2.1 Clinical evaluation

A complete history is an essential part of the clinical evaluation of the patient and should be obtained from the patient if possible and family members when necessary. Specific items include:

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  Level of function prior to injury

  
  
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  Occupation

  
  
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  History of malignancy

  
  
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  History of osteoporosis

  
  
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  History of bisphosphonate use (may be inferred based on the fracture pattern)

  
  
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  History of fracture

  
  
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  History of cognitive impairment

There is evidence that geriatric patients with fractures distal to the hip display functional, cognitive, and comorbidity profiles similar to those of geriatric hip fracture patients [8]. In addition to fracture pattern analysis, the patient′s functional needs, rehabilitation potential (based on functional and cognitive status), and overall medical status are essential to define during initial evaluation. So-called atypical femoral fractures related to bisphosphonate use are discussed in more detail in chapter 3.18 Atypical fractures.

2.2 Imaging

Although patients with FSFs may present with obvious deformities, the fractures must be assessed with a true AP view and a cross-table lateral view of the full femur. Additionally, an AP pelvis x-ray as well as orthogonal hip and knee x-rays should be obtained to assess for concomitant injuries, degenerative changes, or adjacent arthroplasties.

Pain should be appropriately treated prior to any imaging, with a femoral nerve block being a good option. In patients with a history of bisphosphonate use and suspected atypical fracture, the contralateral limb should be imaged to screen for lesions that could indicate impending fractures [9]. Additionally, traction views are valuable for comminuted fractures or fractures with gross angulation [10].

Computed tomography (CT) may be useful in preoperative planning for complex comminuted fractures at the metadiaphyseal junction. An additional benefit of obtaining a CT scan is its ability to infer bone quality based on Hounsfield Units [11–13].

Any patient with a low-energy femoral fracture should be referred for workup of osteoporosis with a dual-energy x-ray absorptiometry study and metabolic bone studies following acute treatment of the fracture.

4.1 Pain management

Pain management is essential, as this can reduce the adrenergic stress on the limited cardiopulmonary and cognitive reserves of most geriatric patients. Recently, studies have investigated the potential benefits of preoperative regional anesthesia for controlling pain while the patient awaits surgery [16, 17].

4.2 Traction

In patients with shortened or angulated FSFs, traction may be applied to the lower extremity to temporarily improve alignment, lengthen the muscles, and reduce spasm while a patient awaits definitive fixation. In a randomized prospective study, there was no difference in pain medication requirements or Visual Analog Scale scores comparing patients who underwent skeletal traction to those who underwent cutaneous traction [18]. Our preference is cutaneous traction for most patients. Adequate padding of the cutaneous traction apparatus is crucial in older patients who are at high risk for pressure ulcers and skin breakdown.

4.3 External fixation

The need for external fixation of FSFs has become less common as the techniques of IM nailing and submuscular plating have improved and their complication rates declined [10]. External fixation is still used as temporary fixation in unstable patients as part of a damage-control approach [19], in patients with an ipsilateral arterial injury that requires repair, and in patients with soft-tissue contamination who will require multiple debridements [20].

4.4 Consideration for nonoperative management

Nonoperative management may be considered in moribund patients with a life expectancy of days to weeks, as long as pain can be controlled. In this case, the injured leg is only positioned in a foam splint or in cutaneous traction for comfort. All other patients should be fixed operatively.

5.1 Intramedullary nailing

Generally, nailing is preferred in FSFs whenever technically feasible. It is a minimally invasive technique that allows for immediate full weight bearing as tolerated. Additionally, the femoral neck may be preventively addressed.

5.1.1 Reduction techniques

Femoral shaft fractures at the isthmus may be treated via closed reduction with the passage of an IM nail. However, more comminuted or complex fracture patterns may require open reduction prior to passing the nail. Surgeons may employ the use of the finger, the “F-tool” (ie, a bar with two attached rods in the shape of an “F” that can be adjusted to accommodate the patient′s leg and assist in reduction of femoral fractures), Schanz pins, blocking screws, or a ball spike pusher to aid in gross reduction of the fracture in order to pass a guide wire ( Case 1: Fig 3.11-1 , Case 2: Fig 3.11-2 ).

CASE 1

Patient

A 63-year-old woman sustained a ground-level fall when a coworker bumped into her.

Comorbidities

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  Diabetes mellitus

  
  
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  Hypertension

  
  
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  Osteoporosis

  
  
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  Hyperlipidemia with previous bisphosphonate use

Treatment and outcome

The patient sustained a transverse midshaft bisphosphonate-related femoral shaft fracture ( Fig 3.11-1a–d ). Beaking of the cortical bone at the level of the fracture could be best seen on the AP view ( Fig 3.11-1d ), and it was consistent with this patient′s history of bisphosphonate use.

Given the transverse nature and the poor bone quality of the patient, the optimal treatment option was an antegrade femoral nail (AFN) that reduced and controlled the fracture and also provided femoral neck protection. Antegrade intramedullary nailing of the left femur was performed in sloppy lateral position and with the standard starting point for a trochanteric entry nail via an open incision. The fracture was reduced with the use of two Schanz pins, one placed in the distal and proximal fragment in order to manipulate the fragments. Once the femur was aligned, a guide wire was passed to the level of the superior patella and measured. Reaming was then performed sequentially from a 9 mm to a 13.5 mm diameter. A 12 mm nail was implanted ( Fig 3.11-1e–i ).

Uneventful healing in anatomical alignment occurred. The authors usually refer patients to a metabolic bone specialist, who may consider use of teriparatide in such patients depending on the results of their metabolic analysis ( Fig 3.11-1j–l).

Key points

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  Consider lateral positioning of patients for passing AFNs.

  
  
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  The use of Schanz pins can obviate the need for open reduction of femoral shaft fractures in certain cases.

  
  
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  In bisphosphonate-related fractures, bilateral femoral x-rays are necessary to look for pathological changes or evidence of impending fracture, even in the absence of symptoms.

  
  
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  Referral to a metabolic bone specialist is recommended in all patients with bisphosphate-related fractures.

CASE 2

Patient

A 67-year-old woman with no history of cognitive impairment. She drank 2 units of alcohol daily, which equals about a glass of wine, beer, or one shot of alcohol, and was living alone. She tripped on a curb sustaining a ground-level fall onto her left lower extremity.

Comorbidities

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  Atrial fibrillation (not on anticoagulation)

  
  
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  Asthma and chronic obstructive pulmonary disease

  
  
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  Previous right lung lower lobectomy

  
  
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  Depression

Treatment and outcome

The AP and cross-table lateral views of the left femur demonstrated a spiral fracture involving the distal third of the diaphysis ( Fig 3.11-2a–d ). The spiral oblique fracture of the distal femoral diaphysis from a low-energy injury resulted in shortening and posterior displacement of the distal femur. Nailing and plating were the two options for fracture fixation:

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  Nailing—given the distal location of this fracture, retrograde nailing was the preferred technique for controlling the fracture.

  
  
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  Plating—another option was the lateral approach to the femur and either direct or submuscular plating.

Retrograde nailing was performed via a paramedical patellar incision. As the fracture was widely displaced, in this case a separate incision was made and Weber clamps were used to perform fracture reduction. The canal was reamed and a 14 mm diameter, 400 mm long retrograde nail was inserted. To augment the fixation, two 1.6 mm braided cables were placed as cerclage wires ( Fig 3.11-2e–h ). Six months after intramedullary nailing, the fracture had healed ( Fig 3.11-2i–l ).

Key point

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  While many diaphyseal femoral fractures can be reduced grossly with the finger, some require minimally invasive or open reduction techniques.

Related posts:

3.5 Olecranon 3.9 Femoral neck 3.6 Distal forearm 3.14 Periprosthetic fractures around the knee 3.1 Proximal humerus 3.17 Ankle

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