Clinical Pathway for Femoral Shaft Fracture
Initial Assessment and Stabilization
For femoral shaft fractures, the clinical pathway depends critically on hemodynamic stability: stable patients should undergo early definitive intramedullary nailing within 24 hours, while unstable patients require damage control with temporary stabilization followed by delayed definitive fixation. 1
Immediate Evaluation
- Assess hemodynamic status, respiratory function, and associated injuries (brain, thorax, abdomen, pelvis, spinal cord) to determine surgical timing strategy 2, 1
- Perform neurovascular examination and obtain ankle-brachial index (ABI); if ABI <0.9 or neurological deficits present, proceed with CT angiography to rule out vascular injury 1
- Obtain CT scan to detect massive bleeding, unstable injuries, and guide risk stratification for fat embolism syndrome and systemic complications 2
Surgical Timing Algorithm
For Hemodynamically Stable Patients
- Perform early definitive intramedullary nailing within 24 hours of admission to reduce ARDS, fat embolism syndrome, and systemic complications (GRADE 1+ Strong Agreement) 2, 1
- This recommendation specifically applies to femoral shaft fractures where early stabilization facilitates mobilization and initiates healing 2
For Unstable Patients (Damage Control Pathway)
- In presence of circulatory shock, severe visceral injuries, respiratory failure, or coagulopathy, perform initial temporary stabilization with external fixator or skeletal traction within first 24 hours (GRADE 2+ Strong Agreement) 2, 1
- Once clinical status stabilizes (hemodynamics, respiratory function, coagulation normalized), convert to definitive intramedullary nailing as early as safely possible 2
- The two-step damage control strategy significantly reduces operative blood loss, surgical hit, and respiratory complications in borderline or severely injured patients 2, 3
Definitive Surgical Treatment
Intramedullary Nailing (Gold Standard)
- Intramedullary nailing remains the definitive treatment for femoral shaft fractures 4
- For simple or short oblique fractures, primary dynamic interlocking nails allow early weight-bearing from postoperative day 1 and promote callus formation through axial loading 4
- Reamed nailing was historically standard, but unreamed nailing has gained acceptance particularly in polytrauma patients to reduce systemic inflammatory response 3
Alternative: Plate Fixation
- Plating is reserved for specific indications where intramedullary nailing is contraindicated 5
- Submuscular plating techniques are more technically challenging and associated with higher rates of suboptimal reduction compared to traditional open plating 5
- Overall infection rate with plating is 5% and nonunion rate 2.5%, though these occurred primarily in type III open fractures 5
Temporary Stabilization Options (For Unstable Patients)
External Fixation vs. Skeletal Traction
- Both external fixation and skeletal traction are acceptable temporization methods with no significant difference in ARDS, multiple organ failure, pulmonary embolism, or mortality rates 6
- Skeletal traction may offer advantages with lower sepsis rates (8.3% vs 31.6%) and shorter hospital length of stay (26.5 vs 36.2 days) compared to external fixation 6
- Skeletal traction remains practical unless patient requires general anesthesia for other life-saving procedures 6
Critical Pitfalls to Avoid
- Do not perform early definitive nailing in unstable patients with ongoing shock, severe respiratory compromise, or multiple visceral injuries—this causes "second hit" phenomenon with increased ARDS and systemic complications 2, 1
- Vascular injuries can be missed—maintain high suspicion and obtain CT angiography when indicated 1
- When using traction tables for nailing, monitor for nerve injuries including foot drop from peroneal nerve traction 7
- Avoid prolonged delays in definitive fixation beyond 24 hours in stable patients, as this increases fat embolism risk 2