Femur shaft fracture
Anatomy of the femur including the long bone shaft

Definition

A fracture of the femur shaft or femoral diaphyseal fracture consists in the break of the long tubular segment of the femur bone, between the hip and the knee joint.

Various forms of femoral shaft fractures

Pathology

A femoral shaft fracture is a serious condition needing immediate management in the Emergency Department, as it is often associated with other life-threatening injuries to the pelvis, hip, knee and head.

It requires high-energy impacts as often seen in road traffic accidents. Contrary to a hip fracture, a femoral shaft fracture is more common in the young population. In the elderly low energy forces are sufficient to cause a femoral shaft fracture due to reduced bone density. Osteoporosis and metastatic tumours can result in spontaneous or pathologic fractures.

Femoral shaft fractures are often associated to injuries of the hip (fracture/dislocation), pelvis and knee as well as compartment syndrome due to extreme soft tissue swelling and damage.

The fracture of the femoral shaft can display various patterns and complexities:

Transverse - horizontal break of the shaft

Oblique - angled break across the shaft

Spiral - line forming a circle around the shaft

Comminuted – bones breaks in 3 or more fragments

Displaced - bone extremities have lost alignment

Non-displaced - bone segments do not separate

Open or compound fracture - broken fragments protrude through the skin

Illustration of an open and closed femoral shaft fracture

Classification

Winquist and Hansen Classification

Type 0 - no comminution       

Type I - minor comminution (transverse/ oblique fractures)

Type II - > 50% cortical intact

Type III - < 50% cortical intact             

Type IV - Segmental fracture with no contact between proximal and distal fragment 

OTA (Orthopaedic Trauma Association) Classification

23A Simple: A1 – Spiral; A2 Oblique > 30 degrees; A3 Transverse < 30 degrees

32B Wedge: B1 – Spiral; B2 - Bending wedge; B3 - Fragmented wedge

32C Complex: C1 – Spiral; C2 – Segmental; C3 - Irregular

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

High force incidents are a common cause of femur shaft fracture in younger people

Causes

In the young population a femoral shaft fracture arises from high-energy traumas such as road traffic accidents and falls from a significant height. In the older population low energy falls are the main cause of a femoral shaft fracture. A fall can be the result of medical conditions including limited vision, impaired balance, sudden drop in blood pressure and heart arrhythmia causing people to faint. A pathologic fracture is the consequence of osteoporosis or metabolic changes. This type of fractures does not require a traumatic impact or a fall to occur. The most frequent causes are:

High speed road traffic accidents (car/motorcycle drivers, passengers, pedestrians)

Falls from significant height (young people)

Sports (high-speed, contact sports with direct trauma, skiing, football, hockey)

Falls on hard surface (elderly)

Pathologic fractures (osteoporosis, primary tumours, metastases, metabolic bone conditions)

Stress fractures (intense sport training, abnormalities in bone integrity, metabolic dysfunctions)

Gun shot

The risk of falls and consequent fractures is high in elderly women

Risk factors

The main risk factors for a femoral shaft fracture include:

Young age < 25, and elderly age > 65 years

Working at height (carpenters, electricians, builders, painters)

Frequent driving (car, motorcycle, high speed races)

Extreme recreational sport and activities

Osteoporosis

Falls in older people

Chronic medical conditions (hyper-/hypotension, stroke, heart arrhythmia, thyroid dysfunction, epilepsy)

Medications e.g. steroids weakening bone density and relaxants facilitating falls

Normal 

A bruise along the femur may be associated a femoral shaft fracture

Symptoms

The symptoms of a fractured femur shaft may be complex due to the possible association to other injuries. Immediately after occurring, this fracture triggers a sharp pain localised on the front, or backside of the thigh, occasionally radiating to the hip, buttock and the entire leg. The patient is unable to move the lower limb and may suffer from local numbness (nerve damage). Deformities of the thigh may also appear including partial rotation, and shortening, incorrect abduction/adduction of the affected limb. The patient may present changes in the soft tissue around the thigh including a bruise, swelling and open wounds (open fracture, gun shot).

X-ray of an oblique/displaced femoral shaft fracture in younger woman before surgery

Diagnosis

Given the serious nature of a femoral shaft fracture the first diagnosis is normally executed at the Emergency Department. Stress fractures may be less evident and firstly diagnosed at the GP practice. The mechanisms of injury and symptoms are discussed with the examiner. The patient is subjected to a medical triage to determine the presence and severity of associated injuries to prioritise treatment strategies. Examination includes the palpation and inspection of the area, assessment of the range of movement, neurologic and vascular testing. Radiologic evaluation with X-ray on antero-posterior view, CT scan or MRI is taken to characterise the fracture type and the involvement of suspected collateral injuries. The orthopaedic surgeon will assess the images and opt for the best treatment suitable to the type of fracture in relation to the general condition of the patient. Bone mineral density is useful for the diagnosis of osteoporosis particularly for stress fractures in the elderly.

Treatment

Nonoperative treatment

A non-displaced femoral shaft fracture is treated conservatively in most cases but requires a longer hospitalisation period particularly in patients with comorbidities. Nonoperative treatment increases the risk for bone displacement and requires frequent monitoring by X-ray to ensure correct healing. In more serious femoral shaft fractures, surgery is avoided only if the patient presents serious medical conditions. Early treatment includes: 

Fluid replacement

Administration of analgesic and anti-inflammatory drugs (NSAIDs)

Long leg cast, protective splint or brace

Immobilisation

Use of crutches

Continuous weighted traction device

Physical therapy

Intramedullar nails are used in different types of femoral fractures
Intramedullar nails are used in femoral shaft fractures. Images are taken intraoperatively while inserting the nail into the bone shaft to the same patient shown in Diagnosis
Example of ORIF using plate and screws to fix the femur shaft fracture
External fixation is a temporary method prior to full repair surgery of the femur

Surgical treatment

Surgical stabilisation of a femoral shaft fracture is achieved with various techniques. Such procedures are achieved at best within 24 hours from the accident and may follow an initial period of traction and ensure the patient’s cardiovascular stability. Current surgical methods are: 

Intramedullary nailing consists in the insertion of a long nail through the rimmed bone marrow canal of the femoral shaft, which is secured with screws on both ends. It allows early mobilisation and reduction of complications (incorrect fracture healing, fat/pulmonary embolism, thrombosis).

Intramedullary nailing is achieved with two approaches:

  1. Antegrade nailing is the preferred method in case of simple fractures. The nail is inserted through an incision at the femoral great trochanter
  2. Retrograde nailing is used in distal femoral shaft fractures. The nail is inserted at the distal tibial side below the patella
  3. ORIF (open reduction internal fixation) applies long plates and screws fixed onto the fracture of the shaft following initial open reduction to realign the      bone fragments. It is indicated in large, complex and / or open fractures extending to the hip or the knee joints.

External fixation in case of haemodynamic instability, or severe multi-traumas is the option when complete fixation surgery poses risks to the patient. With patient improvement the orthopaedic surgeon can proceed to final surgical fixation.

Complications

Complications that may occur following a proximal femur fracture include:

Local infection in open fractures - requiring prolonged antibiotic treatment

Acute compartment syndrome – increased pressure of the soft tissues around the fracture potentially blocking blood flow and causing tissue necrosis (death)

Blood loss (pudental or femoral artery injury) - can occur during or after surgery. Rarely, a blood transfusion is needed

Fracture non-union and delayed union - occurs when the fracture does not heal completely or heals slowly

Iatrogenic fractures  - occurring during surgery e.g. nailing

Malalignment - the healed femur parts are not aligned correctly

Reactive irritation of soft tissue to metal hardware

Heterotopic ossification – bone growth distant from the fracture site

Deep vein thrombosis (DVT) and pulmonary embolism – thrombosis mostly occurs in the deep veins of the lower limbs due to prolonged immobility. Such thrombi can dislodge and cause a life threatening pulmonary embolism. Patients are given prophylactic medications (warfarin, aspirin)

Pressure ulcers - due to extended immobilisation and the fragile skin in the elderly

Pneumonia - used to be the main cause of death in older patient that were immobilised for several weeks. Nowadays aged patients are mobilised soon after surgery to prevent such complications

Following acute rehabilitation care exercise increases strength and reduces the risk of falls

Rehabilitation

Patients with a healing femur shaft fractures begin rehabilitation through gradual and assisted physiotherapy to restore muscle strength, hip flexibility and prevent medical complications. This phase may require the patient to be admitted to a cared facility or receive regular in-home visits by a physiotherapist. Crutches, walking stick, or a walker may be necessary to support the patient during the first weeks up to 12 months after a femoral shaft fracture. Physiotherapy during the first 6-12 weeks post-surgery include:

Ice/heat treatment

Anti-inflammatory therapy (NSAIDs)

Exercise to strengthen quadriceps, hamstrings and gluteal muscles

Hydrotherapy

Massage

Joint mobilisation

Guided return to activity

Weight loss in overweighed patients

Preventing falls in the elderly avoids dangerous fractures

Prevention

A fracture to the femoral shaft can be prevented when risk factors are identified. It is critical to avoid falls and reduce the exposure to high velocity sports and recreational activities as well as adhere to safety rules. In osteoporotic patients it is recommended to administer the bisphosphonate group of drugs with supplements of calcium and vitamin D. Other preventive measures include:

Exercise and maintenance of muscular strength in the elderly (walking, swimming)

Use of supporting walking devices in the elderly

Removal of carpets or other items facilitating falls

Modify habits (laced shoes, illuminate house at night, install railings, non-skid tiles in bathroom)

Adherence to occupational health and safety procedures and road traffic safety equipment (use of seatbelts, harness, balustrades)

Improve incorrect training techniques, footwear

Weight control with diet

Monitoring of chronic diseases and pharmacological use (blood pressure medications)

Quit smoking (impairs bone healing)