Femoral fracture

Fractures are commonly obvious, since femoral fractures are often caused by high energy trauma.{{cite journal | vauthors = Bucholz RW, Jones A | title = Fractures of the shaft of the femur | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 73 | issue = 10 | pages = 1561–1566 | date = December 1991 | pmid = 1748704 | doi = 10.2106/00004623-199173100-00015 }} Signs of fracture include swelling, deformity, and shortening of the leg.{{Cite book|title=Rockwood and Green's fractures in adults|date=2010|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins| vauthors = Rockwood Jr CA, Green DP, Bucholz RW |isbn=9781605476773|edition=7th|location=Philadelphia, PA|oclc=444336477|url-access=registration|url=https://archive.org/details/rockwoodgreensfr0002unse_r0i5}} Extensive soft-tissue injury, bleeding, and shock are common.{{Cite book|title=Current diagnosis & treatment in orthopedics|date=2014|publisher=McGraw-Hill Medical| vauthors = Skinner HB, McMahon PJ |isbn=9780071590754|edition=5th|location=New York|oclc=820106991}} The most common symptom is severe pain, which prevents movement of the leg.{{Cite book|title=Essentials of musculoskeletal care|date=2010|publisher=American Academy of Orthopaedic Surgeons| vauthors = Sarwark JF |isbn=9780892035793|location=Rosemont, Ill.|oclc=706805938}}

File:Common fracture locations of femur.jpg

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. For example, the ligaments and meniscus of the ipsilateral (same side) knee are also commonly injured.

Anterior-posterior (AP) and lateral radiographs are typically obtained. In order to rule out other injuries, hip, pelvis, and knee radiographs are also obtained.{{Cite book|title=Advanced trauma life support : student course manual|date=2012|publisher=American College of Surgeons| author = Committee on Trauma.|isbn=9781880696026|edition=9th|location=Chicago, IL|oclc=846430144}} The hip radiograph is of particular importance, because femoral neck fractures can lead to osteonecrosis of the femoral head.

File:Structure of a Long Bone.png

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.{{citation needed|date=October 2020}}

Femoral shaft fractures can be classified with the Winquist and Hansen classification, which is based on the amount of comminution.{{cite book | vauthors = Stannard JP, Schmidt AH, Kregor PJ |title=Surgical treatment of orthopaedic trauma |date=2007 |publisher=Thieme |location=New York, NY |isbn=978-1-58890-307-5 | page = [https://books.google.com/books?id=zSy-FzCbWBkC&pg=PA612 612] }}

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).{{cite book | vauthors = Moore KL, Dalley AF, Agur AM |title=Clinically Oriented Anatomy |date=2014 |location=Philadelphia |isbn=978-1-4511-8447-1 |edition=Seventh | page = 527 }}

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.{{Cite journal |last1=Claireaux |first1=Henry A. |last2=Searle |first2=Henry Kc |last3=Parsons |first3=Nick R. |last4=Griffin |first4=Xavier L. |date=2022-10-05 |title=Interventions for treating fractures of the distal femur in adults |journal=The Cochrane Database of Systematic Reviews |volume=2022 |issue=10 |pages=CD010606 |doi=10.1002/14651858.CD010606.pub3 |issn=1469-493X |pmc=9534312 |pmid=36197809}} 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.{{Cite journal | vauthors = Büchele G, Rehm M, Halbgebauer R, Rothenbacher D, Huber-Lang M |date=2022-02-26 |title=Trauma-related acute kidney injury during inpatient care of femoral fractures increases the risk of mortality: a claims data analysis |journal=American Journal of Medicine Open |volume=8 |language=en |pages=100009 |doi=10.1016/j.ajmo.2022.100009 |s2cid=247152803 |issn=2667-0364|doi-access=free |pmc=11256273 }}{{Cite web|url=http://orthoinfo.aaos.org/topic.cfm?topic=A00521|title=Femur Shaft Fractures (Broken Thighbone)-OrthoInfo - AAOS|website=orthoinfo.aaos.org|access-date=2016-12-14}}

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.{{cite book |author=Tintinalli, Judith E. |title=Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)) |publisher=McGraw-Hill Companies |location=New York |year=2010 |pages=9 |isbn=978-0-07-148480-0}} Traction should not be used in femoral neck fractures or when there is any other trauma to the leg or pelvis.{{cite book|last=AAOS|author-link=AAOS|title=Emergency Care and Transport of the Sick and Injured|publisher=Jones and Bartlett|location=Sudbury, Massachusetts|isbn=978-1-4496-3056-0|pages=1025–1031|edition=10|editor=Andrew N. Pollak MD. FAAOS|type=Print|chapter=29|date=October 2010}}{{cite book| vauthors = Marx JA |title=Rosen's emergency medicine : concepts and clinical practice|date=2014|publisher=Elsevier Health Sciences|location=London|isbn=9781455749874|page=680|url=https://books.google.com/books?id=uggC0i_jXAsC&pg=PA680|edition=Eighth}} It is typically only a temporary measure used before surgery. It is only considered definitive treatment for patients with significant comorbidities that contraindicate surgical management.

External fixators can be used to prevent further damage to the leg until the patient is stable enough for surgery. 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.{{Cite web|url=https://www.uptodate.com/contents/midshaft-femur-fractures-in-adults?source=search_result&search=femur%20fracture&selectedTitle=1~142#H12|title=Midshaft femur fractures in adults|website=www.uptodate.com|access-date=2017-10-01}}{{cite journal | vauthors = Kovar FM, Jaindl M, Schuster R, Endler G, Platzer P | title = Incidence and analysis of open fractures of the midshaft and distal femur | journal = Wiener Klinische Wochenschrift | volume = 125 | issue = 13–14 | pages = 396–401 | date = July 2013 | pmid = 23797531 | doi = 10.1007/s00508-013-0391-6 | s2cid = 9565227 }}

For femoral shaft fractures, reduction and intramedullary nailing is currently recommended. 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.{{cite journal | vauthors = el Moumni M, Leenhouts PA, ten Duis HJ, Wendt KW | title = The incidence of non-union following unreamed intramedullary nailing of femoral shaft fractures | journal = Injury | volume = 40 | issue = 2 | pages = 205–208 | date = February 2009 | pmid = 19070840 | doi = 10.1016/j.injury.2008.06.022 }}

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.{{cite journal | vauthors = Paterno MV, Archdeacon MT | title = Is there a standard rehabilitation protocol after femoral intramedullary nailing? | journal = Journal of Orthopaedic Trauma | volume = 23 | issue = 5 Suppl | pages = S39–S46 | date = May 2009 | pmid = 19390375 | doi = 10.1097/BOT.0b013e31819f27c2 | s2cid = 11239969 | doi-access = free }}

These fractures can take at least 4–6 months to heal.{{Cite web|url=http://patient.info/doctor/femoral-fractures#nav-1|title=Femoral Fractures. Information about Femur fractures. Patient {{!}} Patient|website=Patient|language=en-GB|access-date=2016-12-14}} 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. Open fractures can result in infection, osteomyelitis, and sepsis.{{citation needed|date=October 2020}}

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).{{cite journal | vauthors = Hemmann P, Friederich M, Körner D, Klopfer T, Bahrs C | title = Changing epidemiology of lower extremity fractures in adults over a 15-year period - a National Hospital Discharge Registry study | journal = BMC Musculoskeletal Disorders | volume = 22 | issue = 1 | pages = 456 | date = May 2021 | pmid = 34011331 | pmc = 8135150 | doi = 10.1186/s12891-021-04291-9 | doi-access = free }}{{Cite book|title=Handbook of fractures |date=2015|publisher=Wolters Kluwer Health| vauthors = Egol KA, Koval KJ, Zuckerman JD |isbn=9781451193626 |edition=5th|location=Philadelphia|oclc=960851324}} In Germany, femoral fractures are the most common type of fracture seen and treated in hospitals.{{cite journal | vauthors = Rapp K, Büchele G, Dreinhöfer K, Bücking B, Becker C, Benzinger P | title = Epidemiology of hip fractures : Systematic literature review of German data and an overview of the international literature | journal = Zeitschrift für Gerontologie und Geriatrie | volume = 52 | issue = 1 | pages = 10–16 | date = February 2019 | pmid = 29594444 | pmc = 6353815 | doi = 10.1007/s00391-018-1382-z }}

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{{medical resources

| ICD10 = {{ICD10|S|72}}

| AO = 31-A1 - 33-C3

| MeshID = 68005264

}}

{{Fractures}}

Category:Bone fractures

Category:Injuries of hip and thigh