Introduction

Major injuries are commonly the result of high-energy mechanisms. They are often associated with life-threatening conditions. Reported incidence of femoral shaft fractures is 37.1 per 100,000 person-years. The mortality rate was upward of 80% during the early part of the First World War. Treatment progressed with the introduction of the Thomas splint (▶ Fig. 35.1 ). Subsequently, femoral shaft fractures were treated with traction typically for weeks or months. Intramedullary fixation was first introduced by Gerhard Kuntscher in 1939.

I. Preoperative

1. 
   

   History and physical examination

   
   
   
   
   1. 
      

      Age and medical comorbidities:

      
      
      
      
      1. 
         

         Older patients with osteoporosis may have excessive bow (smaller radius of curvature) to the femur.

         
         
      2. 
         

         Comorbidities including morbid obesity may influence patient positioning and choice of nailing technique.

      
      
   2. 
      

      Mechanism of injury:

      
      
      
      
      1. 
         

         High-energy mechanisms in younger populations are frequently a result of high-speed motor vehicle accidents.

         
         
      2. 
         

         Low-energy mechanism is more common in the elderly population as a result of a ground level fall; also rule out metastatic lesion in the elderly populations, especially if there are prodromal symptoms.

      
      
   3. 
      

      Other pertinent information from history:

      
      
      
      
      1. 
         

         Time elapse from injury to presentation.

         
         
      2. 
         

         Need for prolonged extrication.

      
      
   4. 
      

      Physical examination:

      
      
      
      
      1. 
         

         Advanced trauma life support protocols are followed in initial evaluation.

         
         
      2. 
         

         Examination should include visual inspection and palpation of all extremities, the pelvis, and the spine. Circumferential inspection of the extremity is done to look for associated open wounds, degloving injuries, bruising, and abrasions.

         
         
      3. 
         

         Pain and swelling at the thigh with obvious deformity is common. Blood loss ranges from 1,000 to 1,500 mL for closed injuries.

         
         
      4. 
         

         Focused examination of the knee ligaments and associated soft tissues is necessary, though often optimally performed at the conclusion of surgical stabilization.

      
      
   5. 
      

      Associated orthopaedic injuries:

      
      
      
      
      1. 
         

         Ipsilateral femoral neck fractures:

         
         
         
         
         • 
           

           i. Incidence of 2 to 6%; missed up to 31% of the time.

           
           
         • 
           

           ii. Often vertical and basicervical.

         
         
      2. 
         

         Ipsilateral knee injuries:

         
         
         
         
         • 
           

           i. Ligamentous laxity reported as high as 50%.

           
           
         • 
           

           ii. Approximately 25% risk of lateral or medial meniscus injury.

   
   
2. 
   

   Anatomy

   
   
   
   
   1. 
      

      The femoral shaft is the longest and strongest bone in the body.

      
      
   2. 
      

      The femoral diaphysis extends from 5 cm distal to the lesser trochanter to 5 cm proximal to the adductor tubercle.

      
      
   3. 
      

      The anterior bow is 12 to 15 degrees with a radius of curvature of approximately 120 cm. The radius of curvature decreases with age and the diameter of the intramedullary canal increases with age (▶ Fig. 35.2 ).

      

      
      
   4. 
      

      The thickened posterior cortex coalesces into a ridge known as the linea aspera.

      
      
   5. 
      

      The lateral cortex is under tension and the medial cortex is under compression.

      
      
   6. 
      

      Compartments (▶ Fig. 35.3 ):

      

      
      
      
      
      1. 
         

         Anterior:

         
         
         
         
         • 
           

           i. Sartorius, quadriceps.

           
           
         • 
           

           ii. Most commonly involved in compartment syndrome of the thigh.

         
         
      2. 
         

         Posterior—biceps femoris, semitendinosus, semimembranosus.

         
         
      3. 
         

         Medial—gracilis, adductor longus, adductor brevis, adductor magnus.

      
      
   7. 
      

      Major muscle-deforming forces:

      
      
      
      
      1. 
         

         Proximally—iliopsoas on the lesser trochanter (flexion, external rotation), the gluteus medius/minimus on the greater trochanter, and the gluteus maximus on the linea aspera.

         
         
      2. 
         

         Distally—adductors on the linea aspera and pectineal line, and gastrocnemius on the posterior aspect of the lateral and medial femoral condyles.

      
      
   8. 
      

      Vascular:

      
      
      
      
      1. 
         

         External iliac artery becomes the femoral artery as it passes underneath the inguinal ligament and enters the anterior compartment through the femoral triangle.

         
         
      2. 
         

         Profundus gives off numerous perforating branches along the length of the femur.

         
         
      3. 
         

         Main blood supply to the femur comes from the profunda and nutrient vessel, which enters posteriorly and proximally near the linea aspera.

         
         
      4. 
         

         Femoral artery is closest to the medial aspect of the femur 4 cm distal to the lesser trochanter. AP interlocks placed in retrograde nails are at risk of injuring the artery when the proximal nail ends below the lesser trochanter.

   
   
3. 
   

   Imaging

   
   
   
   
   1. 
      

      Initial workup:

      
      
      
      
      1. 
         

         Anteroposterior (AP) and lateral views of the entire femur including the hip and knee.

         
         
      2. 
         

         AP and lateral views of the hip.

         
         
      3. 
         

         AP and lateral views of the knee.

      
      
   2. 
      

      Additional imaging—fine-cut (2-mm) CT scan advocated as screening tool to evaluate for femoral neck fracture.

      
      
   3. 
      

      Special considerations—intraoperative fluoroscopic view of the femoral neck with the leg internally rotated 15 degrees and intraoperative AP view of the pelvis and AP and lateral views of the femur following surgical fixation to evaluate for femoral neck fracture (▶ Fig. 35.4a–d ).

      

   
   
4. 
   

   Classification

   
   
   
   
   1. 
      

      AO/OTA: the femur is designated as zone “3” and the shaft is designated as zone “2.”

      
      
      
      
      1. 
         

         32A: simple:

         
         
         
         
         • 
           

           i. A1: spiral.

           
           
         • 
           

           ii. A2: oblique, angle ≥ 30 degrees.

           
           
         • 
           

           iii. A3: transverse, angle less than 30 degrees.

         
         
      2. 
         

         32B: wedge:

         
         
         
         
         • 
           

           i. B2: intact wedge.

           
           
         • 
           

           ii. B3: fragmentary wedge.

         
         
      3. 
         

         32C: multifragmentary:

         
         
         
         
         • 
           

           i. C2: intact segmental.

           
           
         • 
           

           ii. C3: fragmentary segmental.