continuing education activities
Femoral shaft fractures are often associated with other high-energy injuries. These injuries can lead to life-threatening sequelae. Timely intervention and thoughtful management lead to optimal patient outcomes. This activity reviews the etiology, presentation, assessment, and treatment of femoral diaphysis fractures, and reviews the role of an interprofessional team in the assessment, diagnosis, and treatment of this condition.
Describe the mechanisms of injury that can lead to femoral diaphysis fractures.
Review methods for assessing and assessing patients with potential femoral diaphysis fractures, including any assigned imaging studies.
Outlines treatment options for femoral shaft fractures based on the patient population and the severity and location of the fracture.
Explain the importance of interprofessional team strategies to improve care coordination and communication to aid in the rapid diagnosis of femoral diaphysis fractures and improve outcomes for patients diagnosed with this condition.
Femoral shaft fractures are often associated with other high-energy injuries. These injuries can lead to life-threatening sequelae. Timely intervention and thoughtful management lead to optimal patient outcomes. Unlike in the past when only splinting was used to treat these fractures, today intramedullary (IM) nails are the mainstay of treatment. Pediatric patients are treated with flexible rods to promote bone growth.
The femur is divided into the following regions: head, neck, intertrochanteric, subtrochanteric, shaft, supracondylar, and condylar regions.
Younger patients typically involve high-energy mechanisms, most commonly motor vehicle crashes. Osteoporotic femur fractures may occur in elderly patients due to falls on the ground.Another common cause is gunshot wounds to the lower extremities.
Stress fractures can occur in people who are physically active. Finally, some low-energy femoral fractures may be related to osteoporosis or long-term use of bisphosphonates.
It is estimated that between 9 and 22 femur fractures occur annually in 1000 people worldwide. The distribution of these lesions was bimodal. Studies have shown that diaphyseal fractures are common in older patients, with reduced bone density, low body mass index, and extensive anterior and lateral arches.
The femur is the largest bone in the human body. It has a front arch with a radius of curvature of 120 cm.Along the posterior middle third of the diaphysis, there is a raised ridge at the inspiratory line, which is the attachment point of the muscles and fascia, and the strut of the compensating anterior arch.
The characteristic deformity after a femur fracture is due to the attachment of the strong lower body muscles to the femur. The proximal fragment remains in flexion and abduction. The iliopsoas, attached to the lesser trochanter, provides a strong flexion vector. The gluteus medius and minimus attached to the greater trochanter provide powerful abduction. The distal fragment remains varus and extended. The adductor muscle attaches to the medial femoral condyle and provides varus force. The gastrocnemius muscle attaches to the posterior portion of the distal femur and pulls the fracture fragment posteriorly and inferiorly, creating an extension deformity at the fracture site.
history and physics
As life-threatening injuries may co-exist, it is important to assess the patient's overall condition. Adherence to Advanced Trauma Life Support (ATLS) principles is paramount when present in the trauma room. If the patient is unstable or intra-abdominal lesions are suspected, the patient may be rushed to the operating room for an exploratory laparotomy. It is important to remember that the life of the patient precedes the limb.
If the patient is stable, a thorough physical examination is important. Obvious deformity of the thigh can be noted. It is important to perform a thorough neurovascular examination including pulse and to evaluate for open fractures.
Bilateral femoral fractures are associated with an increased risk of pulmonary complications and increased mortality.
Imaging starts with ordinary X-rays. Orthogonal radiographs of the femur should be taken. In addition, orthogonal images of the hip and knee joints should be taken.
It is important to evaluate for ipsilateral femoral neck injuries. Incidence rates of 1-9% have been indicated in the literature. Many level 1 trauma centers have adopted protocols that include computed tomography (CT) scans that include both femurs to the level of the lesser trochanter. Associated ipsilateral femoral neck injuries were ignored for approximately 10 years prior to the widespread adoption of these protocols. 20-50% of the time.
Imaging can also play a role in management decision-making. The initial position of the IM nail may be compromised in diaphyseal fractures with associated proximal femoral fractures. In these cases, CT of the proximal femur is helpful in assessing the integrity of the greater trochanter or piriformis fossa.
Open femoral fractures can be classified by the Gustillo-Anderson classification system. Epidemiological studies documented 43% of grade I, 31% of grade II, and 26% of grade III open fractures. Aggressive treatment is necessary due to the mechanism of injury and the amount of soft tissue that must be violated for the femoral fracture to open.
Two common classification systems are used to describe femoral diaphysis fractures.
Classification of the Orthopedic Trauma Association
32A - Enkel
A1 - Spiral
A2 - Inclined, angle less than 30 degrees
A3 - Inclined, angle less than 30 degrees
32B - kill
B1 - Spiral Ham
B2 - curved wedge
B3 - Fragment Wedge
32C - complex
C1 - Spiral(Video) Femoral Shaft Fracture
C3 - Irregular
Winquist and Hansen classification
Type 0 No Shredding
Type I negligible comminution
Type II with more than 50% cortical contact
Type III cortical contact less than 50%
Type IV segmental with no contact between proximal and distal fragments
Blood tests are always done to assess hemoglobin levels. Femur fractures can cause massive blood loss, which can lead to low blood pressure. If the wound is open, a culture should be obtained.
In the event of an open fracture, antibiotics should be administered promptly according to institutional protocols. Weight-based cefazolin is commonly used. Bedside irrigation and debridement should be performed. Ideally, surgical irrigation and debridement should occur within 2 hours of presentation.
Ipsilateral femoral neck fracture
In the rare case of a femoral shaft fracture combined with an ipsilateral femoral fracture, it is recommended to prioritize femoral neck fracture fixation.The authors recommend anatomical reduction of the femoral neck first to reduce the risk of femoral head nonunion and avascular necrosis (AVN). Following fixation of the femoral neck, femoral shaft fractures are treated.
tail bone traction
Traction provides pain control for the patient and helps the surgeon maintain anatomical length. The strong thigh muscles contract immediately after injury, causing the femur to shorten. After a knee x-ray, a distraction pin can be placed in the distal femur or proximal tibia under local anesthesia. For femoral distraction, insert a 4 mm Steinman pin two finger-widths above the superior border of the patella to ensure it is extra-articular. It is placed in the anterior third of the femur to allow the passage of nails when sterile distraction is required intraoperatively. For tibial distraction, insert the needle three finger-widths from the upper end of the tibial tuberosity. Some argue against tibial distraction because of ligament stress and reports of femoral shaft fractures with concomitant ligament injury.Most of the time, pins are placed just to avoid the injured area. Twelve pounds (five kilograms) of traction is applied in a longitudinal fashion and can be adjusted for the patient's weight and muscle tone. The patient noted relief after thigh muscle fatigue.
External fixation may be required in conjunction with damage control orthopedics.Continued external fixation may be reasonable if the patient is hemodynamically unstable and brought to the operating room for another procedure. External stabilization can be used in conjunction with vascular repair. Insert Schanz pins into the proximal and distal ends of the fracture and apply traction to estimate length, alignment, and rotation. Some structures may require the surgeon to straddle the knee. Studies have shown that the infection rate of external fixation pins is about 10%.Patients with multiple injuries undergo final immobilization once stabilized.
IM nails are the mainstay of treatment for femoral shaft fractures. The pins provide relative stability at the fracture site, and the femur heals through secondary osseounion.
Fracture fixation with IM nails can be achieved either antegradely or retrogradely. The retrograde nail uses an origin in the middle of the intercondylar notch of the distal femur. Antegrade IM nails use 2 different origins, the greater trochanter and the piriformis fossa origin. Trochanteric and piriformis-centric nails have been extensively studied with general consensus of similar results.The advantage of using the piriformis entry point is that it is collinear with the long axis of the femur. This reduces the risk of varus dislocation. The disadvantage of this starting point is the technical skill required to establish this point, especially in obese patients.This entry point puts the insertion of the piriformis muscle at risk of iatrogenic injury, leading to claudication of the abductor muscle. Pediatric patients are also at increased risk of developing AVN of the femoral head. The greater trochanter entry point has the advantage of reducing the risk of adductor muscle injury, is less technically demanding, and is a more appropriate choice for obese patients. The disadvantage of the greater trochanter entry point is that it is not collinear with the femoral axis. This difference requires the use of IM nails designed specifically for this entry point to avoid varus misalignment.
In terms of nail design, the radius of curvature of the IM nail must match the radius of curvature of the patient's femur.AnIM nails with a radius of curvature greater than the radius of the patient's femur (i.e., straighter nails) may perforate the anterior cortex of the femur during insertion.
After IM nailing, patients can usually bear weight as tolerated.
Submuscular plating is usually reserved for complex or periprosthetic fractures where the origin site is compromised or unavailable with a separate implant. Lateral plates can be applied through femoral separation or subfemoral approaches. Load bearing is generally protected after electroplating.
Timing of surgery
If the patient is hemodynamically stable, it is recommended to treat femoral fractures within 2-12 hours of injury. Research shows that intervention within the first 24 hours can have significant benefits. Immediate immobilization reduces pulmonary complications, reduces mortality, and avoids prolonged intensive care. However, the fixed type is still debated
In patients with femoral fractures, ipsilateral femoral neck fractures must be excluded. Depending on the mechanism of injury, patients may have multiple concurrent injuries. In high energy situations, compartment syndrome must be ruled out. In patients with low-energy mechanisms, fractures may be caused by pathological processes caused by tumors or metabolic disturbances, in which case a thorough examination is required.
The prognosis for patients with femoral shaft fractures varies with age, comorbidities, presence of osteoporosis, and type of treatment. IM staples have good results, but a considerable number of patients require future hardware removal due to pain. Death after surgery in elderly patients is not uncommon. Other complications include infection, blood loss, nonunion, delayed union, malunion, and need for repeat surgery. External fixation is effective but is also associated with needle infection and angulation problems. Patients also require extended hospital stays followed by extensive rehabilitation. Many patients still have gait problems and pain.
Non-unions are rare, but they do happen.In these cases, a non-associated root must be established. Revision surgery may be performed when specific aspects of fixation need to be addressed, such as stability or biology. Hypertrophic, aseptic nonunions can be repaired with compression and exchange of nails.In the case of atrophic nonunion, infection must be ruled out, especially in previous open fractures. The nutritional status of the patient must be assessed by laboratory. Repair of atrophic nonunion is usually supplemented by bone grafting.
Deaths related to deep vein thrombosis/pulmonary embolism, infection, nerve damage, and compartment syndrome are not uncommon.
Deterrence and Patient Education
Patients with femoral shaft fractures require close follow-up to monitor fracture healing. Femoral insufficiency fractures are uncommon, but prevention of these fragility fractures can be mitigated through appropriate screening and medical management of those at risk, ie. Elderly or those who are vitamin D deficient.
Improve health team outcomes
Patients with femoral shaft fractures are typically managed by an interdisciplinary team that includes orthopedic surgeons, trauma surgeons, emergency physicians, physical therapists, nurse practitioners, radiologists, and intensivists. These fractures are often caused by high impact energies and may be associated with other injuries. People with femur fractures may experience profuse bleeding and may require blood transfusions. The decision on the type of treatment depends on the type of injury and the stability of the patient. After treatment, most patients require long-term rehabilitation to regain muscle strength and function. For isolated femoral injuries, the prognosis is good, but pain and difficulty walking may be residual problems.
- (Video) Femoral Shaft Fracture When It Is Complex - Everything You Need To Know - Dr. Nabil Ebraheim
Illustration of femoral diaphysis fracture. Courtesy of Chelsea Rowe
Singer BR, McLauchlan GJ, Robinson CM, Christie J. Epidemiology of fractures in 15,000 adults: effects of age and sex.J Orthopedic Surgery Br.March 1998;80(2)：243-8。[Postgraduate entrance examination: 9546453]
Egol KA, Chang EY, Cvitkovic J, Kummer FJ, Koval KJ. Current intramedullary nails do not fit the anterior arch of the femur.J Orthop Trauma.August 2004;18(7):410-5。[Postgraduate entrance examination: 15289685]
Tornetta P, Cain MS, Creevy WR. Diagnosis of femoral neck fractures in patients with femoral shaft fractures. Modifications using a standard protocol.J Bone and Joint Surgery.January 2007;89(1):39-43。[Postgraduate entrance examination: 17200308]
Winquist RA, Hansen ST, Clausen DK. Closing intramedullary nailing for femoral fractures. Five hundred and twenty case reports.J Bone and Joint Surgery.April 1984;66(4)：529-39。[Postgraduate entrance examination: 6707031]
Perjovic AE, Patterson BM. Fracture of the ipsilateral femoral neck and diaphysis.J Am Acad Orthop Surg。March-April 1998;6(2): 106-13。[Postgraduate entrance examination: 9682073]
Walker DM, Kennedy JC. Occult ligamentous injury of the knee joint associated with a femoral shaft fracture.Am J Sports Med.May-June 1980;8(3)：172-4。[Postgraduate entrance examination: 7377448]
Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM. External fixation of femoral shaft fractures in patients with multiple injuries transferred to intramedullary nailing.J Bone and Joint Surgery.June 2000;82(6)：781-8。[Postgraduate entrance examination: 10859097]
Parameswaran AD, Roberts CS, Seligson D, Voor M. Pin tract infection and modern external fixators: how big a problem?J Orthop Trauma.August 2003;17(7)：503-7。[Postgraduate entrance examination: 12902788]
Ricci WM, Schwappach J, Tucker M, Coupe K, Brandt A, Sanders R, Leighton R. Trochanter and piriformis portal in the treatment of femoral shaft fractures.J Orthop Trauma.November-December 2006;20(10):663-7。[Postgraduate entrance examination: 17106375]
Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing for femoral shaft fractures: current concepts.J Am Acad Orthop Surg。2009 major;17(5):296-305。[Postgraduate entrance examination: 19411641]
Giannoudis PV, MacDonald DA, Matthews SJ, Smith RM, Furlong AJ, De Boer P. Nonunion of the femoral diaphysis. Pore reaming and the effects of NSAIDs.J Orthopedic Surgery Br.July 2000;82(5):655-8。[Postgraduate entrance examination: 10963160]
Mr Brinker, O'Connor DP. Replacement of internal nails in nonunion fractures.J Bone and Joint Surgery.January 2007;89(1)：177-88。[Postgraduate entrance examination: 17200326]
Ibrahim JM, Conway D, Haonga BT, Eliezer EN, Morshed S, Shearer DW. Predictors of lower health-related quality of life after surgical repair of femoral shaft fractures in low-resource settings.damage.July 2018;49(7): 1330-1335。[Postgraduate entrance examination: 29866624]
Koso RE, Terhoeve C, Steen RG, Zura R. Healing, nonunion and reoperation after internal fixation of diaphyseal and distal femoral fractures: a systematic review and meta-analysis.International integrity.November 2018;42(11):2675-2683。[Postgraduate entrance examination: 29516238](Video) Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients Using...
The long, straight part of the femur is called the femoral shaft. When there is a break anywhere along this length of bone, it is called a femoral shaft fracture. This type of broken leg almost always requires surgery to heal. The femoral shaft runs from below the hip to where the bone begins to widen at the knee.What is the treatment for a femoral shaft fracture? ›
Currently, the method most surgeons use for treating femoral shaft fractures is intramedullary nailing. During this procedure, a specially designed metal rod is inserted into the canal of the femur. The rod passes across the fracture to keep it in position.What are the complications of a femur shaft fracture? ›
The most common complications in femoral shaft fracture are: Nonunion. Osteomyelitis. Malalignment with malunion.How long does it take for a femur shaft fracture to heal? ›
Recovery most often takes 4 to 6 months. The length of your recovery will depend on how severe your fracture is, whether you have skin wounds, and how severe they are. Recovery also depends on whether your nerves and blood vessels were injured, and what treatment you had.Can you walk with a femoral fracture? ›
Most people experiencing a femur fracture can begin walking with the help of a physical therapist in the first day or two after injury and/or surgery.Can you walk on a fractured femoral head? ›
If you sustain a femoral head fracture, you will usually not be able to walk on your leg due to pain. You will likely be taken to an emergency room for evaluation. At the emergency room, you will have x-rays and/or a CT scan taken of your hip and pelvis.What is the survival rate of a femoral fracture? ›
Mortality rates in the elderly with distal femur fractures have been reported to be around 18% at six months and 18-30% at one year [8,14,15].Is shaft of femur fracture an emergency? ›
All femoral shaft fractures should be referred for an urgent orthopaedic assessment in the ED. Other indications for prompt consultation include: open fractures. neurovascular injury with fracture.Can a femur fracture heal without surgery? ›
Most people with a fractured femur need some sort of surgery, usually ORIF. Without the surgery, your broken femur may not heal properly. ORIF can place your bones back into their proper configuration. This significantly increases the chance that your bone will heal properly.How long is life expectancy with femur fracture? ›
When assessing the overall mortality, 21.3% of our patients had passed away. Although this finding was not statistically significant, mortality rates were found to be higher in patients with proximal femoral fractures compared to distal femoral fractures (25% vs. 8.3%, respectively, p=0.095).
The Femur is often put at the top of the most painful bones to break. Your Femur is the longest and strongest bone in your body, running from your hip to your knee. Given its importance, it's not surprising that breaking this bone is an incredibly painful experience, especially with the constant weight being put on it.What is the long term effect of a broken femur? ›
Most of the time, once your femur fracture heals, you will be able to return to all of the activities you were able to do before your injury. Long term issues may include stiffness of the knee or hip, soreness at the fracture site, or the feeling that your injured leg isn't quite as strong as the other side.How long is hospital stay after femur surgery? ›
Results: The average LOS was 3.9 days. In all, 27 patients stayed longer than 4 days. Reasons included social (7), medical (10), and hospital delays (10). The average time from arrival to surgery was 17 hours.How much force does it take to break a femur? ›
If you're looking for the specifics to snap a piece of your skeleton, it takes about 4,000 newtons of force to break the typical human femur. But don't run out and start applying pressure to femurs and then get upset at us when things don't crack correctly.Should a femur fracture be immobilized? ›
The need to immobilize the femur is primarily due to fractures and dislocations. Each of these injuries dictates a specific immobilization and stabilization technique.How long do you have to be on crutches after a broken femur? ›
After surgery, the leg is put in a cast or set in a brace, for about 8 weeks. A physical therapist will work the patient to make sure that he or she is using crutches safely. The patient may not be able to bear weight on the leg for up to 12 weeks.When do you start weight bearing after femur fracture? ›
There are, however, multiple small studies of distal femur fracture fixation reporting good outcomes with surgeon-dictated full weight bearing post-operatively. In 2016, Smith et al reported on 52 peri-prosthetic distal femur fractures allowed full weight bearing with a fracture union rate of 93% at 20 weeks.Do you need crutches for a femoral stress fracture? ›
Femoral stress fracture treatment
Most likely, your doctor will tell you to keep weight off the leg, and use crutches. It may take 6 to 8 weeks before you start to feel better. And it may take another several months for the symptoms to completely get better.
Excess mortality after hip fracture may be linked to complications following the fracture, such as pulmonary embolism , infections [2,6], and heart failure [2,6]. Factors associated with the risk of falling and sustaining osteoporotic fractures may also be responsible for the excess mortality [1,7].How do you sleep with a broken femur? ›
You should sleep lying flat on your back with your broken femur elevated above the level of your heart. Sleeping like this can keep your broken femur from swelling. As you recover, you'll likely want to move around your home on your own. Ask your healthcare provider how much weight you can put on your leg.
A femur break is a serious break at any age but it can be deadly to seniors that are 65 years and older. The femur is the longest bone in the body. Femur breaks/fractures are most likely at the hip but in some cases can be at the lower extremities.How common are femoral shaft fractures? ›
Femoral shaft fractures are common, especially in high-energy trauma, with an incidence of around 4 per 10000 person-years.How painful is a femoral stress fracture? ›
A stress fracture of the shaft of the femur is characterised by a dull ache felt in the front of the thigh that will develop over a period of weeks. The pain is often hard to localise and may even be felt in the knee.Is femoral fracture a disability? ›
If you have suffered a fracture of your femur, tibia, or pelvis and it has resulted in ongoing problems, you may be eligible for Social Security Disability benefits. If you have been in a serious accident, you may have suffered multiple broken bones.What is the most life threatening bone fracture? ›
Femur. The femur is the only bone in the thigh and is the longest and strongest of all bones in the body. A femur fracture that's not due to a traumatic incident may indicate osteoporosis or bone cancer. If it breaks, it can be potentially life-threatening.What is the most common location for a femoral shaft fracture? ›
The majority of femoral shaft fractures occur in the proximal third of the bone.Is a broken femur the same as a broken hip? ›
A hip fracture is a break in the thighbone (femur) of your hip joint.Do they cast a broken femur after surgery? ›
After reduction or surgery, your child will be put in a spica cast to hold the bone in place while it heals. If your child has surgery, the spica cast will also hold the hip or thigh muscles in place while they heal.How many hours is surgery for a broken femur? ›
The surgeon makes a small incision (cut) on the side of your thigh. Special screws or nails are placed to hold the bones in their correct position. This surgery takes 2 to 4 hours.What is the most painful injury known to man? ›
So Regan goes on to say that it's widely accepted that breaking your femur is the most horrific, painful injury there is.
The femur — your thigh bone — is the largest and strongest bone in your body. When the femur breaks, it takes a long time to heal. Breaking your femur can make everyday tasks much more difficult because it's one of the main bones used to walk.Why is a fracture worse than a break? ›
Some people assume that fractured bones are more serious than broken bones, while others assume it's the other way around. But the truth is that these terms are used interchangeably, and they have the same meaning to medical professionals.How long to drive after broken femur? ›
There are no set rules about when you can return to driving after surgery or an injury.How long does femoral surgery take? ›
The operation should take about 30 to 45 minutes to complete and you'll usually be able to go home the same day. Some people stay in hospital overnight if they have other medical problems or if they live alone. Read more about recovering from femoral hernia repair.What is the weakest bone in your body? ›
The clavicle, or collar bone, is the skin's softest and weakest bone.How much weight can a femur take before breaking? ›
According to the statement that the femur can support 30x body weight, the adult male femur can support roughly 6,000 lbs of compressive force! Such high forces are rarely generated by the body under its own power, thus motor vehicle collisions are the number one cause of femur fractures.How much does a femur cost? ›
It's common for any broken femur to require surgery to realign and reconnect the bone. Without health insurance, the cost of femur surgery can run $17,000 to $35,000 plus the surgeon's fee—typically at least $2,000. Sometimes a femur broken in the hip area may require hip replacement surgery.What is the best treatment for a femur shaft fracture? ›
Treatment of femoral shaft fractures can be operative or non-operative. Operative fixation with intramedullary nailing is the gold standard of treatment in high-income countries. Other operative techniques include plate osteosynthesis and external fixation.What medication is used for femur fracture? ›
These include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, muscle relaxants, opioids, and topical pain medications. Your doctor may use a combination of these medications to help control pain, as well as minimize the need for opioids.How much blood can you lose from a femur fracture? ›
Untreated fractures of the lower limbs can lead to significant blood loss, which may be external and obvious, or covert. The estimated blood loss for a closed fracture of the femur is 1000–1500 ml and for a closed fracture of the tibia is 500–1000 ml.
All femoral shaft fractures should be referred for an urgent orthopaedic assessment in the ED. Other indications for prompt consultation include: open fractures.What are the three types of femur fractures? ›
- Proximal femur fractures involve the upper portion of the bone, next to the hip joint.
- Femoral shaft fractures involve the middle portion of the bone and are usually very severe injuries.
- Supracondylar femur fractures involve the area just above the knee and are considered uncommon.
A stress fracture of the shaft of the femur is characterised by a dull ache felt in the front of the thigh that will develop over a period of weeks. The pain is often hard to localise and may even be felt in the knee.How painful is a broken femur? ›
How painful is a broken femur? Broken femurs can be very painful. Your healthcare provider will provide pain medication as part of your treatment.How long does it take to walk after a broken femur? ›
If the femur fracture does not require surgery, it is often treated with a cast or removable brace, and patients are typically advised not to put any weight on the leg for about 8 weeks. A physical therapist will help the patient to walk safely using crutches or a walker, or other assistive device.