Initial Management of Closed Right 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
Administer systemic analgesia immediately because extracapsular femur fractures cause markedly higher pain than intracapsular fractures due to extensive periosteal disruption, and inadequate analgesia increases morbidity and hampers subsequent treatment. 2
Start with regular paracetamol as the first-line analgesic unless contraindicated, noting that approximately 40% of fracture patients have moderate renal dysfunction requiring dose adjustment. 1
Add opioid analgesia cautiously, particularly in elderly patients or those with unknown renal function, to avoid adverse effects. 1
Avoid NSAIDs until renal function is confirmed, as they are relatively contraindicated in this population with high rates of renal impairment. 1
Consider femoral nerve block or fascia iliaca block for superior analgesia, though these may not reliably block all three nerves (femoral, obturator, lateral cutaneous nerve of thigh). 1 The psoas compartment block is the most reliable method for blocking all three nerves, though it carries risks of neuraxial blockade and deep hematoma formation in anticoagulated patients. 1
Immobilization
Splint the fractured extremity immediately to reduce pain, reduce risk for further injury, and facilitate transport. 1 It is reasonable to treat the deformed fracture in the position found unless straightening is necessary to facilitate safe transport. 1
Hemorrhage Assessment (Not Primary Control)
While bleeding assessment is important, isolated closed femur fractures rarely cause hemodynamic instability. 2, 3
Extracapsular femur fractures can produce blood loss exceeding 1 liter, with greater comminution correlating with increased bleeding; however, isolated femur fractures are rarely the sole source of hemorrhagic shock. 2
In patients presenting with shock, actively search for alternative bleeding sources (thoracic, abdominal, pelvic injuries) because the femur fracture alone seldom accounts for hemodynamic instability. 2
In pediatric studies, no child with an isolated closed femur fracture had evidence of hemodynamic instability or required transfusion; hemodynamic insufficiency was found only in multiply injured children. 3
Baseline hemoglobin measurement is advised, with an anticipated average peri-operative decline of approximately 2.5 g/dL. 2
Neurovascular Evaluation
Perform rapid neurovascular assessment including checking palpable distal pulses and sensory function to identify neurovascular compromise. 2 While vascular injuries are rare (1.3% in one series), they can occur and require early recognition. 4
Fluid Resuscitation
Initiate isotonic crystalloid resuscitation when signs of hypovolemia are present, as patients often become hypovolemic before definitive surgery. 2 Monitor vital signs including heart rate, blood pressure, capillary refill, and urine output to guide fluid therapy. 2
Critical Pitfall to Avoid
Do not attribute hemodynamic instability to the closed femur fracture alone—always search for other sources of bleeding in unstable patients. 2, 3 In closed fractures with no active bleeding, immobilization and pain control take priority over bleeding control. 1
Answer: D - Pain control is the correct initial management priority, followed immediately by immobilization, with hemorrhage assessment (not active control) being secondary in closed fractures without hemodynamic compromise.