Femoral fracture

A femoral fracture is a bone fracture that involves the femur. They are typically sustained in high-impact trauma, such as car crashes, due to the large amount of force needed to break the bone. Fractures of the diaphysis, or middle of the femur, are managed differently from those at the head, neck, and trochanter; those are conventionally called hip fractures (because they involve the hip joint region). Thus, mentions of femoral fracture in medicine usually refer implicitly to femoral fractures at the shaft or distally.

For fractures to the femoral head, neck and trochanteric region, see hip fracture.
Femoral fracture
X-ray image of a femoral shaft fracture
SpecialtyOrthopedic

Signs and symptoms

Fractures are commonly obvious, since femoral fractures are often caused by high energy trauma.[1] Signs of fracture include swelling, deformity, and shortening of the leg.[2] Extensive soft-tissue injury, bleeding, and shock are common.[3] The most common symptom is severe pain, which prevents movement of the leg.[4]

Diagnosis
Common locations of fracture of femur

Physical exam

Femoral shaft fractures occur during extensive trauma, and they can act as distracting injuries, whereby the observer accidentally overlooks other injuries, preventing a thorough exam of the complete body.[4] For example, the ligaments and meniscus of the ipsilateral (same side) knee are also commonly injured.[2][3]

Radiography

Anterior-posterior (AP) and lateral radiographs are typically obtained.[4] In order to rule out other injuries, hip, pelvis, and knee radiographs are also obtained.[5] The hip radiograph is of particular importance, because femoral neck fractures can lead to osteonecrosis of the femoral head.[4]

Classification
The diaphysis is the midshaft of the femur

The fracture may be classed as open, which occurs when the bone fragments protrude through the skin, or there is an overlying wound that penetrates to the bone. These types of fracture cause more damage to the surrounding tissue, are less likely to heal properly, and are at much greater risk of infection.

Femoral shaft fractures

Femoral shaft fractures can be classified with the Winquist and Hansen classification, which is based on the amount of comminution.[6]

Distal femur fractures

Fractures of the inferior or distal femur may be complicated by separation of the condyles, resulting in misalignment of the articular surfaces of the knee joint, or by hemorrhage from the large popliteal artery that runs directly on the posterior surface of the bone. This fracture compromises the blood supply to the leg (an occurrence that should always be considered in knee fractures or dislocations).[7]

Treatment

A 2015 Cochrane review (updated in 2022) found that available evidence for treatment options of distal femur fractures is insufficient to inform clinical practice and that there is a priority for a high-quality trial to be undertaken.[8] Open fractures must undergo urgent surgery to clean and repair them, but closed fractures can be maintained until the patient is stable and ready for surgery.[9][10]

Skeletal traction

Available evidence suggests that treatment depends on the part of the femur that is fractured. Traction may be useful for femoral shaft fractures because it counteracts the force of the muscle pulling the two separated parts together, and thus may decrease bleeding and pain.[11] Traction should not be used in femoral neck fractures or when there is any other trauma to the leg or pelvis.[12][13] It is typically only a temporary measure used before surgery. It only considered definitive treatment for patients with significant comorbidities that contraindicate surgical management.[14]

External fixators

External fixators can be used to prevent further damage to the leg until the patient is stable enough for surgery.[14] It is most commonly used as a temporary measure. However, for some select cases it may be used as an alternative to intramedullary nailing for definitive treatment.[15][16]

Intramedullary nailing

For femoral shaft fractures, reduction and intramedullary nailing is currently recommended.[14] The bone is re-aligned, then a metal rod is placed into the femoral bone marrow, and secured with nails at either end. This method offers less exposure, a 98–99% union rate, lower infection rates (1–2%) and less muscular scarring.[14][15][17]

Rehabilitation

After surgery, the patient should be offered physiotherapy and try to walk as soon as possible, and then every day after that to maximise their chances of a good recovery.[18]

Outcomes

These fractures can take at least 4–6 months to heal.[19] Since femoral shaft fractures are associated with violent trauma, there are many adverse outcomes, including fat embolism, acute respiratory distress syndrome (ARDS), multisystem organ failure, and shock associated with severe blood loss.[4] Open fractures can result in infection, osteomyelitis, and sepsis.

Epidemiology

Femoral shaft fractures occur in a bimodal distribution, whereby they are most commonly seen in males age 15-24 (due to high energy trauma) and females aged 75 or older (pathologic fractures due to osteoporosis, low-energy falls).[20][14] In Germany, femoral fractures are the most common type of fracture seen and treated in hospitals.[9][21]

References
  1. Bucholz RW, Jones A (December 1991). "Fractures of the shaft of the femur". The Journal of Bone and Joint Surgery. American Volume. 73 (10): 1561–1566. doi:10.2106/00004623-199173100-00015. PMID 1748704.
  2. Rockwood Jr CA, Green DP, Bucholz RW (2010). Rockwood and Green's fractures in adults (7th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN 9781605476773. OCLC 444336477.
  3. Skinner HB, McMahon PJ (2014). Current diagnosis & treatment in orthopedics (5th ed.). New York: McGraw-Hill Medical. ISBN 9780071590754. OCLC 820106991.
  4. Sarwark JF (2010). Essentials of musculoskeletal care. Rosemont, Ill.: American Academy of Orthopaedic Surgeons. ISBN 9780892035793. OCLC 706805938.
  5. Committee on Trauma. (2012). Advanced trauma life support : student course manual (9th ed.). Chicago, IL: American College of Surgeons. ISBN 9781880696026. OCLC 846430144.
  6. Stannard JP, Schmidt AH, Kregor PJ (2007). Surgical treatment of orthopaedic trauma. New York, NY: Thieme. p. 612. ISBN 978-1-58890-307-5.
  7. Moore KL, Dalley AF, Agur AM (2014). Clinically Oriented Anatomy (Seventh ed.). Philadelphia. p. 527. ISBN 978-1-4511-8447-1.{{cite book}}: CS1 maint: location missing publisher (link)
  8. Claireaux, Henry A.; Searle, Henry Kc; Parsons, Nick R.; Griffin, Xavier L. (2022-10-05). "Interventions for treating fractures of the distal femur in adults". The Cochrane Database of Systematic Reviews. 2022 (10): CD010606. doi:10.1002/14651858.CD010606.pub3. ISSN 1469-493X. PMC 9534312. PMID 36197809.{{cite journal}}: CS1 maint: PMC embargo expired (link)
  9. Büchele G, Rehm M, Halbgebauer R, Rothenbacher D, Huber-Lang M (2022-02-26). "Trauma-related acute kidney injury during inpatient care of femoral fractures increases the risk of mortality: a claims data analysis". American Journal of Medicine Open. 8: 100009. doi:10.1016/j.ajmo.2022.100009. ISSN 2667-0364. S2CID 247152803.
  10. "Femur Shaft Fractures (Broken Thighbone)-OrthoInfo - AAOS". orthoinfo.aaos.org. Retrieved 2016-12-14.
  11. Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. p. 9. ISBN 978-0-07-148480-0.
  12. AAOS (October 2010). "29". In Andrew N. Pollak MD. FAAOS (ed.). Emergency Care and Transport of the Sick and Injured (Print) (10 ed.). Sudbury, Massachusetts: Jones and Bartlett. pp. 1025–1031. ISBN 978-1-4496-3056-0.
  13. Marx JA (2014). Rosen's emergency medicine : concepts and clinical practice (Eighth ed.). London: Elsevier Health Sciences. p. 680. ISBN 9781455749874.
  14. Egol KA, Koval KJ, Zuckerman JD (2015). Handbook of fractures (5th ed.). Philadelphia: Wolters Kluwer Health. ISBN 9781451193626. OCLC 960851324.
  15. "Midshaft femur fractures in adults". www.uptodate.com. Retrieved 2017-10-01.
  16. Kovar FM, Jaindl M, Schuster R, Endler G, Platzer P (July 2013). "Incidence and analysis of open fractures of the midshaft and distal femur". Wiener Klinische Wochenschrift. 125 (13–14): 396–401. doi:10.1007/s00508-013-0391-6. PMID 23797531. S2CID 9565227.
  17. el Moumni M, Leenhouts PA, ten Duis HJ, Wendt KW (February 2009). "The incidence of non-union following unreamed intramedullary nailing of femoral shaft fractures". Injury. 40 (2): 205–208. doi:10.1016/j.injury.2008.06.022. PMID 19070840.
  18. Paterno MV, Archdeacon MT (May 2009). "Is there a standard rehabilitation protocol after femoral intramedullary nailing?". Journal of Orthopaedic Trauma. 23 (5 Suppl): S39–S46. doi:10.1097/BOT.0b013e31819f27c2. PMID 19390375. S2CID 11239969.
  19. "Femoral Fractures. Information about Femur fractures. Patient | Patient". Patient. Retrieved 2016-12-14.
  20. Hemmann P, Friederich M, Körner D, Klopfer T, Bahrs C (May 2021). "Changing epidemiology of lower extremity fractures in adults over a 15-year period - a National Hospital Discharge Registry study". BMC Musculoskeletal Disorders. 22 (1): 456. doi:10.1186/s12891-021-04291-9. PMC 8135150. PMID 34011331.
  21. Rapp K, Büchele G, Dreinhöfer K, Bücking B, Becker C, Benzinger P (February 2019). "Epidemiology of hip fractures : Systematic literature review of German data and an overview of the international literature". Zeitschrift für Gerontologie und Geriatrie. 52 (1): 10–16. doi:10.1007/s00391-018-1382-z. PMC 6353815. PMID 29594444.
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