eMedicine Specialties > Sports Medicine > Lower Limb
Femur Injuries and Fractures: Treatment & Medication
Updated: Oct 30, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
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
In cases of traumatic femoral fractures, the trauma surgeon implements multisystem stabilization and clearance for surgical intervention. Consultations with appropriate specialists must be arranged for specific systems. Traction may be necessary for initial stabilization to maintain leg length before impending surgery.
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.1,2,8,9
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.
Related eMedicine topics:
Toxicity, Narcotics
Toxicity, Nonsteroidal Anti-inflammatory Agents
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Resource Center Opioids: A Guide to State Opioid Prescribing Policies
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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.
Acetaminophen and codeine (Tylenol With Codeine [# 3])
Indicated for mild to moderate pain.
Adult
30-60 mg/dose PO based on codeine q3-4h, not to exceed 4 g/d of acetaminophen
Pediatric
0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen; not to exceed 2.6 g/d of acetaminophen
Toxicity of codeine increases with CNS depressants, TCAs, MAOIs, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics
Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase the hepatotoxicity of acetaminophen.
Documented hypersensitivity
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
Hepatotoxicity with acetaminophen is possible in the presence of chronic alcoholism 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 and exceed the recommended maximum dose.
Hydrocodone and acetaminophen (Lortab, Norcet, Vicodin)
Drug combination for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg/dose based on acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg based on acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Coadministration with phenothiazines may decrease the analgesic effects; toxicity increases with CNS depressants TCAs.
Documented hypersensitivity; HACE or elevated ICP
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
The tablets contain metabisulfite, which may cause hypersensitivity; 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
Propoxyphene and acetaminophen (Darvocet N-100, Propacet)
Drug combination for mild to moderate pain.
Adult
1-2 tab PO q4h prn; not to exceed 600 mg/d propoxyphene
Pediatric
Not established
May increase the serum concentrations of MAOIs, TCAs, carbamazepine, phenobarbital, and warfarin
Documented hypersensitivity
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
More on Femur Injuries and Fractures |
| Overview: Femur Injuries and Fractures |
| Differential Diagnoses & Workup: Femur Injuries and Fractures |
 Treatment & Medication: Femur Injuries and Fractures |
| Follow-up: Femur Injuries and Fractures |
| Multimedia: Femur Injuries and Fractures |
| References |
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References
Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. 2nd ed. Philadelphia, Pa: WB Saunders; 1998.
Delee JC Jr, Drez D, eds. Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, Pa: WB Saunders; 1993.
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].
Evans FG, Pedersen HE, Lissner HR. The role of tensile stress in the mechanism of femoral fractures. J Bone Joint Surg Am. 1951;333:485-501. [Medline]. [Full Text].
Goodfellow J, O'Connor J. The mechanics of the knee and prosthesis design. J Bone Joint Surg Br. Aug 1978;60-B(3):358-69. [Medline]. [Full Text].
DeFranco MJ, Recht M, Schils J, Parker RD. Stress fractures of the femur in athletes. Clin Sports Med. Jan 2006;25(1):89-103, ix. [Medline].
Fitch KD. Stress fractures of the lower limbs in runners. Aust Fam Physician. Jul 1984;13(7):511-5. [Medline].
Schmal H, Strohm PC, Mehlhorn AT, Hauschild O, Südkamp NP. [Management of ipsilateral femoral neck and shaft fractures] [German]. Unfallchirurg. Sep 6 2008;epub ahead of print. [Medline].
Mutty CE, Jensen EJ, Manka MA Jr, Anders MJ, Bone LB. Femoral nerve block for diaphyseal and distal femoral fractures in the emergency department. Surgical technique. J Bone Joint Surg Am. Oct 2008;90 suppl 2 pt 2:218-26. [Medline].
Sanders DW, MacLeod M, Charyk-Stewart T, et al. Functional outcome and persistent disability after isolated fracture of the femur. Can J Surg. Oct 2008;51(5):366-70. [Medline]. [Full Text].
Thomas HO. Diseases of the Hip, Knee, and Ankle Joints. Liverpool, England: T. Dobb & Co; 1875.
Wolinsky P, Tejwani N, Richmond JH, et al. Controversies in intramedullary nailing of femoral shaft fractures. Instr Course Lect. 2002;51:291-303. [Medline].
Further Reading
Keywords
femur injuries and fracture, femoral shaft fracture, diaphyseal fracture of the femur, femoral stress fracture, femur fracture, femoral neck stress fracture, femur injury, femur stress fracture, femoral diaphyseal fracture, broken leg, leg fracture, fractured femur, femur trauma, leg trauma, fractured leg
