12.53 Femur shaft fractures

The incidence of femur shaft fractures in the United States of America is 1 per 10 000 population per year. They frequently result from high-energy trauma and associated injuries are common. With appropriate treatment, most patients are able to return to pre-injury function and long-term serious sequelae are uncommon.

The femur is the largest bone in the body. It functions mechanically to transmit load, maintain the length of the limb, and anchor muscles for weight bearing and locomotion. The shaft of the femur is that area distal to the lesser trochanter and proximal to the condyles.

The shaft contains the isthmus which is the narrowest portion of the medullary canal. The femoral shaft is bowed convex anteriorly by 10 degrees. There are several paths to the medullary canal proximally. The most direct is through a small fossa at the posteromedial base of the greater trochanter where the piriformis tendon inserts. Entry to the canal from the nearly subcutaneous tip of the greater trochanter is easier but offset from the medullary canal. Distally, direct access to the medullary canal can be obtained through the articular cartilage anterior to the intercondylar notch for rigid nails.

When the femoral shaft fractures, it not only disrupts the skeletal integrity of the limb and precludes ambulating but also has major systemic consequences. These include blood loss, marrow embolization, and acute respiratory distress syndrome (ARDS). Femur shaft fractures are a common component of multiple trauma and the optimal treatment involves application of the principles of damage control.

Associated injuries to the same limb are common. Communicating open wounds are present in about 10% of cases. Associated neurological and superficial or profunda femoral artery injuries are rare with an incidence of less than 1% and 1% respectively. Associated fractures in the same limb are common and the surgeon must be particularly aware of a 10% possibility of an ipsilateral femoral neck fracture. Thirty per cent of associated neck fractures are initially missed. Knee injuries occur in 15–50% of femoral shaft fractures. Injuries to other systems are also common. In prospective study the average Injury Severity Score in patients with femoral shaft fractures was 20.

Femur shaft fractures are major injuries. A large amount of force is required to break the thick cortical bone of the shaft which is covered circumferentially by muscles. Motor vehicle collisions and other high-energy mechanisms cause the vast majority of femur shaft fractures in Europe and North America. Falls may cause femur shaft fractures in the elderly.

The comprehensive classification of fractures published by the Orthopaedic Trauma Association (OTA) is the most logical system for classifying fractures of the femoral shaft.

The history, physical examination, and early treatment should be dictated by ATLS^® guidelines. Any patient who has sustained a femoral shaft fracture has experienced a high-energy injury that may involve multiple systems. Blood loss from a femur shaft fracture is considerable and it is possible to exsanguinate into the thigh. About one-third of patients with isolated femur shaft fractures require transfusion. However, it is dangerous and usually inappropriate to attribute hypotension to blood loss from a femur shaft fracture, other sources of bleeding must be excluded.

With regard to the femoral shaft fracture, the time and mechanism of injury, neurovascular function, and condition of the skin should all be determined and documented. Neurovascular status and integrity of the skin should be assessed and documented. Compartment syndrome of the thigh associated with a femoral shaft fracture is uncommon. Assessment for knee ligament injuries is difficult in the acute setting, but should be reassessed following stabilization.

Plain x-rays should be obtained which show the hip and knee as well as the femoral shaft. Hip dislocation and femoral neck fractures should be identified. These patients will frequently have had computed tomography (CT) scans that include the femoral necks. Even under these circumstances some femoral neck fractures will be missed. An x-ray of the contralateral femur can be helpful in determining appropriate reduction length of the fractured femur when placing a static locked nail, especially in segmental multifragmentary fractures. More complex imaging studies are not usually necessary to manage routine femoral shaft fractures.

It is advantageous to stabilize the fracture with internal or external fixation as soon as possible. However, initial emergency treatment of femoral shaft fractures should include splintage. When definitive treatment is delayed the patient will benefit from balanced suspension and proximal tibial skeletal traction with sufficient weight to slightly distract the fracture. Traction increases patient comfort, facilitates transfers during work-up and treatment of other injuries, partially immobilizes the fracture, and maintains length prior to definitive treatment. Distal femoral traction should be considered when there is clear evidence of a knee injury.

Internal fixation by intramedullary nailing is currently the best treatment for the vast majority of femur shaft fractures. However, in certain situations, traction, plating, and external fixation can be considered

Traction may be appropriate when other techniques are not available or not possible. Approximately one-seventh body weight skeletal traction is applied through a pin placed transversely in the proximal tibial metaphysis. Balanced suspension of the lower extremity is achieved by use of a Thomas splint with a Pearson attachment with the hip and knee at 45 degrees of flexion. The traction needs to be adjusted and corrected daily. Reduction is checked weekly. Active range of motion of the hip and knee is encouraged as soon as the patient will tolerate it. Mobilization in a splint or cast brace with crutches is usually possible by 4–6 weeks.

Traditional femoral plating requires neither fluoroscopy nor as much other special instrumentation as medullary nailing. It is performed in the supine position on a regular operating table without traction. Classic plating requires extensive dissection resulting in blood loss and soft tissue injury. In most series, plating has a lower rate of union and higher rates of refracture, infection, and stiffness than nailing. Direct fracture visualization is detrimental to callus formation due to increased soft tissue stripping. However, it does simplify treatment, which may be particularly important in complex injuries such as fractures at multiple levels of the femur or when the medullary canal will not accept a nail. Plating in selected high-risk patients, may be associated with a lower incidence of pulmonary complications than medullary nailing. In these patients new techniques utilizing percutaneous submuscular locking plates have been described to minimize soft tissue dissection.

Some multiple trauma patients appear to be harmed more than helped by early total care and damage control orthopaedics has been recommended. Staged use of external fixation is an effective component of damage control orthopaedics for severe multiple trauma cases. External fixation is effective initial treatment in severely injured patients, as it is applicable to nearly all fracture patterns with no special equipment requirements and can be applied rapidly. It allows access to the wound for debridement and ongoing care, and stabilizes the limb sufficiently to allow mobilization of the patient and an upright chest for better pulmonary function. After several days, when the patient’s overall condition is more stable, the fixator is converted to a nail. Infection rates after early conversion to a nail are low.

The long-term use of external fixation in femur shaft fractures can be successful but is associated with pin track problems, delayed union, malunion, and knee stiffness. The large muscular soft tissue envelope of the thigh contributes to the pin track problem. The large forces across the femur during ambulation are difficult to control by a fixator. Instability of the construct contributes to the problems of delayed union and loss of reduction.

A preoperative plan is developed including anticipated size and position of the implant (nail length and width, locking screw position), and to ensure that all necessary instrumentation and implants are available.

The procedure can be performed without traction on a radiolucent table or with traction on a fracture table.

If traction is used the patient is positioned supine and the legs are ‘scissored’ or the contralateral leg is placed with the hip and knee flexed and the hip abducted (Figure 12.53.2). Traction is applied to the injured limb through a boot or proximal tibial traction pin. A bar in the perineum provides counter traction. Rotation of the fluoroscopy C arm provides anteroposterior and lateral views. An incision is placed approximately 8cm proximal to the tip of the trochanter in line with the shaft of the femur. The desired entry point into the bone is the piriformis fossa, which is extraca psular and can be located at the junction of the trochanter and femoral neck just medial and posterior to the tip of the trochanter. A sharp awl or guide pin is placed and position is confirmed by biplanar image. The entry site is opened for 5cm in line with the shaft by a cannulated power reamer if a guide wire is used, or by an awl. A cannulated entry tool facilitates placement of subsequent instruments in the medullary canal, helps to remove medullary reamings and protects the soft tissues of the hip. If a cannulated nail or intramedullary reaming is planned, a guide wire is then passed down the medullary canal to the fracture site. Under fluoroscopic control, traction and manipulation are utilized to facilitate passage of the guide across the fracture into the medullary canal of the distal fragment.

If reaming is performed it proceeds sequentially initially in 1-mm and then in 0.5-mm increments. The first reamer is end-cutting for easier passage. The use of well-fluted sharp power reamers will minimize pressure on the medullary canal and embolization of medullary contents into the vascular system. Over-reaming by 1.0–1.5mm facilitates ease of nail insertion. Depending on the type of nail used, the proximal femur entry point may need to be further over-reamed. Since the introduction of interlocking, the most common nail diameters range between 11–12mm. There is no need for the routine use of very large nails with tight endosteal fit. Care is taken to match the anterior bow of the nail to that of the femur and to maintain rotation of both the fracture reduction and nail itself during insertion.

Proximal locking is through a nail-mounted guide and involves placement of one or two bicortical screws through the nail in the mid-coronal plane either transversely or obliquely between the greater and lesser trochanter. Reconstruction nails allow proximal locking into the femoral neck. Distal locking is achieved under image control by placing one or two screws in the coronal plane through the nail with bicortical purchase. A variety of techniques are described for accurate distal locking. Modern nails offer dynamic and static locking options.

Because of difficulty with accessing the piriformis fossa as well as the occurrence of chronic hip pain and abductor weakness after antegrade nailing with a piriformis entry point, nailing systems have been developed to utilize a more lateral entry point on the greater trochanter. This entry point can be surgically accessed without muscle penetration and is much closer to the skin. The trochanteric entry site is lateral to the medullary canal of the femur and requires an additional coronal plane bend in the manufacturing of the nail. Studies have shown the trochanteric entry point nails can be associated with less blood loss and operative time and there is suggestion of improved function with less hip pain and abductor weakness. Healing rates and functional recovery from the fracture itself are equivalent to piriformis nailing.

The optimum position of the entry point is dependent on the coronal plane bend in the proximal nail and this varies depending on design and manufacturer. Failure to accurately place the entry point will result in varus/valgus malalignment. The majority of trochanteric entry point nails are designed to be inserted at the tip of the trochanter in the coronal plane. Varus malalignment is to be avoided and this is seen when a more lateral entry point is used. In the sagittal plane the entry point should be in line with the centre of the femoral canal. However, when using a cephalomedullary device it has been recommended that the junction of the anterior third and posterior two-thirds of the greater trochanter facilitates alignment of the implant with the femoral neck.

Intramedullary femoral nailing can also be performed in the lateral position where access to the piriformis fossa is much easier. This position is advantageous in large patients and proximal fracture patterns. Initial positioning is more time-consuming and there is an increased incidence of external rotation deformity.

Retrograde nailing is performed with the patient supine on the radiolucent operating table with the lower extremity prepared and draped. Access to the knee joint is obtained through or medial to the patellar tendon. The entry site for a retrograde nail is at the top of the intercondylar notch through cartilage, which does not articulate with the patella. Retrograde femoral nailing offers the advantage of easier access to the starting point as the distal femur is not surrounded by muscle. In addition, patient positioning is easy since the fracture table is not used. There are a number of clinical situations in which retrograde nailing has apparent clinical advantages.

Positioning on the fracture table may not be well tolerated by patients with unstable pelvic ring or spine fractures. The proximal incision for antegrade nailing may compromise the approach for acetabular surgery. Set up time can be minimized for bilateral lower-extremity fractures requiring prompt fixation. Ipsilateral lower limb injuries (distal femur, tibia shaft or patella) in addition to the femoral shaft may be dealt with through a single knee incision. In patients with gross obesity positioning on the fracture table and the extensive mass of soft tissue at the hip are problems. In pregnancy there is theoretical reduction in the exposure to the fetus. The entry site problems (hip for antegrade and knee for retrograde) are equivalent. Early results with retrograde nailing suggested a higher non-union rate. However, small diameter and unreamed nails were initially used and more recent reports with standard diameter reamed nails show the union rates of antegrade and retrograde nails are similar.

There are concerns, with this technique, about direct damage to the knee joint, indirect damage from joint debris, and septic arthritis in open fractures. The significance of these problems has not been demonstrated in clinical studies.

It is possible to treat femoral shaft fractures with smaller diameter nails inserted without reaming the canal. The results with this technique have not been as good as with standard nails inserted after reaming. Unreamed nails have higher rates of complications including malunion and delayed union, which are probably related to the small size of the nail relative to the medullary canal and the tendency for excessive motion or overloading the implant prior to fracture healing. However, unreamed nails are quicker and avoid the high intramedullary pressures seen with reaming. This is considered by some to have advantages in the polytrauma patient.

Postoperative management should include careful assessment for correct length and rotation. This should ideally be assessed when the patient is still in the operating room after removing the patient from traction, and again when the patient is mobilizing postoperatively. Rotation should be assessed by comparing the range of hip rotation between the injured and non-injured sides. Radiographs of the femur should be obtained to assess the position of the implant and locking screws, and as a basis of comparison for later films used to assess healing. Fixation is usually sufficient to allow early partial weight bearing as nails are load-sharing devices. Range of motion exercises for the hip and knee should be instituted early in the postoperative course.

The evidence suggests that retained nails do not cause predictable problems and that totally elective removal should be reserved for selected cases. Patients with specific symptoms like trochanteric bursitis over a prominent nail could expect their condition to improve after nail removal. Incomplete resolution of preoperative symptoms commonly occurs. Vague symptoms like ‘cold intolerance’ or ‘thigh ache’ often persist after nail removal and may relate to the healed fracture rather than the presence of the nail. Concerns about infection and fretting corrosion have so far proved unfounded. A variety of complications have been reported with nail removal including an increased cosmetic problem from using a larger incision than required for nail placement, haematoma, infection, femur fracture, and inability to extract the nail. The last problem is minimized by ensuring the correct equipment is available. Removal more than 2 years after implantation is particularly difficult due to bony ingrowth. If nail extraction is difficult, overdrilling locking screw paths or unfilled locking screw holes and passage of a driving guide inside the nail may break up a bone bridge, which is preventing nail removal. Enlarging the entry hole at the top of the femur by inserting narrow straight osteotomes along the proximal 3cm of the nail circumferentially is particularly important for removing ‘shouldered’ nails. Removal of titanium nails has not proved to be any more difficult than stainless steel nails despite the theoretical concern of bone ingrowth and difficult extraction.

Broken nails can generally be removed by placement of a ball-tipped guide out the distal end and gaining an interference fit by stacking additional guides inside the nail. Over-reaming of the proximal canal is helpful. A variety of other hooks have been described for removing broken nails. When other measures fail, a distal incision may be utilized to drive the nail from distal to proximal.

Post removal radiographic evaluation is important to detect femoral fractures and confirm implant removal.

Early stabilization of long-bone fractures in patients with multiple trauma has been shown to increase patient survival and decrease pulmonary complications. Standard techniques can generally be utilized. In patients with severe multiple trauma damage control orthopaedic techniques with initial application of an external fixator and early exchange to a nail are popular as described in the section on external fixation. Other modifications of nailing technique that are used in damage control include second-stage placement of distal locking screws to avoid prolonged operative time, placement of smaller diameter nails with less reaming and retrograde nails. Percutaneous submuscular plating of femoral shaft fractures has also been advocated as a means of avoiding pulmonary complications from intramedullary nailing.

A variety of techniques have been recommended as alternatives to the use of a fracture table to simplify positioning in severely injured patients. Manual traction has been reported as successful in polytrauma patients. The authors emphasized the importance of an accurate preoperative plan for length. However this technique can be associated with a high incidence of non-anatomical reduction. The femoral distractor can be used to generate traction and improve alignment without the use of a fracture table. The proximal pin is placed into the lesser trochanter through the anterior thigh and medial to where the nail will be located. The distal pin is placed in the lateral femoral condyle anterior and distal to the nail.

Approximately 10% of femoral shaft fractures are associated with an ipsilateral fracture of the femoral neck. Many of these are not appreciated on initial evaluation and have been termed missed, occult, or iatrogenic. Femoral neck fractures which become apparent after nailing may have been present initially and subsequently displace as a result of the nailing or have been caused by the insertion of the nail.

A variety of treatments of these combination injuries have been suggested. Operative stabilization of both fractures is indicated. The complications associated with femoral neck fractures (avascular necrosis, non-union, malunion) are generally more severe and more difficult to treat than complications of the femoral shaft fracture; therefore, treatment of the shaft should not put the neck fracture at unnecessary risk. Multiple screws or dynamic hip screw and side plate is the standard treatment of femoral neck fractures in young adults. These typically block the proximal medullary canal preventing standard antegrade nailing. Plating or retrograde nailing are then the preferred alternate techniques to treat the femur shaft fracture. The reported results have been satisfactory. Antegrade nailing of the shaft with screws placed around the nail and then across the femoral neck fracture may be ideal for minimally displaced fractures which become apparent after nail placement. However, an 18% major complication rate when this technique was used routinely. Nails with proximal locking into the head and neck of the femur have been used for the combined neck shaft injury and reported to achieve good results. When using this technique it is important to obtain reduction of the femoral neck fracture and maintain it during the procedure (using a pin), and to obtain good fixation with screws well positioned in the head. Anatomical reduction of the femoral neck fracture should be confirmed radiographically and when in doubt by direct visualization. The canal must be over-reamed so the nail can be rotated freely to match the anteversion of the femoral neck. Only in this way will the proximal locking screws obtain central position in the femoral head. Fluoroscopic imaging is partially obscured by the nail, but confirmation of central placement is essential.

Another type of bifocal femoral fracture is the shaft and distal femur. Operative stabilization of both fractures is recommended. A multitude of different techniques of internal fixation are available depending upon the fracture patterns. Antegrade nailing of the shaft fracture and lateral plating of the distal femur fracture have been the traditional treatments. Plating both fractures has also been reported, especially with a long lateral locking plate. Retrograde nailing as a single method for both fractures is a more recent development and results are generally good and superior to other techniques. The relative infrequency of this injury combination prevents definitive assessment of the optimal technique.

The phrase ‘floating knee’ has been used to describe ipsilateral fractures of the tibia and femur shaft. Knee stiffness and delayed union of one or the other fracture were identified as common consequences of non-operative treatment. Operative stabilization of both fractures has given the best results. Retrograde nailing of the femur and nailing of the tibia have produced very good results. Many series have included various combinations of different major fractures of the femur and tibia. The intra-articular components of these fractures and the soft tissue injuries typically play a major role in determining outcome.

Following stabilization of a femur shaft fracture, ligamentous examination of the ipsilateral knee should always be performed. Ipsilateral knee ligament injuries occur commonly and are often missed. The femur shaft fracture may divert the patient and doctor from recognition of knee ligament injury. Until the fracture is stabilized physical examination of the knee is extremely difficult and unreliable. Early recognition and treatment of associated knee joint injuries will optimize outcome.

All femur shaft fractures have some degree of soft tissue injury even in the presence of intact skin but open femur shaft fractures have a higher complication rate, in particular infection and delayed union. Soft tissue management is the key to optimizing results and the type of skeletal fixation is of less importance. The classic treatment for most open femur fractures has been temporary or definitive external fixation and this remains a reasonable option, particularly for femur fractures associated with severe open wounds. Intramedullary nailing of many open femur fractures can be performed successfully and safely, and if infection can be avoided offers many advantages over external fixation, such as better alignment and less knee stiffness.

Grade 3C open femur shaft fractures are injuries which require repair of the femoral or popliteal artery. Although revascularization is usually possible, the functional outcome after this severe injury is often poor.

Avascular necrosis of the femoral head has been reported in children and adolescents treated with medullary nails and this is a devastating complication. The blood supply to the femoral head in a patient with an open physis is very dependent on the circumflex artery which runs along the posterior neck at the junction with the trochanter. This is very near the piriformis fossa, the classic starting point for femoral nailing. Trochanteric entry nails may avoid the blood supply to the femoral head and are now generally preferred to piriformis entry nails when rigid nailing of adolescent femur shaft fractures is chosen. The trochanteric apophysis may undergo premature closure but this is unlikely to cause any significant problem for patients older than the age of 10 years. The nail should stop proximal to the distal physis if it is still open. External fixation can be successful but has fallen out of favour. Non-operative treatment with traction, splints and casts is effective but has also fallen out of favour except in very young patients who heal within a month or two.

Femoral shaft fractures in the elderly have recently received attention in the literature. One author reported a 10% mortality rate within 60 days of injury which was comparable to that of elderly patients with a proximal femur fracture. Only 39% returned to their pre-injury level of function. New postinjury medical problems were common and adversely affected outcome. In addition to operative stabilization they recommended close vigilance and ongoing medical evaluation. Among survivors, the rate of healing of the fracture was excellent.

In very large patients, positioning on the fracture table is difficult and access to the proximal femur through extensive soft tissue is fraught with a variety of complications including entry site malposition, malunion, increased blood loss, wound healing problems, and infection. Use of the femoral distractor instead of the fracture table has been reported, although the problems of the incision at the hip remain. Retrograde nailing has also been suggested as an effective means of overcoming both problems.

Pathological fractures of the femur shaft occur in an area of abnormal bone and typically have a high rate of non-union. Operative stabilization by intramedullary nail is generally indicated. With the use of interlocking, fixation is typically adequate and adjunctive use of methyl methacrylate is not required and often causes more problems than benefits. Owing to the limited demands of the patient, medullary fixation of shaft lesions or shaft fractures will typically provide adequate stabilization even if the fracture does not heal. However, extensive involvement of the proximal or distal femur may not be adequately stabilized by nailing and replacement arthroplasty may be preferred. Prophylactic nailing of lesions with high risk of fracture (greater than 50% of the cortex) is far easier and has a much lower complication rate than nailing after fracture has occurred. Consideration of life expectancy and quality of life should be discussed with the patient and family. Adjunctive use of radiation or chemotherapy is often helpful after the surgical incision has healed.

Intramedullary nailing facilitates restoration of both form and function and achieves remarkably good short- and long-term results with low complication rates. Systemic complications and death rates have been lowered. The indirect reduction and splinting of the fracture achieved by closed nailing facilitates rather than retards natural healing by callous. Locked nailing accurately restores length and alignment which is important for the long-term function of the limb. Time lost from work has been dramatically reduced and patients are typically able to return to the most strenuous activities. However, patient based outcome studies demonstrate significant residual impact on patient’s perception of their health and well being.

Complications of femur shaft fractures include non-union, malunion, infection, refracture, wound haematoma, neurological injury, vascular injury, deep venous thrombosis (DVT), compartment syndrome, heterotopic ossification, fracture comminution, implant breakage, implant malposition, haemorrhage, ARDS, stiffness, weakness, chronic pain, impaired ambulation, and death. Fortunately, the rate of these numerous complications is very low.

Patients with femur shaft fractures are at risk for deep venous thrombosis. A 40% incidence of thrombosis in patients with femur shaft fractures has been reported, although there were no pulmonary emboli in this series. Early medullary nailing has helped reduce the incidence of thromboembolic problems in patients with femoral shaft fractures.

Femur shaft fractures release medullary contents into the bloodstream which causes pulmonary dysfunction and increased capillary permeability with a variety of undesirable systemic consequences.

Medullary nailing of femur shaft fractures has both beneficial and deleterious effects on pulmonary function. Stabilization prevents motion at the fracture site and ongoing showering of medullary contents into the bloodstream. Stabilization also allows mobilization of the patient to an upright chest and reduces the pain of fracture motion which markedly improves pulmonary function in comparison to prolonged recumbency. However, each manipulation of the medullary canal causes particulate matter to enter the bloodstream with some pulmonary compromise results. Although this problem was greatly feared at the time of the introduction of intramedullary nailing the beneficial effects of nailing have been seen to far outweigh the detrimental effects. In a patient with near normal pulmonary function, the pulmonary consequences of medullary reaming are well tolerated. However, in patients with impaired pulmonary function it can cause major problems.

Heterotopic ossification after femoral nailing has been observed and although it may occur to some degree in up to 30% of patients it rarely is the cause of significant clinical symptoms. Three risk factors have been identified: male patient, more than 2 days between injury and nailing, and prolonged intubation for more than 4 days. Prevention of heterotopic ossification is best achieved by minimizing trauma to the gluteal muscles and by irrigation and debridement of devitalized reamings and muscle after nail insertion. Prophylactic radiation or indomethacin is not warranted.

A15% incidence of pudendal nerve sensory disturbance has been reported as a result of pressure on the nerve between the countertraction post and pelvis. Spontaneous recovery is to be expected. Post-padding and the use of a large-diameter post are suggested ways to prevent this injury. The peroneal branch of the sciatic nerve can also be injured and there is a low incidence of injury to the tibial and femoral nerves.

During femoral nailing, femoral neck fracture and other patterns of iatrogenic comminution have been observed. Careful instrumentation and the correct entry hole are critical in preventing iatrogenic fracture. Nail design is also important since more flexible nails are more forgiving of start points out of line with the medullary canal.

Delayed union has been defined as failure to achieve clinical and radiographic union by 4 months. The reported incidence is 10% although many of these patients will progress to full union without further treatment. Routine dynamization of statically locked nails is not necessary but may be advantageous in the presence of a delayed union or significant fracture distraction. Removal of the static locking screw is a simple procedure and is indicated as the first treatment of delayed union.

Non-union is defined as failure to achieve union by 12 months. The overall incidence is reported at 1%. In an aseptic non-union, exchange nailing with reaming and placement of a larger nail is usually successful. The reaming removes fibrous tissue that may have formed around the original nail and creates space for a larger diameter nail that has more stability. Open debridement of the fracture site is rarely required but drilling of the non-union site may be helpful to stimulate healing and create a space for reamings to function as bone graft. An 85% success rate has been reported with exchange nailing of aseptic femoral shaft non-unions. A very atrophic non-union with flail motion at the non-union site after removal of the initial internal fixation may require debridement of established scar tissue at the non-union site, freshening of the ends of the fragment and placement of cancellous bone graft or other biological stimulants to bone healing in addition to new osteosynthesis.

Recalcitrant femoral shaft non-unions are extremely difficult problems. Extensive debridement and reconstructive techniques have been described including the use of endosteal substitution or vascularized fibular grafts to obtain stability. Unfortunately, even these extensive techniques are not always successful and ablation may be required.

A 20% incidence of angular malunion attributed to poor control of the distal fragment especially in more distal fracture patterns have been reported.

Infected unions are rare. Infections around an implant cannot be eradicated without implant removal. Since union has occurred the nail is no longer necessary or helpful. Typical treatment is removal of the nail, debridement of the surrounding tissue and medullary canal by reaming, and copious irrigation to dilute the residual bacteria. Temporary antibiotic-impregnated beads may be a useful way of delivering high levels of antibiotic to the medullary canal.

Infected non-unions require a careful assessment of the intensity of infection and relative benefits and problems with the fixation. Loose or broken implants that are not providing stability should be removed. The benefits of stable fixation on healing of the bone offset the foreign body effect that makes eradication of infection difficult. In general stable fixation in the face of infection should be retained until fracture healing while the infection is treated and suppressed. After fracture healing the implant can be removed and attempt at infection cure undertaken. When adequate debridement of infected bone creates a segmental bone defect extensive reconstructive techniques like vascularized fibula graft or bone transport distraction osteogenesis may be required.

Hip and thigh weakness has been considered usual for the first 4 months after nailing of femur shaft fractures. Chronic major weakness is unusual. Minor weakness of hip abduction strength at 2 years is prevalent. If present, hip abduction weakness correlated with symptoms of limp and discomfort. They recommended an aggressive strengthening program and careful monitoring of hip abductor function prior to release from care. Knee stiffness and weakness in the first two weeks after retrograde nailing is common but generally responds well to aggressive physical therapy and motion and strength return to near normal by 6–8 weeks.

Continued refinement of medullary nailing will continue. Techniques to avoid pulmonary complications will be developed and the multiple trauma patients who benefit from damage control techniques will be more clearly identified to lower the death rate. Increased ease of insertion of the nail and placement of locking screws as well as other modifications of the technique, instruments and implants will be developed. The optimal entry site for trochanteric antegrade nails will be determined. Nail mounted guides for distal locking will become effective. Biological stimulation to speed healing and minimize soft tissue fracture disease may become available. With an aging population there will be more elderly patients with femur shaft fractures. Increased industrialization around the world will likely outpace any injury prevention advances and the incidence of femur shaft fractures will likely increase in the next 10 years.

Femoral shaft fractures are associated with high-energy mechanisms, polytrauma, bifocal injury and systemic complications. Early stabilization is important. Temporary stabilization techniques can be used in the physiologically unstable patient. Several definitive surgical stabilization techniques are available and they all have their relative merits and pitfalls. Careful planning and execution of the surgical strategy will minimize complication and is associated with high rates of success.