Mechanisms of Injury
Signs and Symptoms
Imaging and Other Diagnostic Studies
Biomechanics and Nailing
Pathoanatomy and Applied Anatomy
Closed and Nonoperative Treatment
Antegrade Intramedullary Nailing
Trochanteric Entry Antegrade Nails
Retrograde Intramedullary Nailing
Special Fracture Patterns and Associated Injuries
Management of Expected Adverse Outcomes and Unexpected Complications
Muscle Weakness and Entry Site Injury
Knee Stiffness, Knee Pain, and Hip Pain
Implant Complications: Broken Nails, Broken Interlocking Screws, and Bent Nails
Femoral Nail Removal
Delayed Union and Nonunion
Infection and Infected Nonunions
Author’s Preferred Method of Treatment
Summary, Controversies, and Future Directions
For closed femoral shaft fractures, the preferred treatment in the majority of cases is immediate closed, statically locked, reamed, antegrade intramedullary nailing using a piriformis starting portal. A trochanteric entry nail with a smaller proximal diameter is used in some instances, typically in obese patients or some other compelling reason to avoid the piriformis entry portal. We tend to use a percutaneous approach with the patient positioned supine on a radiolucent table with the leg draped free. A guide pin with a cannulated drill allows for a precise determination of the starting point. An intraoperative distal femoral traction accurately placed allows for distraction and reduction of the fracture as well as assessment of rotation.
Although femoral shaft fractures can be potentially life-threatening injuries, early treatment with nailing leads to union and allows early patient mobilization. Appropriate patient selection and careful attention to the numerous technical aspects of the procedure can minimize the potential complications. Early treatment of femur fractures with reamed nailing in polytraumatized patients decreases patient mortality.31 Static locking prevents shortening, maintains femoral rotation, and does not have a deleterious effect on union.48,337 Reaming allows for placement of an appropriately sized implant, increases the rate of union, and decreases the incidence of hardware failure.26,53,312 The potential negative impacts of reaming on the patient with multiple or thoracic injuries have not been confirmed clinically.33 Overall, union can be expected in 97% to 99% of cases.53,330,333,337
The choice of an antegrade versus a retrograde entry portal for nail placement is largely based on the preference of the surgeon. At our institution, an antegrade nail is chosen if at all possible mainly because of the ease and predictability of future or secondary procedures. If the patient develops a complication that requires either an exchange nail or implant removal, our preference is to do that procedure at an extra-articular location (the trochanteric fossa) as opposed to an intra-articular location (the knee). As well, the same “relative indications” for retrograde nails can be interpreted as “relative contraindications.” For instance, an ipsilateral patellar or articular injury at the knee suggests local trauma; the iatrogenic trauma of then going through the knee with reamers and a medullary implant seems unjustified. The situations that make a retrograde nail more attractive include ipsilateral femoral neck fractures, morbid obesity, and bilateral injuries in a critically ill patient. With an ipsilateral femoral neck fracture, I prefer to prioritize the femoral neck because of the lack of good salvage procedures for complications related to that injury. A retrograde nail can be placed after the femoral neck is stabilized; however, a plate can be used as well. In morbidly obese patients (BMI >35), in whom the extensive surgical approach for an antegrade nail is associated with an increased risk of infection, a retrograde nail may be desirable. For bilateral injuries in the critically ill patient, the ability to rapidly stabilize both femurs without the need to reposition the patient can make retrograde nailing a good option in rare circumstances. These nails can be placed and locked distally using the attached external jig, saving the proximal interlocking for a time when the patient can undergo a more extensive procedure. However, external fixation with conversion to antegrade intramedullary nails after the patient has stabilized is a reasonable option as well.232,233
The use of plate fixations for femoral shaft fractures is generally reserved for unusual circumstances given the excellent results with intramedullary nailing. Primarily, this procedure is used only in patients with an extremely narrow medullary canal, previously placed hardware, an associated vascular injury, proximal or distal fracture extensions, lack of fluoroscopy, or an associated femoral neck fracture. Submuscular and/or open techniques that maintain maximal femoral vascularity are used.
External fixation of the adult femur is virtually never used as a definitive treatment for a femoral shaft fracture in an adult. However, this technique may be used as a temporary form of stabilization until femoral nailing is deemed safe. This includes patients with an associated vascular injury, patients with multiple injuries, and patients with massive medullary canal contamination. Even in these circumstances, primary treatment reamed nailing is still usually preferred in the majority of circumstances.