Last updated:
November 17, 2025
Table Of Contents
Femoral Shaft Fracture
Femoral shaft fractures are fractures of the diaphysis of the femur. They have a bimodal distribution with high-energy mechanisms in young individuals and low-energy mechanisms in older osteoporotic patients. Closed fractures can lose 1000 – 1500 ml of blood, while open fractures lose 2000 – 3000 ml of blood. They carry a high risk of fat embolism (especially bilateral femur fractures) and are often associated with other life-threatening injuries. Open femoral shaft fractures are an orthopaedic EMERGENCY and require surgical treatment within 6 hours. Most femoral shaft fractures are managed operatively unless the patient is too sick to be operated on or refuses surgery.
Winquist and Hansen Classification: historical classification used to determine whether the femoral shaft fracture required locking, weight-bearing status post-op and prognosis, e.g. degree of malunion. It is not useful nowadays due to the full locking capabilities of implants and full post-op weight bearing with IM nails.
| Classification | Description |
|---|---|
| Type 0 | No comminution |
| Type I | Insignificant amount of comminution |
| Type II | Comminution with greater than 50% cortical contact |
| Type III | Comminution with less than 50% of cortical contact |
| Type IV | Segmental fracture with no cortical contact between the proximal and distal fragment |
- Anatomy
- The femoral shaft has an anterior bow with an isthmus (narrowest part of the intramedullary canal)
- It has a linea aspera in the posterior cortex that acts as a compressive strut against the anterior bow
- The medial cortex is under compression while the lateral cortex is under tension
- The thigh has 3 compartments – anterior posterior and adductor compartment
- Anterior compartment includes sartorius and quadriceps
- Posterior compartment concists biceps femoris, semitendinosus and semimembranosus
- Adductor compartments consists of gracilis, adductor longus, adductor brevis and adductor magnus
- The 2 major arteries include the:
- Profunda femoris: disruption leads to hemorrhage
- Superficial femoral: disruption leads to distal ischemia since it enters the distal extremity as the popliteal artery
- Significant nerves include the sciatic, femoral and obturator nerve. Sciatic nerve damage is most concerning
- Deforming forces
- Proximal flexion by the iliopsoa
- Proximal abduction by the gluteus minimus and medius
- Distal adduction by adductors
- Distal flexion by the gastrocnemius
- Mechanisms
- High-energy mechanism
- High-speed MVA (most common mechanism)
- Low-energy mechanism
- Fall from standing height
- Gunshot
- High-energy mechanism
- Associated injuries
- Ipsilateral femoral neck fracture (2 – 6%, vertically oriented non-displaced basicervical, easy to miss)
- Bilateral femoral shaft fracture (significant risk of pulmonary embolism and increased mortality)
- Ipsilateral tibia shaft fracture
- Ipsilateral acetabular fracture
- Signs and symptoms
- Severe thigh pain
- Tenseness
- Tenderness and swelling
- Limb length shortening
- External rotation (not all the time)
- Physical examination
- Swollen thigh
- Thigh tenderness
- Shortening of the affected limb
- Neurovascular examination
- Investigations
- X-ray: AP and lateral view of the hip-joint, full-length femur and knee joint
- AP internal rotation 15 – 20 degreees hip X-ray
- CT-scan fo the hip: to rule out associated femoral neck fracture
- 1 mm capsular distension between injured and uninjured sides on the axial soft tissue window (capsular sign)
- CBC, ESR, CRP
- X-ray: AP and lateral view of the hip-joint, full-length femur and knee joint
- Imaging to rule out ipsilateral femoral neck fracture
- 10 degrees internal rotation AP hip radiograph (femoral neck is placed in profile)
- Fine-cut CT-scan of the hip
- Intra-operative AP and lateral fluoroscopy of the ipsilateral hip
- Post-operative hip x-rays
- Initial management of femoral shaft fracture
- Thomas splint
- Skeletal traction
- 15% of patient body weight to pins
- Distal femur pin (medial to lateral to avoid injuring the femoral artery), or
- Proximal tibia pin ( 2 cm posterior and 2cm inferior of the tibial tuberosity lateral to medial to avoid injury to the common peroneal nerve)
- Cutaneous traction (Bucks traction)
- Non-operative treatment of femoral shaft fractures
- Long-leg cast or hip spica for paediatric patients or non-operative candidates
- Operative treatment
- External fixator: temporary stabilization for damage control orthopaedics. Converted to nail in 2 – 3 weeks
- Open reduction internal fixation (ORIF) with plate: has an increased risk of infection, non-union and failure
- Locked Intramedullary (IM) nail: preferred mode of treatment. Rate of malunion increased when the starting point is opposite the fracture site e.g. antegrade nail for a distal femoral shaft fracture. Reaming increases union, decreases time to union with no change in pulmonary complications
- Complications of antegrade nails
- Hip pain
- Abductor or quadricep weakness
- Reduced hip range of motion
- Heterotopc ossification
- Iatrogenic femoral neck fracture
- Complications of retrograde nails
- Knee pain
- Cartilage injury
- Cruciate ligament injury if starting posterior to Blumensaat’s line
- Complications of femoral shaft fracture
- Shock
- Fat embolism
- Deep venous thrombosis
- Pulmonary embolism
- Heterotopic ossification
- Avascular necrosis
- Pudendal nerve injury (10%, excessive traction on fracture table, presents with erectile dysfunction)
- Peroneal nerve injury
- Compartment syndrome (non-injured legs in hemilithotomy position, more common in ballistic injuries compared to blunt injury)
- Femoral artery or nerve injry
- Anterior perforation of distal femur if there is a nail/femur radius of curvature mismatch
- Iatrogenic femoral neck fracture
- Delayed-union
- Aseptic non-union
- Septic non-union
- Malunion
- Implant failure
- Hip pain or limp from antegrade nail
- Knee pain or retro-patellar arthritis from a retrograde nail