Adults require skeletal traction as the traction needed to overcome muscle forces will exceeded the limit of skin traction. A Denham pin is inserted into the proximal tibia and balanced skeletal traction with a Thomas splint suspended in a Balkan frame is set up.
An acceptable reduction must be obtained within the first week. Take X rays in the traction after each adjustment to gauge the effect. Initial weights (at 'a' in the drawing) are 10% body weight. These can be adjusted to minimize shortening or distraction. Any abduction of the proximal fragment is counteracted by abducting the distal limb (swing the Balkan frame wide of the bed.) Flexion of the proximal fragment is addressed by flexing the whole limb ( move pulley 'a' up on the vertical pole of the Balkan frame.
Conservative treatment requires at least 3 months in bed in the Thomas Splint and another 3 months mobilization using crutches. It requires about a year before the patient may take part in active sport. For this reason as well as the high cost of hospitalization, most femur shaft fractures today are treated with some form of internal fixation. Indications for conservative treatment are severely contaminated wounds and other sepsis.
Open reduction and internal fixation
The majority of femoral shaft fractures are treated by open reduction and internal fixation. In the past plates and screws were used. This method, however has a high rate of sepsis and the plates are prone to failure from metal fatigue. Each hole of the plate is a stress raiser and the plate can fracture through these.
If a plate is used bone grafting on the medial side may speed up union the race between plate failure and fracture consolidation.
Closed intramedullary nailing is the method of choice. An awl is used to make an entry point in the greater trochanter or piriform fossa and a guide wire is inserted and guided across the fracture using fluoroscopic control. Once this is in position the femur can be reamed by using a series of cannulated reamers of increasing diameters. Unreamed IM pins can be used and these may be preferable in the multiple injured patient or patients otherwise at great risk of fat embolism syndrome.
The IM pin has only proximal and distal fansfixion screws to control rotation and maintain length.
Retrograde intramedullary pins also have a place in the treatment of femur shaft fractures. This type of pin is inserted from the knee upwards and locked both proximally and distally with transfixion screws.
Indications for a retrograde femoral pin