Femur Fracture in the ED – Remove the Traction

This article is brief overview of the management of femur fractures in the emergency department. In general, femur fractures can be identified with x-ray. AP pelvis, hip and femur x-rays will be sufficient in most cases. Femur fractures can be categorized as proximal fractures and femoral shaft fractures. There are subtle differences in management and outcomes depending on the location of the fracture.

Proximal femur fractures: classified by their anatomic location and whether they are intra- or extra-capsular.

Femoral Neck Fractures

• • These are intra-capsular fractures that may disrupt the blood supply to the femoral head. The vessels supplying the femoral head are also intracapsular, so patients are at risk for AVN of femoral head over the next several years (1).

• 10-15% of femoral neck fractures are nondisplaced, so they can be very subtle on x-ray. In order to identify occult fractures you should look for continuation of the trabecular lines in the bone, or look at the S and reverse S of the femoral head and neck (see figure below). If occult fracture is suspected, you should obtain advanced imaging. CT should be first choice, as it is readily available and will catch the vast majority of fractures (2). If CT is negative and there is still concern for fracture, patients will need MRI.

• • In displaced fractures, the leg will be shortened and externally rotated.

• Treatment is operative repair.

Intertrochanteric fractures

• • Extra-capsular fracture.

• • Leg will be externally rotated and shortened.

• Patient’s can lose a significant amount of blood, so resuscitation is key. Operative repair on the day of injury is associated with increased mortality.

Isolated trochanteric fracture

• • Fracture of the greater or lesser trochanter.

• Managed conservatively with non-weight bearing and orthopedics follow up.

Subtrochanteric fracture

• • Leg will be externally rotated and shortened.

• • Takes a high impact mechanism to fracture here, so other injuries are common.

• • Patient’s can lose a significant amount of blood so resuscitation is key.

• Most are managed operatively, however has high rate of hardware failure.

Femoral shaft fracture

• Patients with femoral shaft fracture will often come in with a Hare traction splint placed by EMS. This is called skin splinting and can do more damage than good. The theoretical benefit is pain control and fracture reduction, however a Cochrane review showed that it does not achieve either of these goals (2). The traction splint should be removed on arrival to the ED. It can result in neurologic damage and worsen injury at other sites. Femur fractures rarely result in femoral or sciatic nerve damage, as these are encased in muscle, however placement of a traction splint can stretch the nerves and cause damage. It can also cause skin breakdown at the sites where the splint attaches. Traction splints are contraindicated for several injuries that are commonly encountered with femoral shaft fractures: pelvic fractures, patella fractures, tibia or fibula fractures, and ligamentous knee injury. About 40% of patients who had these splints placed in the field actually had a contraindication to them (3). Traction should only be maintained if there is neuro-vascular compromise or gross deformity, and even then, patient should be going to operating room or orthopedics should be placing pins for skeletal traction. Otherwise, the leg should be immobilized with a pillow placed under the thigh to keep the hip in slight flexion or place a posterior leg splint to keep it immobilized.

• • Patient’s can lose a significant amount of blood so resuscitation is key.

• Treatment is often with internal fixation.

Pain management

• Do a fascia iliaca block or femoral nerve block with 0.5% bupivicaine as this will result in long acting analgesia (4). These produce similar analgesia (5) with the thought that fascia iliaca block is an easier technique.

Femoral nerve block: https://www.youtube.com/watch?v=5ht_N8j2KL8

Fascia iliaca block: https://www.emrap.org/episode/fasciailiaca/fasciailiaca

Key Points

1. 1. Resuscitation is key: though femur fractures can be impressive injuries that will draw your focus, remember that mortality in the first day is high if patient is not properly resuscitated

1. 1. Femoral neck fractures can be occult: if patient has significant pain or cannot ambulate, do advanced imaging

1. 1. Remove the traction splint: this can often result in worsening injury

1. 1. Immobilize the leg: either with a posterior splint or simply a pillow under the thigh

1. Do a fascia iliaca or femoral nerve block: this is a safe and effective way of obtaining analgesia

Read more articles on EM Orthopedic topics: Orthopedics

References

1. Walls, Ron. Rosen’s Emergency Medicine: concepts and clinical practice (9th ed). 2018. Philadelphia, PA: Elsiveier/Saunders
2. Rehman H, Clement RG, Perks F, White TO. Imaging of occult hip fractures: CT or MRI? Injury. 2016 Jun;47(6):1297-301
3. Handoll HH, Queally JM, Parker MJ. Pre-operative traction for hip fractures in adults. Cochrane Database Syst Rev. 2011 Dec 7;(12)
4. Wood SP, Vrahas M, Wedel SK. Femur fracture immobilization with traction splints in multisystem trauma patients. Prehosp Emerg Care. 2003 Apr-Jun;7(2):241-3.
5. Xin Wang, et al. Femoral nerve block versus fascia iliaca block for pain control in total knee and hip arthroplasty: A meta-analysis from randomized controlled trials. Medicine (Baltimore). 2017 Jul; 96(27)
6. Unneby A, Svensson O, Gustafson Y, Olofsson B. Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial. Injury. 2017 Jul;48(7)

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