• Clinical science

Femoral shaft fracture

Abstract

A femoral fracture is a fracture anywhere along the shaft or diaphysis of the femur. These fractures commonly occur in young males as a result of high-impact injuries (e.g., motor vehicle accidents). Low-impact shaft fractures tend to occur in older patients with pre-existing osteopenia, who have fallen from a standing position. Femoral fractures typically present as a painfully swollen, tense thigh with restricted range of motion and signs of fracture (e.g., shortening). Diagnosis is based on clinical examination findings and visualization of the fracture on plain radiographs. Definitive treatment following splinting and traction is usually surgical but depends on the patient's condition. Vascular compromise and fat embolization are common complications.

Epidemiology

  • Age: bimodal distribution, based on exposure to causative force[1][2]
    • 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.

Etiology

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

  • High-impact trauma: motor vehicle accidents, pedestrian-versus-vehicle accidents, falls, gunshot wounds
  • Low-impact injuries associated with pathological fractures : fall from standing (height > 1 m)[2]
  • Stress fractures (rare): seen in long distance runners

References:[1]

Classification

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

  • 0 - no comminution, simple transverse or oblique
  • I - small butterfly fragment, minimal to no comminution
  • II - butterfly fragment with at least 50% of the circumference of the cortices of the two major fragments intact
  • III - butterfly fragment with 50-100% of the circumference of the two major fragments comminuted
  • IV - segmental comminution, all cortical contact is lost

Clinical features

  • Painfully swollen, tense thigh [2]
  • Restricted range of motion
  • Signs of fracture (e.g., shortening, deformity)[1]
  • Crepitus and distal neurovascular deficits could be present.[1]

Beware of symptoms associated with fat emboli: change in mental status, dyspnea, hypoxia, petechiae, or fever!

Open fractures are almost always associated with multiple injuries![3]

Diagnostics

  • Plain x-ray ; [1]:see radiographic signs of fracture
  • CT and MRI if a tumor, infection, or other pathological process is suspected
  • Arteriography if vascular injury is suspected

Treatment

  • Stabilization, analgesia, and open fracture management
  • Splinting and traction[1]
  • Surgery (definitive treatment) [1]
    • Intramedullary rod via an interlocking nail (antegrade nailing): treatment of choice[2]
    • External fixation with conversion to intramedullary nail within 2–3 weeks [2]

Complications

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