The femur, or thighbone, is the longest and strongest bone in the human body. Because of its immense strength, a fracture typically requires a significant amount of force, usually from high-impact events like severe car accidents or major falls. A broken femur is a major medical emergency due to the risk of substantial internal blood loss, which can cause shock. Furthermore, sharp bone fragments can threaten nearby nerves and blood vessels, making rapid stabilization a priority for preserving limb function and life.
Initial Assessment and Temporary Stabilization
Upon arrival at the hospital, the first steps involve a thorough assessment following trauma protocols to stabilize the patient and rule out other life-threatening injuries. This evaluation includes checking for associated injuries and performing neurovascular checks to ensure blood flow and nerve function in the injured leg are intact. Pain management is started immediately, as a femur fracture causes intense pain.
Diagnostic imaging, primarily X-rays, is used to confirm the fracture and determine its precise characteristics. Orthopedic surgeons classify the fracture pattern as transverse (straight across), oblique (at an angle), spiral (a twisting break), or comminuted (shattered into three or more pieces). A Computed Tomography (CT) scan may also be used for a more detailed look at complex breaks, especially those near the knee or hip joints.
Before definitive surgery, the limb requires temporary stabilization to minimize pain and prevent further soft tissue damage. This is often achieved using a traction splint, which applies steady tension to help pull the bone fragments toward proper alignment. If the patient is too unstable for immediate definitive surgery, or if there is severe soft tissue damage, a temporary external fixator may be applied. The goal is to prepare the patient for surgery, ideally within 24 hours of the injury, as early definitive fixation is associated with better outcomes and shorter hospital stays.
Primary Surgical Repair Techniques
The definitive treatment for nearly all femur fractures in adults is surgical repair, known as open reduction and internal fixation (ORIF). ORIF restores the bone’s alignment and holds it securely while it heals using permanently implanted orthopedic hardware. The choice of surgical technique depends heavily on the fracture’s location and complexity.
Intramedullary Nailing
Intramedullary (IM) nailing is the most common technique for fractures in the shaft, or middle section, of the femur. This method involves inserting a specialized metal rod directly into the hollow center of the bone, called the medullary canal, spanning the length of the fracture. The rod acts as an internal splint, providing strong, centralized support against the forces of weight-bearing and muscle contraction.
The rod is secured in place with locking screws that pass through the bone and the rod at both ends of the femur. This construct prevents the bone from rotating or shortening, allowing for earlier mobilization and weight-bearing. Compared to plating, IM nailing often results in decreased operating time, lower blood loss, and a faster healing time for mid-shaft fractures.
Plate and Screw Fixation
Plate and screw fixation is typically reserved for fractures closer to the ends of the bone, specifically near the hip (proximal) or above the knee (distal) where the bone widens. This technique involves placing a contoured metal plate along the outside surface of the bone. The plate is attached to the bone with multiple screws that pass through the plate and into the bone fragments on either side of the break.
Modern plates are often “locked,” meaning the screws lock into the plate itself, creating a fixed-angle construct that maintains alignment even in complex fractures. This method is preferred for fractures that extend into the knee or hip joint surfaces, as it allows for precise anatomical realignment of the joint fragments. While effective, this approach can be associated with a higher rate of nonunion or delayed healing compared to IM nailing for shaft fractures.
External Fixation
External fixation involves inserting metal pins into the bone fragments through small skin incisions, which are then connected to a rigid frame located outside the body. This technique is rarely used as a permanent solution but serves as a temporary stabilizing measure in specific, high-risk situations. It is used when the patient is severely injured and too unstable for complex internal fixation surgery, or in cases of open fractures with significant contamination or soft tissue damage. The external frame rapidly stabilizes the limb, allowing doctors to focus on the patient’s overall health before conversion to definitive internal fixation.
The Recovery and Rehabilitation Timeline
Following surgical repair, the initial focus is on managing post-operative pain and preventing complications like blood clots or infection. The patient typically remains in the hospital for a few days to a week, depending on the injury’s severity and their overall health status. The biological process of bone healing, where new bone tissue bridges the fracture gap, begins immediately but takes several weeks to establish structural integrity.
The orthopedic surgeon will prescribe specific weight-bearing restrictions, determined by the fracture type and the stability of the surgical fixation. Patients may be restricted to non-weight bearing or progress to “toe-touch” or partial weight-bearing over the first six to twelve weeks. The goal is to allow the bone to heal while minimizing stress on the hardware.
Physical therapy (PT) is essential for recovery, starting almost immediately to prevent joint stiffness, especially in the knee and hip. Initial PT involves gentle range-of-motion exercises and strengthening of surrounding muscles. As the bone shows signs of healing on X-rays, typically around three months, the patient progresses to full weight-bearing and intensive strengthening exercises to restore function. While the bone may be clinically healed within three to six months, a complete return to pre-injury activities can take six to twelve months of dedicated rehabilitation.