AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

This article discusses fractures of the femoral diaphysis. For proximal femur fractures (subtrochanteric to femoral head), see the article Fractures, Hip. For fractures of the distal femur (supracondylar to condylar), see the article Fractures, Knee.

The femur is the largest and strongest bone and has a good blood supply. Because of this and its protective surrounding muscle, the shaft requires a large amount of force to fracture. Once a fracture does occur, this same protective musculature usually is the cause of displacement, which commonly occurs with femoral shaft fractures.

As with many orthopedic injuries, neurovascular complications and pain management are the most significant issues in patients who come to the ED. The rich blood supply, when disrupted, can result in significant bleeding. Open fractures have added potential for infection.

The 3 types of femoral shaft fractures are as follows:

• Type I - Spiral or transverse (most common)
• Type II - Comminuted
• Type III - Open

Associated injuries are common.

Pathophysiology

Diaphyseal fractures result from significant force transmitted from a direct blow or from indirect force transmitted at the knee.

Pathologic fractures may occur with relatively little force. These may be the result of bone weakness from osteoporosis or lytic lesions.

Mortality/Morbidity

Morbidity and mortality rates have been reduced in femoral shaft fractures, mainly as the result of changes in methods of fracture immobilization. Current therapies allow for early mobilization, thus reducing the risk of complications associated with prolonged bed rest.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

History usually is obvious in cases of femoral diaphyseal fractures. Typically, patients describe a significant force applied to the extremity. Significant pain and deformity are reported as well.

Physical

• Conduct a thorough examination to rule out associated injury. Hip fractures and ligamentous knee injuries commonly are observed in association.
• At the site of fracture, tenderness on examination and visible deformity typically are noted.
• The extremity may appear shortened, and crepitus may be noted with movement.
• The thigh is often swollen secondary to hematoma formation.
• Perform a thorough vascular examination on the extremity. Signs of vascular compromise should prompt arteriography and a vascular surgery consult. Physical signs of arterial injury include the following:
• • Expanding hematoma
  • Absent or diminished pulses
  • Progressive neurologic deficits in a closed fracture
• Because of extensive blood supply to the musculature surrounding the femur, diaphyseal fractures may be associated with significant blood loss (ie, 1 L or more) and resulting tachycardia and hypotension.
• Test distal neurologic function, though examination is frequently unreliable because of the amount of pain associated with these fractures. Nerve injury is rare because of protective surrounding musculature.

Causes

• Trauma
• Lytic lesions
• • Cancerous metastasis
  • Paget disease
  • Bone cysts
• Osteoporosis

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• No specific laboratory studies are indicated. In a patient with a large, expanding hematoma, measure serial hematocrits and obtain type and crossmatch in case a blood transfusion becomes necessary.
• For patients who require open reduction and internal fixation (ORIF), obtain preoperative tests, including chest radiography and ECG.

Imaging Studies

• Anteroposterior (AP) and lateral views of the femur normally are sufficient. As with all long-bone fractures, obtain images of the joint above and below fracture.
• If a vascular injury is suspected, perform arteriography.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• Prehospital personnel should splint the extremity in the position it was found. If signs of neurovascular compromise are observed, the limb may be reduced after administering adequate analgesia. Well-aligned fractures, with or without neurovascular injury, can be immobilized by using a traction device. Hare or Thomas traction splints are most commonly used.
• Apply wet sterile dressings over an open fracture. If the wound is grossly contaminated, sterile saline irrigation may be used to remove large contaminants.

Emergency Department Care

• Fracture reduction and immobilization
• • Reduce fractures to near-anatomic alignment by using in-line traction. This reduces pain and helps prevent hematoma formation. Hold reduction by a traction device (eg, Hare, Buck) or long-leg posterior splint.
  • Pneumatic splint may have additional benefits of reducing blood loss by direct pressure and tamponade of hematoma formation. Traction is often required to hold the femur out to length because of contraction of large muscle mass in the thigh.
• Pain management: Pain management is the most significant intervention of the emergency physician. Use parenteral opiate-type analgesics to the extent that respiratory and circulatory parameters allow. Intravenous administration allows for the most reliable titration to pain relief while providing ready access for reversal agents (ie, naloxone) if necessary.
• Infection prophylaxis: With open fractures, administer tetanus toxoid (unless given within 5 y) and use antibiotics with excellent staphylococcal coverage and good tissue penetration. Often, a first-generation cephalosporin (ie, cefazolin sodium) is administered in combination with gentamicin.
• Other: In addition to maintenance intravenous fluids, patients suspected of significant blood loss should be resuscitated with crystalloids. Place a Foley catheter, and restrict all patients to taking nothing by mouth (NPO) until seen by an orthopedic surgeon.

Consultations

• Emergently consult an orthopedic surgeon.
• Evidence of vascular or progressing neurologic compromise should prompt emergent consultation with a vascular surgeon. In some hospitals, the general surgeon may have privileges for vascular intervention.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Drugs used to treat fractures are generally nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, and anxiolytics.

Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs)

These drugs are most commonly used for relief of mild to moderately severe pain. Effects of NSAIDs in treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Drug Category: Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Drug Category: Anxiolytics

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow administration of smaller analgesic dose to achieve same effect.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Adults are best treated with immediate operative fixation, typically intramedullary nailing.
• Young children typically are treated with skeletal or skin traction for approximately 4 weeks, followed by a body spica cast.
• Depending on the stage of skeletal maturity, some adolescents may be treated with initial external fixation, intramedullary nailing, or compression screw plate fixation.
• In the presence of contraindications to surgery, this repair may be delayed for days without significant complications if leg length is maintained with traction.
• Open fractures require immediate operative debridement followed by delayed intramedullary nailing.

Transfer

• Transfer patients with femur fractures when the fracture is immobilized adequately. This is best accomplished with a traction device. As an alternative, use a pneumatic or posterior molded splint.
• Reasons for transfer include the following:
• • Lack of appropriate orthopedic staff or operative facilities at the presenting center necessitates transfer.
  • Associated serious injuries, which are common, may require trauma center for ideal evaluation and management.

Complications

• Hemorrhagic shock
• • Closed fractures of the femur can result in significant blood loss (eg, 1 L) within the thigh. Open fractures have the potential for even greater blood loss.
  • Because of the high rate of associated injuries, actively seek out other sources of blood loss in patients with femur fractures and hypovolemic shock.
• Neurovascular injury
• • Injuries to the neurovascular bundle are rare because of the large cushion of muscle protecting neurovascular structures.
  • Compartment syndrome of the thigh does not occur often, and peroneal nerve contusion is seen occasionally.
• Infection: While open fractures are at high risk of soft-tissue and bony infection, postoperative infection is rare following repair of closed fractures.
• Respiratory demise: Fat embolism and adult respiratory distress syndrome (ARDS) can occur.
• More delayed complications include permanent stiffness of the hip or knee, shortening of the extremity, or malrotation, resulting in permanent deformity and decreased performance.
• Complications directly related to repair include (in order of increasing frequency) breakage of fixator hardware, nonunion, malunion, or delayed union.
• Finally, refracture has occurred at the initial injury site.

Prognosis

• Patients who survive the initial trauma associated with the injury typically heal well. Early mobilization following intramedullary nailing greatly reduces complications associated with prolonged immobilization.
• Age affects the speed and quality of recovery. Fractures may be caused by underlying medical conditions such as osteoporosis or cancer metastasis; these conditions may complicate recovery further.
• Patients older than 60 years with closed fractures of femur have a mortality rate of 17% and a complication rate of 54%.

Patient Education

• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Broken Leg.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to conduct a careful assessment to exclude other, potentially life-threatening, injuries in the presence of femur fracture, which generally denotes high-energy trauma
• Failure to consider the possibility of child abuse in young children
• Failure to reduce and stabilize angulated femur fractures as soon as possible to minimize neurovascular injury and hematoma formation

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Alho A. Concurrent ipsilateral fractures of the hip and shaft of the femur. A systematic review of 722 cases. Ann Chir Gynaecol. 1997;86(4):326-36. [Medline].
• Baron JA, Karagas M, Barrett J, Kniffin W, Malenka D, Mayor M, et al. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology. Nov 1996;7(6):612-8. [Medline].
• Blasier RD, Aronson J, Tursky EA. External fixation of pediatric femur fractures. J Pediatr Orthop. May-Jun 1997;17(3):342-6. [Medline].
• Braten M, Helland P, Myhre HO, Molster A, Terjesen T. 11 femoral fractures with vascular injury: good outcome with early vascular repair and internal fixation. Acta Orthop Scand. Apr 1996;67(2):161-4. [Medline].
• Clinkscales CM, Peterson HA. Isolated closed diaphyseal fractures of the femur in children: comparison of effectiveness and cost of several treatment methods. Orthopedics. Dec 1997;20(12):1131-6. [Medline].
• DiChristina DG, Riemer BL, Butterfield SL, Burke CJ 3rd, Herron MK, Phillips DJ. Femur fractures with femoral or popliteal artery injuries in blunt trauma. J Orthop Trauma. Dec 1994;8(6):494-503. [Medline].
• Harrington KD. Orthopaedic management of extremity and pelvic lesions. Clin Orthop. Mar 1995;(312):136-47. [Medline].
• Hogan TM. Hip and femur. In: Hart RG, Rittenberry TJ, Uehara DT, eds. Handbook of Orthopaedic Emergencies. Publishers: Lippincott Williams & Wilkins; 1999:307-8.
• Illgen R 2nd, Rodgers WB, Hresko MT, Waters PM, Zurakowski D, Kasser JR. Femur fractures in children: treatment with early sitting spica casting. J Pediatr Orthop. Jul-Aug 1998;18(4):481-7. [Medline].
• Kanel JS. Treatment of fractures of the femur in children and adolescents. West J Med. Dec 1995;163(6):570. [Medline].
• Macnicol MF. Fracture of the femur in children. J Bone Joint Surg Br. Nov 1997;79(6):891-2. [Medline].
• Mahaisavariya B, Laupattarakasem W. Late open nailing for neglected femoral shaft fractures. Injury. Oct 1995;26(8):527-9. [Medline].
• Mohr VD, Eickhoff U, Haaker R, Klammer HL. External fixation of open femoral shaft fractures. J Trauma. Apr 1995;38(4):648-52. [Medline].
• Robertson P, Karol LA, Rab GT. Open fractures of the tibia and femur in children. J Pediatr Orthop. Sep-Oct 1996;16(5):621-6. [Medline].
• Salminen S, Pihlajamaki H, Avikainen V, Kyro A, Bostman O. Specific features associated with femoral shaft fractures caused by low-energy trauma. J Trauma. Jul 1997;43(1):117-22. [Medline].
• Sartoretti C, Sartoretti-Schefer S, Ruckert R, Buchmann P. Comorbid conditions in old patients with femur fractures. J Trauma. Oct 1997;43(4):570-7. [Medline].
• Starr AJ, Hunt JL, Reinert CM. Treatment of femur fracture with associated vascular injury. J Trauma. Jan 1996;40(1):17-21. [Medline].

Article Last Updated: Aug 21, 2007