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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)


  • This page refers to fractures of the femoral shaft


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



  • Bimodal distribution in young healthy males (15-35) and elderly females (Over 60)
  • Worldwide incidence between 10 and 21 per 100,000 per years[1]
  • Approximately 2% of femoral shaft fractures are open[2]


  • Trauma is most common
    • Force vector often perpendicular to femur from a direct hit to the high
    • Can be indirect force transmitted from the knee


  • High energy trauma most common in younger patients
    • Typically motor vehicle crash (87%), fall from elevation[3]
  • Low energy trauma in elderly patients
    • Most commonly fall from standing, pathologic


Associated Injuries

Risk Factors

Differential Diagnosis

Differential Diagnosis Thigh Pain

Differential Diagnosis Hip Pain

Clinical Features

  • History
    • Clarify trauma
    • Patient endorses thigh pain
    • Patients often endorse swelling, bruising,
  • Physical Exam: Thigh Exam Main
    • Tense, swollen, edematous thigh due to bleeding into fracture space
    • Deformity may or may not be present
    • Leg may be internally/ externally rotated, shortened
    • Tenderness at fracture site
  • Special Tests




  • Typically not indicated


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



  • Reamed nailing (anterograde and retrograde) demonstrate 99-100% union rates[4]
  • Patients with definitive fixation have improved outcomes, fewer complications, and reduced mortality (need citation)
  • Isolated bilateral femur fracture is associated with 9.8% all-cause mortality[5]
    • 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[6]
    • Delays in care more than 48 hours increase mortality by as much as 5-fold


  • 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



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

Rehab and Return to Play


  • Patients should be advanced to weight bearing as tolerated as soon as possible postoperatively
  • Recovery in elderly patients is often slower due to deconditioning, sarcopenia and comorbidities

Return to Play

  • Needs to be updated


See Also


  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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
  6. 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.
  7. 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.
Created by:
John Kiel on 29 June 2020 02:22:23
Last edited:
6 January 2021 16:10:17
Lower Extremity | Trauma | Hip | Thigh | Fractures | Acute