Femur fractureMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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571 items

☷ Legend

01Approach to the Critical Patient/attcp69

Initial priorities

›Initial priorities

›Trauma activation criteria

›High-energy mechanism

›SBP < 90 mmHg

›Altered mental status

›Suspected open fracture

›Suspected vascular injury

›Airway and breathing threats

›Hypoxia

›Aspiration risk

›Circulation threats

›Hemorrhagic shock risk from femoral fracture

›Estimated blood loss up to 1.5 L in closed femoral shaft fracture

›Higher risk with open fracture

›Higher risk with polytrauma

›Analgesia and immobilization first-pass bundle

›Early regional anesthesia option

›Early splint or traction strategy

Hemorrhage and shock

›Hemorrhage and shock

›Hemodynamic targets

›SBP ≥ 90 mmHg

›MAP ≥ 65 mmHg

›Mental status improvement target

›Urine output ≥ 0.5 mL/kg/hour

›Hemorrhage source control

›Femur immobilization to reduce ongoing bleeding

›Thomas splint option

›Traction splint option with contraindication screen

›Concomitant hemorrhage search

›Pelvis

›Abdomen

›Chest

›Resuscitation strategy

›Large-bore IV access

›Massive transfusion protocol trigger

›Persistent hypotension despite initial fluids

›Ongoing bleeding concern

›Shock index > 1

›Balanced blood product strategy

›RBC

›Plasma

›Platelets

›Antifibrinolytic option

›If major trauma with hemorrhagic shock and within 3 hours, initiate TXA protocol

›TXA 1 g IV over 10 minutes

›Then TXA 1 g IV over 8 hours

›Avoid if > 3 hours since injury

Limb threat screening

›Limb threat screening

›Neurovascular compromise triggers

›Absent distal pulses

›Immediate reduction of gross deformity if tensioned

›Immediate vascular surgery consult

›CT angiography lower extremity when stable

›Expanding hematoma

›Immediate vascular surgery consult

›Hard signs of vascular injury

›Pulsatile bleeding

›Bruit or thrill

›Distal ischemia

›Compartment syndrome triggers

›Pain out of proportion

›Pain with passive stretch

›Paresthesia

›Tense compartments

›If high concern, emergent orthopedics

›Open fracture triggers

›Antibiotics within 1 hour

›Tetanus prophylaxis pathway

›Orthoplastic or trauma center transfer if required

02History/hx45

Mechanism and symptom pattern

›Mechanism and symptom pattern

›Mechanism

›High-energy MVC

›Fall from height

›Low-energy fall in older adult

›Timing

›Time of injury

›Time since last oral intake

›Pain characteristics

›Hip pain

›Thigh pain

›Knee pain

›Function baseline

›Pre-injury ambulation

›Baseline ADLs

›Assistive devices

Risk modifiers

›Risk modifiers

›Bleeding risk

›Anticoagulants

›Antiplatelets

›Bleeding disorder

›Bone health

›Osteoporosis history

›Prior fragility fractures

›Long-term glucocorticoids

›Infection risk

›Diabetes

›Immunosuppression

›Associated injury clues

›Head injury symptoms

›Chest pain or dyspnea

›Abdominal pain

›Pelvic pain

Red flags and special contexts

›Red flags and special contexts

›Pathologic fracture concern

›Known malignancy

›Night pain

›Minimal trauma

›Non-accidental trauma concern

›Inconsistent story

›Delay in presentation

›Pregnancy status when applicable

›Gestational age estimate

›Abdominal pain

›Vaginal bleeding

03Physical Exam/exam51

Primary survey focused exam

›Primary survey focused exam

›Vital signs and shock markers

›Tachycardia

›Hypotension

›Cool clammy skin

›Delayed capillary refill

›Mental status

›GCS trend

›Agitation

›Hemorrhage check

›External bleeding

›Pelvic instability concern

Limb and joint exam

›Limb and joint exam

›Inspection

›Shortened externally rotated leg

›Proximal femur fracture pattern suspicion

›Thigh deformity

›Femoral shaft fracture suspicion

›Knee swelling

›Distal femur fracture suspicion

›Open wound

›Contamination assessment

›Palpation and stability

›Hip tenderness

›Thigh tenderness

›Knee tenderness

›Crepitus

›Neurovascular exam

›DP pulse

›Asymmetry vs contralateral

›PT pulse

›Asymmetry vs contralateral

›Capillary refill time

›Motor function foot and ankle

›Sensation dorsum and plantar foot

›Compartment syndrome screen

›Pain with passive stretch

›Tense compartments

›Paresthesia

Pitfalls

›Pitfalls

›Missed associated injuries

›Pelvic ring injury

›Knee ligament injury

›Tibial plateau fracture

›Hip dislocation

›False reassurance from single normal pulse check

›Serial neurovascular exams

›Doppler pulses if equivocal

›Anchoring on hip fracture in older adult

›Consider pelvic fracture

›Consider femoral shaft or distal femur fracture

04Differential Diagnosis/ddx35

Life-threatening and limb-threatening

›Life-threatening and limb-threatening

›Hemorrhagic shock from long bone fracture

›Femoral shaft fracture bleeding

›Vascular injury

›Femoral artery injury

›Popliteal artery injury with distal femur or knee dislocation

›Compartment syndrome thigh

›Post-traumatic

›Fat embolism syndrome

›Hypoxemia

›Neurologic changes

›Petechiae

Mimics and associated injuries

›Mimics and associated injuries

›Hip dislocation

›Posterior dislocation

›Pelvic ring fracture

›Unstable pelvis

›Knee dislocation

›Multiligament injury

›Tibial plateau fracture

›Knee effusion

›Septic arthritis hip

›Fever

›Elevated inflammatory markers

›Acute limb ischemia non-traumatic

›Embolic event

Coding alignment

›Coding alignment

›ICD-10 femoral neck fracture S72.0

›ICD-10 pertrochanteric fracture S72.1

›ICD-10 subtrochanteric fracture S72.2

›ICD-10 femoral shaft fracture S72.3

›ICD-10 distal femur fracture S72.4

›ICD-10 multiple femur fractures S72.7

›SNOMED CT femur fracture concept alignment

›SNOMED CT hip fracture concept alignment

05Laboratory Tests/lt32

Hemorrhage and resuscitation labs

›Hemorrhage and resuscitation labs

›CBC for bleeding concern

›Hemoglobin baseline

›Platelet count baseline

›Group and screen

›Crossmatch if shock or operative pathway

›Coagulation panel if bleeding or anticoagulant use

›INR

›aPTT

›Fibrinogen if massive hemorrhage concern

›Low fibrinogen predictor of severe hemorrhage

›Lactate for shock physiology

›Trend response to resuscitation

›Venous blood gas when indicated

›pH

›pCO2 mmHg

›Base deficit

Pre-op and medical optimization labs

›Pre-op and medical optimization labs

›Electrolytes and renal function

›Sodium mmol/L

›Potassium mmol/L

›Creatinine

›Glucose mmol/L

›Hypoglycemia or hyperglycemia correction planning

›CK if crush injury or prolonged down time

›Rhabdomyolysis risk

Infection and open fracture adjuncts

›Infection and open fracture adjuncts

›Wound culture

›Not routine before antibiotics

›Consider in gross contamination with delayed presentation

›CRP and WBC trend

›Baseline for post-op interpretation

06Diagnostic Tests/dt68

Scoring Systems

›Scoring systems

›Gustilo Anderson open fracture classification

›Type I clean wound < 1 cm

›Type II wound 1 to 10 cm without extensive soft tissue damage

›Type III high-energy with extensive soft tissue damage

›Type IIIA adequate soft tissue coverage

›Type IIIB periosteal stripping with bone exposure

›Type IIIC associated arterial injury requiring repair

›AO OTA femur fracture classification

›Proximal femur

›Diaphyseal femur

›Distal femur

›Garden classification femoral neck fractures

›Type I incomplete or valgus impacted

›Type II complete nondisplaced

›Type III complete displaced partial

›Type IV complete displaced full

›Mangled Extremity Severity Score

›Vascular status component

›Ischemia time component

›Shock component

›Age component

›Shock index

›HR divided by SBP

›> 1 higher risk of severe hemorrhage

MRI

›MRI

›Indications

›Occult femoral neck fracture with negative X-ray and persistent pain

›Stress fracture suspicion

›Performance

›High sensitivity for occult hip fracture

›High specificity for occult hip fracture

›Timing considerations

›Expedite when diagnosis changes weight-bearing and operative pathway

›Contraindications

›Non-MRI compatible implants

›Unstable patient physiology

›CT

›Indications

›Complex proximal femur fracture pattern for operative planning

›Distal femur intra-articular extension assessment

›Polytrauma whole-body CT pathway

›Suspected femoral neck fracture with equivocal X-ray when MRI not available

›CT angiography lower extremity

›Absent distal pulses

›Hard signs pathway

›Vascular surgery consult before imaging if unstable limb

›ABI < 0.9 after reduction or immobilization

›CTA trigger

›Pitfalls

›Contrast nephropathy risk in shock

›False reassurance with intermittent vasospasm

Ultrasound

›Ultrasound

›eFAST in polytrauma

›Pericardial effusion

›Free intraperitoneal fluid

›Pneumothorax

›Hemothorax

›Vascular Doppler adjunct

›DP signal presence

›PT signal presence

›Serial comparison

›Nerve block guidance

›Femoral nerve block

›Fascia iliaca compartment block

›Limitations

›Operator dependence

›Deep vessel visualization limits in obesity

07Disposition/dispo29

Level of care and consults

›Level of care and consults

›Orthopedics consult

›All suspected femur fractures

›Emergent for open fracture

›Emergent for vascular compromise

›Trauma surgery consult

›Polytrauma

›Shock physiology

›Vascular surgery consult

›Hard signs vascular injury

›CTA positive findings

›ICU criteria

›Persistent hemodynamic instability

›Ongoing transfusion needs

›Significant comorbid respiratory failure

Admission and transfer criteria

›Admission and transfer criteria

›Admission criteria

›Femoral neck fracture

›Intertrochanteric fracture

›Subtrochanteric fracture

›Femoral shaft fracture

›Distal femur fracture

›Transfer criteria

›Need for orthoplastic coverage for severe open fracture

›Need for vascular repair capability

›Lack of definitive fixation capability

›Time-sensitive priorities

›Early surgery pathway for hip fractures when medically optimized

›Open fracture antibiotics and debridement pathway

08Treatment/t125

Analgesia and sedation

›Analgesia and sedation

›Multimodal analgesia strategy

›Acetaminophen PO 1000 mg

›Maximum 4000 mg per 24 hours

›Lower maximum with liver disease

›Ibuprofen PO 400 mg

›Avoid in renal failure

›Avoid in active bleeding

›Ketorolac IV 15 mg

›Avoid in renal failure

›Avoid in anticoagulated bleeding concern

›Opioids for severe pain

›Fentanyl IV 25 mcg

›Repeat every 5 minutes for pain and respiratory status

›Typical total 50 to 200 mcg

›Hold for respiratory depression

›Morphine IV 2 mg

›Repeat every 5 to 10 minutes for pain

›Typical total 0.05 to 0.1 mg/kg

›Avoid in hemodynamic instability

›Regional anesthesia

›Fascia iliaca compartment block

›Ropivacaine 0.2% 30 mL

›Maximum local anesthetic dose by weight

›Local anesthetic systemic toxicity precautions

›Femoral nerve block

›Bupivacaine 0.25% 20 mL

›Maximum local anesthetic dose by weight

›Avoid intravascular injection

›Procedural sedation when required

›Ketamine IV 0.5 mg/kg

›Additional 0.25 mg/kg every 5 minutes for effect

›Monitor airway and ventilation

›Emergence reaction precautions

Immobilization and reduction

›Immobilization and reduction

›Immediate immobilization options

›Long leg splint for distal femur fracture

›Knee immobilizer adjunct

›Hip stabilization adjunct

›Traction splint for suspected midshaft femur fracture

›Contraindication screen

›Suspected distal femur fracture

›Suspected knee dislocation

›Ipsilateral tibia or ankle fracture

›Pelvic fracture concern

›Thomas splint option for transport

›Improved pain control

›Reduced motion

›Gross deformity realignment if neurovascular compromise

›If absent pulses, gentle longitudinal traction and realignment

›Recheck pulses after realignment

›Recheck sensation after realignment

Open fracture bundle

›Open fracture bundle

›Wound handling

›Saline-soaked dressing with occlusive cover

›Avoid repeated wound exploration

›Avoid prehospital irrigation of long bone open fractures

›Antibiotics timing

›If open fracture, initiate IV antibiotics within 1 hour

›Infection risk increases with delay beyond 1 hour

›Antibiotic selection framework

›Gustilo type I or II coverage

›Cefazolin IV 2 g

›Repeat every 8 hours

›Weight-based higher dose option

›Gustilo type III coverage

›Cefazolin IV 2 g

›Repeat every 8 hours

›Plus gram-negative coverage

›Gentamicin IV 5 mg/kg

›Farm or fecal contamination coverage

›Add anaerobic coverage

›Penicillin G IV 4 million units

›Repeat every 4 hours

›Tetanus prophylaxis

›Unknown or incomplete immunization and dirty wound

›Tdap

›Single dose

›Tetanus immune globulin 250 units IM

›Separate site from vaccine

Hemorrhage adjuncts and prevention

›Hemorrhage adjuncts and prevention

›TXA pathway in major trauma hemorrhage

›If within 3 hours, initiate TXA

›TXA 1 g IV over 10 minutes

›Then TXA 1 g IV over 8 hours

›Increased harm signal if delayed beyond 3 hours

›Temperature management

›Normothermia goal

›Active warming if hypothermic

›Calcium management during massive transfusion

›Ionized calcium monitoring

›Treat hypocalcemia during transfusion

Definitive management overview

›Definitive management overview

›Femoral neck fracture

›Displaced intracapsular fracture in older adult

›Arthroplasty pathway

›Total hip arthroplasty selection criteria

›Nondisplaced intracapsular fracture

›Internal fixation pathway

›Intertrochanteric fracture

›Cephalomedullary nail option

›Sliding hip screw option

›Subtrochanteric fracture

›Cephalomedullary nail typical strategy

›Femoral shaft fracture

›Intramedullary nailing typical strategy

›External fixation damage control option

›Distal femur fracture

›Locking plate fixation option

›Retrograde nail option

›Evidence framing

›AAOS hip fracture guideline provides recommendations for older adults

›NICE CG124 emphasizes coordinated hip fracture programs and early surgery when appropriate

VTE prophylaxis and secondary prevention

›VTE prophylaxis and secondary prevention

›VTE risk recognition

›Major lower extremity fracture high VTE risk

›Mechanical prophylaxis

›Intermittent pneumatic compression when feasible

›Pharmacologic prophylaxis coordination

›Enoxaparin timing per surgical plan

›Hold for active bleeding or pending neuraxial anesthesia

›Fragility fracture pathway

›Osteoporosis evaluation referral

›Vitamin D and calcium adequacy assessment

›Fall risk evaluation referral

09Special Populations/sp44

Pregnancy

›Pregnancy

›Maternal priorities

›Maternal resuscitation first principle

›Left uterine displacement in later gestation

›Imaging considerations

›Do not delay indicated imaging for maternal stabilization

›Shielding when feasible

›Medication considerations

›Avoid NSAIDs in later pregnancy

›Opioid use with fetal monitoring considerations

›Obstetrics involvement

›Fetal monitoring based on gestational age

›Rh status assessment when indicated

Geriatric

›Geriatric

›Hip fracture high-risk phenotype

›30-day mortality risk recognition

›Delirium risk recognition

›Analgesia considerations

›Lower opioid starting doses

›Regional anesthesia preference when available

›Medical optimization priorities

›Early anesthesia assessment

›Early geriatric co-management where available

›Disposition considerations

›Admission for nearly all femur fractures

›Early mobilization planning post-op

Pediatrics

›Pediatrics

›Mechanism patterns

›High-energy trauma in older child

›Non-accidental trauma consideration in young child

›Immobilization options

›Skin traction option for pain control

›Approx 10% body weight traction reference

›Thomas splint option for transfer

›Analgesia dosing

›Acetaminophen 15 mg/kg PO

›Maximum 1000 mg per dose

›Maximum 60 mg/kg per 24 hours

›Ibuprofen 10 mg/kg PO

›Maximum 600 mg per dose

›Avoid in dehydration

›Surgical pathway differences

›Flexible nails in certain age groups

›Spica casting in selected younger children

10Background/b35

Epidemiology

›Epidemiology

›Fracture patterns by age

›High-energy femoral shaft fractures in younger adults

›Low-energy hip fractures in older adults

›Sex distribution trends

›Higher hip fracture risk in older women

›Mortality and morbidity signals

›Hip fracture associated with substantial short-term mortality in older adults

›30-day mortality reported up to about 8% in older adult cohorts

›One-year mortality reported around 20% to 30% in older adult cohorts

Pathophysiology

›Pathophysiology

›Bleeding physiology

›Medullary canal bleeding contribution

›Soft tissue injury bleeding contribution

›Shock risk amplification with polytrauma

›Fat embolism mechanism

›Marrow fat entry into venous circulation

›Inflammatory cascade contribution

›Osteoporotic fragility fracture mechanism

›Low bone mineral density

›Fall biomechanics

Therapeutic Considerations

›Therapeutic considerations

›Early immobilization rationale

›Pain reduction

›Reduced ongoing bleeding from fracture motion

›Reduced secondary soft tissue injury

›Regional anesthesia rationale

›Opioid sparing effect

›Improved early mobilization potential

›Definitive fixation timing concepts

›Early fixation improves pain control and mobilization in many settings

›Damage control orthopedics in physiologically unstable patients

›Evidence and guideline framing

›NICE CG124 recommends coordinated multidisciplinary hip fracture care and early surgery when appropriate

›AAOS hip fracture guideline provides evidence-based recommendations for older adults with hip fracture

11Patient Discharge Instructions/pdi29

Copy discharge instructions

›Copy discharge instructions

›Activity and weight-bearing

›Weight-bearing status per orthopedics plan

›Crutches or walker use training

›Wound and splint care

›Keep splint clean and dry

›Do not insert objects into splint

›Pain control

›Acetaminophen schedule as directed

›NSAID use only if approved

›Opioid safety

›No driving

›No alcohol

›DVT prevention instructions when prescribed

›Anticoagulant adherence

›Leg exercises as directed

›Return to ED immediately

›Increasing pain not controlled

›New numbness or weakness foot

›Pale or cold foot

›Blue toes

›New swelling calf

›Chest pain

›Shortness of breath

›Fever

›Drainage or foul odor from wound

›Follow-up

›Orthopedics appointment timing per plan

›Primary care follow-up for osteoporosis evaluation if fragility fracture

12References/r9

Guidelines and evidence sources

›Guidelines and evidence sources

›AAOS Management of Hip Fractures in Older Adults clinical practice guideline published 2021

›NICE CG124 Hip fracture management last updated 6 January 2023

›NICE NG37 Fractures complex assessment and management published 2016

›BOAST 4 Open fractures guidance

›BOA and BAPRAS Standards for Open Fractures 2020

›ACS TQIP Best Practices in the Management of Orthopaedic Trauma guideline

›EAST Practice Management Guideline on TXA in trauma updated 2025

›Peer-reviewed review data on hip fracture mortality and systems of care

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.