Femoral shaft fracture

A femoral shaft fracture is a fracture anywhere along the diaphysis of the femur. These injuries typically result from high-impact trauma (e.g., motor vehicle collisions) and are more common in younger individuals. Low-impact shaft fractures most commonly occur in older adults with pre-existing osteopenia. Affected patients often present with pain and swelling along the thigh and additional findings consistent with fracture (e.g., limb shortening). Signs of fracture on x-ray confirm the diagnosis; advanced imaging studies may be required for surgical planning or if results are inconclusive. In adults, a traction splint may be considered as a temporizing measure; definitive treatment involves internal fixation with an intramedullary nail. In children, treatment varies with age. Complications include vascular compromise and fat embolism.

For fractures of the femoral head, neck, and trochanter, see “Hip fractures.”

• Age: bimodal distribution, based on exposure to causative force
  • High-energy trauma associated: common in younger population (< 25 years)
  • Low-energy trauma associated: common in older population (> 65 years)
• Sex: ♂ > ♀

Epidemiological data refers to the US, unless otherwise specified.

A fracture in the diaphysis (shaft) of the femur caused by:

• High-impact trauma: motor vehicle collision, pedestrian-versus-vehicle accidents, falls, gunshot wounds
• Low-impact injuries associated with pathological fractures : fall from standing (height > 1 m)
• Stress fractures (rare): seen in long-distance runners

Femoral shaft fractures are divided by the Winquist-Hansen classification, based on the degree of comminution. This includes the following categories:

• Type 0: no comminution, simple transverse or oblique
• Type I
  • Small butterfly fragment
  • Minimal to no comminution
• Type II: butterfly fragment with at least 50% of the circumference of the cortices of the two major fragments intact
• Type III: butterfly fragment with 50–100% of the circumference of the two major fragments comminuted
• Type IV
  • Segmental comminution
  • All cortical contact is lost

• Painful, swollen, tense thigh
• Restricted range of motion
• Limb shortening
• Signs of fracture (e.g., deformity, crepitus)
• Features of open fractures (e.g., lacerations)
• Signs of neurovascular injury (rare in closed injuries) [1]
• Commonly associated injuries include knee and hip fractures and knee ligament injuries. [1]

Clinical evaluation [1]

Urgent orthopedic consultation is indicated for patients with any features of neurovascular injury or open fracture.

• Neurovascular examination
  • Assess capillary refill time and distal pulses.
  • Evaluate for sciatic nerve injuries.
• Skin examination: Evaluate for lacerations, tearing, and tenting.

X-ray

Views [2]

• Femur: anteroposterior (AP) and lateral views
• Hip: AP and lateral views
• Knee: AP and lateral views
• Pelvis: AP view

Findings [1]

• Radiographic signs of a fracture
• Fracture fragments, displacement, angulation, and/or dislocation

Advanced imaging

• CT
  • Indicated if x-ray findings are inconclusive and for preoperative planning in complicated fractures and assessment of associated injuries
  • See “CT imaging in trauma.”
• CT angiography: indicated for signs of vascular injury
• MRI: : may be indicated to assess for associated tendon and ligament injuries and pathological fractures [3]

Often managed surgically in adults. See “Femoral shaft fractures in children” for the management of pediatric patients.

Initial management [1][4]

For unstable patients and those with polytrauma, follow the ATLS algorithm.

• Initiate general fracture care, including analgesia.
• Consider a traction splint for temporary immobilization. [4]
• Urgently consult orthopedic surgery.
• Admit to the hospital for surgery.

Femoral shaft fractures can cause significant blood loss into the thigh compartment, potentially leading to hemorrhagic shock.

Surgical management [1][5]

• First-line: internal fixation with an intramedullary nail
• Alternatives
  • Temporary external fixation (e.g., in patients with polytrauma or open fractures) [6]
  • Plate fixation [7]

• See “Complications of fractures” (especially vascular injury and fat embolism).
• Posttraumatic deformity
  • Rotational error
  • Osteoarthritis of the knee
• Myositis ossificans

Look out for symptoms of fat embolism: altered mental status, respiratory distress, petechiae, and fever. [8]

We list the most important complications. The selection is not exhaustive.

Femoral shaft fractures in children [9]

• Etiology
  • Blunt trauma (e.g., due to falls, motor vehicle collision, sports injuries)
  • Nonaccidental trauma
• Clinical features: See “Clinical features of femoral shaft fractures.”
• Diagnosis
  • See “Diagnosis of femoral shaft fractures.”
  • Children < 36 months should be evaluated for nonaccidental trauma (e.g., with a skeletal survey).
• Treatment
  • < 6 months of age: Pavlik harness or hip spica cast
  • 6 months–5 years of age: hip spica cast
  • ≥ 5 years of age: surgery (e.g., internal fixation with an intramedullary nail)