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Femoral Shaft Fracture

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Other Names

  • Femur Fracture
  • Femoral Diaphysis fracture
  • Atypical Femoral Shaft Fracture
  • Atypical Femoral Fracture (AFF)
  • Femoral Diaphyseal Fracture
  • Diaphyseal Femur Fracture
  • Midshaft Femur Fracture
  • Femoral Midshaft Fracture
  • Femoral Bone Shaft Fracture

Background

History

  • Hippocrates (c. 460–370 BCE), who described long-bone fractures (including the femur) and their management using traction and splinting techniques[1]
  • More detailed anatomic and clinical descriptions of femoral fractures emerged in the early 1800s, particularly among European surgeons[2]
  • The first documented operative attempt was in the 1850s by Bernhard von Langenbeck[3]

Epidemiology

  • Bimodal distribution in young healthy males (15-35) and elderly females (Over 60)
  • Worldwide incidence between 10 and 21 per 100,000 per years[4]
  • Approximately 2% of femoral shaft fractures are open[5]

Introduction

PA and lateral view of a mid shaft femoral shaft fracture[6]
Illustration of two types of femoral shaft fracture
Some types of femoral shaft fractures
Pre and post op illustration[7]

General

  • Femoral shaft fractures are significant injuries affecting the diaphyseal region of the femur
  • Most commonly seen in violent trauma in young males and minor trauma in geriatic patients
  • Diagnosis is suspected clinically and confirmed radiographically
  • Intramedullary nailing represents the gold standard treatment for most adult femoral shaft fractures

Terminology

  • Classically defined as the region from 5 cm below the lesser trochanter to the metaphyseal flare proximal to the femoral condyles

Etiology

  • High energy trauma most common in younger patients
    • Typically motor vehicle crash (87%), fall from elevation[8]
  • Low energy trauma in elderly patients
    • Most commonly fall from standing, pathologic

Anatomy of the Femur

Associated Injuries

Risk Factors

Bone Quality & Metabolic Factors

Pathologic Bone Conditions

  • Primary bone tumors (e.g., osteosarcoma)
  • Metastatic disease (e.g., breast, prostate, lung cancer)
  • Paget disease of bone[19]
  • Bone cysts or benign lesions

Medications

  • Long-term corticosteroid use
  • Bisphosphonate-associated atypical femur fractures[20]
  • Anticonvulsants (via effects on bone metabolism)

Repetitive Stress / Overuse

Demographic & Lifestyle Factors

Differential Diagnosis

Differential Diagnosis Thigh Pain

Differential Diagnosis Hip Pain

Clinical Features

A midshaft femur fracture is in a field traction splint with obvious swelling[21]

History

  • Characterize the mechanism of injury and trauma, including any other potential injuries[22]
  • Patient endorses severe thigh pain, inability to weight bear
  • Patients often endorse swelling, bruising
  • Often there is a visible deformity or limb shortening

Physical Exam: Thigh Exam Main

  • Tense, swollen, edematous thigh due to bleeding into fracture space
  • Deformity and abnormal limb positioning may or may not be present
  • Leg may be internally/ externally rotated, shortened
  • Tenderness at fracture site
  • A thorough neurovascular exam must be performed
    • Vascualr injuries occur in less than 1% of all long bone fracutres[23]

Special Tests

  • There are no dedicated special physical examination maneuvers specific for diagnosing femoral shaft fractures

Evaluation

Displaced, transverse, mid diaphyseal femur fracture
Distal femur with traction pin

Radiographs

CT

  • Typically not indicated
  • Can be used for fracture characterization, detection of radiographically occult fractures, or operative planning[24]
  • Can be useful for ipsilateral femoral neck fractures

MRI

  • Not indicated for femoral shaft fracture
  • May be considered for ipsilateral femoral neck fractures[25]

Ultrasound

  • Not routinely used in femoral shaft fracture evaluation
  • Can detect long bone fractures with sensitivity 64-100%, specificity 79-100%[26]
  • May be able to evaluate for hemorrhage or hematoma in the setting of undifferentiated hypotension

Classification

Winquist and Hansen Classification

  • Type 0: No comminution
  • Type I: Insignificant amount of comminution
  • Type II: Greater than 50% cortical contact
  • Type III: Less than 50% cortical contact
  • Type IV: Segmental fracture with no contact between proximal and distal fragment

OTA Classification

  • 32A: Simple
    • A1: Spiral
    • A2: Oblique, angle > 30 degrees
    • A3: Transverse, angle < 30 degrees
  • 32B: Wedge
    • B1: Spiral wedge
    • B2: Bending wedge
    • B3: Fragmented wedge
  • 32C: Complex
    • C1: Spiral
    • C2: Segmental
    • C3: Irregular

Management

A A 28-year-old man sustained a right femoral shaft fracture with a fracture fragment; B the lateral view after closed reduction showing that the fracture fragment is turned over and greatly displaced (grade IV displacement); C the lateral view at 3 months postoperatively showing that the fracture site defect and that the medial callus has grown well; D the lateral view at 3 months postoperatively showing that the fracture fragment is free in front of the shaft and that the callus has grown well behind the fracture; E the anteroposterior view at 1 year postoperatively showing good medial callus growth and the lateral bone defect at the fracture site; F the lateral view at 1 year postoperatively showing partial absorption of the free fracture fragment[27]
30-Year-old male suffered fall from > 15 feet height. a, b Pre-op radiograph demonstrates mid-shaft femur fracture. CRIF with AFN was done. c–e Immediate post-op radiographs depicting anatomic reduction and satisfactory implant placement. f, g 3-Month post-op X-ray depicts bony union[28]

Acute

  • Patients with femur fractures should be assessed following Advanced Trauma Life (ATLS) Support
    • Critical to identify other co-occurring and potentially life threatening injuries
  • It is possible to hemorrhage 1-3L of blood into the thigh following a femur fracture
    • Careful monitoring of hemodynamic static and hemoglobin is required
  • Traction
    • In most cases, a traction splint or pin will be placed in the distal femur to stabilize the fracture pre-operatively

Nonoperative

Operative

  • Indications
    • Virtually all non-pediatric cases
  • Technique
    • Anterograde intramedullary nail
    • Retrograde intramedullary nail
    • External fixation
    • Open reduction, internal fixation

Rehab and Return to Play

Rehabilitation following a femoral shaft fracture

General Rehabilitation

  • General
    • Patients should be advanced to weight bearing as tolerated as soon as possible postoperatively
    • Rehab focused on: quadriceps weakness, hip abductor weakness, anterior knee pain, and gait abnormalities[29]
    • Recovery in elderly patients is often slower due to deconditioning, sarcopenia and comorbidities
  • Weight-Bearing Progression
    • Immediate weight bearing as tolerated is safe following intramedullary nailing[30]
    • Retrospective series have reported low complication rates with immediate weight bearing
    • Biomechanical studies indicate that early loading is beneficial for fracture healing
  • Key Impairments to address
    • Include hip abduction weakness, knee extensor weakness, anterior knee pain, and gait abnormalities

Rehabilitation Phases

  • Phase 1 (Weeks 0–6)[31]
    • Focus on: Weight-bearing tolerance, Controlling knee effusion, Achieving quadriceps control, Initiating hip abduction strengthening
    • Early strengthening begins immediately (not delayed for arbitrary timelines)
    • Pediatric outcomes: 88% still use walking aids at 6 weeks, 69% able to navigate stairs
  • Phase 2 (Weeks 6–12)[32]
    • Continue progressive strengthening
    • Emphasis on: Normalizing gait patterns
    • Pediatric outcomes by 12 weeks: Only 25% require walking aids, 100% able to manage stairs
  • Phase 3 (3–6 months)
    • Focus on: Advanced strengthening, Sport-specific training
    • Outcomes: Gait patterns normalize in most patients by 6 months
    • Persistent deficits: Decreased hip and knee extension moments compared to controls
    • Pediatric data: 3D gait analysis confirms normalization of gait patterns at 6 months
  • Phase 4 (6–12 months)
    • Focus on: Return-to-sport progression
    • Monitoring: Strength deficits, Functional performance

Return to Play

  • Timeline
    • Return to sport in professional athletes typically occurs at 7-13 months post-injury[33]
    • Full return to previous performance levels achievable
    • No subjective complaints at 25-month follow-up
  • Return to Play Criteria[34]
    • Anatomical and functional healing confirmed radiographically and clinically
    • Restoration of sport-specific skills through progressive functional testing
    • Psychosocial readiness including absence of fear of reinjury and kinesiophobia
    • Adequate strength particularly of quadriceps and hip abductors
    • Normalized gait mechanics and movement patterns
    • No undue risk to other participants
    • Compliance with governing body regulations

Complications

Summary of complications in intramedullary nail- ing of open grade III femoral shaft fractures[35]
Nonunion in the right femur at postoperative 8 months. A: X-ray showed traumatic fracture at distal femur; B: Postoperative film showed unreamed nailing but unsatisfactory reduction; C: hypertrophic nonunion were found 8 months following surgery.[36]

Prognosis

  • General
    • Prognosis after femoral shaft fracture is generally favorable with intramedullary nailing, achieving union rates of 93-99%
    • Residual disability, pain, and functional deficits persist in a significant proportion even years after injury
    • Patients with definitive fixation have improved outcomes, fewer complications, and reduced mortality (need citation)
  • Surgical Technique
    • Reamed nailing (anterograde and retrograde) demonstrate 99-100% union rates[37]
  • Union Rates and Timing
    • Femoral shaft fractures treated with intramedullary nailing achieve union at a mean time of 4.4-5.4 months[38]
    • Nonunion occurs in 2.8-11.3% of shaft fractures, with rates varying based on fracture complexity and patient factor
  • Mortality
    • Isolated bilateral femur fracture is associated with 9.8% all-cause mortality[39]
    • bilateral fractures with associated injuries had a mortality of 31.6%
    • In a separate study, isolated femur fracture was associated with a 1.4% mortality rate[40]
    • Delays in care more than 48 hours increase mortality by as much as 5-fold
  • Functional Outcomes
    • Despite high union rates, residual functional deficits persist long-term
    • At mean 7.8-year follow-up, 17% of patients report moderate to severe pain
    • At 12 months, 72% of patients with union return to work, though 54% continue to have pain

Complications

  • Heterotopic Ossification
    • Up to 25% of cases, rarely causes symptoms (need citation)
  • Pudendal Nerve Injury
    • Up to 15% of cases[41]
  • Femoral Artery Injury
  • Femoral Nerve Injury
  • Malunion
  • Rotational malalignment
  • Nonunion
    • Most frequent complication requiring reoperation, occurring in 2.8-11.3% of femoral shaft fractures[42]
  • Delayed union
    • Delayed union occurs in 10-33% of cases depending on fracture complexity[43]
  • Infection[44]
    • Deep infection rates are low (1-4%) with modern intramedullary nailing techniques
    • Surgical site infections occurred in 4% of patients in recent series
  • Weakness
  • Fat Emboli Syndrome/ Thromboembolic Complications
    • Thromboembolism is documented in 5-15.2% of patients, with pulmonary emboli being a notable postoperative complication[45]
  • Pain syndromes[45]
    • Prior to nail removal, hip pain occurs in 26% and knee pain in 20% of patients
    • These pain complaints usually disappear after nail removal
  • Respiratory Complications
    • Adult respiratory distress syndrome (ARDS) occurs in approximately 3% of case

See Also

References

  1. ↑ Hellwinkel, Justin E. "Innovations in treatment of femoral fractures throughout history." Journal of Orthopaedic Experience & Innovation 5.2 (2024).
  2. ↑ Bartoníček, J. "The history of fractures of the proximal femur: the contribution of the Dublin surgical school in the first half of the 19th century." The Journal of Bone & Joint Surgery British Volume 84.6 (2002): 795-797.
  3. ↑ Bartonícek, Jan. "Proximal femur fractures: the pioneer era of 1818 to 1925." Clinical Orthopaedics and Related Research (1976-2007) 419 (2004): 306-310.
  4. ↑ Enninghorst N, McDougall D, Evans JA, Sisak K, Balogh ZJ. Population-based epidemiology of femur shaft fractures. J Trauma Acute Care Surg. 2013 Jun;74(6):1516-20.
  5. ↑ Keeney JA, Ingari JV, Mentzer KD, Powell ET. Closed intramedullary nailing of femoral shaft fractures in an echelon III facility. Mil Med. 2009 Feb;174(2):124-8.
  6. ↑ Koskiniotis, Alexandros E., et al. "“Terrible Triad” Injury in an Adolescent Patient With a High-Energy Femoral Shaft Fracture: A Case Report." Cureus 17.3 (2025).
  7. ↑ Image courtesy of orthoinfo.aaos.org
  8. ↑ Weiss RJ, Montgomery SM, Al Dabbagh Z, Jansson KA. National data of 6409 Swedish inpatients with femoral shaft fractures: stable incidence between 1998 and 2004. Injury. 2009 Mar;40(3):304-8.
  9. ↑ Swiontkowski, Marc F., et al. “Ipsilateral Fracture of the Femoral Neck and Shaft.” Journal of Bone and Joint Surgery, vol. 66, no. 2, 1984, pp. 260–68.
  10. ↑ Gustilo, Ramon B., and John T. Anderson. “Prevention of Infection in the Treatment of One Thousand and Twenty-Five Open Fractures of Long Bones.” Journal of Bone and Joint Surgery, vol. 58, no. 4, 1976, pp. 453–58.
  11. ↑ Walker, J. L., and J. C. Kennedy. “Occult Knee Ligament Injuries Associated with Femoral Shaft Fractures.” The American Journal of Sports Medicine, vol. 8, no. 3, 1980, pp. 172–74.
  12. ↑ Tornetta, Paul, et al. “Compartment Syndrome Associated with Femoral Fracture.” Clinical Orthopaedics and Related Research, vol. 370, 2000, pp. 227–33.
  13. ↑ 13.0 13.1 Brumback, Robert J., et al. “Intramedullary Nailing of Femoral Shaft Fractures.” Journal of Bone and Joint Surgery, vol. 74, no. 7, 1992, pp. 1061–75.
  14. ↑ Gurd, A. R., and R. I. Wilson. “The Fat Embolism Syndrome.” Journal of Bone and Joint Surgery, vol. 56, no. 3, 1974, pp. 408–16
  15. ↑ Giannoudis, Peter V., et al. “Fat Embolism: The Re-Emergence of a Clinical Problem.” Injury, vol. 37, Suppl 4, 2006, pp. S3–S7.
  16. ↑ Krettek, Christian, et al. “Femoral Shaft Fractures.” Orthopedic Clinics of North America, vol. 33, no. 1, 2002, pp. 1–12.
  17. ↑ Court-Brown, Charles M., and Margaret M. McQueen. “Global Forum: Fractures in Older Adults.” The Journal of Bone and Joint Surgery, vol. 98, no. 9, 2016, p. e36.
  18. ↑ Burr, David B., and Matthew R. Allen. Basic and Applied Bone Biology. Elsevier, 2019.
  19. ↑ 19.0 19.1 Koval, Kenneth J., and Joseph D. Zuckerman. Handbook of Fractures. 6th ed., Wolters Kluwer, 2020.
  20. ↑ Shane, Elizabeth, et al. “Atypical Subtrochanteric and Diaphyseal Femoral Fractures.” New England Journal of Medicine, vol. 364, no. 18, 2011, pp. 1728–37.
  21. ↑ Khodaee, Morteza, Anna L. Waterbrook, and Matthew Gammons, eds. Sports-related fractures, dislocations and trauma: advanced on-and off-field management. Springer Nature, 2020.
  22. ↑ Salminen, Sari T., et al. "Population based epidemiologic and morphologic study of femoral shaft fractures." Clinical Orthopaedics and Related Research (1976-2007) 372 (2000): 241-249.
  23. ↑ Halvorson, Jason J., et al. "Vascular injury associated with extremity trauma: initial diagnosis and management." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 19.8 (2011): 495-504.
  24. ↑ Lee, James T., et al. "ACR Appropriateness Criteria® Major Blunt Trauma: Update 2025." Journal of the American College of Radiology (2026).
  25. ↑ Rogers, Nathan B., et al. "Improving the diagnosis of ipsilateral femoral neck and shaft fractures: a new imaging protocol." JBJS 102.4 (2020): 309-314.
  26. ↑ Schmid, Gordian Lukas, et al. "The Investigation of suspected fracture—a comparison of ultrasound with conventional imaging: Systematic review and meta-analysis." Deutsches Ärzteblatt International 114.45 (2017): 757.
  27. ↑ Yang, Shuo, et al. "Effect of the degree of displacement of the third fragment on healing of femoral shaft fracture treated by intramedullary nailing." Journal of orthopaedic surgery and research 17.1 (2022): 380.
  28. ↑ Gupta, Anupam, et al. "Femoral shaft fracture in post-polio syndrome patients: case series from a level-I trauma center and review of literature." Indian journal of orthopaedics 56.8 (2022): 1339-1346.
  29. ↑ Paterno, Mark V., and Michael T. Archdeacon. "Is there a standard rehabilitation protocol after femoral intramedullary nailing?." Journal of orthopaedic trauma 23 (2009): S39-S46.
  30. ↑ Kubiak, Erik N., et al. "Early weight bearing after lower extremity fractures in adults." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 21.12 (2013): 727-738.
  31. ↑ Paterno, Mark V., et al. "Early rehabilitation following surgical fixation of a femoral shaft fracture." Physical therapy 86.4 (2006): 558-572.
  32. ↑ Flinck, Marianne, and Jacques Riad. "Recovery of gait in children and adolescents after pediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study." Journal of Pediatric Orthopaedics 44.1 (2024): 1-6.
  33. ↑ Sikka, Robby, et al. "Femur fractures in professional athletes: a case series." Journal of athletic training 50.4 (2015): 442-448.
  34. ↑ Herring, Stanley A. "The team physician and return-to-play issues: a consensus statement." Medicine & Science in Sports & Exercise 34.7 (2002): 1212-1214.
  35. ↑ Singh, D., et al. "Open grade III fractures of femoral shaft: outcome after early reamed intramedullary nailing." Orthopaedics & Traumatology: Surgery & Research 97.5 (2011): 506-511.
  36. ↑ Ma, Yong-Gang, et al. "Surgical factors contributing to nonunion in femoral shaft fracture following intramedullary nailing." Chinese Journal of Traumatology 19.02 (2016): 109-112.
  37. ↑ Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R. Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma. 2001 Mar-Apr;15(3):161-9.
  38. ↑ el Moumni, Mostafa, et al. "Long-term functional outcome following intramedullary nailing of femoral shaft fractures." Injury 43.7 (2012): 1154-1158.
  39. ↑ Willett K, Al-Khateeb H, Kotnis R, Bouamra O, Lecky F. Risk of mortality: the relationship with associated injuries and fracture treatment methods in patients with unilateral or bilateral femoral shaft fractures. J Trauma. 2010 Aug;69(2):405-10
  40. ↑ Cantu RV, Graves SC, Spratt KF. In-hospital mortality from femoral shaft fracture depends on the initial delay to fracture fixation and Injury Severity Score: a retrospective cohort study from the NTDB 2002-2006. J Trauma Acute Care Surg. 2014 Jun;76(6):1433-40.
  41. ↑ Brumback RJ, Ellison TS, Molligan H, Molligan DJ, Mahaffey S, Schmidhauser C. Pudendal nerve palsy complicating intramedullary nailing of the femur. J Bone Joint Surg Am. 1992 Dec;74(10):1450-5.
  42. ↑ Yoon, Yong-Cheol, et al. "Antegrade nailing in femoral shaft fracture patients-comparison of outcomes of isolated fractures, multiple fractures and severely injured patients." Injury 52.10 (2021): 3068-3074.
  43. ↑ Tay, Wei-Han, et al. "Health outcomes of delayed union and nonunion of femoral and tibial shaft fractures." Injury 45.10 (2014): 1653-1658.
  44. ↑ Testa, Gianluca, et al. "Definitive treatment of femoral shaft fractures: comparison between anterograde intramedullary nailing and monoaxial external fixation." Journal of clinical medicine 8.8 (2019): 1119.
  45. ↑ 45.0 45.1 Bråten, M., T. Terjesen, and I. Rossvoll. "Femoral shaft fractures treated by intramedullary nailing. A follow-up study focusing on problems related to the method." Injury 26.6 (1995): 379-383.
Created by:
John Kiel on 29 June 2020 02:22:23
Authors:
Last edited:
31 March 2026 20:23:30
Categories:
Lower Extremity | Trauma | Hip | Thigh | Fractures | Acute | Featured
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