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Shaft of Femur Fracture - Orthopaedic Examination Documentation

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1. HISTORY (Anamnesis)

• High-energy trauma (young patients): motor vehicle/motorcycle accident, fall from height, gunshot wounds, pedestrian hit
• Low-energy trauma (elderly/osteoporotic): fall from standing height
• Pathological fracture: known malignancy, bone metastases, unicameral bone cysts (especially in children)

• Time of injury, interval before presentation

• Immediate severe pain in the thigh
• Inability to bear weight on affected limb
• Visible deformity / shortening of limb

• Previous fractures, osteoporosis, corticosteroid use, bisphosphonate therapy (atypical fracture pattern)
• Diabetes, peripheral vascular disease (neurovascular baseline)
• Smoking and medication history

• Femoral shaft fracture in an infant (<1 year) or child 1-4 years is the most common cause being non-accidental injury (child abuse) until proven otherwise

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2. GENERAL EXAMINATION

• ATLS/ABC assessment first - femoral shaft fractures can result in 1,000-1,500 mL blood loss into the thigh; patient may be haemodynamically unstable
• Vital signs: pulse, BP, respiratory rate, GCS
• Pallor, sweating, agitation (signs of hypovolaemic shock)
• Document whether patient is in polytrauma setting

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3. LOCAL EXAMINATION (LOOK - FEEL - MOVE)

LOOK

FEEL

MOVE

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4. NEUROVASCULAR EXAMINATION (Critical - Document Formally)

• Peripheral pulses: femoral, popliteal, DP, PT - present/absent/diminished
• Capillary refill time
• Skin colour and temperature of foot/toes
• Ankle Brachial Index (ABI) if vascular injury suspected
• Note: Deep femoral artery (DFA) injury - causes haemorrhage; Superficial femoral artery (SFA) injury - causes distal ischaemia
• Vascular injury in femoral shaft fractures occurs in up to 2%, especially with gunshot/penetrating trauma

• Sciatic nerve (most important - always document)
  • Common peroneal division: dorsiflexion of foot, sensation on dorsum
  • Tibial division: plantarflexion, sensation on sole
• Femoral nerve: quadriceps power (knee extension), sensation on anterior thigh/knee
• Document: Motor power (MRC grading 0-5), sensation (intact/reduced/absent) in all distributions

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5. EXAMINATION OF JOINTS ABOVE AND BELOW

• Tenderness over greater trochanter, hip joint line
• Range of motion
• Ipsilateral femoral neck fracture must be excluded (occurs in 1-9% cases; 20-50% missed on initial evaluation)
• Hip dislocation? (limb in flexion, adduction, internal rotation = posterior dislocation)

• Tenderness over medial/lateral joint line
• Effusion (haemarthrosis suggests intraarticular injury)
• Ligamentous laxity testing: ACL (Lachman, anterior draw), PCL (posterior draw), MCL/LCL (valgus/varus stress)
• Rotational mechanism can cause associated knee ligament injury
• Patella fracture, tibial plateau injury

• "Floating knee" injury: ipsilateral tibial shaft fracture with femoral shaft fracture

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6. CLASSIFICATION (Document for Operative Planning)

• Location: proximal / middle / distal third of shaft
• Fracture pattern: transverse / oblique / spiral / comminuted / segmental / butterfly fragment
• Displacement: angulation (degrees, direction), shortening (cm), rotation
• Open / closed: Gustilo-Anderson grade for open fractures

• 32A - Simple (32A1 spiral, 32A2 oblique, 32A3 transverse)
• 32B - Wedge (butterfly fragment)
• 32C - Complex/Comminuted

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7. INVESTIGATIONS TO REQUEST

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8. PROVISIONAL MANAGEMENT (to document)

• IV access, fluid/blood resuscitation
• IV analgesia (nerve block: femoral nerve block or fascia iliaca block - document if performed)
• Traction splint (Hare / Sager / Thomas splint) applied - reduces pain, blood loss, re-displacement
  • Contraindications to traction splint: open fracture, suspected nerve/vascular injury, ipsilateral knee/ankle injury
• Wound dressing for open fractures (saline-soaked gauze); IV antibiotics
• NPO, consent for surgery
• Orthopaedic consult / trauma team activation

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9. SAMPLE DOCUMENTATION NOTE

Date/Time:

Patient: [Name, Age, Sex, MRN]

Mechanism: High-energy RTA, restrained driver, frontal impact.

Complaints: Severe pain right thigh, inability to bear weight, since 2 hours.

Vitals: HR 112, BP 96/60, RR 22, SpO2 98% on air. (Haemodynamically compromised)

Local Examination (Right Thigh):

• Look: Diffuse swelling of mid-thigh, shortening ~3 cm, external rotation deformity, no open wound. No bony protrusion through skin.
• Feel: Tenderness maximal over middle third of femoral shaft. Thigh tense but compressible. No skin tethering. Distal pulses (DP, PT) present and equal bilaterally. Capillary refill <2 seconds.
• Move: Active movements at hip and knee restricted by pain. Passive movements not tested in view of fracture instability. Abnormal mobility at mid-shaft. No crepitus elicited.

Neurovascular: Sciatic nerve: foot dorsiflexion 5/5, plantarflexion 5/5, sensation intact dorsum and sole. Femoral nerve: quadriceps 4/5 (pain-limited), anterior thigh sensation intact. Peripheral pulses intact.

Hip (above): No tenderness over hip joint or greater trochanter. Pelvis stable. Hip ROM restricted by femoral pain.

Knee (below): Small effusion. Ligamentous laxity tests deferred pending fracture stabilisation. Skin intact.

X-ray: Right femur AP/lateral - transverse fracture middle-third femoral shaft with 50% medial displacement and 2 cm shortening. No fracture femoral neck on pelvic X-ray.

Classification: AO 32A3 - simple transverse, closed.

Impression: Right femoral shaft fracture (AO 32A3), closed, middle third, haemodynamically compromised.

Plan: IV access x2, crossmatch 4 units, fluid resuscitation, IV morphine + femoral nerve block, Thomas splint applied, urgent operative planning for IM nailing.

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1. Haemodynamic status - femoral shaft is a "hidden haemorrhage" zone (up to 1.5L lost)
2. Neurovascular status - sciatic nerve and peripheral pulses, formally graded
3. Joints above AND below - ipsilateral femoral neck fracture is missed in up to 50% of cases initially
4. Open vs closed status - changes antibiotic and surgical urgency
5. Compartment status - especially if crushing mechanism or vascular repair done

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