Femoral Shaft Fractures in Emergency Medicine Treatment & Management

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

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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.

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