Executive Editor: Chris Colton, Rick Buckley

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

Femur shaft - Simple, spiral, proximal 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 fixation
Indication summary Skill Equipment
Patient or soft tissues unsuitable for definitive internal fixation Some specialized surgical experience Simple surgical and imaging resources

Further indications

  • Salvage after major complications following internal fixation

Contraindication

  • Osteoporosis (relative contraindication)

Advantage

  • Rapidly applied provisional treatment
  • If the patient requires prolonged intensive care, or has extensive soft-tissue damage with severe contamination, external fixation may be used as definitive treatment.

Disadvantages

  • Pin-track infection
  • May interfere with procedures for soft-tissue reconstruction
  • High risk of nonunion/malunion when used for definitive treatment
ORIF - Compression plating (DCS)
Indication summary Skill Equipment
Failed indirect reduction, polytrauma with chest injury Highly experienced and skilled surgeon Full specialized surgical and imaging resources

The choice between DCS and LCP will depend on surgeon's experience and resources

Further indications

  • All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but the patient is fit for surgery

Contraindications

  • Compromised local soft tissues

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
ORIF - Compression plating (Locking plate)
Indication summary Skill Equipment
Failed indirect reduction, polytrauma with chest injury Some specialized surgical experience Simple surgical and imaging resources

The choice between DCS and LCP will depend on surgeon's experience and resources

Indications

  • All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but the patient is fit for surgery

Contraindications

  • Compromised local soft tissues

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 Some specialized surgical experience Full specialized surgical and imaging resources

Further indications

  • All patients with femoral shaft fractures except those not fit for definitive surgery
  • Isolated fractures
  • 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 until multiply debrided

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
*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