Femur Fracture

[kara]

Hi everyone - i fractured my left femur wakeboarding 4 months ago and I am currently STILL non weight bearing - it is an unstable winquist type IV fracture and suspected to be a non union but they wont declare this until 6 months post op (i have an IM nail and 2 screws)

Until my next appointment in February, I have been instructed to build as much muscle as I can in my leg and use a bone stimulator. I havent had any formal physio (except 2 weeks after operation, one appointment) as I managed to gain very good ROM on my own, although i dont think i have full rom as if i stand on my good leg and try and pull my heel to my butt as if to stretch the quad, i cant get very far, but if im lying down and bend my knees and bring my ankles up to my butt, i can do the same on each leg....hope that makes sense!!

My OS has cleared me to swim and ride a stationery bike.....my question is, how long should i ride the bike for each day?? also, are there specific exercises i should be doing in the pool?? I went swimming (12 lengths) for the first time an hour ago and my knee is now very sore - i never had this problem when i used the bike.

any advice very very much appreciated

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[physiobob]

Firstly a posting for everyone's interesting in classification:

Winquist Classification of Femoral Shaft Frx

Type I:
- comminution is minimal or there is no comminution at frx site

Type II:
- comminution involves a fragment larger than that in type I but has at least 50% of the circumference of the cortices of two major frx fragments intact;
- broad cortical contact following frx reduction & nailing prevents shortening & malrotation, simple IM nailing suffices for most type II frx;

Type III:
- injuries, between 50 and 100% of the circumference of two major frx fragments is comminuted;
- such large butterfly fragments compromises frx fixation since broad cortical abutment of major frx fragments is impossible;
- simple intramedullary nails are insufficient for type III frx and must be supplemented with interlocking screws, cerclage wires, or post operative traction or bracing;

Type IV:
- all cortical contact is lost in type IV injuries;
- cortex is circumferentially comminuted over a segment of bone;
- even w/ intramedullary nailing, there is no contact between proximal and distal fragments; all inherent stability of fracture is lost;


Original Text by Clifford R. Wheeless, III, MD.

[physiobob]

Interesting case. If possible can you attach some x-ray images for us to take a look at?

You are early post fracture and you are perhaps showing non-union. Therefore the idea of muscle strengthening should be taken lightly. Also I am not sure how one can be partial weight-bearing but still be instructed to increase as much muscle strength as possible!

On the bike; although the pedals move there is a 'sort of' of base at both ends of the lower limb movement (seat and foot) and the movement is what we could consider somewhere between an open and closed kinetic chain. Swimming is an open chain where to foot end is free to do what ever (rotate/twist etc) and therefore is a lot more demanding on the leg and the fracture. I would suggest only crawl (freestyle) be done at this stage if you are to swim.

Perhaps you need to discuss more clearly with the surgeon what you can and can't do at this stage. Bone stimulators such as magnetic fields are useful in stimulating fracture healing but there's not to many PT's out there who have one.

In terms of time on the bike that is also hard to say. I would work to a plan of starting out for say 5 mins and repeat daily for a few days before increasing. You need to look at the afteraffects both immediately and cummulatively over a few days before increasing the time spent. Any cramping in the muscles or numbness could be an indication of fracture movement when riding so I would be careful and I would again consult directly with the fracture clinic if in doubt. Seems like you could really do with a private Physio consult if the NHS is taking to long.

[kara]

Thanks heaps for the advice!

here are some xrays and CT scan images. Its a spiral type IV fracture (i only know this as this is what is on my hospital forms) The CT scans were done 2 weeks ago and you can see there is still no contact between the fragments. I was treated in Spain as this is where the accident happened and I am still here as my parents live here so im not using an NHS doc or physio. perhaps i will seek out a decent Physiotherapist here in spain for a couple of sessions. I am waiting on recieving an exogen 4000 bone stimulator - so i hope this helps! Does anyone know if they actually work on a fracture that is 4 months old???







Thanks again for the advice Physiobob
Kara

[physiobob]

Hi Kara

Not sure how long post fracture those units work on but in theory they stimulate normal processes that are active so as long as the fracture healing is taking place then it should assist. Not sure though whether magnetic therapy is better for this. We used to use it when I spent time at the Academy of Sport in Sydney, Australia.

You break doesn't look good to be honest and Spain in general is not a great place to be for rehab (sorry spanish physios as I don't mean to offend).

I might send a link to this page to an orthopaedic surgeon I work with in London for his comments and will come back to you. For now I would not do to much muscle strengthening until we get a clearer picture. more soon

[kara]

Thanks for reply physiobob - i get the exogen on Monday so will give it a go, ive heard quite good things about them, just didnt know whether they worked this late in the day post fracture, i have to use it for 2 months and of course, build some muscle before i go back in feb to see surgeon.

im quite enjoying being on the bike, i was on for 20mins this morning and it feels good, I will go swimming later and see how that fairs but my knee was very painful last time but perhaps my technique is wrong...

Oh god...You say the fracture doesnt look good, do you think its going to be a non union??? or looks bad in some other way??? my leg has been measured and its 6mm longer than the good leg, but this is acceptable apparently - all i want to do is get back to sports!

I really appreciate all your help and would be pleased to hear from an OS

[kara]

me again!! im worried as to why my xrays dont look good i know there is no bone growth, but does anyone think something else is wrong??? a reason why no growth?? should i seek a second opinion from another OS? im getting myself a little bit worked up about it

I have also developed a pain on the inside of my thigh about a third of the way down and i cant figure out whether this is muscular or related to the fracture - it has only started after i started exercising on the bike and swimming - its a dull kind of ache with a bulge - my knee is also really painful on the inside of leg lower than the knee cap, feels very sore to touch aswell....ive always had pain on the front of my knee but the pain on the inside is new. i have bad nerve damage from the surgery (i think - maybe the accident??) that has left me with a numb calf on the inside of my broken leg - its kind of hyper sensitive but also numb if that makes sense, it doesnt give me much pain but i just didnt know if it was related.

I am going to visit a UK physio here in spain to get a thorough exam but this isnt until next week and was after some insights / advice in the meantime

any opinions and advice greatfully appreciated. x

[physiobob]

Here's a brief comment from one of London's top orthpaedic guys (hips and knees)

Hi
Very slow progress
Try Exogen for 2 months and repeat CT
If no progress then will need revision Nail
Cheers
Fares

[kara]

Thanks physiobob!! thats exactly what my surgeon wants me to do use the machine for 2 months and then if no growth, change the nail for a larger one - my next appointment is beginning of feb so until then I will use the exogen.

i am seeing a UK qualified physio here in Spain this week so hoping they will be able to give me some structured exercises to do in the pool.

thanks again