Acta Chir Orthop Traumatol Cech. 2014; 81(2):108-117 | DOI: 10.55095/achot2014/011

Femoral Shaft Fractures in Adults: Treatment Options and ControversiesCurrent concepts review

A. GÄNSSLEN1,*, T. GÖSLING2, F. HILDEBRAND3, H. C. PAPE3, H. J. OESTERN4
1 Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum der Stadt Wolfsburg, Wolfsburg, Germany
2 Klinik für Unfallchirurgie und Orthopädische Chirurgie, Klinikum Braunschweig, Braunschweig, Germany
3 Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Aachen, Germany
4 H. J. Oestern, Celle, Germany

Antegrade reamed femoral nailing via the piriformis entry point is the technique of choice in treating femoral shaft fractures, with retrograde nailing as an alternative. The supine position is favored to reduce complications, especially rotational malalignment. With navigation and robotic assistance fracture reduction can be supported and the rate of rotational, axis and length malalignement can potentially further reduced.
Careful reaming is the procedure of choice to optimize bony healing and reduce systemic and local complications. In multiply injured patients reamed nailing can be safely integrated in the DCO- or ETC-concept and can be performed in the majority of patients, even when additional severe chest and head injuries are present. Initial resuscitation should focus on general stabilization before definitive femur fixation.
Plate osteosynthesis of the femur can be an option in selected patients.

Published: April 1, 2014  Show citation

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GÄNSSLEN A, GÖSLING T, HILDEBRAND F, PAPE HC, OESTERN HJ. Femoral Shaft Fractures in Adults: Treatment Options and Controversies. Acta Chir Orthop Traumatol Cech. 2014;81(2):108-117. doi: 10.55095/achot2014/011. PubMed PMID: 25105784.
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    References

    1. AMARENCO, G., ISMAEL, S., BAyLE, B., DENyS, P., KERDRAON, J.: Electrophysiological analysis of pudendal neuropathy following traction. Muscle Nerve, 24: 116-119, 2001. Go to original source...
    2. ANGELINI, A., LIVANI, B., FLIERL, M., MORGAN, S., BELANGERO, W.: Less invasive percutaneous wave plating of simple femur shaft fractures: A prospective series. Injury, 41: 624-628, 2010. Go to original source... Go to PubMed...
    3. ANSARI MOEIN, C., TEN DUIS, H., OEY, L., DE KORT., G, VAN DER MEULEN, W., VERMEULEN, K. VAN DER WERKEN, C.: Functional outcome after antegrade femoral nailing: a comparison of trochanteric fossa versus tip of greater trochanter entry point. J. Orthop. Trauma, 25: 196-201, 2011. Go to original source... Go to PubMed...
    4. ANSARI MOEIN, C., VERHOFSTAD, M., BLEYS, R., VAN DER WERKEN, C.: Soft tissue injury related to choice of entry point in antegrade femoral nailing: piriform fossa or greater trochanter tip. Injury, 36: 1337-1342, 2005. Go to original source... Go to PubMed...
    5. APOSTLE, K., LEFAIVRE, K., GUy, P., BROEKHUySE, H. BLACHUT, P., O'BRIEN, P., MEEK, R.: The effects of intraoperative positioning on patients undergoing early definitive care for femoral shaft fractures. J. Orthop. Trauma, 23: 615-621, 2009. Go to original source... Go to PubMed...
    6. ATTAL, R., BLAUTH, M.: Unaufgebohrte Marknagelung. Orthopäde. 39: 182-191, 2010. Go to original source... Go to PubMed...
    7. BHANDARI, M., GUyATT, G., TONG, D., ADILI, A., SHAUGHNESSy, S.: Reamed versus nonreamed intramedullary nailing of lower extremity long bone fractures: a systematic overview and meta-analysis. J. Orthop. Trauma, 14: 2-9, 2000. Go to original source... Go to PubMed...
    8. BONE, L., GIANNOUDIS, P.: Femoral shaft fracture fixation and chest injury after polytrauma. J. Bone Jt Surg., 93-A: 311-317, 2011. Go to original source... Go to PubMed...
    9. BONE, L., JOHNSON, K., WEIGELT, J., SCHEINBERG, R.: Early versus delayed stabilization of femoral fractures. A prospective randomized study. J. Bone Jt Surg., 71-A: 336-340, 1989. Go to original source...
    10. BRUMBACK, R., WELLS, J., LAKATOS, R., POKA, A., BATHON, G., BURGESS, A.: Heterotopic ossification about the hip after intramedullary nailing for fractures of the femur. J. Bone Jt Surg., 72-A: 1067-1073, 1990. Go to original source...
    11. BRUNDAGE, S., MCGHAN, R., JURKOVICH, G., MACK, C., MAIER, R.: Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries. J. Trauma, 52: 299-307, 2002. Go to original source... Go to PubMed...
    12. CLATWORTHy, M., CLARK, D., GRAy, D., HARDy, A.: Reamed versus unreamed femoral nails. A randomised, prospective trial. J. Bone Jt Surg., 80-B: 485-489, 1998. Go to original source...
    13. CROWL, A., yOUNG, J., KAHLER, D., CLARIDGE, J., CHRZANOWSKI, D., POMPHREY, M.: Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation. J. Trauma, 48: 260-267, 2000. Go to original source... Go to PubMed...
    14. DORA, C., LEUNIG, M., BECK, M., ROTHENFLUH, D., GANZ, R.: Entry point soft tissue damage in antegrade femoral nailing: a cadaver study. J. Orthop. Trauma, 15: 488-493, 2001. Go to original source... Go to PubMed...
    15. FLIERL, M., STONEBACK, J., BEAUCHAMP, K., HAK, D., MORGAN, S., SMITH, W., STAHEL, P.: Femur shaft fracture fixation in head-injured patients: when is the right time? J. Orthop. Trauma, 24: 107-114, 2010. Go to original source... Go to PubMed...
    16. GANZ, R., MAST, J., WEBER, B., PERREN, S.: Clinical aspects of biological plating. Injury, 22 (Suppl. 1): 4-5, 1991. Go to original source...
    17. GIANNOUDIS, P., SMITH, R., BELLAMy, M., MORRISON, J., DICKSON, R., GUILLOU, P.: Stimulation of the inflammatory system by reamed and unreamed nailing of femoral fractures. An analysis of the second hit. J. Bone Jt Surg., 81-B: 356-361, 1999. Go to original source...
    18. GöSLING, T., KRETTEK, C: Femurschaft. in: HAAS, N. P., KRETTEK, C. (Hrsg). Tscherne Unfallchirurgie. Hüfte und Oberschenkel, 239-318, 2012. Go to original source...
    19. GöSLING, T., OSZWALD, M., KENDOFF, D., CITAK, M., KRETTEK, C., HüFNER, T.: Computer-assisted antetorsion control prevents malrotation in femoral nailing: an experimental study and preliminary clinical case series. Arch. Orthop. Trauma Surg., 129: 1521-1526, 2009. Go to original source... Go to PubMed...
    20. GöSLING, T., WESTPHAL, R., HüFNER, T., FAULSTICH, J., KFURI, M. J., WAHL, F., KRETTEK, C.: Robot-assisted fracture reduction: a preliminary study in the femur shaft. Med. Biol. Eng. Comput., 43: 115-120, 2005. Go to original source... Go to PubMed...
    21. GRECHENIG, W., PICHLER, W., CLEMENT, H., TESCH, N., GRECHENIG, S.: Anatomy of the greater femoral trochanter: clinical importance for intramedullary femoral nailing. Anatomic study of 100 cadaver specimens. Acta Orthop., 77: 899-901, 2006. Go to original source... Go to PubMed...
    22. GUGALA, Z., QAISI, y., HIPP, J., LINDSEy, R.: Long-term functional implications of the iatrogenic rotational malalignment of healed diaphyseal femur fractures following intramedullary nailing. Clin. Biomech., 26: 274-277, 2011. Go to original source... Go to PubMed...
    23. HARWOOD, P., GIANNOUDIS, P., VAN GRIENSVEN, M., KRETTEK, C., PAPE, H.: Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients. J. Trauma, 58: 452-454, 2005. Go to original source... Go to PubMed...
    24. HAUSER, C., ZHOU, X., JOSHI, P., CUCHENS, M., KREGOR, P., DEVIDAS, M., KENNEDy, R., POOLE, G., HUGHES, J.: The immune microenvironment of human fracture/soft-tissue hematomas and its relationship to systemic immunity. J. Trauma, 42: 895-903, 1997. Go to original source... Go to PubMed...
    25. HüFNER, T., CITAK, M., SUERO, E., MILLER, B., KENDOFF, D., KRETTEK, C., CITAK, M.: Femoral malrotation after unreamed intramedullary nailing: an evaluation of influencing operative factors. J. Orthop. Trauma, 25: 224-227, 2011. Go to original source... Go to PubMed...
    26. JAICKS, R., COHN, S., MOLLER, B.: Early fracture fixation may be deleterious after head injury. J. Trauma, 42: 1-6, 1997. Go to original source... Go to PubMed...
    27. KEAST-BUTLER, O., LUTZ, M., ANGELINI, M., LASH, N., PEARCE, D., CROOKSHANK, M., ZDERO, R., SCHEMITSCH, E.: Computer navigation in the reduction and fixation of femoral shaft fractures: a randomized control study. Injury, 43: 749-756, 2012. Go to original source... Go to PubMed...
    28. KEMPF, I., GROSSE, A., BECK, G.: Closed locked intramedullary nailing. Its application to comminuted fractures of the femur. J. Bone Jt Surg., 67-A: 709-720, 1985. Go to original source...
    29. KESEMENLI, C., SUBASI, M., NECMIOGLU, S., KAPUKAYA, A.: Treatment of multifragmentary fractures of the femur by indirect reduction (biological) and plate fixation. Injury, 33: 691-699, 2002. Go to original source... Go to PubMed...
    30. KöSEOGLU, E., DURAK, K., BILGEN, M., KüçüKALP, A., BAYYURT, S.: Comparison of two biological internal fixation techniques in the treatment of adult femur shaft fractures (plate-screws and locked intramedullary nail). Ulus Travma Acil. Cerrahi Derg., 17: 159-165, 2011. Go to original source...
    31. LINKE, B., ANSARI MOEIN, C., BöSL, O., VERHOFSTAD, M., VAN DER WERKEN, C., SCHWIEGER, K., ITO, K.: Lateral insertion points in antegrade femoral nailing and their influence on femoral bone strains. J. Orthop. Trauma, 22: 716-722, 2008. Go to original source... Go to PubMed...
    32. MüLLER, C., GREEN, J., SüDKAMP, N.: Physical and technical aspects of intramedullary reaming. Injury, 37 (Suppl.4): S39-S49, 2006. Go to original source... Go to PubMed...
    33. OESTERN, H., RIEGER, G., WITTKE, M., AG, P.: Lehren und Konsequenzen aus Sammelregistern: Das Polytraumaregister der DGU. Kongressbd. Dtsch. Ges. Chir., 118: 712-715, 2001. Go to original source...
    34. OSTRUM, R., MARCANTONIO, A., MARBURGER, R.: A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J. Orthop. Trauma, 19: 681-686, 2005.
    35. O'TOOLE, R., RICHE, K., CANNADA, L., HENNESSy, M., SCIADINI, M., SHI, L., WOODFORD, M., HARRIS, M.: Analysis of postoperative knee sepsis after retrograde nail insertion of open femoral shaft fractures. J. Orthop. Trauma, 24: 677-682, 2010. Go to original source... Go to PubMed...
    36. PAPADOKOSTAKIS, G., PAPAKOSTIDIS, C., DIMITRIOU, R., GIANNOUDIS, P.: The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature. Injury, 36: 813-822, 2005. Go to original source... Go to PubMed...
    37. PAPAKOSTIDIS, C., GROTZ, M., PAPADOKOSTAKIS, G., DIMITRIOU, R., GIANNOUDIS, P.: Femoral biologic plate fixation. Clin. Orthop., 450: 193-202, 2006. Go to original source... Go to PubMed...
    38. PAPE, H., AUF'M'KOLK, M., PAFFRATH, T., REGEL, G., STURM, J., TSCHERNE, H.: Primary intramedullary femur fixation in multiple trauma patients with associated lung contusion-a cause of posttraumatic ARDS? J. Trauma, 34: 540-547, 1993. Go to original source... Go to PubMed...
    39. PAPE, H., SCHMIDT, R., RICE, J., VAN GRIENSVEN, M., DAS GUPTA, R., KRETTEK, C., TSCHERNE, H.: Biochemical changes after trauma and skeletal surgery of the lower extremity: quantification of the operative burden. Crit. Care Med., 28: 3441-3448, 2000. Go to original source... Go to PubMed...
    40. PAPE, H., STALP, M., DAHLWEID, M., REGEL, G., TSCHERNE, H.: Arbeitsgemeinschaft "Polytrauma" der Deutschen Gesellschaft für Unfallchirurgie: Welche primäre Operationsdauer ist hinsichtlich eines "Borderline-Zustandes" polytraumatisierter Patienten vertretbar? Unfallchirurg, 102: 861-869, 1999. Go to original source... Go to PubMed...
    41. RAMSEIER, L., JANICKI, J., WEIR, S., NARAYANAN, U.: Femoral fractures in adolescents: a comparison of four methods of fixation. J. Bone Jt Surg., 92-A: 1122-1129, 2010. Go to original source... Go to PubMed...
    42. RETHER, J., MUñOZ VIVES, J., BAIL, H., VERHOFSTAD, M., BLAUTH, M., LJUNGQVIST, J., HöNTZSCH, D.: Erfahrungen mit einem helikalen Femurmarknagel (LFN®). Unfallchirurg 2012 Oct 20. (Epub ahead of print), 2012. Go to original source... Go to PubMed...
    43. RICCI, W., SCHWAPPACH, J., TUCKER, M., COUPE, K., BRANDT, A., SANDERS, R., LEIGHTON, R.: Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures. J. Orthop. Trauma, 20: 663-667, 2006.
    44. SCALEA, T., BOSWELL, S., SCOTT, J., MITCHELL, K., KRAMER, M., POLLAK, A.: External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J. Trauma, 48: 613-623, 2000. Go to original source... Go to PubMed...
    45. The Canadian Orthopaedic Trauma Society: Nonunion following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial. J. Bone Jt Surg., 85-A: 2093-2096, 2003. Go to original source...
    46. TAN, V., PEPE, M. D., GLASER, D., SELDES, R., HEPPENSTALL, R., ESTERHAI, J., Jr: Well-leg compartment pressures during hemilithotomy position for fracture fixation. J. Orthop. Trauma, 14: 157-161, 2000. Go to original source... Go to PubMed...
    47. TORNETTA, P., TIBURZI, D.: Antegrade or retrograde reamed femoral nailing. A prospective, randomised trial. J. Bone Jt Surg., 82-B: 652-654, 2000. Go to original source...
    48. TUPIS, T., ALTMAN, G., ALTMAN, D., COOK, H., MILLER, M.: Femoral bone strains during antegrade nailing: a comparison of two entry points with identical nails using finite element analysis. Clin. Biomech., 27: 354-359, 2012. Go to original source... Go to PubMed...
    49. TUTTLE, M., SMITH, W., WILLIAMS, A., AGUDELO, J., HARTSHORN, C., MOORE, E., MORGAN, S.: Safety and efficacy of damage control external fixation versus early definitive stabilization for femoral shaft fractures in the multiple-injured patient. J. Trauma, 67: 602-605, 2009. Go to original source... Go to PubMed...
    50. WILHARM, A., GRAS, F., RAUSCH, S., LINDER, R., MARINTSCHEV, I., HOFMANN, G., MüCKLEy, T.: Navigation in femoral-shaft fractures-from lab tests to clinical routine. Injury, 42: 1346-1352, 2011. Go to original source... Go to PubMed...
    51. WILHARM, A., GRUHN, M., MüLLER, M., GRAS, F., MARINTSCHEV, I., HOFMANN, G., MüCKLEy, T.: (Navigation-assisted nailing of femoral shaft fractures-experimental and clinical results). Z. Orthop. Unfall., 146: 754-759, 2008. Go to original source... Go to PubMed...
    52. WINQUIST, W., HANSEN, S., CLAWSON, D.: Closed intramedullary nailing of femoral fractures. J. Bone Jt Surg., 66-A: 529-539, 1984. Go to original source...
    53. WOLINSKY, P., MCCARTY, E., SHYR, Y., JOHNSON, K. D.: Length of operative procedures: reamed femoral intramedullary nailing performed with and without a fracture table. J. Orthop. Trauma, 12: 485-495, 1998. Go to original source... Go to PubMed...
    54. ZLOWODZKI, M., VOGT, D., COLE, P., KREGOR, P.: Plating of femoral shaft fractures: open reduction and internal fixation versus submuscular fixation. J. Trauma, 63: 1061-1065, 2007. Go to original source... Go to PubMed...

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