Orthopedic Management of Femur Fractures

Diagnosis and Imaging

• The American College of Radiology recommends radiography as the gold standard for diagnosing femur fractures, with orthogonal views (anteroposterior and cross-table lateral) being the standard initial imaging approach, and an AP view of the pelvis is recommended to evaluate for associated pelvic fractures 1
• Bone scintigraphy is a second-line diagnostic test for detecting fractures, with radiography having 90-95% sensitivity and 68-100% specificity for detecting these fractures, and consideration should be given to imaging the contralateral femur as bilateral involvement occurs in up to 30% of cases 2
• For incomplete atypical femur fractures, CT is useful for discerning the presence of lucency in incomplete fractures, and MRI can determine the presence of radio-occult stress-related changes and define the extent of cortical involvement 2
• The following table summarizes the sensitivity of different imaging modalities for detecting occult femur fractures:

3, 4, 1, 5

Treatment and Management

• Surgical stabilization with a cephalomedullary nail is strongly recommended for intertrochanteric lesions with erosion through the anterior cortex to prevent complete fracture and restore function, with a good analgesic effect accomplished in the majority of patients 6, 7
• A sliding hip screw is recommended for stable intertrochanteric fractures, while non-displaced stable femoral neck fractures can be treated with percutaneous cannulated fixation, and displaced femoral neck fractures in active and independent patients without cognitive dysfunction can be treated with total hip replacement 8
• Centromedullary nailing is the technique of choice for stabilizing diaphyseal femoral fractures, providing excellent results in terms of pain relief and recovery of ambulation in most patients, as recommended by the National Comprehensive Cancer Network 9
• Surgical treatment is indicated for patients with persistent or increasing local pain despite radiation therapy, solitary well-defined lytic lesion involving >50% of the cortex, involvement of the proximal femur with erosion through cortex, or diffuse involvement of the bone 7
• Contraindications to surgical treatment include survival expectancy <4 weeks or poor general condition that prevents safe operation, as recommended by the British Association of Surgical Oncologists 7

Adjuvant Therapies and Rehabilitation

• Adjuvant radiotherapy should be performed 2-4 weeks following orthopedic procedure, with a typical schedule of 30 Gy in 10 fractions or an alternative schedule of 20 Gy in 5 fractions, as recommended by the British Association of Surgical Oncologists 7
• Pain management with multimodal analgesia is recommended, and operative intervention for metastatic fractures provides good functional results in approximately 80-85% of patients 7, 10
• Consider bone-modifying agents for metastatic lesions, as recommended by the American Academy of Orthopaedic Surgeons 6
• Early mobilization to improve oxygenation and respiratory function is recommended, with up to 60% of patients with hip fracture being malnourished on admission, and nutritional supplementation may reduce mortality and length of stay 11
• Immediate, full weight-bearing to tolerance after surgery is recommended for most comminuted fractures, and venous thromboembolism prophylaxis is strongly recommended 12
• A suitable rehabilitation program should include early post-fracture physical training, muscle strengthening, and long-term balance training and multidimensional fall prevention, as recommended by the American Academy of Orthopaedic Surgeons and the American College of Rheumatology 8

Follow-up and Complications

• Regular imaging to assess healing progression, including follow-up radiographs at 2, 6, and 12 weeks for surgically treated fractures, is essential for monitoring complications 4
• Fat embolism is a rare complication, but the risk can be reduced with early surgery, and patients on long-term bisphosphonate therapy should be monitored for atypical femoral fractures 13, 2, 14
• Administering tranexamic acid to reduce blood loss and blood transfusion, and monitoring hemoglobin levels closely, especially with extracapsular fractures which can have significant blood loss, is recommended by the American Academy of Orthopaedic Surgeons 10, 11
• Each patient aged 50+ with a recent fracture should be evaluated systematically for the risk of subsequent fractures, and evaluation of osteoporosis is recommended in patients over 50 years old with fragility fractures 8, 12