Femur shaft fracture

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.

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 shaftOblique - angled break across the shaft Spiral - line forming a circle around the shaftComminuted “ bones breaks in 3 or more fragmentsDisplaced - bone extremities have lost alignmentNon-displaced - bone segments do not separateOpen or compound fracture - broken fragments protrude through the skin

Winquist and Hansen ClassificationType 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) Classification23A Simple: A1 “ Spiral; A2 Oblique > 30 degrees; A3 Transverse < 30 degrees 32B Wedge: B1 “ Spiral; B2 - Bending wedge; B3 - Fragmented wedge32C Complex: C1 “ Spiral; C2 “ Segmental; C3 - Irregular

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 main risk factors for a femoral shaft fracture include:Young age < 25, and elderly age > 65 yearsWorking at height (carpenters, electricians, builders, painters)Frequent driving (car, motorcycle, high speed races)Extreme recreational sport and activitiesOsteoporosisFalls in older peopleChronic medical conditions (hyper-/hypotension, stroke, heart arrhythmia, thyroid dysfunction, epilepsy)Medications e.g. steroids weakening bone density and relaxants facilitating fallsNormal ;

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).

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.

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

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 treatmentAnti-inflammatory therapy (NSAIDs)Exercise to strengthen quadriceps, hamstrings and gluteal musclesHydrotherapyMassageJoint mobilisationGuided return to activityWeight loss in overweighed patients

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 elderlyRemoval of carpets or other items facilitating fallsModify 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 dietMonitoring of chronic diseases and pharmacological use (blood pressure medications)Quit smoking (impairs bone healing)