Proximal Femoral Shaft Fracture Management

Key Physical Examination Findings

The affected leg will appear shortened and externally rotated, which is a pathognomonic finding that enables early clinical recognition even before radiography, according to the American College of Surgeons 1, 2, 3, 4, 5
Severe pain on movement is characteristic, as hip fractures are particularly painful with any attempted motion, and patients typically present with hip pain, particularly on movement 1, 2, 3, 4, 5
Complete inability to weight-bear will be present in virtually all cases, which is a key finding in patients with proximal femoral shaft fractures 1, 2, 3, 4, 5

Immobilize the limb immediately to minimize pain and prevent further injury, as recommended by the American Academy of Orthopaedic Surgeons 1, 2, 3, 4, 5
Administer regular paracetamol routinely unless contraindicated, as it is a recommended first-line analgesic for patients with hip fractures 1, 2, 3, 4, 5
Use opioids cautiously, as approximately 40% of hip fracture patients have moderate renal dysfunction, requiring dose reduction until urea and electrolytes are reviewed, according to the American Geriatrics Society 1, 2, 3, 4, 5
Avoid NSAIDs as they are relatively contraindicated due to high prevalence of renal dysfunction in this population, as recommended by the American College of Rheumatology 1, 2, 3, 4, 5

Do not delay pain assessment and management, as early and effective analgesia is crucial in patients with hip fractures, according to the American Society of Anesthesiologists 1, 2, 3, 4, 5
Do not prescribe NSAIDs without checking renal function first, as this population has extremely high rates of renal impairment, as recommended by the National Kidney Foundation 1, 2, 3, 4, 5
Do not use standard opioid dosing in elderly patients, as reduce both dose and frequency, particularly in those with renal dysfunction, according to the American Geriatrics Society 1, 2, 3, 4, 5

In children with proximal femur fractures, opioid analgesia should be added cautiously for severe pain, using weight‑based dosing to achieve adequate relief while minimizing adverse effects. 6
Regular paracetamol (acetaminophen) is recommended throughout the peri‑operative period to provide baseline analgesia and reduce opioid requirements. 7
Opioid use should be reduced in dose and frequency when renal dysfunction is present, to avoid accumulation and toxicity. 7

Non‑steroidal anti‑inflammatory drugs (NSAIDs) must be avoided until renal function has been confirmed, because they are relatively contraindicated in patients at risk for renal impairment. 6

A full blood count should be obtained to detect anemia that may result from fracture‑related hemorrhage, guiding transfusion and overall management. 8
Serum urea and electrolytes should be measured to assess renal function before initiating NSAIDs or adjusting opioid dosing, ensuring safe pharmacologic therapy. [8][6]

Codeine should be avoided in this population because it commonly causes constipation, nausea/vomiting, and may lead to cognitive dysfunction. 7