      • (S) Security & Awareness
      • (M) Massive Hemorrhage
      • (A) Airway
      • (R) Respiration
      • (C) Circulation
      • (H) Hypothermia Prevention
    • Everything Else
    • Equipment
    • Improvised
    • K9 TECC/TCCC
    • Air Travel Emergencies
    • Tactical CBRN
      • Tactical-CBRN Journal Watch
    • Planning Your IFAK
  • Store

(M) Massive Hemorrhage

A medical diagram showing the blood supply to the hip

Best Practices: Tourniquets & Closed Femur Fractures?

  • Posted by Mike Shertz MD/18D
  • Categories (M) Massive Hemorrhage

Updated 18 January 2024

BLUF:* Isolated closed femur fractures are extremely rare, the internal thigh bleeding can be substantial, but tourniquet application in these closed injuries is not likely to help.

🕖 Reading Time, 4 minutes

A closed femur fracture can bleed l to 1.5 liters into the thigh musculature. This bleeding can occur from soft tissue injury from the associated sharp fracture ends, vascular injury, and bleeding from the marrow channel itself.

Periodically students ask whether there would be a role for tourniquet application on a suspected closed femur fracture if the rescuer noticed the thigh was swelling?

In a 2001 study of 4,513 civilian patients in an urban setting, only 16 presented with mid-thigh injuries. Paramedics identified five as midshaft femur fractures.1  Statistically, these are extremely rare injuries.

There is no doubt a suspected open femur fracture with massive external hemorrhage should receive tourniquet placement. However, in a suspected closed femur fracture with expanding hematoma, is there also a role for tourniquet placement?

A tourniquet being placed high and tight pointing out the anatomical landmark of greater trochanter
I have never seen or heard of it being done. With high and tight tourniquet application, the tourniquet would be parallel to the casualty’s perineum. In most people, that corresponds to slightly below / distal to the greater trochanter of the femur (prominent point of the femur that you can feel by pushing on your outside “hip”). Since the proximal/high femur gets its blood supply from above the greater trochanter, tourniquet placement is not likely to decrease bleeding since the tourniquet, by definition, is below where the blood supply enters the high femur. Marrow channel bleeding is likely to be unaffected by tourniquet placement since it is a rigid bony tube, and its blood supply enters proximally. 

Ultimately, in a closed extremity fracture, as bleeding increases within the soft tissue, the tissue pressure will increase, which at some point will decrease the bleeding. This is basically how the iT clamp works: Trap the blood in the wound; eventually, the bleeding stops itself with its own direct pressure. Granted, in this instance, it could be 1.5 liters of blood.

One traditional argument made is that a traction splint will decrease bleeding in these fractures. The Thomas Leg Splint was designed for in-hospital femur fractures in 1875. British and French militaries fielded it during WWI. The splint supposedly saved lives in open femur fractures from gunshot wounds, though there are no studies to demonstrate this.2

IDF physicians in 2007 felt traction splints were “essential” for wartime extremity injuries. However, they noted these splints should be used for isolated femur fractures and gunshot wounds in casualties without concomitant life-threatening injuries. They also noted tourniquets specifically should not be used for femur fractures, citing likely failure and potential further injury. We presume they are referring to femur fractures without significant external bleeding. We would absolutely place a tourniquet for a femoral artery bleed associated with an open femur fracture.2

Life in the Fastlane3 did a nice literature review of traction splints. Their conclusion? There have only been five studies cumulatively providing very little evidence. The studies show traction splints are often applied to casualties with contraindications to the application, take up a lot of space, and have minimal evidence of benefit. Even the IDF acknowledges a traction splint may not be needed in urban settings, noting that simply tying the casualty’s legs together may suffice for adequate fracture mobilization. 

A systematic review on traction splints published in 2023 showed all fracture splinting decreases pain, but without clear benefit, a traction splint does it better for a femur fracture than regular splinting. They cited literature indicating there might be a reduced need for blood products in a femur fracture if a traction splint is applied. The agree there is no other evidence of benefit using a traction splint.4

Interested to learn more? Try our online courses, or get started with a sample of the material in the preview course

Preview CourseNot sure? Try a preview TRAIN NOWOnline Tactical Casualty Care Classes

References:

*For those unfamiliar with this term, BLUF is “Bottom Line Up Front,”

1Abarbanell NR. Prehospital midthigh trauma and traction splint use: recommendations for treatment protocols. Am J Emerg Med. 2001 Mar;19(2):137-40.

2Sacred Cow Slaughterhouse: The Traction Splint. https://www.emsworld.com/article/11542786/sacred-cow-slaughterhouse-traction-splint

3Femoral traction splints, helpful or not https://litfl.com/femoral-traction-splints-helpful-or-not/

4Philipsen SPJ, Vergunst AA, Tan ECTH. Traction Splinting for midshaft femoral fractures in the pre-hospital and Emergency Department environment – A systematic review. Injury. 2022 Dec;53(12):4129-4138.

Mike Shertz MD/18D

Dr. Mike Shertz is the Owner and Lead Instructor at Crisis Medicine. Dr. Shertz is a dual-boarded Emergency Medicine and EMS physician, having spent over 30 years gaining the experience and insight to create and provide his comprehensive, science-informed, training to better prepare everyday citizens, law enforcement, EMS, and the military to manage casualties and wounded in high-risk environments. Drawing on his prior experience as an Army Special Forces medic (18D), two decades as an armed, embedded tactical medic on a regional SWAT team, and as a Fire Service and EMS medical director.

Using a combination of current and historical events, Dr. Shertz’s lectures include relevant, illustrative photos, as well as hands-on demonstrations to demystify the how, why, when to use each emergency medical procedure you need to become a Force Multiplier for Good.

Previous post

Preliminary Lessons Learned from JAL516 Crash

Next post

K9 TCCC Updates

You may also like

A woman places a tourniquet on a bleeding casualty's leg
How Misleading Data Could Change Tourniquet Protocols
21 of 24 tested STAT tourniquets failed as proven with doppler ultrasound
STAT Tourniquet: 21 of 24 applications FAIL
Four photographs showing substantial injuries to various human body parts following contact with industrial high pressure water jet
Industrial high-pressure water jet injury patterns: looks like a gunshot wound

Featured Courses

Tactical Casualty Care – ONLINE

Tactical Casualty Care – ONLINE

$150.00
Advanced TC2 – ONLINE

Advanced TC2 – ONLINE

$395.00
Complete TC2  -ONLINE

Complete TC2 -ONLINE

$595.00
Improvised TECC/TCCC

Improvised TECC/TCCC

$125.00
K9 Tactical Casualty Care for Humans  – ONLINE

K9 Tactical Casualty Care for Humans – ONLINE

$75.00
Tactical CBRN Casualty Care – ONLINE

Tactical CBRN Casualty Care – ONLINE

$225.00
First Receivers – No Notice MCI Events – ONLINE

First Receivers – No Notice MCI Events – ONLINE

$175.00
Air Travel Emergencies – ONLINE

Air Travel Emergencies – ONLINE

$175.00
Sign up for updates
Our privacy policy can be found at https://www.crisis-medicine.com/privacy-policy/
Loading
Learn MoreTactical Casualty Care course

Search

The short version of the Crisis Medicine logo showing a C and M with an arrow in between the two

DUNS: 093140133

CAGE: 8U3A3

Company

  • About Us
  • Disclosures – None
  • Contributors
  • Contact

Courses

  • Online
  • In-Person
  • Content Warning
  • FAQs

Fine Print

  • Terms
  • Privacy Policy
  • Scope of Practice
  • FAQs

Resources

  • N. Amer. Rescue
  • TacMed Solutions
  • Chinook Medical
  • Skedco
  • Wound Cube

©2025 Crisis Medicine, all rights reserved.

  • Privacy
  • Terms
  • Sitemap

Login with your site account

Lost your password?