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Midshaft femur fractures in adults

Chad A Asplund, MD, FACSM, MPH
Thomas J Mezzanotte, MD
Section Editor
Patrice Eiff, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM


The femur is the longest, strongest, and heaviest tubular bone in the human body and one of the principal load bearing bones in the lower extremity [1-4]. Fractures of the femoral shaft often result from high energy forces such as motor vehicle collisions [5]. Complications and injuries associated with midshaft femur fractures in the adult can be life-threatening and may include hemorrhage, internal organ injury, wound infection, fat embolism, and adult respiratory distress syndrome [2,6].

Femoral shaft fractures can also result in major physical impairment due to potential fracture shortening, malalignment, or prolonged immobilization of the extremity with casting or traction [2]. The art of femoral fracture care involves a balancing act between anatomic alignment and early functional rehabilitation of the limb.

The diagnosis and management of midshaft femur fractures in adults will be reviewed here. Pediatric femur fractures, major pelvic trauma, general trauma management, and the management of potential complications of femur fractures are discussed separately. (See "Femoral shaft fractures in children" and "Pelvic trauma: Initial evaluation and management" and 'Complications' below.)


The annual incidence of midshaft femur fractures is approximately 10 per 100,000 person-years [7]. The incidence peaks among the young, decreasing after age 20, and then again in the elderly [8]. A marked increase occurs in those over age 75 years. The majority of femur fractures occur in the proximal third (ie, hip fractures), which are discussed separately [9]. (See "Hip fractures in adults".)

The incidence of femoral, particularly diaphyseal, fractures due to severe trauma is greatest in young men. Patients younger than 40 are more likely to sustain high energy trauma (eg, motor vehicle crash) and fracture the midshaft of the femur, while those over 40 are more likely to sustain low energy trauma (eg, fall) and fracture the proximal third of the femur [10]. Eighty percent of patients 35 years of age or older with femur fractures due to moderate energy trauma had prior evidence of generalized osteopenia or a condition likely to cause localized osteopenia [11]. In older adults, low energy falls are the most common cause, accounting for 65 percent of fractures [12]. These typically occur in the home. Long term use of bisphosphonates may increase the risk of femur fracture. These typically occur in the home. Long-term use of bisphosphonates may increase the risk of femur fracture; however, this may be mitigated by the use of bisphosphonate drug holidays. The association between bisphosphonates and femur fracture is discussed separately (see "Risks of bisphosphonate therapy in patients with osteoporosis", section on 'Atypical femur fractures' and "The use of bisphosphonates in postmenopausal women with osteoporosis", section on 'Overview of approach'). Industrial accidents and gunshot wounds account for most other femur fractures.

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Literature review current through: Nov 2017. | This topic last updated: Aug 15, 2017.
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  1. Moore KL, Agur AM. Clinically Oriented Anatomy, 6th ed, Williams & Wilkins, Baltimore 2009.
  2. Nork SM. Fractures of the shaft of the femur. In: Rockwood and Green's Fractures in Adults, 7th ed, Bucholz RW, Heckman JD, Court-Brown CM, et al (Eds), Lippincott, Williams & Wilkins, Philadelphia 2010. p.1656.
  3. Platzer W. Locomotor system. In: Color Atlas of Human Anatomy, 6th ed, Thieme Medical Publishers, Stuttgart 2009. Vol 1.
  4. Whittle AP. Fractures of the lower extremity. In: Campbell's Operative Orthopedics, 11th ed, Canale ST, Beatty JH (Eds), Mosby, St. Louis 2008. p.3190.
  5. Bucholz RW, Jones A. Fractures of the shaft of the femur. J Bone Joint Surg Am 1991; 73:1561.
  6. Keel M, Trentz O. Pathophysiology of polytrauma. Injury 2005; 36:691.
  7. Weiss RJ, Montgomery SM, Al Dabbagh Z, Jansson KA. National data of 6409 Swedish inpatients with femoral shaft fractures: stable incidence between 1998 and 2004. Injury 2009; 40:304.
  8. Hedlund R, Lindgren U. Epidemiology of diaphyseal femoral fracture. Acta Orthop Scand 1986; 57:423.
  9. Baron JA, Karagas M, Barrett J, et al. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology 1996; 7:612.
  10. Adnan RM, Zia MI, Amin J, et al. Frequency of femoral fractures; comparison in patients less than and more than 40 years of age. Professional Medical Journal 2012; 19:11.
  11. Arneson TJ, Melton LJ 3rd, Lewallen DG, O'Fallon WM. Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 1965-1984. Clin Orthop Relat Res 1988; :188.
  12. ObaidurRahman, Adnan RM, Khan R, et al. Pattern of femoral fractures. Journal of Rawalpindi Medical College 2013; 17:42.
  13. Salminen S. Femoral shaft fractures in adults: epidemiology, fracture patterns, nonunions, and fatigue fractures. Department of Orthopedics and Traumatology, Department of Pediatric Surgery. Thesis. University of Helsinki, Helsinki 2005.
  14. Al-Motabagani, MA. The arterial architecture of the human femoral diaphysis. J Anat Soc India 2002; 51:27.
  15. Lieurance R, Benjamin JB, Rappaport WD. Blood loss and transfusion in patients with isolated femur fractures. J Orthop Trauma 1992; 6:175.
  16. Bengnér U, Ekbom T, Johnell O, Nilsson BE. Incidence of femoral and tibial shaft fractures. Epidemiology 1950-1983 in Malmö, Sweden. Acta Orthop Scand 1990; 61:251.
  17. Mosenthal AC, Livingston DH, Elcavage J, et al. Falls: epidemiology and strategies for prevention. J Trauma 1995; 38:753.
  18. Moriarity A, Ellanti P, Hogan N. A low-energy femoral shaft fracture from performing a yoga posture. BMJ Case Rep 2015; 2015.
  19. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012.
  20. Chaturvedi S, Sahu SC. Ipsilateral concomitant fractures of the femoral neck and shaft. Injury 1993; 24:243.
  21. Alho A. Concurrent ipsilateral fractures of the hip and shaft of the femur. A systematic review of 722 cases. Ann Chir Gynaecol 1997; 86:326.
  22. Müller EJ, Siebenrock K, Ekkernkamp A, et al. Ipsilateral fractures of the pelvis and the femur--floating hip? A retrospective analysis of 42 cases. Arch Orthop Trauma Surg 1999; 119:179.
  23. Nork SE. Fractures of the shaft of the femur. In: Rockwood and Green's Fractures in Adults, 6th ed, Bucholz RW, Heckman JD, Court-Brown CH, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2005. p.1847.
  24. De Campos J, Vangsness CT Jr, Merritt PO, Sher J. Ipsilateral knee injury with femoral fracture. Examination under anesthesia and arthroscopic evaluation. Clin Orthop Relat Res 1994; :178.
  25. Takami H, Takahashi S, Ando M. Sciatic nerve injury associated with fracture of the femoral shaft. Arch Orthop Trauma Surg 1999; 119:103.
  26. Yildirim S, Gideroğlu K, Aköz T. Peroneal nerve injury caused by fracture of the distal femoral shaft. Plast Reconstr Surg 2003; 111:511.
  27. Wolinsky PR, Johnson KD. Ipsilateral femoral neck and shaft fractures. Clin Orthop Relat Res 1995; :81.
  28. Barlow B, Niemirska M, Gandhi R, Shelton M. Response to injury in children with closed femur fractures. J Trauma 1987; 27:429.
  29. Ciarallo L, Fleisher G. Femoral fractures: are children at risk for significant blood loss? Pediatr Emerg Care 1996; 12:343.
  30. Chu UB, Clevenger FW, Imami ER, et al. The impact of selective laboratory evaluation on utilization of laboratory resources and patient care in a level-I trauma center. Am J Surg 1996; 172:558.
  31. Cross KP, Warkentine FH. Ultrasound-guided femoral nerve blocks in the initial emergency department management of pediatric femur fractures. Clin Pediatr Emerg Med 2016; 17:67.
  32. Baker MD, Gullett JP. Ultrasound-Guided Femoral Nerve Blocks. Pediatr Emerg Care 2015; 31:864.
  33. Crozier J. Hare traction splint a case series. Sydney South West Area Health Service Newsletter 1997; 2:2. Available online at: www.haretractionsplint.com/case_study.htm (Accessed on November 06, 2008).
  34. Smith RM, Giannoudis PV. Femoral shaft fractures. In: Skeletal Trauma: Basic Science, Management, and Reconstruction, 4th ed, Browner BD, Jupiter JB, Levine AM, et al (Eds), WB Saunders, Philadelphia 2008. p.2035.
  35. Lee C, Porter KM. Prehospital management of lower limb fractures. Emerg Med J 2005; 22:660.
  36. Brumback RJ, Ellison TS, Poka A, et al. Intramedullary nailing of femoral shaft fractures. Part III: Long-term effects of static interlocking fixation. J Bone Joint Surg Am 1992; 74:106.
  37. Brumback RJ, Ellison PS Jr, Poka A, et al. Intramedullary nailing of open fractures of the femoral shaft. J Bone Joint Surg Am 1989; 71:1324.
  38. Brumback RJ, Uwagie-Ero S, Lakatos RP, et al. Intramedullary nailing of femoral shaft fractures. Part II: Fracture-healing with static interlocking fixation. J Bone Joint Surg Am 1988; 70:1453.
  39. el Moumni M, Leenhouts PA, ten Duis HJ, Wendt KW. The incidence of non-union following unreamed intramedullary nailing of femoral shaft fractures. Injury 2009; 40:205.
  40. Kovar FM, Jaindl M, Schuster R, et al. Incidence and analysis of open fractures of the midshaft and distal femur. Wien Klin Wochenschr 2013; 125:396.
  41. Gillespie WJ, Walenkamp GH. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev 2010; :CD000244.
  42. Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures: a prospective randomized study. 1989. Clin Orthop Relat Res 2004; :11.
  43. Brundage SI, McGhan R, Jurkovich GJ, et al. Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries. J Trauma 2002; 52:299.
  44. Harvin JA, Harvin WH, Camp E, et al. Early femur fracture fixation is associated with a reduction in pulmonary complications and hospital charges: a decade of experience with 1,376 diaphyseal femur fractures. J Trauma Acute Care Surg 2012; 73:1442.
  45. Pape HC, Rixen D, Morley J, et al. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg 2007; 246:491.
  46. Morshed S, Miclau T 3rd, Bembom O, et al. Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem trauma. J Bone Joint Surg Am 2009; 91:3.
  47. Jansen JO, Thomas R, Loudon MA, Brooks A. Damage control resuscitation for patients with major trauma. BMJ 2009; 338:b1778.
  48. Jaunoo SS, Harji DP. Damage control surgery. Int J Surg 2009; 7:110.
  49. Taeger G, Ruchholtz S, Waydhas C, et al. Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe. J Trauma 2005; 59:409.
  50. Giannoudis PV, Smith RM, Bellamy MC, et al. Stimulation of the inflammatory system by reamed and unreamed nailing of femoral fractures. An analysis of the second hit. J Bone Joint Surg Br 1999; 81:356.
  51. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma 2000; 48:613.
  52. Angelini AJ, Livani B, Flierl MA, et al. Less invasive percutaneous wave plating of simple femur shaft fractures: A prospective series. Injury 2010; 41:624.
  53. Grosse A, Christie J, Taglang G, et al. Open adult femoral shaft fracture treated by early intramedullary nailing. J Bone Joint Surg Br 1993; 75:562.
  54. Akoh CC, Schick C, Otero J, Karam M. Fat embolism syndrome after femur fracture fixation: a case report. Iowa Orthop J 2014; 34:55.
  55. Green A, Trafton PG. Early complications in the management of open femur fractures: a retrospective study. J Orthop Trauma 1991; 5:51.
  56. Taitsman LA, Lynch JR, Agel J, et al. Risk factors for femoral nonunion after femoral shaft fracture. J Trauma 2009; 67:1389.
  57. Brumback RJ, Ellison TS, Molligan H, et al. Pudendal nerve palsy complicating intramedullary nailing of the femur. J Bone Joint Surg Am 1992; 74:1450.
  58. Kao JT, Burton D, Comstock C, et al. Pudendal nerve palsy after femoral intramedullary nailing. J Orthop Trauma 1993; 7:58.
  59. Kluger Y, Gonze MD, Paul DB, et al. Blunt vascular injury associated with closed mid-shaft femur fracture: a plea for concern. J Trauma 1994; 36:222.
  60. Shayne PH, Sloan EP, Rydman R, Barrett JA. A case-control study of risk factors that predict femoral arterial injury in penetrating thigh trauma. Ann Emerg Med 1994; 24:678.
  61. Dennis JW, Frykberg ER, Veldenz HC, et al. Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow-up. J Trauma 1998; 44:243.
  62. Holbein O, Strecker W, Rath SA, Kinzl L. [Compartment syndrome of the thigh with sciatic nerve paralysis]. Unfallchirurg 2000; 103:275.
  63. Schwartz JT Jr, Brumback RJ, Lakatos R, et al. Acute compartment syndrome of the thigh. A spectrum of injury. J Bone Joint Surg Am 1989; 71:392.
  64. Walmsley D, Axelrod T, Rodriguez-Elizalde S. Compartment Syndrome following Open Femoral Fracture with an Isolated Femoral Vein Injury Treated with Acute Repair. Case Rep Orthop 2014; 2014:502657.
  65. Kontakis GM, Tossounidis T, Weiss K, et al. Fat embolism: special situations bilateral femoral fractures and pathologic femoral fractures. Injury 2006; 37 Suppl 4:S19.
  66. Bosse MJ, MacKenzie EJ, Riemer BL, et al. Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate. A comparative study. J Bone Joint Surg Am 1997; 79:799.
  67. Lefaivre KA, Starr AJ, Stahel PF, et al. Prediction of pulmonary morbidity and mortality in patients with femur fracture. J Trauma 2010; 69:1527.
  68. Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14:187.
  69. Lefaivre K, Smith W, Stahel P, et al. Prediction of pulmonary morbidity and mortality in femur fracture patients. J Bone Joint Surg Br 2011; 93-B: Supp III 256.
  70. Cramer KE, Tornetta P 3rd, Spero CR, et al. Ender rod fixation of femoral shaft fractures in children. Clin Orthop Relat Res 2000; :119.
  71. Paterno MV, Archdeacon MT. Is there a standard rehabilitation protocol after femoral intramedullary nailing? J Orthop Trauma 2009; 23:S39.
  72. Röder F, Schwab M, Aleker T, et al. Proximal femur fracture in older patients--rehabilitation and clinical outcome. Age Ageing 2003; 32:74.
  73. Paterno MV, Archdeacon MT, Ford KR, et al. Early rehabilitation following surgical fixation of a femoral shaft fracture. Phys Ther 2006; 86:558.
  74. Sikka R, Fetzer G, Hunkele T, et al. Femur fractures in professional athletes: a case series. J Athl Train 2015; 50:442.