Initial Management of Closed Femur Fracture with Deformity
Pain control is the initial management priority for a closed femur fracture with deformity, as these fractures are extremely painful and effective analgesia is the foundation of acute care before definitive stabilization. 1
Immediate Pain Management Algorithm
Administer regular paracetamol (acetaminophen) immediately as the first-line analgesic unless contraindicated, since approximately 40% of fracture patients have moderate renal dysfunction requiring dose adjustment. 1, 2
Opioid Analgesia
- Add opioid analgesia cautiously after paracetamol, particularly if the patient is elderly or has unknown renal function to avoid adverse effects. 1, 2
- Reduce both dose and frequency in elderly patients and those with renal dysfunction rather than using standard dosing. 2
Regional Anesthesia Options
- Consider femoral nerve block or fascia iliaca block for superior analgesia, though these may not reliably block all three nerves (femoral, obturator, lateral cutaneous). 1
Medications to Avoid
- Avoid NSAIDs until renal function is confirmed, as they are relatively contraindicated in this population with high rates of renal impairment. 1, 2
Secondary Priority: Immobilization
Immobilize the limb immediately after initiating pain control to minimize pain and prevent further soft tissue injury. 1, 2 The affected leg will characteristically appear shortened and externally rotated. 2
Splinting Considerations
- Splinting the fractured extremity reduces pain, reduces risk for further injury, and facilitates transport to a medical facility. 3
- It is reasonable to treat the deformed fracture in the position found unless straightening is necessary to facilitate safe transport. 3
Why Pain Control Takes Priority Over Other Options
Soft Tissue Damage (Option A)
While minimizing soft tissue damage is important, immobilization addresses this concern secondarily after pain control is established. 1, 2
Bleeding Control (Option B)
This closed femur fracture has no bleeding as stated in the question. Long-bone fractures can cause substantial internal blood loss, but if severe bleeding were present, it would require immediate attention per guidelines. 3 Since bleeding is absent, this is not the initial priority.
Joint Movement Preservation (Option C)
Preserving joint movement is not an acute management priority. The focus is on immobilization, not movement, in the initial phase. 1, 2
Critical Pitfalls to Avoid
- Do not delay pain assessment and management while focusing on other interventions, and document pain scores before and after analgesia to guide ongoing management. 1, 2
- Do not use standard opioid dosing in elderly patients without considering renal function first. 1, 2
- Do not prescribe NSAIDs without checking renal function first, as this population has extremely high rates of renal impairment. 2
Definitive Management Planning
After initial pain control and immobilization, plan for early definitive fixation within 24 hours in hemodynamically stable patients, as this reduces local and systemic complications. 1, 4, 5
Answer: D - Pain control