The thigh, the largest anatomic portion of any extremity, comprises powerful muscle groups that encase the femoral shaft. The femur is the heaviest and longest bone in the body. It has an excellent blood supply derived from the profunda femoris artery, and its periosteum receives extensive collateral circulation. As a result, the femur is well protected from devascularization and has good healing potential.
The musculature of the thigh is divided into three compartments by intermuscular septa that attach to the linea aspera, a ridge that runs down the posterior aspect of the femur (Fig. 19–1). The anterior compartment contains hip flexors and knee extensors, including the four quadriceps muscles (rectus femoris, vastus medialis, vastus lateralis, and vastus intermedius). The posterior compartment is occupied by the hamstrings, which include the long and short heads of the biceps femoris, as well as the semimembranosus and semitendinosus muscles medially. The medial compartment includes the adductor muscle group, consisting of the adductor longus, brevis, and magnus, as well as the gracilis.
Compartments of the thigh.
The femoral shaft in an adult extends from approximately 5 cm distal to the lesser trochanter to a point approximately 5 cm proximal to the adductor tubercle.1
Femoral shaft fractures are classified into three types:
Spiral, transverse, or oblique shaft fractures
Comminuted femoral shaft fractures
Open femoral shaft fractures
Distinguishing between spiral, transverse, or oblique fractures does not alter the treatment or prognosis. However, comminuted fractures and open fractures have an overall higher rate of nonunion and longer healing time than simple fractures.2,3
Comminuted fractures are further classified by Winquist based on the size of the fracture fragment and the degree of comminution (Fig. 19–2).1,4 Grade I fractures have minimal or no comminution, and fracture fragments are small (≤25% of the width of the femoral shaft). Grade II fractures possess a fracture fragment of 25% to 50%, whereas grade III fractures are associated with a large butterfly fragment (>50% of the width of the femoral shaft). Grade IV fractures possess circumferential comminution over an entire segment of bone with complete loss of abutment of the cortices.
Winquist grading of femoral shaft fractures.
Femoral shaft fractures occur with minimal or no trauma and are associated with abnormally brittle bone and increased cortical thickening. These atypical fractures are characterized by a transverse or short oblique morphology and lack of substantial comminution.5–7 They most commonly occur in the proximal one-third of the femoral shaft but can be anywhere from an area ...