Authors of section


Arnold Besselaar, Daniel Green, Andrew Howard

Executive Editor

James Hunter

General Editor

Fergal Monsell

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Complications and technical failures

1. Introduction

Femoral fractures are often high-energy injuries and are associated with significant but predictable complications.

Treatment related complications can be minimized by anticipating them and paying attention to the general principles of fracture management.

2. Delayed union and nonunion

Delayed union and nonunion are rare in femoral shaft fractures due to excellent muscle coverage.


  • Persistent fracture gap
  • Delayed weight bearing
  • External fixation
  • Open plating
  • Infection
  • Devascularization
  • Bone loss
  • Vitamin D deficiency


  • Confirm reduction before definitive fixation
  • Compress fracture before finalizing fixation
  • Start immediate partial weight bearing
  • Select biologically appropriate fixation where possible (intramedullary nailing > MIPO > open plating > external fixation)
  • Vitamin D supplementation
  • Prophylactic antibiotics
  • Systematic debridement of open fractures

3. Refracture

Refracture is uncommon with intramedullary fixation.

Factors contributing to delayed union and nonunion also increase the risk of refracture.


  • Premature removal of external fixator
  • Removal of plate
  • Malunion


  • Partial weight bearing with crutches following implant removal
  • Activity modification until sufficient bone strength

4. Malunion


  • Unequal ESIN sizes
  • Unequal ESIN bend
  • Inappropriate use of ESIN (> 50 kg)
  • Use of external fixator


  • Use locked reamed nails for femurs of adequate size
  • Attention to detail in ESIN selection and bending
  • Avoid use of external fixator, unless no practical alternative

5. Rotational malunion


  • Difficulty assessing intraoperative rotational alignment


6. Implant pain/prominence


  • Large plates especially proximally and distally
  • Long screws
  • Growth and metaphyseal modeling


  • Use intramedullary devices
  • Measure screw length carefully
  • Anticipate prominence of screws and nail ends after metaphyseal growth especially in patients of 9 years and younger

7. Muscle scarring and knee stiffness


  • Prolonged immobilization
  • Pain preventing early motion
  • Instability preventing early motion
  • Comminution of anterior distal femur
  • Extensive soft-tissue injury


  • Stable fixation
  • Early active motion
  • Manipulation of knee through full range after applying an external fixator
  • Continuous passive motion in high risk patients

8. Peri-implant fracture


  • Stress riser from plate or short nail
  • Pathological bone (eg, osteogenesis imperfecta)
  • Disuse osteopenia


  • Intramedullary fixation where possible
  • Early partial weight bearing

9. Leg-length discrepancy

Note: Overgrowth after femoral fractures will correct small amounts of shortening.


  • Length unstable fracture
  • Spiral fracture treated with cast
  • Segmental fracture treated with cast
  • Spiral fracture treated with ESIN
  • Segmental fracture treated with ESIN


  • Avoid early weight bearing if fixation is length unstable
  • Achieve stable construct
  • Consider MIPO
  • Consider end caps for ESIN

Consider reevaluation of leg length after one year when most of the effect of overgrowth will be apparent.

Clinical assessment of leg length uses a tape measure from the ASIS to the medial malleolus.

Clinical assessment of leg length with tape measure form ASIS to medial malleolus

In a long-leg x-ray the leg length is measured between the radiographical landmarks femoral head and ankle joint.

Leg length measured in a long-leg x-ray from femoral head to ankle joint

10. Angular deformity


  • Fracture malunion (see above)
  • Occult growth plate injury
  • Valgus overgrowth after plating of distal-third fractures


  • Achieve adequate fracture reduction and implant stability
  • Avoid injury of the distal growth plate with instruments and implants
  • Early and repeated assessment of growth or physeal injury after high-energy mechanisms (motor vehicle trauma)
  • Early and repeated assessment of growth or physeal injury after plating of distal third fractures
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