Femoral Shaft Fractures in Emergency Medicine Clinical Presentation

Updated: Nov 13, 2019
  • Author: James E Keany, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH  more...
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Conduct a thorough examination to rule out associated injury. Associated hip fractures and ligamentous knee injuries are commonly observed with femoral shaft fractures. [25] At the site of fracture, tenderness on examination and visible deformity typically are noted.

The extremity may appear shortened, and crepitus may be noted with movement. The thigh is often swollen secondary to hematoma formation.

Perform a thorough vascular examination on the extremity. Signs of vascular compromise should prompt arteriography and a vascular surgery consult. Physical signs of arterial injury include expanding hematoma, absent or diminished pulses, and progressive neurologic deficits in a closed fracture.

Because of extensive blood supply to the musculature surrounding the femur, diaphyseal fractures may be associated with significant blood loss (ie, 1 L or more) and resulting tachycardia and hypotension.

Test distal neurologic function, though examination is frequently unreliable because of the amount of pain associated with these fractures. Nerve injury is rare because of protective surrounding musculature.



Causes diaphyseal femur fracture include trauma, lytic lesions, cancer metastasis, Paget disease, bone cysts, and osteoporosis.

A number of studies have shown an association between atypical femoral fractures (AFFs) and the extended use of bisphosphonates for osteoporosis. [5, 26, 27, 28, 29, 30]  Altered bone material properties associated with bisphosphonate therapy may predispose to atypical femoral shaft fractures by permitting initiation and increasing propagation of micro-cracks. [3]  According to the American Society for Bone and Mineral Research, long-term use may be associated with a risk of approximately 100 per 100,000 person-years. [31]  

AFFs have also been described in individuals with monogenetic bone disorders and can occur in bisphosphonate‐naive individuals, who constitute about 7% of cases. As such, it is likely that genetic variants exist that predispose to AFFs. Targeted sequencing of genes in AFF populations with monogenetic bone disorders have identified variants in CTSKCOL1A2, and ALPL genes. Whole exome sequencing and exon array analysis of AFF cohorts have identified novel genes that may predispose to AFFs, including genes related to the mevalonate pathway. [32]