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Diaphyseal Femur Fractures Workup

  • Author: Bart Eastwood, DO; Chief Editor: William L Jaffe, MD  more...
Updated: Oct 05, 2015

Laboratory Studies

In cases of diaphyseal femur fracture, laboratory studies appropriate for a trauma patient may be indicated, depending on the situation.

The hemoglobin level and hematocrit (H/H) level should be monitored because of the relatively large amount of blood that can be lost into the compartments of the upper leg. However, the amount of blood lost with an isolated femur fracture should not cause clinically significant hypotension. If this occurs, bleeding from another site should be suspected.

Culture and sensitivity results may be obtained in cases of open fractures to determine the optimal antibiotic treatment after empiric therapy, though some believe that this is of little benefit because of gross contamination of the wound.

If a pathologic fracture is suspected, a more extensive workup is needed.


Imaging Studies

In diaphyseal femur fracture, traction or splinting should be applied before radiography to prevent further soft-tissue damage.

Ensure that no radiopaque material obscures the femur; otherwise, pathologic findings or a nondisplaced neck fracture could easily be missed. Nondisplaced femoral shaft fractures can be easily missed on both plain films and computed tomography (CT) scans.[35]  The likelihood of nondisplaced neck fractures increases with femur fractures because some of the energy is dispersed from the fracture site.

Depending on the situation, an entire trauma series may be needed. The initial investigation of a femur fracture should involve an anteroposterior (AP) pelvic view, as well as AP and lateral views of the knee that show the entire femur. (See the images below.) Baseline chest images may also be needed to compare with later images to help in the diagnosis of a fat embolism. As always, poor-quality images are not acceptable.

Anteroposterior radiograph of a femur fracture in Anteroposterior radiograph of a femur fracture in a 45-year-old man.
Lateral radiograph of a femur shaft fracture in a Lateral radiograph of a femur shaft fracture in a 45-year-old man.


Femoral-shaft fractures can be classified by location, as follows: proximal third, middle third, distal third, and the junctions of the segments, among others. Geometry of the fracture, displacement, alignment, comminution, open versus closed status, and the amount of soft-tissue damage are also used.

No classification system is universally accepted. Two of the most commonly used classification systems are the Winquist-Hansen system and the  Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Association for the Study of Internal Fixation (ASIF) system. The Gustilo and Anderson classification of open fractures is also useful.

Winquist-Hansen classification

This system includes the following categories:

  • 0 - No comminution, simple transverse or oblique
  • I - Small butterfly fragment, minimal to no comminution
  • II - Butterfly fragment with at least 50% of the circumference of the cortices of the two major fragments intact
  • III - Butterfly fragment with 50-100% of the circumference of the two major fragments comminuted
  • IV - Segmental comminution, all cortical contact is lost

AO/ASIF classification

This system includes the following categories:

  • A - Simple
  • A1 - Simple spiral
  • A2 - Simple oblique
  • A3 - Simple transverse
  • B - Wedge
  • B1 - Spiral wedge
  • B2 - Bending wedge
  • B3 - Fragmented wedge
  • C - Complex
  • C1 - Complex spiral
  • C2 - Complex segmental
  • C3 - Complex irregular

AO classification

This system includes the following categories:

  • A1 simple fracture, spiral - (1) Subtrochanteric zone, (2) middle zone, (3) distal zone
  • A2 simple fracture, oblique (≥30°) - (1) Subtrochanteric zone, (2) middle zone, (3) distal zone
  • A3 simple fracture, transverse (<30°) - (1) Subtrochanteric zone, (2) middle zone, (3) distal zone
  • B1 wedge fracture, spiral wedge - (1) Subtrochanteric zone, (2) middle zone, (3) distal zone
  • B2 wedge fracture, bending wedge - (1) Subtrochanteric zone, (2) middle zone, (3) distal zone
  • B3 wedge fracture, fragmented wedge - (1) Subtrochanteric zone, (2) middle zone, (3) marked displacement
  • C1 complex fracture, spiral - (1) With 2 intermediate fragments, (2) with three intermediate fragments, (3) with more than 3 intermediate fragments
  • C2 complex fracture, segmental - (1) With one intermediate segmental fragment, (2) with one intermediate segmental and additional wedge fragment(s), (3) with two intermediate segmental fragments
  • C3 complex fracture, irregular - (1) With two or three intermediate fragments, (2) with limited shattering (<5 cm), (3) with extensive shattering (≥5 cm)

Gustilo and Anderson classification of open fractures

This system includes the following categories:

  • Grade I - Clean skin opening, less than 1 cm, most often occurring from inside to out, with minimal soft-tissue damage (eg, chicken bite)
  • Grade II - Skin opening of more than 1 cm, extensive soft-tissue damage
  • Grade III - Massive soft-tissue damage more than 10 cm in length; may include skin, muscle, neurovascular structures; most often high-energy mechanism of injury; includes any open fracture that has not been treated within 8 hours
  • Grade IIIA - Massive soft-tissue damage, adequate bone coverage, minimal periosteal stripping, often occurs with gunshot injuries and often comminuted
  • Grade IIIB - Massive soft-tissue damage with exposed bone and periosteal stripping requiring soft tissue flap coverage, associated with heavy contamination (eg, barnyard injury)
  • Grade IIIC - Vascular injury requiring repair
Contributor Information and Disclosures

Bart Eastwood, DO Orthopedic Surgeon, Southwest Virginia Orthopedics and Spine

Bart Eastwood, DO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Orthopedics, American Osteopathic Association, Arthroscopy Association of North America

Disclosure: Nothing to disclose.


Thomas Knutson, DO Consulting Surgeon, Department of Orthopedic Surgery, Center for Orthopedic Excellence

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

B Sonny Bal, MD, JD, MBA Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

B Sonny Bal, MD, JD, MBA is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Received none from for online orthopaedic marketing and information portal; Received none from OrthoMind for social networking for orthopaedic surgeons; Received stock options and compensation from Amedica Corporation for manufacturer of orthopaedic implants; Received ownership interest from BalBrenner LLC for employment; Received none from ConforMIS for consulting; Received none from Microport for consulting.

Chief Editor

William L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases

William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American College of Surgeons, Eastern Orthopaedic Association, New York Academy of Medicine

Disclosure: Received consulting fee from Stryker Orthopaedics for speaking and teaching.

Additional Contributors

Steven I Rabin, MD Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Orthopedic Surgery, Podiatry, Rheumatology, Sports Medicine, and Pain Management, Dreyer Medical Clinic; Chairman, Department of Surgery, Provena Mercy Medical Center

Steven I Rabin, MD is a member of the following medical societies: AO Foundation, American Academy of Orthopaedic Surgeons, American Fracture Association, Orthopaedic Trauma Association

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author coauthor Dr H Kurtis Biggs to the development and writing of this article.

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Anteroposterior radiograph of a femur fracture in a 45-year-old man.
Lateral radiograph of a femur shaft fracture in a 45-year-old man.
Anteroposterior radiograph of the hip in a 45-year-old man. Distal portion shows the femur fracture.
Anteroposterior radiograph of the hip and proximal femur after antegrade intramedullary (IM) nail placement.
Cross-table radiograph of the hip and proximal femur after antegrade intramedullary (IM) nail placement.
Lateral radiograph of the distal femur after antegrade intramedullary (IM) nail placement.
Anteroposterior radiograph of the distal femur after antegrade intramedullary (IM) nail placement.
Anteroposterior radiograph of a femoral-shaft fracture in a 19-year-old man.
Anteroposterior radiograph of the hip and femur in a 19-year-old man shows a fracture of the femoral shaft.
Lateral radiograph shows flexible nailing in a 19-year-old man.
Anteroposterior radiograph shows flexible nailing in a 19-year-old man.
Anteroposterior and lateral radiographs show flexible nailing in a 19-year-old man.
Example of retrograde nail on distal anteroposterior and lateral radiographs.
Example of retrograde nail on proximal anteroposterior and lateral radiographs.
Patient positioned on a fracture table.
Incision for rod and proximal screw removal.
Example of secondary fracture healing evident on radiography.
Example of an open segmental femur fracture in a 16-year-old, multitrauma patient who sustained this and pelvic, pilon, and Lisfranc injuries on the ipsilateral extremity. Also sustained major chest and head injuries.
As the above patient was extremely unstable, emergent external fixation of the open femur fracture was completed
After delayed antegrade nailing and repeat incision and drainage, note antibiotic beads placed in wound, removed at last incision and drainage.
Table. Spica Casting Results
Group Average Shortening Before Casting, cm Average Shortening After Casting, cm Average Time of Casting Needed, wk Average AP Varus/Valgus Before Average AP Varus/Valgus After
1 (10-49 lb) 1.7 0.7 6 10.4/8.6 7.6/4.3
2 (50-80 lb) 1.5 1 7.1 9.4/5.4 5.6/2.6
3 (81-100 lb) 2.1 0.9 8 12/14 6.8/2.6
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