Executive Editor: Chris Colton, Rick Buckley

Authors: Peter V Giannoudis, Hans Christoph Pape, Michael Sch├╝tz

Femur shaft - Simple, oblique, middle 1/3 fractures

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Glossary

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 Basic surgical experience, no specialized skills Basic equipment only

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) Basic surgical experience, no specialized skills Basic equipment only

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 Some specialized surgical experience Simple surgical and imaging resources

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 - Lag screw with protection plate
Indication summary Skill Equipment
Vascular injury or open fractures, polytrauma Highly experienced and skilled surgeon Simple surgical and imaging resources

Indications

  • Rare circumstances in patients with femoral shaft fractures where intramedullary nailing is contraindicated, but the patient is fit for surgery
  • Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Contraindications

  • Compromised local soft tissues

Advantages

  • Direct reduction
  • Fracture can be reduced (length, angular and rotational control are obtained)
  • Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM nailing

Disadvantages

  • Greater blood loss
  • Exposure of fracture zone / risk of interference with healing process
  • Less appealing cosmetic result
Antegrade nailing
Indication summary Skill Equipment
Closed isolated fractures, most open fractures, and stable polytrauma Some specialized surgical experience Full specialized surgical and imaging resources

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 Highly experienced and skilled surgeon Full specialized surgical and imaging resources

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 Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2018-07-05