Femoral Shaft

Ovid: Handbook of Fractures

Authors: Koval, Kenneth J.; Zuckerman, Joseph D.
Title: Handbook of Fractures, 3rd Edition
> Table of Contents > IV – Lower Extremity Fractures and Dislocations > 32 – Femoral Shaft

Femoral Shaft
  • A femoral shaft fracture is a fracture of
    the femoral diaphysis occurring between 5 cm distal to the lesser
    trochanter and 5 cm proximal to the adductor tubercle.
  • There is an age- and gender-related bimodal distribution of fractures.
  • Femoral shaft fractures occur most frequently in young men after high-energy trauma and elderly women after a low-energy fall.
  • The femur is the largest tubular bone in
    the body and is surrounded by the largest mass of muscle. An important
    feature of the femoral shaft is its anterior bow.
  • The medial cortex is under compression, whereas the lateral cortex is under tension.
  • The isthmus of the femur is the region
    with the smallest intramedullary (IM) diameter; the diameter of the
    isthmus affects the size of the IM nail that can be inserted into the
    femoral shaft.
  • The femoral shaft is subjected to major muscular deforming forces (Fig. 32.1):
    • Abductors (gluteus medius and minimus):
      They insert on the greater trochanter and abduct the proximal femur
      following subtrochanteric and proximal shaft fractures.
    • Iliopsoas: It flexes and externally rotates the proximal fragment by its attachment to the lesser trochanter.
    • Adductors: They span most shaft fractures
      and exert a strong axial and varus load to the bone by traction on the
      distal fragment.
    • Gastrocnemius: It acts on distal shaft fractures and supracondylar fractures by flexing the distal fragment.
    • Fascia lata: It acts as a tension band by resisting the medial angulating forces of the adductors.
  • The thigh musculature is divided into three distinct fascial compartments (Fig. 32.2):
    • Anterior compartment: This is composed of
      the quadriceps femoris, iliopsoas, sartorius, and pectineus, as well as
      the femoral artery, vein, and nerve, and the lateral femoral cutaneous
      Figure 32.1. Deforming muscle forces on the femur; abductors (A), iliopsoas (B), adductors (C), and gastrocnemius origin (D). The medial angulating forces are resisted by the fascia lata (E).
      Potential sites of vascular injury after fracture are at the adductor
      hiatus and the perforating vessels of the profunda femoris.

      (From Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 5th ed. Baltimore: Lippincott Williams & Wilkins, 2002.)
      Figure 32.2. Cross-sectional diagram of the thigh demonstrates the three major compartments.

      (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)
    • P.347


    • Medial compartment: This contains the
      gracilis, adductor longus, brevis, magnus, and obturator externus
      muscles along with the obturator artery, vein, and nerve, and the
      profunda femoris artery.
    • Posterior compartment: This includes the
      biceps femoris, semitendinosus, and semimembranosus, a portion of the
      adductor magnus muscle, branches of the profunda femoris artery, the
      sciatic nerve, and the posterior femoral cutaneous nerve.
    • Because of the large volume of the three
      fascial compartments of the thigh, compartment syndromes are much less
      common than in the lower leg.
    • The vascular supply to the femoral shaft
      is derived mainly from the profunda femoral artery. The one to two
      nutrient vessels usually enter the bone proximally and posteriorly
      along the linea aspera. This artery then arborizes proximally and
      distally to provide the endosteal circulation to the shaft. The
      periosteal vessels also enter the bone along the linea aspera and
      supply blood to the outer one-third of the cortex. The endosteal
      vessels supply the inner two-thirds of the cortex.
    • Following most femoral shaft fractures,
      the endosteal blood supply is disrupted, and the periosteal vessels
      proliferate to act as the primary source of blood for healing. The
      medullary supply is eventually restored late in the healing process.
    • Reaming may further obliterate the endosteal circulation, but it returns fairly rapidly, in 3 to 4 weeks.
    • Femoral shaft fractures heal readily if
      the blood supply is not excessively compromised. Therefore, it is
      important to avoid excessive periosteal stripping, especially
      posteriorly, where the arteries enter the bone at the linea aspera.
  • Femoral shaft fractures in adults are
    almost always the result of high-energy trauma. These fractures result
    from motor vehicle accident, gunshot injury, or fall from a height.
  • Pathologic fractures, especially in the
    elderly, commonly occur at the relatively weak metaphyseal-diaphyseal
    junction. Any fracture that is inconsistent with the degree of trauma
    should arouse suspicion for pathologic fracture.
  • Stress fractures occur mainly in military
    recruits or runners. Most patients report a recent increase in training
    intensity just before the onset of thigh pain.
  • Because these fractures tend to be the result of high-energy trauma, a full trauma survey is indicated.
  • The diagnosis of femoral shaft fracture
    is usually obvious, with the patient presenting nonambulatory with
    pain, variable gross deformity, swelling, and shortening of the
    affected extremity.
  • A careful neurovascular examination is
    essential, although neurovascular injury is uncommonly associated with
    femoral shaft fractures.
  • Thorough examination of the ipsilateral
    hip and knee should be performed, including systematic inspection and
    palpation. Range-of-motion or ligamentous testing is often not feasible
    in the setting of a femoral shaft fracture and may result in
    displacement. Knee ligament injuries are common, however, and need to
    be assessed after fracture fixation.
  • Major blood loss into the thigh may
    occur. The average blood loss in one series was greater than 1200 mL,
    and 40% of patients ultimately required transfusions. Therefore, a
    careful preoperative assessment of hemodynamic stability is essential,
    regardless of the presence or absence of associated injuries.


  • Associated injuries are common and may be
    present in up to 5% to 15% of cases, with patients presenting with
    multisystem trauma, spine, pelvis, and ipsilateral lower extremity
  • Ligamentous and meniscal injuries of the ipsilateral knee are present in 50% of patients with closed femoral shaft fractures.
  • Anteroposterior (AP) and lateral views of the femur, hip, and knee as well as an AP view of the pelvis should be obtained.
  • The radiographs should be critically
    evaluated to determine the fracture pattern, the bone quality, the
    presence of bone loss, associated comminution, the presence of air in
    the soft tissues, and the amount of fracture shortening.
  • One must evaluate the region of the proximal femur for evidence of an associated femoral neck or intertrochanteric fracture.
  • If a computed tomography scan of the
    abdomen and/or pelvis is obtained for other reasons, this should be
    reviewed because it may provide evidence of injury to the ipsilateral
    acetabulum or femoral neck.
  • Open versus closed injury
  • Location: proximal, middle, or distal one-third
  • Location: isthmal, infraisthmal or supracondylar
  • Pattern: spiral, oblique, or transverse
  • Comminuted, segmental, or butterfly fragment
  • Angulation or rotational deformity
  • Displacement: shortening or translation
Winquist and Hansen (Fig. 32.3)
  • This is based on fracture comminution.
  • It was used before routine placement of statically locked IM nails.

Type I: Minimal or no comminution
Type II: Cortices of both fragments at least 50% intact
Type III: 50% to 100% cortical comminution
Type VI: Circumferential comminution with no cortical contact
OTA Classification of Femoral Shaft Fractures
See Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.
Skeletal Traction
  • Currently, closed management as
    definitive treatment for femoral shaft fractures is largely limited to
    adult patients with such significant medical comorbidities that
    operative management is contraindicated.
  • P.350

  • The goal of skeletal traction is to
    restore femoral length, limit rotational and angular deformities,
    reduce painful spasms, and minimize blood loss into the thigh.
    Figure 32.3. Winquist and Hansen classification of femoral shaft fractures.

    (From Browner BD, Jupiter JB, Levine AM, et al. Skeletal Trauma. Philadelphia: WB Saunders, 1992:1537.)
  • Skeletal traction is usually used as a
    temporizing measure before surgery to stabilize the fracture and
    prevent fracture shortening.
  • Twenty to 40 lb of traction is usually applied and a lateral radiograph checked to assess fracture length.
  • Distal femoral pins should be placed in
    an extracapsular location to avoid the possibility of septic arthritis.
    Proximal tibia pins are typically positioned at the level of the tibial
    tubercle and are placed in a bicortical location.
  • Safe pin placement is usually from medial
    to lateral at the distal femur (directed away from the femoral artery)
    and from lateral to medial at the proximal tibia (directed away from
    the peroneal nerve).
  • Problems with use of skeletal traction
    for definitive fracture treatment include knee stiffness, limb
    shortening, prolonged hospitalization, respiratory and skin ailments,
    and malunion.
  • Operative stabilization is the standard of care for most femoral shaft fractures.
  • Surgical stabilization should occur within 24 hours, if possible.
  • Early stabilization of long bone injuries appears to be particularly important in the multiply injured patient.
Intramedullary (IM) Nailing
  • This is the standard of care for femoral shaft fractures.
  • Its IM location results in lower tensile
    and shear stresses on the implant than plate fixation. Benefits of IM
    nailing over plate fixation include less extensive exposure and
    dissection, lower infection rate, and less quadriceps scarring.
  • P.351

  • Closed IM nailing in closed fractures has
    the advantage of maintaining both the fracture hematoma and the
    attached periosteum. If reaming is performed, these elements provide a
    combination of osteoinductive and osteoconductive materials to the site
    of the fracture.
  • Other advantages include early functional
    use of the extremity, restoration of length and alignment with
    comminuted fractures, rapid and high union (>95%), and low
    refracture rates.
Antegrade Inserted Intramedullary (IM) Nailing
  • Surgery can be performed on a fracture table or on a radiolucent table with or without skeletal traction.
  • The patient can be positioned supine or
    lateral. Supine positioning allows unencumbered access to the entire
    patient. Lateral positioning facilitates identification of the
    piriformis starting point but may be contraindicated in the presence of
    pulmonary compromise.
  • One can use either a piriformis fossa or
    greater trochanteric starting point. The advantage of a piriformis
    starting point is that it is in line with the medullary canal of the
    femur. However, it is easier to locate the greater trochanteric
    starting point. Use of a greater trochanteric starting point requires
    use of a nail with a valgus proximal bow to negotiate the off starting
    point axis.
  • With the currently available nails, the
    placement of large diameter nails with an intimate fit along a long
    length of the medullary canal is no longer necessary.
  • The role of unreamed IM nailing for the
    treatment of femoral shaft fractures remains unclear. The potentially
    negative effects of reaming for insertion of IM nails include elevated
    IM pressures, elevated pulmonary artery pressures, increased fat
    embolism, and increased pulmonary dysfunction. The potential advantages
    of reaming rate include the ability to place a larger implant,
    increased union, and decreased hardware failure.
  • All IM nails should be statically locked
    to maintain femoral length and control rotation. The number of distal
    interlocking screws necessary to maintain the proper length, alignment,
    and rotation of the implant bone construct depends on numerous factors
    including fracture comminution, fracture location, implant size,
    patient size, bone quality, and patient activity.
Retrograde Inserted Intramedullary (IM) Nailing
  • The major advantage with a retrograde entry portal is the ease in properly identifying the starting point.
  • Relative indications include:
    • Ipsilateral injuries such as femoral neck, pertrochanteric, acetabular, patellar, or tibial shaft fractures.
    • Bilateral femoral shaft fractures.
    • Morbidly obese patient.
    • Pregnant woman.
    • Periprosthetic fracture above a total knee arthroplasty.
    • Ipsilateral through knee amputation in a patient with an associated femoral shaft fracture.
  • P.352

  • Contraindications include:
    • Restricted knee motion <60 degrees.
    • Patella baja.
    • The presence of an associated open traumatic wound, secondary to the risk of intraarticular knee sepsis.
External Fixation
  • Use as definitive treatment for femoral shaft fractures has limited indications.
  • Its use is most often provisional.
  • Advantages include the following:
    • The procedure is rapid; A temporary external fixator can be applied in less than 30 minutes.
    • The vascular supply to the femur is minimally damaged during application.
    • No additional foreign material is introduced in the region of the fracture.
    • It allows access to the medullary canal and the surrounding tissues in open fractures with significant contamination.
  • Disadvantages: Most are related to use of this technique as a definitive treatment and include:
    • Pin tract infection.
    • Loss of knee motion.
    • Angular malunion and femoral shortening.
    • Limited ability to adequately stabilize the femoral shaft.
    • Potential infection risk associated with conversion to an IM nail.
  • Indications for use of external fixation include:
    • Use as a temporary bridge to IM nailing in the severely injured patient.
    • Ipsilateral arterial injury that requires repair.
    • Patients with severe soft tissue contamination in whom a second debridement would be limited by other devices.
Plate Fixation
Plate fixation for femoral shaft stabilization has decreased with the use of IM nails.
  • Advantages to plating include:
    • Ability to obtain an anatomic reduction in appropriate fracture patterns.
    • Lack of additional trauma to remote locations such as the femoral neck, the acetabulum, and the distal femur.
  • Disadvantages compared with IM nailing include:
    • Need for an extensive surgical approach
      with its associated blood loss, risk of infection, and soft tissue
      insult. This can result in quadriceps scarring and its effects on knee
      motion and quadriceps strength.
    • Decreased vascularization beneath the plate and the stress shielding of the bone spanned by the plate.
    • The plate is a load bearing implant; therefore, higher rate of implant failure.
  • Indications include:
    • Extremely narrow medullary canal where IM nailing is impossible or difficult.
    • P.353

    • Fractures that occur adjacent to or through a previous malunion.
    • Obliteration of the medullary canal due to infection or previous closed management.
    • Fractures that have associated proximal or distal extension into the pertrochanteric or condylar regions.
    • In patients with an associated vascular
      injury, the exposure for the vascular repair frequently involves a wide
      exposure of the medial femur. If rapid femoral stabilization is
      desired, a plate can be applied quickly through the medial open
  • An open or a submuscular technique may be applicable.
  • As the fracture comminution increases, so
    should the plate length such that at least four to five screw holes of
    plate length are present on each side of the fracture.
  • The routine use of cancellous bone
    grafting in plated femoral shaft fractures is questionable if indirect
    reduction techniques are used.
Femur Fracture in Multiply Injured Patient
  • The impact of femoral nailing and reaming is controversial in the polytrauma patient.
  • In a specific subpopulation of patients
    with multiple injuries, early IM nailing is associated with elevation
    of certain proinflammatory markers.
  • It has been recommended that early
    external fixation of long bone fractures followed by delayed IM nailing
    may minimize the additional surgical impact in patients at high risk
    for developing complications (i.e., patients in extremis or
Ipsilateral Fractures of the Proximal or Distal Femur
  • Concomitant femoral neck fractures occur
    in 3% to 10% of patients with femoral shaft fractures. Options for
    operative fixation include antegrade IM nailing with multiple screw
    fixation of the femoral neck, retrograde femoral nailing with multiple
    screw fixation of the femoral neck, and compression plating with screw
    fixation of the femoral neck. The sequence of surgical stabilization is
  • Ipsilateral fractures of the distal femur
    may exist as a distal extension of the shaft fracture or as a distinct
    fracture. Options for fixation include fixation of both fractures with
    a single plate, fixation of the shaft and distal femoral fractures with
    separate plates, IM nailing of the shaft fracture with plate fixation
    of the distal femoral fracture, or interlocked IM nailing spanning both
    fractures (high supracondylar fractures).
Open Femoral Shaft Fractures
  • These are typically the result of high-energy trauma.
  • Patients frequently have multiple other orthopaedic injuries and involvement of several organ systems.
  • Treatment is emergency debridement with skeletal stabilization.
  • Stabilization can usually involve placement of a reamed IM nail.


  • Early patient mobilization out of bed is recommended.
  • Early range of knee motion is indicated.
  • Weight bearing on the extremity is guided
    by a number of factors including the patient’s associated injuries,
    soft tissue status, and the location of the fracture.
  • Nerve injury: This is uncommon because
    the femoral and sciatic nerves are encased in muscle throughout the
    length of the thigh. Most injuries occur as a result of traction or
    compression during surgery.
  • Vascular injury: This may result from tethering of the femoral artery at the adductor hiatus.
  • Compartment syndrome: This occurs only
    with significant bleeding. It presents as pain out of proportion, tense
    thigh swelling, numbness or paresthesias to medial thigh (saphenous
    nerve distribution), or painful passive quadriceps stretch.
  • Infection (<1% incidence in closed
    fractures): The risk is greater with open versus closed IM nailing.
    Grades I, II, and IIIA open fractures carry a low risk of infection
    with IM nailing, whereas fractures with gross contamination, exposed
    bone, and extensive soft tissue injury (grades IIIB, IIIC) have a
    higher risk of infection regardless of treatment method.
  • Refracture: Patients are vulnerable
    during early callus formation and after hardware removal. It is usually
    associated with plate or external fixation.
  • Nonunion and delayed union: This is
    unusual. Delayed union is defined as healing taking longer than 6
    months, usually related to insufficient blood supply (i.e., excessive
    periosteal stripping), uncontrolled repetitive stresses, infection, and
    heavy smoking. Nonunion is diagnosed once the fracture has no further
    potential to unite.
  • Malunion: This is usually varus, internal rotation, and/or shortening owing to muscular deforming forces or surgical technique.
  • Fixation device failure: This results from nonunion or “cycling” of device, especially with plate fixation.
  • Heterotopic ossification may occur.

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