What is the typical treatment and management for a femur fracture?

Treatment and Management of Femur Fractures

Femur fractures require urgent surgical fixation in most cases, with the specific approach determined by fracture location and pattern: intracapsular fractures are treated with internal fixation or arthroplasty, while extracapsular fractures are managed with sliding hip screws or intramedullary nails. 1

Fracture Classification and Initial Approach

Femur fractures are broadly divided into two categories, each requiring distinct management strategies 1:

Intracapsular Fractures (50% of cases)

• Include subcapital, transcervical, and basicervical fractures 1
• Minimal blood loss at injury due to poor vascular supply and capsular tamponade 1
• Risk of avascular necrosis from disrupted capsular blood supply to the femoral head 1

Treatment algorithm for intracapsular fractures:

• Undisplaced fractures: Internal fixation with multiple screws or sliding hip screw (preferred over conservative management due to 30-50% risk of subsequent displacement) 1
• Displaced fractures: Hemiarthroplasty for elderly patients; total hip arthroplasty increasingly preferred for younger patients to prevent long-term arthritis 1
• Cemented arthroplasty is superior to uncemented, improving hip function and reducing residual postoperative pain 1

Extracapsular Fractures (50% of cases)

• Include intertrochanteric and subtrochanteric fractures 1
• Significant blood loss exceeding one liter from cancellous bone bleeding, worsening with greater comminution 1
• Considerably more painful than intracapsular fractures due to greater periosteal disruption 1

Treatment algorithm for extracapsular fractures:

• Conservative management (6-8 weeks traction/bed rest) is associated with increased morbidity, mortality, and reduced chance of returning home 1
• Surgical fixation is invariably required: sliding hip screw for intertrochanteric fractures; proximal femoral intramedullary nail for subtrochanteric fractures 1

Timing of Surgical Intervention

Early fixation within 24 hours shows a trend toward lower mortality, infection, and venous thromboembolism, though evidence quality is low 2. The Eastern Association for the Surgery of Trauma suggests early stabilization, as desirable effects likely outweigh undesirable effects in most patients 2.

Critical Caveat for Type III Open Fractures

Immediate internal fixation of type III open femur fractures carries higher complication risk (6 of 11 developed deep infection versus 1 of 22 for type I/II fractures) and should be applied with caution, particularly in patients with severe multiple trauma 3.

Perioperative Management

Preoperative Assessment

• Complete evaluation including comorbidities, nutritional status, skin condition, and pain assessment 4
• Differentiate pathological from traumatic fractures, as this affects surgical approach 4
• Radiographic imaging with CT or MRI when needed to assess fracture extent 4
• Pain management with simple analgesics (paracetamol) and nerve blocks 4

Anesthetic Considerations

• Neuraxial blockade (spinal/epidural) provides reliable surgical anesthesia and postoperative analgesia by blocking lateral cutaneous nerve of thigh, femoral, obturator, sciatic, and lower subcostal nerves 1
• General anesthesia requires additional peripheral nerve blockade for postoperative pain control 1
• Poor immediate postoperative analgesia increases morbidity 1
• DNAR discussions must precede surgery, with anaesthetists aware of outcomes 1

Surgical Setup

• Dedicated trauma operating room with space for image intensifier and traction table 4
• Surgical team experienced in femoral reconstruction procedures 4
• Proper patient positioning on traction table for lateral femoral access 4

Postoperative Management

Immediate Postoperative Care

• Regular analgesics (paracetamol) for pain control 4
• Active warming strategies during and after surgery 4
• Antithrombotic prophylaxis per hospital protocols 4
• Early mobilization to reduce complications and improve functional outcomes 4

Rehabilitation Protocol

• Early post-fracture physical training followed by long-term balance training and fall prevention 5
• Identify individual rehabilitation goals before developing the plan 5
• Aggressive motion exercises when immobilization discontinued to achieve optimal outcomes 5
• Avoid overly aggressive physical therapy that may increase fixation failure risk 5
• Patient education about injury burden, potential complications, and expected outcomes 5

Common Pitfalls to Avoid

• Do not treat displaced intracapsular fractures conservatively—this leads to avascular necrosis and poor functional outcomes 1
• Do not delay surgical fixation of extracapsular fractures—conservative management significantly increases morbidity and mortality 1
• Exercise caution with immediate fixation of type III open fractures in polytrauma patients due to higher infection rates 3
• Do not use uncemented arthroplasty when cemented is available—cemented provides better function and less pain 1
• Ensure adequate postoperative analgesia—inadequate pain control increases morbidity 1