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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Femoral-shaft fracture

Musculoskeletal medicine and orthopaedics · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Femoral fracture with shock or limb threat

A closed thigh can conceal major blood loss, while open injury, arterial disruption and compartment syndrome threaten the limb; bilateral or high-energy fractures increase systemic physiological burden.

Action: Run ABCDE, control external bleeding, activate major-haemorrhage support when indicated, document distal perfusion and named nerve function, cover open wounds, realign gross deformity, apply appropriate traction or splintage, and involve orthopaedic and vascular trauma teams immediately.

Synopsis

Treat femoral-shaft fracture as a major-trauma and haemorrhage problem, protect skin and neurovascular function, identify ipsilateral neck and knee injury, and choose temporary stabilisation or definitive fixation according to physiology.

  • 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.

Key red flags

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.

Investigation priorities

01
First-line full-length femur radiographsFirst stepFirst line

Define shaft morphology and include hip and knee injury.

Management branches

ImmediateResuscitate and splint

A femoral-shaft fracture is suspected with pain, deformity or abnormal physiology.

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

Fixation and haemostasis are stable enough for rehabilitation.

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

Key medicines

Tranexamic acid for major traumatic bleedingGive 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.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG39 Major trauma: assessment and initial management
  • NICE NG37 Fractures complex: assessment and management
  • BOASt Open Fractures
  • BOASt Diagnosis and Management of Compartment Syndrome of the Extremities
  • BOASt - Diagnosis and management of arterial injuries associated with musculoskeletal trauma
  • Cyklokapron 100 mg per mL solution for injection SmPC

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom