This is one of the most painful injuries that anyone can have, and I think a good part of that is due to the enormous leg muscle contracting on the bone pieces. Also, when someone ‘breaks a hip’ almost always the actual injury is to the femur when the ball in the hip socket breaks off from the rest of the femur--though we do different procedures for this kind of fracture.
Once I’ve determined that the injury is most likely a femur fracture, we’re going to start an IV (because pain meds are a must, and the doctor is usually happy to let us administer them. I have to call in for permission first and to find out how much the doctor wants us to give. A Basic EMT wouldn’t be able to give meds at all, and I’m not sure if paramedics still have to call for a dosage or not. I would guess yes.). We’re also going to get out the traction splint, which looks like this and comes in adult and pediatric sizes:
First the pant leg has to be removed so we can see the fracture. We expose all the way up to the groin area, and possibly on the outside of the hip. This is so we can check for other injuries and to see the affected area better. The splint has twisting locks on either side that make it so you can lengthen it to the right size for the patient, about twelve inches beyond the foot is good and we measure the length against the unbroken leg. While the adjustments are being made to the splint someone is going to provide some pull on the broken leg, either with one hand under the knee, and another on the leg just below the patient's bottom, or under the knee and providing some pull on the ankle.
The little black padded bar on the right end of the picture goes under the patient’s rear end right up to the bone and the straps go around the top of the thigh (after we've padded the groin area, usually with a washcloth or a roll of gauze). Then there is a strap that goes around the ankle which attaches to the hook that you can see on the left end of the picture. This creates the traction. We pad under the knee for comfort and secure the leg to the brace with the other four straps. Then there's a dial at the end that we use to stretch the leg until the femur pops back into place. This actually hurts quite a lot until the bones shifts to where it should be, and then the patient usually reports a major drop in the pain levels when enough traction has been applied. I've heard more than once that the patient will often sigh in relief when you reach the right amount of traction because it instantly feels so much better.
Things to watch for before putting on a traction splint: If there is pelvic damage, or injuries to the knee or lower leg, you can't use the splint or it could cause more damage.
If the injury occurs near the ball of the femur, using the traction splint is ineffective and can cause more pain. In that case we do a pelvic wrap, which is wrapping the whole pelvic area with a folded sheet (we generally use sheets, though creativity is sometimes necessary if we're on a mountain rescue or some other unusual location.) We might also wrap the legs together to stabilize them in this scenario so they don't shift during transport to the hospital.
My rural hospital can’t do surgeries to put in a plate for a broken femur or broken hip. Our doctors do general medicine and do very few surgeries beyond C-sections and basic scope procedures. Anything more serious has to be sent to a larger hospital. We general send ours to a Trauma I or Trauma II hospital, and with a broken femur it’s not uncommon for us to request a helicopter because the trip in the back of an ambulance is grueling, especially over some of the really awful spots of road between us and the closest trauma center. And with few exceptions, any patient under the age of twelve or so is going to the children's hospital, rather than one of the other trauma centers.
Another major concern we have with a femur fracture is whether the broken bone might have nicked the femoral artery—this is such a major artery that if you get a bad slice in it, a patient can literally bleed out in as little as two minutes, and with the leg muscle being so big, a lot of times they can lose several pints of blood into the tissue before you start to see any signs--a serious problem when it takes the volunteer EMTs in my department longer than that to even reach the ambulance. Luckily, this isn’t a common problem, just one we have to keep an eye out for.