The femur is the largest and strongest bone in the body and has a significant soft tissue envelope protecting it. The femoral shaft is defined as the diaphyseal portion of the bone, from below the lesser trochanter to above the metaphyseal portion of the distal femur. Most femoral shaft fractures occur after high-energy trauma such as motor vehicle collisions, vehicles striking pedestrians, falls, gunshots, and sports injuries. Such injuries warrant a complete evaluation according to guidelines established by the American College of Surgeons in the Advanced Trauma Life Support courses. High-energy femoral shaft fractures may be associated with significant damage, including head, thoracic, abdominal, or other extremity injuries. Once the trauma evaluation is complete, one may concentrate on the femoral shaft fracture, which can be associated with significant blood loss in the soft tissue envelope of anywhere from 500–1500 ml or more. The patient must be resuscitated and monitored closely.

The gold standard in the treatment of femoral shaft fracture remains the antegrade locked intramedullary nail. Advances in design and technique offer additional options for nailing: retrograde nailing and reconstruction nailing through a greater trochanter starting point. Additional options include open reduction with a plate and screws and external fixation as a temporizing measure or definitive treatment. The patient's additional injuries, body size, and pre-existing comorbid conditions combined with the personality of the fracture assist the surgeon in determining a treatment plan. The non-operative treatment of femoral shaft fractures in the adult patient is only of historical interest.