Femoral Fractures

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Definition/Description

A femoral fracture is a fracture of the thigh bone. The femur is the largest and strongest bone in the body, so it requires a large or high impact force to break this bone. Most femur fractures are the result of a high energy trauma, such as a motor accident, gunshot wound, or jump/fall from a height. However, in an older population a simple fall may cause a femoral fracture due to reduced bone mineral density. A femoral fracture is a very serious injury and needs 3-6 months to heal.

Femur fractures can be classified in three types:

• Femoral head fracture
• Femoral shaft fracture
• Femoral condyle fracture
  

Clinically relevant anatomy

Osteology

The femur consists of a head, greater and lesser trochantor, shaft, and lateral and medial condyles with the patellar surface in between.

Musculature

The femur is surrounded by different muscles: the quadriceps, the adductors, abductors and the hamstrings.

1. Quadriceps: M rectus femoris, M vastus lateralis, M vastus medialis, M vastus intermedius
2. Adductors: M adductor longus, M adductor brevis, M adductor longus, M pectineus, M gracilis
3. Abductors: M tensor fasciae latae
4. Hamstrings: M biceps femoris, M semimembranosus, M semitendinosus

Following a femoral fracture, most of these muscles are much weaker than before, so physiotherapy is very important for muscle strengthening.

Several large muscles attach to the femur. Proximally, the gluteus medius and minimus attach to the greater trochanter, resulting in abduction of the femur with fracture. The iliopsoas attaches to the lesser trochanter, resulting in internal rotation and external rotation with fractures. The linea aspera (rough line on the posterior shaft of the femur) reinforces the strength and is an attachment for the gluteus maximus, adductor magnus, adductor brevis, vastus lateralis, vastus medialis, vastus intermedius, and short head of the biceps. Distally, the large adductor muscle mass attaches medially, resulting in an apex lateral deformity with fractures. The medial and lateral heads of the gastrocnemius attach over the posterior femoral condyles, resulting in Flexion deformity in distal-third fractures.

Epidemiology/Etiology

The incidence of femoral fractures is reported as 1-1.33 fractures per 10,000 population per year in the USA. In individuals younger than 25 years and those older than 65 years, the rate of femoral fractures is 3 fractures per 10,000 population annually.

Several factors are related to increased risk of femoral fracture. Older persons (over 70) have a higher incidence of femoral fracture. Persons with Osteoporosis are also more likely to break their femur.

Morbidity and mortality rates have been reduced in femoral shaft fractures, mainly as the result of changes in methods of fracture immobilization. Current therapies allow for early mobilization, thus reducing the risk of complications associated with prolonged bed rest.

Characteristics/Clinical presentation

A broken thigh bone is almost always very obvious. Signs of a fracture include severe pain, inability to move the leg or stand on it, and swelling. There individual may also be unable to bear weight, and apparent shortening of the affected leg may occur when the fracture is displaced. There may also be a resultant loss of blood in the femur, and a haematoma may be present in the surrounding soft tissue.

Complications

Complications from the fracture:

• The sharp ends of the broken bone may lacerate blood vessels or nerves.
  
• Acute Compartment Syndrome may develop
  
• Increased risk of infection with open fractures as they expose the bone to the outside environment.
  

Complications from surgery:

• Infection
  
• Blood Clots (Deep Vein Thrombosis or Pulmonary Embolism)
  
• Damage to nerves or blood vessels
  
• Fat Embolism (Bone marrow enters the blood stream and can travel to the lungs)
  
• Malalignment of the bony fragments
  
• Delayed union or non-union
  
• Hardware Irritation (e.g. end of the nail or the screw can irritate the overlying muscles and tendons)

Examination

The Ottawa Knee Rules are a clinical tool that can be used to determine the need for radiography following knee injury based on the patient's presentation. Ante posterior and lateral x-rays (used to look for a break in the bone) views of the femur are typically obtained to confirm the fracture. X-ray views of the hip, the lower leg and the knee are also commonly reviewed to detect any associated injuries, because a femur fracture is almost associated with other traumatic injuries. For that reason a general physical examination should be included. Pain, swelling, deformity, abrasion, and protrusions should be noted.

Outcome Measures

Dynamic Gait Index
International Hip Outcome Tool (iHOT)
Lower Extremity Functional Scale (LEFS)
Timed Up and Go Test (TUG)

Medical Management

Surgical reduction and fixation is indicated for the following types of proximal femur fractures:

• Intracapsular femoral neck fracture
• Dislocated femoral head
• Intertrochanteric fracture
• Subtrochanteric fracture

Alternatively, patients who are not medically stable or nonambulatory may be treated with traction.

Surgical reduction and fixation should be performed within 24-48 of the injury.

Video Animation of Intramedullary Nail Fixation

Physical Therapy Management

Whilst in hospital, a therapist will teach the patient how to use a walking aid to allow them to mobilise, depending on their weight bearing status. The patient should be taught basic range of movement and strengthening exercises to maintain a degree of strength and reduce the risk of blood clots.

Surgical fixation and immobilization are followed by extensive physical therapy. After a femoral fracture, most of the muscles are much weaker than before so physiotherapy is very important.

The physiotherapist will begin with range of motion exercises for the hip, knee and ankle because mobility is decreased following immobilization. Mobilization is a very important treatment in the recovery process. The patient can also begin strengthening exercises based on the surgeon's orders (typically six weeks post-op). Patients should also undergo balance and proprioceptive rehab and these abilities are quickly lost with inactivity.

Mobility exercises

Knee: flexion and extension, abduction and adduction
Hip: flexion and extension, abduction and adduction, rotation
Functional quadriceps exercises should be initiated as soon as possible after the surgery because the quadriceps help provide stability in the knee. Flexion exercises also need to start as soon as possible, provided the fracture is adequated supported (i.e. the selected fixation approach allows for weight bearing). Physiotherapy should be continued until an acceptable functional range has been achieved or until a static position has been reached. It is necessary to record the range of movements in the knee with accuracy; first this should be done at weekly and then at monthly intervals.

Recent Related Research (from Pubmed)

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