Treatment of Closed Mid-Shaft Femoral Fracture
Intramedullary nailing is the definitive treatment for closed mid-shaft femoral fractures, providing optimal stability, early mobilization, and superior outcomes compared to conservative management. 1
Surgical Approach
Primary Treatment Method
- Locked intramedullary nailing is the preferred treatment for most diaphyseal femoral fractures, including AO type 32A and 32B1 mid-shaft fractures, with excellent clinical results and predictable bone union within 12-24 months 1
- Reamed and interlocked intramedullary nailing provides adequate stability for most closed mid-shaft fractures and allows early weight-bearing 2
- Expandable intramedullary nailing may offer advantages over conventional locked nailing with shorter operation time, reduced fluoroscopic exposure, less blood loss, and faster healing time for simple fracture patterns 1
Special Considerations for Pediatric Patients
- Flexible elastic nails (TENS) are the standard for pediatric femoral shaft fractures in school-age children 3
- For length-unstable or comminuted pediatric fractures, augmentation with external fixation provides additional rotational and longitudinal stability, with fixator removal typically at 4 weeks 3
- Immediate cast bracing can be considered for children 5-19 years, though midshaft fractures in adolescent males are difficult to manage with this method and closed intramedullary nailing is recommended instead 4
Pre-operative Management
Fluid Resuscitation
- Pre-operative fluid therapy should be prescribed routinely as many patients become hypovolemic before surgery, particularly with mid-shaft fractures which can result in blood loss exceeding one liter from cancellous bone 5, 6
- Cardiac output-guided fluid administration reduces hospital stay and improves outcomes 6
- Regular monitoring of vital signs including heart rate, blood pressure, capillary refill time, and urine output is essential to guide fluid management 6
Pre-operative Assessment
- Full blood count and urea and electrolyte analyses are required routinely before surgery 5
- ECG is required in all elderly patients 5
- Pre-operative transfusion should be considered if hemoglobin is <9 g/dL, or <10 g/dL with a history of ischemic heart disease 5
Anesthetic Considerations
Technique Selection
- Spinal/epidural anesthesia should be considered for all patients undergoing femoral fracture repair unless contraindicated, as regional anesthesia may reduce postoperative confusion and is the technique of choice based on available evidence 5
- General anesthesia requires additional postoperative analgesia, most commonly peripheral nerve blockade 5
- Regional anesthesia for femoral shaft surgery requires blockade of the lateral cutaneous nerve of the thigh, femoral, obturator, sciatic and lower subcostal nerves 5
Critical Pitfalls and Risk Factors
Vascular Injury
- Thorough clinical examination is mandatory to exclude superficial femoral artery injury, which can occur even in closed mid-shaft fractures and requires immediate computed tomography angiography if suspected 7
- Early vascular repair prevents limb-threatening complications 7
Nonunion Risk Factors
- Fracture at the proximal third junction carries significantly higher risk of oligotrophic nonunion (8.6% rate) 2
- Comorbidities including hypertension, diabetes mellitus, and obesity are significantly associated with nonunion 2
- Comminuted fractures, particularly in obese males, have higher risk of hypertrophic nonunion 2
- Close follow-up is mandatory for high-risk patients, with radiographic union scale assessment at 6 months postoperatively to predict nonunion 2
Intraoperative Considerations
- Fluid management should be optimized during surgery to prevent hypovolemia, particularly at the time of cementation if applicable 6
- Avoiding intravascular volume depletion is crucial to reduce complications 6