Iranian Journal of Orthopedic Surgery

Abstract Concurrent femoral shaft fractures and lower limb amputations around the knee are rare but complex injuries, often resulting from high-energy trauma. This report reviews the challenges and treatment strategies for such cases, focusing on innovative fracture table positioning and fixation methods in transfemoral, through-knee, and transtibial amputations. We present two novel cases: a 29-year-old man with an above-knee amputation and midshaft femoral fracture treated with delayed intramedullary nailing after external fixation, and a 40-year-old man with a through-knee amputation and open midshaft femoral fracture managed with external fixation, skin grafting, and subsequent plate fixation. Key challenges include patient instability, soft tissue defects, osteoporotic bone, and positioning without distal anchors. Techniques such as Schanz pins, Kirschner wires, inverted boots, and skin traction facilitate the reduction. The review underscores the need for staged approaches and standardized protocols to optimize outcome in such rare scenarios.