Femur: Femoral shaft fractures

Femoral shaft fractures used to be devastating injuries before invention of intramedullary nails by Kuentscher during World War 2.

Treatment with intramedullary nail makes all the difference, but is not without risks.

What are the risks of this surgery?

  1. Infection: risk runs about 1%.
  2. Nerve/vessel damage.
  3. Nonunion, malunion, breakage or loosening of hardware.
  4. Continued pain, limping, even after full healing.
  5. Blood clots, PE, sudden death, pneumonia, limping, etc.
  6. Deformity, especially rotational deformity.

How is this operation done?

The operation usually is done on a fracture table. The fracture table helps secure the foot and the body, and helps perform "closed reduction" of the femur by allowing the surgeon to apply a correct amount of traction.

After closed reduction, under xray guidance, 3-5 incisions are made in order to insert the implant:

  • an incision above the hip to ream the inside of the femur, and to insert the main rod. Insertion of the rod usually takes some vigorous pounding with a hammer.
  • a second incision at the hip level to insert an interlocking screw at the hip level.
  • a third set of 1 or 2 incisions above the knee to insert interlocking screws there.

Case study: a high school freshman with femoral shaft fracture

This was a closed fracture, with physes almost fully closed.

Casting is certainly not a good option for this injury.

An external fixator is an option, but not the best option. An external fixator will not hold the alignment as reliably as an intramedullary nail, and there is the issue of pin tract infetion as well.

An intramedullary nail is the correct treatment for this fracture, without any doubt. There is always a small risk of infection, anytime there is an incision through the skin. But the risk-benefit analysis is strongly in favor in intramedullary nailing.

At this age group, there is some talk in orthopedic pediatric circles of the risk of AVN with a traditional pyriformis entry nail. Because of that theoretical risk, I chose to use a Synthes lateral entry intramedullary implant.

The operation is done on a fracture table. The broken femur ends are pulled apart, are aligned by external pressure, and the intramedullary nail is inserted. Power drills and hammers are used during this surgery.

Immediate postoperative xrays

This patient was allowed to bear full weight from the beginning, with this 9 mm nail.

The fracture healed well and on time, as expected.

Limping was severe for the first month, less of a problem in the second month. By 3 months, normal gait had been restored.

Here are the xrays, showing a healed femur, at 3 months.

Issues such as removal of the nail, always come up in discussions with the parents.

As far as I know:

  1. There is no known issue, no known problem, caused by the permanent presence of this titanium implant inside the femur. No known risk of cancer, teratogenicity, poisoning, etc.
  2. Removing the nail is just as difficult and carries the same risk as putting it in. It is not to be taken lightly.
  3. As far as I know, the presence of a femoral titanium implant does not cause problems with the fetus growth and development.