What is the best treatment approach for a patient with a midshaft femoral fracture?

Treatment of Midshaft Femoral Fracture

Intramedullary nailing is the definitive treatment for midshaft femoral fractures, with locked intramedullary nailing being the current standard of care for most diaphyseal fractures. 1, 2

Surgical Management

Primary Treatment Approach

• Perform locked intramedullary nailing as the treatment of choice for midshaft femoral fractures, which has demonstrated excellent clinical outcomes with a 93.6% healing rate and minimal complications 2
• Execute definitive osteosynthesis within 24 hours when the patient is hemodynamically stable, as early fracture stabilization reduces local and systemic complications including fat embolism syndrome 3
• Use antegrade intramedullary nailing as the primary technique for most midshaft fractures, though retrograde approaches remain viable alternatives depending on fracture pattern 4

Alternative Techniques

• Consider expandable intramedullary nailing for AO type 32A and 32B1 fractures, which demonstrates superior outcomes compared to locked nailing in operation time, fluoroscopic time, blood loss, and healing time 5
• Apply damage control principles with temporary external fixation in multiply injured or hemodynamically unstable patients, followed by planned conversion to intramedullary nailing within 7 days (average) once physiologically stable 4, 3

Anesthesia Selection

Preferred Approach

• Consider spinal or epidural anesthesia for all patients undergoing femoral fracture repair unless contraindicated, as regional anesthesia may reduce postoperative confusion compared to general anesthesia, though neither technique demonstrates clear superiority for mortality outcomes 6
• Use lower doses of intrathecal bupivacaine (<10 mg) to reduce associated hypotension in elderly patients 6
• Avoid simultaneous spinal and general anesthesia, as this combination is associated with precipitous intraoperative blood pressure drops 6

Pain Management Strategy

• Implement multimodal analgesia with scheduled paracetamol as the foundation throughout the perioperative period 3
• Consider peripheral nerve blockade (femoral nerve block) as an adjunct to extend postoperative non-opioid analgesia, rather than relying on opioids alone which carry greater risk of respiratory depression and postoperative confusion 6, 3
• Administer opioids cautiously after reviewing renal function, as approximately 40% of trauma patients have at least moderate renal dysfunction 3
• Avoid NSAIDs in the acute setting due to potential renal dysfunction and concerns about fracture healing 3

Critical Technical Considerations

Surgical Execution

• Ensure correct reduction and perioperative control of axis and rotation, as malrotation represents the most frequent complication following intramedullary nailing 1
• Perform sufficient preoperative planning to choose the most adequate fixation device, particularly important in obese patients who represent a challenging patient group 1
• Complete the external fixation procedure within 30 minutes when using damage control principles, with conversion to intramedullary nailing averaging 7 days later 4

Conversion Protocol for Unstable Patients

• Remove external fixators and convert to intramedullary nailing in a one-stage procedure when pin sites are clean 4
• Use skeletal traction for 8-15 days to allow pin-site healing before intramedullary nailing if draining pin sites are present 4

Postoperative Management

Mobilization Protocol

• Implement immediate weight-bearing protocols with weight-bearing as tolerated, as this approach reduces DVT risk, improves functional recovery, and provides the most effective analgesia 3, 7
• Begin physical therapy on postoperative day one if medically stable 8
• Progress strengthening activities early to address impairments in range of motion, knee extensor and hip abductor strength 7

Thromboprophylaxis

• Administer fondaparinux or low molecular weight heparin for DVT prophylaxis throughout the postoperative period 8

Monitoring

• Perform routine systems examinations and regular assessment of cognitive function postoperatively, with monitoring for pressure sores, nutritional status, and renal function 8
• Correct postoperative anemia with transfusion using a threshold no higher than 8 g/dL in asymptomatic patients 8

Expected Outcomes

• Anticipate bone union within 12-24 months with modern intramedullary nailing techniques 5
• Expect average healing time of 19.36 weeks with unreamed intramedullary nailing 2
• Plan for return to manual labor within 6 months when immediate weight-bearing and early strengthening protocols are implemented 7
• Achieve average knee range of motion of 107 degrees following standard rehabilitation 4

Common Pitfalls to Avoid

• Never delay definitive fixation beyond 24 hours in stable patients, as early stabilization reduces complications and provides superior pain control 3
• Never rely solely on opioid analgesia in elderly patients due to increased risk of respiratory depression and cognitive dysfunction 6
• Never ignore rotational alignment during surgery, as malrotation remains the most frequent complication requiring reoperation 1
• Never proceed with immediate intramedullary nailing in hemodynamically unstable patients; use external fixation first and convert when physiologically stable 4