Femoral shaft fractures are usually associated with high-velocity trauma such as motor vehicle accidents (90%). The incidence (2% of all skeletal fractures) is similar for adults and children. In children and adolescents the incidence is three times higher in males than females. A significant number (70%) of fractures in children younger than 3 years of age are related to nonaccidental trauma (child abuse). In patients with hip or knee arthroplasty, fractures tend to occur at the tip of the femoral components.

Associated injuries are common. Proximal shaft fractures may be associated with pelvic, femoral neck (5% to 6%), trochanteric fractures, and hip dislocations. Distal shaft fractures are more often associated with knee or tibial fractures and ligament or meniscal injuries in the knee.

Most femoral fractures involve the middle third of the diaphysis. Classification and radiographic description are based on segment involvement, rotation, angulation, and shortening. Fractures may be closed (soft tissues intact) or open (penetrating wound or fragment extrusion).

Standard radiographs (computed radiographic [CR] images) of the femur include anteroposterior (AP) and lateral views. The hip and knee should be included in the images due to frequently associated involvement of the hip and knee (see Fig. 5-14). These projections provide the necessary data for fracture classification and evaluation of shortening, angulation, and rotation. Associated femoral neck fractures (occurring in 5% to 6% of femoral shaft fractures) should be excluded.

Computed tomography (CT) may be required to more fully evaluate fragment position and callus formation. Magnetic resonance imaging (MRI) may be useful in patients with suspected vascular injury or compartment syndrome. Conventional angiography is still a useful tool to demonstrate small vessel detail in patients with vascular injury.

Treatment goals for femoral shaft fractures include the following:

Fracture management varies with the patient age and presence of other injuries (multiple traumas).

Skeletal traction is useful in early treatment when surgery must be delayed due to other injuries and in children from infancy to 10 years of age before application of a spica cast (see definitions in Chapter 2). Traction is the treatment of choice for highly comminuted fractures when fixation or immobilization cannot be achieved. The goal of early traction is to restore length in the first 24 hours. After this period of time hematoma begins to form and organize about the fracture.

Traction is usually accomplished using a K-wire or threaded Steinman pin in the upper tibia (see Fig. 5-15). Steinman pins are larger and may cause more soft tissue damage while K-wires tend to cut through bone over time. Tibial traction is contraindicated with associated ligament injuries to the knee. In this setting, distal femoral traction can be used (see Fig. 5-16) This allows more direct force to be applied to the fracture. Femoral traction may cause scarring in the vastus medialis and lateralis muscles. Calcaneal traction should be avoided due to the high risk of infection.

This technique is used following traction for open fractures, distal third shaft fractures, and comminuted fractures (see Fig. 5-18). This approach is contraindicated for proximal third fractures and transverse fractures. The cast provides a
supporting capsule about the thigh musculature providing a stabilizing effect on the fractures.

External fixation was introduced in the mid-20th century as an option to cast immobilization and internal fixation. Steinman pins in plaster (see Fig. 5-19), unilateral, ring, or hybrid external fixation systems may be selected. The advantages of external fixation include less disruption of soft tissues, preservation of blood supply, wound access for open fractures, ongoing fracture manipulation, and early ambulation. Unilateral fixation systems allow the extremity to remain functional while providing the ability to manipulate fracture fragments into the desired position and then maintain stability (see Fig. 5-20). Ring fixators use pins, wires, or both. Newer systems with reduced diameter increase the frame stiffness significantly. The classic ring fixator is the Ilizarov system (see Fig. 5-21) which has more recently been integrated with the Taylor Spatial Frame (TSF) by Smith and Nephew, Memphis, Tennessee (see Fig. 5-22). The new frame is designed for more complex axial, sagittal, and rotational deformities. The TSF system is composed of rods, struts, and rings. Variations include full rings, open rings, and arches. Full rings provide the most stability.