eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Femur

Updated: Apr 22, 2009

Introduction

Background

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

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

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

The 3 types of femoral shaft fractures are as follows:

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

Associated injuries are common.

Anteroposterior radiograph of a femoral-shaft fracture in a 19-year-old man.

Pathophysiology

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

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

Mortality/Morbidity

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

Clinical

History

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

Physical

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

Causes

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

Differential Diagnoses

Fractures, Hip
Fractures, Knee
Fractures, Pelvic
Trauma, Peripheral Vascular Injuries

Workup

Laboratory Studies

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

Imaging Studies

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

$Anteroposterior radiograph of a femur fracture in...$

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

Treatment

Prehospital Care

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

Emergency Department Care

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

Consultations

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

Medication

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

Nonsteroidal anti-inflammatory agents (NSAIDs)

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

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h prn; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults

Interactions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients on anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderately severe pain and inflammation.
Administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.

Dosing

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established
3 months to 12 years: 0.10-1 mg/kg PO q6-8h
>12 years: Administer as in adults

Interactions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Dosing

Adult

500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/d PO; not to exceed 10 mg/kg/d

Interactions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Flurbiprofen (Ansaid)

Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis.

Dosing

Adult

200-300 mg/d PO bid/qid

Pediatric

Not established

Interactions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels

Contraindications

Documented hypersensitivity

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

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Analgesics

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

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or those taking oral anticoagulants.

Dosing

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/d PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d

Interactions

Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Dosing

Adult

1-2 tab/cap PO q4-6h prn

Pediatric

<12 years: 10-15 mg/kg/d acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; single dose not to exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses/d

Interactions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure

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

Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Dosing

Adult

30-60 mg based on codeine content PO q4-6h or 1-2 tabs q4h; not to exceed 12 tabs/d

Pediatric

0.5-1 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen

Interactions

CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity

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 dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Dosing

Adult

1-2 tab/cap PO q4-6h prn

Pediatric

0.05-0.15 mg/kg oxycodone PO q4-6h prn; not to exceed 5 mg of oxycodone per dose

Interactions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity

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

Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver toxicity

Anxiolytics

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

Lorazepam (Ativan)

Sedative hypnotic in benzodiazepine class that has short onset of effect and relatively long half-life. By increasing action of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation. Excellent for sedating patients for >24 h. Monitor patient's BP after administering dose and adjust as necessary.

Dosing

Adult

Initial dose: 2 mg total or 0.044 mg/kg IV, whichever is smaller

Pediatric

0.05-0.1 mg/kg IV slowly q2-5min; may repeat dose of 0.05 mg/kg IV slowly

Interactions

Alcohol, phenothiazines, barbiturates, and MAOIs increase CNS toxicity

Contraindications

Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease

Follow-up

Further Inpatient Care

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

Transfer

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

Complications

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

Prognosis

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

Patient Education

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

Miscellaneous

Medicolegal Pitfalls

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

Multimedia

$Anteroposterior radiograph of a femur fracture in...$

Media file 1: Anteroposterior radiograph of a femur fracture in a 45-year-old man.

Media file 2: Anteroposterior radiograph of a femoral-shaft fracture in a 19-year-old man.

References

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

femur fracture, femoral diaphysis, fractures of the femoral diaphysis, femoral shaft fractures, spiral femur fractures, transverse femur fractures, comminuted femur fractures, open femur fractures, diaphyseal fractures, hip fractures, ligamentous knee injuries

Contributor Information and Disclosures

Author

James E Keany, MD, FACEP, Medical Director, JetWest International Air Ambulance; Consulting Staff, Department of Emergency Services, Mission Hospital Regional Medical Center; Host of Healthbuzz at Jim.MD
James E Keany, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, and California Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Francis Counselman, MD, Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School
Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Tom Scaletta, MD, President, Emergency Excellence (EmEx) (www.emergencyexcellence.com); Assistant Professor of Emergency Medicine, Rush Medical College, Cook County Hospital; Chairperson, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine
Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Further Reading