01Approach to the Critical Patient/attcp51

Immediate priorities

›Hemorrhage and shock assessment

›Estimated blood loss 1,000 to 1,500 mL for closed femoral shaft fracture

›Open fracture doubles estimated blood loss

›Hidden blood loss averages 1,445 mL perioperatively

›Isolated femoral shaft fracture rarely causes class III or IV hemorrhagic shock

›If hypotension present, search aggressively for other bleeding sources

›Chest, abdomen, and pelvis as priority sites

›ATLS primary survey ABCs

›Airway and breathing assessment first

›IV access minimum two large bore peripheral lines

›Type and crossmatch immediately

›Damage control resuscitation triggers

›Hypotension SBP < 90 mmHg

›Permissive hypotension if active haemorrhage ongoing

›Balanced resuscitation with blood products

›Tachycardia HR > 100

›Early sign of significant blood loss

›Trending upward despite analgesia is a danger signal

›Lactate > 2 mmol/l or base deficit > 6

›Markers of tissue hypoperfusion and occult shock

›Serial measurement every 2 hours

Fat embolism syndrome recognition

›FES triad and timing

›Classic triad: respiratory distress, altered mental status, petechial rash

›Onset typically 12 to 72 hours post-injury

›Can present as early as 4 hours

›Incidence approximately 1.7% in modern era, down from 8% historically

02History/hx66

Mechanism and presentation

›Mechanism of injury

›High-energy mechanisms in young adults

›Motor vehicle collision

›Pedestrian struck by vehicle

›Fall from height

›Gunshot wound

›Low-energy mechanisms in elderly

›Ground-level fall with osteoporotic bone

›Bisphosphonate-associated atypical fracture

›Time from injury to presentation

›Critical for surgical planning

›Relevant to FES onset risk window

›Presenting symptoms

›Thigh pain, acute onset, inability to bear weight

›Visible deformity and swelling

›Shortening and external rotation of limb

›Neurological symptoms distally

›Numbness or tingling in foot

›Weakness of foot and ankle

›FES early symptoms

›Dyspnea or confusion 12 to 72 hours post-injury

›Petechial rash in axillae or conjunctivae

Associated symptoms and alarm features

›Alarm features requiring urgent evaluation

›Loss of consciousness or confusion

›TBI or FES cerebral involvement

›Hypotension-related cerebral hypoperfusion

03Physical Exam/exam64

Vital signs and general appearance

›Hemodynamic assessment

›Tachycardia

›Early sign of hemorrhage

›HR > 100 with femur fracture warrants urgent source evaluation

›Hypotension SBP < 90 mmHg

›Late sign with isolated femur fracture; search for other bleeding

›Immediate resuscitation activation

›Respiratory rate

›Elevated RR may signal FES pulmonary involvement

›Tachypnea with altered mentation: FES triad concern

›General appearance

›Limb deformity

›Shortened and externally rotated thigh

›Visible angulation or swelling

›Mental status baseline

›Agitation or confusion may indicate FES or TBI

›Establish baseline before analgesia

Limb examination

›Inspection and palpation

›Skin integrity assessment

›Open fracture: skin breach with exposed bone or fat globules

›Gustilo-Anderson classification if open: Grade I, II, IIIA, IIIB, IIIC

›Thigh swelling and tension

›Compartment syndrome: tense, woody thigh

›Pain out of proportion to injury severity

›Crepitus on palpation

›Consistent with fracture; avoid excessive manipulation

04Differential Diagnosis/ddx42

Life-threatening diagnoses

›Hemorrhagic shock

›ICD-10 T79.4 associated with traumatic hemorrhage

›Isolated femur fracture rarely causes class III or IV shock

›Always identify other bleeding sources if hypotension present

›Associated pelvic fracture

›ICD-10 S32 pelvic fracture codes

›Retroperitoneal hemorrhage risk

›Fat embolism syndrome

›ICD-10 T79.1 fat embolism

›Triad onset 12 to 72 hours

›Respiratory failure component may progress to ARDS

›Pulmonary embolism

›ICD-10 I26 pulmonary embolism

›Differentiate from FES: Wells score, CT pulmonary angiography

›Compartment syndrome

›ICD-10 M79.A2 compartment syndrome thigh

›Fasciotomy urgently required if delta pressure < 30 mmHg

›Irreversible muscle necrosis within 6 hours if untreated

›Vascular injury

›ICD-10 S75 injury of blood vessels at hip and thigh level

›Superficial femoral artery most at risk

›Hard signs: absent pulse, expanding hematoma, bruit

Fracture-related mimics

›Pathologic fracture from malignancy

›Low-energy mechanism without osteoporosis

›Lytic lesion on radiograph

›ICD-10 M84.55 pathological fracture femur

05Laboratory Tests/lt58

Hemorrhage and transfusion labs

›Complete blood count

›Baseline hemoglobin strongest predictor of transfusion need

›Average transfusion need 2.5 units PRBCs when required

›Serial monitoring every 4 to 6 hours in first 24 hours

›Platelet count

›Thrombocytopenia supports FES diagnosis

›Anticoagulant effect monitoring

›White blood cell count

›Baseline for infection monitoring

›Leukocytosis common from stress response

›Type and screen or crossmatch

›Mandatory in all femoral shaft fractures

›Anticipate transfusion in bilateral or open fractures

›Crossmatch 2 units PRBCs minimum

›Coagulation studies

›PT and INR

›Anticoagulant use preoperative assessment

›Warfarin reversal planning if elevated

›PTT

›Heparin monitoring if therapeutically anticoagulated

›Bleeding diathesis screening

Metabolic and perfusion labs

›Basic metabolic panel

›Electrolytes

›Potassium monitoring with massive resuscitation

›Sodium for baseline and trend

›Renal function creatinine and BUN

06Diagnostic Tests/dt106

Scoring Systems

›Injury Severity Score

›ISS stratification for treatment pathway

›ISS < 18: stable patient, early total care (IMN within 24 hours)

›ISS > 18: borderline or unstable, consider damage control orthopaedics

›ISS > 40 with hypothermia, coagulopathy, or acidosis: damage control mandatory

›Pape classification for femur fracture management

›Stable: isolated injury, hemodynamically normal, early definitive IMN

›Borderline: ISS 18 to 40, resuscitation required, re-evaluate before fixation

›Unstable: persistent shock requiring resuscitation, damage control

›In extremis: uncontrollable hemorrhage, damage control only

›Gurd and Wilson criteria for fat embolism syndrome

›Major criteria

›Petechial rash

›Respiratory insufficiency PaO2 < 60 mmHg

›Cerebral involvement not due to other cause

›Minor criteria

›Tachycardia > 110 per minute

›Fever > 38.5 degrees Celsius

›Retinal changes

›Thrombocytopenia

›High ESR

›Fat macroglobulinemia

›Diagnosis requires 1 major + 4 minor criteria or 2 major criteria

›Gustilo-Anderson open fracture classification

›Grade I

›Clean wound < 1 cm

›Low contamination

›Grade II

›Wound 1 to 10 cm

›No extensive soft tissue damage

›Grade IIIA

›Wound > 10 cm with adequate soft tissue coverage

›Grade IIIB

›Extensive soft tissue loss requiring flap coverage

›Grade IIIC

›Arterial injury requiring repair

MRI

›MRI femur indications

›Stress fracture diagnosis

›Plain radiograph negative with high clinical suspicion

›MRI sensitivity approaching 100% for occult fractures

›T2 and STIR sequences show periosteal edema and fracture line

›Pathologic fracture evaluation

›Tumor characterization and extent of marrow involvement

›Staging and surgical planning for metastatic disease

›Bisphosphonate-associated atypical fracture

›Lateral cortex signal change and incomplete fracture

›Bilateral femur MRI recommended to identify contralateral risk

›MRI brain in FES

›Starfield pattern of diffusion restriction

›Multiple punctate DWI-positive lesions in white matter

›Gold standard for cerebral FES diagnosis

›FLAIR may show white matter signal change

›Distinguishes FES from traumatic brain injury

›Location and pattern differs from DAI

›Correlates with cognitive outcomes

CT

›CT for fracture characterization

›AO/OTA classification confirmation

›Type 32A: simple (transverse, oblique, spiral)

›Type 32B: wedge (bending wedge, spiral wedge, fragmented wedge)

›Type 32C: complex (spiral, segmental, irregular comminuted)

›Surgical planning

›Entry point selection for IMN

›Comminution extent assessment

›Ipsilateral hip and knee injury identification

›CT angiography

›Indications

›Absent or diminished distal pulses

›Ankle-brachial index < 0.9

›Expanding hematoma or bruit

›Sensitivity and specificity

›Sensitivity approaches 95% for arterial injury

›First-line over formal angiography in most trauma centres

›Identifies injury to superficial femoral artery or popliteal artery

›Vascular surgery consultation urgently triggered

›CT for FES complications

›CT chest findings in FES

›Bilateral ground-glass opacities

›Patchy exudates in centrilobular distribution

›CT pulmonary angiography

›Differentiates FES from pulmonary embolism

›Saddle or lobar filling defect indicates PE over FES

›Whole-body CT in polytrauma

›Standard in high-energy mechanism with hemodynamic instability

›Identifies occult injuries missed on plain films

›Chest, abdomen, pelvis CT with contrast

Ultrasound

›FAST examination

›Indications in femur fracture

›All polytrauma patients with hemodynamic compromise

›Identifies intraperitoneal and pericardial hemorrhage

›Findings

›Free fluid in Morison pouch, splenorenal space, pelvis

›Pericardial effusion

›FAST negative does not exclude retroperitoneal hemorrhage

›CT scan required if mechanism suggests aortic or pelvic vascular injury

›Vascular duplex ultrasound

›Soft signs of vascular injury

›Non-expansile haematoma

›Decreased but present pulse with normal ABI

›Identify arteriovenous fistula or pseudoaneurysm

›Delayed presentation of vascular injury

›Ultrasound-guided femoral nerve block

›Real-time needle guidance to femoral nerve

›In-plane or out-of-plane technique

›Identify femoral nerve lateral to femoral artery

›Reduces need for repeated sedation or opioid dosing in ED

›ACEP Level B recommendation for regional analgesia in lower extremity fractures

07Disposition/dispo49

Admission criteria

›All adult femoral shaft fractures require admission

›Operative fixation required in virtually all adult cases

›No role for conservative management in adults

›Class I recommendation based on fracture biology and outcomes data

›NPO on presentation in anticipation of operative fixation

›Oral medications held or converted to IV equivalents

›ICU admission criteria

›Hemodynamic instability requiring ongoing resuscitation

›Damage control resuscitation phase

›Vasopressor or massive transfusion protocol activation

›Bilateral femoral shaft fractures

›High FES risk requiring monitoring

›Pulmonary function monitoring

›Signs of fat embolism syndrome

›Respiratory support requirement

›Cerebral involvement

›Polytrauma ISS > 15

›Multi-system injury management

›Trauma surgery and orthopaedics co-management

›Need for damage control surgery

›Laparotomy prior to fracture fixation

›Return to OR staged approach

Surgical timing and transfer

›Timing of definitive fixation

›EAST guideline: early fixation within 24 hours trends toward lower infection

›Mortality and VTE rates improved with early fixation

›Class IIa recommendation for early total care in stable patients

08Treatment/t83

Immediate stabilization and analgesia

›Initial stabilization

›ATLS protocol with primary survey

›ABCs prioritized before fracture-specific management

›Two large-bore IVs, type and screen, IV fluids

›Fracture splinting

›Static splint in most ED presentations

›Traction splint if significant shortening and muscle spasm

›Evidence for traction benefit is uncertain per NAEMSP 2025 position statement

›Multimodal analgesia

›Femoral nerve block as first-line analgesic

›20 mL 0.5% bupivacaine ultrasound-guided

›Reduces pain by approximately 3.6 points on VAS

›Significantly decreases opioid requirements

›ACEP Level B recommendation for regional nerve block

›Analgesic-dose ketamine

›0.1 to 0.3 mg/kg IV

›Preferred in hemodynamically unstable due to minimal hemodynamic effects

›Dissociative threshold not approached at sub-analgesic doses

›Fentanyl IV titration

›1 mcg/kg IV titrated in 25 mcg increments

›Preferred opioid due to minimal hemodynamic effects and short half-life

›Avoid morphine in hemodynamically unstable patients

›NSAIDs

›Use cautiously given bleeding risk in acute setting

›Ketorolac 15 to 30 mg IV if hemostasis assured

Resuscitation and blood management

›Hemorrhage control

›Balanced resuscitation: 1:1:1 ratio PRBCs, FFP, platelets if massive transfusion

›Massive transfusion protocol activation if > 4 units PRBCs anticipated

›Tranexamic acid 1 g IV bolus then 1 g over 8 hours

›Best within 3 hours of injury for maximal benefit

›Transfusion triggers

›Hemoglobin < 70 g/L in stable patients

›Hemoglobin < 80 g/L in elderly or cardiac comorbidity

›Ongoing hemorrhage regardless of Hb level

›Open fracture wound management

›Irrigation and saline-soaked dressing

›Do not explore wound in ED

›Cover with sterile moist dressing

›Antibiotics for open fracture

›Cefazolin 2 g IV (3 g if weight > 120 kg) as soon as possible

›Grade I and II: cefazolin alone

›Grade III: add gentamicin 5 mg/kg IV daily

›Anaerobic coverage (penicillin G or metronidazole) if farm contamination

›Tetanus prophylaxis

›dT or Td booster if last vaccination > 5 years

›TIG 250 units IM if not immunized and contaminated wound

Definitive surgical treatment

›Intramedullary nailing: gold standard

›Antegrade IMN (piriformis fossa or trochanteric entry)

›Preferred approach for most diaphyseal shaft fractures

›Union rate > 95%, average time to union 5 to 6 months

›Major complication rate 5.4% vs 21.9% with external fixation

›Retrograde IMN

›Useful for ipsilateral knee injuries

›Bilateral femur fractures

›Pregnancy (avoids fetal radiation and positioning issues)

›Morbid obesity

›Locking screws proximal and distal

›Static locking for comminuted fractures

›Dynamic locking for simple transverse or short oblique fractures

›Damage control orthopaedics pathway

›Temporary external fixation

›Rapid stabilization in unstable or in extremis patients

›Allows resuscitation and physiologic normalization

›Conversion to IMN planned after 24 to 72 hours when stable

›Staged definitive fixation

›Avoid second hit in borderline or unstable patients

›Conversion window: once hypothermia, coagulopathy, and acidosis corrected

VTE prophylaxis

›Chemical prophylaxis

›Enoxaparin 30 mg SQ twice daily

›LMWH preferred by most trauma centres

›Western Trauma Association guideline

›Initiate when hemorrhage risk acceptable, typically 12 to 24 hours post-fixation

›Aspirin 81 mg twice daily

›PREVENT CLOT trial (NEJM 2023): noninferior to enoxaparin for death prevention at 90 days

›Alternative option when LMWH contraindicated or patient preference

›Duration: up to 4 weeks post-injury per EAST guideline

›Mechanical prophylaxis

›Sequential compression devices on contralateral limb

›Applied immediately on admission

›Continued until chemical prophylaxis initiated

›Early mobilization post-fixation

›Weight-bearing as tolerated after locked IMN typically

›Physiotherapy referral in-hospital

09Special Populations/sp90

Pregnancy

›Physiologic considerations

›Anatomic and cardiovascular changes

›Increased blood volume up to 45% by third trimester

›Baseline tachycardia and lower baseline blood pressure

›Delayed recognition of hemorrhagic shock

›Retrograde IMN preferred approach

›Avoids fetal radiation from fluoroscopy over abdomen

›Lateral decubitus positioning may be better tolerated

›Estimated blood loss and transfusion thresholds

›More aggressive transfusion to protect fetal oxygenation

›Target hemoglobin > 90 g/L to maintain fetal oxygen delivery

›Analgesia considerations

›Fentanyl and ketamine acceptable in acute phase

›Opioid use: neonatal monitoring required

›Regional nerve block preferred to reduce systemic opioid exposure

›NSAIDs contraindicated in third trimester

›Premature closure of ductus arteriosus risk

›Avoid ketorolac after 32 weeks gestation

›Enoxaparin for VTE prophylaxis

›Safe in pregnancy; does not cross placenta

›Adjust dose for weight gain in third trimester

›Fetal monitoring

›Continuous fetal monitoring in viable gestation (> 24 weeks)

›Obstetrics consultation urgently

›Maternal stabilization takes priority

›Radiation exposure minimized but not withheld if life-threatening injury

›AP pelvis radiograph shielding

›CT abdomen/pelvis only if clinically necessary

Geriatric

›Low-energy mechanism and osteoporosis

›Bone quality affects nail selection and fixation stability

›Augmentation with calcium phosphate cement may be required

›IMN remains gold standard even in osteoporotic bone

›Elbarbary 2021 outcomes data: good results with locked IMN in patients over 60

›Perioperative medical optimization

›Cardiac and pulmonary risk stratification

›Anticoagulation reversal planning

›Medication reconciliation and hold list

›Atypical fractures from bisphosphonate use

›Lateral cortex, transverse pattern

›Prodromal thigh pain history often present

›Contralateral femur prophylactic nailing consideration

›Hold bisphosphonate post-fracture

›Reassess after fracture healing complete

›DEXA scan and endocrinology referral

›FES risk higher in elderly

›Obese and diabetic patients highest risk

›ICU monitoring preferred in high-risk elderly patients

›Aggressive early fixation to reduce fat embolism load

›Post-operative recovery considerations

›Early physiotherapy and mobilization

›Weight-bearing as tolerated reduces mortality in elderly hip and femur fractures

›Delirium prevention protocols

›VTE prophylaxis duration

›Extended to 4 weeks given high VTE risk in elderly

Pediatrics

›Age-based treatment algorithm

›Less than 6 months: Pavlik harness

›Non-operative management preferred

›Close follow-up for reduction maintenance

›6 months to 5 years: hip spica casting

›Immediate or with brief traction

›Acceptable shortening up to 2 cm

›5 to 11 years: flexible intramedullary nails (FIMN)

›Titanium elastic nailing preferred

›Weight < 50 kg and fracture stability required

›Cochrane review supports FIMN over conservative treatment in this age group

›11 to 16 years (near-skeletal maturity): rigid locked IMN or submuscular plating

›Growth plate closure guides implant selection

›Submuscular plating avoids physis in younger patients

›Nonaccidental trauma consideration

›Children under 3 years

›Mechanism must be scrutinized carefully

›Inconsistency between mechanism and injury pattern raises concern

›Child protection referral mandatory if suspicion arises

›Documentation and mandatory reporting

›Skeletal survey if nonaccidental trauma suspected

›Social work consultation

›Analgesia in pediatrics

›Femoral nerve block

›Effective in all age groups with ultrasound guidance

›Reduces opioid requirements significantly

›Intranasal fentanyl 1.5 mcg/kg if IV access delayed

›Rapid onset and effective for procedural pain

›Oral ibuprofen acceptable post-operative analgesia

›10 mg/kg per dose every 6 to 8 hours

›Maximum 40 mg/kg/day

›Hardware removal in pediatrics

›Recommended after fracture healing 6 to 12 months

›Prevents periprosthetic fracture

›Prevents buried hardware complication

›Routine removal preferred in most paediatric centres

10Background/b93

Epidemiology

›Incidence and demographics

›Bimodal age distribution

›Young adult males: high-energy mechanism (MVC, GSW, falls from height)

›Elderly with osteoporosis: low-energy ground-level fall

›Annual incidence approximately 10 per 100,000 in general population

›Higher in high-income countries with high motorization

›GSW mechanism highest in urban centres

›Bilateral fractures less common

›Incidence approximately 5% of all femoral shaft fractures

›Associated with higher mortality and complication rates

›Mortality and morbidity

›Isolated femoral shaft fracture: low mortality in young adults

›Mortality rises significantly with polytrauma and ISS > 18

›FES mortality 10 to 20% historically; lower with early fixation

›FES incidence in modern era: approximately 1.7%

›Down from 8% prior to modern surgical fixation techniques

›Early operative fixation is the primary prevention strategy

›VTE incidence without prophylaxis estimated 50 to 80%

›Symptomatic DVT up to 20% without prophylaxis

›PE up to 2% without prophylaxis

›Coding

›ICD-10 S72.3 fracture of shaft of femur

›S72.30 unspecified fracture of shaft of femur

›S72.31 displaced fracture of shaft

›S72.32 nondisplaced fracture of shaft

›SNOMED CT: fracture of shaft of femur (disorder)

Pathophysiology

›Fracture mechanics

›High-energy mechanism

›Transverse or comminuted pattern from direct force

›Spiral pattern from torsional mechanism

›Segmental fracture from combined loading

›Low-energy mechanism in osteoporosis

›Cancellous bone failure under physiologic loading

›Lateral cortex stress fracture in bisphosphonate users

›AO/OTA classification reflects injury energy

›Type A: simple (single fracture line)

›Type B: wedge (butterfly fragment retained contact)

›Type C: complex (no cortical contact between main fragments)

›Blood loss mechanisms

›Closed femoral shaft fracture: 1,000 to 1,500 mL estimated blood loss

›Hidden blood loss to thigh compartment and systemic third spacing

›Average total 1,445 mL perioperatively including surgical blood loss

›Muscle bellies and medullary canal are the primary bleeding sources

›Exsanguinating haemorrhage unusual from isolated fracture

›Longitudinal hematoma tracks along fascial planes

›Fat embolism pathophysiology

›Mechanical theory

›Fat globules released from disrupted marrow enter venous circulation

›Reaming during IMN increases intramedullary pressure

›Paradoxical embolism through patent foramen ovale contributes to cerebral FES

›Biochemical theory

›Inflammatory cytokines convert neutral fat to free fatty acids

›Direct pulmonary capillary injury causing permeability edema

›Coagulation cascade activation contributing to thrombocytopenia

›Compartment syndrome mechanism

›Increased pressure within closed fascial compartment

›Hematoma expansion and post-injury edema

›Threshold: delta pressure (diastolic BP minus compartment pressure) < 30 mmHg

›Irreversible ischaemia within 6 hours if untreated

Therapeutic Considerations

›IMN as gold standard: evidence base

›Union rate > 95% with locked IMN

›Average time to union 5 to 6 months

›Antegrade nailing preferred for most diaphyseal fractures

›IMN vs external fixation comparison

›Major complication rate 5.4% IMN vs 21.9% external fixation

›Infection rate lower with IMN

›Malunion rate lower with IMN

›Reaming vs unreamed IMN

›Reamed nail allows larger diameter nail and better stability

›Theoretical increased FES risk from reaming not supported in modern series

›VTE prophylaxis evidence

›PREVENT CLOT trial (NEJM 2023)

›Aspirin 81 mg BID noninferior to enoxaparin 30 mg BID for 90-day mortality

›No significant difference in PE or VTE rates

›Aspirin offers cost and compliance advantages

›Duration recommendation

›4 weeks post-injury per EAST and WTA guidelines

›Extended prophylaxis beneficial given prolonged immobilization

›Analgesia evidence

›Femoral nerve block vs IV fentanyl (Altunbas 2025, AJEM)

›FNB superior pain control at 30 and 60 minutes

›Significantly reduced opioid consumption

›FNB recommended as first-line in hemodynamically stable patients

›Multimodal analgesia ACS Best Practices Guidelines 2020

›Regional block + ketamine + opioid as tolerated

›Reduces opioid-related adverse events

›Damage control orthopaedics rationale

›Second hit hypothesis

›Primed inflammatory state from initial injury

›Major surgery as second hit can precipitate ARDS and MOF

›External fixation as bridge

›Rapid stabilization reduces pain, blood loss, and inflammatory response

›Staged conversion when lactate normalized and physiology corrected

11Patient Discharge Instructions/pdi42

copy discharge instructions

›Femur fracture post-operative home care

›Weight-bearing instructions as directed by your surgeon

›Weight-bearing as tolerated is typical after locked nail fixation

›Use crutches or walker as instructed until comfortable

›Wound care

›Keep surgical wounds clean and dry for 5 to 7 days

›Change dressings as instructed

›No soaking incision in bath or pool until healed

›Medications

›Take prescribed pain medications as directed

›Blood thinner medication (aspirin or injections) to prevent blood clots

›Take until instructed to stop (typically 4 weeks)

›Calcium 1,200 mg and vitamin D 800 IU daily to support bone healing

›Return to ER warning signs

›Breathing problems

›Shortness of breath or chest pain: may indicate blood clot or fat embolism

›Call 911 or go to nearest ER immediately

›Leg signs

›Increasing calf swelling, redness, or pain: possible DVT

›Cold, pale, or numb foot: possible arterial problem

›Go to ER immediately

›Wound signs

›Fever above 38.5 degrees Celsius

›Wound redness, drainage, or wound opening

›Foul smell from wound

›Neurological signs

›Confusion or unusual drowsiness

12References/r31

Guidelines and key sources

›Society guidelines

›Eastern Association for the Surgery of Trauma (EAST) guideline: optimal timing of femur fracture stabilization in polytrauma

›Gandhi RR et al. Journal of Trauma and Acute Care Surgery 2014

›Recommends early fixation within 24 hours in stable polytrauma patients

›American College of Surgeons Best Practices in Orthopaedic Trauma Management 2015

›Davis ML et al.

›Multimodal analgesia and damage control orthopaedics framework

›NAEMSP position statement on prehospital management of femoral shaft fractures 2025

›Lyng JW et al. Prehospital Emergency Care 2025

›Uncertainty regarding traction splint benefit acknowledged

›Western Trauma Association VTE guidelines 2020

›Ley EJ et al. Journal of Trauma and Acute Care Surgery 2020

›Landmark trials

›PREVENT CLOT trial (METRC consortium)

›NEJM 2023; O'Toole RV et al.

›Aspirin 81 mg BID noninferior to enoxaparin for 90-day death prevention

›IMN vs external fixation outcomes

›Testa G et al. Journal of Clinical Medicine 2019

›Major complication 5.4% IMN vs 21.9% external fixation

›Femoral nerve block in ED (Altunbas E et al.)

›American Journal of Emergency Medicine 2025

›FNB superior to IV fentanyl for pain control

›FES incidence systematic review

›Lempert M et al. Journal of Clinical Medicine 2021

›1.7% incidence in modern era

›Key references

›Ricci WM et al. JAAOS 2009: intramedullary nailing current concepts

Evidence & Review