While femoral fractures often occur secondary to serious trauma, they can be seen in low-energy injuries associated with the elderly, osteoporosis, or bone cancer. Diagnosis is usually evident on visualization and confirmed radiographically. Significant hematoma formation and blood loss is common. Patients with comminuted femoral shaft fractures are at risk for fat emboli syndrome. For distal fractures, it is important to rule out intra-articular involvement.
Midshaft Femur Fracture. A closed midshaft femoral fracture. Note the deformity in the middle of the thigh. (Photo contributor: Daniel L. Savitt, MD.)
Femur Fracture. Radiographic examination reveals a comminuted displaced distal femoral fracture. (Photo contributor: Cathleen M. Vossler, MD.)
Management and Disposition
Initial management includes stabilization and evaluation for any life-threatening injuries. A large amount of blood loss (average 1000 mL) can occur; patients should have two large-bore lines and be cross-matched for transfusion. Radiography should include the hip and knee. In-line traction may be required for initial stabilization and to reduce blood loss and pain. This can be held temporarily in the acute setting with a Hare traction or box splint.
Pathologic Femur Fracture. A varus-angulated and mildly displaced fracture through an aggressive, moth-eaten, lytic lesion in the proximal left femoral diaphysis. (Reproduced with permission of Block J, Jordanov MI, Stack LB, Thurman RJ. The Atlas of Emergency Radiology. New York, NY: McGraw Hill; 2013.)
An open fracture is an orthopedic emergency; these patients require tetanus prophylaxis, antibiotic coverage, and emergent irrigation and debridement in the operating room. Orthopedic consultation should be obtained with any femur fracture since the majority requires operative fixation and stabilization.
Pain can be referred. Any injury between the lumbosacral spine and the knee can be referred to the thigh or knee.
Vascular compromise can occur and should be suspected with an expanding hematoma, absent or diminished pulses, or progressive neurologic signs.
Femur fractures can mask the clinical findings of a hip dislocation; thus, radiographs of the pelvis, hips, and knees should be obtained routinely.