Femur Fracture

A femur fracture is a break in the thighbone, the longest and strongest bone in your body. Because of the femur’s exceptional strength, it usually takes tremendous force to break it, such as a car accident or a serious fall. This injury requires immediate medical attention and typically needs surgery to heal properly.

Table of contents

• What Is the Femur and What Happens When It Breaks?
• Anatomy of the Femur
• Types of Femur Fractures
• Causes
• Who Is at Risk?
• Symptoms
• Why Is a Broken Femur Serious?
• Diagnosis
• Treatment
• Recovery

What Is the Femur and What Happens When It Breaks?

Your femur, also known as the thighbone, is the longest, heaviest, and strongest bone in your body^[1]. It extends from your hip joint to your knee joint and plays a vital role in supporting your body’s weight and allowing you to walk and move^[2].

When the femur breaks, it is called a femur fracture. This is a serious injury that requires immediate medical care. Due to the bone’s strength, it takes tremendous force to break it^[1]. If you break your femur, you will not be able to put weight on your injured leg, and healing can take several months^[2].

Anatomy of the Femur

• Hip joint
• Knee joint
• Thigh

The leg has three long bones: the femur, tibia, and fibula, as well as a fourth bone called the patella, or kneecap^[5]. The femur is located in the thigh and connects the hip to the knee. At the top, it forms the hip joint with the pelvis, and at the bottom, it connects with the tibia and patella to form the knee joint^[7].

The femur has different parts. At the top is a specialized area consisting of the head, neck, and greater and lesser trochanters. The middle section is called the femoral shaft, which is the long, straight part of the bone. This shaft runs from below the hip to where the bone begins to widen at the knee^[1]. At the bottom, the femur flares out into the medial and lateral femoral condyles^[4].

Types of Femur Fractures

Femur fractures vary greatly depending on the force that causes the break and the location where it occurs^[1]. Doctors classify these fractures based on several factors: the location of the break, the pattern of the fracture, and whether the skin and muscle over the bone are torn by the injury^[1].

The bone pieces may line up correctly, called a stable fracture, or they may be out of alignment, called a displaced fracture. The skin around the fracture may be intact, which is a closed fracture, or the bone may puncture the skin, which is an open fracture or compound fracture^[1].

Location-based types:

• Proximal femur fracture: A break in the uppermost part of the thighbone, next to the hip joint. This is sometimes referred to as a hip fracture^[3].
• Femoral shaft fracture: A break anywhere along the long, straight middle section of the femur. When there is a break anywhere along this length of bone, it is called a femoral shaft fracture^[1]. This type almost always requires surgery^[5].
• Supracondylar femur fracture: A break just above the knee joint. This commonly occurs when the foot is planted and force is placed on the leg above the knee^[5].
• Distal femur fracture: A break in the top part of the knee joint. This type can extend into the knee joint and disturb the cartilage and growth plate of the knee^[5].

Pattern-based types:

• Transverse fracture: The break is a straight horizontal line going across the femoral shaft^[1].
• Oblique fracture: The fracture has an angled line across the shaft^[1].
• Spiral fracture: The fracture line encircles the shaft like stripes on a candy cane. A twisting force to the thigh causes this type of fracture^[1].
• Comminuted fracture: The bone has broken into three or more pieces^[1].
• Open fracture: Bone fragments stick out through the skin or a wound reaches down to the broken bone. Open fractures often involve much more damage to the surrounding muscles, tendons, and ligaments. They have a higher risk for complications, especially infections, and take a longer time to heal^[1].

Causes

Most people break their femur because of high-energy trauma^[2]. The most common causes include:

• Motor vehicle collisions: Car accidents are the number one cause of femur fractures^[1].
• Falls from height: Falling from a significant height can generate enough force to break the femur^[3].
• Gunshot wounds: Being shot can cause a femur fracture^[2].
• Sports injuries: Extreme or contact sports can result in femur fractures^[4].

In elderly people, even a simple fall from standing position can result in a femur fracture. This happens because bones tend to become weaker and more fragile with advancing age^[3]. People with conditions that weaken bones, such as osteoporosis, bone tumors, or bone infections, are more prone to femur fractures even from minor trauma^[3].

Who Is at Risk?

Femur fractures typically occur in a two-peak pattern. High-energy trauma causes most fractures in young populations, while lower-energy trauma causes fractures in older populations^[4].

People at increased risk include:

• People age 65 and older who have an increased risk for breaking bones, including their femurs, after falling down while standing^[2].
• Individuals with weak or fragile bones due to conditions such as osteoporosis^[2].
• People who have had knee or hip replacements^[2].
• Individuals with muscle weakness or a tendency to fall^[17].
• People with bone diseases such as tumors, Paget disease, or bone cysts^[14].

Despite the size and strength of the thighbone, femur fractures in children are not uncommon^[7]. In infants up to 1 year old, fractures can be caused by difficult deliveries, medical conditions that cause weak bones such as osteogenesis imperfecta, or, unfortunately, child abuse^[5].

Symptoms

If you have fallen or been injured, here are signs you may have a broken femur^[2]:

• Severe, extreme pain in the upper leg, hip, or thigh area
• Inability to walk, move the leg, stand, or put weight on your injured leg
• Swelling in the hip or thigh area
• Severe bruising in the area of the fracture or a change in the color of the skin
• Muscle spasms in the thigh
• Difficulty moving the leg
• Physical deformity—your thigh may look abnormally shaped
• Your injured leg may be shorter than your uninjured leg and may turn out, away from your body^[2]
• Pieces of your femur breaking through your skin with bleeding (open fracture)
• Pieces of your femur pushing up against your skin but not piercing it (closed fracture)^[2]
• Numbness and tingling in the thigh or leg^[14]

If you have a broken femur, you will not be able to walk on it^[2]. Broken femurs are very painful, and you will need immediate medical help^[2].

Why Is a Broken Femur Serious?

A broken femur is a serious injury that can be life-threatening^[14]. Death can occur following a femur fracture due to complications such as blood clots, pneumonia, or infection^[14].

If you break your femur, you might experience the following serious complications^[2]:

• Blood loss: You may lose significant blood if your fracture pierces your skin. You may lose more blood if your fracture pierces your skin than if it does not.
• Shock: You may go into shock from the injury.
• Hip damage: If you break the upper part of your femur, you may also break your hip. This is a common problem for people with osteoporosis.
• Knee damage: If you break the part of your femur just above your knee, you may damage your knee. This is a common problem for people with osteoporosis or people who have had knee replacements.
• Muscle, tendon, and ligament damage: The fracture may damage surrounding soft tissues.
• Nerve and blood vessel injury: The femur has major arteries nearby that can be damaged as a result of the fracture, leading to severe bleeding or blood clots^[7].

Warning signs of life-threatening complications include^[14]:

• Localized swelling in the legs or groin with redness and tenderness to touch
• Fever, sweats, chills, or excessive fatigue
• Chest pain or difficulty breathing
• Heavy or uncontrollable bleeding
• A bone fragment protruding through the skin
• Confusion or loss of consciousness

If you have any of these symptoms, call emergency services (911) immediately to seek urgent medical attention^[14].

Diagnosis

Healthcare providers diagnose broken femurs by examining your injured leg and using imaging tests^[2]. A femur fracture is diagnosed after a physical examination of the leg, during which the physician will evaluate the soft tissue around the joint to identify any signs of nerve or blood vessel injury^[10].

Imaging tests used to diagnose femur fractures include:

• X-rays: Multiple X-rays are taken to identify the location and type of the fracture^[2].
• Computed tomography (CT) scans: CT scans provide detailed images and help healthcare providers identify the exact location and severity of the fracture^[2]. They may also be needed to look for other injuries^[15].
• Magnetic resonance imaging (MRI): MRI scans may be used in some cases to assess soft tissue damage^[10].

These imaging studies allow the physician to identify the exact location of the fracture and determine the best treatment approach^[3].

Treatment

Femur fractures almost always require surgery to heal properly^[1]. The goal of treatment is early healing and long-term functional recovery^[4]. Treatment options depend on the severity of the fracture, the medical condition of the patient, and the patient’s lifestyle^[10].

Emergency and Initial Care

If you break your femur, you will need an ambulance. Paramedics or first responders may put a temporary brace, straps, or pillows around your leg to keep it still and reduce pain^[15]. At the hospital, doctors will check you all over for other injuries, as people with broken femurs often have other injuries too, some of which can be very serious or even life-threatening^[15].

As a temporary measure before surgery, healthcare providers may:

• Apply a splint that covers your whole leg and goes up toward your hip to help with pain and keep your broken femur still^[2].
• Use traction to treat your broken femur. There are two types: weighted traction splints that use a strap on your ankle with weights attached to a frame and pulley to put gentle pressure on your femur, or skeletal traction, where a pin is placed into your femur or tibia^[2]. If doctors cannot do surgery right away, they might put a traction pin in your leg to help keep the bone lined up^[15].

Surgical Treatment

Most femur breaks are fixed with surgery, usually within 24 to 48 hours^[17]. The most common way to fix a broken femur is intramedullary nailing, which is considered the gold standard and results in excellent outcomes^[4]. During this procedure, a metal rod is inserted into the center of the bone, and screws hold the broken bone in place while it heals^[1]. The rod helps support the bone until it heals^[9].

Other surgical methods include:

• Plates and screws: The surgeon may put a plate next to your bone that is attached by screws. This method is used when a rod cannot be put inside your bone^[15].
• External fixator: Sometimes fixation devices are attached to a frame outside your leg^[1]. An external fixator is used when the surrounding soft tissue is severely damaged, as the use of plates and screws may be harmful. Once the patient is prepared for surgery, the surgeon removes the external fixator and places internal fixation devices during surgery^[10].

Most of the time, the rods and plates used to help the bone heal will not need to be removed in a later surgery^[9].

Non-Surgical Treatment

Sometimes fractures that are simple, short cracks in the bone do not require surgery^[14]. Non-surgical treatment includes setting the leg and immobilization through a splint or cast to prevent weight bearing and help the healing process. X-rays are taken at regular intervals to assess the healing process, and weight bearing and movement are initiated gradually^[10]. In very young children, a cast is occasionally used instead of surgery^[15].

Recovery

Recovery from a femur fracture takes time and patience. Your broken femur can take months to heal^[2]. It usually takes about three months or more for the bone to fully heal^[15]. Recovery most often takes 4 to 6 months, depending on how severe your fracture is, whether you have skin wounds and how severe they are, and whether your nerves and blood vessels were injured^[9].

Hospital Stay and Initial Recovery

You will probably stay in the hospital for a few days after surgery. Nurses and therapists will help you start walking again^[15]. You may need crutches or a walker for a while, and you might need to go to a rehabilitation or nursing facility^[15]. Physical therapy may take place in a hospital, in a skilled nursing facility, in your home, or in an outpatient physical therapy clinic^[14].

You might be allowed to put weight on your leg right after surgery, but that depends on your surgeon^[15]. Your doctor will give you instructions about when you can start putting weight on your leg. Make sure you know the correct way to use a cane, crutches, or walker^[9].

Physical Therapy and Exercise

It is important to do exercises to keep your hip and thigh muscles strong and avoid stiffness^[15]. Physical therapists are movement experts who help people recover from femur fractures through hands-on care, patient education, and prescribed movement^[14]. Be sure to do the exercises your surgeon or physical therapist taught you to help build strength and flexibility^[9].

Follow-Up Care

You will see your surgeon a few times for check-ups. X-rays will be taken at these visits to make sure your bone is healing properly^[15]. You should see your surgeon or physician assistant 10-14 days after surgery, and typically at 2 weeks, 6 weeks, and 3 months from surgery^[16].

Home Safety

To promote healing and prevent falls during recovery, consider the following home modifications^[9]:

• Have a bed low enough so your feet touch the floor when you sit on the edge
• Remove tripping hazards such as loose wires, cords, and throw rugs
• Do not keep small pets in your home during recovery
• Fix any uneven flooring in doorways
• Ensure good lighting throughout your home
• Install hand rails in the bathtub or shower and next to the toilet
• Place a slip-proof mat in the bathtub or shower
• Set up your home so you do not have to climb steps—consider using a bedroom on the first floor and having a bathroom or portable commode on the same floor

Long-Term Outlook

Usually, femur breaks heal after surgery. Treatment of modern-day femoral shaft fractures results in excellent outcomes^[4]. Once your femur is healed, you can usually go back to doing the activities you did before your injury. Some people might have stiffness or soreness, but these problems usually get better over time^[15].

If the bone does not heal properly, a condition called non-union, you might need more surgery to help the bone heal^[15]. However, with proper treatment and rehabilitation, most people achieve long-term functional recovery^[4].