Malunions of the Femoral Shaft

The operative management with intramedullary fixation has revolutionized treatment of femoral shaft fractures; however, malunions can still occur. The etiology of femoral shaft malunion is multifactorial, but contributing variables include patient factors such as obesity and noncompliance; fracture personality, such as comminution, bilateral femur injuries, bone loss, and transverse fracture patterns; and surgeon factors, such as inexperience, technical failures, and malreduction. The physical exam should focus on limb alignment, soft tissue envelope, and signs of infection. Obtaining a computed tomography scan can provide an accurate measurement of rotational deformity while orthogonal radiographs are the mainstay of imaging. While no universally accepted guidelines exist for defining treatment of diaphyseal femoral malunions, the key is to listen and understand the patient's concerns, functional limitations, and expectations. Treatment options include plate fixation, intramedullary nail, or external fixation techniques. There is in fact a large armamentarium for orthopedic surgeons to treat patients. Femoral shaft malunions represent a challenging problem for patients as well as a diagnostic and technical challenge for orthopedic surgeons. Using a systematic approach to the evaluation and treatment of femoral shaft malunions can lead to consistent and successful patient outcomes.