Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Femur Injuries and Fractures

  • Author: Nicholas M Romeo, DO; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Oct 01, 2015
 

Background

The spectrum of femur fractures is wide and ranges from non-displaced femoral stress fractures to fractures associated with severe comminution and significant soft-tissue injury. Femur fractures are typically described by location (proximal, shaft, distal). These fractures may then be categorized into three major groups; high-energy traumatic fractures, low energy traumatic fractures through pathologic bone (pathologic fractures) and stress fractures due to repetitive overload.

This article gives a general overview of femoral fractures and injuries that may be encountered in the athlete, with special attention to femoral shaft stress fractures. For fractures of the femoral diaphysis, see Femur Fracture. For proximal femur fractures (subtrochanteric to femoral head), see Hip Fracture in Emergency Medicine. For fractures of the distal femur (supracondylar to condylar), see Knee Fractures. For femoral neck stress fractures, see Femoral Neck Stress Fracture.

An example of an isolated, short, oblique midshaft An example of an isolated, short, oblique midshaft femur fracture. Although not seen in this x-ray film, radiographic visualization of both the proximal and distal joints should be performed for all diaphyseal fractures.

See Football Injuries: Slideshow, a Critical Images slideshow, to help diagnose and treat injuries from a football game that can result in minor to severe complications.

Traumatic femur fractures in the young individual are generally caused by high-energy forces and are often associated with multisystem trauma. In the elderly population, femur fractures are typically caused by a low energy mechanism such as a fall from standing height. Isolated injuries can occur with repetitive stress and in the presence of metabolic bone diseases, metastatic disease or primary bone tumors.[1, 2]

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 three units of blood.[3] This factor is significant, especially in elderly patients who have less cardiac reserve.

Femur 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 increasing amounts of force.[1, 2, 4, 5]

Most femur fractures are treated surgically. The goal of early surgical treatment is stable, anatomic fixation, 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 femur may have significant short and long-term effects on gait kinematics and function if alignment is not restored.

For patient education resources, see the First Aid and Injuries Center and Broken Leg.

Related Medscape resources:

Resource Center Exercise and Sports Medicine

Specialty Site Emergency Medicine

Specialty Site Orthopaedics

CME A 49-Year-Old Man With a Femur Fracture and Hyperdense Bones

CME Vitamin D and Musculoskeletal Health

Next

Epidemiology

Frequency

United States

  • The incidence of femoral shaft fractures ranges from of 9.5 to 18.9 per 100,000 annually. [6]
  • Approximately 250,000 proximal femur fractures occur in the United States annually. This number is anticipated to double by the year 2050. [7]
  • High-energy injuries are most common in younger males. See the images below.
    Radiograph of a high-energy femoral shaft fracture Radiograph of a high-energy femoral shaft fracture.
    Radiograph of a high-energy femoral shaft fracture Radiograph of a high-energy femoral shaft fracture.
  • The incidence of femur fractures increases in elderly patients.
  • Fatigue fractures of the femur occur at a rate of 19.9 per 10,000 persons per year. [8]
  • Stress fractures as a whole occur in up to 37% of runners. [6] The femur accounts for 11% of stress fractures. Approximately 53% of these fractures occur about femoral shaft. [6]
Previous
Next

Functional Anatomy

The femur is the strongest, longest, and heaviest bone in the body and is essential for normal ambulation. The femoral shaft is tubular with a slight anterior bow, extending from the lesser trochanter to the flare of the femoral condyles. The femur is subject to many forces during ambulation including axial loading, bending, and torsional forces. During weight bearing, the medial cortex is subject to compressive forces while tensile forces are placed on the lateral cortex during contraction, the large muscles surrounding the femur account for a large portion of the applied forces.[1, 2, 4, 5]

Several large muscles attach to the femur which can affect displacement of certain fracture patterns. Proximally, the gluteus medius and minimus attach to the greater trochanter. The forces from these muscles may result in an abduction deformity to the proximal fragment of proximal femoral shaft and subtrochanteric femur fractures. The iliopsoas attaches to the lesser trochanter, resulting in a flexion deformity of this same fragment, in fractures occurring below the level of the lesser trochanter. The linea aspera (rough line on the posterior shaft of the femur) reinforces the strength of the femur 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 seen in certain distal femur fractures. The medial and lateral heads of the gastrocnemius attach over the posterior femoral condyles, resulting inflexion deformity in distal-third fractures.

Radiograph of an intra-articular distal femur frac Radiograph of an intra-articular distal femur fracture.
Radiograph of an intra-articular distal femur frac Radiograph of an intra-articular distal femur fracture.

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. Healing of femur fracture is enhanced by the surrounding muscles and soft tissues contributing to 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.

See also Medscape Drugs & Diseases articles Nerve Entrapment Syndromes and Nerve Entrapment Syndromes of the Lower Extremity.

Previous
Next

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. With prolonged activity, the muscles that dissipate force to bone begin to fatigue placing increased force on the bone itself. Muscle fatigue may also contribute by altering gait kinematics. Stress becomes concentrated at susceptible areas with eventual weakening and subsequent microfracture, as these repetitive stresses overcome the ability of the bone to remodel. The area most susceptible to stress fractures is the medial junction of the proximal and middle third of the femur. Fractures in this location occur as a result of the compression forces on the medial femur.[2]

One more recent study has suggested that the lateral cortex of the femoral shaft may also be susceptible to stress fracture due to tensile forces.[9]

Stress fractures can also occur on the lateral aspect of the femoral neck in areas of distraction and are less likely to heal non-operatively than compression-side stress fractures on the medial side. Stress fractures occur most often in repetitive overload sports such as in runners and basketball players. For more information, refer to the Medscape Drugs & Diseases article Femoral Neck Stress Fracture.

Previous
 
 
Contributor Information and Disclosures
Author

Nicholas M Romeo, DO Resident Physician, Department of Orthopedic Surgery, Wellspan York Hospital

Nicholas M Romeo, DO is a member of the following medical societies: American Osteopathic Association, American Osteopathic Academy of Orthopedics, Pennsylvania Osteopathic Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

John R Deitch, MD Director of Sports Medicine, Wellspan Orthopedics

John R Deitch, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Pennsylvania Orthopaedic Society

Disclosure: Nothing to disclose.

Thomas G DiPasquale, DO, FACOS, FAOAO Medical Director, Orthopedic Trauma Services, Director, Orthopedic Trauma Fellowship and Orthopedic Residency Programs, York Hospital; Orthopedic Trauma Consultant, Florida Orthopedic Institute, Tampa General Hospital

Thomas G DiPasquale, DO, FACOS, FAOAO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Osteopathic Association, Florida Medical Association, Florida Orthopaedic Society, American Osteopathic Academy of Orthopedics, Florida Osteopathic Medical Association

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.

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Institute of Ultrasound in Medicine, North American Spine Society, International Spine Intervention Society, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine

Disclosure: Received honoraria from Cephalon for speaking and teaching; Received honoraria from Endo for speaking and teaching; Received honoraria from Genzyme for speaking and teaching; Received honoraria from Prostakan for speaking and teaching; Received consulting fee from Pfizer for speaking and teaching.

Acknowledgements

Douglas F Aukerman, MD Associate Professor, Department of Orthopedics and Rehabilitation, Division of Sports Medicine, Department of Family Medicine, Pennsylvania State University College of Medicine

Douglas F Aukerman, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Association, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, and Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

William Ertl, MD Clinical Assistant Professor, Department of Orthopedics, University of Oklahoma College of Medicine

Disclosure: Nothing to disclose.

References
  1. 1. Browner BD, Jupiter JB, Levine AM, Trafton PG. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. 2nd ed. Philadelphia, PA: WB Saunders; 1998.

  2. Delee JC Jr, Drez D. Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, PA: WB Saunders; 1993.

  3. Lieurance R, Benjamin JB, Rappaport WD. Blood loss and transfusion in patients with isolated femur fractures. J Orthop Trauma. 1992. 6(2):175-9. [Medline].

  4. Evans FG, Pedersen HE, Lissnwe HR. The role of tensile stress in the mechanism of femoral fractures. J Bone Joint Surg Am. 1951 Apr. 33-A(2):485-501. [Medline].

  5. Goodfellow J, O'Connor J. The mechanics of the knee and prosthesis design. J Bone Joint Surg Br. 1978 Aug. 60-B(3):358-69. [Medline].

  6. Nikolaou VS, Stengel D, Konings P, Kontakis G, Petridis G, Petrakakis G. Use of femoral shaft fracture classification for predicting the risk of associated injuries. J Orthop Trauma. 2011 Sep. 25(9):556-9. [Medline].

  7. Koval KJ, Zuckerman JD. Hip Fractures: I. Overview and Evaluation and Treatment of Femoral-Neck Fractures. J Am Acad Orthop Surg. 1994 May. 2(3):141-149. [Medline].

  8. Niva MH, Kiuru MJ, Haataja R, Pihlajamäki HK. Fatigue injuries of the femur. J Bone Joint Surg Br. 2005 Oct. 87(10):1385-90. [Medline].

  9. Koh JS, Goh SK, Png MA, Ng AC, Howe TS. Distribution of atypical fractures and cortical stress lesions in the femur: implications on pathophysiology. Singapore Med J. 2011 Feb. 52(2):77-80. [Medline].

  10. DeFranco MJ, Recht M, Schils J, Parker RD. Stress fractures of the femur in athletes. Clin Sports Med. 2006 Jan. 25(1):89-103, ix. [Medline].

  11. Fitch KD. Stress fractures of the lower limbs in runners. Aust Fam Physician. 1984 Jul. 13(7):511-5. [Medline].

  12. Schnackenburg KE, Macdonald HM, Ferber R, Wiley JP, Boyd SK. Bone quality and muscle strength in female athletes with lower limb stress fractures. Med Sci Sports Exerc. 2011 Nov. 43(11):2110-9. [Medline].

  13. Miller T, Kaeding CC, Flanigan D. The classification systems of stress fractures: a systematic review. Phys Sportsmed. 2011 Feb. 39(1):93-100. [Medline].

  14. Wentz L, Liu PY, Ilich JZ, Haymes EM. Dietary and training predictors of stress fractures in female runners. Int J Sport Nutr Exerc Metab. 2012 Oct. 22(5):374-82. [Medline].

  15. Kang L, Belcher D, Hulstyn MJ. Stress fractures of the femoral shaft in women's college lacrosse: a report of seven cases and a review of the literature. Br J Sports Med. 2005 Dec. 39(12):902-6. [Medline].

  16. Clement DB, Ammann W, Taunton JE, Lloyd-Smith R, Jesperson D, McKay H. Exercise-induced stress injuries to the femur. Int J Sports Med. 1993 Aug. 14(6):347-52. [Medline].

  17. Monteleone GP Jr. Stress fractures in the athlete. Orthop Clin North Am. 1995 Jul. 26(3):423-32. [Medline].

  18. DeFranco MJ, Recht M, Schils J, Parker RD. Stress fractures of the femur in athletes. Clin Sports Med. 2006 Jan. 25(1):89-103, ix. [Medline].

  19. Flaherty EG, Perez-Rossello JM, Levine MA, et al. Evaluating children with fractures for child physical abuse. Pediatrics. 2014 Feb. 133 (2):e477-89. [Medline].

  20. Harrison L. Fractures Linked to Child Abuse: AAP Diagnostic Guidelines. Medscape Medical News. Available at http://www.medscape.com/viewarticle/819735. January 27, 2014; Accessed: October 2, 2015.

  21. Avenell A, Gillespie WJ, Gillespie LD, O'Connell D. Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis. Cochrane Database Syst Rev. 2009 Apr 15. CD000227. [Medline].

  22. Bischoff-Ferrari HA, Willett WC, Wong JB, Giovannucci E, Dietrich T, Dawson-Hughes B. Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA. 2005 May 11. 293(18):2257-64. [Medline].

  23. Tang BM, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet. 2007 Aug 25. 370(9588):657-66. [Medline].

  24. Jackson RD, LaCroix AZ, Gass M, Wallace RB, Robbins J, Lewis CE. Calcium plus vitamin D supplementation and the risk of fractures. N Engl J Med. 2006 Feb 16. 354(7):669-83. [Medline].

  25. Brinker MR, O'Connor DP, Monla YT, Earthman TP. Metabolic and endocrine abnormalities in patients with nonunions. J Orthop Trauma. 2007 Sep. 21(8):557-70. [Medline].

  26. Fu L, Tang T, Miao Y, Hao Y, Dai K. Effect of 1,25-dihydroxy vitamin D3 on fracture healing and bone remodeling in ovariectomized rat femora. Bone. 2009 May. 44(5):893-8. [Medline].

  27. Johnson AL, Smith JJ, Smith JM, Sanzone AG. Vitamin D insufficiency in patients with acute hip fractures of all ages and both sexes in a sunny climate. J Orthop Trauma. 2013 Dec. 27(12):e275-80. [Medline].

  28. Stephenson JW, Davis KW. Imaging of traumatic injuries to the hip. Semin Musculoskelet Radiol. 2013 Jul. 17(3):306-15. [Medline].

  29. Tornetta P 3rd, Kain MS, Creevy WR. Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Improvement with a standard protocol. J Bone Joint Surg Am. 2007 Jan. 89(1):39-43. [Medline].

  30. Harrast MA, Colonno D. Stress fractures in runners. Clin Sports Med. 2010 Jul. 29(3):399-416. [Medline].

  31. Porter JM, Ivatury RR. In search of the optimal end points of resuscitation in trauma patients: a review. J Trauma. 1998 May. 44(5):908-14. [Medline].

  32. Ivkovic A, Bojanic I, Pecina M. Stress fractures of the femoral shaft in athletes: a new treatment algorithm. Br J Sports Med. 2006 Jun. 40(6):518-20; discussion 520. [Medline].

  33. Simon AM, Manigrasso MB, O'Connor JP. Cyclo-oxygenase 2 function is essential for bone fracture healing. J Bone Miner Res. 2002 Jun. 17(6):963-76. [Medline].

  34. Reuling EM, Sierevelt IN, van den Bekerom MP, Hilverdink EF, Schnater JM, van Dijk CN, et al. Predictors of functional outcome following femoral neck fractures treated with an arthroplasty: limitations of the Harris hip score. Arch Orthop Trauma Surg. 2012 Feb. 132(2):249-56. [Medline]. [Full Text].

 
Previous
Next
 
An example of an isolated, short, oblique midshaft femur fracture. Although not seen in this x-ray film, radiographic visualization of both the proximal and distal joints should be performed for all diaphyseal fractures.
Radiograph of a high-energy femoral shaft fracture.
Radiograph of a high-energy femoral shaft fracture.
Radiograph of an intra-articular distal femur fracture.
Radiograph of an intra-articular distal femur fracture.
Full length AP radiograph of an intertrochanteric fracture.
MRI of a patient with a stress fracture at the base of the femoral neck.
AP radiograph of a healing femoral shaft fracture after intramedullary nailing.
Lateral radiograph of a healing femoral shaft fracture after intramedullary nailing.
An intra-articular distal femur fracture treated with intramedullary nailing as well as independent screw fixation.
An intra-articular distal femur fracture treated with intramedullary nailing as well as independent screw fixation.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.