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Femur Injuries and Fractures

Author: Douglas F Aukerman, MD, Associate Professor, Department of


Orthopedics and Rehabilitation, Division of Sports Medicine, Department of Family
Medicine, Penn State University
Coauthor(s): John R Deitch, MD, Director of Sports Medicine, Wellspan
Orthopedics; Janos P Ertl, MD, Assistant Professor, Department of Orthopedic
Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery,
Wishard Hospital; William Ertl, MD, Clinical Assistant Professor, Department of
Orthopedics, University of Oklahoma
Contributor Information and Disclosures

Updated: Oct 30, 2008

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• Overview
• Differential Diagnoses & Workup
• Treatment & Medication
• Follow-up
• Multimedia

• References
• Keywords

Introduction
Background

The spectrum of femoral shaft fractures is wide and ranges from nondisplaced femoral
stress fractures to fractures associated with severe comminution and significant soft-
tissue injury. Femoral shaft (see image below) fractures are generally caused by high-
energy forces and are often associated with multisystem trauma. Isolated injuries can
occur with repetitive stress and may occur in the presence metabolic bone diseases,
metastatic disease, or primary bone tumors. 1,2
An example of an isolated, short, oblique midshaft femoral fracture, which is
very amenable to intramedullary nailing. Although not seen in this x-ray
film, radiographic visualization of both the proximal and distal joints
should be performed for all diaphyseal fractures.

[ CLOSE WINDOW ]

An example of an isolated, short, oblique midshaft femoral fracture, which is


very amenable to intramedullary nailing. Although not seen in this x-ray
film, radiographic visualization of both the proximal and distal joints
should be performed for all diaphyseal fractures.

Most femoral diaphyseal fractures are treated surgically with intramedullary nails or
plate fixation. The goal of treatment is reliable anatomic stabilization, allowing
mobilization as soon as possible. Surgical stabilization is also important for early
extremity function, allowing both hip and knee motion and strengthening. Injuries and
fractures of the femoral shaft may have significant short- and long-term effects on the
hip and knee joints if alignment is not restored.

Treatment of femoral shaft fractures has undergone significant evolution over the past
century. Until the recent past, the definitive method for treating femoral shaft
fractures was traction or splinting. Before the evolution of modern aggressive fracture
treatment and techniques, these injuries were often disabling or fatal. Traction as a
treatment option has many drawbacks, including poor control of the length and
alignment of the fractured bone, development of pulmonary insufficiency, deep vein
thrombosis, and joint stiffness due to supine positioning.

The femur is very vascular and fractures can result in significant blood loss into the
thigh. Up to 40% of isolated fractures may require transfusion, as such injuries can
result in loss of up to 3 units of blood.3 This factor is significant, especially in elderly
patients who have less cardiac reserve.

Femoral fracture patterns vary according to the direction of the force applied and the
quantity of force absorbed. A perpendicular force results in a transverse fracture
pattern, an axial force may injure the hip or knee, and rotational forces may cause
spiral or oblique fracture patterns. The amount of comminution present increases with
the amount of energy absorbed by the femur at the time of fracture.1,2,4,5

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and
Dislocations Center and Sports Injury Center. Also, see eMedicine's patient education
article Broken Leg.

Related eMedicine topics:


Femoral Neck Stress and Insufficiency Fractures [in the Orthopedic Surgery section]
Femoral Neck Stress Fracture
Fracture, Femur [in the Emergency Medicine section]

Related Medscape topics:


Resource Center Exercise and Sports Medicine
Specialty Site Emergency Medicine
Specialty Site Orthopaedics
CME A 49-Year-Old Man With a Femur Fracture and Hyperdense Bones
CME Vitamin D and Musculoskeletal Health
Alendronate Use Linked to Low-Energy Femoral Fractures

Frequency

United States

• The incidence of femoral fractures is reported as 1-1.33 fractures per 10,000


population per year (1 case per 10,000 population).
• In individuals younger than 25 years and those older than 65 years, the rate of
femoral fractures is 3 fractures per 10,000 population annually.
• These injuries are most common in males younger than 30 years. Causes may
include automobile, motorcycle, or recreational vehicle accidents or gunshot
wounds.
• The average number of days lost from work or school from femoral
fractures is 30.
• The average number of days of restricted activity due to femoral fractures is
107.
• The incidence of femoral injuries and fractures increases in elderly patients.

Functional Anatomy

The femur is the strongest, longest, and heaviest bone in the body and is essential for
normal ambulation. It consists of 3 parts (ie, femoral shaft or diaphysis, proximal
metaphysis, distal metaphysis). The femoral shaft is tubular with a slight anterior
bow, extending from the lesser trochanter to the flare of the femoral condyles. During
weight bearing, the anterior bow produces compression forces on the medial side and
tensile forces on the lateral side. The femur is a structure for standing and walking,
and it is subject to many forces during walking, including axial loading, bending, and
torsional forces. During contraction, the large muscles surrounding the femur account
for most of the applied forces.1,2,4,5

Several large muscles attach to the femur. Proximally, the gluteus medius and
minimus attach to the greater trochanter, resulting in abduction of the femur with
fracture. The iliopsoas attaches to the lesser trochanter, resulting in internal rotation
and external rotation with fractures. The linea aspera (rough line on the posterior shaft
of the femur) reinforces the strength and is an attachment for the gluteus maximus,
adductor magnus, adductor brevis, vastus lateralis, vastus medialis, vastus
intermedius, and short head of the biceps. Distally, the large adductor muscle mass
attaches medially, resulting in an apex lateral deformity with fractures. The medial
and lateral heads of the gastrocnemius attach over the posterior femoral condyles,
resulting in flexion deformity in distal-third fractures.

The blood supply enters the femur through metaphyseal arteries and branches of the
profunda femoris artery, penetrating the diaphysis and forming medullary arteries
extending proximally and distally. With intramedullary nailing, the blood supply is
disrupted and progressively reestablishes itself over 6-8 weeks. Healing of the fracture
is enhanced by the surrounding soft tissue and local recruitment of blood supply
around the callus. The femoral artery courses down the medial aspect of the thigh to
the adductor hiatus, at which time it becomes the popliteal artery. Injuries to the artery
occur at the level of the adductor hiatus, where soft-tissue attachments may cause
tethering. Uncommonly, the sciatic nerve is injured in femoral shaft fractures;
however, it may become injured in proximal or distal femoral injuries.

Related eMedicine topics:


Nerve Entrapment Syndromes [in the Neurosurgery section]
Nerve Entrapment Syndromes of the Lower Extremity [in the Orthopedic Surgery
section]

Sport-Specific Biomechanics
Trauma-induced fractures of the femur occur with contact and during high-speed
sports. A significant amount of energy is transferred to the limb in a femur fracture,
such as might be generated in skiing, football, hockey, rodeo, and motor sports.

Stress fracture

A femoral stress fracture is the result of cyclic overloading of the bone or a dramatic
increase in the muscular forces across their insertion, causing microfracture. These
repetitive stresses overcome the ability of the bone to heal the microtrauma. The area
most susceptible to stress fracture is the medial junction of the proximal and middle
third of the femur, which occurs as a result of the compression forces on the medial
femur.

Stress fractures can also occur on the lateral aspect of the femoral neck in areas of
distraction and are less likely to heal nonoperatively than compression-side stress
fractures. Stress fractures occur most often in repetitive overload sports such as in
runners and in baseball and basketball players. For more information, refer to the
eMedicine article Femoral Neck Stress Fracture.

Clinical
History

Femoral shaft fractures are the result of high-energy injuries. These fractures are often
accompanied by other injuries. The first priority in treatment is to rule out other life-
threatening injuries and stabilize the patient. Advanced Trauma Life Support (ACLS)
guidelines should be followed.

• History of traumatic femoral fractures


o The history of a femoral shaft fracture is not subtle.
o A high-velocity injury is usually involved, and significant pain and
inability to bear weight are present.
o Patients may be noted to have a shortening of one leg, swelling, and
gross deformity.
o Fractures are commonly associated with other bony injuries, including
tibial shaft fractures, ipsilateral femoral neck fractures, and extension
of the fracture into the distal femur.
• History of femoral stress fractures
o These are observed with increasing frequency in joggers.6,7
o Factors involved in stress fractures include a sudden increase in
mileage, intensity, or frequency of training.
o A change in terrain or running surface may contribute.
o Improper footwear and poor biomechanics can be another factor.
o The onset of stress fractures is usually gradual; however, it may be
sudden or severe.
o Patients may report groin or thigh pain.
o Symptoms of stress fractures are aggravated by activity and relieved by
rest.
o Female runners may have an abnormal menstrual history and may have
a history of disordered eating.

Related eMedicine topics:


Female Athlete Triad
Low Energy Availability in the Female Athlete
Nutrition for the Female Athlete

Physical

• Physical examination of traumatic femoral fractures


o Serious femoral fracture–associated injuries must be addressed, and
ACLS guidelines must be used.
o A head-to-toe examination is indicated.
o Palpate the pelvis, hips, and knees.
o Correct any lower extremity deformity by applying inline longitudinal
traction.
o A distal vascular assessment is necessary.
o Finally, a distal neurologic assessment is indicated.
• Physical examination of femoral stress fractures
o Usually, the patient has few physical findings in cases of femoral stress
fractures.
o Palpate at the site of symptoms.
o The thigh may be swollen.
o Range of motion is limited by pain.
o Pain may be reported with forced rotation or axial loading.
o Pain usually radiates into the groin area.
o More than 65° of external rotation is believed to be a risk factor.
o Bilateral symptoms have been reported.

Causes

• Traumatic causes of femoral fractures


o Motor vehicle trauma (eg, motorcycle races, auto races, auto crash,
plane crash, auto/pedestrian accident)
o Sports (eg, high-speed and contact sports with direct trauma, skiing,
football, hockey)
o Falls (eg, from height, mountain climbing, pole vaulting)
o Gunshot wounds
o Metabolic bone disease
o Tumors (primary or metastatic)
• Stress fracture causes of femoral fractures
o Running
o Jogging
o Metabolic bone disease
o Amenorrheic or oligomenorrheic female runners
o Abnormal bone mineral density
o Improper training
o Improper footwear
Differential Diagnoses
Compartment Syndromes
Hip Dislocation
Hip Fracture

Other Problems to Be Considered

Associated extremity fractures


Disorders of bone metabolism
Ipsilateral femoral neck fracture
Ipsilateral knee ligament injury (up to 50%)
Ipsilateral meniscal injury (up to 30%)
Spine fractures
Stress fracture - Tumor (osteoid osteoma)
Tibia fracture (floating knee)
Trauma -Knee dislocation
Vascular injuries

Workup
Laboratory Studies

• Laboratory workup in cases of traumatic femoral fractures


o Complete blood cell (CBC) count
o Chemistry panel
o Prothrombin time (PT) / activated partial prothrombin time (aPTT)
o Urinalysis (UA)
o Type and screen or cross-match

Imaging Studies

• Imaging studies in cases of traumatic femoral fractures


o Radiograph of the chest
o Spine radiograph series
o Anteroposterior radiograph of the pelvis
o Anteroposterior-lateral radiograph of the femur (see image below), hip,
and knee
o
X-ray film of femur fracture.

[ CLOSE WINDOW ]
X-ray film of femur fracture.

o Computed tomography (CT) scan of the head, if indicated


• Imaging studies in cases of femoral stress fractures
o Anteroposterior-lateral radiographs of the femur: Findings are typically
delayed for 2-6 weeks after the onset of symptoms; these films are
useful for making a late confirmation of the diagnosis.
o Radionucleotide scanning: This is the criterion standard for diagnosis;
these studies are more sensitive than and may show abnormalities 3
weeks before plain radiographs.
o Magnetic resonance imaging (MRI): MRIs reveal bone marrow signal
earlier in the stress-reaction process than standard radiographs and
radionuclear scanning.
o Bone mineral density evaluation: Use this test to rule out osteoporosis
or osteopenia.

eMedicine Specialties > Sports Medicine > Lower


Limb

Femur Injuries and Fractures:


Treatment & Medication
Author: Douglas F Aukerman, MD, Associate Professor, Department of
Orthopedics and Rehabilitation, Division of Sports Medicine, Department of Family
Medicine, Penn State University
Coauthor(s): John R Deitch, MD, Director of Sports Medicine, Wellspan
Orthopedics; Janos P Ertl, MD, Assistant Professor, Department of Orthopedic
Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery,
Wishard Hospital; William Ertl, MD, Clinical Assistant Professor, Department of
Orthopedics, University of Oklahoma
Contributor Information and Disclosures

Updated: Oct 30, 2008

• Print This

• Email This
• Overview
• Differential Diagnoses & Workup
• Treatment & Medication
• Follow-up
• Multimedia

• References
• Keywords

Treatment
Acute Phase

Rehabilitation Program

Physical Therapy
Treatment for acute trauma-related femoral fractures is performed by an orthopedic
surgeon and usually involves surgical stabilization (see Surgical Intervention).1,2

For femoral stress fractures of the medial compression side, protected crutch-assisted,
touch-down weight bearing is implemented for 1-4 weeks, based on the resolution of
symptoms and the appearance of callus. Progression to full weight bearing can
gradually commence once pain has resolved. Patients must avoid running for 8-16
weeks while the low-impact training program/phase is completed. The progression
can include (1) cycling, (2) swimming, and (3) running in chest-deep water before
resuming more intensive weight-bearing training. Patients must maintain upper
extremity and cardiovascular fitness and avoid lower extremity exercise early in the
healing process. Prophylactic rod placement is not indicated in femoral stress
fractures.

Medical Issues/Complications

The emergent management of femur injuries in the sports setting is intended to restore
alignment. If limb deformity is present, inline longitudinal traction is applied,
realigning the extremity and maintaining limb perfusion. A splint is applied to
maintain the alignment as the patient is transported to the hospital for definitive
treatment.

Surgical Intervention

In cases of traumatic femoral fractures, the trauma surgeon implements multisystem


stabilization and clearance for surgical intervention. Consultations with appropriate
specialists must be arranged for specific systems. Traction may be necessary for
initial stabilization to maintain leg length before impending surgery.

Before definitive operative management of a femoral shaft fracture, the patient should
be hemodynamically stable and fully resuscitated. The goal time to definitive surgical
stabilization is generally 24 hours. However, if the patient is hemodynamically
unstable and has not been adequately resuscitated, femoral fixation should be delayed
and temporized with an external fixator or skeletal traction.

Intramedullary nailing (see image below) is the treatment of choice for the majority of
femoral shaft fractures occurring in adults. Reamed locked antegrade femoral nailing
remains the criterion standard and can be performed with the patient in the supine or
lateral position with or without the use of a fracture table.1,2,8,9
X-ray film of femur fracture repair.

[ CLOSE WINDOW ]
X-ray film of femur fracture repair.

Clinical studies have suggested the results of retrograde femoral nailing approach the
success rates that are found with antegrade techniques. Retrograde nailing may be
preferred when the fracture involves the distal femur or is associated with an
ipsilateral femoral neck fracture. A floating knee (ie, an ipsilateral femoral shaft and
tibia shaft fracture) is also a relative indication for a retrograde technique. The
retrograde technique has also been found to be beneficial in obese patients, pregnant
patients, and patients with total hip or total knee prostheses.

Consultations
Consultation with orthopedic surgeons is required in cases of femoral fractures, and a
definitive treatment plan is left to their judgment.

Recovery Phase

Rehabilitation Program

Physical Therapy

With trauma-related femoral fractures, initiate physical therapy to improve hip and
knee range of motion and for strengthening. Gait training for crutch-assisted, touch-
down weight bearing may be necessary depending on the fracture pattern. In simple
fracture patterns, which are axially stable postoperatively, greater weight bearing can
be initiated. The goal of the therapy program should be immediate weight bearing to
tolerance. Pulmonary therapy is instituted as needed.

For femoral stress fractures, discontinue crutches once pain-free walking is possible.
Increase low-impact lower extremity aerobic training (eg, swimming, biking, elliptical
trainer) as symptoms permit. Attempt to identify causative factors of the femoral
stress fractures (eg, improper training techniques, footwear, diet).

Maintenance Phase

Rehabilitation Program

Physical Therapy

With trauma, weight bearing is permitted once bone-healing stability has been
achieved. Continue to monitor with radiographs in an outpatient setting.

For stress fractures, this phase lasts a minimum 6 weeks since the onset of symptoms.
Recommend 30-45 minutes of pain-free bike riding on a flat surface. The patient must
avoid causative factors. Poor training areas and equipment must be corrected. During
the first week, the patient can begin walking 3-5 mile/wk. At week 2, the patient can
advance to walking or running 5 mile/wk. At week 3, the patient can run 5 mile/wk
(minimum of 9 wk after symptom onset). Patients can gradually return to 50% of their
previous training distance over the ensuing 1-2 weeks. If symptoms recur, return to
the beginning of the previous phase for a minimum of 3 weeks.

Surgical Intervention

Before definitive operative management of a femoral shaft fracture, the patient should
be hemodynamically stable and fully resuscitated. The goal time to definitive surgical
stabilization is generally 24 hours. However, if the patient is hemodynamically
unstable and has not been adequately resuscitated, femoral fixation should be delayed
and temporized with an external fixator or skeletal traction.

Intramedullary nailing is the treatment of choice for the majority of femoral shaft
fractures occurring in adults. Reamed locked antegrade femoral nailing remains the
criterion standard and can be performed with the patient in the supine or lateral
position with or without the use of a fracture table. Clinical studies suggest the results
of retrograde femoral nailing approach the success rates that are found with antegrade
techniques.

Retrograde nailing may be preferred when the fracture involves the distal femur or is
associated with an ipsilateral femoral neck fracture. A floating knee is also a relative
indication for a retrograde technique. The retrograde technique has also been found to
be beneficial in obese patients, pregnant patients, and patients with total hip or total
knee prostheses.

Plate fixation may be used when femoral fractures are associated with vascular injury
that requires repair or with ipsilateral femoral neck fractures. Limited-incision
techniques and the use of locked plating systems are evolving.

Medication
Medication for trauma-related fractures includes pain medication as indicated for
reasonable pain. nonsteroidal anti-inflammatory medications (NSAIDs) may inhibit
bone healing.

Related eMedicine topics:


Toxicity, Narcotics
Toxicity, Nonsteroidal Anti-inflammatory Agents

Related Medscape topics:


Resource Center Opioids: A Guide to State Opioid Prescribing Policies
Resource Center Pain Management: Advanced Approaches to Chronic Pain
Management
Resource Center Pain Management: Pharmacologic Approaches

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort,
promote pulmonary toilet, and have sedating properties, which are beneficial for
patients with trauma.

Acetaminophen and codeine (Tylenol With Codeine [# 3])

Indicated for mild to moderate pain.

• Dosing
• Interactions
• Contraindications
• Precautions

Adult
30-60 mg/dose PO based on codeine q3-4h, not to exceed 4 g/d of acetaminophen

Pediatric

0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on


acetaminophen; not to exceed 2.6 g/d of acetaminophen

• Dosing
• Interactions
• Contraindications
• Precautions

Toxicity of codeine increases with CNS depressants, TCAs, MAOIs, neuromuscular


blockers, CNS depressants, phenothiazines, and narcotic analgesics

Rifampin can reduce the analgesic effects of acetaminophen; coadministration with


barbiturates, carbamazepine, hydantoins, and isoniazid may increase the
hepatotoxicity of acetaminophen.

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in
humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients who are dependent on opiates, because this substitution may result
in acute opiate-withdrawal symptoms; caution in the presence of severe renal or
hepatic dysfunction

Hepatotoxicity with acetaminophen is possible in the presence of chronic alcoholism


following various dose levels; severe or recurrent pain or high or continued fever may
indicate a serious illness; acetaminophen is contained in many OTC products, and
combined use with these products may result in cumulative acetaminophen doses and
exceed the recommended maximum dose.
Hydrocodone and acetaminophen (Lortab, Norcet, Vicodin)

Drug combination for moderate to severe pain.

• Dosing
• Interactions
• Contraindications
• Precautions

Adult

1-2 tab or cap PO q4-6h prn pain

Pediatric

<12 years: 10-15 mg/kg/dose based on acetaminophen PO q4-6h prn; not to exceed
2.6 g/d acetaminophen

>12 years: 750 mg based on acetaminophen PO q4h; not to exceed 10 mg


hydrocodone bitartrate per dose or 5 doses/24 h

• Dosing
• Interactions
• Contraindications
• Precautions

Coadministration with phenothiazines may decrease the analgesic effects; toxicity


increases with CNS depressants TCAs.

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity; HACE or elevated ICP

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in
humans; may use if benefits outweigh risk to fetus

Precautions

The tablets contain metabisulfite, which may cause hypersensitivity; caution in


patients who are dependent on opiates, because this substitution may result in acute
opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic
dysfunction

Propoxyphene and acetaminophen (Darvocet N-100, Propacet)

Drug combination for mild to moderate pain.

• Dosing
• Interactions
• Contraindications
• Precautions

Adult

1-2 tab PO q4h prn; not to exceed 600 mg/d propoxyphene

Pediatric

Not established

Follow-up
Return to Play

In cases of traumatic femoral fractures, schedule a clinic follow-up visit at 2 weeks, 6


weeks, 3 months, 6 months, and 1 year. The femoral fracture should be healed by 3
months. Once bony union is complete, treatment is focused on muscle rehabilitation.
Progressive strengthening of all lower extremity musculature is initiated and
continued until strength is 95% of the contralateral extremity.

Sports-specific rehabilitation is initiated once strength has been regained. The athlete
should be back to preinjury status at 1 year postinjury. Long-term symptoms include
hamstring weakness, limited standing and walking (39%), some intermittent pain
(37%), and inability to return to preinjury work (9%).

For femoral stress fractures, a minimum time of 6 weeks is necessary for bone healing
to occur before the patient is able to resume activities. The athlete should resume
activities in a very gradual fashion over the course of several weeks. If symptoms
recur during training, the athlete should return to the previous phase of treatment for a
minimum of 3 weeks.

Complications

• Complications following traumatic femoral fractures


o Refracture
o Hardware failure
o Prominent hardware
o Neurologic injury
o Peroneal nerve palsy - Most commonly due to traction
o Pudendal nerve injury - Due to compression at the perineal post
o Sciatic nerve injury
o Vascular injury
o False aneurysm
o Atrioventricular fistula - Requires angiogram
o Compartment syndrome
o Nonunion - Rate of 1%
o Delayed union
o Malunion
o Heterotopic ossification
o Infection
• Complications following femoral stress fractures
o Progression to a complete fracture
o Refracture
o Nonunion

Prevention

Femoral stress fractures can be prevented or minimized by proper training techniques.


Gradual increase in activity intensity and duration allow the body to respond to the
increase load stresses. Maintaining proper footwear and not allowing footwear to
break down, adequate rest periods in training, and good nutrition are also important
aspects of prevention.

Prognosis

Of posttraumatic diaphyseal femur fractures, 95% heal with antegrade femoral


nailing. Malunion and infection rates are low (less than 1%).

Surgical management is rarely needed to treat femoral stress fractures; however,


surgical stabilization is recommended for recalcitrant cases.

Miscellaneous
Medicolegal Pitfalls

• Failure to address conditions that may accompany femur fractures and injuries
• Missed fractures or dislocations due to concentration on the obvious pain and
deformity of the femur

Multimedia
Media file 1: An example of an isolated, short, oblique
midshaft femoral fracture, which is very amenable to
intramedullary nailing. Although not seen in this x-ray film,
radiographic visualization of both the proximal and distal
joints should be performed for all diaphyseal fractures.

(Enlarge Image)
[ CLOSE WINDOW ]
An example of an isolated, short, oblique midshaft femoral fracture, which is
very amenable to intramedullary nailing. Although not seen in this x-ray
film, radiographic visualization of both the proximal and distal joints
should be performed for all diaphyseal fractures.

Media file 2: X-ray film of femur fracture.

(Enlarge Image)
[ CLOSE WINDOW ]
X-ray film of femur fracture.

Media file 3: X-ray film of femur fracture


repair.
(Enlarge Image)