Femur Injuries and Fractures Treatment & Management

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

Acute Phase

Femur fractures in the younger patient population are typically the result of high-energy injuries. These fractures are often accompanied by other injuries. The first priority in treatment is to rule out other life-threatening injuries and stabilize the patient. Advanced Trauma Life Support (ATLS) guidelines should be followed.

The emergent management of femur injuries in the sports setting is intended to restore alignment. If limb deformity is present, inline longitudinal traction is applied, realigning the extremity and maintaining limb perfusion. A splint is applied to maintain the alignment as the patient is transported to the hospital for definitive treatment.

Treatment for acute trauma-related femoral fractures and displaced femoral stress fractures is performed by an orthopedic surgeon and usually involves surgical stabilization (see Surgical Intervention). [1, 2]

For non-displaced femoral shaft stress fractures, protected crutch-assisted weight bearing is implemented for a minimum of 1-4 weeks, based on the resolution of symptoms and radiographic evidence of healing (callus formation). Progression to full weight bearing can gradually commence once pain has resolved. Patients must avoid running for 8-16 weeks while the low-impact training program/phase is completed. The progression can include (1) cycling, (2) swimming, and (3) running in chest-deep water before resuming more intensive weight-bearing training. Patients must maintain upper extremity and cardiovascular fitness and avoid lower extremity exercise early in the healing process.

Compression sided femoral neck stress fractures are typically treated conservatively with a period of protected crutch-assisted weight bearing until symptoms resolve. Tension-sided (lateral) femoral neck stress fractures are at risk for displacement and surgical stabilization with percutaneous screws should be considered vs. bed-rest.

Medical Issues/Complications

Patients sustaining a femur fracture as a part of a major traumatic event (e.g., vehicular trauma) should be evaluated and stabilized by the trauma and/or medical team prior to surgical intervention. ATLS guidelines should always be followed. Life threatening injuries should be cared for the appropriate specialists.

In cases of traumatic femur fractures, the trauma surgeon implements multisystem stabilization and clearance for surgical intervention. Consultations with appropriate specialists must be arranged for specific systems. Traction may be necessary for initial stabilization for pain control before impending surgery.

Before definitive operative management of a femur fracture, the patient should be hemodynamically stable and fully resuscitated. Current literature suggests serum lactate levels, base deficit and gastric mucosal pH may be the most reliable measures of resuscitation. [31] The goal time to definitive surgical stabilization is generally 24 hours. However, if the patient is hemodynamically unstable and has not been adequately resuscitated, femoral fixation should be delayed and temporized with an external fixator, skeletal traction or a splint.

Elderly patients require evaluation by the medicine team for management of any acute or chronic medical conditions.

Surgical Intervention

Proximal femur fractures are treated based upon fracture pattern. Femoral neck fractures are typically treated with percutaneous pinning, a sliding hip screw or arthroplasty in elderly patients. Peritrochanteric fractures are typically treated with a sliding hip screw or a cephalomedullary nail. Subtrochanteric fractures are typically treated with an intramedullary nail or a fixed angle device. Treatment of proximal femur fractures is discussed in further detail the article Fractures, Hip.

Intramedullary nailing (see image below) is the treatment of choice for the majority of femoral shaft fractures occurring in adults. Nailing can be preformed in an antegrade or retrograde fashion. Other treatment options include plate and screw fixation as well as external fixation. The method of fixation is dependent upon the personality of the fracture as well as associated injuries. For more detail on the treatment of diaphyseal femur fractures see the article Fractures, Femur.

AP radiograph of a healing femoral shaft fracture AP radiograph of a healing femoral shaft fracture after intramedullary nailing.
Lateral radiograph of a healing femoral shaft frac Lateral radiograph of a healing femoral shaft fracture after intramedullary nailing.

Traumatic distal femurs may be treated with intramedullary nailing, plate and screw fixation or arthroplasty. These fractures are further discussed in the article Fractures, Knee .

An intra-articular distal femur fracture treated w An intra-articular distal femur fracture treated with intramedullary nailing as well as independent screw fixation.
An intra-articular distal femur fracture treated w An intra-articular distal femur fracture treated with intramedullary nailing as well as independent screw fixation.

In cases of pathologic fracture, treatment is dictated by not only location, but also tumor type. In primary bone tumors, the goal of surgical treatment is curative where as in metastatic tumors the goal is palliative.

In the case of femoral shaft stress fracture, operative treatment is reserved for those infrequent cases that have been recalcitrant to a long course of conservative treatment. Intramedullary nailing, whether antegrade or retrograde, is the treatment of choice for these cases.

Tension sided femoral neck stress fractures are typically treated with percutaneous screw fixation. For further details see the article Femoral Neck Stress Fracture.

Consultations

Consultation with orthopedic surgeons is required in cases of femoral fractures, and a definitive treatment plan is left to their judgment.

Physical Therapy

With trauma-related femur fractures, physical therapy following stable fixation of the fracture to improve hip and knee range of motion, strengthening and gait training is recommended. Weight-bearing status is dependent upon fracture pattern and surgical intervention. Ambulatory aids, such as crutches, are used in the initial stages. The goal of the therapy program should be eventual full weight-bearing and restoration of normal function. Pulmonary therapy is often needed in patients sustaining major trauma requiring prolonged bed rest.

For femoral stress fractures, discontinue crutches once pain-free walking is possible. Increase low-impact lower extremity aerobic training (e.g., swimming, biking, elliptical trainer) as symptoms permit. Attempt to identify causative factors of the femoral stress fractures (e.g., improper training techniques, footwear, diet).

One treatment algorithm that has been suggested consists of a graduated four-phase program, each of which last three weeks in duration. [32] Transfer to the next phase is based on the result of fulcrum and hop tests carried out at the end of each phase. If the tests were positive (i.e., a failed test), the patient was returned to the beginning of that phase. In the first phase athletes walked with the help of crutches and were instructed to be non-weight-bearing on the affected leg. In the second phase normal walking was permitted, and swimming and exercising on the unaffected extremities was allowed. In the third phase the patients performed exercises with both upper and lower extremities using light weights. Patients were also permitted to run in a straight line every other day and ride a stationary bicycle. The distance that the subjects were allowed to run was gradually increased. In the fourth phase the patient resumed normal training. In this study all seven patients returned to normalactivitywithin 12-18 weeks with no recurrences noted at 48-96 month follow up. [32]

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Recovery Phase

Rehabilitation Program

Physical Therapy

With trauma-related femur fractures, physical therapy following stable fixation of the fracture to improve hip and knee range of motion, strengthening and gait training is recommended. Weight-bearing status is dependent upon fracture pattern and surgical intervention. Ambulatory aids, such as crutches, are used in the initial stages. The goal of the therapy program should be eventual full weight-bearing and restoration of normal function. Pulmonary therapy is often needed in patients sustaining major trauma requiring prolonged bed rest.

For femoral stress fractures, discontinue crutches once pain-free walking is possible. Increase low-impact lower extremity aerobic training (e.g., swimming, biking, elliptical trainer) as symptoms permit. Attempt to identify causative factors of the femoral stress fractures (e.g., improper training techniques, footwear, diet).

One treatment algorithm that has been suggested consists of a graduated four-phase program, each of which last three weeks in duration. [32] Transfer to the next phase is based on the result of fulcrum and hop tests carried out at the end of each phase. If the tests were positive (i.e., a failed test), the patient was returned to the beginning of that phase. In the first phase athletes walked with the help of crutches and were instructed to be non-weight-bearing on the affected leg. In the second phase normal walking was permitted, and swimming and exercising on the unaffected extremities was allowed. In the third phase the patients performed exercises with both upper and lower extremities using light weights. Patients were also permitted to run in a straight line every other day and ride a stationary bicycle. The distance that the subjects were allowed to run was gradually increased. In the fourth phase the patient resumed normal training. In this study all seven patients returned to normal activitywithin 12-18 weeks with no recurrences noted at 48-96 month follow up. [32]

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Maintenance Phase

Rehabilitation Program

Physical Therapy

Patients should continue with therapy as needed with the goal of improving strength, motion, endurance and ambulatory ability. Continue to monitor with radiographs in an outpatient setting.

Attempt to identify causative factors of the femoral stress fractures (e.g., improper training techniques, footwear, diet). Implementation of an injury prevention program may be beneficial.

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