Femoral Shaft Fractures



Usually young patients

- 15 - 40


15% compound




High velocity injury



- pedestrian v car

- fall from height


Emergency Managment


EMST principles

- need for transfusion not uncommon

- hypotension from isolated closed femoral fracture unlikely



- ipsilateral NOF / pelvic fracture / acetabular fracture

- knee injury / ACL or other ligament injury

- floating knee / ipsilateral tibial fracture


Thorough neurovascular exam

- incidence vascular injury 1%


Thomas splint

- ring against ischium

- velcro around foot

- pneumatic traction

- can only be applied for 12 hours or so


Thomas SplintThomas Splint


Carbon traction splints


Femur carbon traction splint


Balanced Traction


Balanced traction


Compound wound


Compound femur


Betadine pack




Winquist Classification


Type 1                                                                                                                      

- minimal or no comminution                                                                                                                                            

Femoral Shaft Fracture No comminution                    


Type 2  

- < 50% comminution

Femur fracture


Type 3

- 50 - 100% comminution 

- inherently unstable

- needs distal locking

Femoral fracture


Type 4

- segmental comminution

- no contact or inherent stability


Associated injuries


Femoral Shaft Fracture with Neck Fracture


Up to 10% concurrence

- can be missed on plan film

- splints can obscure



- carefully review pelvic xrays

- order CT if required

- assess carefully using fluoroscopy during surgery




Byon et al. Injury 2018

- 87 knee ligament injuries in 429 femoral shaft fractures (20%)

- 20 PCL, 11 ACL, 16 MCL, 8 LCL and 32 multiligament knee injuries

- always assess knee after femoral stabilisation



Femoral Fracture + ACL Reconstruction


Floating Knee


Ipsilateral femur + tibial fracture


Floating Knee 1Floating Knee 2


Operative Management Issues


Surgical Timing


Early fixation < 24 hours

- indicated for isolated injuries

- reduce risk of pulmonary complications


Harvin et al. J Trauma Acute Care Surg 2012

- compared early stabilisation (<24 hrs) with delayed (>24 hrs)

- retrospective review of 1,376 patients

- early IMN associated with decreased pulmonary complications such as pneumonia / PE / ARDS

- decreased length hospital stay



Damage Control Orthopaedics



- severely injured polytrauma patients

- head / chest / abdominal / pelvic injuries

- patients have elevated cytokines (IL-6) in multitrauma

- avoid second hit of surgery during this period

- second hit may be associated with ARDS and multi-organ failure



- stabilise femoral fracture with simple external fixator

- allow return to ICU for warming / stabilisation

- delay definitive treatment until inflammatory state reduces

- approximately day 6




Pape et al J Orthop Trauma 2002

- retrospective study of polytrauma patients at risk of multi-organ failure

- patients treated with early IMN femur v DCO (early stabilisation femur external fixation with later IMN)

- significant reduction in incidence of multiorgan failure

- significant reduction ARDS (15% down to 9%)

- no increased rate of local complications (infection, non union)



Surgical Options


1. External fixation

2. IMN

3. Plate


1. External Fixation



- severely contaminated wound

- Damage Control Orthopaedics

- complex femoral fracture with vascular injury


AO Surgery Technique

- safe zone is lateral



Timing of conversion to IMN


Harwood et al J Orthop Trauma 2006

- two groups

- 81 patients treated with early IMN

- 111 patients treated with external fixation converted to IMN at mean of two weeks

- at time of surgery, pin sites excised, washed, and overdrilled

- no difference in deep infection rates between two groups



2. Antegrade Femoral Nail


Femoral Nail0001Femoral Nail


Reamed v Unreamed IMN


Nonunion rates


Canadian Orthopaedic Trauma Society (COTS) JBJS Am 2003

- multicentred randomised trial

- non union rates reamed v unreamed IMN

- 8 / 107 (7.5%) smaller unreamed femoral nail nonunion

- 2 / 121 (1.7%) larger reamed femoral nail nonunion



Li et al. Medicine 2016

- meta-analysis of 8 RCT and 1078 patients

- reamed nails had shorter times to union

- reamed nails had reduced rates of nonunion and reoperation

- no increased rates of ARDS, mortality or blood loss with reaming





Canadian Orthopaedic Trauma Society (COTS) J Orthop Trauma 2006

- multicentred randomised trial reamed v unreamed

- incidence ARDS in multiply injured patients

- 3/63 reamed v 2/46 unreamed developed ARDS

- very low incidence of ARDS in both groups

- not statistically significant



Trochanteric v Piriformis Entry Point


Kumar et al. Injury 2019

- systematic review of 9 studies

- trochanteric entry reduced OR time, fluoroscopy time, reduced abductor weakness, better functional outcome

- similar union rates



3. Femoral Plate



- associated proximal / distal femoral fracture

- vascular injury

- medulla too narrow for IMN

- paediatric population

- treatment of non union



- tension side / load bearing

- significant disruption to blood supply required

- plate will break early if union not achieved



- large fragment plate

- minimum 8 cortices each side of fracture

- need periord of NWB




Giessler et al Orthopedics 1995

- 71 femurs diaphyseal fractures

- 93% union at 16 weeks

- recommended bone grafting at same time



Difficult Scenarios


1. Floating Knee


Single incision at knee

- retrograde femoral nail

- tibial IMN if appropriate


High complication rates including non union / malunion, knee stiffness and hetertopic ossification






Floating Knee 1Floating Knee 2Floating Knee 3


2. NOF (Neck of Femur) + Femoral shaft fracture


Must pay attention first to meticulous NOF ORIF



1.  Pin and Plate NOF / Retrograde Nail

2.  Pin and Plate NOF / Plate femur

3.  Reconstruction Nail

- difficult to anatomically reduce NOF

- increased incidence NOF non union


Difficult scenario

- antegrade IMN in place before diagnosis of NOF fracture

- if undisplaced, can place screws anterior to nail

- if displaced must remove nail




Ostrum et al. CORR 2014

- 95 cases treated with proximal screws / sliding hip screws inserted first

- retrograde IMN second

- 98% union rate femoral neck

- 91% union rate femoral shaft



Vumedi video



3. Dislocated Hip + Femoral shaft fracture


1.  Simple dislocation

- may be able to reduce hip with proximal steinman pin

- then IMN femur / retrograde or antegrade

- or plate femur


2.  Dislocation with Pipkin fracture

- may need anterior approach to ORIF femoral head fracture

- may be best to plate / retrograde nail femur


3.  Dislocation with posterior acetabular fracture

- may need posterior approach to acetabulum

- consider plating femur / distal femoral or tibial steinman pin

- delayed ORIF posterior wall


4. Distal femoral condylar fracture + shaft fracture



1.  Screws anterior and posterior to retrograde nail

2.  Distal Locking plate


5. Bilateral Femur Fractures


Lane et al. Orthopedics 2015

- 72 patients

- high rate of complications

- mortality rate 6.9%

- increased risk of DVT and pulmonary complications



Stavlas et al. Injury 2009

- systematic review 197 patients

- treated with bilateral reamed IMN

- fat embolism 4.1%

- ARDS 14%

- PE 7%

- suggest damage control orthopaedics



6.  Segmental bone defects / critical bone defects



- temporary fixation with nail / plate / ext fix

- cement spacer

- delayed Masquelet technique / induced membrane technique at 6 - 8 weeks


Morwood et al. J Orthop Trauma 2019

- 65 femurs with critical bone loss

- increased union, time to weight bearing with IMN v plate

- fewer grafting procedures and reoperations with IMN



Trochanteric Entry Antegrade Femoral Nail Surgical Technique


Vumedi Video



Smith and Nephew Trigen TAN FAN




- GA, IV ABx, transexamic acid

- traction table

- patient legs adducted, torso adducted

- allows access to GT

- flex and abduct other hip for image intensifier / fluoroscopy access



- incision proximal to GT

- split abductors in line

- palpate tip of GT

- check entry point on AP xray view

- check entry point on lateral xray view (junction anterior 1/3 posterior 2/3)

- entry with awl or 3.2 mm guide wire

- ensure wire doesn't penetrate medial cortex

- use proximal reamer for thickened proximal portion of nail


Pass guide wire

- ball tipped

- femoral fractures difficult to reduce with traction

- use reduction tool to reduce in AP and lateral views to pass guidewire

- if having difficulty +++, can perform miniopen incision to pass guide wire

- measure guide wire to determine nail length


Note typical deformity of proximal fragment which needs to be corrected

- flexed by psoas

- abducted by G medius

- externally rotated


Femoral Shaft Fracture Standard Displacement Lateral



- tight fit best

- nails come in 8.5, 10, 11 and 12 mm

- need to ream 1 - 2 mm larger than nail


Pass nail

- attach to proximal locking jig

- ensure drill passes through jig into proximal nail holes

- insert nail

- visualise with flurosocopy at fracture site

- ensure nail doesn't get caught on one cortex

- excessive hammering in this position can cause fracture





- usually proximal locking first

- screw should purchase cortex of lesser trochanter


Femoral Nail Proximal Locking0001Femoral Nail Proximal Locking0002



- straighten out other leg / lower so can obtain lateral II

- perfect circle technique

- distal locking performed


Femoral Nail Distal Locking0001Femoral Nail Distal Locking0002




Arazi et al. J Trauma 2001

- 24 patients with comminuted femoral fractures allowed to weight bear in first 2 weeks

- all full weight bearing without aids by second month

- 100% union

- 2 slightly bent locking screws


Complications of Femoral Nail


Nerve Palsy


Kao et al. 1993 J Orthop Trauma

- 15% incidence pudenal nerve palsy

- usually transient

- related to longer traction times








> 100 may be prevalent in up to 40% of patients

Probably not relevant unless > 300

May be associated with anterior knee pain and/or hip pain




A.  Clinical

- difficult

- probably best to assess internal and external rotation of the hip

- when swelling goes down can assess internal and external rotation of the foot


B.  CT

- axial cuts of the femoral neck and the femoral condyles


Femoral Nail Malrotation CT 1Femoral Nail Malrotation CT 2




A.  Match cortices on the proximal and distal fragment


B. Both patellas pointing anterior

- match lesser trochanter position of  both hips




A.  Early

- remove distal locking screws but leave in wires

- correct rotation based upon CT measurement

- insert new distal locking screws at the predetermined angle from previous screws


B.  Late

- may need osteotomy


Vergano 2020 Summary article



Distal femoral breach



- insufficient curvature of femoral nail

- abnormal femoral curvature

- posterior starting point on the greater trochanter


Distal femoral breachDistal Breach ORIF


Non union


Femoral Non union




- uncommon

- 1 - 2% with reamed nails

- increased with unreamed nails



- not united (3/4 cortices) after 6 months

- no progressive union for 3 months



1.  Dynamisation / removal of distal locking screws

2.  Exchange nailing +/- bone graft

3.  Remove nail / plate + bone graft

4.  Augmentation with plating and bone grafting

5.  External Fixation


1.  Dynamisation



- stable fractures

- non comminuted / non segmental

- evidence of fracture gapping from over traction or bone resorption


Huang et al. Injury 2012

- 39 patients

- union rate 83% when dynamisation performed 10 - 24 weeks

- union rate 33% when dynamisation performed after 24 weeks



Vaughn et al. World J Orthop 2018

- systematic review of exchange nail v dynamisation

- union rate dynamisation 66%

- exchange nail union rate 85%

- dynamisation good for delayed union

- exhange nail best for nonunion



2.  Exchange nailing



- remove old nail

- ream up to larger size

- insert new larger nail


Swanson et al. J Orthop Trauma 2015

- 50 cases

- removal of nail, ream

- insertion of different manufacturer nail at least 2 mm bigger

- static locking

- early dynamisation if signs slow healing

- union in 100% at mean 7 months



Tsang et al. Injury 2015

- risk factors for failure of exchange nail

- infection

- cigarette smoking

- may require repeat procedure

- technique eventually successful in 91%



3.  Removal Nail / Plating / Bone Graft


Maimaitiyiming et al. Injury 2015

- 14 patients nonunion

- bone grafting and double plating

- union in 100% at mean of 5 months



4.  Augment nail with Plate + Bone Graft


Medlock et al. Strategies Traumatic Limb Reconstruction 2018

- systematic review of augmentive plating v exchange nailing

- union rate 99.8% with augmentive plating

- 74% with exchange nail



Infected Non union


Exchange Nail Bone Graft




1.  Open debridement

- antibiotic beads


2. Removal of nail

- ream and irrigate

- antibiotic nail / cover IMN with antibiotic cement

- IV antibiotics

- definitive nail / external fixator


Pradhan et al. Injury 2017

- infection nonunion femoral shaft 21 patients

- infection eliminated in 100%

- union in 16/21, others required further surgery to obtain union

- 2 broken nails due to noncompliance with weightbearing



Infected Femoral Nail 1Infected Femoral Nail2Infected Femoral Nail3Infected Femoral Nail4




No evidence increased risk if nail removed > 1 year