Diaphyseal Femur Fractures Workup

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

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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.
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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
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