Summary

The femur is the strongest bone in the body. Fractures typically require high-energy trauma (MVC, pedestrian struck) in the young, or low-energy falls in the elderly (spiral fractures). It is a life-threatening injury due to hemorrhage (1-2 Litres into the thigh) and the risk of Fat Embolism Syndrome. Treatment is universally surgical (Intramedullary Nailing). A dreaded complication is the missed Ipsilateral Femoral Neck Fracture, which occurs in 5-10% of high-energy shaft fractures and must be actively sought (CT Scan). [1,2,3]

Key Facts

• Hemorrhage Class: A single closed femur fracture can cause Class II or III shock (1500ml blood loss).
• Fat Embolism Syndrome (FES): Marrow fat enters the venous system. Triad: Hypoxia, Confusion, Petechial Rash. Early stabilization (Nailing) reduces this risk.
• The "Floating Knee": Fracture of the femoral shaft AND ipsilateral tibial shaft. The knee is disconnected from the skeleton. High rate of ligamentous injury and vascular damage.

Clinical Pearls

"Fix the Neck First": If there is an ipsilateral neck fracture and shaft fracture, the neck takes priority. A missed neck fracture leads to AVN and definitive disability. Fix the neck with screws, then nail the shaft (Retrograde or Cephalomedullary).

"Traction Splint": The Thomas Splint or Kendrick Traction Device is critical in pre-hospital care. It reduces pain, reduces bleeding (tamponade), and aligns the leg. Contraindication: Suspected Ipsilateral Neck Fracture (traction may pull the head off).

"The Third Fragment": In high energy comminuted fractures, look for a large butterfly fragment. If it is on the medial side, stability is compromised.

              FEMORAL SHAFT FRACTURE
                       ↓
              TRAUMA RESUSCITATION
             (Splint / IV Access / CT)
                       ↓
              STABLE? (Physiologically)
              ┌───────┴───────┐
             YES             NO
          (EUC)        (Damage Control)
             ↓                ↓
       DEFINITIVE FIXATION   EXTERNAL FIXATION
        (Within 24 hours)    (Stop bleeding)
             ↓                ↓
       FRACTURE LOCATION?    ICU -> CONVERT
      ┌──────┴───────┐       TO NAIL (Day 5)
   PROXIMAL/MID    DISTAL
      ↓              ↓
  ANTEGRADE NAIL  RETROGRADE NAIL
      OR             OR
  PLATE (If neck) PLATE (If intra-articular)

1. Damage Control Orthopaedics (DCO)

• Indication: Patient in extremis (pH <7.2, Lactate >4, Coagulopathy, Hypothermia). This is the "Triad of Death". Long surgery (Nailing) will kill them via inflammatory "Second Hit".
• Action: External Fixator (<30 mins). ICU.
• Conversion: Convert ExFix to Nail when stable (usually Day 4-7).

2. Intramedullary Nail (Gold Standard)

• Antegrade Nail: Entered via Greater Trochanter (Piriformis Fossa).
  • Pros: Gold standard. 98% union rate.
  • Cons: Hip abductor damage (limp).
• Retrograde Nail: Entered via Knee (Intercondylar notch).
  • Pros: Good for distal fractures, obesity, bilateral fractures (no need to reposition patient).
  • Cons: Opens the knee joint (septic arthritis risk).

3. Open Reduction Internal Fixation (Plating)

• Indication:
  • Distal/Proximal fractures extending into joint.
  • vascular injury (needs repair first).
  • paediatric patients (physeal sparing).
• Cons: Huge incision, strips periosteum, slower healing, higher infection rate.

The SPRINT Trial (2008)

• Question: Reamed vs Unreamed Nails?
• Result: Reaming (drilling the canal) stimulates blood flow/healing but theoretically pushes fat emboli. Trial showed Reaming is safe and leads to lower non-union rates.

BOAST 4 Guidelines (Open Fractures)

• Antibiotics <1h.
• Debridement immediately (if highly contaminated/vascular) or <24h.
• Coverage (Plastic surgery) <72h.

The Injury

You have snapped the thigh bone. It is the strongest bone in your body. It takes a huge force to do this.

The Operation

We put a "Rod" (titanium nail) down the hollow centre of the bone. This acts as an internal splint. It shares the load so you can walk on it almost immediately.

Recovery

• Walking: You can walk tomorrow with crutches.
• Driving: 6-8 weeks (when you can emergency stop).
• Healing: 3-6 months for full consolidation.

Q1: What are Gurd's Criteria for Fat Embolism Syndrome? A: Diagnosis requires 1 Major + 4 Minor.

• Major: (1) Petechial Rash (Axilla/Conjunctiva - pathognomonic). (2) Respiratory Insufficiency (Hypoxia). (3) Cerebral Involvement (Confusion/Coma).
• Minor: Tachycardia, Pyrexia, Retinal changes, Jaundice, Renal impairment.

Q2: How do you treat a femoral shaft fracture with an ipsilateral neck fracture? A: Priority to the Neck. The neck fracture threatens the hip joint (AVN). I would fix the neck first (usually with Cannulated Screws or a DHS) BEFORE nailing the shaft, to avoid displacing the neck during nail insertion. Alternatively, use a Reconstruction Nail (Cephalomedullary nail) which sends screws up into the neck through the nail, fixing both.

Q3: Define "Damage Control Orthopaedics". A: A strategy for physiolgically unstable polytrauma patients (Acidosis, Coagulopathy, Hypothermia). The goal is to minimize the "Second Hit" of surgery. We perform rapid, temporary stabilization (External Fixation) <30 mins, resuscitate in ICU, and return for definitive Nailing days later when the patient is stable (Day 5-7).

(End of Topic)