Femoral shaft fracturesMANAGEMENT

THIGH & KNEE · 12 SECTIONS

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509 items

☷ Legend

01Approach to the Critical Patient/attcp45

Immediate priorities

›First 5 minutes

›ABC threats

›Airway compromise from polytrauma

›Respiratory failure from chest injury

›Hemorrhagic shock from long bone bleeding

›Hemorrhage recognition

›Femoral shaft fracture as major bleeding source

›Occult bleeding from pelvis or abdomen in high energy mechanism

›Monitoring

›Continuous ECG

›SpO2

›Noninvasive BP cycling

›End tidal CO2 if sedation or intubation

›Immediate limb threat screen

›Neurovascular status

›Dorsalis pedis pulse

›Posterior tibial pulse

›Capillary refill

›Motor ankle dorsiflexion

›Motor ankle plantarflexion

›Sensation dorsal foot

›Sensation plantar foot

›Compartment syndrome triggers

›Pain out of proportion

›Pain with passive stretch of toes

›Increasing tense thigh swelling

›New paresthesia

›Analgesia resistant pain

Hemodynamic goals and resuscitation

›Perfusion targets

›SBP at least 90 mmHg in adult trauma until definitive hemorrhage control

›MAP at least 65 mmHg if not TBI

›Urine output at least 0.5 mL/kg/hour

›Access and blood readiness

›Two large bore IV lines

›14 to 16 gauge preferred

›IO access if IV failure

›Massive transfusion activation triggers

›Persistent hypotension with suspected hemorrhage

›Tachycardia with shock physiology

›Positive FAST with instability

›Hemorrhage reduction maneuvers

›Long bone stabilization

›Traction splint for isolated midshaft femur with intact distal pulses

›Temporary immobilization if traction contraindicated

›Reassessment after alignment and immobilization

02History/hx51

Mechanism and context

›Injury story

›Mechanism pattern

›High energy MVC

›Motorcycle collision

›Pedestrian struck

›Fall from height

›Low energy twist with atypical fracture pattern

›Time course

›Time since injury

›Change in pain or deformity over time

›Prehospital care

›Splinting or traction applied

›Analgesia given

Associated injury clues

›Co injury screen

›Head injury symptoms

›Loss of consciousness

›Amnesia

›Chest symptoms

›Dyspnea

›Chest pain

›Abdominal or pelvic symptoms

›Abdominal pain

›Pelvic pain

›Ipsilateral hip symptoms

›Groin pain

›Hip pain with minimal thigh tenderness

›Knee symptoms

›Instability sensation

›Effusion onset

Patient factors

›Bleeding and bone risk

›Anticoagulants

›DOAC use

›Warfarin use

›Antiplatelets

›Aspirin

›P2Y12 inhibitor

›Bone health risks

›Osteoporosis

›Chronic glucocorticoids

›Bisphosphonate or denosumab exposure

›Prior ipsilateral fracture or hardware

›Intramedullary nail

›Plate fixation

›Open fracture risk

›Wound at fracture site

›Gross contamination

›Farm or soil exposure

›Neurovascular symptoms

›Numbness

›Cold foot

›Weakness distal to injury

03Physical Exam/exam57

Primary survey adjuncts

›Global trauma assessment

›Mental status trend

›GCS trajectory

›Agitation as hypoperfusion marker

›Shock signs

›Cool clammy skin

›Delayed cap refill

›Narrow pulse pressure

›Tachycardia

Limb exam

›Femur and adjacent joints

›Thigh inspection

›Deformity

›Shortening

›External rotation

›Swelling and expanding hematoma

›Skin integrity

›Open wound

›Blanching or threatened skin

›Fracture blisters

›Palpation

›Focal tenderness along shaft

›Crepitus with minimal manipulation

›Hip and knee screen

›Hip tenderness

›Knee effusion

›Joint line tenderness

Neurovascular and compartment exam

›Distal perfusion

›Dorsalis pedis pulse quality

›Doppler signal if nonpalpable

›Symmetry compared to contralateral side

›Posterior tibial pulse quality

›Doppler signal if nonpalpable

›Symmetry compared to contralateral side

›Distal neurologic function

›Peroneal nerve

›Ankle dorsiflexion strength

›Dorsal foot sensation

›Tibial nerve

›Plantarflexion strength

›Plantar foot sensation

›Thigh compartments

›Tense swelling

›Increasing firmness over time

›Pain with passive knee motion

›Early findings

›Pain out of proportion

›Analgesia resistant pain

PITFALLS

›Common misses

›Ipsilateral femoral neck fracture with femoral shaft fracture

›Minimal hip pain in distracted patient

›Normal initial hip radiograph possible

›Knee ligament injury with shaft fracture

›Exam limited by pain

›Delayed diagnosis if no follow up plan

›Thigh compartment syndrome

›Pulses may remain present

›Late paresthesia and weakness

04Differential Diagnosis/ddx39

Life threatening and limb threatening

›Immediate threats

›Hemorrhagic shock

›Isolated long bone bleeding

›Occult pelvis injury with associated femur fracture

›Vascular injury of femoral artery

›Expanding thigh hematoma

›Hard signs of vascular injury

›Compartment syndrome of thigh

›Evolving neurovascular symptoms

›Rising pain and tightness

›Fat embolism syndrome

›Hypoxemia after long bone fracture

›Altered mental status after trauma

Mimics and related diagnoses

›Alternative diagnoses and co injuries

›Femoral neck fracture

›ICD-10 S72.0

›Groin pain predominance

›Intertrochanteric fracture

›ICD-10 S72.1

›Leg shortened and externally rotated

›Distal femur fracture

›ICD-10 S72.4

›Knee swelling and deformity

›Hip dislocation

›ICD-10 S73.0

›Fixed position and limited ROM

›Knee dislocation

›ICD-10 S83.1

›High risk popliteal artery injury

›Quadriceps tendon rupture

›Extensor mechanism failure

›Normal femur radiograph

Pathologic fracture considerations

›Underlying bone pathology

›Metastatic lesion

›Atraumatic or low energy fracture

›Lytic lesion on imaging

›Atypical femoral fracture

›Lateral cortex beaking

›Bisphosphonate association

05Laboratory Tests/lt35

Baseline trauma labs

›Hemorrhage and resuscitation labs

›Complete blood count for bleeding concern

›Hemoglobin trend over time

›Platelet count for transfusion planning

›Type and screen for likely operative fixation

›Crossmatch if instability or ongoing blood loss

›Massive transfusion pathway compatibility

›Electrolytes and creatinine for contrast and perioperative planning

›Potassium abnormalities before anesthesia

›Baseline renal function

›Coagulation assessment

›INR for warfarin exposure or liver disease

›Reversal planning if urgent OR

›Baseline if massive transfusion

›aPTT when heparin exposure possible

›Interpretation limited with DOACs

›Not reliable to exclude DOAC effect

Injury complication labs

›Rhabdomyolysis and crush risk

›Creatine kinase for prolonged entrapment or crush

›Rising trend as severity marker

›Renal injury risk when markedly elevated

›Urinalysis for heme positive with few RBC

›Myoglobinuria suggestion

›Not specific

›Shock physiology

›Venous blood gas with lactate for perfusion

›Lactate mmol/L trend for resuscitation response

›Elevated lactate not specific to bleeding

Procedural sedation labs when relevant

›Sedation and operative pathway

›Glucose for altered mental status or diabetes

›Hypoglycemia mimic of concussion

›Hyperglycemia as stress marker

›Pregnancy test when pregnancy possible

›Imaging pathway impact

›Medication safety impact

06Diagnostic Tests/dt58

Scoring Systems

›Classification and severity tools

›AO OTA femoral diaphysis

›AO OTA 32-A simple

›AO OTA 32-B wedge

›AO OTA 32-C complex

›Gustilo Anderson for open fractures

›Type I wound less than 1 cm

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

›Type IIIA adequate soft tissue coverage despite high energy

›Type IIIB extensive soft tissue loss with periosteal stripping

›Type IIIC arterial injury requiring repair

›Mangled Extremity Severity Score when limb salvage question

›Skeletal and soft tissue injury

›Limb ischemia duration

›Shock component

›Age component

Radiographs

›Core imaging

›Femur radiographs

›AP view including hip and knee

›Lateral view including hip and knee

›Hip evaluation for associated fracture

›AP pelvis if high energy mechanism

›Dedicated hip views if groin pain

›Knee evaluation when concern

›Knee radiographs if effusion or instability concern

›Tibia fibula films if distal pain

›Post intervention imaging

›Post traction or reduction films

›Alignment confirmation

›Length and rotation estimate

›Post splint or immobilization films

›Hardware position for traction pin if used

›Interval displacement check

MRI

›Occult injury pathways

›Occult femoral neck fracture suspicion

›Persistent groin pain with negative radiographs

›High energy shaft fracture with normal hip films

›Stress fracture suspicion in low energy presentation

›Activity related thigh pain

›Negative initial radiographs

›Soft tissue evaluation when needed

›Knee ligament injury assessment

›Instability after pain control

›Planned outpatient evaluation timing

›Contraindications and limitations

›Ferromagnetic implants

›Limited availability in unstable trauma

›Surgical planning and associated injuries

›CT femoral neck or hip when concern persists

›High energy shaft fracture with equivocal hip radiographs

›Inability to obtain adequate radiographic views

›CT angiography for vascular injury concern

›Absent distal pulses after alignment

›Expanding hematoma

›Hard signs or ABI abnormality

›CT for polytrauma protocols

›Pan scan pathways per trauma team

›Concurrent pelvic or abdominal injury evaluation

07Disposition/dispo33

Admission and operative pathways

›Inpatient criteria

›Femoral shaft fracture as operative injury

›Intramedullary nailing typical definitive management

›Early fixation in stable patients

›Hemodynamic instability

›Ongoing transfusion requirement

›Persistent tachycardia with suspected bleeding

›Open fracture

›IV antibiotics initiated

›Urgent orthopedics and OR planning

›Neurovascular compromise

›Persistent pulse deficit after alignment

›Progressive neurologic deficit

Transfer criteria

›Higher level care needs

›Vascular surgery requirement

›Suspected femoral artery injury

›CTA positive for arterial disruption

›Compartment syndrome concern

›Need for emergent fasciotomy

›Worsening exam despite analgesia

›Polytrauma resource needs

›ICU capacity requirement

›Multi specialty operative coordination

Follow up and mobility planning

›Post acute planning

›Weight bearing status

›Typically non weight bearing preop

›Ortho directed post op plan

›Mobility aids

›Crutches walker wheelchair depending on stability

›Fall risk mitigation

›Pain control plan

›Multimodal regimen

›Avoid oversedation in polytrauma

08Treatment/t91

Immediate life-saving interventions

›Hemorrhage and shock management

›Damage control resuscitation principles

›Balanced blood products when massive transfusion

›Permissive hypotension when no TBI and uncontrolled hemorrhage

›Femur stabilization to reduce bleeding

›Traction splint when appropriate

›Splinting if traction contraindicated

›Analgesia with hemodynamic awareness

›Avoid hypotension from rapid opioid bolus

›Ketamine as option in shock

Immobilization and Splinting

›Stabilization options

›Lower extremity immobilization menu

›Traction splint when indicated

›Posterior long leg splint

›Traction splint indications

›Isolated midshaft femoral fracture

›Intact distal perfusion

›Traction splint contraindications

›Suspected pelvic fracture

›Suspected ipsilateral knee dislocation

›Suspected ipsilateral tibia fracture

›Partial amputation or severe ankle foot injury

›Immobilization principles

›Hip and knee motion minimization

›Neurovascular reassessment after application

Reduction

›Provisional alignment

›Indications for immediate traction alignment

›Severe deformity with skin compromise

›Neurovascular compromise

›Uncontrolled pain from muscle spasm

›Technique principles

›Longitudinal traction

›Countertraction at pelvis

›Gentle correction of angulation

›Avoid repeated forceful attempts

›Analgesia and anesthesia options

›Multimodal pain control

›Acetaminophen PO 1000 mg once

›Ibuprofen PO 400 mg once if no contraindication

›Opioid titration

›Fentanyl IV 25 to 50 mcg increments

›Repeat every 5 minutes to effect

›Monitor RR and SpO2

›Hydromorphone IV 0.2 to 0.5 mg increments

›Repeat every 10 minutes to effect

›Caution in older adults

›Ketamine for analgesia

›Ketamine IV 0.1 to 0.3 mg/kg slow push

›Repeat every 10 to 15 minutes as needed

›Monitor for emergence reactions

›Procedural sedation when required

›Ketamine IV 1 to 2 mg/kg

›Additional 0.5 mg/kg doses as needed

›Continuous cardiorespiratory monitoring

›Post alignment requirements

›Repeat distal pulse exam

›Repeat motor and sensory exam

›Post maneuver radiographs

Open fracture medications and timing

›Antibiotics and tetanus

›Timing target

›Antibiotics within 60 minutes of recognition

›Earlier in gross contamination

›Gustilo type I or II coverage

›Cefazolin IV 2 g every 8 hours

›Clindamycin IV 900 mg every 8 hours if severe beta lactam allergy

›Gustilo type III coverage

›Cefazolin IV 2 g every 8 hours

›Gentamicin IV 5 mg/kg once daily

›Farm soil or fecal contamination

›Add metronidazole IV 500 mg every 8 hours

›Alternative add penicillin G per local protocol

›Tetanus prophylaxis logic

›Tdap if immunization unknown or incomplete

›Tetanus immune globulin if high risk wound and unimmunized

›Wound care

›Sterile saline moistened dressing

›Avoid aggressive probing in ED

DVT prophylaxis when relevant

›Venous thromboembolism risk management

›High risk features

›Long bone fracture

›Reduced mobility

›Surgery planned

›Pharmacologic prophylaxis typical inpatient pathway

›Enoxaparin SC 30 mg every 12 hours in trauma protocols

›Dose adjustment per renal function and weight

›Contraindications

›Active bleeding

›Severe traumatic brain injury with evolving hemorrhage

›Mechanical prophylaxis

›Intermittent pneumatic compression when anticoagulation held

›Early mobilization when feasible

09Special Populations/sp36

Pregnancy

›Maternal and fetal priorities

›Maternal stabilization first

›Standard trauma resuscitation principles

›Left lateral uterine displacement in later gestation

›Imaging considerations

›Radiographs when clinically indicated

›Shielding when feasible without compromising imaging

›Analgesia considerations

›Acetaminophen preferred baseline

›Opioids when needed with monitoring

›Obstetric involvement triggers

›Viable gestation with trauma

›Abdominal pain or vaginal bleeding

Geriatric

›Frailty and comorbidity considerations

›Lower energy mechanisms possible

›Fall from standing with pathologic bone

›Osteoporosis contribution

›Medication sensitivity

›Opioid delirium risk

›Renal dosing for anticoagulation

›Higher admission threshold

›Baseline mobility impairment

›Social support limitations

Pediatrics

›Growth and safety considerations

›Physeal injury risk

›Distal femur physeal fracture consideration

›Salter Harris patterns for adjacent injuries

›Non accidental trauma consideration

›Inconsistent mechanism

›Developmental mismatch

›Weight based analgesia

›Fentanyl IV 1 mcg/kg increments

›Ketamine IV 0.1 to 0.3 mg/kg for analgesia

›Immobilization considerations

›Age appropriate splinting

›Spica casting pathways for certain patterns

10Background/b32

Epidemiology

›Population patterns

›Mechanism distribution

›High energy trauma common in younger patients

›Low energy fragility or pathologic fractures in older patients

›Hemorrhage burden

›Femoral shaft fracture associated with major blood loss

›Higher transfusion risk in polytrauma

›Associated injury frequency

›Ipsilateral femoral neck fracture association

›Knee ligament injury association

Pathophysiology

›Injury mechanics

›Force vectors

›Bending leading to transverse fracture

›Torsion leading to spiral fracture

›Combined forces leading to comminution

›Bleeding mechanisms

›Medullary canal bleeding

›Surrounding muscle compartment bleeding

›Neurovascular risk

›Femoral artery proximity

›Sciatic nerve vulnerability with high energy trauma

Therapeutic Considerations

›Treatment rationale

›Early stabilization benefits

›Pain reduction

›Bleeding reduction

›Improved transport safety

›Definitive fixation principles

›Intramedullary nailing standard for most adult diaphyseal fractures

›External fixation as damage control in unstable polytrauma

›Evidence and guideline framing

›ATLS prioritization of hemorrhage control and limb stabilization

›Procedural sedation safety principles aligned with ACEP guidance level B for ED sedation monitoring

11Patient Discharge Instructions/pdi23

Copy discharge instructions

›Discharge eligibility context

›Femoral shaft fracture usually requires admission and operative management

›Discharge rare and only in exceptional specialist directed pathways

›If discharged under specialist plan

›Immobilization care

›Keep splint clean and dry

›Elevation above heart level when resting

›Pain plan

›Acetaminophen as baseline

›NSAID use only if permitted by surgeon

›Opioid only as prescribed

›Activity restriction

›Non weight bearing until cleared

›No driving

›Return to ED now

›Increasing pain not controlled by medication

›New numbness or weakness in foot

›Pale or cool foot

›Increasing tightness or swelling of thigh

›Fever or wound drainage

›Follow up

›Orthopedics appointment timing per plan

›Imaging follow up if instructed

12References/r9

Clinical guidelines and core sources

›Trauma and orthopedic references

›ATLS principles for initial management of long bone fractures and hemorrhage control

›AAOS guidance on fracture care and perioperative considerations

›BOAST guidance for open fracture management principles and timing

›NICE guidance for major trauma pathways and imaging principles

Evidence based sources

›Sedation and procedural references

›ACEP clinical policy and consensus guidance for ED procedural sedation monitoring and safety

›Evidence supporting early antibiotics for open fractures and infection reduction

›Evidence supporting traction splinting for pain control and hemorrhage mitigation in appropriate femoral shaft fractures

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 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.