Outlinne:  
Fracture of femoral shaft refers to the femoral fracture occurring between 2 to 5 cm below the lesser trochanter and 2 to 4 cm above the femoral condyle. It is often caused by strong violent force, and commonly seen in children and young adults. Fractures caused by direct violence are usually transverse and those caused by indirect violence are usually oblique or spiral. Both belong to unstable fracture. The fracture end is markedly displaced, the tissues are seriously injured and internal bleeding is severe. So the fracture may be complicated by traumatic shock. Or it may result in crush syndrome in the case of crash injury of the thigh. Fractures in children are commonly incomplete or greenstick, belonging to stable fracture.
 
When the fracture occurs in the upper one-third of femoral shaft, there often appear various deformities. The flexion, abduction and extorsion deformities result from traction of the proximal end of fracture by lumbosacral muscle, middle gluteal muscle, least gluteal muscle and other extortors. And backward, inward and upward deformities result from traction of the distal end of fracture by the adductors. When the fracture occurs in the middle one-third of femoral shaft, the deformity is of no definite rule except that the two ends of fracture often overlap.

The proximal end is mostly of tendency of abduction and flexion and the distal end is displaced superomedially due to the action of adductors, the fracture ends makes an angle with its vertex stood up anterolaterally. When the fracture occurs in the lower one-third, the distal end is often displaced backward (see Fig. 16) due to traction by joint capsule posterior to the knee and gastrocnemius muscle. In serve cases, the popliteal artery or vein and sciatic nerve may be injured.

Major points for diagnosis  
1. The patient has an obvious traumatic history.
 
2. The patient suffers from so intense a pain that he may have shock symptoms such as pale complexion, cold sweating, and thready and rapid pulse.
 
3. Marked swelling and angulation deformity can be observed on the affected limb. Pseudoarthrosis movement and bony crepitus can be felt. The case of overlapped displacement manifests itself by shortening and dysfunction of the affected limb.
 
4. The location and type of fracture can be confirmed by roentgenogram. In the case of fracture in the upper one-third of femoral shaft, X-ray films taken should include the hip for fear that the dislocation of hip joint might be neglected.

Treatment:   
Fracture of femoral shaft in adults may be complicated by shock due to large traumatic wound and local massive bleeding. Chinese medicine should be applied in combination with Western medicine for saving life. After the patient's condition gets better, the reduction and fixation should be actively done. But reduction is not needed for greenstick fracture and stable fracture with no displacement. For displaced fracture the manipulative reduction and splintage may be applied in combination with continuous traction, or reduction through continuous traction in combination with splintage may be used. For the cases of complications, surgical reduction and internal fixation should be taken.

Reduction:    
The patient takes a supine position. Under effective analgesia and anesthesia, one assistant holds the pelvis firmly and the other holds the above part of ankle. For the fracture in the upper one-third, the distal assistant uses his elbow to hold the popliteal fossa to make the knee bent at the angle of 900, the hip joint flexed to a moderate extent, and the distal end being in slight extorsion position. Then he applies traction by pulling slowly and forcefully, while the assistant holding the proximal end squeezes and presses it backward; and the operator holds the distal end, pulls and lifts it from the back to the front. For the fracture in the middle one-third, traction is done with the limb straightened and slightly abducted. The operator uses his hands to squeeze and press the fracture end from the lateral to the medial, then does the counter-squeezing on the fracture end posteroanteriorly and lateromedially. For the fracture in the lower one-third, traction is done with the knee bent. As the traction is done, the operator takes his two hands pressing hard on the polipteal fossa as the supporting point to push and squeeze the distal end from the back to the front.

Fixation:
For children's stable fractures, the injured limb should be wrapped with cotton cushion and fixed with 5 to 6 pieces of small splints for 3 weeks. For unstable fracture, splintage combined with continuous traction should be applied.
 
Splintage:
After reduction, pressure pads should be put respectively on the front and lateral aspects of the proximal end for fracture in the upper one-third, on the front and lateral aspects of the fracture end for the fracture in the middle one-third, and on the front of the proximal end for the fracture in the lower one-third. Then splints are put down. The length of the medial splint should be from the groin to the internal epicondyle of femur; the length of the lateral splint should be from the greater trochanter to the lateral epicondyle; the length of the anterior splint should be from the groin to the upper border of the patella, and the length of the posterior splint from the transverse gluteal crease to the upper border of popliteal fossa. Finally, it is wrapped tightly up with 4 strings.

Continuous traction:
Skin traction on single side is suited for old persons. The weight for traction is 3 to 5 kg. Children under 3 may be treated with suspending skin traction on both sides. The traction weight should be heavy enough to keep the children's hip10 cm apart from the bed. After 3 weeks the fixation can be removed. The upper border of adhesive tape in skin traction should not go beyond the level of fracture. In skeletal traction, following the reduction and fixation with splints, the affected limb is put on the traction frame. For the fractures of middle and upper one-third, traction is apPlied to supracondyle of femur. For the fractures of lower one-third with fracture line deviating from the posteroinferior to the anterosuperior, traction is applied to tibial tubercle. When the fracture line is going from the anteroinferior obliquely to the posterosuperior, traction is applied to the supracondyle of femur. The traction weight is 6 to10 kg, the duration is 8 to 10 weeks.
 
Functional exercise:   
Under the prerequisite that an effective reduction and traction of the affected limb has been gained, children and youngsters should be allowed to move their normal limbs. In the case that the patient is an adult, the patient should only practice movements of the toes and ankle joints in the early stage. After the fracture is stablized, the patient may take a semisitting position with the upper limbs supporting the trunk to move up and down on the bed. And gradually with the normal lower limb supporting the trunk in combination with hands pulling the handle of the traction frame, he makes the superior trunk in semistanding position. Great care should be taken as the patient lifts his affected limb horizontally. In the late stage, following removal of the traction, local protection by small splints should be applied when the patient practices flexion and extension of his hip and knee joints. After satisfactory function has been obtained, the patient is asked to practice walking on crutches.

Herbal therapy
Internal treatment based on syndrome differentiation  

1. In the early stage  
Main symptoms and signs:
Swelling and pain in the affected limb, abdominal distension and fullness, difficulty in urination and defecation, fever and restlessness
 
Therapeutic methods:
Promoting blood flow to remove the stasis, loosing the bowel movement and relieving the swelling.
 
Recipe and herbs:
Modified Fuyuan Houxue Decoction. Specifically, Chaihu (Radix Bupleuri)12 g, Tianhuafen (Radix Trichosanthis)12 g, Zhidahuang (Radix et Rhizoma Rhei Praeparata )10 g, Taoren ( Semen Persicae)10 g, Dangguiwei (Extremitas Radix Angelicae Sinensis )15 g, Chishaoyao (Radix Paeniae Rubrae )10 g, Houpo ( Cortex Magnoliae Officinalis)10 g, Honghua (Flos Carthmi)10 g, Chuanshanjia ( Squama Maniris Pentadactylae )10 g and Gancao (Radix Glycyrrhizae)3g.
 
2. In the middle stage
Main symptoms and signs:
Subsided swelling and pain, disunited fracture.

Therapeutic method:
Reuniting the bones, muscles and ligaments.

Recipe and herbs:
Modified Xugu Huoxue Decoction. Specifically, Dangguiwei (Extremitas Radix Angelicae Sinensis )10 g, Chishaoyao ( Radix Paeniae Rubrae )10 g, Shengdihuang ( Radix Rehmanniae )15 g, Huainiuxi (Radix Achyranthis Bidentatae )10 g, Zhechong (Eupolyphaga seu Steleophaga)10 g, Gusuibu ( Rhizoma Drgnarii )12 g, Duanzirantong ( Pyritum Carcinatum) (to be decocted first)10 g, Xuduan (Radix Dipsaci )10 g, Luodeda ( Herba Centellae )10 g, Ruxiang ( Gummi Olibanum)6 g, Moyao (Myrrha)6 g and Gancao (Radix Glycyrrhizae)5 g.

3. In the late stage
Main symptoms and signs:
Adhesion of tendons and bones, rigidity of the joint, and general weakness.

Therapeutic methods:
Promoting blood flow and relaxing tendons.
 
Recipe and herbs:
Modified Huoxue Shujin Decoction. Specifically, Danggui ( Radix Angelicae Sinensis )15 g, Jixueteng (Caulis Spatholobi)12 g, Duhuo (Radix Angelicae Pubescentis )10 g, Sangzhi ( Ramulus Mori Albae)12 g, Honghua (Flos Carthmi)6 g, Chuanxiong (Rhizoma Ligustici Chuanxiong)10 g, Qinjiao ( Radix Gentianae Macrophyllae )10 g, Weilingxian (Radix Clematidis )10 g, Jianghuang ( Rhizoma Curcumae longae )10 g, Qianghuo ( Rhizoma seu Radix Notopterygii )10g, Niuxi ( Radix Achyranthis Bidentatae)10 g and Gancao (Radix Glycyrrhizae)5 g.
 
External therapy:
In the early stage, Sanse Application is topically used. In the middle stage, Jiegu Xujin Plaster is externally used. In the late stage,fumigation and bathing of the affected limb and joint may be applied with Xiazhi Sunshang Lotion. Specifically, Shenjincao (Herba Lycopodii Japonici) 15 g, Tougucao (Herba Speranskiae seu Impatientis )15 g, Wujiapi ( Cortex Acanthopanacis )12 g, Sanleng ( Rhizoma Sparganii Stoloniferi )12 g, Ezhu ( Rhizoma Curcumae)12g, Qinjiao ( Radix Gentianae Macrophyllae )12 g, Haitongpi (Cortex Erythrinae)12 g, Sumu (Lignum Sappan )10 g, Honghua ( Flos Carthmi )10 g, Mugua (Fructus Chaenomelis )10 g and Niuxi (Radix Achyranthis Bidentatae)10 g. All above herbs are decocted in water, using the hot decoction to fumigate and bathe the affected limb, 2 to 4 times daily.