What are the treatment options for a fracture of the femur (thigh bone)?

From the Guidelines

Treatment for a fracture of the femur typically involves early definitive osteosynthesis within the first 24 hours, using intramedullary nailing or plate osteosynthesis, to reduce the incidence of local and systemic complications, as recommended by the most recent guidelines 1. The choice of surgical technique depends on the fracture location and severity, as well as the patient's overall health status.

• In patients with severe visceral injuries, circulatory shock, or respiratory failure, a delayed definitive osteosynthesis may be recommended to reduce the risk of systemic complications 1.
• A temporary stabilisation using external fixation or osseous traction may be necessary in some cases, followed by definitive osteosynthesis once the patient's clinical status is stabilised 1.
• Pain management is also crucial, with intravenous opioids and oral medications used to control pain, and DVT prophylaxis with enoxaparin or rivaroxaban to prevent deep vein thrombosis 1.
• Physical therapy should begin as soon as possible after surgery, with a focus on gentle range of motion exercises and progressing to weight-bearing activities as healing permits, typically starting 6-12 weeks post-surgery 1. The goal of treatment is to achieve full recovery, which can take 3-6 months for most patients, while minimizing the risk of morbidity and mortality, and improving quality of life 1.
• The treatment approach should be individualized based on the patient's specific needs and health status, taking into account the potential risks and benefits of each treatment option 1.
• The use of intramedullary nailing or plate osteosynthesis has been shown to be effective in reducing the incidence of local and systemic complications, and improving outcomes for patients with femur fractures 1.

From the Research

Treatment Options for Femur Fractures

The treatment options for femur fractures include:

• Internal fixation with intramedullary nailing, which is considered the ideal method of treatment 2
• Open reduction internal fixation (ORIF) using periarticular locking plates 3
• Retrograde intramedullary nail (IMN) 3
• Distal femoral replacement (DFR) 3
• Flexible intramedullary nailing, which is used for pediatric patients with substantial growth remaining 4
• Spica cast immobilization, which is used for pediatric patients who are too large for spica cast immobilization but have substantial growth remaining 4
• Submuscular plating, which is beneficial for length-unstable fractures but is a longer procedure and implant removal is more difficult 4
• External fixation, which comes with pin-track complications and infections, as well as a bulky device external to the thigh 4

Timing of Treatment

The timing of treatment for femur fractures is also an important consideration:

• Early stabilization of femur fractures shows a trend towards lower risk of infection, mortality, and venous thromboembolism (VTE), although the evidence is rated as "low" 2
• Delaying fracture fixation until resuscitation is succeeding does not lead to a significant reduction in remote organ damage 5
• Early fixation and aggressive management of medical complications may decrease patients' length of stay 6

Complications and Reoperation Rates

The complications and reoperation rates for different treatment options are:

• Major complication rates and reoperation rates are not significantly different between ORIF, IMN, and DFR 3
• Deep infection rates are higher in DFR relative to internal fixation 3
• Malunion rates are higher in IMN versus ORIF 3
• Periprosthetic fracture rates are higher in DFR and IMN versus ORIF 3