Fracture shaft of femur

Causes

• Road traffic collision, pedestrian injury, fall from height, or crush injury
• Gunshot or other penetrating injury may cause open fracture
• Low-energy fracture suggests pathological bone disease, such as tumor, osteoporosis, or metabolic bone disease
• In children, consider non-accidental injury when the history is inconsistent

Types

• Level: proximal, middle, or distal third
• Pattern: transverse, oblique, spiral, wedge, segmental, or comminuted
• Skin status: closed or open
• Displacement: shortening, angulation, rotation, and translation

Clinical features

• Severe thigh pain and inability to bear weight
• Swelling, deformity, shortening, and external rotation of limb
• Tenderness and abnormal mobility
• Large concealed blood loss into the thigh may cause hypovolemic shock
• Examine and document distal pulses, capillary refill, motor and sensory function
• Look for associated injuries: femoral-neck/hip injury, knee ligament injury, patellar injury, pelvic injury, chest and abdominal trauma.

Investigations

• AP and lateral X-rays of the entire femur, including hip and knee
• Pelvic/hip X-ray to exclude ipsilateral neck-of-femur fracture
• CT if fracture extension or associated injury is uncertain
• CBC, blood group and cross-match, coagulation profile, renal function
• Trauma imaging and assessment as indicated by mechanism and examination

Emergency management

1. Follow ATLS principles: airway, breathing, circulation, hemorrhage control.
2. Give adequate analgesia.
3. Immobilize the leg with a traction splint only if appropriate and no suspected pelvic, hip, knee, or lower-leg contraindication.
4. Establish IV access, cross-match blood, and treat shock.
5. Perform repeated neurovascular checks.
6. For open fractures: sterile dressing, urgent IV antibiotics, tetanus prophylaxis, and urgent orthopedic debridement.

Definitive treatment

• Reamed, locked intramedullary nailing is the usual definitive treatment for most adult femoral shaft fractures. It provides stable fixation, permits early mobilization, and has a high union rate. The AAOS overview and AO guidance describe intramedullary nailing as the standard approach where feasible.
• Temporary external fixation may be used in unstable polytrauma, severe open fracture, major soft-tissue injury, or damage-control orthopedics.
• Plate fixation is reserved for selected situations, including certain proximal/distal extensions, inability to nail, or particular fracture configurations.
• Nonoperative traction is uncommon in adults and mainly used where surgery is unavailable or contraindicated.

• Infants and younger children may be treated with traction followed by hip spica casting.
• Children aged about 4-12 years may be managed with elastic stable intramedullary nails, spica/traction in selected cases, external fixation, or plating.
• Older children and adolescents more often need operative fixation. Bailey and Love's Short Practice of Surgery, pediatric femoral shaft fracture section.

Complications

• Hemorrhagic shock
• Fat embolism syndrome, typically 24-72 hours after injury
• Open-fracture infection
• Acute compartment syndrome, though uncommon in the thigh
• DVT and pulmonary embolism
• Associated femoral neck or knee ligament injury

• Delayed union, nonunion, or malunion
• Rotational deformity and limb-length discrepancy
• Knee stiffness and reduced hip/knee function
• Infection or implant failure
• Chronic pain

Prognosis

ATLS management of a femoral shaft fracture

X: Catastrophic external hemorrhage

• Immediately control visible external bleeding with direct pressure and a pressure dressing.
• If the fracture is open, cover the wound with a sterile dressing. Do not repeatedly explore the wound or push protruding bone back.
• Give IV antibiotics and tetanus prophylaxis as early as feasible for an open fracture.
• A femoral shaft fracture can cause major concealed blood loss into the thigh, so treat it as a possible source of hemorrhagic shock even when there is no external bleeding.

A: Airway with cervical-spine protection

• Assess whether the patient can speak and maintain the airway.
• Clear and protect the airway as needed.
• Maintain manual in-line cervical stabilization and use a cervical collar when the mechanism or examination suggests possible spinal injury.
• Secure the airway if there is actual or impending airway compromise, reduced consciousness, or inability to protect the airway.

B: Breathing and ventilation

• Expose and examine the chest: inspect, palpate, percuss, and auscultate.
• Give oxygen and monitor oxygen saturation.
• Identify and immediately treat lethal thoracic injuries, especially tension pneumothorax, open pneumothorax, massive hemothorax, and flail chest.
• In a patient with a femoral fracture and hypoxia or respiratory deterioration, consider associated chest trauma initially. Fat embolism syndrome is usually a later complication rather than a first-minute diagnosis.

C: Circulation with hemorrhage control

• Assess pulse, blood pressure, skin perfusion, mental status, capillary refill, and ongoing bleeding.
• Insert two large-bore IV cannulas, or intraosseous access if needed.
• Send blood for CBC, group and cross-match, coagulation studies, and other trauma blood tests.
• Start warmed blood-product-based resuscitation when hemorrhagic shock is suspected, according to local massive hemorrhage protocol. Avoid excessive crystalloid.
• Look systematically for bleeding in the chest, abdomen, pelvis, retroperitoneum, external wounds, and long-bone fractures.
• Examine and record distal limb perfusion: dorsalis pedis and posterior tibial pulses, capillary refill, temperature, motor function, and sensation.
• Splint the femur early. Gentle alignment and immobilization reduce pain, movement, bleeding, and soft-tissue injury.

D: Disability, neurologic assessment

• Assess GCS, pupils, and limb movement.
• Check sensation and motor function in the affected leg, especially foot and ankle movement.
• Repeat the neurovascular examination after splinting or any manipulation and document findings.

E: Exposure and environmental control

• Fully expose the patient to detect other injuries, including pelvic wounds, open fractures, bruising, and deformity.
• Prevent hypothermia with warm blankets, a warmed environment, and warmed fluids/blood products.
• Log-roll only when appropriate and maintain spinal precautions until spinal injury is excluded.

Adjuncts to the primary survey

• Continuous monitoring: ECG, pulse oximetry, blood pressure, temperature, and urine output when indicated.
• Portable chest and pelvic X-rays in the unstable trauma patient.
• Full-length AP and lateral radiographs of the femur including hip and knee once the patient is stable enough.
• CT trauma imaging only after resuscitation and stabilization, unless it would delay necessary hemorrhage control or surgery.
• Give adequate analgesia, but do not let it delay ABCDE management.

Secondary survey

• Ipsilateral femoral-neck fracture or hip dislocation
• Pelvic fracture
• Knee ligament injury, patellar injury, and distal femoral injury
• Open fracture and soft-tissue damage
• Compartment syndrome
• Fat embolism syndrome during subsequent observation
• DVT and pulmonary embolism risk

Definitive orthopedic management

• Hemodynamically stable patient: early definitive fixation, usually locked intramedullary nailing.
• Unstable polytrauma patient: damage-control orthopedics, commonly temporary external fixation, with later definitive fixation once physiology has normalized.
• Open fracture: urgent orthopedic debridement, antibiotics, tetanus prophylaxis, stabilization, and coordinated soft-tissue management.

Exam summary