General considerations
Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the strongest mechanical fixation and is the best treatment for early mobilization.
Nonoperative treatment is undertaken only temporarily. Nonoperative treatment is reserved for exceptional cases, e.g. if the general medical condition does not allow safe anesthesia.
Relative stability is not suitable for transverse, or short oblique, single plane fractures, because all the implant and tissue strains are concentrated at one place; absolute stability with no interfragmentary motion is required. This is achieved by compression plating, which requires an open technique.
| Nonoperative treatment with limited resources | ||
| Indication summary | Skill | Equipment |
|---|---|---|
| Neither facilities, nor skills, for surgical treatment available |  |
 |
Femoral shaft fractures are normally treated operatively, using intramedullary nailing.
They should only be considered for nonoperative fracture treatment if there are neither facilities, nor skills, for surgical treatment
| Temporary Thomas splint | ||
| Indication summary | Skill | Equipment |
|---|---|---|
| Damage control (medically unfit for surgery, usually temporary) | |
|
Further indications
- Limited operative resources
Advantages
- Stabilization when immediate surgery is not possible or practical
Disadvantages
- Failure to follow AO principles
| Temporary external fixator | ||
| Indication summary | Skill | Equipment |
|---|---|---|
| Patient or soft tissues unsuitable for definitive internal fixation |  |
 |
Further indications for external fixation
- Salvage after major complications following internal fixation
Contraindication
- Osteoporosis (relative contraindication)
Advantage
- Rapidly applied provisional treatment
Disadvantages
- Pin-track infection
- May interfere with procedures for soft-tissue reconstruction
- High risk of nonunion/malunion when used for definitive treatment
| ORIF - DCS and compression plating | ||
| Indication summary | Skill | Equipment |
|---|---|---|
| Polytrauma with chest injury, limited operative resources |  |
 |
Indications
- All patients where intramedullary nailing is contraindicated, but the patient is fit for surgery
Contraindications
- Severe open fractures of the distal femur
Advantages
- Fracture can be reduced (length, angular and rotational control are obtained)
- Reduced incidence of fat embolization compared to IM nailing
Disadvantages
- Greater blood loss
- Exposure of fracture zone / risk of interference with healing process
- Larger operative soft-tissue trauma
| Antegrade nailing | ||
| Indication summary | Skill | Equipment |
|---|---|---|
| Closed isolated fractures, most open fractures, and stable polytrauma | |
|
Indications
- All patients with femoral shaft fractures except those not fit for definitive surgery
- Closed fractures
- Gustilo types I & II open, and clean IIIA fractures
- Polytrauma patients in stable condition
Contraindications
- Polytrauma patients in unstable condition
- Occluded intramedullary canal
- Gustilo type III B and C open fractures
Advantages over other techniques
- Less invasive procedure / indirect reduction
- Fracture can be reduced (length, angular and rotational control are obtained)
- Better biomechanical properties
- Rapid mobilization of patients postoperatively
- Minimal blood loss
Disadvantages against other techniques
- Risk of iatrogenic femoral neck fracture
- Risk of fat embolization
- Risk of malrotation
| Retrograde nailing | ||
| Indication summary | Skill | Equipment |
|---|---|---|
| Middle or distal third fractures, "floating knee", obesity, polytrauma | |
|
General Indications
- Polytrauma patients in stable condition
Relative Indications (retrograde vs. antegrade nailing)
- Bilateral lower extremity fractures
- Ipsilateral femoral neck and shaft fractures
- Concomitant ipsilateral acetabular / pelvic ring fractures
- Fracture below hip prosthesis
Contraindications
- Polytrauma patients in unstable condition
- Occluded intramedullary canal
- Gustilo type III B and C open fractures
Advantages over other techniques
- Less invasive procedure / indirect reduction
- Minimizes soft-tissue damage
- Fracture can be reduced (length, angular and rotational control are obtained)
- Better biomechanical properties
- Rapid mobilization of patients postoperatively
- Minimal blood loss
Disadvantages
- Risk of iatrogenic intraarticular damage to the knee joint
- Risk of fat embolization
- Difficult control of proximal fracture fragment in more proximal fractures
- Risk of damage to the anterior cruciate ligament
- Risk of malrotation – angular deformity
- Risk of damage to the patellar tendon
- Risk of chronic knee pain
| *Skill | |
|---|---|
|
Basic surgical experience, no specialized skills |
|
Some specialized surgical experience |
|
Highly experienced and skilled surgeon |
| *Equipment | |
|---|---|
|
Basic equipment only |
|
Simple surgical and imaging resources |
|
Full specialized surgical and imaging resources |