Disclosure Orthopedic surgeons often encounter diaphyseal femur fractures. Because these fractures most often result from high-energy trauma, one must have a high index of suspension for complications or other injuries. While the mainstay of treatment has been reamed interlocking intramedullary nailing, a variety of treatment options exist for solitary fractures or fractures with associated injury. Adult nonsurgical treatment options include skin traction, skeletal traction, cast brace, casting. Nonsurgical options are used infrequently outside of the younger pediatric population. Children have the same options, as well as spica casting for those weighing less than 80 lb. Surgical options in adults include the mainstays of intramedullary nailing, either antegrade or retrograde. Plate fixation and external fixation are used less frequently, but these have a place in the decision-making process for the ideal treatment in certain cases. Pediatric cases may also use flexible rods in addition to the adult options mentioned. However, one must consider the patient's immature bones, open physes, parental care available, and growth potential when forming a treatment plan in children. For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles Broken Leg and Cast Care. History of the Procedure: Prior to the 1900s, femoral-shaft fractures were treated with various types of splinting. However, with the discovery of skeletal radiology near the end of the 19th century came an understanding of the forces acting on fractured bones and a change in the treatment of such injuries. In 1907 and 1909, Steinmann and Kirschner respectively developed the first traction treatment modalities with the use of pins or wires under tension. Early attempts at internal fixation of such fractures achieved little success until Küntscher developed and utilized the intramedullary nail in 1937. After a short period of disagreement, the nailing method began to spread during World War II in Europe and later in North America. Intramedullary nailing became prominent in the United States in the 1970s. Since the intramedullary nailing technique was introduced in 1939, it has continued to evolve into the antegrade reamed interlocking nails that are the standard today. Problem: Femoral-shaft fractures are usually easy to treat compared with the high-energy injuries associated with the fracture, in which complications tend to occur. Severe–to–life-threatening injuries often occur along with the femoral-shaft fracture. Death, fat embolism, deep venous thrombosis (DVT), pulmonary embolism, pneumonia development, multiorgan failure, long intensive care unit (ICU) stays, infection, hemorrhage, nerve palsies, rare compartment syndrome, nonunion, delayed union, and malunion may also occur as complications of a diaphyseal femur fracture. Frequency: Fractures of the femoral shaft are among the most common fractures that orthopedist see. Injury is most common among persons younger than 25 years and those older than 65 years. Analysis of a statewide discharge database for 1989-1992 revealed an incidence of 1.33 fractures per 10,000 people. The number of shaft fractures in the elderly is increasing secondary to the greater number of geriatric patients in the general population. Etiology: Femoral-shaft fractures are usually due to trauma. Motor vehicle accidents, pedestrian-versus-vehicle accidents, falls, and gunshot wounds are among the most common causes. Pathologic fractures in adults are most often the result of osteoporosis and metastatic disease. In children, it is also important to consider abuse and underlying neuromuscular disorders and metabolic bone disease as causes of the fracture. Stress fractures also may develop in the femur shaft, often associated with an increase in physical activity. Pathophysiology: Fractures are most often due to a bending load applied to the femur with comminution occurring via higher magnitude forces. Torsional loads, in contrast, form a spiral fracture pattern. Clinical: The usual history is that of trauma. If the history does not consist of trauma, one should suspect a pathologic bone condition. Clinically, the injury is most often apparent. Pain, swelling, shortening, and deformity are usually present in the region. Because of the high association of other injuries, the advanced trauma life support (ATLS) protocol should be followed. As always, a neurovascular assessment should be completed, though this type of injury is rare with femoral-shaft fractures. Examination of the pelvis and hip is of great importance to investigate possible fracture or dislocation. A thorough examination of the knee also should be completed to detect any ligamentous or bony injury.
Currently, surgery is indicated for most femur fractures because of the high rate of union, low rate of complications, and the advantage of early fracture stabilization, which decreases the morbidity and mortality rates in patients (especially polytrauma patients) with these fractures. Definite indications include polytrauma patients, especially those with head and chest injuries, and those with injuries to multiple limbs or those otherwise unable to care for themselves to maximize postoperative independence. Most others are surgical candidates because of the lower incidence of complication and the higher union rates with surgery. Those who should not be treated surgically include patients too unstable to tolerate the procedure and children under 80 lb.
Relevant Anatomy: The femur is one of the largest and strongest bones in the human body. The femur can be divided into regions consisting of the head, neck, intertrochanteric, subtrochanteric (extending 5 cm distal to the lesser trochanter), shaft, supracondylar, and condylar regions. The structures of the thigh also can be divided into compartments. Within the anterior compartment lies the quadriceps femoris, sartorius, psoas, iliacus, pectineus, as well as the femoral artery, vein, and nerve along with the lateral femoral cutaneous nerve. The medial compartment holds the gracilis, adductor brevis and longus, adductor magnus, obturator externus, profunda femoris artery and vein, and the obturator artery, vein, and nerve. Finally, the posterior compartment holds the semitendinosus, the semimembranosus, the biceps femoris, portions of the adductor magnus, perforating branches of the profunda femoris artery, the sciatic nerve, and posterior femoral cutaneous nerve. The metaphyseal area begins proximally with the subtrochanteric region and distally with the supracondylar region with the diaphysis in between. Lying posterior on the femur is the linea aspera, which provides a major attachment for fascia. The femur is not perfectly straight; it has a noted anterior bow. The degree of the bow varies from person to person, but explains the need for curved nails in order to hold the reduction. The femur has an abundant vascular supply, receiving the bulk of the blood from the profunda femoral artery. A nutrient artery usually enters along the linea aspera posteriorly and proximally on the femur and supplies the endosteal circulation. The endosteal circulation supplies the inner two thirds to three fourths of the cortex, making the normal blood flow centrifugal in direction. The periosteal circulation enters posteriorly for the most part along the linea aspera. The periosteal circulation is almost entirely directed in a circumferential direction, having little or no longitudinal spread. Therefore, small wires may be placed around the femur without the danger of devascularizing an area, but large bands should be avoided. Periosteal circulation has been estimated to serve only the outer one fourth of the cortex. However, the periosteal circulation is critical to fracture healing in the diaphysis. When a fracture is displaced, the medullary vessels are disrupted and the periosteal vessels predominate as the vascular supply to the fracture site during early healing. In response to fracture, the periosteal vessels proliferate, while the endosteal circulation is restored much later. Therefore, the use of slotted nails may allow for enhanced return of endosteal neovascularization and a more normal blood flow pattern. The significance of periosteal blood flow in healing also emphasizes the importance of avoiding periosteal stripping especially along the linea aspera. Depending on the level of the fracture and the insertion and attachment of the different muscles of the thigh, varied deformities result. The proximal segment of the femur is under a valgus force of abduction by the gluteus minimus, medius, and maximus. The short external rotators also exert a force on the proximal segment of fractures. A component of flexion and external rotation also exists due to the attachment of the iliopsoas on the less trochanter. The adductors span most of the medial femur and produce an axial and varus force on the femur. Some of these medial forces are countered by the tension band effect of the fascia lata. The distal femur is under a flexing influence by the gastrocnemius. Contraindications: Surgery should be reserved for those able to tolerate the appropriate procedure for their unique circumstance. Young children can often be treated successfully with noninvasive measures; thus, surgery can be avoided. |
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Lab Studies:
Imaging Studies:
Medical therapy: Skin traction and splinting are used in the field in emergent situations to provide comfort for the patient and to prevent any further soft tissue damage. Skeletal traction is seldom used in modern practice aside and is usually only a temporary treatment or a treatment in young children. A pin is placed in the distal femur or proximal tibia, upon which traction can be placed against the patient's own weight. Skeletal traction is usually combined with one of many splinting systems. The main goal in traction is to regain the anatomic length of the limb. If a knee injury is associated with the fracture, the pin should be placed in the distal femur to avoid further injury. In most other cases, the proximal tibia is the choice location. The amount of traction needed varies with a patient's unique situation. Internal fixation is still the treatment of choice for most closed injuries and some open because of the higher union rate, lower rate of complications, lower morbidity, earlier weight bearing, shorter hospital stay, and better control of alignment. However, in some situations in which the hardware is not available or the patient cannot undergo surgery relatively soon, temporary skeletal traction may be a viable choice. Perhaps the most common use of traction is in the treatment of young children (usually 5-10 y) with 2-3 weeks duration in the face of soft-tissue injury. The soft tissue injury may or may not be indicated by a positive telescope test result. However, flexible nailing may be better for children weighing more than 80 lb with a positive telescope test result. In the rare instance in which an adult is treated with skeletal traction and splinting as the definitive treatment, at least 6 weeks of spica casting is needed after radiographs show significant healing. Possible disadvantages include less-than-ideal control of fragments, prolonged bed rest and hospital stays, difficult nursing care, high cost, limited rehabilitation, potential of pin-tract infection, and possible tethering of the quadriceps muscle. Cast bracing is more of a historical treatment in light of the options available in modern orthopedics. Cast braces were usually applied after a period of traction. The advantage is an earlier return to motion. The cast brace helps to reduce the load on the fracture, albeit by only 10-20%, and helps to counteract deforming forces. Only relative indications exist today; these include distal-third fractures or comminuted fractures in patients who are not surgical candidates and as supplemental support for nonrigid internal fixation. Spica casting is not used often in adults or adolescents and is a treatment of choice in young children with isolated uncomplicated femoral-shaft fractures. It is usually performed immediately after reduction in children aged 0-2 years and either immediately or after 2-3 weeks of skeletal traction in children aged 2-10 years if they weigh less than 80 lb. The positive aspect of the spica cast is avoidance of primary and secondary surgery for hardware removal. Spica casting also helps prevent infection, blood loss, and scar formation. On the other hand, stability is less than that of many operative treatments, and patient care is prolonged, especially if traction is used beforehand, and mobility is limited. Time away from work for the parents can cause a financial burden. These children require a great deal of care and reliable caregivers. The length of cast time needed for healing can be established by using radiographs. The duration can also be roughly calculated roughly on the basis of the patient's weight. Children less than 50 lb can have the spica bar removed after 4 weeks and the cast removed after 6 weeks. Children weighing 50-80 lb can have the bar removed after 5 weeks and the cast removed after 7 weeks. Surgical therapy: The American College of Surgeons Committee on Trauma has recommended that femoral shaft fractures in polytrauma patients be treated within 2-12 hours after injury, provided they are hemodynamically stable. Studies have also shown the significant benefit of intervention within the first 24 hours. Immediate fixation has been shown to decrease fatalities, respiratory complications, multisystem organ failure, and the length of ICU stays in most patients. The type of early fixation used can be debated, but the timing appears to be what makes the difference. The optimal timing and treatment for this patient group varies in different reports, though a recent large prospective study showed equal results in the isolated fracture group with either early or late treatment. Those with head and chest injury had a lower morbidity and mortality rate when fixation was achieved in the first 24 hours (Brundage, 2002). Each patient's treatment must be selected with clinical consideration of the patient's health status on presentation, the level of emergent treatment needed, the available materials, the patient's age, and the physician's personal experience. Intramedullary rod placement Intramedullary nailing is the criterion standard. Currently, antegrade reamed interlocked intramedullary nailing is the treatment of choice for diaphyseal femur fractures. Antegrade reamed locked nailing is ideal in fracture stabilization. The exposure is small, and soft tissue damage is limited. The nail itself has the advantage of being centrally located in the shaft and load sharing. Antegrade reamed locked nailing promotes healing through abundant callus formation. The fixation is solid and able to hold length even in the face of extensive comminution. It allows early and, in some cases, immediate weight bearing. It is associated with easier nursing care, shorter hospital stays, and lower morbidity. The results of treatment have been excellent, with a 99% rate of union and 1% incidence of infection. Its use has been studied extensively, and it has proven effective in the short and long terms. An unscrubbed assistant surgeon must assist by first examining the radiographs and determining the appropriate direction of force needed to reduce the fracture. After reduction, AP and lateral imaging with fluoroscopy should be performed to confirm the reduction. At this time, the femoral neck also can be critically examined with fluoroscopy. The entry point of the nail is critical to success. A small, 2- to 3-cm longitudinal incision is made 10-15 cm proximal to the greater trochanter. The entry point used on the femur is within the piriformis fossa medial to the body of the trochanter and posterior to the gluteus medius. Before penetrating bone, an AP and lateral view obtained with fluoroscopy should used to confirm the location. Various fixation systems may vary slightly in certain steps and techniques. In general, the metaphyseal bone is penetrated with an awl, and a bulb-tipped guide wire is inserted into the femoral canal. The guide wire is passed to the fracture site, where the assistant then manipulates the distal fragment allowing passage of the guide wire. AP and lateral radiographs are then checked to ensure the guide wire is in the canal of the distal fragment. Reaming is usually started with an 8- or 9-mm reamer. It is placed over the guide wire and passed down past the fracture site to the bulb end. Reaming then progresses at increments of 1 to 0.5 mm until the desired amount of cortical contact is achieved. Fracture reduction should be monitored closely with each pass of the reamer. The surgeon also must ensure that the guide does not back out during the reaming process. When reaming is completed, the guide wire can then be switched. The nail is then mounted on the insertion device. The curve of the femur and the nail must be taken into consideration when inserting. The nail is slid over the guide wire and inserted with an inward 90° twist. Advance past the fracture site and insert to the recommended position for the system. Locking screws can be placed distally and proximally after aligning the holes so that they appear perfectly round on fluoroscopy. More recently, retrograde intramedullary nailing of the femur has presented itself as an alternative to the antegrade nail. Fairly similar results have been achieved in some comparisons, but it lacks the long-term studies that have made antegrade nailing the criterion standard. The nail is inserted in the intracondylar notch .5-1 cm anterior to the femoral origin of the posterior cruciate ligament (PCL) via either a 2- or 4-cm transpatellar or medial parapatellar approach. The rest is much the same as the antegrade reaming, insertion, and locking. For optimal control, have a locking screw at least 5 cm beyond the fracture site. Advantages of retrograde nailing might include decreased operative time, decreased blood loss, and amenability to polytrauma situations (allowing simultaneous cranial, abdominal, or contralateral leg procedures). Retrograde nailing also allows separate treatment of femoral neck fractures and limits heterotopic ossification formation. It may be ideal in floating knee injuries and ipsilateral supracondylar fractures and patients who are obese or pregnant (allowing easier starting point access and exposing the fetus to less radiation). This approach also may be used in patients who have an injury to the pelvis or acetabulum in whom surgery involving the area may further injure or complicate the patient's health. Regarding retrograde nailing, the long-term studies that have made antegrade nailing the treatment of choice are still lacking. Retrograde nailing also should be avoided in IIIB open fractures, septic knees, subtrochanteric fractures, open physes, and knee injuries, and it is not as effective in very proximal shaft fractures. Knee pain can occur. Although a small area of articular cartilage is lost with insertion and is rapidly filled with fibrocartilage, the development of degeneration is still a concern. Also, damage to the PCL is possible because of the proximity to the insertion point on the femur. External fixation External fixation is the treatment of choice for many patients with grade IIIB or IIIC open fractures, for patients with fractures in which vascular surgery is needed, for patients in unstable condition, and for those in whom definitive surgery cannot be performed relatively soon. Because of the relatively short operative time, the surgeon also may consider this a feasible option when time is of the essence, as in a mass casualty situation. For this procedure, 2 or 3 pins are usually placed into the femur in the proximal and distal fragments. For maximal stability, 1 pin should be placed as close to the fracture site as possible on either side of the fracture. The connecting rod also should be placed as close to the skin as possible without touching the skin and allowing room for swelling. Unilateral external fixation devices can be placed strategically in a certain plane, depending on the fracture geometry, to provide more stability. A lateral fixator is more stable in the mediolateral plane, whereas an anterior fixator is more stable in the sagittal plane. Larger circular devices are also available but are more cumbersome to the patient and nurse. External fixation External fixation is the treatment of choice for many patients with grade IIIB or IIIC open fractures, for patients with fractures in which vascular surgery is needed, for patients in unstable condition, and for those in whom definitive surgery cannot be performed relatively soon. Because of the relatively short operative time, the surgeon also may consider this a feasible option when time is of the essence, as in a mass casualty situation. For this procedure, 2 or 3 pins are usually placed into the femur in the proximal and distal fragments. For maximal stability, 1 pin should be placed as close to the fracture site as possible on either side of the fracture. The connecting rod also should be placed as close to the skin as possible without touching the skin and allowing room for swelling. Unilateral external fixation devices can be placed strategically in a certain plane, depending on the fracture geometry, to provide more stability. A lateral fixator is more stable in the mediolateral plane, whereas an anterior fixator is more stable in the sagittal plane. Larger circular devices are also available but are more cumbersome to the patient and nurse. Plating Compression plating has been met with much less enthusiasm than intramedullary nailing. The extensive approach, periosteal stripping, potential blood loss, stress shielding (load sparing), less aesthetic scar, and higher rate of complications tend to favor other methods of treatment. Healing occurs without callus formation, and the bone is slower to regain strength. Bone under the plate is also prone to stress shielding and may become osteopenic. Compression plating may be used in distal metaphyseal-diaphyseal junction fractures and in certain situations with ipsilateral femoral neck fractures. Plating is done via a lateral approach in the skin and spitting the vastus lateralis. One should be careful to avoid stripping the periosteum and muscle. Most often, a 10 or 12 whole dynamic compression plate is used. A total of 4-5 screws should be placed on either side of the fracture, and 8-10 cortices should be obtained on either side of the fracture. If possible, an interfragmentary screw can be placed to enhance the rotary stability of the fracture. Bone grafting should be considered with comminution, especially if there is a cortical defect greater than 1 cm. Ipsilateral femoral neck fractures Ipsilateral femoral neck fractures occur in 2-6% of diaphyseal femur fractures. They are commonly nondisplaced, which is thought to be due to a large portion of the fracture energy exiting out the shaft fracture. The findings can be subtle, and some of the neck fractures have been diagnosed intraoperatively or postoperatively. Some concern also exists about the possibility of antegrade nailing, further compromising the blood supply to the femoral neck and head. No standard treatment consensus exists currently. However, most agree that anatomic reduction of the femoral neck is important to avoid the devastating complication of avascular necrosis (AVN). Some reports give the neck priority and recommends treating the neck separately with screws or a screw plate device and the shaft with compression plating or retrograde nailing. If the neck fracture is discovered after an antegrade nail is placed, supplemental screws are placed anterior to the nail into the neck. If anatomic reduction cannot be achieved, the hardware should be removed and revised as previously stated. Some worry that the increased technical demand of the second generation nails or primary standard antegrade nail and screws may displace nondisplaced fractures or not give enough attention to the reduction of the neck fracture. Others consider these 2 methods as first line treatment in nondisplaced fractures and reserve treating the fractures separately for displaced neck fractures. Open fractures The treatment of open fractures is also not without some controversy. Gustilo class I, II, and IIIA fractures treated with standard reamed antegrade nailing is supported by a wealth of literature. Many authors still agree that grade IIIB and IIIC fractures should be treated with external fixation after initial debridement, which can be exchanged later for another modality if needed. Serial debridement and delayed closure are required. If the surgeon believes that the intramedullary canal is grossly contaminated, intramedullary nailing should be avoided. Treatment initiated within the first 8 hours has shown to decrease the incidence of infection. Because of the higher rate of infection in any open fracture that has gone untreated for longer than 8 hours, the injury should be treated as a grade III open fracture by using external fixation. Several studies have shown good results with closed antegrade reamed or unreamed intramedullary nailing in grade IIIB fractures, and a couple of studies included both grade IIIB and grade IIIC fractures. Because past studies showed fewer complications when polytrauma patients were treated with intramedullary nailing, one also should consider the level of injury when treating open fractures in light of the recent low infection rates in open fractures treated with intramedullary nailing. Antibiotics must be administered. For grades I and II, the recommended treatment is with a first-generation cephalosporin. A grade III injury requires a first-generation cephalosporin and an aminoglycoside. Extensively contaminated open fractures should be treated with a first-generation cephalosporin, an aminoglycoside, and penicillin. Tetanus prophylaxis also should be given to patients with an open fracture. Gunshot injury Gunshot injury is also one of the leading causes of femur fractures. A variety of fracture types can result depending on the location and amount of bone that is struck by the projectile. The distal metaphysis may develop a drill-hole type fracture, whereas a graze may cause an incomplete fracture, and a direct hit usually causes comminution and a butterfly fragment. Occasionally, a spiral fracture may form; this is thought to be caused by the femur being struck while the individual places is walking or running on the leg in an attempt to flee. Neurovascular injury must be excluded because of the possibility of the projectile or fragments penetrating such structures. Low-velocity (<2000 ft/s) injuries are the most common. Such injuries can be treated with little or no initial debridement and immediate intramedullary nailing. High-velocity (>2000 ft/s) and shotgun injuries are treated as grade III open fractures. Serial debridement and external fixation are often used; however, some physicians also use intramedullary nailing as the primary treatment. Debridement should be meticulous as shotgun wadding, clothing, and other debris may be embedded in tissues near or distant to the missile path. Shotgun injuries can be devastating. The severity of injury can be associated with the range at which the victim was shot, this also can classify the wound. Sherman's modified classification of shotgun wounds is as follows:
Children Femoral-shaft fractures in children are associated with many of the same concerns as those in adults. Again, the level of injury sustained by the patient is of great importance in selecting treatment. However, in children, age, growth and remodeling potential, and family stability (both financial and functional) are of concern. Unique concerns in children are the preservation of the retinacular and lateral epiphyseal blood supply to the femoral neck and head and physis deformation via implant insertion. In children, growth of the bone might potentially be stimulated after a fracture, and limb-length overgrowth could occur. However, the tolerances for angulation and displacement are greater than those in adults with fractures due to the potential to remodel. A child with more growth potential also has more potential to remodel the involved bony structures, and those fractures closer to a physis may remodel more than others. Rotational deformities cannot be remodeled, and remodeling should not be counted on to correct deformity in children older than 9 years. Most treatments can be broken down by the age of the patient. Patients aged 0-2 years usually are treated with immediate spica cast application. In infants younger than 4 months, some authors advocate the use of splinting instead of a spica cast. Children aged 2-10 years (if <80 lb) usually are treated with either immediate spica casting, or spica casting is delayed 2-3 weeks until callus formation is evident on radiographs. Some authors suggest the use of traction if more extensive soft tissue damage is suspected or there is a positive telescope test result (>30 mm). If the fracture cannot be treated with less invasive methods, is complicated, open, or the patient is a polytrauma patient, external fixation should be used. There is some mention of internal fixation being used in the upper limits of this group within the orthopedic community. Less consensus regarding treatment has been reached for patients aged 10 years and older. Options are external fixation, compression plating, rigid intramedullary fixation, flexible intramedullary fixation, and casting. External fixation is an option for cases of polytrauma or open fracture in a child and occasionally for isolated fracture in this age group. External fixation helps to avoid prolonged immobilization, long hospital stays, and extensive approaches. It also preserves the blood supply by preventing periosteal and provides a quick and less invasive means to stabilize the fracture. The treatment is still somewhat cumbersome to the patient, the potential remains for pin tract infection and tethering of the quadriceps muscle, and the rate of repeat fracture is higher than in other treatments. Compression plating has provided good results in studies on children. Indications for use include head injury, open fracture, spasticity, seizures, floating knee, and vascular injury. However, the same features as in adults make it a less attractive option. The potential for blood loss, infection, extensive approach, component failure, large scar, more-extensive repeat surgery to remove components, and existence of less invasive options make this an unpopular choice in children. Removal of such hardware may be more difficult in children due to bony overgrowth. Compression plating in children has been found to be of most value in treating those that have sustained multiple or head injuries in addition to the femur fracture, necessitating immediate fracture stabilization. Rigid intramedullary fixation in children has advantages and disadvantages. Although it is highly successful for stabilization and control, it also has the most devastating potential consequence. Antegrade nailing of femoral-shaft fractures can disrupt the blood supply to the femoral neck via the lateral epiphyseal artery and retinacular branches, possibly causing irreversible AVN of the femoral head and severe disabling arthritis. The procedure may also lead to premature apophyseal arrest in the greater trochanter, though this is thought to be of little clinical significance in children younger than 10 years. The age at which ridge nailing becomes risky is not defined; ages of 10 and 15 years are mentioned as safe in the literature, along with judging whether there is more than a year of growth left by the appearance of the physis on radiographs. The patient must undergo a second procedure for hardware removal at a later date. Some literature advises using the tip of the greater trochanter as the entry point for the nail to avoid the complications of AVN. The lateral starting point increases the likelihood of intraoperative fracture, however. The use of rigid antegrade intramedullary nailing is preferred in skeletally mature adolescents, obese children, and those with multiple injuries, very proximal fracture level, and high levels of comminution. Flexible intramedullary nailing of the femur in children can provide good results and avoid the potentially devastating complications of rigid nailing. Flexible nailing provides a safe choice of fixation for children who are too young for rigid nailing but too old or large for spica casting or who do not have caregivers able to comply with the high maintenance of spica casting. Safe treatment of children younger than 4 years has been described in the literature. Flexible stainless steel or titanium rods (usually 2-4 mm in diameter) can be inserted retrograde from small lateral and medial incisions above the distal physis of the femur. A 2-cm incision is made on the medial and lateral side of the thigh about 2.5 cm proximal to the distal physis of the femur. A drill is used to make an oblique opening, though which the nails can be passed into the canal. The nails should be bent and inserted so the apex of the curve is at the level of the fracture. The stability is provided by the opposing forces of the bent nails pushing at the apex of the curve against the canal wall at the level of the fracture. About 1-1.5 cm of the nail is left extending into the soft tissue distally. Small eyes in the distal ends of some nails allow the passage of a small screw to prevent backing out and may add additional stability. Some authors have used antegrade insertion with some success. The smaller 3.5-mm nails are recommended in children aged 5-10 years, whereas 4-mm nails are generally used in older or larger children. Flexible nails have gained a great deal of popularity because of the high rate of success and early weight bearing with crutches the day of surgery and full weight bearing when callus formation is observed. The short hospital stay and ease of care combined with the above-mentioned features have made flexible nailing a commonly used option in school-aged patients. Complications seem to be minor and include issues such as soft tissue irritation and possible comminution or loss of reduction when passing the nails. Flexible nails lack the rotational stability of rigid nails and should not be used in highly unstable or comminuted fractures. Preoperative details: A patient injured with a high-energy mechanism must be stabilized before proceeding to surgery. Again, current recommendations are for early fracture stabilization because this has been shown to be beneficial to the patient's overall health status. Blood loss must be monitored because a large volume of blood can be lost into the compartments of the upper leg. Appropriate images should be obtained and scrutinized. Often, the isthmus on radiographs can be used to estimate the size of the nail needed. If severe comminution is present, it also may be helpful to use radiographs of the uninjured leg to estimate leg lengths. Equipment and hardware should be gathered, and backup materials should be available. If surgery is to be delayed, balanced skeletal traction should be applied. Antibiotics also should be started 30 minutes before initial skin incision. One must decide whether to use a fracture table or radiolucent table. The exposure for antegrade nailing is good; however, the fracture table limits the exposure for other fractures or injuries in multiply injured patients. The fracture table should not be used in patients with bilateral lower extremity fractures, an unstable spine, pelvic fractures, multiple injuries, or ligamentous knee injury. Consider using a distal femur traction pin to avoid further injuring a knee that may possibly have ligamentous knee injury. The fracture table may be ideal for an obese patient, in whom the entry point is more difficult to assess for antegrade nailing. Complications are usually due to excess or prolonged traction resulting in pudendal, femoral, and sciatic nerve palsies. Skin sloughing and well-leg compartment syndrome can also occur. On a radiolucent table, the patent is supine. This table may be best for the above-mentioned patients not able to be placed on the fracture table. However, the supine position may be more problematic in dealing with obese patients. Significant consideration for use of this table is warranted if any likelihood of ligamentous knee injury exists because no traction is put across the knee joint. Most studies have shown no difference in the outcome of fracture treatment based on the table used. One of the large studies comparing the use of the two tables showed no difference in the outcomes for fracture treatment, but the use of the fracture table was associated with increased operating room time. Some of the increased time may be associated with one's own comfort or familiarity with the fracture table. Irrigation should be delayed until the operative period for open fractures that are going to be treated surgically. Irrigation in the emergency department could drive contamination further into the wound. The wound should be covered with a sterile wet dressing until surgery. Intraoperative details: Careful investigation with fluoroscopy should be used to identify any missed fractures, namely those of the femoral neck. When using intramedullary nailing, careful attention must be paid to fracture reduction and reduction maintenance during the passing of the guide, reamer, and nail. Position and alignment also can be double-checked before placing the locking screws. Postoperative details: A knee examination should be completed after all fixation is completed because performing a preoperative ligamentous knee examination on a patient with a femur fracture is nearly impossible. Antibiotics should be continued for at least 24 hours in patients with uncomplicated cases. Severe open fractures may require delayed closure, serial debridement, and extended antibiotic treatment. Follow-up care: Strengthening of the quadriceps and hamstring muscles can begin almost immediately in the postoperative period. Hip, knee, and ankle range-of-motion (ROM) exercises should be started early. Patients treated with a 12-mm statically locked nail with 2 distal locking screws may even begin with immediate full weight bearing. In other treatments, progressive weight bearing is often used and graded with consideration to the method of treatment, the condition of the patient, and the extent of the fracture. In stable fractures, patients usually can begin early weight bearing with crutch support, while those with unstable fractures proceed with protected weight bearing until callus formation is evident on radiographs. Prolonged supervised therapy is not often needed, since full ROM is usually attained within 4-6 weeks. Follow-up radiographs are obtained at 1, 3, 6, and 12 months to ensure that the fracture is healing in an acceptable position. If retained hardware removal is needed, it can usually be performed 1 year after union.
As with any surgical procedure, femoral-shaft stabilization with surgical intervention is associated with complications. The most common complications include infection, malunion, delayed union (eg, generally no signs of healing at 3 mo), nonunion (no signs of healing at 6 mo), and pain from hardware. Less common complications include neurovascular injury, hemorrhage, compartment syndrome, repeat fracture, and component failure. Rare but more serous complications include death; multiorgan failure; and respiratory complications, which are usually secondary to acute respiratory distress syndrome (ARDS), pulmonary embolism, or fat embolism; all of these are more common in the polytrauma patient than in others. Infection is a rare complication of closed intramedullary nailing of the femur and occurs in about 1% of cases. Factors that increase the risk of postoperative infection include open fractures and comminuted fractures treated with open reduction. Grade IIIB femur fractures are associated with a higher incidence of infection secondary to gross contamination and extensive soft tissue necrosis. Many cases of infection are treated with antibiotics and retaining the implant until healing is evident. After the fracture site is healed, the implant is removed. Rarely, a staged reconstruction must be completed. Ranging from implant removal, incision and drainage (I&D), and primary exchange to implant removal, primary I&D, intravenous antibiotics for several days followed by a second I&D and new implant placement. Both sequences followed by weeks of antibiotic therapy by either intravenously or orally depending on the sensitivity of the microorganisms. Delayed union and nonunion can be treated with dynamization, new or different implant, bone grafting, and/or bone stimulation. Exchange nailing has had the best results when treating a nonunion. Bone grafting should be used in combination with another method, as it can produce poor results when used alone. Malunion of clinical significance is fairly rare. The hip, knee, and ankle joints compensate a great deal for many minor malunions. If the patient is symptomatic, osteotomy and exchange nailing, placement of a different device, or simply retaining the antegrade intramedullary nail and locking the nail in the revised position may be appropriate. Current tolerances for adult fractures are 5-15° varus/valgus, up to 15° AP, 15° rotation, and 1-1.5 cm of shortening. Tolerances in children are grouped by age. In patients aged 0-2 years, up to 30° varus/valgus is accepted, and 30° AP, 10° rotation, and 15 mm of shortening are accepted. In children aged 2-5 years, up to 15° varus/valgus is accepted, and 20° AP, 10° rotation, and 20 mm of shortening are accepted. In children aged 6-10 years, up to 10° varus/valgus is accepted, and 15° AP, 10° rotation, and 15 mm of shortening are acceptable. In patients older than 11 years, up to 5° varus/valgus is accepted, and 10° AP, 10° rotation, and 10 mm of shortening can be accepted. Most primary nerve injuries are associated with penetrating trauma to the thigh region. The sciatic and femoral nerves are well protected within the muscle envelope surrounding the femoral shaft. Neurapraxias can occur with prolonged stretching of the nerves during difficult reductions of the shaft. In addition, intraoperative nerve compression can result from poor padding on the operative table. The most commonly injured nerve is the pudendal nerve, followed by the sciatic nerve. If a male patient sustains a pudendal nerve injury, he most often will complain of penile numbness and impotence. Heterotopic ossification is the most common complication after reamed antegrade intramedullary nailing. Up to 25% of patients undergoing the procedure may be affected. Implant failure most often occurs in the locking screws. This complication can best be avoided by placing a locking screw at least 5 cm from the fracture site. Arterial injury is documented in less than 2% of femoral-shaft fractures. Any fracture pattern can lead to disruption of the artery; however, penetrating injuries have a higher incidence of trauma to the vessel. Vascular injury can occur in a variety of ways, including tearing, thrombosis, or spasm of the artery. Note that pulses may be present even in the face of vascular injury due to heavy collateral circulation. Arterial injury requires prompt diagnosis and treatment to ensure preservation of the lower extremity. Compartment syndrome of the thigh with femur fracture is extremely rare because of large volume of the thigh compartments, which blend with those of the hip. Only a few cases are reported in literature. Compartment syndrome occurs because of an increase in volume or pressure or because a force decreases the capacity of the compartments. If this is suspected, pressure should be measured and rechecked after fracture reduction. Compartment syndrome is most often associated with multiple injuries. Again, the presence of pulses does not preclude the diagnosis. Immediate fasciotomy should follow diagnosis. Pulmonary complications include fat embolism, thromboembolic event, and pneumonia. The further development of fat embolism syndrome and ARDS is associated with a high mortality rate. However, ARDS develops in only about 2% of patients who have a femur fracture and multiple injuries. Early fracture fixation within 24 hours has shown to decrease not only the pulmonary complications mentioned but also multiorgan failure, time using a ventilator, ICU stays, and hospital costs. As with many injuries and surgery to the lower extremity, DVT can be encountered and prophylaxis should be used. The surgeon should always have a high index of suspicion for this complication as its clinical presentation is many times subtle or absent but it potential devastating. Death is exceeding rare in patients with femur fractures, especially in those with isolated injuries. A population study of 2805 patients with femur fractures showed only a 0.042% mortality rate. Patients who sustained an injury severity score of less than 15 had a mortality rate of 0.0272%, while those with an injury severity score higher than 15 had a mortality rate of 0.109%. The mortality rate, especially in those with an injury severity score higher than 15, was also higher in the nonsurgically treated patients. Repeat fracture is also rare after fracture treatment of the femoral shaft. Rates vary with the different methods of fixation. Most repeat fractures occur within the first year of healing.
Treatment in adultsAntegrade intramedullary nailing Reamed intramedullary nailing has been shown to have excellent results. In a study of 551 cases of femoral-shaft fractures, Wolinsky et al included the following results:
More surprising was that 38% of the patients required some type of hardware removal; the reason in the vast majority was pain. Eighty locking bolts were removed, and 130 nails were removed. Note that nail removal should be done 1-2 years after placement to ensure complete fracture healing. Winquist and associates conducted 1 of the first large studies, which included 500 patients treated with intramedullary nailing. The study gave much the same results; however, the technology and technique were modified as the study progressed. Retrograde nailing In a study of 45 femoral-shaft fractures, Herscovici and Whiteman reported the following results: About 95.5% of the fractures healed after the original procedure. No infections or arthrosis occurred, though 7 complications included 2 cases of nonunion (both had broken nails), 1 malrotation, 1 case of reflex sympathetic dystrophy (RSD), 1 case of skin loss (open knee injury), 1 ileus, and 1 DVT. The average ROM was 129° of flexion at the knee. Eight patients had decreased strength in the thigh. Ricci and associates retrospectively compared 104 femoral-shaft fractures treated with retrograde intramedullary nailing and 94 treated with antegrade intramedullary nailing. The following results were obtained:
Ostrum et al completed a prospective study comparing antegrade treatment of 39 shaft fractures with 47 shaft fractures treated with retrograde nailing. At the beginning of the study, 54 patients were treated retrograde and 46, antegrade. Later results were after some deaths and loss to follow-up, leaving 39 patients treated antegrade and 47, retrograde. The following results were obtained:
They also found a significant relationship between the difference in the canal and nail diameter to time of union. Plate fixation Most studies involving plating of femoral-shaft fractures have shown less than desirable results compared with other modalities. In a study of 102 femoral-shaft fractures, Bostman et al demonstrated that 24% had some form of major complication, as follows: 12% mechanical failure, approximately 5% delayed or nonunion, approximately 4% repeat fracture, 7% infection, and 25% second operation. However, articles exist in which results are better, such as study done on 500 shaft fractures in Slovenia in which 85% of the patients experienced no complications (Smrke, 2000). In another smaller study by Seligson et al of 15 cases of femoral-shaft fractures, 7 complications occurred. Three delayed unions, 4 nonunions, and 2 implant failures occurred. No axial deformity greater than 1 cm was observed. External fixation Alonso et al treated 24 femoral-shaft fractures with external fixation. Ten of the initial operations were used as the definitive treatment, and the others were changed for other options at a later date. Twenty-one fractures eventually developed solid union. Results included 1 nonunion and 2 delayed unions. Eleven patients lost an average of 56° of motion about the knee. Of the 10 patients treated primarily with external fixation, no infections occurred, and 2 had shortening of greater than 2 cm. Dabezies treated 20 fractures with definitive external fixation. Nineteen developed solid union in an average of 4.8 months. No cases of chronic osteomyelitis were reported even though 65% of the fractures were open. Fourteen needed cast bracing for an average of 1.5 months after the external fixator was removed. Four pin tract infections and 3 cases of shortening occurred. Nine lost an average of 50° of knee motion. No device failures occurred. Treatment in childrenFlexible nailing Cramer et al conducted a prospective trial of 53 femur fractures treated with Ender nails in children aged 5-14 years (average, 8.5 years). Isolated injuries averaged only a 3 days' stay in the hospital. Bridging callus was observed in an average of 3 weeks, while the time to healing averaged 12 weeks. On average, full weight bearing was achieved at 30 days. Forty-nine patients had no angulations after treatment. Four reported angulations were less than 15° in any plane and less than 10° rotation. No leg length discrepancy exceeded 2 cm. An average of 7 mm of overgrowth occurred. Additional results included 5 complications, 4 butterfly fragments displaced on rod insertion, 1 comminution at the fracture site with passage of rods, 3 cases of inflammation at the insertion site, 1 hematoma at the removal site, and 2 broken locking screws after healing. Flynn reported on 50 cases treated with a titanium elastic nail for pediatric femur fractures with excellent results. Thirty-eight had excellent results, including good alignment, leg lengths within 1 cm, no wound problems or irritation at fracture site, no malrotation, and full ROM at the knee. Some had a knee effusion that resolved when the nails were removed. Nine patients experienced irritation at the insertion site. One nonunion was treated with successful repeat nailing. One fracture occurred with 20° varus angulation; remodeling reduced this to 7°. One repeat fracture occurred. Rigid intramedullary nailing Momberger et al retrospectively reviewed 50 patients aged 10-16 years who were treated with statically locked intramedullary nailing with a greater trochanter starting point. No infection, nonunion, osseous necrosis, or nerve palsies occurred. Full weight bearing occurred at an average of 5.7 weeks. Complications included 1 intraoperative fracture, 1 delayed union, 1 DVT, and patellofemoral pain in 1 patient. Of these patients, 25 underwent radiographic analysis, which revealed an average of only 1 mm in limb-length discrepancy, and none had more than 11 mm discrepancy. The average increase in articulotrochanteric distance compared with the contralateral side was 4.5 cm. Spica casting Infante et al conducted a study comparing immediate spica casting in 3 different weight classes from 10-100 lb for closed, isolated femur fractures in children. A total of 175 fractures were treated with one and one half spica casts. Union was achieved in all fractures by 8 weeks. All patients were discharged from the hospital within 24 hours. Infante et al recommend from their findings and past literature that in patients 10-80 lb with close isolated fractures of the femur, spica casting should still be used as a criterion standard. Group 3 could not be included in these recommendations because of the low number of patients in this group. Spica Casting Results
Plate fixation Kregor et al reported 15 fractures treated with plate fixation. All healed in an average of 8 weeks. No infections were reported, and 14 of 15 healed with anatomic alignment. Overgrowth averaged 9 mm. No restrictions in activities were reported at 26 months. Ward also reported on 25 fractures treated with plate fixation. Healing occurred in 23 of 25 in an average time of 11 weeks. External fixation Blasier and Turskey reported on 139 fractures treated with external fixation. All healed in an average of 11.4 weeks. Eighteen were followed up at 2 years, and 15 patients had overgrowth averaging 8.7 mm, 3 had shortening averaging 7.7 mm, and none required treatment. Pin tract infection was common; 6 required intravenous antibiotics for pin tract infection treatment. Two repeat fractures occurred. Miner and Carrol reported on 37 fractures treated in children aged 4-14 years. Healing occurred in 36 of 37. Minimal leg-length discrepancies and angulations were reported. Pin tract infection was reported in 72.7%; more alarming was the 21.6% rate of repeat fracture. Patients with bilateral femur fractures seemed to be at the greatest risk of repeat fracture.
No one can argue with the high success rate of reamed locked antegrade nailing. However, patients with femoral-shaft fractures often present with a multitude of injuries including head and chest trauma. Laboratory studies have shown that a showering of small emboli occurs with reaming and also insertion of the nail into the medullary canal. Moreover, pulmonary function is affected. A definitive answer has yet to be made to the question of the clinical significance in those with multiple traumas that include chest injury or in those with preexisting poor pulmonary function. Further studies are needed to further evaluate primary reamed or unreamed nailing, along with delayed nailing after external fixation, to determine the optimal treatment in these patients. Many chose a compromise between the options of quick, noninvasive external fixation and intramedullary nailing by using external fixation as a bridge to an early conversion to intramedullary nailing. Intramedullary nailing in cases of head injury raises concerns. Potential hypotension and hypoxia in the intraoperative period with intramedullary nailing may cause further detriment to an already-damaged CNS. The incidence of heterotopic ossification is increased in femur fractures associated with head injury. Again, more studies are needed to define the role of intramedullary nailing and its timing in these patients. Opposing views can be found in the literature. The treatment of open fractures is also not without controversy. Most surgeons agree that open fractures types I and II can be treated with primary reamed intramedullary nailing, and some even attest to this treatment for type IIIA fractures. The standard has been to use external fixation in types IIIB and IIIC. Recent studies have shown good results in some cases with primary reamed or unreamed intramedullary nailing.
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