Femur Injuries and Fractures Clinical Presentation

Updated: Oct 01, 2015
  • Author: Nicholas M Romeo, DO; Chief Editor: Sherwin SW Ho, MD  more...
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Presentation

History

A thorough history is imperative for all femur fractures, but particularly for fractures that occur with overuse or minimal trauma. The required details of the history will vary based upon the category of fracture (i.e., traumatic versus pathologic or overuse). The history should entail a chronological order of events including onset and location of pain. Prodromal pain prior to a traumatic event is suggestive of a pathological or overuse origin. The mechanism of the injury will differentiate between traumatic versus pathologic or overuse etiologies and in cases of trauma, will help determine other body regions that may require evaluation (e.g., intracranial injury). The history should entail pain and or deformity in other anatomic areas. Patients should be questioned as to aggravating and alleviating factors. Any interventions prior to presentation should be noted. A detailed past medical, surgical, drug allergy, social, and family history is obtained in all patients. Timing of last meal is imperative todelineate for those who require surgical management. Specifics to each category are listed below.

History of traumatic femoral fractures:

  • Significant pain and inability to bear weight are typically present.
  • Patients may be noted to have a shortening of one leg, swelling, and gross deformity.
  • Fractures are commonly associated with other bony injuries, including tibial shaft fractures, ipsilateral femoral neck fractures, and extension of the fracture into the distal femur.

History of pathologic fractures:

  • Patients will typically have an insidious onset of pain and/or deformity in the affected extremity.
  • Patients frequently complain of night pain.
  • level of pain and narcotic requirement is important to elicit.
  • Prior health screening exam history is essential in evaluation of these patients including a complete review of systems to rule out metastatic or metabolic disease as a cause of pathologic bone disease.

History of femoral stress fractures

  • A detailed training and competition history should be obtained.
  • These are observed with increasing frequency in joggers. [10, 11, 12]
  • Factors involved in stress fractures include a sudden increase in mileage, intensity, or frequency of training. [13]
  • A change in terrain or running surface may contribute. [14, 15]
  • Patients should be evaluated for and questioned about improper footwear and poor biomechanics.
  • Pain is typically insidious; however, it may be sudden or severe.
  • Patients may report groin, thigh or knee pain.
  • Pain from femoral shaft stress fracture is most frequently located in the anterior thigh. [16]
  • Symptoms of stress fractures are aggravated by activity and relieved by rest.
  • Female runners may have an abnormal menstrual history and a history of disordered eating.

For more information, see Medscape Drugs & Diseases topics Female Athlete Triad, Low Energy Availability in Female Athletes, and Nutrition for the Female Athlete.

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Physical

See the list below:

  • Physical examination of traumatic femoral fractures
    • Associated injuries must be addressed, and ATLS guidelines must be followed.
    • A head-to-toe examination is indicated.
    • Palpate the pelvis as well as bilateral lower and upper extremities observing for any deformity, instability, crepitation or pain generation.
    • Palpate the lumbar spine and heels if the injury involved a fall from a height to rule out vertebral compression fractures and/or calcaneal fractures.
    • Assess the patient’s skin for any abrasions, lacerations or other disruptions; it is imperative that open fracture is ruled out.
    • Assess all joints for deformity and any blocks to motion or pain with motion.
    • Correct any lower extremity deformity by applying inline longitudinal traction.
    • A distal vascular assessment is necessary to rule out a vascular injury.
    • A distal neurologic assessment is indicated to rule out a nerve injury.
  • Physical examination of pathologic fracture
    • A head to toe complete physical examination is imperative
    • Assess involved and uninvolved extremities for masses, deformity and tenderness
    • A thorough neurovascular examination of all extremities is required
    • Pain out of proportion to the injury could suggest an acute compartment syndrome and/or muscle ischemia due to a hematoma or an arterial injury. This would constitute a surgical emergency (within 6 hours of injury) to prevent loss of limb.
  • Physical exam of femoral stress fractures
    • A complete examination of the involved and uninvolved extremity including complete strength testing and neurovascular examination should be preformed.
    • Palpation of the thigh may display subtle tenderness and/or swelling.
    • Muscle bulk and tone is typically normal.
    • The point of maximum tenderness with palpation is often difficult to elicit given the large muscle envelope surrounding the femoral shaft.
    • Pain may be present at the extremes of passive range of motion.
    • Pain may be reported with forced rotation or axial loading.
    • Pain usually radiates into the groin area in cases of femoral neck fracture.
    • Observe gait: patient may ambulate with a limp.
    • Hop Test: Single leg hop will on the involved extremity often reproduce symptoms in approximately 70% of patients. [17]
    • Torsional or bending stress to the thigh may elicit pain in shaft fractures (see Fulcrum Test below).
    • Fulcrum Test: Patient seated while the examiner applies gentle downward pressure on the knee while the other arm is used as a fulcrum producing an anterior force vector on the posterior thigh. [18] This test may reproduce the patients symptoms.
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Causes

See the list below:

  • Traumatic causes of femoral fractures
    • Motor vehicle trauma (e.g., motor vehicle collision, motorcycle collision, auto/pedestrian collision)
    • Sports (e.g., high-speed and contact/collision sports with direct trauma, skiing, football, hockey)
    • Falls (e.g., from height, mountain climbing, pole vaulting)
    • Gunshot wounds
    • An update to the American Academy of Pediatrics’ 2006 guidelines for differential diagnosis of fractures caused by child abuse reported that abuse causes between 12% and 20% of all fractures in infants and children, however, in children younger than 3 years, physicians misdiagnose as many as 20% of fractures caused by abuse. The femur, humerus, and tibia are the most common long bones fractured in child abuse. The report further added that In the nonambulatory child, femoral fractures are more likely to be caused by child abuse, whereas these fractures in ambulatory children are rarely inflicted by abuse. [19, 20]
  • Pathologic causes
    • Metabolic bone disease
    • Primary bone tumor
    • Metastatic tumor
    • Infection
    • Prolonged bisphosphonate use
  • Causes of stress fracture
    • Repetitive impact activities such as running (jogging) and jumping
    • Metabolic bone disease
    • Amenorrheic or oligomenorrheic female runners
    • Abnormal bone mineral density
    • Improper training
    • Improper footwear
     
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