Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Femoral Shaft Fracture in the Adult

Basics
Description
  • Femoral shaft fractures occur in the diaphysis of the bone.
  • High-energy trauma such as vehicular accidents, falls, or gunshots are the common causes of these fractures in normal bone.
  • Low-energy trauma may cause femoral shaft fractures in pathologic or osteoporotic bone.
  • Classification:
    • Winquist and Hansen assessed fractures according to the proportion of cortical contact between proximal and distal fragments:
      • Type I: >75% bony contact
      • Type II: At least 50% cortical contact
      • Type III: <50% contact
      • Type IV: No bone contact
    • The AO/Orthopaedic Trauma Association classifies these fractures as:
      • Type 32A (simple), 32B (wedge), or 32C (complex)
      • Each type is subdivided as 1, 2, or 3 according to the inherent instability of the fracture configuration.
General Prevention
  • Accident prevention and safety measures for both pedestrians and vehicle occupants
  • Reduction and prevention of gun crime
  • Preemptive stabilization of impending pathologic fractures
Epidemiology
Incidence
  • Bimodal incidence, <25 years old and >65 years old
  • Estimated to be 1 per 10,000 persons per year
Risk Factors
  • Young adult males
  • Urban living
  • Alcohol or drug abuse
Etiology
  • Mechanism of injury:
    • Motor vehicle accident
    • Pedestrian hit by car
    • Fall from height
    • Gunshot
    • Low-energy falls or twisting injuries in pathologic bone
Associated Conditions
  • Trauma patients with a femoral shaft fracture must be assessed for injuries in all other systems.
  • Orthopaedic injuries:
    • Ipsilateral femoral neck fracture is relatively infrequent, but up to 30% are missed
    • Ligamentous derangement of the knee
    • Lower leg and foot trauma
    • Pelvic and spinal fractures
Diagnosis
Signs and Symptoms
  • Signs of hemorrhagic shock:
    • Average blood loss from an isolated femoral shaft fracture is estimated to be >1,200 mL.
  • 5-10% are open fractures.
  • The injured limb appears swollen and shortened.
History
It is vital to understand the mechanism of injury to recognize possible associated injuries.
 
Physical Exam
  • Perform the ATLS primary survey to eliminate associated life-threatening injuries.
  • Carefully check and document the neurovascular status of the lower limb.
  • Examine for associated fractures, especially of the hip and knee.
  • Examine the knee for ligamentous injuries after stabilization of the fracture.
Tests
Lab
  • All preoperative trauma laboratory tests
  • Blood must be made available by type and cross-matching.
  • Hematocrit checks for blood loss anemia
Imaging
  • AP and lateral, full-length radiographs of the affected femur
  • Internal rotation view or CT scan of ipsilateral femoral neck to rule out neck fracture
  • Cervical spine, chest, and pelvis radiographs
  • Full-length contralateral femur films are useful for length determination with comminuted or long oblique femoral fractures.
Pathological Findings
  • Injured tissues: Bone, muscle, and fascia
  • Rarely, injury to femoral artery or sciatic nerve
Differential Diagnosis
  • Suspicion of a pathologic cause should be raised if a femur fracture occurs in the presence of any of the following criteria:
    • Spontaneous fracture (zero or very-low-energy trauma)
    • History of pain before fracture
    • Destructive or permeative lesion on radiograph
Treatment
Initial Stabilization
  • Treat life-threatening airway and breathing injuries.
  • Control hemorrhage: Resuscitate with intravenous fluids and cross-matched blood.
  • Splint the limb with a Thomas-type splint to help reduce blood loss from the fracture and relieve pain.
  • Intravenous antibiotics and saline dressings for open fractures
  • Narcotic pain medicines
General Measures
  • Damage-control orthopaedics has emerged in the polytrauma patient:
    • Intramedullary nailing compounds the systemic inflammatory response by increasing inflammatory mediators and toxic metabolites in patients with high Injury Severity Scores.
    • Life-threatening hemorrhage should be controlled, and the skeleton should be stabilized with external fixation.
    • A few days later, when the initial systemic inflammatory response has subsided, the external fixator can be exchanged for definitive skeletal stabilization.
  • Most femoral shaft fractures are treated operatively with intramedullary nailing.
Activity
  • Before skeletal stabilization, patients should be restricted to bed rest.
  • Skeletal traction should be used if a delay in operative fixation is anticipated.
Nursing
  • Care should be taken to avoid pressure sores on the heel and buttocks before surgery.
  • Traction PINS must be monitored carefully to avoid pressure necrosis or osteomyelitis.
Special Therapy
Physical Therapy
  • Early physical therapy to regain motion and strength of the hip, knee, and ankle
Medication
First Line
Oral narcotic analgesics
 
Surgery
  • External fixation:
    • Initial stabilization in polytrauma patients (damage-control orthopaedics)
    • Severe open fractures
    • Vascular injury
  • Plating:
    • Rarely indicated for femoral shaft fractures
    • Periprosthetic fractures where implant is well fixed
  • Intramedullary nailing:
    • Reamed anterograde nailing is the standard treatment for most femoral shaft fractures.
    • Retrograde reamed nail may be indicated for patients with:
      • Distal femoral shaft fractures
      • Ipsilateral acetabular fractures
      • Ipsilateral femoral neck fractures
      • Obese patients in whom access to the piriformis fossa for antegrade nailing may prove too difficult
      • Bilateral femur fractures
Follow-up
Disposition
  • Patients may bear weight early in the postoperative period.
  • Physical therapy should focus on gait training, hip and knee ROM, and strengthening of the leg.
Prognosis
95% of femoral shaft fractures unite without complications.
 
Complications
  • Fat embolization, adults respiratory distress syndrome, and pulmonary complications can result from reamed femoral nailing, particularly in the polytrauma patient with chest and head trauma.
  • Nonunion is uncommon and usually is treated successfully by exchange nailing.
    • Rotational malunions and limb-length inequalities can occur, particularly in comminuted shaft fractures.
    • Rotational malalignments of >15° and length discrepancies of >2 cm should be corrected.
  • Vascular injuries are uncommon in femoral shaft fractures, except in those caused by penetrating trauma.
  • Nerve injuries resulting at the same time as shaft fracture are uncommon, although there are reported cases of pudendal nerve palsies resulting from the peroneal post while the patient is on the traction table.
  • Heterotopic ossification can occur around the hip after anterograde nailing, particularly in a patient with a head injury.
  • Compartment syndrome in the thigh may occur pre- or postoperatively.
Patient Monitoring
  • Neurovascular check postoperatively to assess for compartment syndrome
  • Radiographs are taken every 6-8 weeks until bony union.
Miscellaneous
Codes
ICD9-CM
  • 821.0 Closed femoral shaft fracture
  • 821.1 Open femoral shaft fracture
Patient Teaching
Activity
Most patients can bear weight as tolerated and resume activities gradually.
 
Prevention
  • High-energy injuries should be prevented.
  • Seat belt and airbag use help prevent injury in car crashes.
FAQ
Q: How long do femoral shaft fractures take to heal?
A: Closed fractures heal faster than open ones, usually within 3 months. Open fractures may take 3-6 months to heal.

1 comment to Femoral Shaft Fracture in the Adult

  • Жаль, что сейчас не могу высказаться – нет свободного времени. Но освобожусь – обязательно напишу что я думаю….

    Classification:

    Winquist and Hansen assessed fractures according to the proportion of cortical contact between proximal and distal fragments:

    Type […….