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Midshaft femur fractures in adults

Midshaft femur fractures in adults
Literature review current through: Jan 2024.
This topic last updated: Dec 04, 2023.

INTRODUCTION — The femur is the longest, strongest, and heaviest tubular bone in the human body and one of the principal load-bearing bones in the lower extremity [1-4]. Fractures of the femoral shaft often result from high-energy forces such as motor vehicle collisions [5]. Complications and injuries associated with midshaft femur fractures in the adult can be life threatening and may include hemorrhage, internal organ injury, wound infection, fat embolism, and acute respiratory distress syndrome [2,6].

Femoral shaft fractures can also result in major physical impairment due to potential fracture shortening, malalignment, or prolonged immobilization of the extremity with casting or traction [2]. The art of femoral fracture care involves a balancing act between anatomic alignment and early functional rehabilitation of the limb.

The diagnosis and nonoperative management of midshaft femur fractures in adults will be reviewed here. Pediatric femur fractures, major pelvic trauma, general trauma management, and the management of potential complications of femur fractures are discussed separately. (See "Femoral shaft fractures in children" and "Pelvic trauma: Initial evaluation and management" and 'Complications' below.)

EPIDEMIOLOGY AND RISK FACTORS — The annual incidence of midshaft femur fractures is approximately 10 to 21 per 100,000 person-years [7,8]. The incidence peaks among the young, decreasing after age 20 and then again in older adults [9,10]. A marked increase occurs in those over age 75 years. The majority of femur fractures occur in the proximal third (ie, hip fractures), which is discussed separately [11]. (See "Overview of common hip fractures in adults".)

The incidence of femoral, particularly diaphyseal, fractures due to severe trauma is greatest in young males [12]. Patients younger than 40 are more likely to sustain high-energy trauma (eg, motor vehicle collision) and fracture the midshaft of the femur, while those over 40 are more likely to sustain low-energy trauma (eg, fall) and fracture the proximal third of the femur [12,13]. Eighty percent of patients 35 years or older with femur fractures due to moderate-energy trauma had prior evidence of generalized osteopenia or a condition likely to cause localized osteopenia [14].

As the average age of populations in industrialized countries continues to increase, the incidence of femoral shaft fractures has increased as well [8]. In older adults, low-energy falls are the most common cause, accounting for 65 percent of fractures [15]. These typically occur in the home. Long-term use of bisphosphonates may increase the risk of femur fracture. The association between bisphosphonates and femur fracture is discussed separately (see "Risks of bisphosphonate therapy in patients with osteoporosis", section on 'Atypical femur fracture' and "Bisphosphonate therapy for the treatment of osteoporosis", section on 'General Principles'). Industrial accidents and gunshot wounds account for most other femur fractures.

Preventative measures against femoral shaft fractures should focus on prevention of automobile accidents, especially in younger males, and effective treatment of osteoporosis in older females [16]. (See "Overview of the management of low bone mass and osteoporosis in postmenopausal women".)

CLINICAL ANATOMY — For the purposes of fracture management, the femoral shaft can be divided into three parts: the proximal portion, including the femoral head and neck and the intertrochanteric area; the middle portion, involving the femoral shaft; and the distal portion, including the supracondylar area (figure 1). Here, we discuss the midshaft of the femur.

The femoral shaft is tube shaped and extends from the lesser trochanter to the flare of the femoral condyles. It is convex along its anterior surface and concave along the posterior side.

The muscles that surround the femoral shaft are divided into three compartments: the anterior (sartorius, pectineus, quadriceps, and iliopsoas) (figure 2 and figure 3), medial (gracilis and adductors longus, brevis, and magnus) (figure 4), and posterior (biceps femoris, semitendinosus, and semimembranosus) (figure 5). The quadriceps muscles, which are responsible for knee extension, include the vastus medialis, rectus femoris, vastus intermedius, and vastus lateralis. The muscles of the posterior compartment, which are responsible for knee flexion, are commonly referred to as the "hamstrings." The pull of muscles in all three compartments upon a fractured femur leads to displacement and angulation, increasing the complexity of fracture management.

The femur has an abundant vascular supply, receiving the bulk of its arterial blood flow from the profunda femoral artery (figure 6). A nutrient artery usually enters along the linea aspera posteriorly and proximally on the femur and supplies the endosteal circulation. The endosteal circulation supplies the inner two-thirds to three-fourths of the cortex. The periosteal circulation enters posteriorly primarily along the linea aspera.

When a fracture is displaced, the medullary blood vessels are disrupted, and the periosteal vessels become the primary arterial source for the fracture site during early healing. Periosteal blood flow is nearly always adequate; the risk of nonunion from an insufficient blood supply is low. In response to a fracture, periosteal vessels proliferate, while endosteal circulation may not be restored for up to three weeks [17].

Femur fractures can cause extensive hemorrhage, with blood loss of up to 3 liters and an average loss of 1 liter [18]. The sciatic nerve and the femoral nerve and its branches are surrounded by protective muscle. Therefore, neurologic injury from isolated femoral shaft fractures is rare. Although rare, injury to the peroneal branch of the sciatic nerve (figure 7) may occur, as it travels near the distal femoral shaft.

MECHANISM OF INJURY — Midshaft femur fractures in younger adults are most commonly caused by high-energy trauma, but low-energy trauma is becoming an increasingly important cause among older adults [9,19,20].

High-energy trauma commonly involved in femur fractures includes motor vehicle collisions, pedestrians struck by a motor vehicle, motorcycle accidents, falls from a height of 3 meters or greater, and gunshot wounds [2,21]. Low-energy mechanisms include slipping or stumbling at ground level, falls from a height of less than 1 meter, and sports-related injuries [13,22]. The femur, like other long bones, fractures as a result of direct or indirect force or muscular action.

Pathologic midshaft femur fractures are uncommon but can occur from metastases (breast, lung, and prostate cancer are most common) or, rarely, secondary to primary bone tumors such as osteogenic sarcoma. (See "Mechanisms of bone metastases" and "Bone tumors: Diagnosis and biopsy techniques".)

CLINICAL PRESENTATION AND EXAMINATION — With the rare exception of insufficiency fractures, the clinical presentation of a midshaft femur fracture is not subtle. The clinical diagnosis is usually obvious based upon the mechanism and the presence of pain, swelling, and deformity, including shortening of the thigh [2]. Extensive soft tissue injury and bleeding are common, and shock may develop. (See "Approach to shock in the adult trauma patient".)

Because of the high association of femur fractures with other injuries, particularly if high-energy trauma is involved, the patient must be carefully assessed following the basic guidelines of advanced trauma life support. As always, stabilization of the patient's airway, breathing, and circulation takes priority. Once the patient is stabilized, a thorough secondary survey is performed looking for other major injuries. (See "Initial management of trauma in adults".)

As part of the secondary survey, the pelvic ring and hip should be inspected for tenderness, swelling, and ecchymosis, which may indicate concomitant pelvic disruption or hip fracture [23,24]. Since the patient often cannot move the hip voluntarily due to pain, palpation of the groin and buttocks is important [23,25]. Fullness of the buttock in a patient whose hip is flexed and abducted may represent a posterior hip dislocation [2]. (See "Pelvic trauma: Initial evaluation and management".)

Correlation between femur fractures and soft tissue injuries of the ipsilateral knee is well documented [26,27]. Partial or complete anterior or posterior cruciate ligament tears, or meniscal injuries, occur in approximately 20 to 50 percent of cases. Therefore, the ipsilateral knee should be carefully examined (to the extent possible given the painful nature of femur fractures), looking for noncontiguous fractures and ligamentous or other soft tissue injuries. Given the degree of pain patients experience, the knee examination, including assessment of ligament integrity, is often best performed in the operating room while patient is under anesthesia. (See "Physical examination of the knee".)

Neurologic injury caused directly by a femoral shaft fracture is rare [28,29]. Nevertheless, a careful neurovascular assessment of the affected limb should be performed. Distal pulses should be palpated and sensation and motor function assessed. It is often useful to compare findings with the contralateral limb, assuming it is uninjured.

DIAGNOSTIC IMAGING AND LABORATORY STUDIES — Anterior-posterior (AP) and lateral plain radiographs of the thigh should be obtained when a femur fracture is suspected (image 1 and image 2). Careful radiographic examination in at least two planes is necessary to determine the exact site and configuration of the fracture pattern.

The hip and knee should also be examined with AP and lateral plain radiographs to rule out associated injury [30]. A femoral neck fracture may occur in association with a midshaft femur fracture and, if overlooked, can result in significant morbidity and even mortality [31]. Femoral neck fractures are discussed separately. (See "Overview of common hip fractures in adults".)

While not typically the initial imaging modality obtained, computed tomography (CT) or CT angiogram may be performed in patients who have sustained high-energy trauma or manifest signs of multiple injuries, or when vascular injury is suspected.

Ultrasound may have utility in the diagnosis of midshaft femur fractures in an otherwise stable patient. Small, observational studies suggest that ultrasound has high sensitivity and specificity for midshaft femur fractures [32-34]. Ultrasonic examination can be performed with a high-frequency (12 to 15 MHz) linear array transducer by scanning over the area of maximal tenderness in both the transverse and longitudinal planes, looking for cortical irregularity, stepoff, or frank fracture.

In cases of multiple trauma, laboratory testing is obtained according to standard hospital trauma protocols. For otherwise healthy patients with isolated femoral shaft fractures and no evidence of major complications, routine laboratory testing is generally unnecessary [35-37]. (See "Initial management of trauma in adults", section on 'Diagnostic studies'.)

DIAGNOSIS — Definitive diagnosis of a midshaft femur fracture is made with diagnostic imaging studies, typically plain radiographs. Radiographs are obtained when the diagnosis is suspected based on a suggestive history and examination findings.

MANAGEMENT

Initial management

Initial care — Essential initial management consists of evaluating the patient for major injuries and treating them as appropriate, placing an intravenous catheter and providing analgesia, and immobilizing the injured extremity. Patients with open fractures receive antibiotics and tetanus prophylaxis. (See "Initial management of trauma in adults".)

Prehospital personnel should splint the extremity in the position it was found. If signs of neurovascular compromise are observed, the limb should be reduced after administering analgesia. Pain control is a major goal in the early management of these injuries. Ultrasound-guided femoral nerve block may be a safe and effective way to provide initial pain control for up to six hours [38,39].

Splinting and traction — Little clinical evidence exists to support the use of traction in the preoperative management of midshaft femur fractures. Some orthopedic surgeons advocate immobilizing well-aligned fractures, with or without neurovascular injury, in a skin traction device [2,40,41]. Those who support the use of traction claim that it reduces patient discomfort, improves fracture alignment, and may resolve problems with arterial flow. A systematic review of limited evidence reported an association between traction splinting and reduced need for blood transfusions and fewer pulmonary complications [42].

Skin traction splints can be used for both closed and open fractures of the femoral shaft. Hare or Thomas traction splints are most commonly used. The device is attached to the ankle at one end and secured against the pelvis at the other. Traction is applied by pulling the ankle distally while the proximal end braces the pelvis to prevent it from moving, thereby enabling distraction of the femoral fracture fragments.

A splint without traction can be used to support injuries around the knee. Relative contraindications to splint use include dislocation of the hip, fracture-dislocation of the knee, and concomitant ankle injury [43]. Hemodynamic instability is the only absolute contraindication for traction splinting.

The use of traction for open femur fractures is controversial. Concern exists that the use of traction in such cases may allow contaminated bone fragments to retract into the wound. In general, stabilization of the fracture site to prevent further hemorrhage, neurovascular damage, or soft tissue injury takes precedence over the theoretical risk of increased contamination. However, decisions about splinting and traction are best made in consultation with the orthopedic or trauma surgeon who will assume care of the patient.

Indications for orthopedic referral — Surgery is indicated for the large majority of femur fractures because of the high rate of union, low rate of complications, and the advantage of early fracture stabilization, which decreases morbidity and mortality [2,41]. Therefore, orthopedic consultation should be obtained in all cases of midshaft femur fractures.

Definitive management — Decisions about definitive treatment for midshaft femur fractures must take into consideration the patient's age, concomitant injuries, and underlying comorbidities, as well as resource availability and clinician experience. Among the few patients not treated surgically are those who are too unstable to tolerate the procedure and children, in some cases. (See "Femoral shaft fractures in children".)

Surgical and nonsurgical interventions — According to many orthopedic sources, standard treatment of a femoral shaft fracture is an antegrade reamed intramedullary nail (image 3) [2,41,44]. Antegrade intramedullary nailing is associated with a 98 to 99 percent union rate and low risk of infection (1 to 2 percent), even when used in open fractures. Although reamed nailing is accepted as the standard of care, unreamed intramedullary nailing is also associated with low rates of nonunion (approximately 1.9 percent) and infection [45]. According to some retrospective observational studies, external fixation may be a safe and effective alternative to intramedullary nailing for open femoral shaft fractures [46], while a combination of intramedullary nailing and external fixation may be needed for complex or unstable fractures [47].

Although surgical repair is the definitive treatment in the great majority of midshaft femur fractures, closed (ie, nonoperative) management using traction may be appropriate in some patients with major medical comorbidities or in locations without surgical resources. Percutaneous bridge wave plating may also be a reasonable treatment alternative to internal fixation where resources are limited [48]. Closed management by traction is both complex to manage and slow, often requiring months of bed rest, thereby preventing early mobilization and rehabilitation [41].

According to a systematic review of 23 studies involving 8447 patients, antibiotic prophylaxis significantly reduces deep surgical site infections in patients undergoing surgical repair of closed long bone fractures [49]. Antibiotic selection for such procedures is discussed separately. (See "Osteomyelitis associated with open fractures in adults".)

Timing of surgery — The American College of Surgeons' Committee on Trauma recommends that femoral shaft fractures in polytrauma patients be repaired within 2 to 12 hours of injury, provided the patient is hemodynamically stable [30]. Randomized and observational studies suggest that performing operative fracture repair within the first 24 hours decreases mortality, respiratory complications, multisystem organ failure, and length of hospitalization [50-53]. Early surgical repair may be less important in patients with isolated femoral shaft fractures. One prospective observational study of such patients found no difference in outcome based upon the timing of surgery [25]. Nevertheless, most experts advocate early repair.

For trauma patients who are hemodynamically unstable (or at significant risk of becoming so) or who have sustained severe concomitant injuries, early definitive repair is associated with higher morbidity [54]. Thus, delayed definitive repair of midshaft femur fractures may be the best approach in these patients. According to a large retrospective study, surgical repair delayed beyond 12 hours may reduce mortality by as much as 50 percent in severely injured, hemodynamically compromised patients [55]. This strategy is part of the evolving concept of damage control surgery (or damage control resuscitation) in trauma, the details of which are beyond the scope of this review [56,57]. Essentially, damage control surgery involves stabilizing trauma patients using the least invasive means available to minimize additional physiologic stress to a patient already in extremis. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury".)

From an orthopedic standpoint, damage control involves stabilizing major fractures using the least invasive method [58]. In the case of midshaft femur fractures, rapid fracture stabilization using external fixators is the most common approach. Definitive repair, usually with reamed intramedullary nailing, is delayed for approximately five days, until the patient is stabilized and better able to tolerate the physiologic stress of the procedure [59,60].

Medical comorbidities — Particularly with older adult patients, management of medical comorbidities to reduce the risk of perioperative complications and subsequent injury is an important element of care. These issues are discussed separately, including the topics listed below.

Perioperative management:

General prophylaxis (see "Hip fracture in older adults: Epidemiology and medical management", section on 'Medical management')

Medications (see "Perioperative medication management")

Diabetes management (see "Perioperative management of blood glucose in adults with diabetes mellitus")

Cardiovascular disease management (see "Perioperative management of hypertension" and "Perioperative management of patients receiving anticoagulants")

Risk assessment and long-term management:

Osteoporosis assessment (see "Osteoporotic fracture risk assessment" and "Overview of the management of low bone mass and osteoporosis in postmenopausal women")

Bisphosphonate therapy (see "Risks of bisphosphonate therapy in patients with osteoporosis", section on 'Atypical femur fracture')

Fall prevention (see "Falls: Prevention in community-dwelling older persons" and "Falls in older persons: Risk factors and patient evaluation")

Social work referral — Femoral shaft fractures frequently involve major trauma, significant concomitant injury, and intensive surgical intervention. The extent of injury to bone and muscle can prevent patients from returning to their previous level of function. Social workers can provide invaluable assistance to such patients and their families, and early referral is encouraged.

COMPLICATIONS

Overview — Overall, complication rates are low for isolated femoral shaft fractures managed with intramedullary rods [2,41,61]. The most common complications following femur fracture include infection, malunion (femur heals at an abnormal angle), delayed union (no sign of healing at three months), nonunion (no sign of healing at six months), and pain associated with orthopedic hardware. (See "General principles of fracture management: Early and late complications".)

Less common complications include hemorrhage, neurovascular injury, compartment syndrome, repeat fracture, and hardware failure (eg, broken screw). Rare but life-threatening complications occur more often in multiple trauma patients and include death, multiorgan failure, and respiratory complications, which are usually secondary to acute respiratory distress syndrome, pneumonia, and pulmonary or fat embolism [62]. The risk of pulmonary complications is reduced with early surgical repair. (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis" and "Acute respiratory distress syndrome: Epidemiology, pathophysiology, pathology, and etiology in adults" and "Epidemiology and pathogenesis of acute pulmonary embolism in adults" and "Fat embolism syndrome".)

Infection — Infection occurs in about 1 percent of cases treated with closed intramedullary nailing [61,63]. Factors associated with an increased risk of postoperative infection include open fractures and comminuted fractures treated with open reduction. More extensive femur fractures are associated with a higher incidence of infection secondary to gross contamination and extensive soft tissue necrosis [63]. In many cases, orthopedic hardware is left in place until the fracture heals while the infection is treated with antibiotics. (See "Osteomyelitis associated with open fractures in adults".)

Malunion and nonunion — Nonunion rates range from approximately 2 to 5 percent [64]. Among several factors associated with the development of a nonunion, the most important may be the degree of damage to the local soft tissues and the related damage to the local bone vasculature. Indeed, the success of intramedullary nailing, compared with plating, most likely stems from the reduction of local soft tissue damage. Other factors associated with nonunion include tobacco use and delayed weightbearing [65].

Concerns have been raised about the effect of nonsteroidal antiinflammatory drugs (NSAIDs) on fracture healing, but evidence is limited. This is discussed separately. (See "Nonselective NSAIDs: Overview of adverse effects", section on 'Possible effect on fracture healing'.)

Malunion of clinical significance is uncommon. However, rotational malalignment may occur with comminuted fractures. The hip, knee, and ankle joints compensate a great deal for many minor malunions. If the patient is symptomatic, surgical correction may be needed.

Neurovascular injury — The sciatic (figure 8) and femoral (figure 9) nerves are well protected by the muscles surrounding the femur, and nerve injury associated with a femoral shaft fracture is rare. Most primary nerve injuries occur from penetrating trauma to the thigh. Neurapraxia can occur with prolonged stretching of the nerves during difficult reductions of the femoral shaft. In addition, intraoperative nerve compression can result from inadequate padding on the operating table. The most commonly injured nerve is the pudendal nerve, followed by the sciatic nerve [66,67].

Pudendal nerve injury usually presents as numbness of the penis and scrotum or labia and, rarely, as erectile dysfunction. In a prospective study of 106 patients, six males and four females (9 percent of patients) developed a pudendal nerve palsy [66]. Symptoms resolved completely in nearly all patients within 1 to 11 weeks (average four weeks); altered sensation in the penis and scrotum persisted at six months in one patient. Sciatic nerve injury can lead to hamstring muscle weakness and paresthesias over the lateral calf and foot. (See "Overview of lower extremity peripheral nerve syndromes".)

Arterial injury is documented in less than 2 percent of femoral shaft injuries [68]. Penetrating injuries (particularly of the medial thigh) are the most common cause, although any fracture pattern can lead to arterial disruption [69]. Vascular injury can occur in several ways, including tearing, thrombosis, and arterial spasm. Distal pulses may be palpable even in the presence of arterial injury due to extensive collateral circulation.

Arterial injury requires prompt diagnosis and treatment to ensure preservation of the lower extremity. Patients who have sustained a peripheral arterial injury generally demonstrate either hard or soft signs [69,70]. Hard signs of arterial injury include any of the classic signs of arterial occlusion (6 Ps: pulselessness, pallor, paresthesias, pain, paralysis, poikilothermy), massive bleeding, expanding hematoma, and a palpable thrill or audible bruit over a hematoma. (See "Severe lower extremity injury in the adult patient", section on 'Lower extremity evaluation'.)

Soft indications of arterial injury include a history of arterial bleeding at the scene or in transit; proximity of a penetrating wound or blunt injury to an artery in the extremity; a small, nonpulsatile hematoma over an artery in an extremity; and a deficit in a nerve adjacent to an artery. An arterial pulse may be present in these patients, either by direct palpation or Doppler device.

Compartment syndrome, lung injury, and other complications — Compartment syndrome of the thigh from a femur fracture is extremely rare because of the large volume of the thigh compartments, which blend with those of the hip [71-73]. When it does occur, compartment syndrome is typically associated with a closed fracture or multiple injuries. The presence of pulses does not preclude the diagnosis. Treatment consists of urgent fasciotomy. (See "Acute compartment syndrome of the extremities".)

Pulmonary complications associated with femur fractures are uncommon but may include pulmonary embolism, fat embolism, acute respiratory distress syndrome, and pneumonia. Fat embolism syndrome is more common with bilateral femur fractures or fractures where definitive treatment is delayed [53,62,74,75]. Evidence from several large, retrospective studies suggests that early fracture fixation (within 8 to 24 hours) reduces the rate of pulmonary complications [52,53,76]. (See "Fat embolism syndrome" and "Acute respiratory distress syndrome: Clinical features, diagnosis, and complications in adults".)

Physical impairment often persists beyond one year after surgery, limiting the patient's ability to resume activities of daily living, normal gait, or employment. According to one prospective observational study, only 72 percent of patients treated for lower extremity fractures at level I trauma facilities are able to return to work by 12 months after the injury, and only 82 percent are able to do so by 30 months [77].

Death is exceedingly rare in patients with isolated femur fractures. An observational study of 2805 patients with femur fracture found a mortality rate of 0.04 percent [78]. However, large retrospective studies of trauma patients report that femur fractures are associated with an increased risk of death and pulmonary injury [53,79]. Mortality is increased in patients with femur fractures and higher injury severity scores. This holds true in both surgically and nonsurgically treated patients [16].

REHABILITATION — Physical therapy should begin a soon as possible and, in many patients, starts shortly after recovering from anesthesia [80-83]. Initial therapy includes instruction on transfers, moving in bed, exercises to maintain strength and minimize muscle atrophy, wheelchair management, and mobility training.

Postoperative activity depends upon the adequacy of internal fixation. If fixation is solid, an agile, cooperative patient can be out of bed within a few days of surgery and ambulating on crutches with toe-touch weightbearing on the affected side.

The rate of fracture healing varies but generally requires between three and six months. Once fracture healing is complete, rehabilitation to regain strength and mobility becomes the focus of treatment. Progressive resistance training of all lower extremity muscles is performed until strength is approximately 95 percent of the contralateral extremity.

In young patients, early aggressive physical therapy can return patients to baseline function in as little as six months [81,83]. In older patients, recovery of strength and function may take closer to 12 to 24 months [82].

FOLLOW-UP AND RETURN TO SPORTS — Follow-up patient visits with the orthopedic surgeon to monitor fracture healing with radiographs are generally performed at approximately two weeks, six weeks, three months, six months, and one year postinjury. The time required for fracture healing varies but generally is between three and six months. Patients are generally able to return to daily activities once the fracture is healed.

Athletes may safely return to sports when the femur is completely healed and normal strength and range of motion are regained. This can take from three to nine months or longer depending upon the complexity of the injury [84]. Sports-specific rehabilitation is initiated once strength has been regained. Most younger athletes return to preinjury levels of function approximately one year after injury. Case series describe professional athletes who sustained femur fractures returning to their preinjury level of function within one year [84]. In older patients, the return to preinjury levels of activity may require closer to two years [82].

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

(See "General principles of fracture management: Bone healing and fracture description".)

(See "General principles of fracture management: Fracture patterns and description in children".)

(See "General principles of definitive fracture management".)

(See "General principles of acute fracture management".)

(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lower extremity (excluding hip) fractures in adults" and "Society guideline links: Acute pain management".)

SUMMARY AND RECOMMENDATIONS

Epidemiology – Midshaft femur fractures commonly occur in young adults as a result of high-energy trauma and in older patients with weak bone from lower-energy falls. (See 'Epidemiology and risk factors' above and 'Mechanism of injury' above.)

Clinical presentation – With the rare exception of insufficiency fractures, diagnosis is usually obvious based upon the mechanism and the presence of pain, swelling, and deformity. Extensive soft tissue injury and bleeding are common. Midshaft femur fractures are often associated with soft tissue injuries of the ipsilateral knee. (See 'Clinical presentation and examination' above.)

High association with other major injuries – Because of the high association of femur fractures with other injuries, particularly if high-energy trauma is involved, the patient should be assessed according to the guidelines of advanced trauma life support. (See "Initial management of trauma in adults".)

Diagnostic imaging – An anterior-posterior and lateral radiograph of the thigh should be obtained when a femur fracture is suspected. The hip and knee should also be imaged to rule out associated injury. A femoral neck fracture may occur in association with a midshaft femur fracture and, if overlooked, can result in significant morbidity and even mortality. (See 'Diagnostic imaging and laboratory studies' above.)

Initial management – Some orthopedic surgeons advocate immobilizing well-aligned fractures, with or without neurovascular injury, in a skin traction device despite a dearth of evidence to support such treatment. Patients with open fractures receive antibiotics and tetanus prophylaxis; all patients should receive appropriate analgesia. If signs of neurovascular compromise are observed, the fracture should be reduced as soon as possible after administering analgesia. (See 'Initial management' above.)

Indications for orthopedic consultation – Orthopedic consultation should be obtained in all cases of midshaft femur fractures. Surgery is indicated for the large majority of fractures because of the high rate of union, low rate of complications, and advantages of early fracture stabilization, which decreases morbidity and mortality.

Definitive management – Early definitive surgical repair improves outcome in hemodynamically stable patients with isolated midshaft femur fractures or only minor concomitant injuries. For trauma patients with hemodynamic instability or severe concomitant injuries, early definitive repair is associated with higher morbidity, and delayed surgery may be the best approach. (See 'Definitive management' above.)

Complications – Overall, complication rates for midshaft femur fracture are low. The most common complications include infection, abnormal fracture healing, and pain. Less common complications include hemorrhage, neurovascular injury, compartment syndrome, repeat fracture, and hardware failure. Rare but life-threatening complications occur more often in trauma patients with multiple associated injuries and include death, multiorgan failure, and respiratory complications, usually due to acute respiratory distress syndrome and pulmonary or fat embolism. (See 'Complications' above.)

Rehabilitation – Rehabilitation should begin a soon as possible and, in many patients, starts shortly after recovering from anesthesia. In young patients, early aggressive physical therapy can return patients to baseline function in as little as six months. In older patients, recovery of strength and function may take closer to 12 to 24 months. (See 'Rehabilitation' above and 'Follow-up and return to sports' above.)

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Topic 228 Version 23.0

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