Standard compression plating can be done in any simple fracture pattern (transverse, spiral, short oblique) through a direct lateral approach or through a traumatic wound. Anatomic reduction of the fracture in these simple patterns can be performed directly with reduction clamps. Interfragmentary lag screws should be placed if possible, and then a large fragment compression plate can be placed laterally to be used as a neutralization plate. Current recommendations suggest three to four well-spaced bicortical screws proximal and distal to the fracture site through a 10–14-hole plate to provide long, balanced fixation.

If there is a significant amount of comminution present, bridge plating can be considered. Reduction of the fracture mostly occurs indirectly in these fractures. Direct manipulation of fragments can be undertaken, but care should be taken to avoid stripping the soft tissues from any pieces. Correct length, alignment, and rotation of the femur must be restored. Longer plates are typically required and should ideally have a bow in order to restore the patient’s normal anatomic femoral bow. Comparison radiographs of the uninjured leg can be a helpful adjunct in significantly comminuted fractures or in open fractures with a significant amount of bone loss. One can also consider prepping the nonoperative limb into the operative field for direct comparison.

Percutaneous bridge plating is also an option. A small incision is made through the tensor fascia lata at the level of the epicondyle distally, and a counter incision is made laterally at the level of the vastus ridge. The plate can then be slid submuscularly in a retrograde fashion. Typically the plate is then attached to the bone with a single bicortical screw at one of the incisions, and the leg is then manipulated to gain a reduction prior to fixation through the opposite incision. Care must be taken as mentioned above to assure that the correct length, alignment, and rotation has been accomplished prior to fixation. Additional screws can then be placed percutaneously into the plate with the goal of four well-spaced bicortical screws on both sides of the fracture site.

Most femoral diaphyseal fractures can be managed with an antegrade femoral nail, and antegrade nailing is the preferred method of treatment of these authors. Common positioning strategies include supine on the fracture table with the limb in a traction boot or skeletal traction, supine on a radiolucent table with a large bump underneath the patient’s injured hip and the entire limb draped free into the field, or lateral either on a traction table or with the limb draped free. Each position has its advantages and disadvantages. Use of a fracture table may be helpful when a surgeon does not have any assistants as the fracture position is maintained by the traction (Fig. 6.4). The fracture tends to sag on the fracture table, however, and reaching the piriformis fossa can sometimes be a challenge, especially in obese patients. The supine position on a radiolucent table is preferentially employed at many centers where ample help available. Setup time is minimal. The limb can be manipulated during the procedure to assist in obtaining an appropriate starting point in the piriformis fossa or greater trochanter, depending on the type of nail selected. Assistants are necessary to manipulate the limb, or a distal femoral or proximal tibial traction pin may be placed to facilitate regaining length and achieving reduction (Figs. 6.5 and 6.6). Finally, the lateral position is extremely useful when nailing morbidly obese patients in an antegrade fashion, but setup time can be quite extensive. This position provides easier access to the piriformis or trochanteric starting point. It can also be advantageous in very proximal femoral shaft fractures in order to counteract the usual flexion deformity in these types of fractures. However, fluoroscopic visualization of the proximal femur is difficult in the lateral position, and care must be taken to avoid allowing the distal fragment to drift into valgus because of gravity.

As noted, modern nail instrumentation allows the surgeon to choose nails designed to be inserted either through the piriformis fossa in line with the canal or through the greater trochanter slightly lateral to the femoral canal. No compelling data demonstrate superiority of one approach over the other. Both nail types contain an anterior bow, and the trochanteric nails also have a lateral bend proximally to account for the off-axis starting point. Modern straight femoral nails should not be placed through a greater trochanteric insertion point because the femoral neck is at risk of being damaged by the stiff nail, and this tends to malreduce the fracture. Similarly, one must be very meticulous with reduction of the fracture when using trochanteric start nails to assure that the implant does not force the femur into varus upon insertion.

It is also critical to ream the canal with the fracture site well reduced. Fluoroscopy should be used during reaming to assure that the canal is not eccentrically reamed at the fracture site. Passage of the nail will facilitate improved alignment when the fracture is in the isthmus, the narrowest portion of the femoral diaphysis. However, if the fracture is proximal or distal to the isthmus and the canal eccentrically reamed, reduction may not be affected by nail passage. Most sources now recommend a ream to fit approach, and most manufacturers recommend over-reaming 1 mm larger than the selected nail size. In straightforward diaphyseal femur fractures, a smaller nail (typically an 11 or 12 mm nail) is sufficient in most adult femur fractures.

Multiple established indications for retrograde femoral nailing include but are not limited to ipsilateral femoral neck fractures identified prior to nailing, ipsilateral tibia fracture (“floating knee” injuries), ipsilateral acetabulum fractures, bilateral femur fractures, morbid obesity, and pregnancy. Some centers preferentially treat virtually all femoral shaft fractures with a retrograde reamed nailing technique, citing ease of positioning, relative rapidity of the procedure, and equivalent functional results as support. As in antegrade nailing, the starting point is critical in retrograde nailing and must be in line with the somewhat more distant canal to avoid creating angular malalignment. The knee joint and proximal femur must both be adequately visualized using fluoroscopy. The nail is inserted through an entry point in the knee joint at the level of Blumensaat’s line on the lateral view and just anterior to the posterior cruciate ligament fibers.