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.
Previously, femoral shaft fractures had a mortality as high as 50%, primarily because the treatment was prolonged bed rest. Current therapy uses plates or intramedullary rods, thus allowing earlier mobilization. Femoral shaft fractures are classified into three types.
Spiral, transverse, or oblique shaft fractures
Comminuted femoral shaft fractures
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 comminution1 (Fig. 19–1). Grade I fractures have minimal or no comminution. Fracture fragments are small (≤25% of the width of the femoral shaft). Grade II fractures possess a fracture fragment of 25% to 50%, while grade III fractures are associated with a large butterfly fragment (>50% of the width of the femoral shaft). Grade IV fractures possess circumferential comminution over an entire segment of bone with complete loss of abutment of the cortices.
Comminuted femoral shaft fractures.
Femoral shaft fractures are secondary to a high-energy force in 75% of cases.2 The mechanism can be a direct blow or an indirect force transmitted through the flexed knee. Automobile collisions are the most common cause, but gunshot wounds represent an increasing proportion of these fractures.3 Fracture of the femur following a low-energy mechanism is rare, and the clinician should suspect a pathologic fracture in this scenario.
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.4 In infants, the incidence of abuse was 65% in one study.5 Children aged 1 to 5 with femoral shaft fractures are abused in 5% to 35% of cases.4,5 Although spiral fractures are classically associated with child abuse, transverse fractures are seen in an equal number of abused children.6
The patient will present with severe pain in the involved extremity and will usually have visible deformities (Fig. 19–2). 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 ...