What is the appropriate management for a patient with bleeding in the shaft of the femur?

Management of Bleeding in Femoral Shaft Fractures

For bleeding in the shaft of the femur, immediate temporary stabilization with external fixation or traction is essential if the patient has hemodynamic instability, followed by aggressive resuscitation and definitive surgical fixation once physiologically stable. 1

Initial Assessment and Hemodynamic Stabilization

Determine the patient's physiological status immediately – this dictates your entire management pathway. 1

• If hemodynamically stable (no circulatory shock, no respiratory failure, no severe visceral injuries): Proceed directly to early definitive osteosynthesis within 24 hours to reduce local and systemic complications including fat embolism syndrome and ARDS. 1

• If hemodynamically unstable (circulatory shock present, respiratory failure, or severe associated injuries to brain/thorax/abdomen/pelvis/spinal cord): Implement damage control orthopedic surgery (DCO) with temporary stabilization using external fixator or skeletal traction, delaying definitive fixation until physiological parameters normalize. 1

Quantifying Blood Loss and Monitoring

Femoral shaft fractures cause substantial blood loss that is largely hidden:

• Expect total perioperative blood loss of 1,800-1,900 mL with intramedullary nailing, with approximately 79% being hidden blood loss (1,500+ mL). 2
• Monitor serum lactate and base deficit rather than isolated hematocrit values, as single hematocrit measurements are unreliable for assessing bleeding severity. 3, 4
• Obtain early, repeated measurements of PT, aPTT, fibrinogen, and platelet count to detect coagulopathy, especially in anticoagulated patients. 3

Immediate Hemorrhage Control Measures

Apply direct manual pressure to any external bleeding sites for at least 10-15 minutes continuously. 5, 3

• Use topical hemostatic agents (collagen-based, gelatin-based, or polysaccharide-based) combined with direct pressure for external bleeding, achieving hemostasis in 90.8% of severe bleeding cases. 5
• For life-threatening extremity bleeding uncontrolled by pressure, apply a tourniquet proximal to the wound. 3
• Never remove initial dressings to "check" bleeding, as this disrupts clot formation. 5

Temporary Fracture Stabilization (Damage Control Phase)

For unstable patients, perform simplified temporary stabilization immediately:

• External fixation or skeletal traction reduces operative delays and blood loss in severe trauma patients with femoral shaft fractures. 1
• This DCO approach significantly reduces respiratory complications and systemic inflammatory response compared to early definitive fixation in physiologically compromised patients. 1
• CT scan is essential to detect massive bleeding or unstable injuries and identify patients at risk for fat embolism syndrome or multiple organ failure. 1

Pharmacologic Hemostatic Therapy

Administer tranexamic acid 1 g IV over 10 minutes, followed by 1 g IV over 8 hours if ongoing significant bleeding is present, ideally within 3 hours of injury. 3, 4

• Do not delay tranexamic acid while awaiting coagulation results. 3, 4
• If fibrinogen is low or coagulopathy present, administer fibrinogen concentrate 3-4 g or cryoprecipitate 5-20 units. 3
• For coagulopathy with PT or aPTT >1.5 times normal, give FFP at 10-15 mL/kg. 3
• Maintain platelet count >50 × 10⁹/L, or >100 × 10⁹/L if multiple trauma present. 3

Resuscitation Strategy

Target permissive hypotension with systolic BP 80-100 mmHg until definitive bleeding control is achieved. 4

• Initiate crystalloid resuscitation as first-line, with colloids added within prescribed limits. 4
• Use restrictive transfusion strategy, maintaining hemoglobin ≥7 g/dL (≥8 g/dL if coronary artery disease present). 4
• Avoid hyperventilation and excessive PEEP in severely hypovolemic patients, as this worsens hemodynamics. 4

Definitive Surgical Management Timing

Once physiologically stable, perform definitive osteosynthesis as early as possible:

• Stable patients without severe visceral injuries: Early definitive osteosynthesis within 24 hours reduces complications. 1
• Unstable patients or those with severe associated injuries: Delayed definitive surgery after temporary stabilization and medical optimization reduces surgical hit, perioperative blood loss, and coagulopathy. 1
• The PRISM approach (Prompt Individualized Safe Management) guides timing based on circulatory status, respiratory function, coagulation status, and anatomy of injuries. 1

Critical Pitfalls to Avoid

Shock with isolated femoral shaft fracture is rare (8.5%) – if shock is present, aggressively investigate for other bleeding sources including thoracic (9.9% concurrent) and abdominal injuries (26.3% concurrent). 6

• Open femoral fractures are present in 72.7% of isolated FSF patients in shock and present with difficult-to-control thigh bleeding. 6
• Do not perform urgent prehospital traction splinting in all cases, as this may delay evacuation to definitive care; reserve for suspected FSF with shock or persistent thigh bleeding. 6
• Correct hypothermia and acidosis, as these worsen coagulopathy and perpetuate bleeding. 4
• Be vigilant for fat embolism syndrome and thromboembolic events in bilateral femoral shaft fractures, which can delay definitive fixation. 7

Special Considerations for Anticoagulated Patients

For patients on warfarin, reverse effects with early vitamin K administration to allow surgery within 24 hours; reserve prothrombin complex concentrate (PCC) for extreme cases only. 8

For patients on direct oral anticoagulants (DOACs), discontinue 24-48 hours prior to surgery depending on drug type and renal function; antidotes (idarucizumab, andexanet alfa) or PCC reserved for extreme cases. 8

Antiplatelet therapy (aspirin, clopidogrel) does not require discontinuation prior to surgery; use antifibrinolytic therapy if bleeding occurs. 8