LITERATURE REVIEWS

ANATOMY

The femur is the largest tubular bone in the body and is surrounded by the largest mass of
muscle. An important feature of the femoral shaft is its anterior bow. The medial cortex is under
compression, whereas the lateral cortex is under tension. The isthmus of the femur is the region
with the smallest intramedullary (IM) diameter; the diameter of the isthmus affects the size of the
IM nail that can be inserted into the femoral shaft. (1)

The femoral shaft is subjected to major muscular deforming forces (1) (Fig. 1.0):
o Abductors (gluteus medius and minimus): They insert on the greater trochanter and abduct
the proximal femur following subtrochanteric and proximal shaft fractures.
o Iliopsoas: It flexes and externally rotates the proximal fragment by its attachment to the
lesser trochanter.
o Adductors: They span most shaft fractures and exert a strong axial and varus load to the bone
by traction on the distal fragment.
o Gastrocnemius: It acts on distal shaft fractures and supracondylar fractures by flexing the
distal fragment.
o Fascia lata: It acts as a tension band by resisting the medial angulating forces of the
adductors.

The thigh musculature is divided into three distinct fascial compartments(1) (Fig. 1.1):
o Anterior compartment: This is composed of the quadriceps femoris, iliopsoas, sartorius, and
pectineus, as well as the femoral artery, vein, and nerve, and the lateral femoral cutaneous
nerve.
o Medial compartment: This contains the gracilis, adductor longus, brevis, magnus, and
obturator externus muscles along with the obturator artery, vein, and nerve, and the profunda
femoris artery.
o Posterior compartment: This includes the biceps femoris, semitendinosus, and
semimembranosus, a portion of the adductor magnus muscle, branches of the profunda
femoris artery, the sciatic nerve, and the posterior femoral cutaneous nerve.

1) Koval KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations in Handbook of Fractures, Third Edition,
2006, New York, Lippincott Williams & Wilkins.
 Figure 1.0. Deforming muscle forces
on the femur; abductors (A),
iliopsoas (B), adductors (C), and
gastrocnemius origin (D). The medial
angulating forces are resisted by the
fascia lata (E). Potential sites of
vascular injury after fracture are at
the adductor hiatus and the
perforating vessels of the profunda
femoris.

Figure 1.1. Cross-sectional diagram

of the thigh demonstrates the three
major compartments.
 Because of the large volume of the three fascial compartments of the thigh, compartment
syndromes are much less common than in the lower leg. (1)

The vascular supply to the femoral shaft is derived mainly from the profunda femoral
artery. The one to two nutrient vessels usually enter the bone proximally and posteriorly along
the linea aspera. This artery then arborizes proximally and distally to provide the endosteal
circulation to the shaft. The periosteal vessels also enter the bone along the linea aspera and
supply blood to the outer one-third of the cortex. The endosteal vessels supply the inner two-
thirds of the cortex. (1)

Following most femoral shaft fractures, the endosteal blood supply is disrupted, and the
periosteal vessels proliferate to act as the primary source of blood for healing. The medullary
supply is eventually restored late in the healing process.Reaming may further obliterate the
endosteal circulation, but it returns fairly rapidly, in 3 to 4 weeks. (1)

Femoral shaft fractures heal readily if the blood supply is not excessively compromised.
Therefore, it is important to avoid excessive periosteal stripping, especially posteriorly, where
the arteries enter the bone at the linea aspera. (1)

1) Koval KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations in Handbook of Fractures, Third Edition,
2006, New York, Lippincott Williams & Wilkins.
FEMORAL SHAFT
A femoral shaft fracture is a fracture of the femoral diaphysis occurring between 5 cm distal to
(1)
the lesser trochanter and 5 cm proximal to the adductor tubercle . Diaphyseal fractures of the
femur are the result of significant trauma and usually are associated with considerable soft-tissue
damage. Blood loss of 2 to 3 units is common. In addition, these fractures have a high incidence
of associated injury in the same extremity, including fractures of the femoral neck, posterior
fracture-dislocations of the hip, tears of the collateral ligaments of the knee, and osteochondral
fractures involving the distal femur or patella and fractures of the tibia (2).

Fractures of the femoral shaft more frequently are caused by high-energy trauma. It is common
for such patients to have associated injuries. Almost all femoral shaft injuries are managed
(3)
surgically, usually by intramedullary nailing . The femoral shaft extends from an area 5 cm
distal to the lesser trochanter to a point 6 cm proximal to the adductor tubercle. The femur is a
strong bone with an excellent blood supply and therefore good healing potential. These fractures
are more common in children and adolescents (4).

EPIDEMIOLOGY
There is an age- and gender-related bimodal distribution of fractures. Femoral shaft fractures
occur most frequently in young men after high-energy trauma and elderly women after a low-
energy fall (1). Previously, femoral shaft fractures had a mortality rate as high as 50%, primarily
because the treatment was prolonged bed rest (4).

MECHANISM OF INJURY
Femoral shaft fractures in adults are almost always the result of high-energy trauma. These
fractures result from motor vehicle accident, gunshot injury, or fall from a height. Pathologic
fractures, especially in the elderly, commonly occur at the relatively weak metaphyseal-
diaphyseal junction. Any fracture that is inconsistent with the degree of trauma should arouse
suspicion for pathologic fracture. Stress fractures occur mainly in military recruits or runners.
Most patients report a recent increase in training intensity just before the onset of thigh pain(1).

1) Koval KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations in Handbook of Fractures, Third Edition,
2006, New York, Lippincott Williams & Wilkins.
2) Swiontkowski, MF, Stovitz, SD. Fractures of the Femur in Manual of Orthopaedics, Sixth Edition, 2001, Minnesota, Lippincott
Williams & Wilkins.
3) Brunicardi FC, Andersen DK, Billiar TR et al. Orthopaedic Surgery in Schwartz's Principles of Surgery, Ninth Edition, 2010,
Texas, The McGraw-Hill Companies.
4) Simon RR, Sherman SC, Koenigsknecht SJ. Fractures in Thigh in Emergency Orthopaedics, Fifth Edition, 2007, Illinois, The
McGraw-Hill Companies.
Femoral shaft fractures are secondary to a high-energy force, such as a direct blow or an indirect
force transmitted through the flexed knee, in 75% of cases. Automobile collisions are the most
common cause, but gunshot wounds represent an increasing proportion of these fractures.
Fracture of the femur following a low-energy mechanism is rare, and the clinician should suspect
a pathologic fracture in this scenario(4).

In children, a fall from a significant height must occur to create such a fracture. Abuse must be
considered in children who suffer femoral shaft fractures, especially when the history seems
unrealistic or there is an inappropriate delay in seeking medical care. In infants, the incidence of
abuse was 65% in one study. Children ages 1 to 5 with femoral shaft fractures are abused in 5%
to 35% of cases. While spiral fractures are classically associated with child abuse, transverse
fractures are seen in an equal number of abused children (4).

CLINICAL EVALUATION
Because these fractures tend to be the result of high-energy trauma, a full trauma survey is
indicated. The diagnosis of femoral shaft fracture is usually obvious, with the patient presenting
nonambulatory with pain, variable gross deformity, swelling, and shortening of the affected
extremity. A careful neurovascular examination is essential, although neurovascular injury is
uncommonly associated with femoral shaft fractures. (1)

Thorough examination of the ipsilateral hip and knee should be performed, including systematic
inspection and palpation. Range-of-motion or ligamentous testing is often not feasible in the
setting of a femoral shaft fracture and may result in displacement. Knee ligament injuries are
common, however, and need to be assessed after fracture fixation. (1)

Major blood loss into the thigh may occur. The average blood loss in one series was greater than
1200 mL, and 40% of patients ultimately required transfusions. Therefore, a careful preoperative
assessment of hemodynamic stability is essential, regardless of the presence or absence of
associated injuries. (1)

Diagnosis usually does not present any clinical problem if care is taken to rule out the other
associated injuries by physical examination and radiographs. (2)

1) Koval KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations in Handbook of Fractures, Third Edition,
2006, New York, Lippincott Williams & Wilkins.
2) Swiontkowski, MF, Stovitz, SD. Fractures of the Femur in Manual of Orthopaedics, Sixth Edition, 2001, Minnesota, Lippincott
Williams & Wilkins.
4) Simon RR, Sherman SC, Koenigsknecht SJ. Fractures in Thigh in Emergency Orthopaedics, Fifth Edition, 2007, Illinois, The
McGraw-Hill Companies.
The patient will present with severe pain in the involved extremity and will usually have visible
deformities. The extremity may be shortened and there may be crepitation with movement. The
thigh will be swollen and tense secondary to hemorrhage and formation of a hematoma.
Neurologic examination should be performed to assess the function of the sciatic nerve. Arterial
(4)
injuries are rare, but they must be excluded on the initial examination . Arterial injuries
associated with a femoral shaft fracture should be suspected in the presence of:
 Expanding hematoma
 Absent or diminishing pulses
 Progressive neurologic signs in the presence of a closed fracture

ASSOCIATED INJURIES
Associated injuries are common and may be present in up to 5% to 15% of cases, with patients
presenting with multisystem trauma, spine, pelvis, and ipsilateral lower extremity injuries.
Ligamentous and meniscal injuries of the ipsilateral knee are present in 50% of patients with
closed femoral shaft fractures. (1)

Because of the severe injuring forces involved, many of these patients have multiple injuries and
require a careful systematic initial examination. These fractures may be associated with
ipsilateral fractures, dislocations, and ligamentous soft-tissue injuries to the hip and knee.
Ipsilateral femoral neck fractures occur in 6% of patients with femoral shaft fractures(4).
The femoral shaft has a rich blood supply. As a result, fractures are associated with significant
bleeding. The average blood loss following a femoral shaft fracture is 1 to 1.5 liters. However,
bleeding into the thigh in a patient with a closed femoral shaft fracture is not enough, by itself, to
cause hypotension. In patients with a femur fracture and hypotension, another source of bleeding
should be sought (4).

Associated sciatic nerve injuries are rarely encountered with these fractures secondary to the
protective surrounding musculature. The incidence of sciatic or peroneal nerve injury in the
setting of a femoral shaft fracture is 2% after a blunt mechanism and increases to 9% after a
gunshot wound (4).

1) Koval KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations in Handbook of Fractures, Third
Edition, 2006, New York, Lippincott Williams & Wilkins.
4) Simon RR, Sherman SC, Koenigsknecht SJ. Fractures in Thigh in Emergency Orthopaedics, Fifth Edition, 2007, Illinois,
The McGraw-Hill Companies.
RADIOGRAPHIC EVALUATION

Anteroposterior (AP) and lateral views of the femur, hip, and knee as well as an AP view of the
pelvis should be obtained.The radiographs should be critically evaluated to determine the
fracture pattern, the bone quality, the presence of bone loss, associated comminution, the
presence of air in the soft tissues, and the amount of fracture shortening. (1)

One must evaluate the region of the proximal femur for evidence of an associated femoral neck
or intertrochanteric fracture. If a computed tomography scan of the abdomen and/or pelvis is
obtained for other reasons, this should be reviewed because it may provide evidence of injury to
the ipsilateral acetabulum or femoral neck. (1)

Films are obtained primarily to confirm the diagnosis and for preoperative planning. It is
essential to view the joint above and the joint below the fracture. Films of the uninjured femur
are helpful for selecting the appropriate internal fixation device. An anteroposterior and lateral
roentgenogram of the injured femur should be supplemented by the anteroposterior pelvis to
obtain optimum views of the femoral neck (49). Unpublished data indicate that routine computed
tomographic (CT) imaging of the femoral neck reduces the rate of missed ipsilateral femoral
neck fracture. (2)

Routine anteroposterior (AP) and lateral views are usually adequate in demonstrating the
fracture. Stress fractures of the femoral shaft may not be visualized on these routine views. Hip
and knee views should be included as there is a significant incidence of associated injury (4).The
extensive musculature surrounding the femoral shaft is often the source of displacement. The
proximal fragment of a proximal one-third femoral shaft fracture is abducted, flexed, and
externally rotated. The gluteal muscles inserting on the greater trochanter result in an abduction
deformity, whereas the iliopsoas muscle inserting on the lesser trochanter exerts an external
rotation and flexion force on the proximal fragment. Midshaft fractures undergo a varus
deformity because of the force of the medial adductors on the distal fragment and the pull of the
lateral muscles on the proximal fragment. Distal one-third shaft fractures are angulated anteriorly
due to the force applied by the gastrocnemius muscle(4).

1) Koval KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations in Handbook of Fractures, Third
Edition, 2006, New York, Lippincott Williams & Wilkins.
2) Swiontkowski, MF, Stovitz, SD. Fractures of the Femur in Manual of Orthopaedics, Sixth Edition, 2001, Minnesota,
Lippincott Williams & Wilkins.
4) Simon RR, Sherman SC, Koenigsknecht SJ. Fractures in Thigh in Emergency Orthopaedics, Fifth Edition, 2007, Illinois,
The McGraw-Hill Companies.
CLASSIFICATION
Descriptive (1)
 Open versus closed injury
 Location: proximal, middle, or distal one-third
 Location: isthmal, infraisthmal or supracondylar
 Pattern: spiral, oblique, or transverse
 Comminuted, segmental, or butterfly fragment
 Angulation or rotational deformity
 Displacement: shortening or translation

Current therapy uses plates or intramedullary rods, thus allowing earlier mobilization. Femoral
shaft fractures are classified into three types(4).
1. Spiral, transverse, or oblique shaft fractures
2. Comminuted femoral shaft fractures
3. Open femoral shaft fractures
Distinguishing between a spiral, transverse, or oblique fracture does not alter either the treatment
or prognosis of the fracture. Comminuted fractures are further classified by Winquist based on
the size of the fracture fragment and the degree of comminution(4).
Winquist and Hansen(1) (Fig. 1.3)
 This is based on fracture comminution.
 It was used before routine placement of statically locked IM nails.
Type I: Minimal or no comminution
Type II: Cortices of both fragments at least 50% intact
Type III:50% to 100% cortical comminution
Type VI:Circumferential comminution with no cortical contact

1) Koval KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations in Handbook of Fractures, Third Edition, 2006,
New York, Lippincott Williams & Wilkins.
4) Simon RR, Sherman SC, Koenigsknecht SJ. Fractures in Thigh in Emergency Orthopaedics, Fifth Edition, 2007, Illinois, The McGraw-
Hill Companies.
 Figure 1.1. Winquist and Hansen
classification of femoral shaft
fractures.

TREATMENT
The treatment for femoral shaft fracture can be divided into two, non-operative and operative.

Nonoperative
Currently, closed management as definitive treatment for femoral shaft fractures is largely
limited to adult patients with such significant medical comorbidities that operative management
is contraindicated. (1)

Skeletal Traction

 The goal of skeletal traction is to restore femoral length, limit rotational and angular
deformities, reduce painful spasms, and minimize blood loss into the thigh.
 Skeletal traction is usually used as a temporizing measure before surgery to stabilize the
fracture and prevent fracture shortening.
 Twenty to 40 lb of traction is usually applied and a lateral radiograph checked to assess
fracture length.
 Distal femoral pins should be placed in an extracapsular location to avoid the possibility
of septic arthritis. Proximal tibia pins are typically positioned at the level of the tibial
tubercle and are placed in a bicortical location.
 Safe pin placement is usually from medial to lateral at the distal femur (directed away
from the femoral artery) and from lateral to medial at the proximal tibia (directed away
from the peroneal nerve).

1) Koval KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations in Handbook of Fractures, Third Edition, 2006,
New York, Lippincott Williams & Wilkins.
  Problems with use of skeletal traction for definitive fracture treatment include knee
stiffness, limb shortening, prolonged hospitalization, respiratory and skin ailments, and
malunion.

Operative
Operative stabilization is the standard of care for most femoral shaft fractures.Surgical
stabilization should occur within 24 hours, if possible. Early stabilization of long bone injuries
appears to be particularly important in the multiply injured patient. (1)

Intramedullary (IM) Nailing

 This is the standard of care for femoral shaft fractures.

 Its IM location results in lower tensile and shear stresses on the implant than plate
fixation. Benefits of IM nailing over plate fixation include less extensive exposure and
dissection, lower infection rate, and less quadriceps scarring.
 Closed IM nailing in closed fractures has the advantage of maintaining both the fracture
hematoma and the attached periosteum. If reaming is performed, these elements provide
a combination of osteoinductive and osteoconductive materials to the site of the fracture.
 Other advantages include early functional use of the extremity, restoration of length and
alignment with comminuted fractures, rapid and high union (>95%), and low refracture
rates.

Antegrade Inserted Intramedullary (IM) Nailing

 Surgery can be performed on a fracture table or on a radiolucent table with or without

skeletal traction.
 The patient can be positioned supine or lateral. Supine positioning allows unencumbered
access to the entire patient. Lateral positioning facilitates identification of the piriformis
starting point but may be contraindicated in the presence of pulmonary compromise.
 One can use either a piriformis fossa or greater trochanteric starting point. The advantage
of a piriformis starting point is that it is in line with the medullary canal of the femur.
However, it is easier to locate the greater trochanteric starting point. Use of a greater
trochanteric starting point requires use of a nail with a valgus proximal bow to negotiate
the off starting point axis.
  With the currently available nails, the placement of large diameter nails with an intimate
fit along a long length of the medullary canal is no longer necessary.
 The role of unreamed IM nailing for the treatment of femoral shaft fractures remains
unclear.
1) Koval The potentially negative effects of reaming for insertion of IM nails include
KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations in Handbook of Fractures, Third Edition, 2006,
elevated
New IM pressures,
York, Lippincott elevated
Williams & Wilkins. pulmonary artery pressures, increased fat embolism, and
increased pulmonary dysfunction. The potential advantages of reaming rate include the
ability to place a larger implant, increased union, and decreased hardware failure.
 All IM nails should be statically locked to maintain femoral length and control rotation.
The number of distal interlocking screws necessary to maintain the proper length,
alignment, and rotation of the implant bone construct depends on numerous factors
including fracture comminution, fracture location, implant size, patient size, bone quality,
and patient activity.

Retrograde Inserted Intramedullary (IM) Nailing

 The major advantage with a retrograde entry portal is the ease in properly identifying the
starting point.
 Relative indications include:
o Ipsilateral injuries such as femoral neck, pertrochanteric, acetabular, patellar, or
tibial shaft fractures.
o Bilateral femoral shaft fractures.
o Morbidly obese patient.
o Pregnant woman.
o Periprosthetic fracture above a total knee arthroplasty.
o Ipsilateral through knee amputation in a patient with an associated femoral shaft
fracture.
 Contraindications include:
o Restricted knee motion <60 degrees.
o Patella baja.
o The presence of an associated open traumatic wound, secondary to the risk of
intraarticular knee sepsis.

External Fixation

 Use as definitive treatment for femoral shaft fractures has limited indications.
  Its use is most often provisional.

 Advantages include the following:

o The procedure is rapid; A temporary external fixator can be applied in less than
30 minutes.

1)
o The vascular supply to the femur is minimally damaged during application.
Koval KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations in Handbook of Fractures, Third Edition, 2006,

No additional
o Lippincott
New York, Williams &foreign
Wilkins. material is introduced in the region of the fracture.
o It allows access to the medullary canal and the surrounding tissues in open
fractures with significant contamination.
 Disadvantages: Most are related to use of this technique as a definitive treatment and
include:
o Pin tract infection.
o Loss of knee motion.
o Angular malunion and femoral shortening.
o Limited ability to adequately stabilize the femoral shaft.
o Potential infection risk associated with conversion to an IM nail.
 Indications for use of external fixation include:
o Use as a temporary bridge to IM nailing in the severely injured patient.
o Ipsilateral arterial injury that requires repair.
o Patients with severe soft tissue contamination in whom a second debridement
would be limited by other devices.

Plate Fixation
Plate fixation for femoral shaft stabilization has decreased with the use of IM nails.

 Advantages to plating include:

o Ability to obtain an anatomic reduction in appropriate fracture patterns.
o Lack of additional trauma to remote locations such as the femoral neck, the
acetabulum, and the distal femur.
 Disadvantages compared with IM nailing include:
o Need for an extensive surgical approach with its associated blood loss, risk of
infection, and soft tissue insult. This can result in quadriceps scarring and its
effects on knee motion and quadriceps strength.
o Decreased vascularization beneath the plate and the stress shielding of the bone
spanned by the plate.
 o The plate is a load bearing implant; therefore, higher rate of implant failure.
 Indications include:
o Extremely narrow medullary canal where IM nailing is impossible or difficult.

o Fractures that occur adjacent to or through a previous malunion.

o Obliteration of the medullary canal due to infection or previous closed
1) Koval KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations in Handbook of Fractures, Third Edition, 2006,
management.
New York, Lippincott Williams & Wilkins.
o Fractures that have associated proximal or distal extension into the
pertrochanteric or condylar regions.
o In patients with an associated vascular injury, the exposure for the vascular repair
frequently involves a wide exposure of the medial femur. If rapid femoral
stabilization is desired, a plate can be applied quickly through the medial open
exposure.
 An open or a submuscular technique may be applicable.
 As the fracture comminution increases, so should the plate length such that at least four
to five screw holes of plate length are present on each side of the fracture.
 The routine use of cancellous bone grafting in plated femoral shaft fractures is
questionable if indirect reduction techniques are used.

Femur Fracture in Multiply Injured Patient

 The impact of femoral nailing and reaming is controversial in the polytrauma patient.
 In a specific subpopulation of patients with multiple injuries, early IM nailing is
associated with elevation of certain proinflammatory markers.
 It has been recommended that early external fixation of long bone fractures followed by
delayed IM nailing may minimize the additional surgical impact in patients at high risk
for developing complications (i.e., patients in extremis or underresuscitated).

Ipsilateral Fractures of the Proximal or Distal Femur

 Concomitant femoral neck fractures occur in 3% to 10% of patients with femoral shaft
fractures. Options for operative fixation include antegrade IM nailing with multiple screw
fixation of the femoral neck, retrograde femoral nailing with multiple screw fixation of
the femoral neck, and compression plating with screw fixation of the femoral neck. The
sequence of surgical stabilization is controversial.
  Ipsilateral fractures of the distal femur may exist as a distal extension of the shaft fracture
or as a distinct fracture. Options for fixation include fixation of both fractures with a
single plate, fixation of the shaft and distal femoral fractures with separate plates, IM
nailing of the shaft fracture with plate fixation of the distal femoral fracture, or
interlocked IM nailing spanning both fractures (high supracondylar fractures).

Open Femoral Shaft Fractures

1) Koval KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations in Handbook of Fractures, Third Edition, 2006,
 These are typically the result of high-energy trauma.
New York, Lippincott Williams & Wilkins.

 Patients frequently have multiple other orthopaedic injuries and involvement of several
organ systems.
 Treatment is emergency debridement with skeletal stabilization.
 Stabilization can usually involve placement of a reamed IM nail.

REHABILITATION
Early patient mobilization out of bed is recommended. Early range of knee motion is indicated.
Weight bearing on the extremity is guided by a number of factors including the patient’s
associated injuries, soft tissue status, and the location of the fracture. (1)

COMPLICATIONS
There are several complications that can occur as a result from patients with femoral shaft
fracture. These complications also involving other body systems beside the skeletal system such
as (1):

 Nerve injury: This is uncommon because the femoral and sciatic nerves are encased in
muscle throughout the length of the thigh. Most injuries occur as a result of traction or
compression during surgery.
 Vascular injury: This may result from tethering of the femoral artery at the adductor
hiatus.
 Compartment syndrome: This occurs only with significant bleeding. It presents as pain
out of proportion, tense thigh swelling, numbness or paresthesias to medial thigh
(saphenous nerve distribution), or painful passive quadriceps stretch.
 Infection (<1% incidence in closed fractures): The risk is greater with open versus closed
IM nailing. Grades I, II, and IIIA open fractures carry a low risk of infection with IM
nailing, whereas fractures with gross contamination, exposed bone, and extensive soft
 tissue injury (grades IIIB, IIIC) have a higher risk of infection regardless of treatment
method.
 Refracture: Patients are vulnerable during early callus formation and after hardware
removal. It is usually associated with plate or external fixation.

 Nonunion and delayed union: This is unusual. Delayed union is defined as healing taking
longer than 6 months, usually related to insufficient blood supply (i.e., excessive
periosteal stripping), uncontrolled repetitive stresses, infection, and heavy smoking.
Nonunion is diagnosed once the fracture has no further potential to unite.
1) Malunion:
Koval KJ, Zuckerman
This JD.
is Femoral
usually Shaft in Lowerinternal
varus, Extremity Fractures
rotation,and Dislocations in Handbook ofowing
and/or shortening Fractures,to
Third Edition, 2006,
muscular
New York, Lippincott Williams & Wilkins.
deforming forces or surgical technique.
 Fixation device failure: This results from nonunion or “cycling” of device,
especially with plate fixation.
 Heterotopic ossification may occur.
 1) REFERRENCES
Koval KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations in Handbook of Fractures, Third Edition, 2006,
New York, Lippincott Williams & Wilkins.

1) Koval KJ, Zuckerman JD. Femoral Shaft in Lower Extremity Fractures and Dislocations
in Handbook of Fractures, Third Edition, 2006, New York, Lippincott Williams &
Wilkins.
2) Swiontkowski, MF, Stovitz, SD. Fractures of the Femur in Manual of Orthopaedics, Sixth
Edition, 2001, Minnesota, Lippincott Williams & Wilkins.
3) Brunicardi FC, Andersen DK, Billiar TR et al. Orthopaedic Surgery in Schwartz's
Principles of Surgery, Ninth Edition, 2010, Texas, The McGraw-Hill Companies.
4) Simon RR, Sherman SC, Koenigsknecht SJ. Fractures in Thigh in Emergency
Orthopaedics, Fifth Edition, 2007, Illinois, The McGraw-Hill Companies.