It is imperative to assess the clinico-epidemiological characterstics, mechanisms of injury and pattern of femoral fractures to review the appropriateness of management practices and develop preventive measures. There are several key features of the current analysis. It has been identified that the proportion of traumatic femur fracture cases managed at our centre is 11% which is in agreement with an earlier study that reported similar rates of femoral fractures treated at a regional trauma centre from South Nigeria [17]. The result of our study showed preponderance of male gender (89.4%) and young age (mean 30 years) which is in line but with a slightly lower mean age in comparison to an earlier study from Saudi Arabia (33 years) [18]. In contrast, Khan et al [3] reported higher proportion of females (58%) and advanced age (mean 63 yeras) among distal femoral shaft fractures treated at a tertiary referral hospital in London. An earlier study from Saudia Arabia reported that half of femur fracture victims belongs to age group of 16 to <30 years followed by 30 to <60 years (39.3%) [18]. The present study also shows predominance of age 14-30 years (46.4%) and 31-59 years (36.9%) which is in agreement with Saudia Arabia study and could be due to the sociodemographic similarity between the two countries.
Road traffic accidents (65%) remains the most common injury mechanism followed by fall from height in our series. These findings are in agreement with earlier studies which also reported high impact trauma mainly road traffic crashes as the commonest cause of femur fractures [2,17]. Furthermore, traffic related injuries were more evident among young individuals (14-30 years) who represents the most active age group of young individuals usually involved in overspeeding and reckless driving. On the other hand, in our series fall-related injuries predominated in the 31-59 years group which is often related to occupational injuries and domestic fall. In our study group, victims of traffic-related accidents had associated fractures of tibia and fibula and more likely to undergo rIMN. Similarly, predominance of femoral shaft fractures secondary to road traffic accidents among younger males have been reported by an earlier study from Romania [19]. A recent study on management of femoral shaft fractures reported road traffic accidents as the commonest cause and suggested interlocking intramedullary nailing as the modality of choice for candidates requiring operative intervention [20]. In our study, thorax, head and abdomen were the frequently associated injured body regions which is supported by a recent meta-analysis that reported high-energy trauma as the major cause of femur fracture; with concomitant injuries to the chest and head region [21].
In our series, the majority of femur fractures were closed and were frequently unilateral. The pattern of closed femoral fractures is frequently observed due to soft tissue cover of the femur which in contrast with the tibial fractures [8]. Ibeanusi and Chioma [17] reported higher proportion of femoral fractures to be closed (78%) as compared to open fratures (22%) which were more likely to involve diaphyseal femur fracture (58.1%) secondary to high impact trauma by road traffic accidents or gunshot injuries. On the other hand , open femur fractures are not uncommon and ranges from 16.5-23% [22,23]. An external fixator construct could be used to stabilize hemodynamically unstable patients or those with severe open fractures, in accordance with the recommendations of Brumbacks and colleagues for safely performing intramedullary nailing in lower grade open femoral shaft fractures [24,25]. Reamed intramedullary nailing is the standard of care treatment in our institution for shaft fractures of long bones particularly the closed method which has been suggested as superior to other procedures, despite the controversy [26-28]. In our series, the median time to stabilize femur fractures by rIMN was within the first 20 hours of admission but early stabilization was observed in 34.3% of cases as opposed to 51% reported in an earlier study from our center [21]. The earlier studies have advocated the beneficial effect of early definitive fixation of femur fractures within 24 hours among suitable patients for IMN [13, 29]. Interestingly, the type of implant, duration of surgery, DVT prophylaxis, and in-hospital complication did not differ significantly based on time to IMN in the present study. This could be due to the fact that we have categorized the time of rIMN as very early, early and delayed surgery but still demonstrate that two-third were treated after 12 hours of admission.
Antegrade nailing was performed in the majority of our cases with lateral positioning without the use of a fracture table as described by Bishop and colleagues [30]. An earlier study by Wolinsky et al [31] suggested a significant decrease in the operating times with this technique; however, the current study did not compare operating times based on positioning (lateral versus supine). In about one-fourth of fractures , a retrograde nail was inserted in the supine position which is in accordance with the indications described by sanders et al [32]. Surgeons preference in our series was antegrade nails involving entry from pyriform fossa in the majority (72%) of cases and the remaining cases had trochanteric entry nails. In contrast to our practice , a systematic review by Kumar et al [33] identified trochanteric entry nailing to be superior to Pyriform fossa nailing to treat femur shaft fractures in adults. The authors also suggested the ease of learning the technique of entry through greater trochanteric tip that resulted in improved functional outcomes; although there is no differece in the rates of union among the two entry sites. Another prospective cohort study on antegrade femoral nailing reported similar higher rate of union, lower complication rates, and comparable functional results of trochanteric insertion as compared to the piriformis fossa nailing [34]. In addition, the authors demonstrated lesser fluoroscopy and operation time with greater trochanter entry in obese patients. Further supporting the notion of trochanteric entry nails, another study on cadavers found lesser structural and iatrogenic injury to the surrounding structures and the gluteal musculature with trochanteric nailings [35]. In our series, open reduction was performed in about one-third of patients and this approach is secondary to difficult closed reduction procedure that has consistently been described as a safe alternative technique [36,37]. In this study, external fixation for the treatment of femoral shaft was primarily done for open fractures. Although, this is not a standard technique to treat femoral shaft fractures but exceptionally can be used to manage open fractures with concomitent complex soft tissue injuries [17].
In this study, about 40% of the patients required blood transfusion which is markedly lower than the reported incidence in an earlier study [38]. This is attributed to the fact that post-initial resuscitation in polytrauma patient, we meticulously avoid blood transfusions for a hemoglobin level more than 8mg/dl [39] among asymptomatic patient who responded well to physiotherapy and ambulation efforts.
The rates of surgical site infection after IMN have been reported to be 11.8% for combined femur and tibial fractures [40]. Whereas, the overall rate of infection for isolated femur fractures was found to be as low as 0.8% [41]. Notably, the rate of wound infection in our series was higher and all patients with surgical site infection were managed with local wound care and antibiotics, implant retention and did not require surgical debridement or implant removal. An earlier study analysed the outcome of femoral fractures reported a lower infection rate (5.4%) as compared to our findings [17].
In our cohort, the rate of pulmonary embolism and ARDS was found to be 1.2%. Similar to our observations, Kim et al [42] reported slightly higher frequency of pulmonary embolism (2.2%) which developed soon post-trauma. Bosse et al [43] reviewed femur fractures magement at two different settings, one center has used rIMN and the other mainly used plates to treat femoral fractures. The authors suggested that rIMN of femoral fractures did not increase the risk of pulmonary complications and there was no significant difference between the two cohorts with respect to the incidence of pulmonary complication and mortality. Other studies have also recommended that hemodynamically stable patients with pulmonary injuries and femoral fracture can be successfully treated with rIMN [44,45]. Moreover, a recent meta-analysis identified that early IMN has lower risk of pulmonary complications such as ARDS, and pneumonia as compared to delayed IMN fixation [21]. Therefore, in polytrauma patients the reported pulmonary complications might be associated with thorax trauma rather than the IMN [46].
There are certain limitations to this study owing to the retrospective study design and data retrival from registry database, having some variables with incomplete information. Moreover, the registry databse did not capture the duration and details of the surgical procedures which was retrieved from the patient’s medical record. We lack details of the force and location of impact and use of protection measure while driving or at workplace.
Third, the lack of information regarding the exact site of femur, fracture geometry (transverse or short oblique type or comminuted), fracture classification and risk factors for fracture. Finally, this study did not address the functional outcome as radiological union (nonunioun, malunion, extended delayed union) and clinical follow-up details about physical therapy, early mobilization, and counseling.
In conclusion, the frequency of femoral fracture is 11% mainly in severely injured young males by traffic-related accidents and fall from height. The femoral fracture represents a spectrum of injury characteristics from simple isolated injuries requiring a simple intramedullary nail to polytrauma patient with associated injuries that require multidisciplinary treatment approach. We believe that clinico-epidemiological study may help the surgeons to understand pattern of fractures, management and complications to improve patient’s outcomes. Our findings may help healthcare policy prioritization, resource allocation planning and implementation of best practices. Further studies are needed to focus on type and side of fracture, exact location and prognoses of femur fracture patients.