1. Traction may be used for initial management, or rarely as definitive treatment with balanced skeletal traction in a Thomas splint. A traction force of 10-15 lb is used and the patient's hip and knee are mobilized in bed. When the fracture shows signs of union at 6-8 weeks, the patient is mobilized partially weight-bearing, often in a cast brace. Traction is occasionally advocated where co-morbidity prevents surgical stabilization.
2. Internal fixation with an IM nail, inserted by a closed technique with interlocking screws, is the treatment of choice for the majority of femoral shaft fractures, with predictable healing rates. An accurately placed entry point is crucial to successful insertion. The femoral canal should be reamed 1-2 mm greater than the nail diameter. Stability of the knee should be assessed under anaesthetic at the end of the procedure. Infection is seen in less than 1% of cases and non-union is rare even with static interlocking screws. Reconstruction nails, with screws inserted along the femoral neck into the head, are used for ipsilateral femoral neck fractures. Open fractures up to Gustilo-Anderson grade IIIA may be safely treated with intramedullary fixation and appropriate soft tissue management. It may be better to use an external fixator for IIIB and IIIC fractures, or an unreamed nail, although the literature is controversial.
Fixation should be performed within 24 hours of a closed fracture. IM nailing has the advantage of achieving accurate fracture reduction and stabilization, with out extensive soft tissue dissection, and early patient mobilization. With rigid fixation and a stable fracture configuration, full weight-bearing is safe at an early stage.
3. External fixation is rarely required for the adult, even with open fractures. Pins with a diameter greater than 5 mm are required for adequate frame stiffness. Knee stiffness may be a major problem due to quadriceps tethering. The long pin tracts are accompanied by infection in 50% of reported cases.
4. Dynamic compression plate (DCP) fixation is seldom indicated. A broad DCP should be employed and with the advent of excellent intramedullary techniques, the only real indication in the adult for DCP fixation is an associated ipsilateral pelvic or acetabular fracture. Early surgical stabilization of a pelvic fracture may be prevented if there is a recent wound around the hip joint.
5. Paediatric femoral fractures are commonly treated by skin or skeletal traction in a Thomas splint to allow fracture union, before mobilization in a suitable cast. For the young infant, and in some centres children up to the age of 10, early immobilization in a hip spica is favoured, obviating the need for prolonged hospital treatment. In the polytraumatized child, plate fixation is indicated, or an external fixator can be used with less disturbance of the soft tissues.
There may be some limb overgrowth, rarely > 1 cm, with conservative treatment and hence it is acceptable to allow the fracture to heal with some shortening. Overgrowth is more marked between the ages of 2 and 10 years. IM nailing beyond the age of 12 years, avoiding violation of the distal epiphysis, is considered safe practice.
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