Fractures of the shaft of the femur most often occur in men during their most active period in life. Falls, industrial and automobile accidents, and gunshot wounds account for the majority of these fractures.36 Severe, direct trauma may result in transverse fractures (most common) with displacement, oblique or spiral oblique fractures, or badly comminuted segments. Pathologic fractures are uncommon but can occur secondary to metastases (breast, lung, or prostate most common) or rarely secondary to primary bone tumors such as osteogenic sarcoma.
Spiral midshaft femur fractures can occur in toddlers who are running and trip with a twisting motion.37 Midshaft femur fractures in children are often the result of neglect or abuse; however, up to 80 percent of fractures during the first year of life are possibly due to abuse. 38 The suspicion of abuse should be greater if the fracture occurs in an infant, child with preexisting brain damage, child with bilateral femur fractures, subtrochanteric femur fractures, or fractures occurring in children with other concomitant trauma. Distal metaphyseal chip fractures and delays in the family seeking medical care for the child should also raise the clinical suspicion for abuse. A femoral fracture in a young child with no history suggestive of abuse or significant trauma should suggest the possibility of osteogenesis imperfecta.
The femur is surrounded by large muscle groups with a rich vascular supply. Therefore, femoral fractures may result in a loss of 1 L or more of blood into the soft tissue of the thigh, producing clinical shock. The initial evaluation should always include careful neurovascular examination of the extremity. Vascular occlusion or disruption can occur, but nerve damage is rare.
Femoral shaft fractures are generally evident in the field to prehospital personnel because of the shortening, deformity and associated swelling. Initially, basic stabilization of the patient should take place in the field, along with spinal assessment and immobilization. External hemorrhage should be controlled by direct pressure, open wounds covered with a sterile dressing and then neurovascular examination of the extremities performed. It is best to splint the affected extremity with a traction splint at the time of injury. Hare (Dyna-Med, Carlsbad, CA) or Sager (Minto Research & Development, Redding, CA) traction splints can be placed over the trousers, applying traction to a sling around the ankle and forefoot. Traction splints are relatively contraindicated in cases of open fracture with grossly contaminated exposed bone ends or when sciatic nerve injury is probable because traction can exacerbate nerve injury. For the latter, splint placement without application of traction is indicated.
Emergency Department management includes basic stabilization of the patient followed by careful neurovascular examination of the affected extremity. Open fractures require broad spectrum antibiotics, debridement, and copious irrigation, generally in the operating room. Radiographs of the femur are generally lower priority in the acute resuscitation phase and parenteral analgesics are generally required if there is no contraindication to their use. Orthopedic consultation should be obtained early and most patients require hospitalization and surgical intervention.
Definitive management options include traction, external fixation, pins and plaster, and internal fixation. In infants and in children up to 2 years of age or 30 pounds, fractures of the shaft of the femur are treated by direct overhead traction applied to both legs (Bryant's traction) followed by spica casting. Spica casting is also used for children up to age six. In an older child or young adult, the Fisk-type of traction by means of a half-Thomas ring and Pearson attachment, to allow flexion of the knee, is satisfactory for unstable fractures followed by spica casting or cast bracing. External fixation and flexible intramedullary rod fixation are being employed more frequently in this age group.39 The intermedullary interlocking nailing is the method of choice for the treatment of uncomplicated fractures of the mid shaft and junction of the upper and middle third of the femur in adults, except where comminution is so extensive that stability with the rod cannot be maintained. In cases where comminution is severe, either dual-plating or the use of a compression plate device can result in excellent fixation. Open femur fractures require early orthopedic consultation for copious irrigation and debridement in the operating room. These injuries can generally be nailed immediately. 40 In severely contaminated open fractures, external fixation may be the preferred method of treatment.
The overall prognosis of midshaft femur fractures is very good, with most patients being able to return to work within six months. Union rates approach 100 percent, with non-union being very uncommon. Mild degrees of limb shortening or malalignment can result in limp and posttraumatic arthritis.
Patients with preexisting internal hardware may suffer recurrent fractures with trauma. These fractures tend to be very severe and comminuted because the bone is weaker than the hardware. Evaluation and treatment principles are the same as without hardware. Hardware migration, loosening and rarely breakage can occur. Pain at the site and radiographic changes compared to old films are present. Infection, suggested by pain at the fracture site and fever, may also occur, but is uncommon with closed procedures.
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