Surgical Anatomy. — The shaft of the femur consists of a tube of heavy compact tissue which is capable of withstanding greater strain than the shafts of other long bones. The diameter of the shaft grows larger and the compact tissue thinner as the extremities are approached. Ossification spreads from a single center which makes its appearance about the seventh week of foetal life. The shaft is slightly curved with the concavity backward. The linea aspera serves to strengthen the concave posterior aspect and affords attachment to the adductor muscles. In the upper third of the shaft this line divides into three ridges, while in the lower third of the bone it bifurcates to form the supracondylar ridges. The femoral vessels cross the internal supracondj^lar ridge under a fibrous arch in the adductor magnus and become the popliteal ves- sels. From the point where the artery pierces the adductor mag- nus to the knee joint, it lies in close relation to the posterior surface of the bone, and in fractures of this region the vessel may be injured by a displaced fragment. The nerve and vein lie more superficially in the popliteal space and are less subject to injury from the bone, than is the artery.
<Callout type="important" title="Important">Injuries to the femoral vessels can lead to severe blood loss; immediate immobilization is crucial.</Callout>
Etiology. — Fractures of the femoral shaft constitute less than three percent of all fractures. Approximately one-fifth of the fractures of the femoral shaft occur in the upper third (not including the femoral neck), three-fifths occur in the middle third, while one-fifth is seen in the lower end. Fracture of the femoral shaft is the result of violence, direct and indirect and of muscular action, although the latter cause is probably never responsible for fracture in a healthy bone.
<Callout type="risk" title="Risk">Muscular action can exacerbate displacement; careful handling is essential.</Callout>
Symptoms. — Immediate and total loss of function is seen following the accident, except in the green-stick type occurring in children. Pain is usually pronounced and the deformity is characteristic. The limb below the break is rolled, either inward or outward (usually the latter), and the helplessness of the condition is typical.
<Callout type="tip" title="Tip">Recognize the characteristic deformity; it can be easily identified without X-rays.</Callout>
Diagnosis. — There is seldom any difficulty in recognizing fracture of the femoral shaft. The deformity, shortening, loss of function, abnormal mobility and crepitus render the diagnosis easy.
<Callout type="warning" title="Warning">Manipulation can increase pain; avoid unnecessary movement.</Callout>
Treatment. — The treatment of fracture of the femoral shaft varies with the age and condition of the patient and the nature and position of the fracture. The emergency treatment and the care of the case during the first week are practically the same in all instances and will be considered first.
<Callout type="gear" title="Gear">Broomsticks and blankets can serve as temporary splints for immediate transport.</Callout>
During the first week or ten days the usual case of simple fracture of the thigh is treated by means of Buck's extension, coaptation splints and the long side or T-splint. Buck's extension and the long side or T-splint have already been described under the treatment of fractures of the femoral neck.
<Callout type="important" title="Important">Accurate reduction is crucial; X-rays can guide proper alignment.</Callout>
Non-operative treatment is reserved for those rare cases in which good reduction can be accomplished and maintained by manipulation and traction and immobilization, and in cases in which operation is contraindicated on constitutional grounds.
<Callout type="tip" title="Tip">Use Buck's extension apparatus to control spasm in the thigh muscles.</Callout>
After the traumatic reaction has sub- sided the cast may be employed instead of the above apparatus. The cast is usually applied with the lower extremity in the straight, extended position.
<Callout type="risk" title="Risk">Improper application can interfere with circulation or cause muscle damage.</Callout>
These attitudes of fixation may favor
Key Takeaways
- Femoral shaft fractures are rare but require immediate and careful handling.
- Proper immobilization is crucial to prevent further injury.
- X-rays can guide accurate reduction in complex cases.
Practical Tips
- Use simple materials like broomsticks and blankets for temporary splinting during transport.
- Maintain the patient's comfort by minimizing unnecessary movement, especially of the injured limb.
- Apply Buck's extension apparatus to control muscle spasm and maintain alignment.
Warnings & Risks
- Manipulation can increase pain and should be minimized.
- Improper application of coaptation splints can cause harm.
- Injuries to the femoral vessels can lead to severe blood loss; immediate immobilization is crucial.
Modern Application
While the techniques described in this chapter are rooted in historical practices, they still provide valuable insights into the principles of fracture management. Modern medical advancements have improved imaging and surgical techniques, but the importance of proper initial stabilization remains critical for survival in pre-hospital settings.
Frequently Asked Questions
Q: How can one recognize a femoral shaft fracture without X-rays?
The characteristic deformity, shortening, loss of function, abnormal mobility, and crepitus are key signs that can be identified even without X-rays. These symptoms typically make the diagnosis easy.
Q: What is the importance of using Buck's extension apparatus in treating femoral shaft fractures?
Buck's extension apparatus helps control muscle spasm and maintain alignment, which are crucial for proper reduction and immobilization during the initial treatment phase.
Q: Why is it important to avoid unnecessary movement of the injured limb during transport?
Unnecessary movement can increase pain, exacerbate displacement, and potentially cause further injury. It's essential to keep the limb as still as possible until proper immobilization can be achieved.