What is the therapeutic regimen for a femur (thigh bone) fracture?

Therapeutic Regimen for Femur Fracture

Surgical Treatment Selection

The therapeutic regimen for femur fractures depends critically on fracture location and pattern: intramedullary nailing is the gold standard for femoral shaft fractures, while proximal femur fractures require either dynamic hip screw (DHS) or cephalomedullary nailing based on fracture stability. 1, 2

Proximal Femur (Intertrochanteric) Fractures

Surgical stabilization should be performed within 24-48 hours of admission to optimize outcomes and reduce mortality. 1

• For stable intertrochanteric fractures: Use either a sliding hip screw (SHS/DHS) or cephalomedullary nail 1
• For unstable intertrochanteric fractures: A cephalomedullary nail is strongly recommended 1
• For subtrochanteric or reverse oblique fractures: A cephalomedullary device is mandatory 1

The DHS allows for stable fixation and early mobilization, which is critical for reducing morbidity and mortality in this patient population 3.

Femoral Shaft Fractures

Intramedullary nailing is the preferred and gold standard method for treating femoral shaft fractures, providing stable fixation with high union rates and low complication rates. 4, 2

• Both antegrade (piriformis fossa or greater trochanter entry) and retrograde approaches are viable options 2
• The choice depends on patient positioning, body habitus, and associated injuries 2
• Average bone union time is approximately 26.9 weeks with intramedullary nailing 4

Distal Femur Fractures

For distal femur fractures, both retrograde intramedullary nailing (RIMN) and locking plates can be used, though RIMN demonstrates significantly fewer nonunions and infections compared to locking plates 5.

Metastatic Femur Fractures

For pathologic fractures from metastatic disease, treatment depends on lesion location 6:

• Femoral neck involvement: Total hip arthroplasty is preferred 6
• Diaphyseal lesions: Cephalomedullary rod fixation with consideration for intralesional resection 6
• Multiple lesions: Combined approaches with overlapping fixation may be necessary 6
• Postoperative whole-bone radiation should be administered 6

Preoperative Management

Timing and Preparation

• Do NOT use preoperative traction 1
• Administer prophylactic antibiotics within one hour of skin incision 6, 3, 1
• Prescribe pre-operative fluid therapy routinely, as many patients become hypovolemic before surgery 6
• Cardiac output-guided fluid administration reduces hospital stay and improves outcomes 6

Anesthesia Selection

Either spinal/epidural or general anesthesia is appropriate with no clear superiority of one over the other. 1 Consider peripheral nerve blocks for enhanced postoperative pain management 3.

Monitoring

Standard monitoring should include 6:

• Core temperature monitoring routinely
• Point-of-care hemoglobin analyzers at surgery completion
• Consider invasive blood pressure monitoring for patients with limited left ventricular function or valvular heart disease 6
• Consider central venous pressure monitoring for patients with limited left ventricular function 6

Intraoperative Management

Key Surgical Principles

• Implement active warming strategies to prevent hypothermia, particularly in elderly patients 6, 3
• Ensure proper patient positioning to avoid pressure sores and neuropraxia 6
• For cemented procedures, use proper technique including medullary lavage, cement gun use, and femoral venting to reduce bone cement implantation syndrome risk 6
• Increase inspired oxygen concentration at time of cementation 6

Thromboembolism Prevention

• Use thromboembolism stockings or intermittent compression devices intraoperatively 6
• Ensure patients remain warm and well-hydrated 6
• Low molecular weight heparin should be administered between 18:00-20:00 to minimize bleeding risk with neuraxial anesthesia 6

Postoperative Management

Thromboprophylaxis

Continue fondaparinux or low molecular weight heparin for thromboprophylaxis. 6, 3, 1 This is critical as venogram studies show 37% prevalence of DVT and 6% prevalence of PE, though clinical symptoms appear in only 1-3% of DVTs and 0.5-3% of PEs 6.

Pain Management

• Administer regular paracetamol throughout the perioperative period 6, 3, 1
• Use opioids cautiously, especially in patients with renal dysfunction—reduce both dose and frequency (e.g., halve the dose) 6, 1
• Avoid codeine as it is constipating, emetic, and associated with perioperative cognitive dysfunction 6
• NSAIDs should be used with extreme caution and are contraindicated in renal dysfunction 6

Mobilization

Implement early mobilization protocols immediately to reduce complications and restore ambulatory capacity. 3 This is a cornerstone of reducing morbidity and mortality in femur fracture patients.

Monitoring for Complications

Patients remain at high risk postoperatively and require vigilant monitoring for 6:

• Bone cement implantation syndrome (hypoxia, hypotension, loss of consciousness)
• Thromboembolic events
• Infection
• Implant failure

Critical Pitfalls to Avoid

• Failure to assess the entire femoral length before surgery increases risk of implant failure and need for additional surgery, particularly important in metastatic disease 6
• Avoid excessive flexion and internal rotation of the non-operative hip during DHS insertion 6
• Do not use preoperative traction 1
• Avoid codeine for pain management 6
• Be cautious with NSAIDs in elderly patients with renal dysfunction 6