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Introduction
Background
The spectrum of femoral shaft fractures is wide and ranges from nondisplaced femoral
stress fractures to fractures associated with severe comminution and significant soft-
tissue injury. Femoral shaft (see image below) fractures are generally caused by high-
energy forces and are often associated with multisystem trauma. Isolated injuries can
occur with repetitive stress and may occur in the presence metabolic bone diseases,
metastatic disease, or primary bone tumors. 1,2
An example of an isolated, short, oblique midshaft femoral fracture, which is
very amenable to intramedullary nailing. Although not seen in this x-ray
film, radiographic visualization of both the proximal and distal joints
should be performed for all diaphyseal fractures.
[ CLOSE WINDOW ]
Most femoral diaphyseal fractures are treated surgically with intramedullary nails or
plate fixation. The goal of treatment is reliable anatomic stabilization, allowing
mobilization as soon as possible. Surgical stabilization is also important for early
extremity function, allowing both hip and knee motion and strengthening. Injuries and
fractures of the femoral shaft may have significant short- and long-term effects on the
hip and knee joints if alignment is not restored.
Treatment of femoral shaft fractures has undergone significant evolution over the past
century. Until the recent past, the definitive method for treating femoral shaft
fractures was traction or splinting. Before the evolution of modern aggressive fracture
treatment and techniques, these injuries were often disabling or fatal. Traction as a
treatment option has many drawbacks, including poor control of the length and
alignment of the fractured bone, development of pulmonary insufficiency, deep vein
thrombosis, and joint stiffness due to supine positioning.
The femur is very vascular and fractures can result in significant blood loss into the
thigh. Up to 40% of isolated fractures may require transfusion, as such injuries can
result in loss of up to 3 units of blood.3 This factor is significant, especially in elderly
patients who have less cardiac reserve.
Femoral fracture patterns vary according to the direction of the force applied and the
quantity of force absorbed. A perpendicular force results in a transverse fracture
pattern, an axial force may injure the hip or knee, and rotational forces may cause
spiral or oblique fracture patterns. The amount of comminution present increases with
the amount of energy absorbed by the femur at the time of fracture.1,2,4,5
For excellent patient education resources, visit eMedicine's Breaks, Fractures, and
Dislocations Center and Sports Injury Center. Also, see eMedicine's patient education
article Broken Leg.
Frequency
United States
Functional Anatomy
The femur is the strongest, longest, and heaviest bone in the body and is essential for
normal ambulation. It consists of 3 parts (ie, femoral shaft or diaphysis, proximal
metaphysis, distal metaphysis). The femoral shaft is tubular with a slight anterior
bow, extending from the lesser trochanter to the flare of the femoral condyles. During
weight bearing, the anterior bow produces compression forces on the medial side and
tensile forces on the lateral side. The femur is a structure for standing and walking,
and it is subject to many forces during walking, including axial loading, bending, and
torsional forces. During contraction, the large muscles surrounding the femur account
for most of the applied forces.1,2,4,5
Several large muscles attach to the femur. Proximally, the gluteus medius and
minimus attach to the greater trochanter, resulting in abduction of the femur with
fracture. The iliopsoas attaches to the lesser trochanter, resulting in internal rotation
and external rotation with fractures. The linea aspera (rough line on the posterior shaft
of the femur) reinforces the strength and is an attachment for the gluteus maximus,
adductor magnus, adductor brevis, vastus lateralis, vastus medialis, vastus
intermedius, and short head of the biceps. Distally, the large adductor muscle mass
attaches medially, resulting in an apex lateral deformity with fractures. The medial
and lateral heads of the gastrocnemius attach over the posterior femoral condyles,
resulting in flexion deformity in distal-third fractures.
The blood supply enters the femur through metaphyseal arteries and branches of the
profunda femoris artery, penetrating the diaphysis and forming medullary arteries
extending proximally and distally. With intramedullary nailing, the blood supply is
disrupted and progressively reestablishes itself over 6-8 weeks. Healing of the fracture
is enhanced by the surrounding soft tissue and local recruitment of blood supply
around the callus. The femoral artery courses down the medial aspect of the thigh to
the adductor hiatus, at which time it becomes the popliteal artery. Injuries to the artery
occur at the level of the adductor hiatus, where soft-tissue attachments may cause
tethering. Uncommonly, the sciatic nerve is injured in femoral shaft fractures;
however, it may become injured in proximal or distal femoral injuries.
Sport-Specific Biomechanics
Trauma-induced fractures of the femur occur with contact and during high-speed
sports. A significant amount of energy is transferred to the limb in a femur fracture,
such as might be generated in skiing, football, hockey, rodeo, and motor sports.
Stress fracture
A femoral stress fracture is the result of cyclic overloading of the bone or a dramatic
increase in the muscular forces across their insertion, causing microfracture. These
repetitive stresses overcome the ability of the bone to heal the microtrauma. The area
most susceptible to stress fracture is the medial junction of the proximal and middle
third of the femur, which occurs as a result of the compression forces on the medial
femur.
Stress fractures can also occur on the lateral aspect of the femoral neck in areas of
distraction and are less likely to heal nonoperatively than compression-side stress
fractures. Stress fractures occur most often in repetitive overload sports such as in
runners and in baseball and basketball players. For more information, refer to the
eMedicine article Femoral Neck Stress Fracture.
Clinical
History
Femoral shaft fractures are the result of high-energy injuries. These fractures are often
accompanied by other injuries. The first priority in treatment is to rule out other life-
threatening injuries and stabilize the patient. Advanced Trauma Life Support (ACLS)
guidelines should be followed.
Physical
Causes
Workup
Laboratory Studies
Imaging Studies
[ CLOSE WINDOW ]
X-ray film of femur fracture.
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Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Treatment for acute trauma-related femoral fractures is performed by an orthopedic
surgeon and usually involves surgical stabilization (see Surgical Intervention).1,2
For femoral stress fractures of the medial compression side, protected crutch-assisted,
touch-down weight bearing is implemented for 1-4 weeks, based on the resolution of
symptoms and the appearance of callus. Progression to full weight bearing can
gradually commence once pain has resolved. Patients must avoid running for 8-16
weeks while the low-impact training program/phase is completed. The progression
can include (1) cycling, (2) swimming, and (3) running in chest-deep water before
resuming more intensive weight-bearing training. Patients must maintain upper
extremity and cardiovascular fitness and avoid lower extremity exercise early in the
healing process. Prophylactic rod placement is not indicated in femoral stress
fractures.
Medical Issues/Complications
The emergent management of femur injuries in the sports setting is intended to restore
alignment. If limb deformity is present, inline longitudinal traction is applied,
realigning the extremity and maintaining limb perfusion. A splint is applied to
maintain the alignment as the patient is transported to the hospital for definitive
treatment.
Surgical Intervention
Before definitive operative management of a femoral shaft fracture, the patient should
be hemodynamically stable and fully resuscitated. The goal time to definitive surgical
stabilization is generally 24 hours. However, if the patient is hemodynamically
unstable and has not been adequately resuscitated, femoral fixation should be delayed
and temporized with an external fixator or skeletal traction.
Intramedullary nailing (see image below) is the treatment of choice for the majority of
femoral shaft fractures occurring in adults. Reamed locked antegrade femoral nailing
remains the criterion standard and can be performed with the patient in the supine or
lateral position with or without the use of a fracture table.1,2,8,9
X-ray film of femur fracture repair.
[ CLOSE WINDOW ]
X-ray film of femur fracture repair.
Clinical studies have suggested the results of retrograde femoral nailing approach the
success rates that are found with antegrade techniques. Retrograde nailing may be
preferred when the fracture involves the distal femur or is associated with an
ipsilateral femoral neck fracture. A floating knee (ie, an ipsilateral femoral shaft and
tibia shaft fracture) is also a relative indication for a retrograde technique. The
retrograde technique has also been found to be beneficial in obese patients, pregnant
patients, and patients with total hip or total knee prostheses.
Consultations
Consultation with orthopedic surgeons is required in cases of femoral fractures, and a
definitive treatment plan is left to their judgment.
Recovery Phase
Rehabilitation Program
Physical Therapy
With trauma-related femoral fractures, initiate physical therapy to improve hip and
knee range of motion and for strengthening. Gait training for crutch-assisted, touch-
down weight bearing may be necessary depending on the fracture pattern. In simple
fracture patterns, which are axially stable postoperatively, greater weight bearing can
be initiated. The goal of the therapy program should be immediate weight bearing to
tolerance. Pulmonary therapy is instituted as needed.
For femoral stress fractures, discontinue crutches once pain-free walking is possible.
Increase low-impact lower extremity aerobic training (eg, swimming, biking, elliptical
trainer) as symptoms permit. Attempt to identify causative factors of the femoral
stress fractures (eg, improper training techniques, footwear, diet).
Maintenance Phase
Rehabilitation Program
Physical Therapy
With trauma, weight bearing is permitted once bone-healing stability has been
achieved. Continue to monitor with radiographs in an outpatient setting.
For stress fractures, this phase lasts a minimum 6 weeks since the onset of symptoms.
Recommend 30-45 minutes of pain-free bike riding on a flat surface. The patient must
avoid causative factors. Poor training areas and equipment must be corrected. During
the first week, the patient can begin walking 3-5 mile/wk. At week 2, the patient can
advance to walking or running 5 mile/wk. At week 3, the patient can run 5 mile/wk
(minimum of 9 wk after symptom onset). Patients can gradually return to 50% of their
previous training distance over the ensuing 1-2 weeks. If symptoms recur, return to
the beginning of the previous phase for a minimum of 3 weeks.
Surgical Intervention
Before definitive operative management of a femoral shaft fracture, the patient should
be hemodynamically stable and fully resuscitated. The goal time to definitive surgical
stabilization is generally 24 hours. However, if the patient is hemodynamically
unstable and has not been adequately resuscitated, femoral fixation should be delayed
and temporized with an external fixator or skeletal traction.
Intramedullary nailing is the treatment of choice for the majority of femoral shaft
fractures occurring in adults. Reamed locked antegrade femoral nailing remains the
criterion standard and can be performed with the patient in the supine or lateral
position with or without the use of a fracture table. Clinical studies suggest the results
of retrograde femoral nailing approach the success rates that are found with antegrade
techniques.
Retrograde nailing may be preferred when the fracture involves the distal femur or is
associated with an ipsilateral femoral neck fracture. A floating knee is also a relative
indication for a retrograde technique. The retrograde technique has also been found to
be beneficial in obese patients, pregnant patients, and patients with total hip or total
knee prostheses.
Plate fixation may be used when femoral fractures are associated with vascular injury
that requires repair or with ipsilateral femoral neck fractures. Limited-incision
techniques and the use of locked plating systems are evolving.
Medication
Medication for trauma-related fractures includes pain medication as indicated for
reasonable pain. nonsteroidal anti-inflammatory medications (NSAIDs) may inhibit
bone healing.
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort,
promote pulmonary toilet, and have sedating properties, which are beneficial for
patients with trauma.
• Dosing
• Interactions
• Contraindications
• Precautions
Adult
30-60 mg/dose PO based on codeine q3-4h, not to exceed 4 g/d of acetaminophen
Pediatric
• Dosing
• Interactions
• Contraindications
• Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
Documented hypersensitivity
• Dosing
• Interactions
• Contraindications
• Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in
humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients who are dependent on opiates, because this substitution may result
in acute opiate-withdrawal symptoms; caution in the presence of severe renal or
hepatic dysfunction
• Dosing
• Interactions
• Contraindications
• Precautions
Adult
Pediatric
<12 years: 10-15 mg/kg/dose based on acetaminophen PO q4-6h prn; not to exceed
2.6 g/d acetaminophen
• Dosing
• Interactions
• Contraindications
• Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in
humans; may use if benefits outweigh risk to fetus
Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
Adult
Pediatric
Not established
Follow-up
Return to Play
Sports-specific rehabilitation is initiated once strength has been regained. The athlete
should be back to preinjury status at 1 year postinjury. Long-term symptoms include
hamstring weakness, limited standing and walking (39%), some intermittent pain
(37%), and inability to return to preinjury work (9%).
For femoral stress fractures, a minimum time of 6 weeks is necessary for bone healing
to occur before the patient is able to resume activities. The athlete should resume
activities in a very gradual fashion over the course of several weeks. If symptoms
recur during training, the athlete should return to the previous phase of treatment for a
minimum of 3 weeks.
Complications
Prevention
Prognosis
Miscellaneous
Medicolegal Pitfalls
• Failure to address conditions that may accompany femur fractures and injuries
• Missed fractures or dislocations due to concentration on the obvious pain and
deformity of the femur
Multimedia
Media file 1: An example of an isolated, short, oblique
midshaft femoral fracture, which is very amenable to
intramedullary nailing. Although not seen in this x-ray film,
radiographic visualization of both the proximal and distal
joints should be performed for all diaphyseal fractures.
(Enlarge Image)
[ CLOSE WINDOW ]
An example of an isolated, short, oblique midshaft femoral fracture, which is
very amenable to intramedullary nailing. Although not seen in this x-ray
film, radiographic visualization of both the proximal and distal joints
should be performed for all diaphyseal fractures.
(Enlarge Image)
[ CLOSE WINDOW ]
X-ray film of femur fracture.