FEMORAL SHAFT

Simple fracture, spiral

Type A fractures often result from medium to moderate impacts to the femur. Spiral fractures of the
femoral shaft occur due to axial loading with torsion and may be caused by falls from a height.

1. 32-A1.1 Subtrochanteric zone

2. 32-A1.2 Middle zone

3. 32-A1.3 Distal zone

1. 32-A1.1 Subtrochanteric zone

32-A1.1

The subgroup A1.1 classifies simple spiral fractures in the subtrochanteric zone of the femoral shaft.
32-A1.1

X-ray taken from Orozco R et al, (1998) Atlas of Internal Fixation. Used with kind permission.

2. 32-A1.2 Middle zone

32-A1.2

The A1.2 subgroup denotes simple spiral fractures in the middle zone of the femoral shaft.

32-A1.2

3. 32-A1.3 Distal zone

44-A1.3

Simple spiral fractures in the distal zone of the femoral shaft are classified as A1.3.

General considerations
In an A 1 fracture there are only two fragments, and the fracture plane is a spiral, caused by a
twisting force on the shaft of the femur.

The majority of femoral shaft fractures in adults are treated with intramedullary nailing where this is
practical.

Temporary Thomas splint

Indication summary

Medically unfit for surgery. Usually temporary

Femoral shaft fractures are usually treated surgically, and nonoperative treatment is undertaken only
temporarily. Nonoperative treatment is reserved for exceptional cases, e.g. if the general medical
condition does not allow safe anesthesia.

Indications

Medically unfit for surgery

Polytrauma, in extremis

Advantages

Stabilization when immediate surgery is not possible or practical

Disadvantages

Overlap of the fracture can occur despite traction

Continuing motion at the fracture site

Continuing soft-tissue compromise and bleeding

External fixator (midshaft/distal shaft)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation
Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

External fixator (subtrochanteric)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation
Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

Antegrade nailing (subtrochanteric)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures
 Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Periprosthetic fractures

Ongoing infection (osteomyelitis)

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Risk of malrotation

Difficult control of proximal fracture fragment

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Antegrade nailing (midshaft/distal shaft)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Periprosthetic fractures

Continuing infection

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

 Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Retrograde nailing (midshaft/distal shaft)

Indication summary

Closed fractures, Gustilo types I & II open fractures, stable polytrauma. Floating knee
injury, bilateral lower extremity fractures. Pregnancy. Obesity. Ipsilateral femoral neck and
shaft fractures. Concomitant ipsilateral acetabular / pelvic ring fractures. Fracture below
hip prosthesis.

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

General Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

"Floating knee injury

Bilateral lower extremity fractures

Relative Indications (retrograde vs. antegrade nailing)

 Pregnancy

Obesity

Ipsilateral femoral neck and shaft fractures

Concomitant ipsilateral acetabular / pelvic ring fractures

Fracture below hip prosthesis

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Continuing infection

Occluded intramedullary canal

Gustilo type III C open fractures

Concomitant multifragmentary intraarticular fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Difficult control of proximal fracture fragment in more proximal fractures

Frequent use of image intensifier risk of increased radiation exposure

Risk of iatrogenic intraarticular damage to the knee joint

Risk of infection
 Risk of damage to the anterior cruciate ligament

Risk of malrotation angular deformity

Risk of damage to the patellar tendon

Risk of chronic knee pain

Compression plating - DCS (subtrochanteric)

Indication summary

Failed indirect reduction, polytrauma with chest injury

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)
 Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Compression plating - locking plate (subtrochanteric)

Indication summary

Failed indirect reduction, polytrauma with chest injury, early pregnancy, image
intensification not available

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis
 Compromised local soft tissues

Advantages

Less demanding procedure

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Compression plating - DCS (distal shaft)

Indication summary

Failed indirect reduction, polytrauma with chest injury

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

 No image intensifier available

Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Lag screw with protection plate (midshaft)

Indication summary

Failed indirect reduction, polytrauma with chest injury, early pregnancy, image
intensification not available
Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Simple fracture, oblique

Type A fractures often result from medium to moderate impacts to the femur.
1. 32-A2.1 Subtrochanteric zone

2. 32-A2.2 Middle zone

3. 32-A2.3 Distal zone

1. 32-A2.1 Subtrochanteric zone

32-A2.1

The subgroup A2.1 classifies simple oblique fractures in the subtrochanteric zone of the femoral
shaft.

32-A2.1

2. 32-A2.2 Middle zone

32-A2.2

The A2.2 subgroup denotes simple oblique fractures in the middle zone of the femoral shaft.

32-A2.2

3. 32-A2.3 Distal zone

44-A2.3

Simple oblique fractures in the distal zone of the femoral shaft are classified as A2.3.

General considerations

In an A 2 fracture there are only two fragments, and the fracture plane is short and oblique.

The majority of femoral shaft fractures in adults are treated with intramedullary nailing where this is
practical.

Temporary Thomas splint

Indication summary

Medically unfit for surgery. Usually temporary

Femoral shaft fractures are usually treated surgically, and nonoperative treatment is undertaken only
temporarily. Nonoperative treatment is reserved for exceptional cases, e.g. if the general medical
condition does not allow safe anesthesia.

Indications

Medically unfit for surgery

Polytrauma, in extremis

Advantage

Stabilization when immediate surgery is not possible or practical

Disadvantages
 Overlap of the fracture can occur despite traction

Continuing motion at the fracture site

Continuing soft-tissue compromise and bleeding

External fixator (midshaft/distal shaft)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

External fixator (subtrochanteric)

Indication summary
 External fixator (subtrochanteric)

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

Antegrade nailing (subtrochanteric)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Periprosthetic fractures

Ongoing infection (osteomyelitis)

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Risk of malrotation

Difficult control of proximal fracture fragment

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Antegrade nailing (midshaft/distal shaft)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

 Periprosthetic fractures

Continuing infection

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Retrograde nailing (midshaft/distal shaft)

Indication summary

Closed fractures, Gustilo types I & II open fractures, stable polytrauma. Floating knee
injury, bilateral lower extremity fractures. Pregnancy. Obesity. Ipsilateral femoral neck and
shaft fractures. Concomitant ipsilateral acetabular / pelvic ring fractures. Fracture below
hip prosthesis.

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

General Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable conditio

"Floating knee injury

Bilateral lower extremity fractures

Relative Indications (retrograde vs. antegrade nailing)

Pregnancy

Obesity

Ipsilateral femoral neck and shaft fractures

Concomitant ipsilateral acetabular / pelvic ring fractures

Fracture below hip prosthesis

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Continuing infection

Occluded intramedullary canal

Gustilo type III C open fractures

Concomitant multifragmentary intraarticular fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure
 Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Difficult control of proximal fracture fragment in more proximal fractures

Frequent use of image intensifier risk of increased radiation exposure

Risk of iatrogenic intraarticular damage to the knee joint

Risk of infection

Risk of damage to the anterior cruciate ligament

Risk of malrotation angular deformity

Risk of damage to the patellar tendon

Risk of chronic knee pain

Compression plating - DCS (subtrochanteric)

Indication summary

Failed indirect reduction, polytrauma with chest injury

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

 Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Compression plating - locking plate (subtrochanteric)

Indication summary

Failed indirect reduction, polytrauma with chest injury, early pregnancy, image
intensification not available
Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Lag screw with protection plate (midshaft)

Indication summary

Failed indirect reduction, polytrauma with chest injury, early pregnancy, image
 Lag screw with protection plate (midshaft)

intensification not available

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

 Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Compression plating - DCS (distal shaft)

Indication summary

Failed indirect reduction, polytrauma with chest injury

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure

Less exposure to ionizing radiation

Direct reduction
 Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Simple fracture, transverse

Type A fractures often result from medium to moderate impacts to the femur. Transverse femoral
shaft fractures occur due to direct bending force and can be caused by a local impact.

1. 32-A3.1 Subtrochanteric zone

2. 32-A3.2 Middle zone

3. 32-A3.3 Distal zone

1. 32-A3.1 Subtrochanteric zone

32-A3.1

The subgroup A3.1 classifies simple transverse fractures in the subtrochanteric zone of the femoral
shaft.
32-A3.1

2. 32-A3.2 Middle zone

32-A3.2

The A3.2 subgroup denotes simple transverse fractures in the middle zone of the femoral shaft.
32-A3.2

3. 32-A3.3 Distal zone

44-A3.3

Simple transverse fractures in the distal zone of the femoral shaft are classified as A3.3.

General considerations
In an A 3 fracture there are only two fragments, and the fracture plane is transverse.

The majority of femoral shaft fractures in adults are treated with intramedullary nailing where this is
practical.

Temporary Thomas splint

Indication summary

Medically unfit for surgery. Usually temporary

Femoral shaft fractures are usually treated surgically, and nonoperative treatment is undertaken only
temporarily. Nonoperative treatment is reserved for exceptional cases, e.g. if the general medical
condition does not allow safe anesthesia.

Indications

Medically unfit for surgery

Polytrauma, in extremis

Advantage

Stabilization when immediate surgery is not possible or practical

Disadvantages

Overlap of the fracture can occur despite traction

Continuing motion at the fracture site

Continuing soft-tissue compromise and bleeding

 External fixator (midshaft/distal shaft)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

External fixator (subtrochanteric)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation
Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

Antegrade nailing (subtrochanteric)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Periprosthetic fractures

Ongoing infection (osteomyelitis)

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Risk of malrotation

Difficult control of proximal fracture fragment

 Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Antegrade nailing (midshaft/distal shaft)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Periprosthetic fractures

Continuing infection

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages
 Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Retrograde nailing (midshaft/distal shaft)

Indication summary

Closed fractures, Gustilo types I & II open fractures, stable polytrauma. Floating knee
injury, bilateral lower extremity fractures. Pregnancy. Obesity. Ipsilateral femoral neck and
shaft fractures. Concomitant ipsilateral acetabular / pelvic ring fractures. Fracture below
hip prosthesis.

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

General Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures
 Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

"Floating knee injury

Bilateral lower extremity fractures

Relative Indications (retrograde vs. antegrade nailing)

Pregnancy

Obesity

Ipsilateral femoral neck and shaft fractures

Concomitant ipsilateral acetabular / pelvic ring fractures

Fracture below hip prosthesis

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Continuing infection

Occluded intramedullary canal

Gustilo type III C open fractures

Concomitant multifragmentary intraarticular fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

 Risk of fat embolization

Closed reduction may be more challenging than open reduction

Difficult control of proximal fracture fragment in more proximal fractures

Frequent use of image intensifier risk of increased radiation exposure

Risk of iatrogenic intraarticular damage to the knee joint

Risk of infection

Risk of damage to the anterior cruciate ligament

Risk of malrotation angular deformity

Risk of damage to the patellar tendon

Risk of chronic knee pain

Compression plating - DCS (subtrochanteric)

Indication summary

Failed indirect reduction, polytrauma with chest injury

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis
 Compromised local soft tissues

Advantages

Less demanding procedure

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Compression plating - locking plate (subtrochanteric)

Indication summary

Failed indirect reduction, polytrauma with chest injury, early pregnancy, image
intensification not available

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

 No image intensifier available

Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Compression plating - blade plate (subtrochanteric)

Indication summary

Failed indirect reduction, polytrauma with chest injury, early pregnancy, (image
intensification not available)
Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteporotic bone to use locking plates and screws.

The 95 angled blade plate is used in the proximal femur for 31-A3 fractures and, more often, for
corrective osteotomies.

It can also be used as a bridging implant for more comminuted subtrochanteric fractures.
Subtrochanteric nonunions are strong indications for the 95 angled blade plate.

If there is any possibility of a fracture line involving the region of the greater trochanter, the dynamic
condylar screw (DCS) is the preferred implant.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

 There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Compression plating (midshaft)

Indication summary

Failed indirect reduction, polytrauma with chest injury, early pregnancy, image
intensification not available

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing
 Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Compression plating - DCS (distal shaft)

Indication summary

Failed indirect reduction, polytrauma with chest injury

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation) due to the risks from radiation exposure

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages
 Less demanding procedure

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Wedge

Wedge fracture, spiral wedge

In B type fractures there are three fragments, a proximal, a distal and a wedge fragment. After
reduction there is some contact between the proximal and distal fragments.

Type B fractures often result from medium to moderate impacts to the femur. Spiral fractures of the
femoral shaft occur due to axial loading with torsion and may be caused by falls from a height.

1. 32-B1.1 Subtrochanteric zone

2. 32-B1.2 Middle zone

3. 32-B1.3 Distal zone

1. 32-B1.1 Subtrochanteric zone

32-B1.1

The subgroup B1.1 classifies spiral wedge fractures in the subtrochanteric zone of the femoral shaft.

32-B1.1

2. 32-B1.2 Middle zone

32-B1.2

The B1.2 subgroup denotes spiral wedge fractures in the middle zone of the femoral shaft.

32-B1.2

3. 32-B1.3 Distal zone

44-B1.3

Spiral wedge fractures in the distal zone of the femoral shaft are classified as B1.3.
32-B1.3

General considerations

In B type fractures there are three fragments, a proximal, a distal and a wedge fragment. After
reduction there is some contact between the proximal and distal fragments.

B 1 fractures have a spiral wedge resulting from a twisting injury.

Temporary Thomas splint

Indication summary

Medically unfit for surgery. Usually temporary

Femoral shaft fractures are usually treated surgically, and nonoperative treatment is undertaken only
temporarily. Nonoperative treatment is reserved for exceptional cases, e.g. if the general medical
condition does not allow safe anesthesia.

Indications

Medically unfit for surgery

Polytrauma, in extremis

Advantage

Stabilization when immediate surgery is not possible or practical

Disadvantages

Overlap of the fracture can occur despite traction

Continuing motion at the fracture site

Continuing soft-tissue compromise and bleeding

External fixator (midshaft/distal shaft)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

External fixator (subtrochanteric)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

 Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

Antegrade nailing (subtrochanteric)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Periprosthetic fractures

Ongoing infection (osteomyelitis)

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages
 Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Risk of malrotation

Difficult control of proximal fracture fragment

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Antegrade nailing (midshaft/distal shaft)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures
 Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Periprosthetic fractures

Continuing infection

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Retrograde nailing (midshaft/distal shaft)

Indication summary

Closed fractures, Gustilo types I & II open fractures, stable polytrauma. Floating knee
injury, bilateral lower extremity fractures. Pregnancy. Obesity. Ipsilateral femoral neck and
shaft fractures. Concomitant ipsilateral acetabular / pelvic ring fractures. Fracture below
 Retrograde nailing (midshaft/distal shaft)

hip prosthesis.

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

General Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

"Floating knee injury

Bilateral lower extremity fractures

Relative Indications (retrograde vs. antegrade nailing)

Pregnancy

Obesity

Ipsilateral femoral neck and shaft fractures

Concomitant ipsilateral acetabular / pelvic ring fractures

Fracture below hip prosthesis

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Continuing infection
 Occluded intramedullary canal

Gustilo type III C open fractures

Concomitant multifragmentary intraarticular fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Difficult control of proximal fracture fragment in more proximal fractures

Frequent use of image intensifier risk of increased radiation exposure

Risk of iatrogenic intraarticular damage to the knee joint

Risk of infection

Risk of damage to the anterior cruciate ligament

Risk of malrotation angular deformity

Risk of damage to the patellar tendon

Risk of chronic knee pain

Bridge plating (MIO) - locking plate (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

 There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - DCS (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation
 Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - (midshaft)

Indication summary

Polytrauma with associated chest injury

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)
 Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - DCS (distal shaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

 Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - LISS (distal shaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications
 All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (ORIF) - DCS (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, failed indirect reduction
Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating (ORIF) - locking plate (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
 Bridge plating (ORIF) - locking plate (subtrochanteric)

available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

 Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Lag screw with protection plate (midshaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding than closed reduction

Less exposure to ionizing radiation

Direct reduction
 Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating (midshaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

 Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating - DCS (distal shaft)

Indication summary

Polytrauma with associated chest injury, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

 No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Wedge fracture, bending wedge

In B type fractures there are three fragments, a proximal, a distal and a wedge fragment. After
reduction there is some contact between the proximal and distal fragments.

Type B fractures often result from medium to moderate impacts to the femur.

1. 32-B2.1 Subtrochanteric zone

2. 32-B2.2 Middle zone

3. 32-B2.3 Distal zone

1. 32-B2.1 Subtrochanteric zone

32-B2.1

The subgroup B2.1 classifies bending wedge fractures in the subtrochanteric zone of the femoral
shaft.

32-B2.1

2. 32-B2.2 Middle zone

32-B2.2

The B2.2 subgroup denotes bending wedge fractures in the middle zone of the femoral shaft.

32-B2.2

3. 32-B2.3 Distal zone

44-B2.3

Bending wedge fractures in the distal zone of the femoral shaft are classified as B2.3.

32-B2.3

General considerations

In B type fractures there are three fragments, a proximal, a distal and a wedge fragment. After
reduction there is some contact between the proximal and distal fragments.

In B 2 fractures the fracture is caused by a bending rather than a twisting injury.

Temporary Thomas splint

Indication summary

Medically unfit for surgery. Usually temporary

 Temporary Thomas splint

Usually, femoral shaft fractures are treated surgically. Nonoperative treatment should be undertaken
only temporarily. Nonoperative treatment is reserved for exceptional cases, e.g. if the general
medical condition does not allow safe anesthesia.

Indications

Medically unfit for surgery

Polytrauma, in extremis

Advantage

Stabilization when immediate surgery is not possible or practical

Disadvantages

Overlap of the fracture can occur despite traction

Continuing motion at the fracture site

Continuing soft-tissue compromise and bleeding

External fixator (midshaft/distal shaft)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

 Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

External fixator (subtrochanteric)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage
 Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

Antegrade nailing (subtrochanteric)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Periprosthetic fractures

Ongoing infection (osteomyelitis)

 Occluded intramedullary canal

Gustilo type III C open fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Risk of malrotation

Difficult control of proximal fracture fragment

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Antegrade nailing (midshaft/distal shaft)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.
Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Periprosthetic fractures

Continuing infection

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

 Retrograde nailing (midshaft/distal shaft)

Indication summary

Closed fractures, Gustilo types I & II open fractures, stable polytrauma. Floating knee
injury, bilateral lower extremity fractures. Pregnancy. Obesity. Ipsilateral femoral neck and
shaft fractures. Concomitant ipsilateral acetabular / pelvic ring fractures. Fracture below
hip prosthesis.

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

General Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

"Floating knee injury

Bilateral lower extremity fractures

Relative Indications (retrograde vs. antegrade nailing)

Pregnancy

Obesity

Ipsilateral femoral neck and shaft fractures

Concomitant ipsilateral acetabular / pelvic ring fractures

Fracture below hip prosthesis

Contraindications

Polytrauma patients in unstable condition

 Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Continuing infection

Occluded intramedullary canal

Gustilo type III C open fractures

Concomitant multifragmentary intraarticular fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Difficult control of proximal fracture fragment in more proximal fractures

Frequent use of image intensifier risk of increased radiation exposure

Risk of iatrogenic intraarticular damage to the knee joint

Risk of infection

Risk of damage to the anterior cruciate ligament

Risk of malrotation angular deformity

Risk of damage to the patellar tendon

Risk of chronic knee pain

Bridge plating (MIO) - DCS (subtrochanteric)

Indication summary
 Bridge plating (MIO) - DCS (subtrochanteric)

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction
 Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - locking plate (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing
 Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - (midshaft)

Indication summary

Polytrauma with associated chest injury

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - DCS (distal shaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery
 Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - LISS (distal shaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.
It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating - DCS (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, failed indirect reduction
Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

 There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating - locking plate (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing
 Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Lag screw with protection plate (midshaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages
 Less demanding than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating (midshaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

 Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating - DCS (distal shaft)

Indication summary

Polytrauma with associated chest injury, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.
Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Wedge fracture, fragmented wedge

In B type fractures there are three fragments, a proximal, a distal and a wedge fragment. After
reduction there is some contact between the proximal and distal fragments.

Type B fractures often result from medium to moderate impacts to the femur.
1. 32-B3.1 Subtrochanteric zone

2. 32-B3.2 Middle zone

3. 32-B3.3 Distal zone

1. 32-B3.1 Subtrochanteric zone

32-B3.1

The subgroup B3.1 classifies fragmented wedge fractures in the subtrochanteric zone of the femoral
shaft.

32-B3.1

X-ray taken from Orozco R et al, (1998) Atlas of Internal Fixation. Used with kind permission.

2. 32-B3.2 Middle zone

32-B3.2

The B3.2 subgroup denotes fragmented wedge fractures in the middle zone of the femoral shaft.

32-B3.2

3. 32-B3.3 Distal zone

44-B3.3

Fragmented wedge fractures in the distal zone of the femoral shaft are classified as B3.3.

32-B3.3

General considerations

In B 3 type fractures there are two main fragments, a proximal and a distal. After reduction there is
some contact between the proximal and distal fragments. There is also a fragmented wedge.

Temporary Thomas splint

Indication summary

Medically unfit for surgery. Usually temporary

Usually, femoral shaft fractures are treated surgically. Nonoperative treatment should be undertaken
only temporarily. Nonoperative treatment is reserved for exceptional cases, e.g. if the general
medical condition does not allow safe anesthesia.

Indications

Medically unfit for surgery

Polytrauma, in extremis

Advantage

Stabilization when immediate surgery is not possible or practical

Disadvantages

Overlap of the fracture can occur despite traction

Continuing motion at the fracture site

Continuing soft-tissue compromise and bleeding

External fixator (midshaft/distal shaft)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

External fixator (subtrochanteric)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

 Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

Antegrade nailing (subtrochanteric)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Periprosthetic fractures

Ongoing infection (osteomyelitis)

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages
 Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Risk of malrotation

Difficult control of proximal fracture fragment

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Antegrade nailing (midshaft/distal shaft)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures
 Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Periprosthetic fractures

Continuing infection

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Retrograde nailing (midshaft/distal shaft)

Indication summary

Closed fractures, Gustilo types I & II open fractures, stable polytrauma. Floating knee
injury, bilateral lower extremity fractures. Pregnancy. Obesity. Ipsilateral femoral neck and
shaft fractures. Concomitant ipsilateral acetabular / pelvic ring fractures. Fracture below
 Retrograde nailing (midshaft/distal shaft)

hip prosthesis.

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

General Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

"Floating knee injury

Bilateral lower extremity fractures

Relative Indications (retrograde vs. antegrade nailing)

Pregnancy

Obesity

Ipsilateral femoral neck and shaft fractures

Concomitant ipsilateral acetabular / pelvic ring fractures

Fracture below hip prosthesis

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Continuing infection
 Occluded intramedullary canal

Gustilo type III C open fractures

Concomitant multifragmentary intraarticular fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Difficult control of proximal fracture fragment in more proximal fractures

Frequent use of image intensifier risk of increased radiation exposure

Risk of iatrogenic intraarticular damage to the knee joint

Risk of infection

Risk of damage to the anterior cruciate ligament

Risk of malrotation angular deformity

Risk of damage to the patellar tendon

Risk of chronic knee pain

Bridge plating (MIO) - DCS (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

 There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - locking plate (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation
 Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - (midshaft)

Indication summary

Polytrauma with associated chest injury

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)
 Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - DCS (distal shaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

 Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - LISS (distal shaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications
 All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating - DCS (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, failed indirect reduction
Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating - locking plate (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
 Bridge plating - locking plate (subtrochanteric)

available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

 Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating (midshaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction
 Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating - DCS (distal shaft)

Indication summary

Polytrauma with associated chest injury, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis
 Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Complex

Complex fracture, spiral

C type fractures result from moderate to severe impacts to the femur. Spiral fractures of the femoral
shaft occur due to axial loading with torsion and may be caused by falls from a height.

32-C1

32-C1

Spiral complex fractures of the femoral shaft are classified as C1.

32-C1

General considerations

C type fractures are multifragmentary. After reduction there is no contact between the proximal and
distal fragments.

In C 1 fractures the multiple fragments are in a spiral pattern, resulting from a high energy twisting
injury.

Temporary Thomas splint

Indication summary

Medically unfit for surgery. Usually temporary

Usually, femoral shaft fractures are treated surgically. Nonoperative treatment should be undertaken
only temporarily. Nonoperative treatment is reserved for exceptional cases, e.g. if the general
medical condition does not allow safe anesthesia.

Indications

Medically unfit for surgery

Polytrauma, in extremis

Advantage

Stabilization when immediate surgery is not possible or practical

Disadvantages

Overlap of the fracture can occur despite traction

Continuing motion at the fracture site

Continuing soft-tissue compromise and bleeding

External fixator (midshaft/distal shaft)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

External fixator (subtrochanteric)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

 Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

Antegrade nailing (subtrochanteric)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Periprosthetic fractures

Ongoing infection (osteomyelitis)

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages
 Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Risk of malrotation

Difficult control of proximal fracture fragment

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Antegrade nailing (midshaft/distal shaft)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures
 Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Periprosthetic fractures

Continuing infection

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Retrograde nailing (midshaft/distal shaft)

Indication summary

Closed fractures, Gustilo types I & II open fractures, stable polytrauma. Floating knee
injury, bilateral lower extremity fractures. Pregnancy. Obesity. Ipsilateral femoral neck and
shaft fractures. Concomitant ipsilateral acetabular / pelvic ring fractures. Fracture below
 Retrograde nailing (midshaft/distal shaft)

hip prosthesis.

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

General Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

"Floating knee injury

Bilateral lower extremity fractures

Relative Indications (retrograde vs. antegrade nailing)

Pregnancy

Obesity

Ipsilateral femoral neck and shaft fractures

Concomitant ipsilateral acetabular / pelvic ring fractures

Fracture below hip prosthesis

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Continuing infection
 Occluded intramedullary canal

Gustilo type III C open fractures

Concomitant multifragmentary intraarticular fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Difficult control of proximal fracture fragment in more proximal fractures

Frequent use of image intensifier risk of increased radiation exposure

Risk of iatrogenic intraarticular damage to the knee joint

Risk of infection

Risk of damage to the anterior cruciate ligament

Risk of malrotation angular deformity

Risk of damage to the patellar tendon

Risk of chronic knee pain

Bridge plating (MIO) - DCS (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

 There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - locking plate (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation
 Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - (midshaft)

Indication summary

Polytrauma with associated chest injury

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)
 Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - DCS (distal shaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

 Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - LISS (distal shaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications
 All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating - DCS (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, failed indirect reduction
Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating - locking plate (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
 Bridge plating - locking plate (subtrochanteric)

available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

 Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating (midshaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction
 Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating - DCS (distal shaft)

Indication summary

Polytrauma with associated chest injury, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis
 Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Complex fracture, segmented

C type fractures result from moderate to severe impacts to the femur.

32-C2

32-C2

Segmented complex fractures of the femoral shaft are classified as C2.

32-C2

General considerations

C type fractures are multifragmentary. After reduction there is no contact between the proximal and
distal fragments.

C 2 fractures are segmental.

Temporary Thomas splint

Indication summary

Medically unfit for surgery. Usually temporary

Usually, femoral shaft fractures are treated surgically. Nonoperative treatment should be undertaken
only temporarily. Nonoperative treatment is reserved for exceptional cases, e.g. if the general
medical condition does not allow safe anesthesia.

Indications

Medically unfit for surgery

Polytrauma, in extremis

Advantage

Stabilization when immediate surgery is not possible or practical

Disadvantages

Overlap of the fracture can occur despite traction

Continuing motion at the fracture site

Continuing soft-tissue compromise and bleeding

External fixator (midshaft/distal shaft)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

External fixator (subtrochanteric)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

 Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

Antegrade nailing (subtrochanteric)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Periprosthetic fractures

Ongoing infection (osteomyelitis)

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages
 Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Risk of malrotation

Difficult control of proximal fracture fragment

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Antegrade nailing (midshaft/distal shaft)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures
 Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Periprosthetic fractures

Continuing infection

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Retrograde nailing (midshaft/distal shaft)

Indication summary

Closed fractures, Gustilo types I & II open fractures, stable polytrauma. Floating knee
injury, bilateral lower extremity fractures. Pregnancy. Obesity. Ipsilateral femoral neck and
shaft fractures. Concomitant ipsilateral acetabular / pelvic ring fractures. Fracture below
 Retrograde nailing (midshaft/distal shaft)

hip prosthesis.

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

General Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

"Floating knee injury

Bilateral lower extremity fractures

Relative Indications (retrograde vs. antegrade nailing)

Pregnancy

Obesity

Ipsilateral femoral neck and shaft fractures

Concomitant ipsilateral acetabular / pelvic ring fractures

Fracture below hip prosthesis

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Continuing infection
 Occluded intramedullary canal

Gustilo type III C open fractures

Concomitant multifragmentary intraarticular fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Difficult control of proximal fracture fragment in more proximal fractures

Frequent use of image intensifier risk of increased radiation exposure

Risk of iatrogenic intraarticular damage to the knee joint

Risk of infection

Risk of damage to the anterior cruciate ligament

Risk of malrotation angular deformity

Risk of damage to the patellar tendon

Risk of chronic knee pain

Bridge plating (MIO) - DCS (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

 There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - locking plate (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation
 Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - (midshaft)

Indication summary

Polytrauma with associated chest injury

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)
 Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - DCS (distal shaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

 Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - LISS (distal shaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications
 All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating - DCS (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, failed indirect reduction
Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating - locking plate (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
 Bridge plating - locking plate (subtrochanteric)

available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

 Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating (midshaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction
 Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating - DCS (distal shaft)

Indication summary

Polytrauma with associated chest injury, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis
 Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Complex fracture, irregular

C type fractures result from moderate to severe impacts to the femur.

32-C3

32-C3

Irregular complex fractures of the femoral shaft are classified as C3.

32-C3

General considerations

C type fractures are multifragmentary. After reduction there is no contact between the proximal and
distal fragments.

In C 3 fractures there is a complex multifragmentary zone between the proximal and distal
fragments.

Temporary Thomas splint

Indication summary

Medically unfit for surgery. Usually temporary

Usually, femoral shaft fractures are treated surgically. Nonoperative treatment should be undertaken
only temporarily. Nonoperative treatment is reserved for exceptional cases, e.g. if the general
medical condition does not allow safe anesthesia.

Indications

Medically unfit for surgery

Polytrauma, in extremis

Advantage

Stabilization when immediate surgery is not possible or practical

Disadvantages

Overlap of the fracture can occur despite traction

Continuing motion at the fracture site

Continuing soft-tissue compromise and bleeding

External fixator (midshaft/distal shaft)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

External fixator (subtrochanteric)

Indication summary

Unstable fracture, patient or soft tissues unsuitable for definitive internal fixation

Most femoral fractures would normally be managed with internal fixation.

Further indications for external fixation

Subtotal amputation or prolonged vascular deficit

Salvage after major complications following internal fixation

Unavailability of other treatment options

Contraindication

Osteoporosis (relative contraindication)

Advantage

Rapidly applied provisional treatment

Disadvantages

Possible loss of fixation

 Pin-track infection

Cumbersome fixation interferes with lower limb function

May interfere with procedures for soft-tissue reconstruction

High risk of nonunion/malunion when used for definitive treatment

Antegrade nailing (subtrochanteric)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Periprosthetic fractures

Ongoing infection (osteomyelitis)

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages
 Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Risk of malrotation

Difficult control of proximal fracture fragment

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Antegrade nailing (midshaft/distal shaft)

Indication summary

Closed isolated fractures, Gustilo I and II open fractures, stable polytrauma

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures
 Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Periprosthetic fractures

Continuing infection

Occluded intramedullary canal

Gustilo type III C open fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Frequent use of image intensifier risk of increased radiation exposure

Retrograde nailing (midshaft/distal shaft)

Indication summary

Closed fractures, Gustilo types I & II open fractures, stable polytrauma. Floating knee
injury, bilateral lower extremity fractures. Pregnancy. Obesity. Ipsilateral femoral neck and
shaft fractures. Concomitant ipsilateral acetabular / pelvic ring fractures. Fracture below
 Retrograde nailing (midshaft/distal shaft)

hip prosthesis.

Most femoral shaft fractures are treated with intramedullary nailing where practical. This gives the
strongest mechanical fixation and is the best treatment for early mobilization. Special consideration
may be needed in obese patients, and a lateral decubitus position with the hip in flexion may allow
easier access for antegrade nailing.

General Indications

All patients with femoral shaft fractures except those not fit for definitive surgery

Isolated fractures

Closed fractures

Gustilo types I & II open fractures

Polytrauma patients in stable condition

"Floating knee injury

Bilateral lower extremity fractures

Relative Indications (retrograde vs. antegrade nailing)

Pregnancy

Obesity

Ipsilateral femoral neck and shaft fractures

Concomitant ipsilateral acetabular / pelvic ring fractures

Fracture below hip prosthesis

Contraindications

Polytrauma patients in unstable condition

Not medically fit for surgery

Image intensifier unavailable

Associated vascular injury requiring open repair

Continuing infection
 Occluded intramedullary canal

Gustilo type III C open fractures

Concomitant multifragmentary intraarticular fractures

Advantages

Less invasive procedure / indirect reduction

Minimizes soft-tissue damage

Fracture can be reduced (length, angular and rotational control are obtained)

Better biomechanical properties

Definitive procedure

Rapid mobilization of patients postoperatively

Minimal blood loss

Good cosmetic results

Disadvantages

Risk of iatrogenic femoral neck fracture

Risk of fat embolization

Closed reduction may be more challenging than open reduction

Difficult control of proximal fracture fragment in more proximal fractures

Frequent use of image intensifier risk of increased radiation exposure

Risk of iatrogenic intraarticular damage to the knee joint

Risk of infection

Risk of damage to the anterior cruciate ligament

Risk of malrotation angular deformity

Risk of damage to the patellar tendon

Risk of chronic knee pain

Bridge plating (MIO) - DCS (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

 There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - locking plate (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation
 Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - (midshaft)

Indication summary

Polytrauma with associated chest injury

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)
 Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - DCS (distal shaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

 Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating (MIO) - LISS (distal shaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which plate fixation may be indicated. If plating is performed, it may be advantageous in osteoporotic
bone to use locking plates and screws.

It is technically less demanding to open the fracture when performing plating, but this interferes with
the soft tissues and the fracture healing process. By performing this procedure through a minimal
invasive approach there is less disruption of the soft tissues and fracture environment, but it is more
challenging and there is a greater risk of malrotation or other deformity.

Indications
 All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Respectful of soft tissues

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Risk of malrotation

Risk of varus and/or valgus malposition

Demanding surgical procedure/ Closed reduction is more challenging than open reduction

Risk of increased exposure to ionizing radiation/ Frequent use of image intensifier risk of
increased radiation exposure

Difficult control of proximal fracture fragment

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws.

Bridge plating - DCS (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, failed indirect reduction
Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating - locking plate (subtrochanteric)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
 Bridge plating - locking plate (subtrochanteric)

available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

 Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating (midshaft)

Indication summary

Polytrauma with associated chest injury, surgeon's preference, image intensification not
available, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis

Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction
 Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws

Bridge plating - DCS (distal shaft)

Indication summary

Polytrauma with associated chest injury, failed indirect reduction

Although the majority of femoral shaft fractures are fixed with IM nails, there are circumstances in
which ORIF with a plate may be indicated. If plating is performed, it may be advantageous in
osteoporotic bone to use locking plates and screws.

Indications

All patients with femoral shaft fractures where intramedullary nailing is contraindicated, but
the patient is fit for surgery

Indirect reduction impossible

No image intensifier available

Early pregnancy (up to 12 weeks gestation)

Polytrauma patient with associated chest injury

Contraindications

Patient not medically fit for surgery

Osteomyelitis
 Compromised local soft tissues

Advantages

Less demanding procedure than closed reduction

Less exposure to ionizing radiation

Direct reduction

Fracture can be reduced (length, angular and rotational control are obtained)

Fracture stabilization with a plate reduces the incidence of fat embolization compared to IM
nailing

Fracture stabilization allows for early patient mobilization

Disadvantages

Greater blood loss

Exposure of fracture zone / risk of interference with healing process

Larger operative soft-tissue trauma

Less appealing cosmetic result

There is a risk of screws pulling out in osteoporotic bone. This risk is reduced with locking
screws