Introduction
The femur bone (thigh bone) is the longest and strongest bone in the body. The main function of the femur bone is weight bearing and gait stability. The femur bone is divided into the proximal end, the femoral shaft, and the distal end. The proximal end consists of the femoral head, neck, and greater and lesser trochanter. The distal end consists of the lateral and medial condyles, epicondyles, and intercondylar fossa. The shaft is a cylindrical structure, wide at the proximal end and narrow towards the middle, and widens at the distal end. The femoral artery supplies the lower extremities, bifurcating into the superficial and deep femoral arteries. The branches of the deep femoral artery supply the femoral shaft and distal portion of the femur. The thigh muscles are divided into anterior, posterior, medial, and gluteal compartments. The femur bone is supported by the anterior compartment muscles, which help in hip flexion and knee extension.
What Are Femoral Shaft Fractures?
A break or discontinuity anywhere along the length of the femur bone is called a femoral shaft fracture. It is one of the most common fractures in children and adolescents, mostly seen in males rather than females. It may occur due to low-impact injuries such as falls in elderly individuals with weak bones or osteoporosis (low bone density). In young adults, femoral shaft fractures are caused due to high-impact injuries, which may be associated with multiple trauma, can be life-threatening and require immediate management.
What Are the Types of Femoral Shaft Fractures?
Femoral fractures may be displaced (bones are not in alignment) or stable fractures (bones are in alignment), or it may be an open (skin around the fracture is exposed) or closed fracture (skin around the fracture is intact), depending on the force that causes the fracture. Femoral shaft fractures are classified based on the location, fracture pattern, and fracture comminution.
1. Based on location, these fractures are classified into distal third, middle third, and proximal third.
2. Based on the fracture pattern, these fractures are classified into:
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Transverse Fracture: The fracture is along the horizontal line across the femoral shaft.
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Spiral Fracture: The fracture line encircles the femoral shaft.
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Oblique Fracture: The fracture is at an angle to the long axis of the shaft.
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Comminuted Fracture: A fracture wherein the shaft is broken into three or more fragments.
3. Based on the degree of comminution, femoral shaft fractures are classified by Winquist and Hansen as follows:
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Type 0: No comminution present.
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Type I: Comminution is minimal or insignificant, less than 25 percent of the width of the bone.
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Type II: Comminution involves fragments larger than type I but less than 50 percent of the width of the bone (cortical contact).
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Type III: Comminution involves larger fragments, more than 50 percent of the width of the bone.
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Type IV: Severe comminution of an entire segment of bone.
What Are the Causes of Femoral Shaft Fractures?
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Femoral shaft fractures occur in children and adolescents mainly due to falls.
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In young adults, these fractures are due to high-impact injuries like motor accidents, crash injuries, or being hit by a vehicle while walking or crossing roads.
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Falls from a ladder or great heights.
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Gunshot wounds caused during the violence.
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It can occur in elderly individuals with weak bones or low bone density (osteoporosis) due to falls from standing height.
What Are the Signs and Symptoms of Femoral Shaft Fractures?
Some of the signs and symptoms of femoral shaft fractures include
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Lacerations and skin abrasions are seen in cases of accidents.
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Severe pain and swelling.
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Unable to bear weight or walk.
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The injured leg appears to be shorter than the unaffected leg.
What Are the Associated Injuries With Femoral Shaft Fractures?
Some associated injuries with femoral shaft fractures include
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Fractures of the proximal end of the femur bone, such as the femoral head, neck, or intertrochanteric fractures.
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Bilateral femoral fractures wherein the right and the left femur bones are fractured. It is generally rare and may occur due to motor accidents or falls from heights.
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Fat emboli syndrome, wherein the fat globules are released into the bloodstream, obstructing circulation and causing fever, rashes, and shortness of breath.
What Are the Complications of Femoral Shaft Fractures?
Some of the complications include
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Damage to the blood vessels and nerves, and ligaments.
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Open fractures may lead to bone infections, which may delay the healing process.
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Severe fractures may cause pressure build-up within the muscles, which reduces the blood flow and oxygen to the tissues resulting in severe pain; it is called acute compartment syndrome.
How Are Femoral Shaft Fractures Diagnosed?
A complete medical history is taken, followed by a thorough physical examination to check for the extent of injuries, deformity, skin breaks, bruises, and lacerations. Range of motion and touch sensation is also assessed. Radiological investigations include
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X-rays are recommended to determine the fracture's location, type, pattern, and extent. In cases of severe trauma, X-rays of the chest and pelvis are obtained as a part of the advanced trauma life support (ATLS) protocol. When the patient is stabilized, X-rays of the femur or the suspected injuries are taken. It helps to identify the fractures of the hip socket, proximal femur, and proximal tibial bone.
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Computed tomography (CT) scan is advised in some cases, as it provides a cross-sectional view of the fracture and a clear image compared to radiographs. It is advised in cases of multiple injuries and helps in surgical planning, femoral neck fractures, and vascular lesions.
How Are Femoral Shaft Fractures Managed?
Femoral shaft fractures usually require surgical management; non-surgical or conservative management is carried out only in young children or non-displaced fractures in patients with multiple medical comorbidities such as cardiovascular or cerebrovascular diseases, respiratory diseases, etc. It is based on the patient’s age, weight, and fracture type. The main aim is to realign the fractured fragments and immobilization to promote healing. Non-surgical management includes
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Pavlik Harness Treatment: It is used to treat infants less than six months of age. It is a soft splint with chest and leg straps. The chest strap is positioned across the baby’s back, reaching around to close in the front. The leg strap is attached in the front with a loop under each foot, crossed over at the back, and attached to the top of the body strap. It immobilizes and supports the legs in an outwardly rotated position, promoting healing. It is regularly monitored by ultrasound for around three weeks.
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Spica Casting: It is recommended for children under five years of age but is contraindicated in cases of multiple injuries, open fractures, or in cases of shortening of the femur that is more than three cm (centimeters). It is a soft padded lining wrapped around the leg and hip joint with a plaster cast or a fiberglass cast for around six weeks, followed by periodic monitoring. In some cases, a gentle and steady pulling of the bones (traction) is done to realign the bones, and then a cast is applied to promote healing.
Femoral shaft fractures usually require immediate care and management to avoid further complications. Surgical management includes
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External Fixation: In this procedure, metal screws and pins are used above and below the site to fix the fractured bone fragments. A bar is placed outside, which attaches the pins and screws to stabilize the fracture and facilitate healing. It provides good support and stability to the healing tissues but is a temporary treatment for patients who have multiple injuries and are not yet healthy for the final surgery.
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Intramedullary Nailing: It is a standard gold method to treat femoral shaft fractures, during which a metal rod is inserted into the canal of the femur bone, which passes across the fracture and fixes its position. Intramedullary nails made of titanium are inserted either at the hip or knee, with the screws placed above and below the fractured bones to maintain proper alignment during the healing process. In cases where intramedullary nailing is not feasible, metal screws and plates are attached to the outer surface of the femur bone to hold the fracture fragments to facilitate healing, followed by antibiotics to prevent infections, and analgesics such as Acetaminophen, Ibuprofen to reduce pain and swelling.
Conclusion
A break or discontinuity anywhere along the length of the femur bone is called a femoral shaft fracture. It is commonly seen in children and adolescents; it occurs in young adults due to high-energy trauma like motor accidents, falls from heights, or due to falls in elderly people with osteoporosis. It is associated with pain, swelling, and loss of function and is usually managed by surgical treatment through an intramedullary nailing procedure.
