Femur Fractures

Descriptors

Open vs. closed

Location: proximal, middle or distal one-third

Fracture Patterns:
Transverse - pure bending
Spiral - rotational
Oblique - uneven bending
Segmental - 4-point bending
Comminuted - high-energy
Butterfly fragment
Angulation or rotational deformity
Shortening or translation

Exam Pearls

This is a high energy fracture; always return to your ATLS principles. Blood loss into the thigh can be significant (~1.5L). Low energy mechanisms should raise concern for pathologic fracture

Always document a good neurovascular exam, although neurovascular injuries are less common with femoral shaft fractures

Workup

Radiographs: AP and lateral of entire femur, AP and lateral of ipsilateral hip, AP and lateral of ipsilateral knee. AP pelvis if high-energy injury

Other imaging: Thin-cut CT ipsilateral hip to assess for ipsilateral femoral neck fracture (2-6% incidence, most are non-displaced vertically-oriented basicervical fractures)
2mm cuts with leg in 10° IR to put femoral neck en face
Pediatric patients do not require hip CTs due to decreased incidence of concomitant femoral neck fractures (<0.5%)

Consider a CT scan of the knee for distal-third spiral fractures in order to assess intra-articular extension

Labs: Preop CBC/BMP/Coags/T&S/COVID

Other: CXR, EKG pre-op if indicated

Management

Need for acute intervention: Yes, immobilization with mild reduction (can attempt to pull out to length, does not require formal reduction with sedation)

Weight-bearing and range of motion: NWB, should be essentially bedrest until stabilization in OR

Type of immobilization: If comfortable without significant shortening, Knee immobilizer placed as high as possible. At MGH, Thomas traction. At BWH, skeletal traction through proximal tibia (lateral to medial to avoid peroneal nerve)

If applying knee immobilizer, make sure fracture does not hinge over the proximal aspect resulting in increased deformity.

Admission or discharge status: Admit

Anticoagulation: per HOTI protoco - usually LVX before 8 pm. If poor kidney function, SQH

Antibiotics: Indicated if open fracture

Surgical Indications

Absolute: All femoral shaft fractures with the exception of nondisplaced fractures in poor surgical candidates (medically ill) or in pediatric patients

Relative: n/a

Not an indication: n/a

Surgical Options

Antegrade intramedullary nail: for proximal ⅓ and midshaft
Retrograde intramedullary nail: for midshaft or distal ⅓ in addition to the below considerations

Indications: Ipsilateral femoral neck, peritrochanteric, acetabular (avoids compromising surgical approach to acetabulum), patellar or tibial shaft (avoids separate incisions) fractures
Bilateral femoral shaft fractures (avoids intra-operative repositioning)
Multiple system trauma
Morbid obesity (avoids difficult starting point of antegrade nail)

Contraindications: H/o knee sepsis
Soft tissue injury at entry point
Skeletal immaturity
Knee motion limited <60°
Patella baja
Ipsilateral femoral neck fracture necessitating screw fixation Distal metaphyseal-diaphyseal junction fracture Poor access to medullary canal (previous closed management, infection, too narrow) Fractures through a malunion