Makindo Medical Notes

Related Subjects: |Fractured Neck of Femur |Fractured Shaft Femur |Supracondylar Femur Fractures |Femoral fractures and Injuries

Femoral Shaft Fractures 🦴🚨 are high-energy injuries (RTAs, falls, gunshots). If history/mechanism seems minor → always consider pathological fracture (osteoporosis, tumour, Paget’s, infection).

📖 About

• Femur = longest & strongest bone in the body.
• Fracture usually implies extreme forces (car crash, fall from height).
• The femoral shaft = long straight diaphyseal part of the femur.

⚙️ Aetiology

• High-energy trauma (RTA, fall from height, gunshot wound).
• Pathological fractures in abnormal bone (osteoporosis, malignancy, Paget’s, infection).

🔎 Types

• Transverse: break at right angles across shaft.
• Oblique: diagonal fracture line.
• Spiral: corkscrew line from twisting force.
• Comminuted: ≥3 fragments; suggests very high energy.
• Open fracture 🚨: bone pierces skin, associated with soft tissue injury, ↑ infection risk, slow healing.

🩺 Clinical Features

• Major trauma history (RTA, fall from height, gunshot).
• Severe pain + inability to walk.
• Shortened, externally rotated, deformed thigh/leg.
• Shock can occur from blood loss (1–2 L into thigh compartment).

⚠️ Complications

• Compartment syndrome → may require fasciotomy.
• Fat embolism → hypoxia, neuro changes, petechial rash.
• VTE (DVT/PE) → common, needs prophylaxis.
• Vascular injury (femoral/popliteal artery laceration).
• Delayed union / nonunion / malunion.
• Osteomyelitis (esp. open fractures).
• Post-traumatic arthritis (if intra-articular extension).

🧪 Investigations

• X-rays: AP & lateral of hip, femur, and knee (always image whole femur).
• CT: if complex or intra-articular extension.
• Bloods: FBC, U&E, coagulation, G&S (major trauma protocol).

💊 Management

• Initial (ATLS): ABCDE, high-flow O₂, 2 large-bore IV lines, fluids. Analgesia (IV opiates, regional blocks). Document distal pulses & neurology.
• First aid: sterile dressings to wounds, tetanus prophylaxis. Gentle traction to correct gross deformity → apply long-leg splint or skeletal traction while awaiting surgery.
• Open fracture 🚨: IV antibiotics (e.g., co-amoxiclav or clindamycin), urgent ortho referral for debridement & fixation.
• Definitive: most require operative fixation:
  • Intramedullary nailing (gold standard): titanium rod down marrow canal, fixed with screws at both ends.
  • Plate + screws: for fractures extending into hip/knee joints.
  • External fixation: temporising measure in unstable polytrauma (“damage control orthopaedics”).
• Rehabilitation: early physio, progressive weight-bearing once stable.
• VTE prophylaxis: LMWH unless contraindicated.

📌 OSCE / Exam Pearls

• Always check distal pulses & neurology — femoral/popliteal artery & sciatic nerve at risk.
• Remember femur can hide up to 2 litres of blood loss → hypovolaemic shock risk.
• In open fracture: “IV antibiotics + saline dressing + tetanus + urgent ortho.”
• Fat embolism triad: respiratory distress, neuro symptoms, petechial rash.

📚 References

• ATLS®: Advanced Trauma Life Support, 10th edition.
• Rockwood & Green’s Fractures in Adults, 9th edition.
• BOAST guidelines: Management of Femoral Shaft Fractures.