What is the diagnosis and treatment for a femur fracture?

Diagnosis and Treatment of Femur Fractures

Radiography is the gold standard for diagnosing femur fractures, with anteroposterior and cross-table lateral views being the standard initial imaging approach, followed by appropriate surgical intervention based on fracture type and patient characteristics. 1

Diagnosis

Clinical Presentation

• Pain, inability to weight-bear
• Shortened, externally rotated leg on affected side
• Visible deformity in some cases

Imaging

1. Initial Imaging:

   • Standard radiographs: Anteroposterior (AP) view with approximately 15° internal rotation and cross-table lateral view 2
   • Consider AP view of pelvis to evaluate for associated pelvic fractures 1

2. For Occult Fractures (when standard radiographs are negative but clinical suspicion remains):

   • MRI without contrast (sensitivity nearly 100%) 1
   • CT scan (sensitivity 69-87%) 1

Treatment Algorithm

Initial Management

1. Pain Control:

   • Immobilization of the affected limb
   • Multimodal analgesia including:
     • Regular paracetamol (unless contraindicated)
     • Cautious use of opioids (especially in patients with renal dysfunction)
     • Consider femoral/fascia iliaca nerve blocks 2

2. Pre-operative Care:

   • Intravenous fluid therapy
   • Warming strategies to prevent hypothermia
   • Pressure care to prevent skin breakdown 2

Definitive Treatment Based on Fracture Type

1. Femoral Neck Fractures:

   • Non-displaced stable fractures: Percutaneous cannulated fixation
   • Displaced fractures in active patients without cognitive dysfunction: Total hip replacement 1

2. Intertrochanteric Fractures:

   • Stable fractures: Sliding hip screw
   • Unstable fractures with anterior cortex erosion: Cephalomedullary nail 1

3. Diaphyseal (Shaft) Fractures:

   • Centromedullary nailing is the technique of choice 1

Post-operative Care

1. Early Mobilization:

   • Immediate, full weight-bearing to tolerance after surgery for most fractures 1
   • Physical therapy for muscle strengthening and gait training

2. Complication Prevention:

   • Venous thromboembolism prophylaxis
   • Nutritional supplementation (up to 60% of hip fracture patients are malnourished) 1
   • Regular follow-up imaging at 2,6, and 12 weeks 1

Special Considerations

Age-Specific Causes

• Children: Consider abuse as potential cause 3
• Adults: Most commonly caused by motor vehicle accidents 3
• Elderly: Usually result from falls; evaluate for osteoporosis in patients over 50 1

Atypical Femur Fractures

• Associated with long-term bisphosphonate therapy
• If incomplete atypical femur fracture is discovered:
  • Stop antiresorptive medications
  • Take measures to prevent progression to complete fracture 4
• Monitor contralateral femur as bilateral involvement occurs in up to 30% of cases 1

Follow-up Care

• Rehabilitation program should include early physical training, muscle strengthening, and long-term balance training 1
• For patients over 50, evaluate for osteoporosis and risk of subsequent fractures 1
• Regular imaging to assess healing progression and monitor for complications 1

Pitfalls to Avoid

• Delays in diagnosis and treatment are associated with increased complications, longer hospital stays, and higher mortality 2
• Don't rely solely on physical examination for diagnosis, as hip fractures cannot be reliably diagnosed or excluded without imaging 2
• Be cautious with traction splints in multisystem trauma patients, as 38% may have concomitant injuries that complicate or contraindicate their use 5
• Don't overlook the contralateral femur, as bilateral involvement occurs in up to 30% of cases 1