Femoral Shaft Fracture in the Adult

By admin On Jan 20, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > Femoral Shaft Fracture in the Adult

Femoral Shaft Fracture in the Adult

Matthew D. Waites AFRCS (Ed)

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 (1) 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 (2) 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 (3)
Estimated to be 1 per 10,000 persons per year (3).

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 (3).
- 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 (4).
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 (5) 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 (6):
- Intramedullary nailing compounds the
  systemic inflammatory response by increasing inflammatory mediators and
  toxic metabolites in patients with high Injury Severity Scores (7).
- 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

P.129

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 (8).
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 (3,9).
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 (10).
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.

References

1. Winquist
RA, Hansen ST, Jr, Clawson DK. Closed intramedullary nailing of femoral
fractures. A report of five hundred and twenty cases. J Bone Joint Surg 1984;66A:529–539.

2. Orthopaedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma 1996;10:v–154.

3. Bennett FS, Zinar DM, Kilgus DJ. Ipsilateral hip and femoral shaft fractures. Clin Orthop Relat Res 1993;296:168–177.

4. Lieurance R, Benjamin JB, Rappaport WD. Blood loss and transfusion in patients with isolated femur fractures. J Orthop Trauma 1992;6:175–179.

5. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Program for Doctors, 6th ed. Chicago: American College of Surgeons, 1997.

6. Pape
HC, Hildebrand F, Pertschy S, et al. Changes in the management of
femoral shaft fractures in polytrauma patients: from early total care
to damage control orthopaedic surgery. J Trauma 2002;53:452–461.

7. Harwood
PJ, Giannoudis PV, van Griensven M, et al. Alterations in the systemic
inflammatory response after early total care and damage control
procedures for femoral shaft fracture in severely injured patients. J Trauma 2005;58:446–452 [disc 452–454].

8. Brumback
RJ, Toal TR, Jr, Murphy-Zane MS, et al. Immediate weight-bearing after
treatment of a comminuted fracture of the femoral shaft with a
statically locked intramedullary nail. J Bone Joint Surg 1999;81A:1538–1544.

9. Jaarsma RL, Pakvis DFM, Verdonschot N, et al. Rotational malalignment after intramedullary nailing of femoral fractures. J Orthop Trauma 2004;18:403–409.

10. Brumback RJ, Ellison TS, Molligan H, et al. Pudendal nerve palsy complicating intramedullary nailing of the femur. J Bone Joint Surg 1992;74A:1450–1455.

Additional Reading

Bradford HM. Fractures of the femoral shaft and subtrochanteric region. In: Brinker MR, ed. Review of Orthopaedic Trauma. Philadelphia: WB Saunders, 2001:67–86.

Ricci WM. Femur: trauma. In: Vaccaro AR, ed. Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005;425–431.

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.