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Clinical Practice Guidelines

Femoral shaft fractures - Fracture clinics

  • Fracture Guideline Index

    See also:  Femoral shaft fractures - Emergency Department

    1. How often should these fractures be followed up in fracture clinics?
    2. What should I review at each appointment?
    3. What are the potential complications associated with this injury?
    4. When should I refer for an orthopaedic consultant opinion?
    5. What are the indications for discharge?

    1. How often should these fractures be followed up in fracture clinics?

    Fracture type

    First appointment

    Subsequent review appointments

    Discharge advice to parents

    Hip spica

    At 1 week with x-ray to check position

    At 2 weeks with x-ray, then at 6 weeks with x-ray and cast removal

    Use pusher and allow child to take up walking when ready

    TENS nails

    At 2 weeks for wound check and x-ray

    At 6 weeks with x-ray to determine weight bearing status, then 12 weeks with x-ray to determine timing of nail removal

    Continue with crutch walking until confident. Physiotherapy to ensure knee range of motion (ROM)

    No contact sports for two months

    Plating/intramedullary nail

    At 2 weeks for wound check and x-ray

    At 6 weeks and 12 weeks with x-rays. Consider need for hardware removal when fracture healed at 12 -18 months

    Continue with crutch walking until confident. Physiotherapy to ensure knee ROM

    No contact sports for two months

    2. What should I review at each appointment?

    • Fracture position and healing
    • Any surgical wounds
    • Assessment of hip spica cast if applicable

    Acceptable position for femoral fractures:

    • Age <2 years: 30 degree varus/valgus, 30 degree flex/ext, 20 mm shortening
    • Age 2-5 years: 15 degree varus/valgus, 20 degree flex/ext, 20 mm shortening
    • Age 6-10 years: 10 degree varus/valgus, 15 degree flex/ext, 15 mm shortening
    • Age 11-maturity: 5 degree varus/valgus, 10 degree flex/ext, 10 mm shortening

    3. What are the potential complications associated with this injury?

    • Leg length difference - femoral shaft fractures can overgrow up to 2 cm (average 1 cm) in the 2 years after the fracture for patients aged 2-10 years. The fracture can also heal in a shortened position
    • Malunion - the fracture is at risk of malunion, dependent on location and method of stabilisation.  Varus and procurvatum are the most common malunions.  Torsional deformity is rarely of clinical consequence
    • Refracture - most common with short oblique/transverse fracture patterns. Also potential risk post-ex-fix or hardware removal
    • Delayed/nonunion - more common with weight bearing implants (e.g. plates, ex-fix)

    4. When should I refer for an orthopaedic consultant opinion?

    Indications for a consultant orthopaedic surgeon opinion are:

    • loss of position of the fracture beyond an acceptable position
    • any complication that develops

    5. What are the indications for discharge?

    Healed fracture, with hardware removed or no need for any hardware removal.  No concerns for growth disturbance or avascular necrosis (AVN) for proximal fractures. 

    References (Outpatient setting)

    Flynn JM, Skaggs DL. Femoral shaft fractures. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.797 -841.