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 Protocol
Administer regular paracetamol immediately as the first-line analgesic unless contraindicated, since approximately 40% of femur fracture patients have moderate renal dysfunction requiring careful medication selection. 2, 1
Add opioid analgesia cautiously after considering renal function, particularly in elderly patients or those with unknown renal status. 2, 1 Use reduced doses and frequencies (e.g., halved) in patients with renal impairment to avoid adverse effects. 2
Avoid NSAIDs until renal function is confirmed, as they are relatively contraindicated in this population with high rates of renal impairment. 2, 1
Consider femoral nerve block or fascia iliaca block for superior analgesia if appropriately trained staff are available, though these may not reliably block all three nerves (femoral, obturator, lateral cutaneous). 2, 1
Concurrent Immobilization
Immobilize the limb immediately to minimize pain and prevent further soft tissue injury. 1, 3 The affected leg will characteristically appear shortened and externally rotated. 3
Treat the deformed fracture in the position found unless straightening is necessary to facilitate safe transport. 1
Why Pain Control Takes Priority Over Other Options
Bleeding control (Option B) is not indicated in this closed fracture without bleeding, making it irrelevant to the clinical scenario. 1
Decreasing soft tissue damage (Option A) is achieved secondarily through immobilization, but pain control must come first as the patient's immediate need. 1
Preserving joint movement (Option C) is not an acute priority and would actually worsen pain and potentially cause further injury in an unstabilized fracture. 2
Critical Documentation Requirements
Document pain scores before and after analgesia administration at rest and on movement to guide ongoing management. 2, 1 Use alternative scoring systems for patients with cognitive dysfunction. 2
Common Pitfalls to Avoid
Do not delay pain assessment while focusing on other interventions, as inadequate immediate analgesia increases morbidity. 1
Do not use standard opioid dosing without considering renal function, as this population has extremely high rates of renal impairment. 1, 3
Do not prescribe codeine, as it is constipating, emetic, and associated with perioperative cognitive dysfunction. 2
Planning for Definitive Management
Plan for early definitive fixation within 24 hours in hemodynamically stable patients, as this provides the most effective long-term analgesia and reduces local and systemic complications. 2, 1, 4