Background

The spectrum of femoral shaft fractures is wide and ranges from nondisplacedfemoral stress fractures to fractures associated with severe comminution and significant soft-tissue injury. Femoral shaft (see image below) fractures are generally caused by high-energy forces and are often associated with multisystemtrauma. Isolated injuries can occur with repetitive stress and may occur in the presence metabolic bone diseases, metastatic disease, or primary bone tumors.[1, 2]

An example of an isolated, short, oblique midshaft femoral fracture, which is very amenable to intramedullary nailing. Although not seen in this x-ray film, radiographic visualization of both the proximal and distal joints should be performed for all diaphyseal fractures.

Most femoral diaphyseal fractures are treated surgically with intramedullary nails or plate fixation. The goal of treatment is reliable anatomic stabilization, allowing mobilization as soon as possible. Surgical stabilization is also important for early extremity function, allowing both hip and knee motion and strengthening. Injuries and fractures of the femoral shaft may have significant short- and long-term effects on the hip and knee joints if alignment is not restored. Treatment of femoral shaft fractures has undergone significant evolution over the past century. Until the recent past, the definitive method for treating femoral shaft fractures was traction or splinting. Before the evolution of modern aggressive fracture treatment and techniques, these injuries were often disabling or fatal. Traction as a treatment option has many drawbacks, including poor control of the length and alignment of the fractured bone, development of pulmonary insufficiency, deep vein thrombosis, and joint stiffness due to supine positioning. The femur is very vascular and fractures can result in significant blood loss into the thigh. Up to 40% of isolated fractures may require transfusion, as such injuries can result in loss of up to 3 units of blood.[3] This factor is significant, especially in elderly patients who have less cardiac reserve. Femoral fracture patterns vary according to the direction of the force applied and the quantity of force absorbed. A perpendicular force results in a transverse fracture pattern, an axial force may injure the hip or knee, and rotational forces may cause spiral or oblique fracture patterns. The amount of comminution present increases with the amount of energy absorbed by the femur at the time of fracture. [1, 2, 4, 5] For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center and Sports Injury Center. Also, see eMedicine's patient education article Broken Leg. Related eMedicine topics: Femoral Neck Stress and Insufficiency Fractures [in the Orthopedic Surgery section] Femoral Neck Stress Fracture Fracture, Femur [in the Emergency Medicine section] Related Medscape topics: Resource Center Exercise and Sports Medicine

Specialty Site Emergency Medicine Specialty Site Orthopaedics CME A 49-Year-Old Man With a Femur Fracture and Hyperdense Bones CME Vitamin D and Musculoskeletal Health Alendronate Use Linked to Low-Energy Femoral Fractures

Epidemiology
Frequency
United States The incidence of femoral fractures is reported as 1-1.33 fractures per 10,000 population per year (1 case per 10,000 population). In individuals younger than 25 years and those older than 65 years, the rate of femoral fractures is 3 fractures per 10,000 population annually. These injuries are most common in males younger than 30 years. Causes may include automobile, motorcycle, or recreational vehicle accidents or gunshot wounds. The average number of days lost from work or school from femoral fractures is 30. The average number of days of restricted activity due to femoral fractures is 107. The incidence of femoral injuries and fractures increases in elderly patients.

Functional Anatomy
The femur is the strongest, longest, and heaviest bone in the body and is essential for normal ambulation. It consists of 3 parts (ie, femoral shaft or diaphysis, proximal metaphysis, distal metaphysis). The femoral shaft is tubular with a slight anterior bow, extending from the lesser trochanter to the flare of the femoral condyles. During weight bearing, the anterior bow produces compression forces on the medial side and tensile forces on the lateral side. The femur is a structure for standing and walking, and it is subject to many forces during walking, including axial loading, bending, and torsional forces. During contraction, the large muscles surrounding the femur account for most of the applied forces. [1, 2, 4, 5] Several large muscles attach to the femur. Proximally, the gluteus medius and minimus attach to the greater trochanter, resulting in abduction of the femur with fracture. The iliopsoas attaches to the lesser trochanter, resulting in internal rotation and external rotation with fractures. The linea aspera (rough line on the posterior shaft of the femur) reinforces the strength and is an attachment for the gluteus maximus, adductor magnus, adductor brevis, vastus lateralis, vastus medialis, vastus intermedius, and short head of the biceps. Distally, the large adductor muscle mass attaches medially, resulting in an apex lateral deformity with fractures. The medial and lateral heads of the gastrocnemius attach over the posterior femoral condyles, resulting in flexion deformity in distal-third fractures. The blood supply enters the femur through metaphyseal arteries and branches of the profunda femoris artery, penetrating the diaphysis and forming medullary arteries extending proximally and distally. With intramedullary nailing, the blood supply is disrupted and progressively reestablishes itself over 6-8 weeks. Healing of the fracture is enhanced by the surrounding soft tissue and local recruitment of blood supply around the callus. The femoral artery courses down the medial aspect of the thigh to the adductor hiatus, at which time it becomes the popliteal artery. Injuries to the artery occur at the level of the adductor hiatus, where soft-tissue attachments may cause tethering. Uncommonly, the sciatic nerve is injured in femoral shaft fractures; however, it may become injured in proximal or distal femoral injuries. Related eMedicine topics: Nerve Entrapment Syndromes [in the Neurosurgery section] Nerve Entrapment Syndromes of the Lower Extremity [in the Orthopedic Surgery section]

Sport-Specific Biomechanics

Trauma-induced fractures of the femur occur with contact and during high-speed sports. A significant amount of energy is transferred to the limb in a femur fracture, such as might be generated in skiing, football, hockey, rodeo, and motor sports.

Stress fracture
A femoral stress fracture is the result of cyclic overloading of the bone or a dramatic increase in the muscular forces across their insertion, causing microfracture. These repetitive stresses overcome the ability of the bone to heal the microtrauma. The area most susceptible to stress fracture is the medial junction of the proximal and middle third of the femur, which occurs as a result of the compression forces on the medial femur. Stress fractures can also occur on the lateral aspect of the femoral neck in areas of distraction and are less likely to heal nonoperatively than compression-side stress fractures. Stress fractures occur most often in repetitive overload sports such as in runners and in baseball and basketball players. For more information, refer to the eMedicine article Femoral Neck Stress Fracture.

History
Femoral shaft fractures are the result of high-energy injuries. These fractures are often accompanied by other injuries. The first priority in treatment is to rule out other life-threatening injuries and stabilize the patient. Advanced Trauma Life Support (ACLS) guidelines should be followed. History of traumatic femoral fractures The history of a femoral shaft fracture is not subtle. A high-velocity injury is usually involved, and significant pain and inability to bear weight are present. Patients may be noted to have a shortening of one leg, swelling, and gross deformity. Fractures are commonly associated with other bony injuries, including tibial shaft fractures, ipsilateral femoral neck fractures, and extension of the fracture into the distal femur. History of femoral stress fractures o These are observed with increasing frequency in joggers.[6, 7, 8] o Factors involved in stress fractures include a sudden increase in mileage, intensity, or frequency of training.[9] o A change in terrain or running surface may contribute. o Improper footwear and poor biomechanics can be another factor. o The onset of stress fractures is usually gradual; however, it may be sudden or severe. o Patients may report groin or thigh pain. o Symptoms of stress fractures are aggravated by activity and relieved by rest. o Female runners may have an abnormal menstrual history and may have a history of disordered eating. Related eMedicine topics: o o o o Female Athlete Triad Low Energy Availability in the Female Athlete Nutrition for the Female Athlete

Physical
Physical examination of traumatic femoral fractures Serious femoral fractureassociated injuries must be addressed, and ACLS guidelines must be used. A head-to-toe examination is indicated. Palpate the pelvis, hips, and knees. Correct any lower extremity deformity by applying inline longitudinal traction. A distal vascular assessment is necessary. Finally, a distal neurologic assessment is indicated. Physical examination of femoral stress fractures

Usually, the patient has few physical findings in cases of femoral stress fractures. Palpate at the site of symptoms. The thigh may be swollen. Range of motion is limited by pain. Pain may be reported with forced rotation or axial loading. Pain usually radiates into the groin area. More than 65 of external rotation is believed to be a risk factor. Bilateral symptoms have been reported.

Causes
Traumatic causes of femoral fractures Motor vehicle trauma (eg, motorcycle races, auto races, auto crash, plane crash, auto/pedestrian accident) Sports (eg, high-speed and contact sports with direct trauma, skiing, football, hockey) Falls (eg, from height, mountain climbing, pole vaulting) Gunshot wounds Metabolic bone disease Tumors (primary or metastatic) Stress fracture causes of femoral fractures Running Jogging Metabolic bone disease Amenorrheic or oligomenorrheic female runners Abnormal bone mineral density Improper training Improper footwear

Differential Diagnoses
Compartment Syndromes Hip Dislocation Hip Fracture

Laboratory Studies
Laboratory workup in cases of traumatic femoral fractures Complete blood cell (CBC) count Chemistry panel Prothrombin time (PT) / activated partial prothrombin time (aPTT) Urinalysis (UA) Type and screen or cross-match

Imaging Studies
Imaging studies in cases of traumatic femoral fractures Radiograph of the chest Spine radiograph series Anteroposterior radiograph of the pelvis

Anteroposterior-lateral radiograph of the femur (see image below), hip, and knee

X-ray film of femur fracture.

Computed tomography (CT) scan of the head, if indicated Imaging studies in cases of femoral stress fractures Anteroposterior-lateral radiographs of the femur: Findings are typically delayed for 2-6 weeks after the onset of symptoms; these films are useful for making a late confirmation of the diagnosis. Radionucleotide scanning: This is the criterion standard for diagnosis; these studies are more sensitive than and may show abnormalities 3 weeks before plain radiographs. Magnetic resonance imaging (MRI): MRIs reveal bone marrow signal earlier in the stress-reaction process than standard radiographs and radionuclear scanning. Bone mineral density evaluation: Use this test to rule out osteoporosis or osteopenia.

Acute Phase
Rehabilitation Program
Physical Therapy Treatment for acute trauma-related femoral fractures is performed by an orthopedic surgeon and usually involves surgical stabilization (see Surgical Intervention). [1, 2] For femoral stress fractures of the medial compression side, protected crutch-assisted, touch-down weight bearing is implemented for 1-4 weeks, based on the resolution of symptoms and the appearance of callus. Progression to full weight bearing can gradually commence once pain has resolved. Patients must avoid running for 8-16 weeks while the low-impact training program/phase is completed. The progression can include (1) cycling, (2) swimming, and (3) running in chest-deep water before resuming more intensive weight-bearing training. Patients must maintain upper extremity and cardiovascular fitness and avoid lower extremity exercise early in the healing process. Prophylactic rod placement is not indicated in femoral stress fractures.

Medical Issues/Complications
The emergent management of femur injuries in the sports setting is intended to restore alignment. If limb deformity is present, inline longitudinal traction is applied, realigning the extremity and maintaining limb perfusion. A splint is applied to maintain the alignment as the patient is transported to the hospital for definitive treatment.

Surgical Intervention
In cases of traumatic femoral fractures, the trauma surgeon implements multisystem stabilization and clearance for surgical intervention. Consultations with appropriate specialists must be arranged for specific systems. Traction may be necessary for initial stabilization to maintain leg length before impending surgery. Before definitive operative management of a femoral shaft fracture, the patient should be hemodynamically stable and fully resuscitated. The goal time to definitive surgical stabilization is

generally 24 hours. However, if the patient is hemodynamically unstable and has not been adequately resuscitated, femoral fixation should be delayed and temporized with an external fixator or skeletal traction. Intramedullary nailing (see image below) is the treatment of choice for the majority of femoral shaft fractures occurring in adults. Reamed locked antegrade femoral nailing remains the criterion standard and can be performed with the patient in the supine or lateral position with or without the use of a fracture table.[1, 2, 10, 11]

X-ray film of femur fracture repair.

Clinical studies have suggested the results of retrograde femoral nailing approach the success rates that are found with antegrade techniques. Retrograde nailing may be preferred when the fracture involves the distal femur or is associated with an ipsilateral femoral neck fracture. A floating knee (ie, an ipsilateral femoral shaft and tibia shaft fracture) is also a relative indication for a retrograde technique. The retrograde technique has also been found to be beneficial in obese patients,pregnant patients, and patients with total hip or total knee prostheses.

Consultations
Consultation with orthopedic surgeons is required in cases of femoral fractures, and a definitive treatment plan is left to their judgment.

Recovery Phase
Rehabilitation Program
Physical Therapy With trauma-related femoral fractures, initiate physical therapy to improve hip and knee range of motion and for strengthening. Gait training for crutch-assisted, touch-down weight bearing may be necessary depending on the fracture pattern. In simple fracture patterns, which are axially stable postoperatively, greater weight bearing can be initiated. The goal of the therapy program should be immediate weight bearing to tolerance. Pulmonary therapy is instituted as needed. For femoral stress fractures, discontinue crutches once pain-free walking is possible. Increase low-impact lower extremity aerobic training (eg, swimming, biking, elliptical trainer) as symptoms permit. Attempt to identify causative factors of the femoral stress fractures (eg, improper training techniques, footwear, diet).

Maintenance Phase
Rehabilitation Program
Physical Therapy With trauma, weight bearing is permitted once bone-healing stability has been achieved. Continue to monitor with radiographs in an outpatient setting. For stress fractures, this phase lasts a minimum 6 weeks since the onset of symptoms. Recommend 3045 minutes of pain-free bike riding on a flat surface. The patient must avoid causative factors. Poor

training areas and equipment must be corrected. During the first week, the patient can begin walking 3-5 mile/wk. At week 2, the patient can advance to walking or running 5 mile/wk. At week 3, the patient can run 5 mile/wk (minimum of 9 wk after symptom onset). Patients can gradually return to 50% of their previous training distance over the ensuing 1-2 weeks. If symptoms recur, return to the beginning of the previous phase for a minimum of 3 weeks.

Surgical Intervention
Before definitive operative management of a femoral shaft fracture, the patient should be hemodynamically stable and fully resuscitated. The goal time to definitive surgical stabilization is generally 24 hours. However, if the patient is hemodynamically unstable and has not been adequately resuscitated, femoral fixation should be delayed and temporized with an external fixator or skeletal traction. Intramedullary nailing is the treatment of choice for the majority of femoral shaft fractures occurring in adults. Reamed locked antegrade femoral nailing remains the criterion standard and can be performed with the patient in the supine or lateral position with or without the use of a fracture table. Clinical studies suggest the results of retrograde femoral nailing approach the success rates that are found with antegrade techniques. Retrograde nailing may be preferred when the fracture involves the distal femur or is associated with an ipsilateral femoral neck fracture. A floating knee is also a relative indication for a retrograde technique. The retrograde technique has also been found to be beneficial in obese patients, pregnant patients, and patients with total hip or total knee prostheses. Plate fixation may be used when femoral fractures are associated with vascular injury that requires repair or with ipsilateral femoral neck fractures. Limited-incision techniques and the use of locked plating systems are evolving.