Femur Fractures – Treatment Options

Femur Anatomy: 

Femoral Shaft Fractures:


  • Young: high energy (MVA, polytrauma)
  • Old: low energy (falls), osteoporotic, insufficiency fractures


  • Thigh and knee pain
  • Deformity, if displaced (shortened + externally rotated)
  • Inability to bear weight

Treatment options:

  • Gold standard: Reamed antegrade IM nailing (piriformis entry is inferior to trochanteric entry bc it causes an abductor limp)
    • Reaming of the IM nail has been shown to be equivalent to un-reamed nails in terms of fat embolism, except in pts w\ bilateral lung injuries and bilateral long bone fractures. But reamed nails are superior in terms of time to union of fractures, and therefore; it’s the gold standard
  • Retrograde IM nailing: if ipsilateral femoral neck, tibial, patellar fx (bc you’ll use same entry point). Also, obese pts w\ bilateral femoral shaft fractures
    • Patello-femoral fractures are fixed by retrograde IM nailing of the femur + tension band wiring for the patella (distributes compressive forces around the patella)
Femur fractures 5
Patellar tension band wiring
  • Plate and screws: in ipsilateral femoral neck fx, or distal metaphyseal-diaphyseal junction fx, in children and adolescents (to prevent growth plate disruption which can happen w\ IM nailing)
    • MIPO: minimally invasive plate osteosynthesis -> a technique used to place a long plate through small multiple incisions
    • Plates have grooves so that it doesn’t compromise periosteal vascular supply

Femur fractures 6

  • External fixation w\ conversion to reamed IM nail in 2-3 wks: if the pt has multiple traumas and you want to just to stabilize them and get as less time as possible in the OR
    • You can leave external fixation in femur fractures up to 2-3 weeks before converting to IM nail. While in tibial fractures, it’s up to 7-10 days? Less soft tissue around it -> faster risk of infection

Femur fractures 7

  • Non-operative (long cast): sometimes in non-displaced fx in pts w\ many co-morbidities (not usually used)
  • If vascular compromise in closed femur fx (lateral x-ray will show the edge of the femur going posterior to the knee) -> manual reduction in the ER

Reduction techniques:

  • Supine position using a radiolucent table:
  • Prox femur fracture -> open reduction using a bone clamp to hold the free segment and avoid its rotation while reaming
  • Dist femur fracture -> get the guide rod centered + lag screw technique (to compress fracture segment)

Femur fractures 8


  • Fat embolism: due to the reaming while placing the IM nail -> leading to ARDS. Higher risk w\ bilateral femoral shaft fx and bilateral lung injuries
  • Non-union
  • Malunion and rotational malalignment
  • Infection
  • Nerve injuries 

 Femur fractures 9

Random notes:

  • Always rule out ipsilateral femoral neck fx in femoral shaft fx (incidence is 5-7%)
  • The aim is to restore: alignment, length, and rotation
  • Plates are weight-bearing implants, while IM nails are weight-sharing implants (it shares the weight with the femur bone itself bc it runs w\in the canal)
  • Types of tables used in femoral shaft reduction: radiolucent table (needs extra pair of hands and interlocking screws for alignment) and fracture table w\ traction
  • If you see one or multiple interlocking-screws broken, it may indicate fracture non-union
  • Lag screw with callus formation? Means the screw is loose; converted from primary to secondary healing
  • Blood loss in open-book pelvic fx = 2.5 L, in femur shaft fx (either open or closed) = 1.5-2 L. (Of course, open femur fractures will have blood loss closer to 2 L)



Download the PDF version: here


  • Dr. Khalid Alsheikh’s clinical PBL (This summary has been reviewed and edited by Dr. Khalid)
  • Toronto notes
  • Orthobullets


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