Femur Injuries and Fractures 2

Femur Injuries and FracturesAuthor: Douglas F Aukerman, MD, Associate Professor, Department of Orthopedics and Rehabilitation, Division of Sports Medicine, Department of Family Medicine, Penn State UniversityCoauthor(s): John R Deitch, MD, Director of Sports Medicine, Wellspan Orthopedics; Janos P Ertl, MD, Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; William Ertl, MD, Clinical Assistant Professor, Department of Orthopedics, University of OklahomaContributor Information and Disclosures

Updated: Oct 30, 2008

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Introduction

Background

The spectrum of femoral shaft fractures is wide and ranges from nondisplaced femoral 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 multisystem trauma. 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.

[ CLOSE WINDOW ]

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

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.

Clinical

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 fractureso The history of a femoral shaft fracture is not subtle.o A high-velocity injury is usually involved, and significant pain and

inability to bear weight are present.o Patients may be noted to have a shortening of one leg, swelling, and

gross deformity.o 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 fractureso These are observed with increasing frequency in joggers.6,7

o Factors involved in stress fractures include a sudden increase in mileage, intensity, or frequency of training.

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:Female Athlete Triad Low Energy Availability in the Female Athlete Nutrition for the Female Athlete

Physical

Physical examination of traumatic femoral fractureso Serious femoral fracture–associated injuries must be addressed, and

ACLS guidelines must be used.o A head-to-toe examination is indicated.o Palpate the pelvis, hips, and knees.o Correct any lower extremity deformity by applying inline longitudinal

traction.o A distal vascular assessment is necessary.o Finally, a distal neurologic assessment is indicated.

Physical examination of femoral stress fractureso Usually, the patient has few physical findings in cases of femoral stress

fractures.o Palpate at the site of symptoms.o The thigh may be swollen.o Range of motion is limited by pain.o Pain may be reported with forced rotation or axial loading.o Pain usually radiates into the groin area.o More than 65° of external rotation is believed to be a risk factor.o Bilateral symptoms have been reported.

Causes

Traumatic causes of femoral fractureso Motor vehicle trauma (eg, motorcycle races, auto races, auto crash,

plane crash, auto/pedestrian accident)o Sports (eg, high-speed and contact sports with direct trauma, skiing,

football, hockey)o Falls (eg, from height, mountain climbing, pole vaulting)o Gunshot woundso Metabolic bone diseaseo Tumors (primary or metastatic)

Stress fracture causes of femoral fractureso Runningo Joggingo Metabolic bone diseaseo Amenorrheic or oligomenorrheic female runnerso Abnormal bone mineral density o Improper trainingo Improper footwear

Differential Diagnoses

Compartment SyndromesHip DislocationHip Fracture

Other Problems to Be Considered

Associated extremity fracturesDisorders of bone metabolismIpsilateral femoral neck fractureIpsilateral knee ligament injury (up to 50%)Ipsilateral meniscal injury (up to 30%)Spine fracturesStress fracture - Tumor (osteoid osteoma)Tibia fracture (floating knee)Trauma -Knee dislocation Vascular injuries

Workup

Laboratory Studies

Laboratory workup in cases of traumatic femoral fractureso Complete blood cell (CBC) counto Chemistry panelo Prothrombin time (PT) / activated partial prothrombin time (aPTT)o Urinalysis (UA)o Type and screen or cross-match

Imaging Studies

Imaging studies in cases of traumatic femoral fractureso Radiograph of the chesto Spine radiograph serieso Anteroposterior radiograph of the pelviso Anteroposterior-lateral radiograph of the femur (see image below), hip,

and kneeo

X-ray film of femur fracture.

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X-ray film of femur fracture.

o Computed tomography (CT) scan of the head, if indicated Imaging studies in cases of femoral stress fractures

o 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.

o Radionucleotide scanning: This is the criterion standard for diagnosis; these studies are more sensitive than and may show abnormalities 3 weeks before plain radiographs.

o Magnetic resonance imaging (MRI): MRIs reveal bone marrow signal earlier in the stress-reaction process than standard radiographs and radionuclear scanning.

o Bone mineral density evaluation: Use this test to rule out osteoporosis or osteopenia.

eMedicine Specialties > Sports Medicine > Lower Limb

Femur Injuries and Fractures: Treatment & MedicationAuthor: Douglas F Aukerman, MD, Associate Professor, Department of Orthopedics and Rehabilitation, Division of Sports Medicine, Department of Family Medicine, Penn State UniversityCoauthor(s): John R Deitch, MD, Director of Sports Medicine, Wellspan Orthopedics; Janos P Ertl, MD, Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; William Ertl, MD, Clinical Assistant Professor, Department of Orthopedics, University of OklahomaContributor Information and Disclosures

Updated: Oct 30, 2008

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Treatment

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.1,2,8,9

X-ray film of femur fracture repair.

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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 30-45 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.

Medication

Medication for trauma-related fractures includes pain medication as indicated for reasonable pain. nonsteroidal anti-inflammatory medications (NSAIDs) may inhibit bone healing.

Related eMedicine topics:Toxicity, Narcotics Toxicity, Nonsteroidal Anti-inflammatory Agents

Related Medscape topics:Resource Center Opioids: A Guide to State Opioid Prescribing Policies Resource Center Pain Management: Advanced Approaches to Chronic Pain Management Resource Center Pain Management: Pharmacologic Approaches

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients with trauma.

Acetaminophen and codeine (Tylenol With Codeine [# 3])

Indicated for mild to moderate pain.

Dosing Interactions Contraindications Precautions

Adult

30-60 mg/dose PO based on codeine q3-4h, not to exceed 4 g/d of acetaminophen

Pediatric

0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen; not to exceed 2.6 g/d of acetaminophen

Dosing Interactions Contraindications Precautions

Toxicity of codeine increases with CNS depressants, TCAs, MAOIs, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics

Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase the hepatotoxicity of acetaminophen.

Dosing Interactions Contraindications Precautions

Documented hypersensitivity

Dosing Interactions Contraindications Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients who are dependent on opiates, because this substitution may result in acute opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction

Hepatotoxicity with acetaminophen is possible in the presence of chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses and exceed the recommended maximum dose.

Hydrocodone and acetaminophen (Lortab, Norcet, Vicodin)

Drug combination for moderate to severe pain.

Dosing Interactions Contraindications Precautions

Adult

1-2 tab or cap PO q4-6h prn pain

Pediatric

<12 years: 10-15 mg/kg/dose based on acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen

>12 years: 750 mg based on acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h

Dosing Interactions Contraindications Precautions

Coadministration with phenothiazines may decrease the analgesic effects; toxicity increases with CNS depressants TCAs.

Dosing Interactions Contraindications Precautions

Documented hypersensitivity; HACE or elevated ICP

Dosing Interactions Contraindications Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

The tablets contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates, because this substitution may result in acute

opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction

Propoxyphene and acetaminophen (Darvocet N-100, Propacet)

Drug combination for mild to moderate pain.

Dosing Interactions Contraindications Precautions

Adult

1-2 tab PO q4h prn; not to exceed 600 mg/d propoxyphene

Pediatric

Not established

Follow-up

Return to Play

In cases of traumatic femoral fractures, schedule a clinic follow-up visit at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. The femoral fracture should be healed by 3 months. Once bony union is complete, treatment is focused on muscle rehabilitation. Progressive strengthening of all lower extremity musculature is initiated and continued until strength is 95% of the contralateral extremity.

Sports-specific rehabilitation is initiated once strength has been regained. The athlete should be back to preinjury status at 1 year postinjury. Long-term symptoms include hamstring weakness, limited standing and walking (39%), some intermittent pain (37%), and inability to return to preinjury work (9%).

For femoral stress fractures, a minimum time of 6 weeks is necessary for bone healing to occur before the patient is able to resume activities. The athlete should resume activities in a very gradual fashion over the course of several weeks. If symptoms recur during training, the athlete should return to the previous phase of treatment for a minimum of 3 weeks.

Complications

Complications following traumatic femoral fractureso Refractureo Hardware failureo Prominent hardware

o Neurologic injuryo Peroneal nerve palsy - Most commonly due to tractiono Pudendal nerve injury - Due to compression at the perineal posto Sciatic nerve injuryo Vascular injuryo False aneurysmo Atrioventricular fistula - Requires angiogramo Compartment syndromeo Nonunion - Rate of 1%o Delayed uniono Maluniono Heterotopic ossification o Infection

Complications following femoral stress fractureso Progression to a complete fractureo Refractureo Nonunion

Prevention

Femoral stress fractures can be prevented or minimized by proper training techniques. Gradual increase in activity intensity and duration allow the body to respond to the increase load stresses. Maintaining proper footwear and not allowing footwear to break down, adequate rest periods in training, and good nutrition are also important aspects of prevention.

Prognosis

Of posttraumatic diaphyseal femur fractures, 95% heal with antegrade femoral nailing. Malunion and infection rates are low (less than 1%).

Surgical management is rarely needed to treat femoral stress fractures; however, surgical stabilization is recommended for recalcitrant cases.

Miscellaneous

Medicolegal Pitfalls

Failure to address conditions that may accompany femur fractures and injuries Missed fractures or dislocations due to concentration on the obvious pain and

deformity of the femur

Multimedia

(Enlarge Image)

Media file 1: 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.

[ CLOSE WINDOW ]

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.

(Enlarge Image)

Media file 2: X-ray film of femur fracture.

[ CLOSE WINDOW ]

X-ray film of femur fracture.

Media file 3: X-ray film of femur fracture repair.

(Enlarge Image)