Diaphyseal femur fractures are common injuries globally and range in complexity. The most common mechanism worldwide is motor vehicle accidents. Initial evaluation should include Advanced Trauma Life Support protocol and evaluation of the soft tissues, neurovascular examination, and associated injuries. The gold standard for treatment is a closed functional reduction (restoration of length, alignment, and rotation) and fixation with a reamed, statically locked, intramedullary nail. Fracture pattern, associated injuries, and patient factors can increase the difficulty of treatment. Malrotation and limb length discrepancy are not uncommon. Awareness of the problem and knowledge of the how to obtain and verify adequate reduction is critical. Diagnosis of malrotation and/or limb length discrepancy should prompt a detailed discussion of the deformity and treatment options with the patient. Most patients recover remarkably well from diaphyseal femur fractures. They should be followed until union and return to prior functional level with a watchful eye placed on any warning signs of complications such as nonunion and infection.

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