Femoral Shaft Fracture

  • Femoral shaft fractures are usually the result of high energy trauma
  • A full trauma exam should be performed given that this is a major distracting injury
    • Full secondary exam to prevent missed injuries
  • Major blood loss can occur into the thigh
    • Hemodynamic stability must be monitored
    • Monitor for symptoms of shock
    • 40% of patients eventually require transfusion
  • Mandates an orthopaedic consult
    • Patients are typically admitted for pain control and definitive (operative) treatment

  • Mechanism
    • Often high energy  (MVA, gunshot, fall from height)
  • Timing of injury
  • Other locations of pain (distracting injury)
    • Common distracting injury
    • Groin pain - concern for concomitant femoral neck fracture (hip fracture)
      • Large operative implications and may lead to poor outcome if missed
      • Concomitant femoral necks may occur in up 9% of cases and are frequently initially missed
  • Numbness and tingling
  • Antecedent leg pain
  • Should alert consideration of pathologic fracture, especially with a low energy mechanism
  • Anticoagulation
  • Time of last dose
  • Last time patient last ate (NPO status)

    Vitals

  • Remove any splint/wrapping
  • Basic appearance (swelling, bruising)
  • Assess for poke holes or punctate wounds as the femoral spike can protrude through the skin at the time of injury and auto-reduce prior to presentation → open fracture
    • Do not miss this and ensure (2-3g) ancef and (5mg/kg) gentamicin are given
      • Even though these wounds are typically < 10cm, these are considered Gustilo III open fractures due to the high energy required to push the femur out the large soft tissue envelope
  • Pain with logroll of the extremity
    • Be wary of groin pain
      • Concerning for ipsilateral femoral neck fractures
  • Palpate the compartments (anterior, posterior, adductor) in the leg
    • Good to establish baseline, as subsequent bleeding and edema can develop into compartment syndrome after presentation
      • Lower risk than lower leg due to increased soft tissue space
  • Palpation of all four extremities to identify other concomitant injuries
    • Typically high energy, distracting injury

Motor Exam:
    Motor Exam:
    • Tibialis Anterior - Dorsiflexion
    • Gastroc/Soleus - Plantar flexion
    • EHL/FHL - Extension/Flexion of the great toe
    Sensory Exam:
    • Sural (Lateral)
    • Saphenous (medial)
    • Superficial Peroneal(dorsum)
    • Deep Peroneal (1st web space)
    • Tibial (plantar)
  • Vascular Exam:
    • Dorsalis Pedis/Posterior Tibial
    • Capillary refill to toes

  • Motion at the hip and knee limited secondary to pain

  • AP pelvis (per ATLS  protocol), AP/L ipsilateral hip, AP/L femur, AP/L knee
    • If concerned about concomitant femoral neck with equivocal XRs, obtain a CT scan to assess for occult fracture
    • The entire femur should be imaged.  Do not stop at a knee or hip simply because a femoral shaft fracture is evident.
  • CT of the ipsilateral hip - not routinely needed
    • Leave to discretion of orthopaedics
      • Only needed if X-rays are equivocal and there is concern about an ipsilateral occult femoral neck fracture

     Medical Decision Making

Closed femoral shaft fracture :
*** is a *** y/o ***M/F with hx of *** who presents with an injury to the ***R/L lower extremity which occurred while mechanism***, found to have a closed femoral shaft fracture. Associated injuries include ***. On exam, the patient is neurovascularly intact with pain on logroll. The injury was closed without any poke holes or punctate wounds that probe deep. The patient denied groin pain. Radiographs reveal ***. The patient was kept npo and last ate ***. Orthopaedics was consulted and will provide further recommendations.
Open femoral shaft fracture:
*** is a *** y/o ***M/F with hx of *** who presents with an injury to the ***R/L lower extremity which occurred while mechanism***, found to have an open femoral shaft fracture. Associated injuries include ***. On exam, the patient is neurovascularly intact with a laceration on the *** side of the leg that probed deep. The patient was given an immediate dose of IV ancef/gentamicin. The laceration was irrigated at the bedside for gross contaminants. The patient denied groin pain. Orthopaedics was consulted and the patient was made NPO. The patient last ate at ***.

Closed femoral shaft fracture:
  • Consult Orthopaedic Surgery
  • WB status: Non-weight-bearing injured lower extremity
  • Diet:  NPO
  • Labs: ABG, Lactate (for high energy mechanism and polytrauma)
    • Used to assess operative timing
  • Analgesia: oral analgesia with IV narcotic for breakthrough
    • Ex: 5-10mg oxycodone q4, 0.5mg hydromorphone q4 prn, tylenol 975mg q8hr scheduled
  • Immobilization: None
    • Orthopaedics may use skeletal traction
    • If transfer is  necessary, consider long leg splint
  • Disposition: Likely admission to orthopaedics versus general surgery trauma
    • If polytraumized patient often admitted to general surgery trauma
Open distal femur fracture: :
  • Consult Orthopaedic Surgery
  • Ensure IV antibiotics were given (ancef and gentamicin)
  • Diet:  NPO preop labs (type and screen, INR, aPTT,  CBC, BMP)
  • Labs: ABG, Lactate (for high energy mechanism and polytrauma)
    • Used to assess operative timing
  • Immobilization: None
    • Orthopaedics may use skeletal traction
    • If transfer is necessary, consider long leg splint
  • Disposition: Likely admission to orthopaedics versus general surgery trauma
    • If polytraumized patient often admitted to general surgery trauma

Materials

Bedside Irrigation / Washout

Common ICD-10 Codes Brief Description
S72.32 Transverse fracture of shaft of femur
S72.33 Oblique fracture of shaft of femur
S72.34 Spiral fracture of shaft of femur
S72.35 Comminuted fracture of shaft of femur
S72.36 Segmental fracture of shaft of femur