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Femoral shaft fractures in adults

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TRAUMA
Femoral shaft fractures in
adults
Alex Trompeter
Kevin Newman
Abstract
Diaphyseal femoral fractures are common and can present as isolated in-
juries or as part of a polytrauma situation. Management of these fractures
requires an understanding of the timing of definitive surgery in systemi-
cally unwell patients, as well as the physiologic effects of reaming and
instrumentation of the femoral canal. An appreciation of biomechanics
of femoral nails, along with other implants, and the nuances of their
application is essential in achieving a satisfactory outcome.
Keywords adult; diaphysis; femoral fractures; femur
Introduction
This review will focus primarily on intramedullary nailing for
diaphyseal femoral fractures in adults, though plating and
external fixation will be touched upon. Paediatric fractures and
fractures of the proximal and distal femoral metaphyses are
beyond the scope of this review. Emphasis will be placed on the
systemic effects of both the fractures themselves, and the act of
reaming and nailing the femur. High-energy fracture patterns and
those that are open have been covered in a recent review article1
and a discussion on the management of vascular injuries asso-
ciated with fractures is outside the scope of this review.
Epidemiology
Several studies have examined the incidence of femoral frac-
tures.2e5 Figures vary and quoted ranges are from 0.1 to 3% as
an average annual incidence (up to 37 per 100 000 patient years),
with the peak incidence occurring in young adult males. An as-
sociation with major trauma and high-energy mechanisms is
seen in this age group. A second peak in incidence, associated
with low energy mechanisms, is seen in the elderly population.
Anatomy and blood supply
The femoral shaft is curved in the sagittal plane, with an anterior
bow. The cortex is thickened posteriorly, as it is the compression
Alex Trompeter MBBS BSc FRCS(TrþOrth) Trauma and Limb Reconstruction
Fellow, Rowley Bristow Unit, Department of Trauma and Orthopaedics,
St Peter’s Hospital, Chertsey, UK. Conflict of interest: none declared.
Kevin Newman MBBS FRCS FRCS(Orth) Consultant Orthopaedic Trauma
Surgeon, Rowley Bristow Unit, Department of Trauma and Orthopae-
dics, St Peter’s Hospital, Chertsey, UK. Conflict of interest: none
declared.
ORTHOPAEDICS AND TRAUMA 27:5
side of the bone in the sagittal plane and also carries the linea
aspera. Distally the cortex thins and expands into the meta-
physis. Proximally the femoral anatomy is characterized by the
head, neck and trochanters. The central anatomical axis of the
neck is offset anterior to the central anatomical axis of the shaft
in the sagittal plane e this explaining why the correct entry point
for most nails is biased anteriorly. The neck-shaft angle is of the
order of 130
(124e136
) in the coronal plane.
The blood supply to the femoral head arises from the anas-
tamotic ring around the base of the neck, which superiorly tra-
verses the piriformis fossa, putting it at risk when using this as an
entry point in nailing. Blood to the diaphysis is supplied via both
the higher pressure endosteal system (from the nutrient vessels)
and the lower pressure periosteal system (from the areas of
muscle attachment), accounting for the inner 2/3 and outer 1/3
of the cortical blood supply respectively.
Reaming initially reduces the endosteal blood supply,
although any instrumentation of the femoral canal (such as an
unreamed nail) also has a significant effect (see below). With
increasing age, the morphology of the femoral diaphysis changes,
with endosteal resorption and periosteal apposition of bone. This
leads to the characteristically larger diameter but thinner cortical
diaphysis, often accompanied by an increase in the anterior bow.
Classification
The two most commonly used classification systems for diaph-
yseal femoral fractures are the AO-OTA system (Figure 1) and
that described by Winquist (Figure 2).
Both systems are useful in predicting axial and rotational
instability of the fracture and therefore help with management
planning. Neither is necessarily predictive of outcome or time to
union.
The AO-OTA system uses an alphanumeric code to describe
the bone involved, which segment of the bone, and the fracture
pattern/energy.6
For the femoral diaphysis (bone 3, segment 2) the patterns of
fracture are described as simple (A), wedge (B) and complex (C)
with further subdivisions (Figure 1).
Winquist described the degree of comminution in a fracture
and thus the degree of cortical contact or continuity (Figure 2).7
The Winquist classification has been modified to include
segmental bone loss as well as simple (non-comminuted) frac-
tures (Table 1).
Assessment and initial management
In the polytrauma and major trauma situation patients are typi-
cally assessed and managed according to standardized protocols,
such as the Advanced Trauma and Life Support (ATLS) system.
Femoral fractures can be a major source of blood loss and should
be splinted as a means of haemorrhage control. In clinical situ-
ations where patients present with isolated femoral injuries, or
not as part of a major trauma situation, a thorough history and
clinical examination is mandated.
History
This can be taken from the patient and/or paramedics and will
give valuable clues as to the mechanism of injury and the po-
tential for associated soft tissue and skeletal injuries. The
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32 diaphyseal
32-A1 32-A2 32-A3 32-B1 32-B2 32-B3 32-C1 32-C2 32-C3

30°

32-A simple fracture 32-B wedge fracture 32-C complex fracture

32-A1 spiral 32-B1 spiral wedge 32-C1 spiral
32-A2 oblique (>– ° 32-B2 bending wedge 32-C2 segmental
32-A3 transverse (< 30°) 32-B3 fragmented wedge 32-C3 irregular
32-A(1–3).1 = subtrochanteric fracture 32-B(1–3).1 = subtrochanteric fracture 32-C(1–3).1 = subtrochanteric fracture

Figure 1 AO-OTA classification of femoral diaphyseal fractures.6

patient’s general medical status, drug and past medical history,
allergies, co-morbidities, timing of last food and drink and other
relevant clinical information are essential to the pre-operative
assessment.
Examination
Examination of the affected limb should include a neurological
and vascular assessment and a visual inspection of the soft tis-
sues, including a careful assessment for compartment syndrome.
Imaging
Plain radiographic imaging is usually sufficient for diagnosis and
operative planning and should include the ipsilateral hip and
knee to rule out an associated femoral neck fracture or articular
injury. Computed tomography (CT) is usually reserved for major
trauma patients undergoing trauma CT or for patients who
require CT angiography to assess possible vascular injuries.
Initial management
Splintage of the femoral fracture, initially in the form of fixed-
point traction, typically against the pubis and ischium, pro-
vides the best analgesia and can allow for gross correction of
rotational malalignment. These splints should be removed early
to reduce the risk of pressure necrosis and pudendal nerve injury.
Balanced traction (skin or skeletal) can be used in patients who
are waiting for surgery and are physiologically well. In terms of
pain relief, adequate oral and intravenous analgesia and regional
femoral nerve block with local anaesthetic should be considered.
Fluid resuscitation (blood product or crystalloid) should be
administered as required.
Timing of surgery
The 1980’s heralded the era of Early Total Care (ETC), as part of
which definitive surgical fixation was achieved at the index
operation, typically within the first 24 h after injury. Increased
appreciation and understanding of the physiology of trauma
patients saw a shift towards Damage Control Orthopaedics
(DCO), reaching its peak in popularity in the 2000’s.9
If the injury causing the fracture is considered the ‘first hit’ to
the patients systemic inflammatory system, then any surgical
intervention subsequently is considered the ‘second hit’.
The ‘first hit’ primes the inflammatory cascade and causes a
degree of Systemic Inflammatory Response Syndrome (SIRS).

Modified Winquist classification of femoral diaphyseal

fractures to include Type 0 and V
Type Description

0 No comminution
I Small butterfly fragment<25% of circumference
II Larger butterfly fragment<50% of circumference
III Very large butterfly fragment>50% of
circumference. Only a small area of cortical
contact remains
IV No cortical contact. Segmental fracture
V Segmental bone loss
Figure 2 Winquist classification of femoral diaphyseal fractures (see also
Table 1).8 Table 1

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Exaggerated SIRS
response to second hit
SECOND
O
Hyper-inflammatory HIT
I
Normal SIRS response

Normal CARS response

Day1 Day 4-5

Anti-inflammatory

DCO NO TOUCH
N WINDOW OF NO TOUCH
OPPORTUNITY

Figure 3 The physiological rationale for Damage Control Orthopaedics (modified from Flierl et al., 2010).19 A normal SIRS response occurs with the initial
injury and resuscitation. The system is in effect primed, and the SIRS response has the potential to be greatly exaggerated if the ‘second hit’ surgery is
significant, hence the rationale of DCO. The timing of the definitive surgery falls into a window of opportunity beyond the initial inflammatory phase, and
before the relative immunosuppression that occurs in the Compensatory Antiinflammatory Response Syndrome (CARS) phase.

Any secondary insult can tip the response into overdrive, leading It is the ‘borderline patient’ who must be looked at closely.
to worsening SIRS and ultimately Multi-Organ Dysfunction These patients typically have femoral fractures (single or bilat-
Syndrome (MODS). eral) with pulmonary injury but no other major system injury
DCO relies on moving the large ‘second hit’ associated with (Table 2).
definitive surgery out of the window of hyperinflammation, and Those with pulmonary dysfunction and those with bilateral
allows time for the patient to be stabilized and reduce the fractures are physiologically considered to be as ill as polytrauma
physiological burden of reconstructive surgery (Figure 3). patients and may be best served with DCO treatment.15 In stable
DCO still requires there to be a ‘second hit’ in the early post patients, primary femoral nailing is associated with shorter
injury phase, in the form of temporizing surgery (haemorrhage ventilation times. In borderline patients, it is associated with a
control, debridement of open wounds, vascular repair and rapid
external fixation), but this insult is smaller and typically avoids
the instrumentation of the femoral canal that is so physiologically
taxing.10 The differences between stable and borderline
Significant reductions in mortality and complications were patients. Note the increased incidence of bilateral
seen as a consequence of the shift to DCO in femoral fracture femoral fractures and pulmonary injury in borderline
patients. Morshed et al., showed that waiting just 12 h before patients and the significantly higher requirement for
fixation in patients with an Injury Severity Score (ISS) of over ventilation (modified from Pape et al., 2007)16
15 reduced mortality by 50%.9,11 Stable Borderline P
In the last 10 years, focus has shifted towards trying to patient patient
identify which patient groups can have their femoral fractures
treated early and which should wait. Injury Severity Score 24  8 32  11 <0.001
Three patient groups are now considered: those who can have Severe thoracic and Unlikely Likely <0.001
their fractures treated early (ETC), those who must wait (DCO) pulmonary injuries
and those who fall in between e the so-called ‘borderline Bilateral femoral 8.3% 20.5% 0.03
patient’. fractures
Physiological parameters such as venous lactate, interleukin-6 Hours on ITU and 165 and 98 438 and 337 <0.001
(IL-6), temperature, coagulopathy and respiratory function have Ventilation
all been shown to be useful in guiding this decision making Blood transfusion 23% 50% 0.03
process. Rising lactate (>2.5 mg/dl) and IL-6 (>200 pcg/L), SIRS 31% 51% 0.023
falling temperature and altered clotting parameters are good MODS 0% 19.4% <0.001
predictors of SIRS and mortality after trauma and thus can be
used as indicators that DCO is probably needed.12e14 Table 2

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higher incidence of lung dysfunction when compared to those
that receive initial external fixation.16
In the absence of major head or chest injuries, patients with
multiple injuries and bilateral femoral shaft fractures have a
similar complication rate to polytrauma patients with unilateral
fractures.17,18 In patients with head injury and femoral fractures
(without other body system injuries) no greater risk is seen with
early fixation as long as the patient is resuscitated adequately.19,20
Definitive treatment
Rarely are fractures of the femoral shaft in adults treated without
operative intervention. Skin or skeletal traction, as definitive
methods of fixation, are now largely historical although occa-
sionally may still be used. Non-operative methods are associated
with high rates of malunion and shortening. The commonest
surgical method of treating femoral shaft fractures is using an
intramedullary nail. Modern nailing traces its origins to
Ku€ ntscher in 1939, but descriptions of intramedullary devices
have been found from well before the 20th Century.21
Intramedullary nailing
Nail design: despite early scepticism of the methods of Ku € ntscher
and his intramedullary device, the concept and use of nailing was
eventually embraced and nails have now evolved into highly
engineered orthopaedic devices. Nails are typically made from
either titanium alloy or stainless steel. Even though titanium has
an elastic modulus approximately half that of steel, this differ-
ence in material has little effect upon union or failure rates with
modern generation nails. The size of the nail, however, does
have an effect, with thicker nails of a larger external diameter
having significantly higher fatigue strength than thinner nails. It
has been shown that nails with an external diameter of 11e12
mm have a bending stiffness over 50% greater than smaller
cannulated nails.22
Older generation nails were typically thin-walled and may or
may not have been slotted. These nails were weak in torsion,
although offered excellent interference fit within the femoral
canal. Modern generation nails are thick walled and no longer
rely on slotted geometry to facilitate insertion, but rather rely
more on anatomic contouring. Typically nails now have a radius
of curvature (150 cm) that is nearer that of the radius of curva-
ture of the femur (around 120 cm) compared to the straight nails
of old. Most modern generation nails are cannulated to facilitate
insertion e by keeping the cannulation small there is little effect
on the strength of the nail. Flutes may be present to facilitate
rotatory stability of the nail and to reduce intramedullary pres-
sure at the tip of the nail on insertion. All modern nails offer
multiple locking options both proximally and distally.
Patient set up: in the broadest sense, femoral nailing can be
performed freehand on a radiolucent flat-topped trauma table or
in traction on a fracture reduction table. Both can be used with
the patient either supine or in a lateral position.
Faster operating times and less risk of malreduction have been
shown with freehand techniques, but there is no difference in
functional outcome or other parameters.23 Traditional fracture
table techniques rely on the application of traction through
the leg extension with foot piece, or via a traction pin in the distal
femur. This allows application of traction, rotation and
ORTHOPAEDICS AND TRAUMA 27:5
correction of varus/valgus and flexion/extension. The Posterior
Reduction Device (PORD) (Orthofix: Lewisville, Texas; Verona,
Italy) can be used to overcome posterior sag in a similar manner
to a crutch.
Nailing freehand typically requires one assistant to apply
traction or the use of a femoral distractor. Rotation is easier to
assess with the freehand technique as it allows radiographic
visualization of the lesser trochanter and patella of the contra-
lateral femur as a comparison.
Lateral positioning is beneficial in that it provides easier ac-
cess to the piriformis fossa and facilitates nailing of fractures in
the proximal portion of the femur, as well as in large or obese
patients. However, it is not suitable in a polytrauma situation and
limits the assessment of rotation.
A floppy lateral position is described with good results in
polytrauma patients but again risks malrotation.
Entry points for antegrade nailing: classically, the pirfiormis
fossa is used as an entry point for antegrade femoral nailing. This
was based on Hey-Groves’ method of opening the fracture and
reaming the proximal segment in a retrograde fashion, which
brought the reamer out directly through the fossa.24
Earlier nails with overhanging jigs risked iatrogenic fracture
using this entry point25 and misplaced anterior or medial entry in
the fossa also risks fracture. There is a risk to the blood supply of
the femoral head especially in adolescents with the piriformis
entry nails.
It is also noted that certain fracture patterns such as reverse
oblique proximal fractures with an abducted proximal segment
have a tendency to collapse into varus if straight piriformis nails
are used. This is usually due to inaccurate lateral placement of
the entry point on the trochanter for a nail intended for the pir-
iformis fossa.
Trochanteric entry nails have been developed with a lateral
bend on the proximal segment of the nail, typically ranging from 4

to 10
. The trochanteric entry portal has been shown to reduce
operative time and be easier to use in obese patients, as well as the
polytrauma situation26,27 although there seems to be no difference
in functional outcome between the two methods at one year.28
Retrograde nailing: nailing the femur from distal to proximal is
well described and certainly has its place (Figure 4). The entry
Figure 4 A distal diaphyseal femoral fracture treated with retrograde
intramedullary nailing.
325 Ó 2013 Elsevier Ltd. All rights reserved.
 Author's personal copy
TRAUMA
point is at the anterior end of Blumensaat’s line on the lateral
projection, essentially at the top of the intercondylar notch, in
line with the femoral shaft. This technique is commonly used in
ipsilateral neck-shaft fractures (see below), fractures below old
implants (such as compression hip screws), in obese patients
where antegrade entry points are difficult to access, and in ipsi-
lateral femoral and tibial shaft injuries. It has also been used in
Damage Control Orthopaedics, employing the technique of rapid
nailing with small diameter implants.29
Retrograde techniques have been shown to have a higher
incidence of malrotation and shortening than antegrade, and
there may be an association with knee pain.30 There was previ-
ously thought to be a risk of knee sepsis in retrograde nailing of
open fractures but this has not subsequently been proved to be
the case.31
There is little difference in functional outcome, time to union
and malunion comparing antegrade and retrograde nailing. Un-
surprisingly, antegrade nails cause more problems related to the
hip and retrograde give problems with the knee.32
Reduction methods: whilst every effort is made to reduce and
align the fracture appropriately before the operative procedure
begins, it is not uncommon for additional reduction manoeuvres
to be required during the nailing procedure. The nail is inserted
and locked at sites away from the fracture and zone of soft tissue
injury, and intramedullary nailing relies on the applying the
principles of relative stability techniques and healing by sec-
ondary intention. Every effort should be made to preserve the
biology of the fracture site and open reduction techniques should
be avoided if possible.
Intramedullary techniques to assist fracture reduction include
bending the tip of the guidewire to allow for control in guiding
into the centre of the distal segment, and also the use of a rigid
cannulated scoop to guide the wire across the fracture site.
Another method is to ream and insert the nail into the proximal
segment, and then use the nail itself as a joystick to align the
fracture and pass the wire through the nail. The nail can then be
backed out and reaming of the distal segment can be achieved e
this technique is good for mid diaphyseal fractures and can be
used in unreamed nailing with ease (Figure 5).
Extramedullary techniques can be closed, instrumented or
fully open. Closed techniques include use of mallets as
pushers, and the PORD or a crutch to reduce posterior sag. The
F-tool is a radiolucent device with adjustable limbs that allows
for the application of countering forces either side of the
fracture to aid reduction. Historically described techniques
include the use of sheets around the limb to be pulled in
opposing directions.
Instrumentation of the fracture fragments may be needed.
This need not be a fully open procedure. The use of Schanz pins
as joysticks, or attached to a femoral distractor, are examples of
this. Full open reduction in the acute setting should be avoided if
possible. Perhaps an exception to this is the use of a clamp or
cable to reduce a subtrochanteric fracture, as any malreduction
here (especially varus) will lead to an increased risk of implant
fatigue failure. Colinear reduction clamps have a smaller foot-
print than Hey-Groves or Verbrugge clamps and require smaller
incisions; nonetheless, their use still leads to a disturbance of the
fracture biology.
ORTHOPAEDICS AND TRAUMA 27:5
Figure 5 Using the nail itself as a reduction tool. This works well in
unreamed nails.
Reamed vs Unreamed and union rates: early nails were all
unreamed. Although flexible reaming was developed by
Ku€ ntscher, it was not popularized until the 1980s. Reaming dis-
turbs the endosteal blood supply. There is a shift in the balance
of blood flow in favour of the periosteal system after nailing e it
is noted that the early callus in intramedullary nailing is perios-
teal, not medullary. Over 6e12 weeks the endosteal blood supply
recovers and allows the formation of internal callus. Contrary to
popular belief, unreamed nails also disturb the endosteal blood
supply but to a lesser extent. However the reactive increase in
periosteal blood flow is less in unreamed nails and this may help
explain why they may not offer as predictable or rapid time to
union as reamed nails. Several studies (including many ran-
domized control trials) have now shown that reaming increases
union rates in acute fractures. There is up to a 5x risk of non-
union in unreamed nails.33e37
Reaming: systemic effects, fat embolism syndrome: reaming is
a physiologic insult and while any surgery is considered a second
hit, there is no doubt that the demands on the patient are greater
if the second hit involves nailing, even more so if reaming is
used. Any instrumentation of the femoral canal causes a rise in
intraosseous pressure that forces fat and inflammatory exudate
into the venous circulation.
This leads to up-regulation of the systemic inflammatory
response and it is this that can be physiologically catastrophic for
the polytrauma patient e hence the advent of DCO.
Mu€ ller demonstrated that it is the first broaching of the canal
and the initial instrumentation that cause the highest pressure
spikes, not the reamers themselves. Although the reamers do
induce lesser pressure spikes, the subsequent insertion of the nail
gives another more significant peak. As such, it can be seen that
unreamed nails are equally at risk of inducing a physiologic
response.38 Others have shown that using the hand awl rather
than an initial reamer cutter reduces pressure. Rapid penetration
of the reamer in both proximal and distal metaphyses causes
much higher pressures than reaming the cortex of the diaphysis,
and the speed of penetration and volume of the reaming shaft
were found to be important parameters.39e43
Fat embolism is characterized by the clinical picture of hyp-
oxia, confusion and altered mental status, with a petechial rash
as well as pulmonary oedema, tachycardia and shock. The
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 Author's personal copy
TRAUMA
classic textbook description is a triad of rash, confusion and
hypoxia. It is considered a systemic response to embolized fat
globules. Two theories exist as to why these globules appear in
the blood. The mechanical theory is supported by the fact that fat
is typically liberated by reaming the femoral canal, although can
occur due to the fracture itself. Reaming is associated due to the
high intraosseous pressures achieved, forcing fat into the sys-
temic circulation, it is assumed, via the venous drainage system
of long bones. The second theory is the metabolic theory and is
supported by the fact that the inflammatory response induces
change in the chylomicrons (fat carrying protein-based compo-
nents in the circulating blood) resulting in de novo synthesis and
accumulation of fat globules away from the site of injury. Fat
embolism is seen in up to 3% of patients with isolated long bone
trauma and in up to 15% of polytrauma victims; it can be fatal in
up to 15% of cases.44,45 The management of fat embolism syn-
drome revolves around the combination of supportive therapy
for the pulmonary injury and stabilization of the long bone
injuries.
Reaming: reamer design, RIA: reamers should be sharp. Blunt
reamers generate more heat and risk thermal necrosis of the
endosteal bone. No significant difference has been shown be-
tween different types of reamer head design, though the ratio of
the shaft to head is important. A narrow shaft significantly re-
duces reaming pressures.43,46 In the last decade the use of suc-
tion and irrigation reamers has been well described. The Reamer
Irrigator Aspirator (RIA) (DePuy Synthes, Warsaw, Indiana) in-
corporates a single reamer head, sized appropriately for the
desired amount of bone to be removed. It is used in graft harvest,
debridement of intramedullary infection and nailing in acute
trauma. The irrigation and suction reduces the volume of
embolized fat and reduces reaming temperature. There are fewer
systemic effects with RIA compared to standard reaming in acute
trauma and the benefit of a single reamer pass on reducing
operating time is significant.47 However, the RIA is technically
challenging and unforgiving in use,48e50 with recent reports of
iatrogenic fracture being described.
Correct rotation, correct length: correct angulation, rotation
and length are the goals of all methods of fixation in long bone
fractures. The use of an intramedullary nail in diaphyseal frac-
tures lends itself to achieving correct angulation, although
proximal and distal diaphysealemetaphyseal junction fractures
require careful placement of the guidewire to prevent eccentric
positioning of the nail and thus an induced angular deformity.
Correct rotation and length are harder to achieve. As mentioned
above, different methods of set-up will influence the surgeon’s
ability to assess and correct rotation and length. If possible, every
effort should be made to assess the uninjured side preoperatively
as a comparison and template.
Assessment of rotation intraoperatively can be made using
one of two principal methods. The first is the cortical step sign.
This relies on the same cortex (medial or lateral) either side of
the fracture being the same diameter, indicating correct rotation.
A difference in cortical width indicates malrotation. It is impor-
tant to note that the femur has differing widths to its cortical
bone along its length, being widest medially in the proximal
third, widest posteriorly in the middle third, before thinning
ORTHOPAEDICS AND TRAUMA 27:5
significantly in the distal third.51 The second technique,
described by Krettek, is to use the profile of the lesser trochanter
and the patella imaged in the anteroposterior view to guide
rotation. This primarily relies on the ability to assess the
contralateral side and is thus easiest to use when nailing free-
hand on a radiolucent trauma table52 and is shown to be an ac-
curate method of controlling rotation.53
Femoral malrotation after nailing is common, reported in up
to 20e30% of cases. However it would seem that only de-
formities of 15 degrees or more are clinically and functionally
significant, with external rotation deformities causing the most
symptoms.54,55 An appreciation of the risk of malrotation with
femoral nailing, and applying simple steps as outlined above to
overcome the problem, can lead to a 50% reduction in
incidence.56
Locking and working length: almost all modern intramedullary
nails offer the option of locking proximally and distally. It is
important to note that the locking bolts are bolts, not screws,
having very large core diameter to thread diameter ratios.
The working length of a nail is essentially defined by the dis-
tance between the two closest points of stable contact the nail
makes with bone either side of the fracture. This can be the dis-
tance between locking bolts, although if there is a good contact
between nail and bone at the isthmus, this can affect the working
length. Leaving a nail unlocked at one end can be safe in either
proximal or distal third fractures, where there is a good isthmic fit.
Here the working length of the nail is between the isthmic point of
contact and the locked screws the other side of the fracture, thus
eliminating the need to lock the far end of the nail.
Historically the gold standard for femoral nailing has been
reamed, statically locked nails, as shown in a series of landmark
papers by Brumback.57e59 His work showed that static locking
does not impede fracture healing compared to dynamic locking
of nails (Figure 6).
There is little evidence to support the dynamization of nails
either acutely or in a delayed fashion to prevent or treat non-
union. Rarely, nails can be left unlocked either proximally,
distally, or both: predominantly in axially and rotationally stable
fractures. This is an unusual beast, however, as an axially stable
fracture is typically transverse and thus rotationally unstable and
vice versa.
The size and number of locking bolts, along with their config-
uration, is important. Bolts of less than 5 mm diameter have
significantly lower fatigue strengths and are prone to early failure.
A 20% increase in core diameter equates to a 50% increase in
bending strength e hence a 5 mm bolt is significantly stronger than
a 4 mm bolt e there is a 20% difference in diameter. Although
most research on locking bolts relates to tibial implants, the evi-
dence is against using narrow diameter bolts60e62 and this is
translated to all nailing settings.
Post-operative weight bearing: if cortical bony contact is ach-
ieved, the femoral nail will be a load sharing device, but if there
is any gap at all the nail construct immediately becomes load
bearing. Despite the nail taking the entire body weight, imme-
diate full weight bearing remains the goal of treatment and has
been shown to be safe, even in comminuted fracture
patterns.63,64
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 Author's personal copy
TRAUMA
Figure 6 The ‘Gold Standard’ e a statically locked, reamed antegrade nail.
Even in a segmental fracture, this construct allows for immediate full
weight bearing.
Complications: the systemic effects of reaming, the complica-
tions of malrotation and non-union and the strategies to reduce
their incidence have been discussed above. Other complications,
such as iatrogenic femoral neck fracture and damage to the
femoral neck vascularity are also described.
Winquist’s original series described a rate of non-union of less
than 1% even in open fractures when using reamed nails.7
Average times to union for reamed nails are 80  35 versus
109  62 days for the unreamed nails according to Tornetta35;
and over nine months in 57% of unreamed nails versus 18% in
reamed nails according to Clatworthy.36 The relative risk of non-
union is 4e5 greater in unreamed nails (7.5% vs 1.7%).33
Infection rates of less than 1% are the norm, rather than the
exception, even in the case of open fractures.7,65 It would seem
that the femur, with it’s excellent circumferential soft tissue en-
velope, is far more resistant to infection than the tibia. Infection
rates tend to rise to an average of 1.7% if the patient has had a
prior external fixator, as part of DCO, but this rate does not rise
any higher so long as the fixator is converted to a nail within 3
weeks.66 Retrograde nailing is associated with a risk of knee
sepsis with an incidence of approximately 1%.31
Heterotopic ossification is described as occurring radio-
graphically in over 50% of patients although the majority are
very mild and have little clinical significance. It is seen perhaps
more commonly with piriformis rather than trochanteric entry
antegrade nails, but there are few parameters with which to
predict its occurrence.67
ORTHOPAEDICS AND TRAUMA 27:5
Although far more common in the tibia, compartment syn-
drome can occur in the thigh and risk factors include multiply
injured patients, systemic hypotension, a history of external
compression of the thigh, the use of military anti-shock trousers,
coagulopathy, and vascular injury.68
Rarer complications include pudendal nerve palsy associated
with prolonged time on the traction table69 and damage to the
superior glutaeal nerve on reaming and nail insertion.70,71
Definitive treatment e other methods
It stands to reason, of course, that there is more than one way to
treat femoral diaphyseal fractures. Even though closed intra-
medullary nailing has become the gold standard for most clinical
situations, plate osteosynthesis and external fixation are also
well described and can be acceptable methods of treatment.
External fixation, in the form of monolateral rigid fixators, is
typically reserved for patients who remain systemically
compromised. Initial temporary stabilization is achieved in the
damage control situation in the same manner as described above.
The fixator can be stiffened with the addition of further pins and
bars as needed, with limited physiological effect on the patient.
Despite the systemic benefit of this treatment method, pinsite
infections around half-pins, loosening and loss of reduction are
all limitations. Circular frames are an alternative, although rarely
used as primary fracture management in the femur, unless the
soft tissue envelope is severely compromised.
Internal fixation was previously the accepted standard of
management before and during the early years of Ku € ntscher’s
work. It has remained an acceptable but not necessarily first
choice method of treatment. The off-axis fixation of plate
osteosynthesis is less mechanically favourable than the on-axis
support offered by an intramedullary nail. Modern plating
methods rely on minimally invasive techniques to preserve
fracture biology. With percutaneous techniques, avoidance of
opening the fracture site means that the correction of alignment
and rotation is achieved in a similar fashion to nailing. One of the
biggest limitations of plate fixation is the potential need to restrict
weight bearing, especially in patients who have a lack of cortical
contact at the fracture. There is a higher incidence of non-union
and infection when comparing plate fixation with intramedullary
nailing.
Ipsilateral femoral neck and shaft fractures
Special consideration must be given to the unique situation of an
ipsilateral femoral shaft fracture and femoral neck fracture. This
bifocal injury is commonly missed, occurs more frequently than
anticipated and is an entirely separate entity to the iatrogenic
fractures seen with the piriformis entry nails. Although the
incidence of ipsilateral neck fracture is between 3 and 5%, it is
reported that up to 31% of cases are missed, and in 20e40%
there is a concomitant ipsilateral knee injury.72,73 Aside from the
obvious physiological considerations, the time-critical goal in
these cases is anatomic reduction and stable internal fixation of
the femoral neck fracture. High union rates are reported but
depend on anatomic reconstruction. It is suggested that separate
implants be used for the neck and the shaft fractures if the neck
fracture is displaced. Although the neck fracture is in some ways
a priority, it may be necessary to stabilize the shaft initially to
328 Ó 2013 Elsevier Ltd. All rights reserved.
 Author's personal copy
TRAUMA
allow for reduction of the neck to occur. In these bifocal injuries
retrograde nails and plate fixation are often considered for fixa-
tion of the shaft fractures.
Conclusion
Femoral shaft fractures in adults are reasonably common and can
occur in isolation or in association with other injuries. They are
typically high-energy in aetiology, especially in young adults,
and require special consideration to the physiological impact of
injury on the patient. The evolution of treatment for these frac-
tures has seen changes in the timing of surgery as well as the
techniques employed, but the principles of stable internal fixa-
tion remain. Good outcomes and low complication rates can be
expected if the operating surgeon has a thorough understanding
of the anatomy, basic science and surgical technique relating to
the treatment of femoral shaft fractures. A 1998; 12: 315e9.
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