Femoral-shaft fracture

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Femoral-shaft fracture is a major injury even when closed. Follow ABCDE, obtain a pre-hospital mechanism and quantify physiological response. A swollen thigh can conceal substantial blood, but do not anchor there: abdominal, thoracic and pelvic haemorrhage commonly coexists. Establish large-bore access, blood testing and major-haemorrhage support when indicated, provide warming and tranexamic acid within the evidence-based trauma window and move toward source control.

Examine before and after every intervention. Inspect circumferentially for small open wounds, contamination, Morel-Lavallée degloving and skin tension. Palpate compartments and document distal pulses, refill, temperature, foot dorsiflexion, great-toe extension, plantarflexion and dorsal and plantar sensation. A pulseless deformed limb is realigned and splinted immediately, then re-examined. Hard arterial signs require emergency consultant-led vascular and orthopaedic repair.

Splintage reduces pain, movement and further soft-tissue bleeding. Apply simple padded splints during initial care, or a traction splint by trained staff when injury is an isolated diaphyseal pattern and no contraindicating pelvis, hip, knee or ipsilateral lower-leg injury exists. Traction is not a ritual; if it worsens pain, perfusion or alignment, stop and use another method. Document device time, skin and neurovascular response.

Radiographs include the entire femur and both joints in orthogonal planes. Look carefully for an ipsilateral femoral-neck fracture, which may be subtle and changes the operative sequence, and for patellar or ligament injury at the knee. Suitable high-energy patients often receive whole-body CT; use thin sections or dedicated views where the neck remains uncertain. Pathological features require staging and biopsy planning before an implant contaminates tissue planes.

Definitive management depends on physiology and pattern. Locked intramedullary nailing provides stable load-sharing fixation for most adult shaft fractures. Severe shock, coagulopathy, hypothermia, chest injury, contamination or complex soft-tissue damage can make temporary external fixation the safer damage-control bridge. Open fractures need formal orthoplastic debridement and cover timing, not a mini-washout. Children, periprosthetic and pathological fractures require distinct specialist methods.

Fat embolism syndrome usually appears after an interval with hypoxaemia, confusion and petechiae. It is a clinical diagnosis of exclusion: assess pulmonary embolus, aspiration, pneumonia, intracranial injury and haemorrhage. Treatment is supportive oxygenation and organ care; routine corticosteroid treatment is not established. Early appropriate fracture stabilisation and resuscitation reduce systemic insult, but sudden respiratory decline still demands a complete emergency assessment.

Follow-up assesses union, rotation and the whole limb. Compare foot progression, hip rotation and limb length, not only callus. Begin hip and knee movement and quadriceps rehabilitation when safe, with VTE prevention and mobilisation. Persistent pain, motion at the fracture, drainage, deformity or delayed callus prompts investigation for infection, nonunion, malrotation and metabolic or pathological bone factors.

Key points

Treat a femoral-shaft fracture as a potential major haemorrhage: assess physiology and search chest, abdomen, pelvis and other limbs rather than attributing all shock to one thigh.
Expose the whole limb for wounds and degloving and document femoral, popliteal, dorsalis pedis and posterior tibial pulses plus peroneal and tibial nerve function.
Give early analgesia, gently restore gross length and alignment and splint; a traction splint can reduce pain and bleeding in an isolated shaft injury but is unsuitable with some pelvic, hip, knee or lower-leg injuries.
For an open fracture, give the network intravenous antibiotic immediately and ideally within 1 hour, cover without emergency-department washout and transfer to an orthoplastic-capable service.
Obtain AP and lateral full-length femur radiographs including hip and knee and look deliberately for ipsilateral femoral-neck fracture and knee injury.
Use CT as part of suitable major-trauma imaging and for occult proximal fracture or complex distal extension; hard vascular signs should not wait for avoidable imaging.
Definitive intramedullary nailing is usual for adult diaphyseal fractures, while damage-control external fixation or traction may bridge severe physiological instability or soft-tissue injury.
After fixation, confirm length, alignment and rotation, permit specialist-defined weight bearing and begin knee, hip, VTE and respiratory rehabilitation with union surveillance.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

High-energy direct trauma

Road collision, crush and fall from height produce transverse, comminuted or segmental fractures with substantial soft-tissue damage and associated injuries.

Torsional sport injury

Rotational force can cause a spiral shaft fracture, particularly in younger bone, and may extend toward subtrochanteric or distal regions.

Fragility or pathology

Low-energy fracture in older or atypical bone raises osteoporosis, metastasis, myeloma, primary tumour, infection or bisphosphonate-associated atypical fracture.

Ballistic or penetrating injury

Direct violation causes open fracture, contamination, vascular and nerve injury and requires trauma-network antibiotic and debridement pathways.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Concealed blood loss
The thigh accommodates substantial haemorrhage from cancellous bone and muscle vessels, reducing circulating volume despite no external bleeding.
2
Deforming muscle forces
Iliopsoas, abductors, adductors, hamstrings and quadriceps shorten, angulate and rotate fragments, causing pain, further tissue injury and limb shortening.
3
Systemic inflammatory injury
Marrow and tissue trauma contributes to coagulopathy and pulmonary inflammation; bilateral fractures and multiple injury increase respiratory failure risk.
4
Healing biology
Stable fixation, preserved blood supply and soft-tissue health permit union, while comminution, smoking, infection and pathological bone increase nonunion.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Shaft fracture pattern

Severe thigh pain, swelling, shortening, deformity and inability to load after high energy strongly suggests diaphyseal fracture and concealed blood loss.

Open injury

Any wound in the thigh segment may communicate with fracture; exposed bone is not required and probing is avoided.

Arterial injury

Active haemorrhage, expanding haematoma, bruit, absent distal pulses, coolness or rapid neurological deterioration demands immediate repair planning.

Compartment syndrome

Increasing analgesic need, disproportionate pain, passive-stretch pain, tense thigh and new nerve signs require emergency surgical assessment.

Ipsilateral neck fracture

High-energy axial load, hip pain or a subtle neck line can accompany the shaft fracture and may be overlooked on initial films.

Atypical pathological pattern

Lateral cortical beaking, transverse low-energy fracture, lytic destruction or antecedent pain warrants metabolic or oncological investigation.

Red flags requiring action

Hypotension, tachycardia, increasing thigh size, falling haemoglobin or a transient response to blood indicates significant ongoing haemorrhage until chest, abdomen, pelvis and limbs are controlled.
Absent pulses, expanding haematoma, active bleeding, bruit, pallor, coolness or deteriorating nerve function requires emergency revascularisation and skeletal stabilisation planning.
Escalating pain, tense swelling, pain on passive knee movement or new sensory and motor change suggests thigh compartment syndrome and requires urgent fasciotomy assessment.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
First-line full-length femur radiographsFirst stepFirst line
Why
Define shaft morphology and include hip and knee injury.
Interpretation and limitations
Obtain AP and lateral views including both joints; scrutinise femoral neck, distal articular extension, patella and alignment.
02
Major-trauma CT
Why
Identify associated torso, pelvis and occult proximal femoral injury in a suitable patient.
Interpretation and limitations
Use according to physiology and mechanism; CT does not replace timely reduction, haemorrhage control or complete limb examination.
03
CT angiography
Why
Map suspected arterial injury without hard signs requiring immediate operation.
Interpretation and limitations
Occlusion, extravasation or intimal injury guides combined vascular and skeletal repair; threatened ischaemia should not wait for scanner access.
04
Serial blood gas and haemorrhage panel
Why
Track concealed blood loss and resuscitation physiology.
Interpretation and limitations
Trend lactate or base deficit, haemoglobin, coagulation, fibrinogen, calcium and temperature; early haemoglobin can remain deceptively normal.
05
Knee ligament assessment
Why
Detect associated internal derangement once pain and stability permit.
Interpretation and limitations
Repeat after fixation or anaesthesia if initial examination is limited; use MRI selectively when instability will change treatment.
06
Pathological-fracture work-up
Why
Define bone disease before definitive tumour surgery.
Interpretation and limitations
Image the whole bone and stage suspected malignancy, involve orthopaedic oncology and obtain biopsy through a planned tract rather than at casual fixation.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Hip dislocation or proximal fracture

Shortening and rotation may originate at the hip or femoral neck and must be assessed on images including the joint.

Distal femoral or knee injury

Dashboard and direct force can fracture distal femur, patella or tibial plateau and cause ligament injury despite dominant shaft pain.

Pelvic haemorrhage

Shock with femoral deformity does not prove the thigh is the only source; pelvic, abdominal and thoracic bleeding require active exclusion.

Pathological lesion

Antecedent pain, cortical beaking or destruction, lytic change and minimal force require oncological imaging and biopsy planning before routine fixation.

Morel-Lavallée lesion

Fluctuant degloving around thigh or greater trochanter can coexist without open skin and threatens tissue viability and infection.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01ImmediateResuscitate and splintFirst stepA femoral-shaft fracture is suspected with pain, deformity or abnormal physiology.

1Run ABCDE, control bleeding, activate major-haemorrhage support when indicated and examine for pelvic, abdominal, chest and contralateral injury.
2Document open wounds, degloving, compartments, named distal nerve function and pulses before manipulation.
3Give titrated analgesia, correct gross length and alignment and apply an appropriate padded or traction splint after checking contraindications.
4Repeat neurovascular findings and transfer promptly to orthopaedic, vascular or orthoplastic care according to threats.

02DefinitiveChoose damage control or nailingDefinitiveImaging defines a diaphyseal pattern and the patient's physiology and soft tissues are assessed.

1Use temporary external fixation or another damage-control method when shock, hypothermia, coagulopathy, chest injury or contamination makes long surgery unsafe.
2Proceed to locked intramedullary fixation for most suitable adult shaft fractures, addressing an ipsilateral neck fracture in the planned sequence.
3Debride and cover open injury through the orthoplastic timetable and coordinate arterial repair and fasciotomy where needed.
4Confirm length, coronal and sagittal alignment and rotation clinically and radiographically before leaving theatre.

03RecoveryRestore limb and systemic functionFixation and haemostasis are stable enough for rehabilitation.

1Begin specialist-defined weight bearing and hip and knee motion, quadriceps activation, respiratory care and VTE prevention.
2Monitor for hypoxaemia, confusion and petechiae and investigate the full differential rather than labelling every desaturation fat embolism.
3Review wound, infection markers where clinically indicated, radiographic union, limb length, rotation, gait and knee stability.
4EscalationEscalate drainage, persistent pain, delayed callus, deformity or implant failure for infection and nonunion investigation.

Key medicines and prescribing safety1 treatment · regimens, roles and cautions

Reduces death from traumatic bleeding as part of blood-component resuscitation and rapid source control for femoral and associated injuries.

Tranexamic acid for major traumatic bleeding

Give 1 g intravenously over 10 minutes followed by 1 g infused over 8 hours, starting as soon as possible and within 3 hours of injury when significant bleeding is present or suspected.

Do not delay surgery or vascular control, avoid routine initiation after 3 hours unless hyperfibrinolysis is specifically present and adjust maintenance exposure in significant renal impairment.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Haemorrhagic shock

Unrecognised thigh and associated cavity bleeding causes hypoperfusion, coagulopathy, renal injury and death before definitive skeletal treatment.

Fat embolism syndrome

Hypoxaemia, neurological change and petechiae after long-bone injury suggest inflammatory fat embolism, requiring supportive critical care and exclusion of other causes.

Nonunion or malrotation

Inadequate stability, infection, impaired biology and unrecognised rotational error cause persistent pain, abnormal gait, functional loss and revision surgery.

Infection

Open fracture and operative implants risk deep fracture-related infection with drainage, nonunion and possible limb reconstruction.

Knee stiffness and weakness

Pain, immobilisation and muscle injury reduce knee movement and quadriceps strength unless rehabilitation starts when fixation and soft tissue permit.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Trend haemodynamics, thigh size, blood requirement, lactate, haemoglobin, temperature, calcium and coagulation during active bleeding.
Repeat pulses, refill, foot motor and sensory function and compartment signs after alignment, splintage, transfer and fixation.
Monitor respiratory status and cognition for fat embolism, pulmonary embolism, aspiration and chest-injury complications.
Confirm postoperative length, alignment, rotation, wound status, knee movement and permitted weight bearing before handover.
Follow radiographic union and functional recovery and investigate persistent pain, drainage, malrotation or implant failure promptly.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

The thigh can hide blood

A closed skin envelope does not prevent clinically important haemorrhage or remove the need to search other major cavities.

Traction is conditional

It can improve an isolated shaft injury but may worsen associated pelvis, hip, knee or lower-leg pathology.

Look above and below

Ipsilateral femoral-neck and knee injuries are classic distractions when the dramatic shaft fracture dominates attention.

Rotation is a clinical outcome

Acceptable AP and lateral alignment can still conceal malrotation that causes an abnormal foot progression and gait.

Respiratory decline has a differential

Fat embolism is possible, but pulmonary embolus, aspiration, contusion and shock need concurrent exclusion.

11Common pitfallsFrequent interpretation and management errors.

01
Attributing all hypotension to the thigh and missing chest, abdominal or pelvic bleeding.
02
Applying traction without checking for pelvic, hip, knee and ipsilateral lower-leg injury.
03
Omitting the hip and knee from radiographs and missing femoral-neck or ligament injury.
04
Waiting for CT angiography despite hard vascular signs and threatened perfusion.
05
Using routine emergency-department washout for an open fracture instead of cover, antibiotics and orthoplastic transfer.
06
Checking only coronal alignment and leaving a clinically important rotational deformity.