# A nurse is assessing a client with a suspected fracture of the femur. Which assessment finding would be most indicative of a femoral fracture?

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## 문제

A nurse is assessing a client with a suspected fracture of the femur. Which assessment finding would be most indicative of a femoral fracture?

## 보기

1. Numbness and tingling in the toes of the affected leg
2. Shortening and external rotation of the affected leg **✔ 정답**
3. Swelling and tenderness around the ankle joint
4. Bruising and swelling on the lateral knee aspect

**정답: 2**

## 해설

Shortening and external rotation are classic signs of a femoral fracture due to muscle spasm and displacement. Other options (numbness/tingling, ankle swelling, knee bruising) are less specific or indicate other injuries.

## 심화 해설

When a femur fracture occurs, the powerful muscles surrounding the thigh—such as the iliopsoas, gluteals, and adductors—immediately contract in spasm. These unopposed muscle forces pull the distal fragment into a characteristic position. The proximal fragment is flexed and abducted by the gluteal and iliopsoas muscles, while the distal fragment is pulled proximally and externally rotated by the adductors and the weight of the limb. This results in the classic clinical presentation of a shortened and externally rotated lower extremity, which is the most indicative finding of a femoral shaft fracture.

The other options represent findings more consistent with complications or injuries at different anatomical sites. Numbness and tingling in the toes suggests neurovascular compromise, such as compartment syndrome or nerve injury, which can be a complication of a fracture but is not the primary defining assessment finding. Swelling and tenderness around the ankle would direct the assessment toward a more distal injury, like an ankle fracture or sprain. Bruising and swelling on the lateral knee aspect is more suggestive of a ligamentous injury or a fracture of the tibial plateau or distal femur, not the femoral shaft itself.

The biomechanical consequences of a femur fracture extend beyond the acute deformity. As noted in the literature, even when a fracture heals, malunion—defined as healing in an anatomically incorrect position—can create significant functional impairment. A distal femoral malunion, for instance, alters knee loading through its longest lever arm, shifting the mechanical axis and creating abnormal compartmental contact pressures [3]. This principle underscores why the initial gross deformity of shortening and external rotation is so clinically significant; it reflects the powerful biomechanical forces that, if not anatomically reduced, can lead to long-term gait disturbance and accelerated joint degeneration [3].

References (research sources)

- [3]Distal femoral malunion: Biomechanical drivers, fixation strategies and the role of fixator assisted correction.Research articleD'souza JJ, Peterson N. (2026) · DOI: 10.1016/j.jcot.2026.103428

## 임상 시나리오

Clinical Snapshot

A 28-year-old male is brought to the emergency department following a high-speed motor vehicle collision. The primary survey is intact, but the patient reports severe right thigh pain. On inspection, the right lower extremity appears shortened and is lying in a position of external rotation compared to the left. The skin is intact, but significant swelling is noted in the mid-thigh region.

Key Assessment Findings

- **Inspection:** Visible shortening and external rotation of the affected leg. Thigh appears swollen and may have visible deformity or ecchymosis.

- **Palpation:** Point tenderness over the femoral shaft. Crepitus may be felt but should not be intentionally elicited.

- **Neurovascular Check:** Perform a thorough assessment of distal pulses (dorsalis pedis, posterior tibial), capillary refill, sensation, and motor function. Document findings before and after any manipulation or splinting.

- **Pain:** Severe, exacerbated by any movement of the leg. Muscle spasm contributes significantly to the pain and the characteristic deformity.

Immediate Nursing Actions

- **Stabilize and Immobilize:** Do not attempt to reduce the deformity. Apply gentle inline traction and immobilize the entire limb, including the hip, knee, and ankle, using a padded splint or traction splint. Reassess neurovascular status immediately after splinting.

- **Pain Management:** Administer prescribed analgesics, typically intravenous opioids, to manage severe pain and reduce muscle spasm.

- **Monitor for Complications:** Perform serial neurovascular assessments to monitor for developing compartment syndrome (increasing pain unrelieved by medication, paresthesia, pallor, pulselessness, paralysis). Assess for signs of hypovolemic shock, as a femoral fracture can result in significant blood loss (up to 1-2 liters) into the thigh.

- **Prepare for Definitive Care:** Anticipate diagnostic imaging (X-ray, CT) and prepare the patient for surgical intervention, which is the standard treatment for femoral shaft fractures in adults (intramedullary nailing).

Patient Education Focus

Explain the rationale for immobilization and frequent neurovascular checks to the patient. Reassure them that the position of the leg is a normal result of the injury and muscle forces, and that surgical stabilization will correct the alignment. Provide information on the expected postoperative course, including early mobilization with physical therapy and weight-bearing restrictions.

## 핵심 개념

- **External Rotation** — Outward turning of the limb away from the body's midline; in femur fractures, caused by the pull of adductor muscles and gravity on the distal fragment.
- **Muscle Spasm** — Involuntary, forceful contraction of muscles surrounding a fracture site, contributing to characteristic deformity and pain.
- **Malunion** — Healing of a fracture in an anatomically incorrect position, which can lead to functional impairment and altered gait mechanics.
- **Compartment Syndrome** — A serious complication involving increased pressure within a muscle compartment, compromising circulation and nerve function, often signaled by pain and paresthesia.

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