For an adult with a closed mid‑shaft femur fracture when an orthopaedic surgeon is not immediately available, is it appropriate to apply a posterior plaster slab temporarily?

Temporary Immobilization for Closed Midshaft Femur Fracture When Orthopedic Surgeon Unavailable

Yes, apply a posterior plaster slab (splint) for temporary immobilization of a closed midshaft femur fracture when an orthopedic surgeon is not immediately available, but prioritize urgent orthopedic consultation and definitive surgical stabilization within 24 hours.

Immediate Temporary Management

Apply a posterior long leg splint for pain control and fracture stabilization while awaiting orthopedic evaluation. 1, 2 This temporary measure:

• Provides immediate pain relief through fracture immobilization 2
• Prevents further soft tissue injury from fracture fragment movement 1
• Reduces ongoing fat particle release from the fracture site 1
• Serves as a bridge to definitive surgical treatment, not a treatment endpoint 1, 2

Administer multimodal analgesia immediately, including consideration of femoral nerve block for superior pain control. 2 Femoral or fascia iliaca nerve blocks using low-concentration local anesthetics provide excellent analgesia without masking compartment syndrome symptoms when properly dosed. 2

Critical Time-Sensitive Actions

Arrange urgent orthopedic consultation and transfer to definitive care immediately—surgery must occur within 24 hours of injury in hemodynamically stable patients. 3, 1, 2 The evidence strongly supports this narrow window:

• Early definitive osteosynthesis within 24 hours markedly reduces fat embolism syndrome and acute respiratory distress syndrome (ARDS) incidence 1, 2
• Surgery within 24-48 hours is associated with better outcomes, shorter hospital stays, and greater likelihood of discharge to home versus extended care 3, 2
• Delaying beyond 24 hours in stable patients increases complication rates without clinical benefit 1, 2

Assess hemodynamic stability immediately to determine the treatment pathway. 1, 2 This is the first critical step that dictates all subsequent management:

• Hemodynamically stable patients proceed directly to early definitive intramedullary nailing within 24 hours 1, 2
• Hemodynamically unstable patients require damage control orthopedics with temporary external fixation or skeletal traction, followed by delayed definitive fixation 1

What NOT to Do: Critical Pitfalls

Never use a posterior splint as definitive treatment—it is only a temporizing measure. 1, 2 Prolonged conservative management with splinting alone leads to:

• Increased risk of fat embolism syndrome and ARDS 1, 2
• Higher complication rates 1
• Worse functional outcomes 2

Do not delay transfer or orthopedic consultation beyond what is absolutely necessary. 3 Guidelines emphasize that surgical fixation should not be delayed more than 48 hours from admission unless there are clear reversible medical conditions. 3

Never dismiss escalating pain as "normal" post-injury pain—this is the cardinal sign of evolving compartment syndrome requiring immediate fasciotomy. 2 Monitor neurovascular status continuously while awaiting definitive care.

Avoid dense regional anesthesia that could completely mask compartment syndrome; use low-concentration techniques instead. 2

Practical Algorithm for Non-Orthopedic Provider

1. Immediate assessment (first 15 minutes):

   • Confirm hemodynamic stability (blood pressure, heart rate, respiratory status) 1, 2
   • Perform neurovascular examination of affected limb 2
   • Assess for compartment syndrome signs (pain out of proportion, pain with passive stretch) 2
   • Rule out open fracture 1

2. Immediate interventions (first 30 minutes):

   • Apply posterior long leg splint for temporary immobilization 1, 2
   • Administer multimodal analgesia, consider femoral nerve block 2
   • Initiate orthopedic consultation and arrange transfer 3

3. Ongoing management until orthopedic arrival:

   • Monitor neurovascular status every 2 hours 2
   • Maintain nil per os (NPO) status in preparation for surgery 3
   • Ensure adequate hydration and maintain systolic blood pressure within 20% of baseline 1
   • Document time of injury and time of splint application 3

Why Definitive Surgery Cannot Wait

More than 98% of femoral fractures are repaired surgically for purposes of analgesia and early rehabilitation. 3 The mechanism of early stabilization prevents ongoing fat particle release from the fracture site and reduces the inflammatory "second hit" that occurs with delayed surgery. 1 Intramedullary nailing provides the most effective long-term analgesia through fracture stabilization. 2

The goal is surgery as soon as safely possible—ideally within 24 hours, but no later than 48 hours from admission. 3 This recommendation applies to both trauma centers and non-trauma centers, as both manage substantial numbers of patients with closed midshaft femur fractures with low mortality when appropriate protocols are followed. 4