Diaphyseal Femur Fractures 

Updated: Jun 29, 2020
Author: Bart Eastwood, DO; Chief Editor: William L Jaffe, MD 

Overview

Practice Essentials

Orthopedic surgeons often encounter diaphyseal femur fractures.[1]  Because these fractures most often result from high-energy trauma, one must have a high index of suspension for complications or other injuries. The mainstay of treatment has been reamed interlocking intramedullary nailing, but a variety of treatment options now exist for solitary fractures or fractures with associated injury.

Before the 1900s, diaphyseal femur fractures were treated with various types of splinting. However, with the discovery of skeletal radiology near the end of the 19th century came an understanding of the forces acting on fractured bones and a change in the treatment of such injuries. Steinmann in 1907 and Kirschner in 1909 developed the first traction treatment modalities with the use of pins or wires under tension.

Early attempts at internal fixation of such fractures achieved little success until Küntscher developed and utilized the intramedullary nail in 1937. After a short period of disagreement, the nailing method began to spread during World War II in Europe and later in North America. Intramedullary nailing became prominent in the United States in the 1970s. Since the intramedullary nailing technique was introduced in 1939, it has continued to evolve into the antegrade reamed interlocking nails that are the standard today.

Adult nonsurgical treatment options include skin traction, skeletal traction, cast brace, and casting. Nonsurgical options are used infrequently outside of the younger pediatric population. Children have the same options, as well as spica casting for those patients weighing less than 80 lb.[2, 3, 4]

Surgical options in adults include the mainstays of intramedullary nailing, either antegrade or retrograde. Plate fixation and external fixation are used less frequently, but these have a place in the decision-making process for the ideal treatment in certain cases. Pediatric cases may also use flexible rods in addition to the adult options mentioned. However, one must consider the patient's immature bones, open physes, parental care available, and growth potential when forming a treatment plan in children.[2, 3, 4, 5]

Anatomy

The femur is one of the largest and strongest bones in the human body. The femur can be divided into regions consisting of the head, neck, intertrochanteric, subtrochanteric (extending 5 cm distal to the lesser trochanter), shaft, supracondylar, and condylar regions.

The structures of the thigh also can be divided into compartments as follows:

  • Within the anterior compartment lies the quadriceps femoris, the sartorius, the psoas, the iliacus, and the pectineus, as well as the femoral artery, vein, and nerve, along with the lateral femoral cutaneous nerve
  • The medial compartment holds the gracilis, the adductor brevis and longus, the adductor magnus, the obturator externus, the deep femoral artery and vein, and the obturator artery, vein, and nerve
  • The posterior compartment holds the semitendinosus, the semimembranosus, the biceps femoris, portions of the adductor magnus, perforating branches of the deep femoral artery, the sciatic nerve, and the posterior femoral cutaneous nerve

The metaphyseal area begins proximally with the subtrochanteric region and distally with the supracondylar region, with the diaphysis in between. Lying posterior on the femur is the linea aspera, which provides a major attachment for fascia. The femur is not perfectly straight; it has a noted anterior bow. The bow varies in degree from person to person, but its presence explains the need for curved nails in order to hold the reduction.

The femur has an abundant vascular supply, receiving the bulk of the blood from the profunda femoral artery.[6] A nutrient artery usually enters along the linea aspera posteriorly and proximally on the femur and supplies the endosteal circulation. The endosteal circulation supplies the inner two thirds to three fourths of the cortex, making the normal blood flow centrifugal in direction. The periosteal circulation enters posteriorly for the most part along the linea aspera.

The periosteal circulation is almost entirely directed in a circumferential direction, having little or no longitudinal spread. Therefore, small wires may be placed around the femur without the danger of devascularizing an area; however, large bands should be avoided. Periosteal circulation has been estimated to serve only the outer one fourth of the cortex. However, the periosteal circulation is critical to fracture healing in the diaphysis.

When a fracture is displaced, the medullary vessels are disrupted and the periosteal vessels predominate as the vascular supply to the fracture site during early healing. In response to fracture, the periosteal vessels proliferate, while the endosteal circulation is restored much later. Therefore, the use of slotted nails may allow for enhanced return of endosteal neovascularization and a more normal blood flow pattern. The significance of periosteal blood flow in healing also emphasizes the importance of avoiding periosteal stripping especially along the linea aspera.

Depending on the level of the fracture and the insertion and attachment of the different muscles of the thigh, varied deformities result. The proximal segment of the femur is under a valgus force of abduction by the gluteus minimus, medius, and maximus. The short external rotators also exert a force on the proximal segment of fractures. A component of flexion and external rotation also exists due to the attachment of the iliopsoas on the less trochanter.

The adductors span most of the medial femur and produce an axial and varus force on the femur. Some of these medial forces are countered by the tension band effect of the fascia lata. The distal femur is under a flexing influence by the gastrocnemius.

Pathophysiology and Etiology

Fractures most often involve the application of a bending load to the femur, with comminution occurring via higher magnitude forces. Torsional loads, in contrast, form a spiral fracture pattern.

Femoral-shaft fractures are usually the result of trauma.[7, 8] Motor vehicle accidents, pedestrian-versus-vehicle accidents, falls, and gunshot wounds are among the most common causes. Pathologic fractures in adults are most often the result of osteoporosis and metastatic disease. In children, it is also important to consider abuse[9] and underlying neuromuscular disorders and metabolic bone disease as causes of the fracture.

Stress fractures also may develop in the femur shaft, often associated with an increase in physical activity. Low-energy shaft fractures have also been associated with the prolonged use of bisphosphonate drugs for treating osteoporosis.[10]

Epidemiology

Fractures of the femoral shaft are among the more common fractures that an orthopedist sees.[11] Injury is most common among persons younger than 25 years and those older than 65 years. Analysis of a statewide discharge database revealed an incidence of 1.33 fractures per 10,000 people. The number of shaft fractures in the elderly is increasing secondary to the growing number of geriatric patients in the general population.

Kim et al studied the characteristics of 147 atypical femoral fractures and concluded that patients with diaphyseal fractures were older, had a lower body mass index (BMI), lower bone mineral density (BMD), and larger lateral and anterior bowing than patients with subtrochanteric fractures.[12]

Prognosis

Antegrade intramedullary nailing in adults

Reamed intramedullary nailing has been shown to have excellent results. In a study of 551 cases of femoral-shaft fractures, Wolinsky et al included the following results[13] :

  • Union - 98.9%
  • Infection - 1.1%
  • Component failure - 2.4% (1 nail and 13 bolts failed)
  • Alignment - No fracture healing with more than 10° of varus/valgus or procurvatum/recurvatum and with less than 5° angulation in 89%

More surprising was that 38% of the patients required some type of hardware removal; the reason in the vast majority was pain. Eighty locking bolts were removed, and 130 nails were removed. Note that nail removal should be done 1-2 years after placement to ensure complete fracture healing.

Winquist et al conducted one of the first large studies, which included 500 patients treated with intramedullary nailing.[14] The study gave much the same results; however, the technology and technique were modified as the study progressed.

A study of 152 middle aged patients with closed femur shaft fracture who underwent closed reduction with intramedullary nailing had a nonunion rate of 10.5%; the majority were oligotrophic nonunion. Three cases of hypertrophic nonunion were reported. Risk factors for nonunion included obesity, hypertension, and diabetes mellitus.[15]

Retrograde nailing in adults

In a study of 45 femoral-shaft fractures, Herscovici et al reported the following results:[16] About 95.5% of the fractures healed after the original procedure. No infections or arthrosis occurred, though seven complications included two cases of nonunion (both had broken nails), one malrotation, one case of reflex sympathetic dystrophy (RSD), one case of skin loss (open knee injury), one ileus, and one deep vein thrombosis (DVT). The average ROM was 129° of flexion at the knee. Eight patients had decreased strength in the thigh.

Ricci et al retrospectively compared 104 femoral-shaft fractures treated with retrograde intramedullary nailing and 94 treated with antegrade intramedullary nailing.[17] The following results were obtained:

  • Union - Retrograde, 88%; antegrade, 89% (no statistical difference)
  • Delayed union - Retrograde, 7%; antegrade 4%
  • Nonunion - Retrograde, 6%; antegrade, 6%
  • Eventual union - Retrograde, 97%, antegrade 99%
  • Malunion - Retrograde, 11%; antegrade, 13% (no statistical difference)
  • Knee pain - Retrograde, 36%; antegrade, 9% (significant difference excluding direct knee injury)
  • Hip pain - Retrograde, 4%; antegrade, 10%
  • Repeat operations - Retrograde, 16%; antegrade, 17%
  • Heterotopic ossification - Retrograde, 0%; antegrade, 26%
  • Locking screw broken - Retrograde, 9%; antegrade, 4%

Ostrum et al completed a prospective study comparing antegrade treatment of 39 shaft fractures with 47 shaft fractures treated with retrograde nailing.[18] At the beginning of the study, 54 patients were treated retrograde and 46, antegrade. Later results were after some deaths and loss to follow-up, leaving 39 patients treated antegrade and 47, retrograde. The following results were obtained:

  • Operative time - Antegrade, 71.3 minutes; retrograde, 68.3 minutes
  • Blood loss - Antegrade, 304 cc; retrograde, 256.5 cc
  • Full return to ROM - Antegrade, 9.1 weeks; retrograde, 16.4 weeks
  • Number of fractures - Antegrade, 39; retrograde, 47
  • Unions, including repeat operations - Retrograde, 46 unions of 47 fractures at an average of 18 weeks to achieve union; antegrade, 39 unions of 39 fractures at an average of 14.4 weeks to achieve union
  • No difference in knee motion was noted; only one patient (with vascular repair) had less than 120° of knee flexion
  • Knee pain - Antegrade, four; retrograde, five
  • Hip/thigh pain - Antegrade, 10; retrograde, two
  • Dynamizations - Antegrade, two; retrograde, 10
  • Symptomatic distal locking screws - Antegrade, four; retrograde, 18

They also found a significant relation between the difference in the canal and nail diameter to time of union.

Plate fixation in adults

Most studies involving plating of femoral-shaft fractures have shown less than desirable results compared with other modalities. In a study of 102 femoral-shaft fractures, Bostman et al[19] demonstrated that 24% had some form of major complication, as follows: 12% mechanical failure, approximately 5% delayed or nonunion, approximately 4% repeat fracture, 7% infection, and 25% second operation.

However, articles exist in which results are better, such as study done on 500 shaft fractures in Slovenia in which 85% of the patients experienced no complications.[20]

In another smaller study by Seligson et al of 15 cases of femoral-shaft fractures, seven complications occurred. Three delayed unions, four nonunions, and two implant failures occurred.[21] No axial deformity greater than 1 cm was observed.

External fixation in adults

Alonso et al treated 24 femoral-shaft fractures with external fixation.[22] Ten of the initial operations were used as the definitive treatment, and the others were changed for other options at a later date. Twenty-one fractures eventually developed solid union. Results included one nonunion and two delayed unions. Eleven patients lost an average of 56° of motion about the knee. Of the 10 patients treated primarily with external fixation, no infections occurred, and two had shortening of greater than 2 cm.

Dabezies treated 20 fractures with definitive external fixation.[23] Nineteen developed solid union in an average of 4.8 months. No cases of chronic osteomyelitis were reported even though 65% of the fractures were open. Fourteen needed cast bracing for an average of 1.5 months after the external fixator was removed. Four pin tract infections and three cases of shortening occurred. Nine lost an average of 50° of knee motion. No device failures occurred.

Flexible nailing in children

Cramer et al[24] conducted a prospective trial of 53 femur fractures treated with Ender nails in children aged 5-14 years (average, 8.5 years). Isolated injuries averaged only a 3-day stay in the hospital. Bridging callus was observed in an average of 3 weeks, while the time to healing averaged 12 weeks. On average, full weightbearing was achieved at 30 days.

Forty-nine patients had no angulations after treatment. Four reported angulations were less than 15° in any plane and less than 10° rotation. No leg length discrepancy exceeded 2 cm. An average of 7 mm of overgrowth occurred. Additional results included five complications, four butterfly fragments displaced on rod insertion, one comminution at the fracture site with passage of rods, three cases of inflammation at the insertion site, one hematoma at the removal site, and two broken locking screws after healing.

Flynn reported on 50 cases treated with a titanium elastic nail for pediatric femur fractures with excellent results.[25] Thirty-eight had excellent results, including good alignment, leg lengths within 1 cm, no wound problems or irritation at fracture site, no malrotation, and full ROM at the knee. Some had a knee effusion that resolved when the nails were removed. Nine patients experienced irritation at the insertion site. One nonunion was treated with successful repeat nailing. One fracture occurred with 20° varus angulation; remodeling reduced this to 7°. One repeat fracture occurred.

Frei et al retrospectively reviewed medical records and plain X-ray images of 22 children (between 2–15 years old) treated with elastic stabile intramedullary nailing for unstable femoral shaft fractures. A complication rate of 13.6% was reported. Two children experienced retrotorsion of the femoral neck; diminished anteversion of the femoral neck occurred in one child.[26]

Rigid intramedullary nailing in children

Momberger et al retrospectively reviewed 50 patients aged 10-16 years who were treated with statically locked intramedullary nailing with a greater trochanter starting point.[27] No infection, nonunion, osseous necrosis, or nerve palsies occurred. Full weightbearing occurred at an average of 5.7 weeks.

Complications included one intraoperative fracture, one delayed union, one DVT, and patellofemoral pain in one patient. Of these patients, 25 underwent radiographic analysis, which revealed an average of only 1 mm in limb-length discrepancy, and none had more than 11 mm discrepancy. The average increase in articulotrochanteric distance compared with the contralateral side was 4.5 cm.

A systematic review study analyzed retrospective data on rigid, locked, intramedullary nail insertion sites in pediatric femur fracture patients and whether the entry site of the nail affected the risk of avascular necrosis (AVN). The results found that the AVN rate for the piriform fossa insertion site was 2% and the rate for the tip of the greater trochanter entry site was 1.4%. No cases of AVN were reported for the lateral trochanter insertion site, indicating that this site is associated with the lowest risk of AVN.[28]

Spica casting in children

Infante et al conducted a study comparing immediate spica casting in three different weight classes from 10 to 100 lb for closed, isolated femur fractures in children. A total of 175 fractures were treated with one and one half spica casts. Union was achieved in all fractures by 8 weeks. All patients were discharged from the hospital within 24 hours.

Infante et al recommend from their findings and past literature that in patients 10-80 lb with close isolated fractures of the femur, spica casting should still be used as a criterion standard.[29] Group 3 could not be included in these recommendations because of the low number of patients in this group.

Table. Spica Casting Results (Open Table in a new window)

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

Plate fixation in children

Kregor et al reported 15 fractures treated with plate fixation.[30] All healed in an average of 8 weeks. No infections were reported, and 14 of 15 healed with anatomic alignment. Overgrowth averaged 9 mm. No restrictions in activities were reported at 26 months. Ward also reported on 25 fractures treated with plate fixation. Healing occurred in 23 of 25 in an average time of 11 weeks.[31]

External fixation in children

Blasier et al reported on 139 fractures treated with external fixation.[32] All healed in an average of 11.4 weeks. Eighteen were followed up at 2 years, and 15 patients had overgrowth averaging 8.7 mm, three had shortening averaging 7.7 mm, and none required treatment. Pin tract infection was common; six required intravenous antibiotics for pin tract infection treatment. Two repeat fractures occurred.

Miner and Carrol reported on 37 fractures treated in children aged 4-14 years.[33] Healing occurred in 36 of 37. Minimal leg-length discrepancies and angulations were reported. Pin tract infection was reported in 72.7%; more alarming was the 21.6% rate of repeat fracture. Patients with bilateral femur fractures seemed to be at the greatest risk of repeat fracture.

 

Presentation

History

The usual history of diaphyseal femur fractures is that of trauma.[34] If the history does not consist of trauma, one should suspect a pathologic bone condition. Clinically, the injury is most often apparent. Pain, swelling, shortening, and deformity are usually present in the region.

Physical Examination

Because of the high association of other injuries, the advanced trauma life support (ATLS) protocol should be followed. As always, a neurovascular assessment should be completed, though this type of injury is rare with femoral-shaft fractures. Examination of the pelvis and hip is of great importance to investigate possible fracture or dislocation. A thorough examination of the knee also should be completed to detect any ligamentous or bony injury.

Complications

Femoral-shaft fractures are usually easy to treat compared with the high-energy injuries associated with the fracture, in which complications tend to occur. Severe–to–life-threatening injuries often occur along with the femoral-shaft fracture. Death, fat embolism,deep venous thrombosis (DVT),pulmonary embolism, pneumonia development, multiorgan failure, long intensive care unit (ICU) stays, infection, hemorrhage, nerve palsies, rare compartment syndrome, nonunion, delayed union, and malunion may also occur as complications of a diaphyseal femur fracture.

 

Workup

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 radiography and computed tomography (CT).[35, 36] 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.

Classification

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)–Orthopaedic Trauma Association (OTA) 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-OTA classification

This system includes the following categories[37] :

  • Type A, simple fracture - (1) Spiral, (2) oblique (≥30º), (3) transverse (< 30º); these may be further qualified as (a) proximal third, (b) middle third, or (c) distal third
  • Type B, wedge fracture - (2) Intact, (3) fragmentary; these may be further qualified as (a) proximal third, (b) middle third, or (c) distal third
  • Type C, multifragmentary fracture - (2) Intact segmental, (3) fragmentary segmental; these may be further qualified as (a) proximal diaphyseal-metaphyseal, (b) pure diaphyseal, or (c) distal diaphyseal-metaphyseal

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
 

Treatment

Approach Considerations

Currently, surgery is indicated for most femur fractures because of the high rate of union, low rate of complications, and the advantage of early fracture stabilization, which decreases morbidity and mortality in patients (especially polytrauma patients) with these fractures. Surgery for diaphyseal femur fracture should be reserved for those able to tolerate the appropriate procedure for their circumstance. Young children can often be treated successfully with noninvasive measures; thus, surgery can be avoided.

Definite indications include polytrauma patients, especially those with head and chest injuries, and those with injuries to multiple limbs or those otherwise unable to care for themselves to maximize postoperative independence. Most others are surgical candidates because of the lower incidence of complication and the higher union rates with surgery. Those who should not be treated surgically include patients too unstable to tolerate the procedure and children weighing less than 80 lb.

No one can argue with the high success rate of reamed locked antegrade nailing. However, patients with femoral-shaft fractures often present with a multitude of injuries including head and chest trauma. Laboratory studies have shown that a showering of small emboli occurs with reaming and also insertion of the nail into the medullary canal. Moreover, pulmonary function is affected.

A definitive answer has yet to be made to the question of the clinical significance in those with multiple traumas that include chest injury or in those with preexisting poor pulmonary function. Further studies are needed to further evaluate primary reamed or unreamed nailing, along with delayed nailing after external fixation, to determine the optimal treatment in these patients. Many chose a compromise between the options of quick, noninvasive external fixation and intramedullary nailing by using external fixation as a bridge to an early conversion to intramedullary nailing.

Intramedullary nailing in cases of head injury raises concerns. Potential hypotension and hypoxia in the intraoperative period with intramedullary nailing may cause further detriment to an already-damaged central nervous system (CNS). The incidence of heterotopic ossification is increased in femur fractures associated with head injury. Again, more studies are needed to define the role of intramedullary nailing and its timing in these patients. Opposing views can be found in the literature.

The treatment of open fractures is also not without controversy. Most surgeons agree that open fractures types I and II can be treated with primary reamed intramedullary nailing, and some even attest to this treatment for type IIIA fractures. The standard has been to use external fixation in types IIIB and IIIC. Studies have shown good results in some cases with primary reamed or unreamed intramedullary nailing.

Nonoperative Therapy

In cases of diaphyseal femur fracture, skin traction and splinting are used in the field in emergency situations to provide comfort for the patient and to prevent any further soft-tissue damage.

Skeletal traction is seldom used in modern practice and is usually only a temporary treatment or a treatment in young children. A pin is placed in the distal femur or proximal tibia, upon which traction can be placed against the patient's own weight. Skeletal traction is usually combined with one of many splinting systems.

The main goal in traction is to regain the anatomic length of the limb. If a knee injury is associated with the fracture, the pin should be placed in the distal femur to avoid further injury. In most other cases, the proximal tibia is the choice location. The amount of traction needed varies with a patient's unique situation.

Internal fixation is still the treatment of choice for most closed injuries and some open ones because of the higher union rate, lower rate of complications, lower morbidity, earlier weightbearing, shorter hospital stay, and better control of alignment. However, in some situations, such as when the hardware is not available or the patient cannot undergo surgery relatively soon, temporary skeletal traction may be a viable choice.

Perhaps the most common use of traction is in the treatment of young children (usually 5-10 years) with 2-3 weeks duration in the face of soft-tissue injury. The soft-tissue injury may or may not be indicated by a positive telescope test result. However, flexible nailing may be better for children weighing more than 80 lb (~36 kg) with a positive telescope test result.

In the rare instance in which an adult is treated with skeletal traction and splinting as the definitive treatment, at least 6 weeks of spica casting is needed after radiographs show significant healing. Possible disadvantages include less-than-ideal control of fragments, prolonged bed rest and hospital stays, difficult nursing care, high cost, limited rehabilitation, potential of pin-tract infection, and possible tethering of the quadriceps.

In view of the options available in modern orthopedics, cast bracing is more of a historical treatment. Cast braces were usually applied after a period of traction. The advantage is an earlier return to motion. The cast brace helps to reduce the load on the fracture, albeit by only 10-20%, and helps to counteract deforming forces. Only relative indications for this approach exist today; these include distal-third fractures or comminuted fractures in patients who are not surgical candidates and as supplemental support for nonrigid internal fixation.

Spica casting is not used often in adults or adolescents and is a treatment of choice in young children with isolated uncomplicated femoral-shaft fractures. It is usually performed immediately after reduction in children aged 0-2 years and either immediately or after 2-3 weeks of skeletal traction in children aged 2-10 years if they weigh less than 80 lb.

The positive aspect of the spica cast is avoidance of primary and secondary surgery for hardware removal. Spica casting also helps prevent infection, blood loss, and scar formation. On the other hand, stability is less than that of many operative treatments, and patient care is prolonged, especially if traction is used beforehand, and mobility is limited. Time away from work for the parents can cause a financial burden. These children require a great deal of care and reliable caregivers.

The length of cast time needed for healing can be established by using radiographs. The duration can also be roughly calculated roughly on the basis of the patient's weight. Children weighing less than 50 lb (~23 kg) can have the spica bar removed after 4 weeks and the cast removed after 6 weeks. Children weighing 50-80 lb can have the bar removed after 5 weeks and the cast removed after 7 weeks.

General Principles of Surgical Therapy

Timing

The American College of Surgeons Committee on Trauma recommended that femoral-shaft fractures in polytrauma patients be treated within 2-12 hours after injury, provided that they are hemodynamically stable.[8, 38]  The Eastern Association for the Surgery of Trauma (EAST) recommended open reduction and internal fixation (ORIF) within 24 hours for trauma patients with open or closed femur fractures.[39]

Studies have also shown the significant benefit of intervention within the first 24 hours. Immediate fixation has been shown to decrease fatalities, respiratory complications, multisystem organ failure, and the length of intensive care unit (ICU) stays in most patients. The type of early fixation used can be debated, but the timing appears to be what makes the difference.[40, 41, 42, 43]

The optimal timing and treatment for this patient group varies in different reports, though a large prospective study showed equal results in the isolated fracture group with either early or late treatment. Those patients with head and chest injuries had a lower morbidity and mortality when fixation was achieved in the first 24 hours.[44, 45] Each patient's treatment must be selected with clinical consideration of the patient's health status on presentation, the level of emergent treatment needed, the available materials, the patient's age, and the physician's personal experience.

Surgical options

Intramedullary rod placement

Intramedullary nailing is the criterion standard for treating diaphyseal femur fractures. Currently, antegrade reamed interlocked intramedullary nailing is the treatment of choice for diaphyseal femur fractures.[13, 46] Antegrade reamed locked nailing is ideal in fracture stabilization.[47, 48, 49] The exposure is small, and soft-tissue damage is limited. Two recent studies concluded that expandable nails result in a higher nonunion rate than locked nails.[50, 51]

Anteroposterior radiograph of the hip and proximal Anteroposterior radiograph of the hip and proximal femur after antegrade intramedullary (IM) nail placement.
Lateral radiograph of the distal femur after anteg Lateral radiograph of the distal femur after antegrade intramedullary (IM) nail placement.
Anteroposterior radiograph of the distal femur aft Anteroposterior radiograph of the distal femur after antegrade intramedullary (IM) nail placement.

The nail itself has the advantage of being centrally located in the shaft and load sharing. Antegrade reamed locked nailing promotes healing through abundant callus formation. The fixation is solid and able to hold length even in the face of extensive comminution. It allows early and, in some cases, immediate weightbearing. It is associated with easier nursing care, shorter hospital stays, and lower morbidity. The results of treatment have been excellent, with a 99% rate of union and 1% incidence of infection. Its use has been studied extensively, and it has proved effective in the short and long terms.

An unscrubbed assistant surgeon must assist by first examining the radiographs and determining the appropriate direction of force needed to reduce the fracture. After reduction, anteroposterior (AP) and lateral imaging with fluoroscopy should be performed to confirm the reduction. At this time, the femoral neck also can be critically examined with fluoroscopy.

The patient is positioned on the fracture table. The entry point of the nail is critical to success. A small 2- to 3-cm longitudinal incision is made 10-15 cm proximal to the greater trochanter. The entry point used on the femur is within the piriformis fossa medial to the body of the trochanter and posterior to the gluteus medius. Before bone is penetrated, AP and lateral views obtained with fluoroscopy should used to confirm the location.

Nails are on the market that are designed specifically for femoral-shaft fractures and that use a trochanteric entry point, which may be more familiar to some surgeons. These may provide an antegrade alternative. Early studies have had similar results to standard antegrade approaches and may have the benefits of decreased surgical and fluoroscopy time.[52, 53]

Various fixation systems may vary slightly with regard to certain steps and techniques. In general, the metaphyseal bone is penetrated with an awl, and a bulb-tipped guide wire is inserted into the femoral canal. The guide wire is passed to the fracture site, where the assistant then manipulates the distal fragment so as to allow passage of the guide wire. AP and lateral radiographs are then checked to ensure that the guide wire is in the canal of the distal fragment.

Reaming is usually started with an 8- or 9-mm reamer. It is placed over the guide wire and passed down past the fracture site to the bulb end. Reaming then progresses at increments of 1 to 0.5 mm until the desired amount of cortical contact is achieved. Fracture reduction should be monitored closely with each pass of the reamer. The surgeon also must ensure that the guide does not back out during the reaming process. When reaming is completed, the guide wire can then be switched.

The nail is then mounted on the insertion device. The curve of the femur and the nail must be taken into consideration when inserting. The nail is slid over the guide wire and inserted with an inward 90° twist. Advance past the fracture site and insert to the recommended position for the system. Locking screws can be placed distally and proximally after aligning the holes so that they appear perfectly round on fluoroscopy.

Retrograde intramedullary nailing of the femur has been studied as an alternative to the antegrade nail.[54, 55] (See the images below.) Fairly similar results have been achieved in some comparisons, but it lacks the long-term studies that have made antegrade nailing the criterion standard. The nail is inserted in the intracondylar notch 0.5-1 cm anterior to the femoral origin of the posterior cruciate ligament (PCL) via a 2- or 4-cm transpatellar or medial parapatellar approach. The rest is much the same as the antegrade reaming, insertion, and locking. For optimal control, have a locking screw at least 5 cm beyond the fracture site.

Example of retrograde nail on distal anteroposteri Example of retrograde nail on distal anteroposterior and lateral radiographs.
Example of retrograde nail on proximal anteroposte Example of retrograde nail on proximal anteroposterior and lateral radiographs.

Advantages of retrograde nailing might include decreased operating time, decreased blood loss, and amenability to polytrauma situations (allowing simultaneous cranial, abdominal, or contralateral leg procedures). Retrograde nailing also allows separate treatment of femoral-neck fractures and limits heterotopic ossification formation. It may be ideal in floating knee injuries and ipsilateral supracondylar fractures and patients who are obese or pregnant (allowing easier starting point access and exposing the fetus to less radiation). This approach also may be used in patients who have an injury to the pelvis or acetabulum in whom surgery involving the area may further injure or complicate the patient's health.

Retrograde nailing still lacks long-term data of the type that have made antegrade nailing the treatment of choice. Retrograde nailing also should be avoided in IIIB open fractures, septic knees, subtrochanteric fractures, open physes, and knee injuries, and it is not as effective in very proximal shaft fractures. Knee pain can occur. Although a small area of articular cartilage is lost with insertion and is rapidly filled with fibrocartilage, the development of degeneration is still a concern. Also, damage to the posterior cruciate ligament (PCL) is possible because of the proximity to the insertion point on the femur.

External fixation

External fixation is the treatment of choice for many patients with grade IIIB or IIIC open fractures, for patients with fractures in which vascular surgery is needed, for patients in unstable condition, and for those in whom definitive surgery cannot be performed relatively soon. Because of the relatively short operating time, the surgeon also may consider this a feasible option when time is of the essence, as in a mass casualty situation.[56, 57, 58]  (See the images below.)

Example of an open segmental femur fracture in a 1 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, emerg As the above patient was extremely unstable, emergent external fixation of the open femur fracture was completed

For this procedure, two or three pins are usually placed into the femur in the proximal and distal fragments. For maximal stability, one pin should be placed as close to the fracture site as possible on either side of the fracture. The connecting rod also should be placed as close to the skin as possible without touching the skin and allowing room for swelling.

Unilateral external fixation devices can be placed strategically in a certain plane, depending on the fracture geometry, to provide more stability. A lateral fixator is more stable in the mediolateral plane, whereas an anterior fixator is more stable in the sagittal plane. Larger circular devices are also available but are more cumbersome to the patient and nurse.

Plating

Compression plating has been met with much less enthusiasm than intramedullary nailing.[59] The extensive approach, periosteal stripping, potential blood loss, stress shielding (load sparing), less aesthetic scar, and higher rate of complications tend to favor other methods of treatment. Healing occurs without callus formation, and the bone is slower to regain strength. Bone under the plate is also prone to stress shielding and may become osteopenic. Compression plating may be used in distal metaphyseal-diaphyseal junction fractures and in certain situations with ipsilateral femoral-neck fractures.

Plating is done via a lateral approach in the skin and spitting the vastus lateralis. One should be careful to avoid stripping the periosteum and muscle. Most often, a 10- or 12-hole dynamic compression plate is used. A total of four or five screws should be placed on either side of the fracture, and eight to 10 cortices should be obtained on either side of the fracture. If possible, an interfragmentary screw can be placed to enhance the rotary stability of the fracture. Bone grafting should be considered with comminution, especially if there is a cortical defect greater than 1 cm.[60, 61]

Locked plating technology has introduced the concept of relative stability to promote more rapid callus healing versus more slow primary healing. It has also allowed bridge plating of comminuted areas and promoted the development of minimally invasive surgical approaches that spare the soft tissues. It has made plating a more biologic friendly option for the orthopedic surgeon and patient.

Surgical Treatment of Specific Injuries

Ipsilateral femoral neck fractures

Ipsilateral femoral neck fractures occur in 2-6% of diaphyseal femur fractures.[62, 63]  They are commonly nondisplaced, possibly because a large portion of the fracture energy is exiting out the shaft fracture. The findings can be subtle, and some of the neck fractures have been diagnosed intraoperatively or postoperatively. Some concern also exists about the possibility of antegrade nailing, further compromising the blood supply to the femoral neck and head. No standard treatment consensus currently exists. However, most agree that anatomic reduction of the femoral neck is important to avoid the devastating complication of avascular necrosis (AVN).

Some reports give the neck priority and recommend treating the neck separately with screws or a screw-plate device and the shaft with compression plating or retrograde nailing. If the neck fracture is discovered after an antegrade nail is placed, supplemental screws are placed anterior to the nail into the neck. If anatomic reduction cannot be achieved, the hardware should be removed and revised as previously stated.

Some worry that the increased technical demand of the second-generation nails or primary standard antegrade nail and screws may displace nondisplaced fractures or not give enough attention to the reduction of the neck fracture. Others consider these two methods to be first-line treatment in nondisplaced fractures and reserve treating the fractures separately for displaced neck fractures.

Open fractures

The treatment of open fractures is also not without some controversy. Treatment of Gustilo class I, II, and IIIA fractures with standard reamed antegrade nailing is supported by a wealth of literature. Many authors still agree that grade IIIB and IIIC fractures should be treated with external fixation after initial debridement, which can be exchanged later for another modality if needed. Serial debridement and delayed closure are required. If the surgeon believes that the intramedullary canal is grossly contaminated, intramedullary nailing should be avoided.

Treatment initiated within the first 8 hours has shown to decrease the incidence of infection. Because of the higher rate of infection in any open fracture that has gone untreated for longer than 8 hours, the injury should be treated as a grade III open fracture by using external fixation.

Several studies have shown good results with closed antegrade reamed or unreamed intramedullary nailing in grade IIIB fractures, and a couple of studies included both grade IIIB and grade IIIC fractures. Because past studies showed fewer complications when polytrauma patients were treated with intramedullary nailing, one also should consider the level of injury when treating open fractures in light of the low infection rates in open fractures treated with intramedullary nailing.

Antibiotics must be administered. For grades I and II, the recommended treatment is with a first-generation cephalosporin. A grade III injury requires a first-generation cephalosporin and an aminoglycoside. Extensively contaminated open fractures should be treated with a first-generation cephalosporin, an aminoglycoside, and penicillin. Tetanus prophylaxis also should be given to patients with an open fracture.

Gunshot injury

Gunshot injury is also one of the leading causes of femur fractures.[64, 65, 66, 67, 36]  A variety of fracture types can result, depending on the location and amount of bone that is struck by the projectile.[68]  The distal metaphysis may develop a drill-hole type fracture, whereas a graze may cause an incomplete fracture, and a direct hit usually causes comminution and a butterfly fragment. Occasionally, a spiral fracture may form; this is thought to be caused by the femur being struck while the individual places is walking or running on the leg in an attempt to flee.

Neurovascular injury must be excluded because of the possibility of the projectile or fragments penetrating such structures. Low-velocity (< 2000 ft/s) injuries are the most common. Such injuries can be treated with little or no initial debridement and immediate intramedullary nailing. High-velocity (>2000 ft/s) and shotgun injuries are treated as grade III open fractures. Serial debridement and external fixation are often used; however, some physicians also use intramedullary nailing as the primary treatment. Debridement should be meticulous as shotgun wadding, clothing, and other debris may be embedded in tissues near or distant to the missile path.[69]

Shotgun injuries can be devastating. The severity of injury can be associated with the range at which the victim was shot, this also can classify the wound. Sherman's modified classification of shotgun wounds is as follows:

  • Type 0 occurs at a range of greater than 12 m and is superficial with skin penetration (mortality, 0%)
  • Type I occurs at greater than 12 m and penetrates only subcutaneous and deep fascia (mortality, 0-5%)
  • Type II occurs at 5-12 m and penetrates beyond deep fascia (mortality, 15-20%)
  • Type III occurs at less than 5 m and causes extensive tissue damage (mortality, 85-90%)

Children

Femoral-shaft fractures in children are associated with many of the same concerns as those in adults.[70, 71]  Again, the level of injury sustained by the patient is of great importance in selecting treatment. However, in children, age, growth and remodeling potential, and family stability (both financial and functional) are of concern. Unique concerns in children are the preservation of the retinacular and lateral epiphyseal blood supply to the femoral neck and head and physis deformation via implant insertion.[72, 73, 74]

In children, growth of the bone might potentially be stimulated after a fracture, and limb-length overgrowth could occur.[75, 76]  However, the tolerances for angulation and displacement are greater than those in adults with fractures due to the potential to remodel. A child with more growth potential also has more potential to remodel the involved bony structures, and those fractures closer to a physis may remodel more than others. Rotational deformities cannot be remodeled, and remodeling should not be counted on to correct deformity in children older than 9 years.

Most treatments can be broken down by the age of the patient. Patients aged 0-2 years usually are treated with immediate spica cast application. In infants younger than 4 months, some authors advocate the use of splinting instead of a spica cast.

Children aged 2-10 years (if < 80 lb) usually are treated with either immediate spica casting, or spica casting is delayed 2-3 weeks until callus formation is evident on radiographs. Some authors suggest the use of traction if more extensive soft-tissue damage is suspected or there is a positive telescope test result (>30 mm). If the fracture cannot be treated with less invasive methods, is complicated, open, or the patient is a polytrauma patient, external fixation should be used. There is some mention of internal fixation being used in the upper limits of this group within the orthopedic community.

There is less of a consensus regarding treatment of patients aged 10 years and older. Options are external fixation, compression plating, rigid intramedullary fixation, flexible intramedullary fixation, and casting.[77]

External fixation is an option for cases of polytrauma or open fracture in a child and occasionally for isolated fracture in this age group.[32, 78]  It helps avoid prolonged immobilization, long hospital stays, and extensive approaches. It also preserves the blood supply by preventing periosteal and provides a quick and less invasive means to stabilize the fracture. The treatment is still somewhat cumbersome to the patient, the potential remains for pin-tract infection and tethering of the quadriceps, and the rate of repeat fracture is higher than in other treatments.[79]

Compression plating has provided good results in studies on children. Indications for use include head injury, open fracture, spasticity, seizures, floating knee, and vascular injury. However, the same features as in adults make it a less attractive option.

The potential for blood loss, infection, an extensive approach, component failure, large scar, and more extensive repeat surgery to remove components, coupled with the existence of less invasive options, makes this an unpopular choice in children. Removal of such hardware may be more difficult in children because of bony overgrowth. Compression plating in children has been found to be of most value in treating those that have sustained multiple or head injuries in addition to the femur fracture, necessitating immediate fracture stabilization.

Rigid intramedullary fixation in children has advantages and disadvantages.[80, 81]  Although it is highly successful for stabilization and control, it also has the most devastating potential consequence. Antegrade nailing of femoral-shaft fractures can disrupt the blood supply to the femoral neck via the lateral epiphyseal artery and retinacular branches, possibly causing irreversible AVN of the femoral head and severe disabling arthritis. The procedure may also lead to premature apophyseal arrest in the greater trochanter, though this is thought to be of little clinical significance in children younger than 10 years.

The age at which rigid nailing becomes risky is not defined; ages of 10 and 15 years are mentioned as safe in the literature, along with judging whether there is more than a year of growth left by the appearance of the physis on radiographs. The patient must undergo a second procedure for hardware removal at a later date.

Some literature advises using the tip of the greater trochanter as the entry point for the nail to avoid the complications of AVN. However, the lateral starting point increases the likelihood of intraoperative fracture. The use of rigid antegrade intramedullary nailing is preferred in skeletally mature adolescents, obese children, and those with multiple injuries, very proximal fracture level, and high levels of comminution.

Flexible intramedullary nailing of the femur in children can provide good results and avoid the potentially devastating complications of rigid nailing.[82]  Flexible nailing provides a safe choice of fixation for children who are too young for rigid nailing but too old or large for spica casting or who do not have caregivers able to comply with the high maintenance of spica casting. Safe treatment of children younger than 4 years has been described in the literature.[83]  (See the images below.)

Lateral radiograph shows flexible nailing in a 19- Lateral radiograph shows flexible nailing in a 19-year-old man.
Anteroposterior radiograph shows flexible nailing Anteroposterior radiograph shows flexible nailing in a 19-year-old man.
Anteroposterior and lateral radiographs show flexi Anteroposterior and lateral radiographs show flexible nailing in a 19-year-old man.

Flexible stainless steel or titanium rods (usually 2-4 mm in diameter) can be inserted retrograde from small lateral and medial incisions above the distal physis of the femur. A 2-cm incision is made on the medial and lateral side of the thigh about 2.5 cm proximal to the distal physis of the femur. A drill is used to make an oblique opening, though which the nails can be passed into the canal. The nails should be bent and inserted so the apex of the curve is at the level of the fracture.

The stability is provided by the opposing forces of the bent nails pushing at the apex of the curve against the canal wall at the level of the fracture. About 1-1.5 cm of the nail is left extending into the soft tissue distally. Small eyes in the distal ends of some nails allow the passage of a small screw to prevent backing out and may add additional stability.

Some authors have used antegrade insertion with some success. The smaller 3.5-mm nails are recommended in children aged 5-10 years, whereas 4-mm nails are generally used in older or larger children.

Flexible nails have gained a great deal of popularity because of the high rate of success and early weightbearing with crutches the day of surgery and full weightbearing when callus formation is observed. The short hospital stay and ease of care combined with the above-mentioned features have made flexible nailing a commonly used option in school-aged patients. Complications seem to be minor and include issues such as soft-tissue irritation and possible comminution or loss of reduction when passing the nails. Flexible nails lack the rotational stability of rigid nails and should not be used in highly unstable or comminuted fractures.

Operative details

A patient injured with a high-energy mechanism must be stabilized before proceeding to surgery. Again, current recommendations are for early fracture stabilization because this has been shown to be beneficial to the patient's overall health status. Blood loss must be monitored because a large volume of blood can be lost into the compartments of the upper leg.

Appropriate images should be obtained and scrutinized. Often, the isthmus on radiographs can be used to estimate the size of the nail needed. If severe comminution is present, it also may be helpful to use radiographs of the uninjured leg to estimate leg lengths. Equipment and hardware should be gathered, and backup materials should be available. If surgery is to be delayed, balanced skeletal traction should be applied. Antibiotics also should be started 30 minutes before initial skin incision.

One must decide whether to use a fracture table or radiolucent table. The exposure for antegrade nailing is good on a fracture table; however, this table limits the exposure for other fractures or injuries in multiply injured patients. The fracture table should not be used in patients with bilateral lower-extremity fractures, an unstable spine, pelvic fractures, multiple injuries, or ligamentous knee injury. Consider using a distal femur traction pin to avoid further injuring a knee that may possibly have ligamentous knee injury.

The fracture table may be ideal for an obese patient, in whom the entry point is more difficult to assess for antegrade nailing. Complications are usually due to excess or prolonged traction resulting in pudendal, femoral, and sciatic nerve palsies. Skin sloughing and well-leg compartment syndrome can also occur.

On a radiolucent table, the patent is supine. This table may be best for the above-mentioned patients who cannot be placed on the fracture table. However, the supine position may be more problematic in dealing with obese patients. Significant consideration for use of this table is warranted if any likelihood of ligamentous knee injury exists because no traction is put across the knee joint.

Most studies have shown no differences between table types with respect to the outcome of fracture treatment. One of the large studies comparing the use of the two tables showed no difference in the outcomes for fracture treatment, but the use of the fracture table was associated with increased operating room time. Some of the increased time may be associated with one's own comfort or familiarity with the fracture table.

Irrigation should be delayed until the operative period for open fractures that are going to be treated surgically. Irrigation in the emergency department could drive contamination further into the wound. The wound should be covered with a sterile wet dressing until surgery.

Intraoperatively, careful investigation with fluoroscopy should be used to identify any missed fractures, namely those of the femoral neck. With intramedullary nailing, careful attention must be paid to fracture reduction and reduction maintenance during the passing of the guide, reamer, and nail. Position and alignment also can be double-checked before placing the locking screws. One study found electromagnetic navigation had advantages in treating long diaphyseal fractures by enabling easy targeting and reducing intraoperative fluoroscopy and operation time.[84]

Postoperative Care

A knee examination should be completed after all fixation is completed because performing a preoperative ligamentous knee examination on a patient with a femur fracture is nearly impossible. Antibiotics should be continued for at least 24 hours in patients with uncomplicated cases. Severe open fractures may require delayed closure, serial debridement, and extended antibiotic treatment.

A study of platelet-rich plasma therapy found that while it had no effect of healing in patients treated with closed intramedullary nailing, it did have an effect in the early stages of healing in open or failed closed intramedullary nailing.[85]

Complications

Like any surgical procedure, femoral-shaft stabilization with surgical intervention is associated with complications. The most common complications are as follows:

  • Infection
  • Malunion
  • Delayed union (eg, generally no signs of healing at 3 months)
  • Nonunion (no signs of healing at 6 months)
  • Pain from hardware

Less common complications include neurovascular injury, hemorrhage, compartment syndrome, repeat fracture, and component failure. Rare but more serious complications include death, multiorgan failure, and respiratory complications (usually secondary to acute respiratory distress syndrome [ARDS], pulmonary embolism [PE], or fat embolism); all of these are more common in polytrauma patients than in others.[86, 14]

Infection is a rare complication of closed intramedullary nailing of the femur and occurs in about 1% of cases. Factors that increase the risk of postoperative infection include open fractures and comminuted fractures treated with open reduction. Grade IIIB femur fractures are associated with a higher incidence of infection secondary to gross contamination and extensive soft tissue necrosis. Many cases of infection are treated with antibiotics and retaining the implant until healing is evident.

After the fracture site is healed, the implant is removed. Rarely, a staged reconstruction must be completed. Ranging from implant removal, incision and drainage (I&D), and primary exchange to implant removal, primary I&D, intravenous antibiotics for several days followed by a second I&D and new implant placement. Both sequences followed by weeks of antibiotic therapy by either intravenously or orally depending on the sensitivity of the microorganisms.

Delayed union and nonunion can be treated with dynamization, new or different implant, bone grafting, and/or bone stimulation.[87, 88] Exchange nailing has had the best results in treating a nonunion. Bone grafting should be used in combination with another method; it can produce poor results when used alone. Malunion of clinical significance is fairly rare. The hip, knee, and ankle joints compensate a great deal for many minor malunions. If the patient is symptomatic, osteotomy and exchange nailing, placement of a different device, or simply retaining the antegrade intramedullary nail and locking the nail in the revised position may be appropriate.

Current tolerances for adult fractures are 5-15° varus/valgus, up to 15° AP, 15° rotation, and 1-1.5 cm of shortening. Tolerances in children are grouped by age, as follows:

  • In patients aged 0-2 years, up to 30° varus/valgus is accepted, and 30° AP, 10° rotation, and 15 mm of shortening are accepted
  • In children aged 2-5 years, up to 15° varus/valgus is accepted, and 20° AP, 10° rotation, and 20 mm of shortening are accepted
  • In children aged 6-10 years, up to 10° varus/valgus is accepted, and 15° AP, 10° rotation, and 15 mm of shortening are acceptable
  • In patients older than 11 years, up to 5° varus/valgus is accepted, and 10° AP, 10° rotation, and 10 mm of shortening can be accepted

Most primary nerve injuries are associated with penetrating trauma to the thigh region. The sciatic and femoral nerves are well protected within the muscle envelope surrounding the femoral shaft. Neurapraxias can occur with prolonged stretching of the nerves during difficult reductions of the shaft. In addition, intraoperative nerve compression can result from poor padding on the operative table. The most commonly injured nerve is the pudendal nerve, followed by the sciatic nerve. If a male patient sustains a pudendal nerve injury, he most often will complain of penile numbness and impotence.

Heterotopic ossification is the most common complication after reamed antegrade intramedullary nailing. As many as 25% of patients undergoing the procedure may be affected.

Implant failure most often occurs in the locking screws. This complication can best be avoided by placing a locking screw at least 5 cm from the fracture site.

Arterial injury is documented in fewer than 2% of femoral-shaft fractures. Any fracture pattern can lead to disruption of the artery; however, penetrating injuries have a higher incidence of trauma to the vessel. Vascular injury can occur in a variety of ways, including tearing, thrombosis, or spasm of the artery. Note that pulses may be present even in the face of vascular injury due to heavy collateral circulation. Arterial injury requires prompt diagnosis and treatment to ensure preservation of the lower extremity.

Compartment syndrome of the thigh with femur fracture is extremely rare because of large volume of the thigh compartments, which blend with those of the hip.[89] Only a few cases are reported in the literature. Compartment syndrome occurs because of an increase in volume or pressure or because a force decreases the capacity of the compartments. If this is suspected, pressure should be measured and rechecked after fracture reduction.

Compartment syndrome is most often associated with multiple injuries. Again, the presence of pulses does not preclude the diagnosis. Immediate fasciotomy should follow diagnosis.

Pulmonary complications include fat embolism, thromboembolic event, and pneumonia. The further development of fat embolism syndrome and ARDS is associated with a high mortality rate. However, ARDS develops in only about 2% of patients who have a femur fracture and multiple injuries. Early fracture fixation within 24 hours has shown to decrease not only the pulmonary complications mentioned but also multiorgan failure, time using a ventilator, ICU stays, and hospital costs.

As with many injuries and surgery to the lower extremity, DVT can be encountered and prophylaxis should be used. The surgeon should always have a high index of suspicion for this complication as its clinical presentation is many times subtle or absent but it potential devastating.

Death is exceeding rare in patients with femur fractures, especially in those with isolated injuries. A population study of 2805 patients with femur fractures showed only a 0.042% mortality. Patients who sustained an injury severity score of less than 15 had a mortality of 0.0272%, whereas those with an injury severity score higher than 15 had a mortality of 0.109%. Mortality, especially in those with an injury severity score higher than 15, was also higher in the nonsurgically treated patients.

Repeat fracture is also rare after fracture treatment of the femoral shaft. Rates vary with the different methods of fixation. Most repeat fractures occur within the first year of healing.

Long-Term Monitoring

Strengthening of the quadriceps and hamstring muscles can begin almost immediately in the postoperative period. Hip, knee, and ankle range-of-motion (ROM) exercises should be started early.

Patients treated with a 12-mm statically locked nail with two distal locking screws may even begin with immediate full weightbearing. In other treatments, progressive weightbearing is often used and graded with consideration to the method of treatment, the condition of the patient, and the extent of the fracture. In stable fractures, patients usually can begin early weightbearing with crutch support, while those with unstable fractures proceed with protected weightbearing until callus formation is evident on radiographs.

Prolonged supervised therapy is not often needed, because full ROM is usually attained within 4-6 weeks. Follow-up radiographs are obtained at 1, 3, 6, and 12 months to ensure that the fracture is healing in an acceptable position. If retained hardware removal is needed, it can usually be performed 1 year after union.

 

Guidelines

ACS COVID-19 Guidelines for Triage of Orthopedic Patients

On March 24, 2020, the American College of Surgeons (ACS) published COVID-19 guidelines for triage of orthopedic patients. The general recommendations for all surgical cases include the following[90] :

  • Provide appropriate and timely surgical care based on sound surgical judgment and availability of resources
  • Consider nonoperative management whenever it is clinically appropriate for the patient
  • Consider waiting on results of COVID-19 testing in patients who may be infected
  • If possible, avoid emergency surgical procedures at night when staff may be more limited
  • Aerosol generating procedures (AGPs) increase risk to the health care worker; for patients who are or may be infected, AGPs should only be performed while wearing full PPE including an N95 mask or powered, air-purifying respirator (PAPR) that has been designed for the operating room 

During phase II, hospitals have many COVID-19 patients, intensive care unit (ICU) and ventilator capacity are limited, or supplies are limited or the COVID-19 trajectory within the hospital is in a rapidly escalating phase. For trauma patients during this phase, the guidelines recommend restricting orthopedic procedures to new fractures, acute traumatic injury, nonunions, malunions and infections.

During phase III, hospital resources are all routed to COVID-19 patients, there is no ventilator or ICU capacity, or supplies have been exhausted. For trauma patients during this phase, the guidelines recommend restricting orthopedic procedures to new fractures, quad tendon rupture, patellear tendon rupture and acute changes of a chronic injury with inability to function.

AAOS Guidelines for Pediatric Diaphyseal Femur Fractures

American Academy of Orthopaedic Surgeons (AAOS) guidelines for treatment of diaphyseal femur fractures in children include the following[91] :

  • Strong evidence supports that children younger than 36 months with a diaphyseal femur fracture be evaluated for child abuse
  • Moderate evidence supports early spica casting or traction with delayed spica casting for children age 6 months to 5 years with a diaphyseal femur fracture with less than 2 cm of shortening
  • Limited evidence supports treatment with a Pavlik harness or a spica cast for infants 6 months and younger with a diaphyseal femur fracture, because their outcomes are similar
  • Limited evidence supports the option for physicians to use flexible intramedullary nailing to treat children age 5-11 years diagnosed with diaphyseal femur fractures
  • Limited evidence supports rigid trochanteric entry nailing, submuscular plating, and flexible intramedullary nailing as treatment options for children age 11 years to skeletal maturity diagnosed with diaphyseal femur fractures, but piriformis or near piriformis entry rigid nailing are not treatment options
  • Limited evidence supports regional pain management for patient comfort perioperatively
  • Limited evidence supports waterproof cast liners for spica casts are an option for use in children diagnosed with pediatric diaphyseal femur fractures