Femur Fracture: Rehabilitation and Timelines

Femur fracture

Table of Contents

• Classification of Femur Fractures
• Epidemiology
• Symptoms
• Surgical Treatment
• Rehabilitation
• Complications
• Recovery Timelines
• Prevention
• Frequently Asked Questions (FAQ)
• Frequently Asked Questions
• Sources and Scientific References

Classification of Femur Fractures

Proximal fractures (hip)

The most common in the elderly:

Femoral neck fracture (intracapsular):

• Between the head and the greater trochanter
• Risk of avascular necrosis of the head (vascular interruption)
• Garden classification (I-IV) based on displacement

Pertrochanteric fracture (extracapsular):

• Between the greater and lesser trochanter
• Good vascularization, lower risk of necrosis
• The most frequent in the elderly

Subtrochanteric fracture:

• Immediately below the lesser trochanter
• Strong muscle traction that makes the fracture unstable

Diaphyseal fractures

• Fracture of the central portion of the femur
• Typical of high-energy trauma (accidents, sports)
• Almost always surgically treated with an intramedullary nail

Distal fractures (supracondylar)

• Involve the lower end of the femur, near the knee
• May affect the articular surface
• Frequent in osteoporotic elderly and in sports trauma

Epidemiology

Proximal femur fracture in the elderly is a health emergency: in Italy, approximately 90,000 femur fractures per year occur in the over-65 population. One-year mortality is 20-30%, mainly linked to complications of immobility.

Symptoms

Proximal fracture (hip)

• Intense pain in the groin and hip
• Inability to bear weight on the limb and to walk
• Shortened and externally rotated limb (foot points outwards)
• Swelling and bruising in the hip region
• In some cases (impacted Garden I fractures), the patient may still walk with pain

Diaphyseal fracture

• Violent pain throughout the thigh
• Obvious limb deformity
• Inability to move the leg
• Significant swelling due to muscle hemorrhage (the thigh can lose up to 1-1.5 liters of blood)

Distal fracture

• Pain and swelling in the knee and distal thigh
• Inability to flex the knee
• Possible hemarthrosis (blood in the knee)

Surgical Treatment

Femur fractures are classified by anatomical location—proximal (hip), diaphyseal (shaft), or distal (knee end)—each presenting with localized pain, swelling, limb deformity, and weight-bearing inability. Almost all femur fractures are treated surgically to allow early mobilization.

Femoral neck fracture

Osteosynthesis (screws or screw-plate):

• Indicated in stable fractures (Garden I-II) in young patients
• Objective: preserve the femoral head
• Risk of avascular necrosis: 10-30%

Partial prosthesis (endoprosthesis):

• Indicated in displaced fractures (Garden III-IV) in patients > 70 years with low functional demands
• Replacement of the femoral head with a prosthetic implant

Total hip replacement:

• Indicated in active patients with good life expectancy
• Replacement of both the femoral head and the acetabulum
• Better long-term functional results

Pertrochanteric fracture

• Cephalomedullary intramedullary nail (e.g., Gamma nail): gold standard
• Dynamic Hip Screw (DHS): for stable fractures
• Early weight-bearing allowed in most cases

Diaphyseal fracture

• Locked intramedullary nail: gold standard
• Allows early weight-bearing in most cases
• Consolidation: 3-6 months

Distal fracture

• Angular stability plate: for extra-articular fractures
• Plate with articular reconstruction: for fractures involving the knee
• Retrograde nail: alternative in some fracture patterns

Rehabilitation

Rehabilitation is the most important phase of the healing process and should begin as early as possible, ideally within 24-48 hours of surgery.

Phase 1 — Acute post-operative phase (days 1-14)

Objectives:

• Prevent complications of immobility (venous thrombosis, pneumonia, pressure injuries)
• Reduce pain
• Initiate early mobilization

Interventions:

• Verticalization: transition to sitting and then standing with a walker, as soon as possible
• Breathing exercises: deep breathing, assisted coughing to prevent pneumonia
• Isometric contractions: quadriceps, glutes (10 contractions x 10 seconds, several times a day)
• Venous pumping: ankle dorsiflexion and plantarflexion (circulation)
• Passive and active assisted mobilization of the hip and knee
• Ambulation: with a walker or two crutches, weight-bearing according to surgical indication

Permitted weight-bearing:

Phase 2 — Early functional recovery (weeks 2-6)

Objectives:

• Achieve independent ambulation with aids
• Regain joint mobility
• Begin muscle strengthening

Mobility exercises:

• Hip flexion: seated, lift knee towards chest (assisted, then active)
• Knee extension: seated, extend leg
• Hip abduction: lying down, move leg sideways
• Heel slides on the bed to improve flexion

Strengthening:

• Bilateral gluteal bridge: lift pelvis keeping feet on the ground. 10 repetitions, 3 sets
• Hip abduction in side lying: 10 repetitions per side
• Seated knee extension: lift foot holding for 5 seconds
• Straight leg raise (SLR): lying down, straight leg, lift 15 cm. 10 repetitions

Ambulation:

• Progression: walker → two crutches → one crutch → free walking
• Increasing distance: corridor → ward → stairs (with supervision)
• Teaching correct gait pattern

Phase 3 — Strengthening and independence (weeks 6-12)

Progressive strengthening:

• Controlled mini-squat (knees not exceeding toes)
• Step-ups and step-downs on progressively higher steps
• Unilateral gluteal bridge
• Light lunges
• Calf raises
• Hip abduction and extension with resistance bands

Balance and proprioception:

• Single-leg stance (with support initially)
• Walking on soft surfaces
• Balance exercises with perturbations
• Backward and lateral walking

Functional activities:

• Getting up and sitting down from a chair without armrests
• Going up and down stairs independently
• Putting on and taking off footwear
• Getting in and out of the bathtub/shower

Phase 4 — Return to active life (months 3-6+)

Advanced strengthening:

• Progressive squats with load
• Leg press
• Specific functional exercises for daily living activities
• Aerobic activity: prolonged walking, cycling, swimming

In the elderly — specific goals:

• Recovery of ambulation without aids
• Independence in daily activities (ADLs)
• Fall prevention: balance exercises, home environment review
• Maintenance of a long-term exercise program

In young people — return to sport:

• Light running after 3-4 months (diaphyseal fractures with nail)
• Contact sports: 6-9 months, after radiographic confirmation of consolidation
• Return to pre-injury performance: 6-12 months

Complications

Early complications

• Deep vein thrombosis: prevention with low molecular weight heparin and early mobilization
• Pulmonary embolism: potentially fatal complication of venous thrombosis
• Surgical wound infection: superficial or deep
• Nerve injuries: sciatic nerve (posterior hip fractures)
• Compartment syndrome: in diaphyseal fractures (surgical emergency)

Late complications

• Avascular necrosis of the femoral head: in neck fractures (10-30%)
• Pseudoarthrosis (non-union): more frequent in the femoral neck
• Malunion: healing in a non-anatomical position
• Joint stiffness: of the hip and/or knee
• Limb length discrepancy: difference in length between the two legs
• Loosening of fixation devices: breakage or migration of screws/plates

Recovery Timelines

Prevention

In the elderly (fall and osteoporosis prevention)

• Regular physical activity: walking, tai chi, balance exercises
• Muscle strengthening: prevent sarcopenia with bodyweight exercises or light weights
• Osteoporosis prevention: vitamin D, calcium, eventual pharmacological therapy
• Medication review: reduce medications that cause dizziness or hypotension
• Home safety: remove slippery rugs, good lighting, grab bars in the bathroom, stair handrails
• Hip protectors: padded cushions worn under clothing (useful for high-risk individuals)

In young people (trauma prevention)

• Use of protective gear in contact sports
• Adherence to traffic laws (road accidents are the primary cause)
• Adequate warm-up before sports activity

Frequently Asked Questions (FAQ)

Frequently Asked Questions

After a femur fracture, is it possible to regain normal walking ability?

The primary goal of rehabilitation following a femur fracture is to restore as much function as possible, often enabling individuals to return to their previous activity levels. A structured physical therapy program is crucial for regaining strength, mobility, and gait patterns. While full recovery is common, individual outcomes can vary based on fracture severity, age, and adherence to the rehabilitation plan.

What are the risks associated with a femur fracture in older adults?

Femur fractures in older adults, particularly proximal fractures, are considered serious due to the potential for significant complications and impact on independence. These fractures often require prompt surgical intervention and comprehensive rehabilitation to mitigate risks such as reduced mobility, secondary health issues, and increased mortality. Effective management aims to improve recovery outcomes and prevent long-term disability.

How can a second femur fracture be prevented?

Preventing a second femur fracture involves addressing underlying risk factors specific to the individual’s age group. For older adults, strategies focus on fall prevention, such as home modifications and balance exercises, alongside managing osteoporosis through medication and nutritional support. In younger individuals, prevention primarily involves promoting safety measures to avoid high-energy trauma.

What is the typical timeline for resuming driving after a femur fracture?

The timeline for resuming driving after a femur fracture is highly individualized and depends on several factors, including the fractured limb, the type of vehicle, and the individual’s functional recovery. It is generally advised to wait until sufficient strength, range of motion, and reaction time are restored, and the individual is no longer using pain medication that could impair judgment. A healthcare professional, often in consultation with a physical therapist, can provide guidance on when it is safe to return to driving.

Sources and Scientific References

1. Siminiuc D et al. (2024). Rehabilitation after surgery for hip fracture – the impact of prompt, frequent and mobilisation-focused physiotherapy on discharge outcomes: an observational cohort study. BMC Geriatr. 24:629. DOI | PubMed
2. Snow CM et al. (2000). Long-term exercise using weighted vests prevents hip bone loss in postmenopausal women. J Gerontol A Biol Sci Med Sci. 55:M489-91. DOI | PubMed
3. Hall AJ et al. (2017). Physiotherapy interventions for people with dementia and a hip fracture-a scoping review of the literature. Physiotherapy. 103:361-368. DOI | PubMed
4. Fuchs RK et al. (2017). Physical Activity for Strengthening Fracture Prone Regions of the Proximal Femur. Curr Osteoporos Rep. 15:43-52. DOI | PubMed
5. Purcell K et al. (2022). Mobilisation and physiotherapy intervention following hip fracture: snapshot survey across six countries from the Fragility Fracture Network Physiotherapy Group. Disabil Rehabil. 44:6788-6795. DOI | PubMed