Author

Nicholas M Romeo, DO Resident Physician, Department of Orthopedic Surgery, Wellspan

York Hospital

Nicholas M Romeo, DO is a member of the following medical societies: American Osteopathic

Association, American Osteopathic Academy of Orthopedics, Pennsylvania Osteopathic Medical
Association

Disclosure: Nothing to disclose.

Coauthor(s)

John R Deitch, MD Director of Sports Medicine, Wellspan Orthopedics

John R Deitch, MD is a member of the following medical societies: Alpha Omega Alpha,
American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports
Medicine, Arthroscopy Association of North America, Pennsylvania Orthopaedic Society

Disclosure: Nothing to disclose.

Thomas G DiPasquale, DO, FACOS, FAOAO Medical Director, Orthopedic Trauma Services,
Director, Orthopedic Trauma Fellowship and Orthopedic Residency Programs, York Hospital;
Orthopedic Trauma Consultant, Florida Orthopedic Institute, Tampa General Hospital

Thomas G DiPasquale, DO, FACOS, FAOAO is a member of the following medical societies:
American Academy of Orthopaedic Surgeons, American Medical Association, American
Osteopathic Association, Florida Medical Association, Florida Orthopaedic Society, American
Osteopathic Academy of Orthopedics, Florida Osteopathic Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska

Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and

Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of

Family Physicians, American College of Sports Medicine, American Medical Society for Sports
Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic

Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences,
The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of

Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society,
American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received
grant/research funds from Smith and Nephew for fellowship funding; Received grant/research
funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical
Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New
Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor,
Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of
New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha,
American Academy of Physical Medicine and Rehabilitation, American College of Sports
Medicine, American Institute of Ultrasound in Medicine, International Spine Intervention
Society, North American Spine Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Lipogems.

Acknowledgements

Douglas F Aukerman, MD Associate Professor, Department of Orthopedics and Rehabilitation,

Division of Sports Medicine, Department of Family Medicine, Pennsylvania State University
College of Medicine

Douglas F Aukerman, MD is a member of the following medical societies: American Academy

of Family Physicians, American College of Sports Medicine, American Medical Association,
and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University
School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and
Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of

Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of
America, and Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

William Ertl, MD Clinical Assistant Professor, Department of Orthopedics, University of

Oklahoma College of Medicine

Disclosure: Nothing to disclose.

Acute Phase
Femur fractures in the younger patient population are typically the result of high-energy injuries.
These fractures are often accompanied by other injuries. The first priority in treatment is to rule
out other life-threatening injuries and stabilize the patient. Advanced Trauma Life Support
(ATLS) guidelines should be followed.

The emergent management of femur injuries in the sports setting is intended to restore
alignment. If limb deformity is present, inline longitudinal traction is applied, realigning the
extremity and maintaining limb perfusion. A splint is applied to maintain the alignment as the
patient is transported to the hospital for definitive treatment.

Treatment for acute trauma-related femoral fractures and displaced femoral stress fractures is
performed by an orthopedic surgeon and usually involves surgical stabilization (see Surgical
Intervention). [1, 2]

For non-displaced femoral shaft stress fractures, protected crutch-assisted weight bearing is
implemented for a minimum of 1-4 weeks, based on the resolution of symptoms and
radiographic evidence of healing (callus formation). Progression to full weight bearing can
gradually commence once pain has resolved. Patients must avoid running for 8-16 weeks while
the low-impact training program/phase is completed. The progression can include (1) cycling, (2)
swimming, and (3) running in chest-deep water before resuming more intensive weight-bearing
training. Patients must maintain upper extremity and cardiovascular fitness and avoid lower
extremity exercise early in the healing process.

Compression sided femoral neck stress fractures are typically treated conservatively with a
period of protected crutch-assisted weight bearing until symptoms resolve. Tension-sided
(lateral) femoral neck stress fractures are at risk for displacement and surgical stabilization with
percutaneous screws should be considered vs. bed-rest.

Medical Issues/Complications
Patients sustaining a femur fracture as a part of a major traumatic event (e.g., vehicular trauma)
should be evaluated and stabilized by the trauma and/or medical team prior to surgical
intervention. ATLS guidelines should always be followed. Life threatening injuries should be
cared for the appropriate specialists.

In cases of traumatic femur fractures, the trauma surgeon implements multisystem stabilization
and clearance for surgical intervention. Consultations with appropriate specialists must be
arranged for specific systems. Traction may be necessary for initial stabilization for pain control
before impending surgery.

Before definitive operative management of a femur fracture, the patient should be

hemodynamically stable and fully resuscitated. Current literature suggests serum lactate levels,
base deficit and gastric mucosal pH may be the most reliable measures of resuscitation. [32] The
goal time to definitive surgical stabilization is generally 24 hours. However, if the patient is
hemodynamically unstable and has not been adequately resuscitated, femoral fixation should be
delayed and temporized with an external fixator, skeletal traction or a splint.

Elderly patients require evaluation by the medicine team for management of any acute or chronic
medical conditions.

Surgical Intervention

Proximal femur fractures are treated based upon fracture pattern. Femoral neck fractures are
typically treated with percutaneous pinning, a sliding hip screw or arthroplasty in elderly
patients. Peritrochanteric fractures are typically treated with a sliding hip screw or a
cephalomedullary nail. Subtrochanteric fractures are typically treated with an intramedullary nail
or a fixed angle device. Treatment of proximal femur fractures is discussed in further detail the
article Fractures, Hip.

Intramedullary nailing (see image below) is the treatment of choice for the majority of femoral
shaft fractures occurring in adults. Nailing can be preformed in an antegrade or retrograde
fashion. Other treatment options include plate and screw fixation as well as external fixation. The
method of fixation is dependent upon the personality of the fracture as well as associated
injuries. For more detail on the treatment of diaphyseal femur fractures see the article Fractures,
Femur.
 AP radiograph of a healing femoral shaft fracture after intramedullary nailing.
View Media Gallery

Lateral radiograph of a healing femoral shaft fracture after

intramedullary nailing.
View Media Gallery
Traumatic distal femurs may be treated with intramedullary nailing, plate and screw fixation or
arthroplasty. These fractures are further discussed in the article Fractures, Knee .

An intra-articular distal femur fracture treated with intramedullary

nailing as well as independent screw fixation.
View Media Gallery
 An intra-articular distal femur fracture treated with intramedullary
nailing as well as independent screw fixation.
View Media Gallery

In cases of pathologic fracture, treatment is dictated by not only location, but also tumor type. In
primary bone tumors, the goal of surgical treatment is curative where as in metastatic tumors the
goal is palliative.

In the case of femoral shaft stress fracture, operative treatment is reserved for those infrequent
cases that have been recalcitrant to a long course of conservative treatment. Intramedullary
nailing, whether antegrade or retrograde, is the treatment of choice for these cases.

Tension sided femoral neck stress fractures are typically treated with percutaneous screw
fixation. For further details see the article Femoral Neck Stress Fracture.

Consultations

Consultation with orthopedic surgeons is required in cases of femoral fractures, and a definitive
treatment plan is left to their judgment.

Physical Therapy

With trauma-related femur fractures, physical therapy following stable fixation of the fracture to
improve hip and knee range of motion, strengthening and gait training is recommended. Weight-
bearing status is dependent upon fracture pattern and surgical intervention. Ambulatory aids,
such as crutches, are used in the initial stages. The goal of the therapy program should be
eventual full weight-bearing and restoration of normal function. Pulmonary therapy is often
needed in patients sustaining major trauma requiring prolonged bed rest.

For femoral stress fractures, discontinue crutches once pain-free walking is possible. Increase
low-impact lower extremity aerobic training (e.g., swimming, biking, elliptical trainer) as
symptoms permit. Attempt to identify causative factors of the femoral stress fractures (e.g.,
improper training techniques, footwear, diet).

One treatment algorithm that has been suggested consists of a graduated four-phase program,
each of which last three weeks in duration. [33] Transfer to the next phase is based on the result of
fulcrum and hop tests carried out at the end of each phase. If the tests were positive (i.e., a failed
test), the patient was returned to the beginning of that phase. In the first phase athletes walked
with the help of crutches and were instructed to be non-weight-bearing on the affected leg. In the
second phase normal walking was permitted, and swimming and exercising on the unaffected
extremities was allowed. In the third phase the patients performed exercises with both upper and
lower extremities using light weights. Patients were also permitted to run in a straight line every
other day and ride a stationary bicycle. The distance that the subjects were allowed to run was
gradually increased. In the fourth phase the patient resumed normal training. In this study all
seven patients returned to normal activitywithin 12-18 weeks with no recurrences noted at 48-96
month follow up. [33]

Maintenance Phase
Rehabilitation Program

Physical Therapy

Patients should continue with therapy as needed with the goal of improving strength, motion,
endurance and ambulatory ability. Continue to monitor with radiographs in an outpatient setting.

Attempt to identify causative factors of the femoral stress fractures (e.g., improper training
techniques, footwear, diet). Implementation of an injury prevention program may be beneficial.