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Fracture shaft of femur physiotherapy management

Currently, the method most surgeons use for treating femoral shaft fractures is intramedullary nailing. During this procedure, a specially designed metal rod is inserted into the canal of the femur. The rod passes across the fracture to keep it in position. An intramedullary nail can be inserted into the canal either at the hip or the knee Femoral shaft fractures occur in 10-37 / 100.000 pa-tients per year (1, 37), and mainly male young patients are affected (median age 27 years) compared to the frac-ture of the elderly in female patients (median age 80 years). In multiple injured patients femoral fractures ac-count for up to 30%, with open femoral fractures foun Management of Femoral Shaft Fractures. EC Microbiology 15.8 (2019): 884-890. Management of Femoral Shaft Fractures to be extremely crucial to very carefully assess the status femoral neck in all patients who present to the hospital after getting high-energy fractures of femoral shaft Treatment of femoral shaft fractures can be operative or non-operative. Operative fixation with intramedullary nailing is the gold standard of treatment in high-income countries. Other operative techniques include plate osteosynthesis and external fixation

Femur Shaft Fracture Treatment Boston Medical Cente

  1. The long, straight part of the femur is called the femoral shaft. When there is a break anywhere along this length of bone, it is called a femoral shaft fracture. This type of broken leg almost always requires surgery to heal. The femoral shaft runs from below the hip to where the bone begins to widen at the knee
  2. fracture of the shaft of the thigh bone is a serious injury with the potential for severe long term problems. It is also commonly associated with other injuries. Modern treatment with Intramedullary Rod fixation fixes the fracture in a good position and allows early mobilization, pain relief and discharge from hospital. Complications from this type of treatment are relatively rare and it is normal to return to full activity. Full recovery can take up to 18 months
  3. FEMORAL SHAFT FRACTURE P.T. PROTOCOL. gentle range of motion exercise in hip, knee, and ankle and focus in knee extension. initiation of weight bearing as tolerated ambulationwith either a walker B/L crutch. Following discharge from the hospital patient utilized a toe touch to 25% weight bearing status. 1
  4. If a break occurs anywhere along this bone length, it is known as a femoral shaft fracture. Femoral shaft fracture usually requires surgical treatment. Types of Femoral Shaft Fractures. Generally, femur fractures can be classified on the basis of force applied, location and pattern of the fracture, and nature of the injury. 1
  5. During the 1st week: Femoral neck fracture Physiotherapy Management The wound is inspected for evidence of infection and the drains are removed after 24 hours. Pulmonary embolism and hypovolaemia are a distinct possibility and a careful watch is kept to prevent bedsores from developing, the patient is frequently turned in the bed

Patients with a femoral shaft fracture usually make a full recovery with appropriate management (whether surgical or conservative). Depending on the severity of the fracture (and the type of activity), return to activity or sport usually occurs between 3-12 months. This should be guided by the treating physiotherapist and specialist Antegrade reamed femoral nailing via the piriformis entry point is the technique of choice in treating femoral shaft fractures, with retrograde nailing as an alternative. The supine position is favored to reduce complications, especially rotational malalignment. With navigation and robotic assistanc SURGICAL MANAGEMENT. Surgical treatment of femoral shaft fractures with an IM nail is considered the standard of care with union rates between 95% and 99%, 13 Despite this success, functional limitations and impairments often persist after the injury and surgical procedure, which may result in residual disability. 2,3,13 This disconnect between. With trauma-related femur fractures, physical therapy following stable fixation of the fracture to improve hip and knee range of motion, strengthening and gait training is recommended... Femur Fractures • Common injury due to major violent trauma • 1 femur fracture/ 10,000 people • More common in people < 25 yo or >65 yo • Femur fracture leads to reduced activity for 107 days, the average length of hospital stay is 25 days • Motor vehicle, motorcycle, auto- pedestrian, aircraft, and gunshot wound accidents are mos

Traction(orthopedics)

Abstract Femoral shaft fractures are the most common major pediatric injuries managed by the orthopaedic surgeon. Management is influenced by associated injuries or multiple trauma, fracture personality, age, family issues, and cost. In addition, child abuse should be considered in a young child with a femoral fracture Femoral shaft fractures should be put into skin traction (10% of body weight) to help with pain management. If the patient is to be transferred to another hospital, the leg should be immobilised in a Thomas type splint (if available) or a backslab Summary. Femoral shaft fractures are high energy injuries to the femur that are associated with life-threatening injuries (pulmonary, cerebral) and ipsilateral femoral neck fractures. Diagnosis is made radiographically with radiographs of the femur as well as the hip to rule out ipsilateral femoral neck fractures

INTRODUCTION. The femur is the longest, strongest, and heaviest tubular bone in the human body and one of the principal load bearing bones in the lower extremity [].Fractures of the femoral shaft often result from high energy forces such as motor vehicle collisions [].Complications and injuries associated with midshaft femur fractures in the adult can be life-threatening and may include. Quadriceps femoris muscle weakness is a common outcome following femoral fracture, with or without surgical management. 3, 6, 7, 16 Long-term studies (16-44 months postinjury) documented that following both conservative 3 and surgical 6, 7, 16 management of femoral fractures, significant residual quadriceps femoris muscle weakness persists

T1 - Management of femur shaft fractures in obese patients. AU - Streubel, Philipp N. AU - Gardner, Michael J. AU - Ricci, William M. PY - 2011/1. Y1 - 2011/1. N2 - Given the ongoing epidemic of obesity, femoral fracture management in the population affected by this condition is likely to become more frequent Treatment / Management. Treatment of femoral shaft fractures can be operative or non-operative. Operative fixation with intramedullary nailing is the gold standard of treatment in high-income countries. Other operative techniques include plate osteosynthesis and external fixation A femoral shaft fracture is a fracture anywhere along the shaft or. diaphysis. of the femur. These fractures commonly occur in young males as a result of high-impact injuries (e.g., motor vehicle accidents). Low-impact shaft fractures tend to occur in older patients with pre-existing. osteopenia

Femoral Shaft Fractures - StatPearls - NCBI Bookshel

  1. Management of Pediatric Femur Shaft Fractures . Aaron Dickens MD. 1. 1. UNM Department of Orthopaedics & Rehabilitation. Background . The incidence of pediatric femur fractures is 19 in . 100,000 patients and is more common in boys than girls.1-4. Femur fractures account for 1.4% to 1.7 % of all pediatric . fractures. 1-4 . In the 1990s it was.
  2. Femur Shaft Fracture. begins to widen at the knee. Your thighbone (femur) is the longest and strongest bone in your body. Because the femur is so strong, it usually takes a lot of force to break it. Motor vehicle collisions, for example, are the number one cause of femur fractures. The long, straight part of the femur is called the femoral shaft
  3. right sided femur fractures and 25 left sided femur fractures. Fracture sites were proximal shaft in 13, middle shaft in 22, and distal shaft in 12 cases. Fracture type per Winquest and Hansen's Classification8 were as in Table-2. Table-2: Type of Fracture Type of Fracture Number Percent Type I 12 25.5 Type II 19 40.
  4. In up to 9% of femoral shaft fractures, there is an associated ipsilateral femoral neck fracture. 20%-50% of those are initially missed, so a proactive investigation of ipsilateral femoral neck fractures should be performed. There are ipsilateral knee injuries in 20%-40% of patients and ipsilateral tibial fractures in approximately 10% of cases
  5. From that point the management is similar to the procedure outlined in other forms of treatment. ß. Adhesive Traction with Thomas Splint. An efficient form of treatment for femoral shaft fractures in children, and in adults with poorly developed musculature, may be arranged with adhesive skin traction and the use of the Thomas splint

Femur Shaft Fractures (Broken Thighbone) - OrthoInfo - AAO

  1. Management Fracture management stages include (4 Rs): 1. Resuscitate 2. Reduce (if displaced) - may be by open reduction, closed manipulation, or traction 3. Retain (to maintain position while healing occurs) - by internal fixation, external fixation, or conservative methods 4. Rehabilitate R esuscitate Advanced trauma life suppor
  2. By 12-16 weeks: Femoral neck fracture Physiotherapy Management. Full weight-bearing is allowed. Full active and passive range of motion exercises are permitted to the hip and knee joints. Isometrics, isotonic and progressive resistive exercises are continued to the hip, knee and ankle joints
  3. Physical Therapy Management [edit | edit source] The main aim of Physiotherapy post distal femur fracture is to get the patient back to his/ her baseline function and to prevent complications. Whilst the patient is admitted to hospital, the Physiotherapist will teach the patient how to mobilise using the correct walking aid, with the correct.
  4. uted femoral shaft fractures. In these situations, bridge plating of the femoral shaft fracture may be considered. 40,41 (E). Note 2: In the setting of distal third pediatric femoral shaft fractures, in vitro . biomechanical data suggest tha
  5. femoral shaft fractures as seen in Kenyatta National Hospital (K.N.H.) and various methods used in management of these fractures and compare them in the following ways. (i) Rate and type of complications associated with each individual method. '(ii) Average duration of hospitalisation for each method. (iii) Average healing time for each method
  6. Pediatric femoral shaft fractures: current and future treatment Femoral shaft fractures can occur in children of all ages. They account for 1.6% of all childhood fractures, and they lead to significant impact on the child and family [1]. The treatment of these fractures can vary greatly depending on the age of the patient and the fracture pat-tern
  7. The proximal femoral fracture in the elderly is a serious public health problem. Surgical treatment of this fracture is used to reduce morbidity, together with postoperative physical therapy

Physical Therapy Protocol: FEMORAL SHAFT FRACTURE P

  1. Core Curriculum V5 Introduction • Account for 7% of all femur fractures • Bimodal distribution: High -energy injuries in the young, low- energy in the elderly • Historical treatment • 1960's and earlier: Skeletal traction favored • Neer et al. (JBJS 1967) advocated for closed, non-operative treatment based on poor results and high complications resulting from ORI
  2. They estimated that with bisphosphonate therapy, for every 100 typical osteoporotic femur fractures that were prevented, there was an increase of one subtrochanteric fragility fracture. 15 In another analysis, Meier and colleagues found a 47% reduction in classic fractures, but increased risk of AFF of 10.7% per year, with long-term.
  3. Management of proximal humeral shaft fractures depends on the Neer classification: 1-part fractures generally do well with conservative management; analgesia, ice, and immobilisation in a sling are generally followed by institution of early range of motion exercises; and 2-, 3-, and 4-part fractures require orthopaedic surgery evaluation
  4. Fractures of the femoral shaft are associated with high-energy, multisystem trauma. Management must be methodical, initially excluding life-threatening injuries. Patients surviving for the first 24 hours after major injury as a result of effective resuscitation remain at risk of progressive organ failure and death from a local and general.
FEMORAL SHAFT FRACTURES: MECHANISMS, PATTERNS AND

Femoral shaft fractures. 1. Femoral Shaft Fractures Hiren M Divecha FTSTA1 T&O. 2. Femur• Tubular with slight anterior bow• Average femur is 48 cm x 2.34 cm• Longest and strongest bone• Support up to 30 times weight of an adult• Blood supply - Nutrient artery - Medullary arteries. 3 - Non Operative Treatment: - suspension traction - femoral traction pins - references: - Temporizing Management of Pediatric Femur Fractures Using J-splints - Skeletal traction for fractures of the femoral shaft in children A femoral shaft fracture is a severe injury that usually occurs as a result of a high-speed car collision or a fall from a great height. The treatment almost always requires surgery. The most common procedure involves the insertion of a metal pole (known as an intramedullary rod) into the center of the thigh bone

Subtrochanteric femur fractures are an uncommon injury in orthopedics, but when they are encountered they may present difficulties in management. The purpose of this paper is to examine the recent literature on the epidemiology, classification, initial evaluation, and definitely treatment for these injuries. These will assist the physician to determine the optimal treatment strategy and avoid. Femoral shaft fractures are common, especially in high-energy trauma, with an incidence of around 4 per 10000 person-years.. The femur is the longest bone in the body and a highly vascularised bone, due to its role in haematopoesis. The bone is supplied by penetrating branches of the profunda femoris artery, therefore large volumes of blood (up to 1500ml) can be lost when fractured The recovery from a femur fracture depends on the severity of the fracture. Most of the femur fractures heal within 3 to 6 months. But if an open fracture or the bone is broken into pieces or the patient consumes tobacco products, the fracture takes more time to heal. For the best femur fracture treatment, management and care plan - and for. EPIDEMIOLOGY. Pediatric shaft femur fractures are 2.6 times more common in boys than in girls [3-5].A bimodal distribution has been noted, with the first peak occurring in the age group of 1-3 years (usually low energy) and the second peak during early adolescence period (high energy), which constitutes the majority of the fractures [3, 5].Although, the etiology of the fracture varies with the.

Physiotherapy treatment for a stress fracture of the shaft of the femur. Physiotherapy is important in the treatment of a stress fracture of the shaft of the femur. Initially, your physiotherapist can provide you with a diagnosis. This may require the referral for imaging techniques such as a MRI scan The incidence of non-union following unreamed intramedullary nailing of femoral shaft fractures. Injury. 2009; 40(2):205-208. 10.1016/j.injury.2008.06.022. Google Scholar; 5. Swiontkowski MF, Hansen ST, Kellam J. Ipsilateral fractures of the femoral neck and shaft. A treatment protocol. J Bone Joint Surg Am. 1984; 66(2):260-268. Google. Proximal femoral fractures present unique challenges for anaesthetic departments throughout Great Britain and Ireland, involving the peri-operative care of large numbers of older patients with significant co-morbidities. (25%) in patients with hip fracture, interrupting routine management and rehabilitation. Treatment involves multimodal. This video discusses treatment of pediatric femur fractures using 90-90 traction, followed by delayed spica casting. This study details the treatment of a 2-year-old girl with a subtrochanteric.

Doctors generally agree that displaced femur fractures that have shortened more than 3 cm require treatment to correct at least a portion of the shortening. In some more complicated injuries, the doctor may need to surgically realign the bone and use an implant to stabilize the fracture Multiple fractures-patient with a femoral shaft fracture may also have a hip fracture which is easily missed unless the pelvis is x rayed. 10/16/2012 29 30. RADIOGRAPHIC EVALUATION An anteroposterior (AP) view of the pelvis both hip in 15 internal rotation and a cross-table lateral view of the involved proximal femur are indicated Technetium.

Femur Shaft Fractures, Causes, Symptoms & Treatment

Forty-four patients (45 fractures) with open physes (age range 11-16 years) underwent treatment for femoral shaft fractures. Seven malunions occurred in the 24 fractures in the nonoperative group; none occurred in the 21 fractures treated by intramedullary nailing. Hospital stay was significantly shorter in the operatively treated patients Femoral Shaft Fracture Retrograde Intramedullary Nailing continue physical therapy and range of motion exercises repeat xrays of femur postop: ~ 3 month postoperative visit Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral . 3. Arranges for long term management of geriatric patients.

A femoral stress fracture often starts with a deep, dull gnawing or aching in the groin (inside of the leg) or front of the hip. Sometimes, the pain is felt in the thigh. It may even travel down into the knee. The pain is more noticeable when you walk or put weight on the leg. And it becomes stronger or sharper with more strenuous movement. Distal Femur Fractures. Distal femur fractures are traumatic injuries involving the region extending from the distal metaphyseal-diaphyseal junction to the articular surface of the femoral condyles. Diagnosis is made radiographically with CT studies often required to assess for intra-articular extension Femoral shaft fracture: A femoral shaft fracture is a break that occurs anywhere along the femoral shaft, long, straight part of the femur. Proximal femur fracture: A hip fracture or proximal femur fracture is a break in the proximal end of the thigh bone near the hip. Causes . Femur fractures may be caused by high energy injuries such as a. Femoral shaft fractures are among the most common diaphyseal fractures in children with an estimated annual incidence of 19 fractures per 100,000 children in the United States . They are also the most common pediatric fracture of the femur, accounting for up to 62 percent of all femur fractures [ 3 ] J Bone Joint Surg Am 54(5): 1015-1032. graft. J Orthop Trauma 9(4): 278-284. 7. Thomas P Reudi, Richard E Buckley, Christopher G 20. Kregor PJ, Stannard JA, Zlowodzki M, Cole PA (2004) Moran (2007) A O Principles of Fracture Management. Treatment of Distal Femur Fractures Using the Less 2nd (Edn.), Switzerland: A O Publishing

Femoral Neck Fracture Physiotherap

Femoral Shaft Fracture - PhysioAdviso

Distal femur fractures include fractures of the supracondylar and intercondylar region and are relatively common injuries. The goals of treatment follow AO principles of anatomic reduction of the articular surface, restoration of limb alignment, length, and rotation. Despite improvements in implant design, management of distal femur fractures. To study surgical management of distal femoral fractures & its complication. and improvement in surgical implants, including knee joint AP and lateral views treatment of distal femoral fractures remains were taken. Muller's classification was a challenge in many situations. Anatomical used Femoral Shaft Fracture Retrograde Intramedullary Nailing Provides post-operative management and rehabilitation . postop: 2-3 week postoperative visit continue physical therapy and range of motion exercises discontinue DVT prophylaxis wound check repeat radiographs of femur.

Femoral shaft fractures in adults: treatment options and

CONCLUSION: Treatment of ipsilateral femoral neck and shaft fractures is still demanding, but diagnosis has improved with regular use of CT body scans in the management of multiply injured patients. Furthermore, possibilities for operative treatment have been advanced by the introduction of the long proximal femoral nail and the antegrade. Physical Therapist's Guide to Femur Fracture A femur fracture is a break, crack, or crush injury of the thigh bone. It is sometimes referred to as a hip fracture; or broken hip if the break is in the upper part of the bone near the hip-joint area. Femur fractures that are simple, short cracks in the bone usually do not require surgery Management of compound fractures of shaft femur: a study of 55 cases Gaurav Singla1*, Amita Aggarwal2, Ravinder Singh1 fractures by various modalities like INTRODUCTION Open femoral shaft fractures occur in young population following high energy trauma, either from direct trauma (e.g. motor vehicle accident) or from axial loading (e.g Femoral shaft fractures are severe injuries and are often associated with a high impact trauma mechanism, frequently seen in multiple injured patients. In contrast an indirect trauma mechanism can lead to a complex femoral shaft fracture especially in elderly patients with minor bone stock quality. Hence management of femoral shaft fractures is. The management of femoral shaft fractures, a common clinical entity, is one such process with the potential to influence important clinical outcomes. While evidence is strong that definitive fixation within 24 hours is both feasible [ 5 ] and associated with improved outcomes [ 2 - 4 ], managing the therapeutic needs of patients with multiple.

Is There a Standard Rehabilitation Protocol After Femoral

Femur Injuries and Fractures Treatment & Management: Acute

Management of pediatric femoral shaft fracture

The concept of intramedullary fixation in the treatment of femoral shaft fractures has gained wide acceptance. Delayed union or nonunion following intramedullary nailing of the femur has been considered an infrequent clinical problem. As a consequence of the more frequent use of intramedullary nailing for the treatment of femoral shaft fractures Further management Proximal femur. In children, proximal femoral fractures (physeal, intertrochanteric and femoral neck fractures) are less common than femoral shaft fractures but have higher rates of complication (osseous necrosis) All proximal femoral fractures should be referred to the Orthopaedic team for further management

fracture It femur

Clinical Practice Guidelines : Femoral shaft fractures

Distal Humerus Fractures of the Elbow - OrthoInfo - AAOS

Management Options and Controversies. Many investigators contend that the complications of the femoral neck trump those of the femoral shaft. These investigators suggest that avascular necrosis is the most significant complication, and therefore the femoral neck fracture should be treated first. 15, 16 Others suggest that the femur should be treated initially to allow for ease of closed. Following treatment, the orthopedic surgeon continues to monitor the patient for a period of several years to ensure that there is no limb length discrepancy. When a fracture in the shaft of the femur occurs, the bone tends to shorten at the point where it breaks, Dr. Scher explains

Femoral Shaft Fractures - Trauma - Orthobullet

Dan Cavallari Physical therapy will be required of patients suffering from a spiral fracture of the femur. A spiral fracture of the femur occurs when the thigh bone, commonly known as the femur, is twisted in a helical motion, causing it to break. This type of fracture is most common in small children or elderly people, though this bone is usually very strong Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries. J Trauma. 2002; 52:(2): 299-307. Morshed S, Miclau T, Bembom O, Cohen M, Knudson MM, Colford JM. Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem trauma. J Bone Joint Surg. 2009; 91: 3-13

Distal femoral fracture - Physiopedi

Femoral Shaft Fracture Retrograde Intramedullary Nailing Provides post-operative management and rehabilitation . postop: 2-3 week postoperative visit continue physical therapy and range of motion exercises wound check repeat radiographs of femur. The femur is a large and strong bone that helps form the hip and knee joints at its proximal and distal ends and has a long shaft that runs down the entire length of the thigh. The femur helps support the weight of the body and move the leg. Stress Fractures of the Femur can be caused by disease, poor nutrition, osteoporosis and overuse

Fractured Shaft Of Femur - Hip - Surgery - What We Treat

A femoral neck fracture is a type of hip fracture of the thigh bone (femur) —just below the ball of the ball-and-socket hip joint. This type of fracture disconnects the ball from the rest of the femur. It often causes groin pain that worsens when you putting weight on the injured leg. Hip fractures are more common among the elderly, but they. A broken femur is usually caused by a severe accident; vehicle accidents are one of the primary causes. Older adults can fracture their femur from a fall because their bones tend to be weaker.

Management of Distal Femur Fractures in Adults

6.6.2 Femur, shaft (incl. subtrochanteric fractures) Femur - shaft fracture 32-B2. Intramedullary nailing with the expert lateral femoral nail (LFN) Femur - shaft fractures. Intramedullary nailing with the antegrade femoral nail (AFN) Neumann MV et al. ( Acta Chir Orthop Trauma Cech. 2015;82 (1):22-32) intramedullary nailing of femoral shaft fractures, in the less economically developed context Rebekah J Parkes,1 Gary Parkes,2 Kyle James3 Research To cite: Parkes RJ, Parkes G, James K. A systematic review of cost-effectiveness, comparing traction to intramedullary nailing of femoral shaft fractures, in the less economically developed context

Femoral Shaft Fractures in Emergency Medicine Treatment

The femoral neck is the weakest part of the femur, the largest bone in the skeleton. Neck of femur (NOF) fractures typically occur in the elderly, with a predominance for women (4:1). However, they can occur in young patients as a result of high-energy trauma. In 2011, approximately 80,000 hip fractures were treated in the United Kingdom The femoral shaft fracture was managed with an external fixator application, and the femoral neck fracture management was delayed due to unhealthy soft tissue conditions around the proximal lateral aspect of the thigh. The treatment of both fractures was further delayed because the patient developed an infection of the open wound of the femoral. Gustilo et al. demonstrated a 50% risk of osteomyelitis after such injuries, with amputation (early or late) a frequent outcome ( Gustilo et al. (1990) The management of open fractures. J Bone Joint Surg 72(2):299-304). This illustration shows a severe open injury of the shaft of the lower humerus, after a high-energy motor vehicle collision Ipsilateral femoral neck and shaft fractures: complications and their treatment. Clin Orthop Relat Res. 2002; 399:78-86. 10.1097/00003086-200206000-00011. Google Scholar; 3. McDonald LS, Tepolt F, Leonardelli D, Hammerberg EM, Stahel PF. A cascade of preventable complications following a missed femoral neck fracture after antegrade femoral.

Application of traction in orthopaedics

Femoral Shaft Fractures - Core E

The role of allografts in the treatment of periprosthetic femoral fractures. Treatment of Periprosthetic Femoral Fractures Following Total Hip Arthroplasty with Femoral Component Revision. Intraoperative Fracture of the Femur in Revision Total Hip Arthroplasty with a Diaphyseal Fitting Stem. Three Hundred and Twenty-one Periprosthetic Femoral. Abstract. This study aims to prove that the treatment of fracture shaft of the femur in children is according to their age and values of varus-valgus angle, Anterior-posterior angle, and shortening which compared with the standard acceptable angulations values, also to prove that these standard acceptable angulations are suitable in the treatment of these fractures Femoral pediatric shaft fractures are a common orthopedic injury. Conservative treatment is still the preferred method by orthopedic surgeons. The walking spica cast is used in patients between 1 year old and 6 years old, in patients with isolated and low-energy fractures Diagnosis of femoral neck fractures in patients with a femoral shaft fracture: improvement with a standard protocol. J Bone Joint Surg Am. 2007;89:39-43. O'Toole R, et al. Diagnosis of femoral neck fracture associated with femoral shaft fracture: blinded comparison of computed tomography and plain radiography The femur is indeed one of the strongest bones in the body, and a fracture of the shaft of the femur usually occurs only after a car accident or ski accident or some other major trauma.A normal.