Femoral Shaft Fractures in Emergency Medicine 

Updated: Nov 13, 2019
Author: James E Keany, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH 

Overview

Practice Essentials

Diaphyseal femur fractures (femoral shaft fractures) result from significant force transmitted from a direct blow or from indirect force transmitted at the knee. These may be the result of bone weakness from osteoporosis or lytic lesions. The femur is the largest and strongest bone and has a good blood supply. Because of this and its protective surrounding muscle, the femoral shaft requires a large amount of force to fracture. Once a fracture does occur, this same protective musculature usually is the cause of displacement, which commonly occurs with femoral shaft fractures.[1, 2, 3, 4, 5, 6]

As with many orthopedic injuries, neurovascular complications and pain management are the most significant issues in patients who come to the ED with a femoral shaft fracture. The rich blood supply, when disrupted, can result in significant bleeding. Open fractures have added potential for infection.[7, 8, 4, 9]

The 3 types of femoral shaft fracture are as follows: type I (spiral or transverse [most common]), type II (comminuted), and type III (open). Associated injuries are common.

Diagnosis

History usually is obvious in cases of femoral diaphyseal fractures. Typically, patients describe a significant force applied to the extremity. Significant pain and deformity are reported as well. Causes include trauma, lytic lesions, cancer metastasis, Paget disease, bone cysts, and osteoporosis.

In a patient with a large, expanding hematoma, measure serial hematocrits and obtain type and crossmatch in case a blood transfusion becomes necessary. For patients who require open reduction and internal fixation (ORIF), obtain preoperative tests, including chest radiography and ECG.

Anteroposterior (AP) and lateral radiographic views of the femur normally are sufficient. As with all long-bone fractures, obtain images of the joint above and below the fracture. If a vascular injury is suspected, perform arteriography.

(See the images below.)

Anteroposterior radiograph of a femur fracture in Anteroposterior radiograph of a femur fracture in a 45-year-old man.
Anteroposterior radiograph of a femoral-shaft frac Anteroposterior radiograph of a femoral-shaft fracture in a 19-year-old man.

Treatment

Prehospital personnel should splint the extremity in the position it was found. If signs of neurovascular compromise are observed, the limb may be reduced after administering adequate analgesia. Well-aligned fractures, with or without neurovascular injury, can be immobilized by using a traction device. Hare or Thomas traction splints are most commonly used.

Apply wet sterile dressings over an open fracture. If the wound is grossly contaminated, sterile saline irrigation may be used to remove large contaminants.

Adults with a femur fracture are best treated with immediate operative fixation, typically intramedullary nailing.[10, 11, 12]  In children, femoral shaft fractures constitute approximately 4% of all long-bone fractures. The preferred treatment for diaphyseal shaft fractures in the first or second year of life is spica casting or traction. For children 3 years of age, these fractures can be treated operatively or nonoperatively. In children older than 3 years, elastic stable intramedullary nailing is standard treatment.[6, 9, 13, 14, 15, 16, 17]

Depending on the stage of skeletal maturity, some adolescents may be treated with initial external fixation, intramedullary nailing, or compression screw plate fixation.[18, 19]  In the presence of contraindications to surgery, this repair may be delayed for days without significant complications if leg length is maintained with traction.[20] ​Open fractures require immediate operative debridement followed by delayed intramedullary nailing.[21]

Transfer patients with femur fractures when the fracture is immobilized adequately. This is best accomplished with a traction device. As an alternative, use a pneumatic or posterior molded splint. Reasons for transfer include lack of appropriate orthopedic staff or operative facilities at the presenting center and associated serious injuries, which are common, that require a trauma center for ideal evaluation and management.

Morbidity and mortality rates have been reduced in femoral shaft fractures, mainly as the result of changes in methods of fracture immobilization. Current therapies allow for early mobilization, thus reducing the risk of complications associated with prolonged bed rest.[22, 23]

Emergently consult an orthopedic surgeon. Evidence of vascular or progressing neurologic compromise should prompt emergent consultation with a vascular surgeon. In some hospitals, the general surgeon may have privileges for vascular intervention.

AAOS guidelines for diaphyseal fracture in children

American Academy of Orthopaedic Surgeons (AAOS) guidelines for treatment of diaphyseal fractures in children include the following[6, 16] :

  • 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.

For proximal femur fractures (subtrochanteric to femoral head), see the article Fractures, Hip. For fractures of the distal femur (supracondylar to condylar), see the article Fractures, Knee.

Prognosis

Patients who survive the initial trauma associated with the injury typically heal well. Early mobilization following intramedullary nailing greatly reduces complications associated with prolonged immobilization.

Age affects the speed and quality of recovery. Fractures may be caused by underlying medical conditions such as osteoporosis or cancer metastasis; these conditions may complicate recovery further.[24]

Patients older than 60 years with closed fractures of femur have a mortality rate of 17% and a complication rate of 54%.[10]

 

Presentation

Physical

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

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 CTSK, COL1A2, 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]

 

 

DDx

 

Treatment

Emergency Department Care

In addition to maintenance intravenous fluids, patients with femoral shaft fractures who are suspected of having significant blood loss should be resuscitated with crystalloids. Place a Foley catheter, and restrict all patients to taking nothing by mouth (NPO) until seen by an orthopedic surgeon.[33]

Fracture reduction and immobilization

Reduce fractures to near-anatomic alignment by using in-line traction, which reduces pain and helps prevent hematoma formation. Hold reduction by a traction device (eg, Hare, Buck) or long-leg posterior splint. Pneumatic splint may have additional benefits of reducing blood loss by direct pressure and tamponade of hematoma formation. Traction is often required to hold the femur out to length because of contraction of large muscle mass in the thigh.

Pain management

Pain management is the most significant intervention of the emergency physician. Use parenteral opiate-type analgesics to the extent that respiratory and circulatory parameters allow. Intravenous administration allows for the most reliable titration to pain relief while providing ready access for reversal agents (ie, naloxone) if necessary.

Infection prophylaxis 

With open fractures, administer tetanus toxoid (unless given within 5 yr) and use antibiotics with excellent staphylococcal coverage and good tissue penetration. Often, a first-generation cephalosporin (ie, cefazolin sodium) is administered in combination with gentamicin.

Treatment in children

In children, femoral shaft fractures constitute approximately 4% of all long-bone fractures. The preferred treatment for diaphyseal shaft fractures in the first or second year of life is spica casting or traction. For children 3 years of age, these fractures can be treated operatively or nonoperatively. In children older than 3 years, elastic stable intramedullary nailing is standard treatment.[6, 9, 13, 14, 15, 16, 17, 34, 35, 36]

Depending on the stage of skeletal maturity, some adolescents may be treated with initial external fixation, intramedullary nailing, or compression screw plate fixation.[18, 19]   In the presence of contraindications to surgery, this repair may be delayed for days without significant complications if leg length is maintained with traction.[20]  ​Open fractures require immediate operative debridement followed by delayed intramedullary nailing. [21]

Complications

Complications include the following:

  • Hemorrhagic shock: Closed fractures of the femur can result in significant blood loss (eg, 1 L) within the thigh. Open fractures have the potential for even greater blood loss. Because of the high rate of associated injuries, actively seek out other sources of blood loss in patients with femur fractures and hypovolemic shock.

  • Neurovascular injury: Injuries to the neurovascular bundle are rare because of the large cushion of muscle protecting neurovascular structures. Compartment syndrome of the thigh does not occur often, and peroneal nerve contusion is seen occasionally.

  • Infection: While open fractures are at high risk of soft-tissue and bony infection, postoperative infection is rare following repair of closed fractures.

  • Respiratory demise: Fat embolism and adult respiratory distress syndrome (ARDS) can occur. Femur fractures at a level one trauma center have been associated with double the risk of developing ARDS (odds ratio [OR], 2.129; 95% confidence interval [CI], 1.382-3.278)[22] as compared to other patients admitted for musculoskeletal injury. The risk trends upward with delays in surgical repair greater than 24 hours.

  • More delayed complications include permanent stiffness of the hip or knee, shortening of the extremity, or malrotation, resulting in permanent deformity and decreased performance.

  • Complications directly related to repair include (in order of increasing frequency) breakage of fixator hardware, nonunion, malunion, or delayed union.

  • Refracture has occurred at the initial injury site.

 

Guidelines

Guidelines Summary

AAOS guidelines for diaphyseal femur fracture in children

American Academy of Orthopaedic Surgeons (AAOS) guidelines for treatment of diaphyseal femur fractures in children include the following[16] :

  • 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.
 

Medication

Medication Summary

Drugs used to treat fractures are generally nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, and anxiolytics.

Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

These drugs are most commonly used for relief of mild to moderately severe pain. Effects of NSAIDs in treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.

Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderately severe pain and inflammation.

Administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Flurbiprofen (Ansaid)

Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis.

Analgesics

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or those taking oral anticoagulants.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Anxiolytics

Class Summary

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow administration of smaller analgesic dose to achieve same effect.

Lorazepam (Ativan)

Sedative hypnotic in benzodiazepine class that has short onset of effect and relatively long half-life. By increasing action of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation. Excellent for sedating patients for >24 h. Monitor patient's BP after administering dose and adjust as necessary.