Femoral Shaft Fracture, ABOS Oral Boards Preparation

This is a 28-year-old male construction worker brought to the trauma bay after a motorcycle collision at approximately 40 miles per hour. He was helmeted. He was hemodynamically stable after two liters of crystalloid in the field. ATLS primary survey was intact. On secondary survey, his right thigh was swollen, deformed, and shortened. Skin was intact. He had palpable dorsalis pedis and posterior tibial pulses, intact sensation, and soft compartments. I could not reliably assess knee ligaments due to thigh pain, but there was no knee effusion.

AP and lateral radiographs showed a comminuted midshaft femoral fracture, AO 32-B2, with about 3 centimeters of shortening. Given the high-energy mechanism, I obtained ipsilateral hip and knee films, both normal, and a CT of the femoral neck, which showed no occult neck fracture. I performed antegrade reamed intramedullary nailing through a piriformis entry point with static locking. Final fluoroscopy confirmed anatomic alignment with restored length and rotation.

He was made weight-bearing as tolerated immediately and discharged on hospital day two. At two weeks, his wound was healing well. At six weeks, X-rays showed early callus formation with maintained alignment. At three months, the fracture was consolidated and he had symmetric thigh circumference and knee range of motion. He returned to construction work at four months without restrictions.

He was very satisfied with his outcome and eager to get back to work. Looking back, I would have more carefully assessed rotation intraoperatively using both the cortical step sign and the lesser trochanter profile on fluoroscopy. I was satisfied with my reduction at the time, but I have since adopted a more systematic bilateral comparison protocol for rotation that I think improves consistency. I watched him closely for signs of nonunion given the comminution, and he healed without issue.