AAOS Comprehensive Orthopaedic Review

Section 6 - Trauma

Chapter 56. Fractures of the Femoral Shaft and Distal Femur

I. Fractures of the Femoral Shaft

A. Anatomy


1. The femur is the largest, strongest bone in the body and is enveloped by a thick mass of muscle (

Figure 1).


2. The femoral shaft is defined as the diaphyseal portion of the bone, which extends from below the lesser trochanter to above the metaphyseal portion of the distal femur.


3. The bony anatomy of the femoral shaft includes an anterior bow.


4. Compartments of the thigh


a. Anterior compartment with the quadriceps muscles


b. Posterior compartment with the hamstrings


c. Adductor compartment


5. Deforming forces after a fracture


a. The abductors—gluteus medius and minimus—insert on the greater trochanter and abduct the proximal segment.


b. The iliopsoas inserts on the lesser trochanter and flexes the proximal fragment.


c. The adductor longus, adductor brevis, gracilis, and adductor magnus have a broad area of insertion on the distal femur and contribute to a varus force on the distal segment.


d. The gastrocnemius originates on the distal femur and causes a flexion deformity with more distal femoral shaft fractures.


B. Surgical approaches


1. Antegrade insertion points include the piriformis fossa or greater trochanter.


a. The incision is made approximately 6 cm proximal to the tip of the greater trochanter.


b. The gluteus maximus fascia is incised, and the muscle is spread in line with the incision.


2. Retrograde insertion


a. Midline incision with entry point in the center of the distal femoral condyle and approximately 10 mm anterior to the posterior cruciate ligament femoral insertion.


b. On the lateral knee view, the starting point is at the anterior aspect of the Blumensaat line.


C. Mechanisms of injury


1. Femoral shaft fractures often are high-energy injuries, such as from a motor vehicle or motorcycle accident. The most common mechanism in motor vehicle accident is impact of the knee against the car's dashboard. Common associated injuries include pelvis/acetabulum fractures, hip fractures and/or dislocations, and fractures of the femoral head, distal femur, patella, and tibial plateau.


2. A small percentage occur as a result of repeated stress, such as that experienced by a young military recruit or runner following an increase in the intensity of physical training.


3. A fall from a standing height is a common mechanism in the elderly, underscoring the emphasis of osteoporotic fracture prevention.


4. Pathologic fractures may be the first presentation of metastatic cancer. Radiographs should be evaluated for possibility of bony lesions, especially when the injury is not consistent with the mechanism (eg, stepping off a curb).


5. Bilateral femur fractures have a mortality rate of up to 25%.


D. Clinical evaluation


1. Advanced Trauma Life Support (ATLS) principles should be initiated in these patients.


2. Physical examination


a. Obvious thigh deformity with the limb shortened and swollen compared with the contralateral extremity.


[Figure 1. The primary muscular attachments on the anterior (A) and posterior (B) aspects of the femur.]

b. The limb should be palpated for tenderness and deformity.


c. The distal extremity should be evaluated for pulses, sensation, and motor function.


d. The presence of ecchymosis, crepitus, and deformity indicates that the patient should be examined for additional injuries.


3. Additional injuries to the spine, pelvis, and ipsilateral lower extremity can occur, as can soft-tissue injuries, specifically ligamentous and/or meniscal injuries of the knee; therefore, patients with femur fractures should always be closely evaluated for associated injuries.


4. Ipsilateral femoral neck fracture also can occur but is still routinely missed (up to 50% of patients).


a. Initially these fractures are nondisplaced or minimally displaced in up to 60% of patients.


b. The femoral neck fracture often is oriented vertically.


E. Radiographic evaluation


1. An AP view of the pelvis and AP and lateral radiographs of the femur, including the knee joint, are indicated.


2. CT evaluation of the hip is recommended in trauma patients who have sustained a femoral shaft fracture to detect associated nondisplaced femoral neck fracture.


F. Fracture classification


1. The Winquist and Hansen classification is based on the amount of comminution and has implications regarding weight-bearing status and the use of interlocking screws (

Figure 2).


[Figure 2. The Winquist and Hansen classification of femoral shaft fractures. Type 0—no comminution; type I—minimal or no comminution; type II—at least 50% of the cortices intact; type III—comminution of at least 50% to 100% of the circumference of the bone; Type IV—no cortical contact at the fracture site with circumferential comminution.]

2. The AO/Orthopaedic Trauma Association (OTA) fracture classification/universal classification system is used more commonly for research purposes and is not very useful in guiding treatment (

Figure 3).


G. Nonsurgical treatment


1. Early stabilization (within the first 24 hours) of femur fractures minimizes the complication rates and can decrease the length of stay.


2. Skeletal traction may be the definitive treatment in patients who are too sick for surgical treatment.


3. A long period of bed rest may be detrimental, however, and patients should be monitored closely.


a. Patients should be closely evaluated for pin tract infection and decubiti secondary to prolonged immobilization.


b. Serial radiographs should be obtained to monitor for distraction at the fracture site during treatment.


c. Mechanical and chemical deep vein thrombosis (DVT) prophylaxis is important in these patients.


H. Surgical treatment


1. A statically locked, reamed intramedullary (IM) nail is the standard of care for femoral shaft fractures.


a. An IM nail can be a load-sharing device, as opposed to a compression plate, which is a load-bearing device.


b. Central placement of an IM nail within the femoral canal results in lower tensile and shear stresses on the implant.


c. IM nailing has a number of benefits over plate and screws, including less extensive exposure and dissection, a lower infection rate, less quadriceps scarring, early functional use of the extremity, improved restoration of length and alignment with comminuted fractures, rapid fracture healing, and low refracture rate.


d. The starting point should be based on surgeon preference.


e. At least two interlocking screws, one proximal and one distal, should be used for all fractures.


2. Retrograde approach


a. Indications for this approach include multiple-system trauma; trauma to the ipsilateral extremity,


[Figure 3. The OTA classification of femoral shaft fractures. Type A fractures are simple fractures, type B are wedge fractures, and type C are complex fractures.]

   pelvis/acetabulum, and/or spine; bilateral femur fractures; and morbid obesity.


b. The overall union rate of retrograde nailing is comparable to that of antegrade nailing.


c. The approach has several advantages, including ease of entry point, the potential for quicker surgical times, and no need to set up the fracture table.


d. The recommended starting point for retrograde nailing is 10 mm anterior to the posterior cruciate ligament in the intercondylar notch and in line with the femoral canal.


e. The optimum starting point in the lateral plane is just anterior to the Blumensaat line.


f. A true lateral radiograph should be obtained preoperatively, with both femoral condyles overlapping and appearing as a single condyle. The radiograph should be reviewed preoperatively to assess for patella baja that may interfere with a percutaneous incision and require an arthrotomy (rare).


g. Surgical pearls


i. Use a radiolucent triangle or bump strategically placed to assist with reduction.


ii. Protect the prepatellar skin and patella during reaming by seating the reamer in bone before starting.


iii. Before the patient wakes up, an AP pelvic radiograph should be obtained to rule out a femoral neck fracture; limb rotation and length should be evaluated and the knee should be checked for ligamentous injuries.


h. Complications include malalignment (proximal third fractures) and knee pain.


3. Piriformis entry point


a. This entry point is in line with the mechanical axis of the femur.


b. A too-anterior entry point increases the risk for femoral neck fracture secondary to hoop stresses.


c. The piriformis entry point may result in more muscle and tendon damage and damage to the blood supply of the femoral head than the trochanteric entry point.


4. Trochanteric entry point


a. This entry point has several advantages over a piriformis entry point, including that its more lateral location is easier to find, it may result in less abductor muscle damage, and fluoroscopic time and surgical time are shorter.


b. Complications include iatrogenic fracture if a straight piriformis-type nail is used and iatrogenic comminution with malreduction.


I. Reamed versus nonreamed IM nailing


1. Reamed IM nailing is recommended over nonreamed nailing because it allows placement of a larger diameter nail with better cortical fit.


2. Previous concerns with reaming included increased incidence of adult respiratory distress syndrome (ARDS) and lung complications in patients who had associated pulmonary injury. However, a study comparing open reduction and internal fixation with reamed IM nailing in this patient population showed no increased incidence.


J. Flat table versus fracture table


1. Whether to use a fracture table or a fluoroscopic flat table is a decision to be made with all antegrade nailings. Studies support either choice.


2. Considerations include the fracture pattern, patient body habitus, the number of assistants available, associated injuries, and surgeon preference.


K. Plate and screws


1. Plate fixation of femur fractures is not commonly used and has few indications.


2. The best indication for compression plating is a fracture involving the distal metaphyseal-diaphyseal junction of the femur.


3. Complications of compression plating


a. Failure of fixation


b. Infection


c. Nonunion


d. Devitalization of fracture fragments with excessive periosteal stripping


e. Stress shielding with possible refracture


L. External fixation


1. External fixation of femur fractures is often used as a form of damage control orthopaedics.


2. External fixation is useful for the unstable trauma patient and patients whose skin does not permit initial definitive fracture fixation.


3. Concerns regarding external fixation include


a. Pin tract infection


b. Timing of external fixation removal and conversion to IM nailing. The literature supports safe conversion to IM nailing within the first 2 weeks to minimize the risk for infection.


M. Ipsilateral femoral neck and shaft fractures


1. Radiographic evaluation


a. Most femoral neck fractures that are associated with an ipsilateral shaft fracture are vertically oriented and nondisplaced or minimally displaced, making radiographic detection difficult.


b. Fine-cut CT may help to detect femoral neck fractures before surgery.


2. Treatment


a. The timing of discovery of the femoral neck fracture has implications for its treatment.


b. No matter when the fracture is discovered, it is essential to obtain an anatomic reduction.


c. Treatment options—One device or two devices may be used.


i. With one device, either a cephalomedullary nail or a centromedullary nail with cannulated screws strategically placed using the "miss a nail" technique may be used.


ii. With two devices, either a retrograde nail with cannulated screws or a retrograde nail with a sliding hip screw may be used. The optimal treatment option has yet to be decided.


N. Open femoral shaft fractures


1. Open femoral shaft fractures should be treated with irrigation and debridement and primary intramedullary nailing.


2. The infection rate of open fractures of the femur is significantly lower than that of open tibia fractures.


O. Rehabilitation


1. With stable fracture fixation, early mobilization and weight bearing are permitted. Most patients are allowed to bear weight to varying degrees, with associated injuries, fracture pattern, implant selection, and surgeon preference dictating the exact postoperative therapy orders.


2. Early active motion of the hip and knee joint is encouraged.


P. Complications


1. Perioperative


a. Fat embolism syndrome


i. This usually occurs 24 to 72 hours after initial trauma in a small percentage of patients with long bone fractures.


ii. It can be fatal in up to 15% of patients.


iii. Classic symptoms include tachypnea, tachycardia, hypoxemia, mental status changes, and petechiae.


iv. Treatment includes mechanical ventilation with high positive end-expiratory pressure levels.


v. Prevention involves early (within 24 hours) stabilization of long bone fractures.


b. Thromboembolism


i. DVT is a concern in trauma patients, especially those with long bone trauma, pelvic and acetabular fractures, and spine trauma. It may lead to a fatal pulmonary embolism (PE).


ii. A duplex ultrasound may be used to diagnose DVT.


iii. In patients with suspected PE, a spiral CT scan, ventilation-perfusion scan, or pulmonary angiography (gold standard) may be used for diagnosis.


iv. The symptoms of a PE include acute onset tachypnea, tachycardia, low-grade fevers, hypoxia, mental status changes, and chest pain.


v. Preventive measures include chemical prophylaxis: warfarin, subcutaneous heparin, low-molecular weight heparin; sequential compression devices or foot pumps; and early surgical stabilization and subsequent mobilization, which are important, controllable measures.


c. Adult respiratory distress syndrome


i. ARDS is an acute respiratory failure with pulmonary edema.


ii. It can result from multiple etiologies and is known to occur after trauma and shock.


iii. The patient may be difficult to ventilate secondary to decreased lung compliance.


iv. Other signs/symptoms include tachypnea, tachycardia, and hypoxemia.


v. Treatment is with high positive end-expiratory pressure.


vi. The mortality can be up to 50%.


vii. From an orthopaedic surgeon's perspective, early stabilization of long bone fractures helps decrease the incidence of ARDS.


d. Compartment syndrome


i. Compartment syndrome after femur fractures is rare. It is important to consider the mechanism of injury; a crush injury or an injury with a prolonged extrication in which the dashboard console was crushing the leg compartments should be followed closely.


ii. Compartment syndrome has been reported after IM nailing on the fracture table.


e. Nerve palsy


i. In femur fractures stabilized on the fracture table, pudendal nerve palsy may occur as a result of excessive traction and/or improper positioning with the perineal post.


ii. A peroneal nerve neurapraxia may also occur secondary to excessive traction.


f. Nonunion, delayed union, malunion


i. The rate of nonunion after treatment of femoral shaft fractures with a locked IM nail is low.


ii. Treatment is exchange nailing with a larger IM nail.


iii. With an infected nonunion (a rare complication), the use of chronic suppressive antibiotics until healing occurs is recommended, followed by implant removal.


iv. Delayed unions may occur because of technical concerns. Removal of the interlocking screw may allow compression across the fracture and allow union to occur.


v. Up to 20% of patients may have limb rotational deformities.


vi. Previously it was thought that internal rotation deformities were not well tolerated, but in most patients, rotational deformities of less than 20° are well tolerated.


g. Hardware failure and recurrent fracture


i. With reamed, statically locked IM nailing of femur fractures, the occurrence of hardware failure is low.


ii. The closer a fracture is to the interlocking screw placement, the higher the stresses on the hardware.


h. Heterotopic ossification


i. The insertion site for an antegrade nail involves soft-tissue disruption of the abductors. Thus, some patients may develop heterotopic ossification about the hip.


ii. Heterotopic ossification of minimal clinical significance has been reported to occur in up to 26% of patients with fractures stabilized using a piriformis starting point. The occurrence rate associated with a trochanteric starting point has not yet been reported.

II. Fractures of the Distal Femur

A. Epidemiology


1. Distal femur fractures are bimodally distributed.


2. There is a higher incidence in young, healthy males (often from high-energy trauma) and elderly, osteopenic females (from low-energy mechanisms).


B. Anatomy


1. The geometric cross-section of the femoral shaft transitions from cylindrical to trapezoidal, with the medial condyle extending further distally.


2. The distal femur is trapezoidal and is composed of cancellous bone.


3. The distal femur is in physiologic valgus.


4. It is important to keep in mind that the posterior half of both femoral condyles lies posterior to the femoral shaft.


5. Deforming forces after a fracture


a. The origin of the gastrocnemius characteristically pulls the distal fragment into flexion.


b. Closely evaluate preoperatively for a coronal plane Hoffa fracture.


C. Surgical approach


1. Depends on choice of reduction type (indirect or direct) and plate.


2. Minimally invasive surgical approaches include minimally invasive plate osteosynthesis (MIPO).


a. This approach is ideal for extra-articular fractures, which can be reduced indirectly.

b. A small lateral incision is made to facilitate plate placement, with stab incisions for screw placement.


3. Transarticular approach with retrograde plate fixation (TARPO) and lateral parapatellar arthrotomy


a. Can also be used with indirect reduction techniques


b. Can be useful for partial articular fractures


4. Lateral parapatellar approach


a. Affords excellent exposure of the femoral shaft and permits eversion of the patella.


b. One disadvantage is that a different incision is needed for future total knee arthroplasties (TKAs).


c. The advantage of the approach is that it affords good visualization of the joint surface.


d. The lateral parapatellar approach should be used for reduction of lateral Hoffa fragments.


D. Mechanism of injury


1. Fractures involving the supracondylar femur are often a result of the same high-energy mechanisms seen in fractures of the femoral shaft.


2. Low-energy mechanisms, such as minor falls, are common in the older population.


E. Clinical evaluation


1. Consider the mechanism of injury: with high-energy mechanisms, a full trauma evaluation should be completed.


2. The patient usually presents with pain, swelling, and deformity in the distal femur region.


3. Neurovascular structures lie close to these fractures, so neurovascular status should be assessed thoroughly.


4. The skin should be examined closely for open wounds.


5. In the elderly patient, preexisting medical conditions and degenerative knee joint disease should be considered.


F. Radiographic evaluation


1. AP and lateral radiographs of the distal femur are standard.


2. Radiographic evaluation of the ipsilateral lower extremity should be considered because of the risk of associated injuries.


3. Oblique views may be helpful to provide further details regarding the intercondylar anatomy; however, with use of CT scanning there is often no need for these additional radiographs.


4. Traction radiographs are helpful but may be too uncomfortable for the patient.


5. Contralateral views may be helpful in preoperative planning and templating.


6. CT provides details regarding intra-articular involvement and can identify coronal plane deformities with reconstruction views.


G. Classification—The OTA classification is the universally accepted system for characterizing injuries of the distal femur (

Figure 4).


1. Type A fractures are extra-articular injuries.


2. Type B fractures are partially articular and involve a single condyle.


3. Type C fractures are intercondylar or bicondylar intra-articular injuries with varying degrees of comminution.


H. Nonsurgical treatment—Nonsurgical treatment is indicated only for nondisplaced distal femur fractures. Nonsurgical treatment of displaced supracondylar and intercondylar femur fractures is generally associated with poor results and should be reserved for patients who otherwise represent an unacceptable surgical risk.


I. Surgical treatment


1. The goal of surgical treatment should be stable fixation to permit early mobility.


2. The trend in recent years regarding periarticular fractures has changed from large, extensile approaches, subperiosteal dissection, circumferential clamps, absolute stability with compression by lag screws and use of short plates with multiple screws to the concept of biologic reduction techniques that emphasize limited lateral exposures and preservation of the soft-tissue attachments.


3. The locking plate has become quite popular. Multiple manufacturers offer locking plate systems.


a. The main advantages of the newer plating systems include the ability to place the implant percutaneously, less periosteal stripping, and application of a plate laterally without need for additional medial plate stabilization.


b. The locked nature of the screws in the femoral condyles allow for the placement of multiple "internal external fixators" that have been shown to be axially superior to earlier fixation techniques. The improved axial strength of the newer implants should not lead to a false sense of security, however.


c. Another advantage of the newer design plates is the submuscular advancement of the plate to the bone, which minimizes periosteal stripping and preserves the blood supply. The implants do not rely on direct contact of the plate to the bone for stability. The concept is called relative stability, and longer plates and fewer screws are used.


d. If using a long percutaneous plate, proximal visualization of the plate placement may be difficult. Consider making an incision to ensure proper placement proximally on the femur.


J. Surgical technique


1. The patient should be positioned supine on a radiolucent table.


2. Open fractures should be treated in accordance with open fracture treatment principles. Temporizing knee-spanning external fixators should be used until the soft tissue permits the placement of internal fixation.


3. Once the soft tissues have been stabilized, the surgical approach and tactic is dictated by the degree of articular comminution (

Table 1).


a. Type A fractures


i. Plate fixation is a viable option and is associated with good results.


ii. Traditional plating options include dynamic condylar screw, a 95° blade plate, or a locking plate. Dynamic condylar screw or blade plating requires the use of a more invasive incision for direct reduction techniques.


[Figure 4. The OTA classification of distal femur fractures.]

iii. Locked plating can be performed through a minimally invasive lateral approach to the distal femur, exposing only the portion of the distal lateral condyle necessary to facilitate placement of the implant.


b. Type B fractures


i. Lag screw fixation


ii. Plate fixation


c. Type C fractures


i. Open reduction and internal fixation with plates


ii. An anatomic articular reduction is critical for a good result.


K. IM nails


1. Retrograde IM nailing represents a good choice for distal femur fractures not involving the articular surface.


2. When attempting retrograde IM nailing of a distal femur fracture with extension into the articular surface, the articular surface should be stabilized with Kirschner wires and/or screws before nail placement.


[Table 1. Possible Implants for Distal Femur Fractures as Determined by the AO/OTA Classification System.]

3. There are few indications for a short retrograde nail.


L. External fixation—Bridging external fixation may be advantageous as a temporizing measure in open fractures or in fractures with significant comminution or soft-tissue compromise. When using a bridging external fixation, the external fixator pins should be placed away from the planned plate.


M. Associated vascular injury


1. Neurovascular status should be evaluated carefully because of the proximity of vascular structures to these fractures.


2. If the fracture is associated with a knee dislocation, angiography may be considered because the risk of vascular injury is significantly greater with associated dislocation.


N. Supracondylar fracture after TKA


1. Retrograde nail (if the implant permits)


2. Locking plate


a. The locking plate is the fixation device of choice for very distal fractures in osteopenic bone.


b. The literature supports good results for locking plate fixation of periprosthetic fractures proximal to a TKA.


c. A locked plate should be considered for very distal periprosthetic supracondylar femur fractures.


O. Rehabilitation


1. Postoperative treatment should include the administration of intravenous antibiotics for 24 to 48 hours following closure of all wounds and the routine use of mechanical and chemical prophylaxis for DVT.


2. Patients are assisted out of bed on the first postoperative day and should be non-weight-bearing on the affected limb with the use of ambulatory assistive devices.


3. Active assisted range-of-motion exercises should be initiated in the early postoperative period. Early range-of-motion exercises are critical in that functionally poor results are most often attributed to knee stiffness, and little improvement is gained after 1 year.


P. Complications


1. The metaphyseal location and preponderance of cancellous bone in these fractures can lead to significant comminution, even with low-energy injury mechanisms. Therefore, meticulous attention to preoperative planning with full consideration of all patient factors (condition of the soft tissues, concomitant injuries, comorbidities, functional level before injury) is of paramount importance.


2. Even with locking plate fixation, failures have been reported. The need for bone grafting, therefore, should not be ignored in those fractures where it is warranted.


3. Nonunions


a. The rate of nonunion has improved with the use of more biologically friendly techniques such as minimally invasive plate application.


b. Nonunions should be treated with bone grafting and/or implant revision.


4. Infection


a. Infection rates have improved with the use of soft-tissue friendly surgery.


b. Infection should be managed with thorough debridement, cultures, and appropriate antibiotics, and consideration of removal of hardware if the fracture permits.

Top Testing Facts

Femoral Shaft Fractures

1. Always closely evaluate the patient with a femur fracture for associated injuries.


2. Early stabilization (within the first 24 hours) of femur fractures minimizes the complication rates and can decrease the length of stay.


3. Bilateral femur fractures have a mortality rate of up to 25%.


4. The infection rate for open femur fractures is significantly lower than that of open tibia fractures.


5. Rotation deformities may occur if the leg is not properly positioned on the fracture table.


6. A statically locked, reamed IM nail is the standard of care for femoral shaft fractures.


7. The starting point should be based on surgeon preference.


8. At least two interlocking screws, one proximal and one distal, should be used for all fractures.


9. Before the patient wakes up, AP pelvic radiographic imaging should be performed to rule out a femoral neck fracture; limb rotation and length should be evaluated and the knee should be checked for ligamentous injuries.


10. Conversion of an external fixator to an IM nail should occur within the first 2 weeks to minimize the risk of infection.


Distal Femur Fractures

1. The origin of the gastrocnemius characteristically pulls the distal fragment into flexion.


2. A bump or radiographic triangle strategically placed under the deformity may assist with reduction.


3. Closely evaluate preoperatively for a coronal plane Hoffa fracture.


4. If using a long percutaneous plate, proximal visualization of the plate placement on the femur may be difficult. Consider making an incision to ensure proper placement proximally on the femur.


5. When using a bridging external fixator, place the external fixator pins away from the planned plate location.


6. The goal of surgical treatment should be stable fixation to permit early mobility.


7. Even with locking plate fixation, failures have been reported. The need for bone grafting, therefore, should not be ignored in those fractures where it is warranted.


8. A locked plate should be considered for very distal periprosthetic surpracondylar femur fractures.


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