Broken Femur, can't bend knee enough to sit in chair

mcoulstring,

Unfortunately, regaining knee motion is one of the first and most difficult parts of recovery.

First, remember, that not only the bone is broken when the femur fractures, all of the soft tissues around it are also damaged. The periosteum gets ripped apart and off the bone, the muscles are torn off their attachments, the tendons, ligaments, nerves, blood vessels can all get stretched and twisted when there is no support of the thigh. All of this soft tissue damage heals, but it heals with scar tissue.

Right now is when the soft tissues are healing and laying down all that collagen which will become scar. It takes about 6 weeks for soft tissues it heal physiologically. But, then the scar tissue has to mature. During the maturation, the collagen fibers in the scar line up better with the stress lines and the scar softens and stretches. This maturation process can take months to even a year or so.

So, if you can get the knee moving, stretching the quad muscles while the scar is being laid down, the easier it is to get the motion in the knee. But, that is not to say it will be easy.


Sometimes, if you warm up the tissues first, it helps when you are doing stretching exercises. A hot shower, hot tub, hot packs, whatever, will help, as warm tissues are more pliable and stretchable.

If you have access to a pool, water exercises are great for femur fracture patients. The warmth of the water heats up the tissues and the buoyancy of the water makes the patient nonweight bearing. You can work on range of motion, gait mechanics, walk, etc all in the chest deep water. Later on, you can even get to running in the water (and of course swimming) for cardiovascular fitness.

So, warm up the quad muscles before doing your range of motion. After you exercise period, you can use ice if you are having some discomfort. Of course, you can also try ice before exercise, but when you are trying to stretch tissues, heat is actually better.


However, if you continue to have problems within the knee joint itself, that can be coming from a couple of things. Swelling within the joint makes it hard to flex the knee, like trying to bend a water balloon or hot dog. The swelling can also cause adhesions within the joint cavity, which essentially scar the joint down.

Occasionally, when a femur is broken, the knee (and/or hip) joints can also be injured. But, because the femur is the most important to get stabilized, the joints only get cursory (quick) examinations. So, sometimes, injuries to the joints get overlooked, until later, once rehab is started. So, if you continue to have knee problems, make sure to have your orthopedic surgeon examine the knee specifically.


You still have a long road ahead of you. Getting the bone to unite is just the first step, then you have to rehabilitate all of the soft tissues. It can sometimes take a year to 18 months before the final outcome is known.

Getting that knee motion going is the first hurdle. Again, if the knee joint is just staying swollen and tender (the quad muscles are expected to be tender for a long time), have the surgeon look at the knee specifically.

Good luck.

Thanks a million! I still have little swelling in my knee but what worries me is that it almost locked. While standing, I've tried to touch the top of my foot to the ground and push downwards trying to bend it and it literally won't go past a certain point. And I do notice a serious decline in the inner quad above my knee so is it possible that because my quad is nearly non existent at this point, my knee joint and ligaments are simply taking on more pressure? I feel like the pressure is coming from under my knee cap itself. As far as the scaring is concerned: that makes perfect sense, the crazy knot/cramp that I'm getting when trying to use my quad feels like hard tissue balling up. I'm ready to work my butt off in PT I'm just worried that my knee isn't ready yet or it's damaged. Doc did say I have the early signs of arthritis because I'm also knock kneed...and I'm sure the board sports don't help that because my stance is naturally Knees bent inward. Thanks for the info! And no worries I'm doing everything my docs are telling me to do with the exception of my knee because I can't....

mcoulstring,

Though it is a little early in your time course, you could be developing a problem called arthrofibrosis of the knee. You may have injured the knee at the same time as the femur fracture, and due to the injury, developed swelling within the knee joint. This sets up an inflammatory response (actually the first stage of healing), but in some patients, this inflammation gets out of hand and the joint becomes very scarred. Patients with arthrofibrosis just can't get range of motion, no matter how hard they try. The joint just will not go past a certain point.

It is very important that, if you do have arthrofibrosis, that it be diagnosed and treated early. The longer it is left alone, the harder it is to treat later. And, in some patients with arthrofibrosis, they never get their range of motion back.

So, if the knee is just socked in and has a very firm endpoint (as opposed to a rubbery endpoint), then you should have your surgeon examine the knee, not only for injury, but for the possibility of you developing arthrofibrosis.

Arthrofibrosis is usually seen in post-op knees, after procedures like ACL reconstructions or total joints. But, it can occur in any knee that has sustained trauma. And, if a surgeon does not have it in the back of his/her mind, he/she may not think of it.

However, because it is so difficult to treat, most of the surgeons who are the experts in its treatment say the best way to treat it is to prevent it. In other words, there aren't very good treatments for it. The first is intensive supervised physical therapy. But, if this is not producing results, then manipulation under anesthesia and/or surgical lysis of adhesions has to be tried. But, operating on arthrofibrosis is a double edged sword, as the surgery causes more trauma and scarring, that has to dealt with.

But, again, if the surgeon is not thinking of this problem, it won't be picked up. You may have to mention it, for it to be thought about.


The atrophy of the quad muscles is to be expected and it will take a while to regain the strength and bulk. Muscle atrophies very quickly and when you are not using the muscle it also loses its normal tone. This can make the muscle look and feel just that more flabby. We usually tell the athletes that it takes two days of rehab for every day they are out of practice. As you probably know, it is a lot harder to get into shape to play a sport, than it is to get out of shape in the off season. So, until you can start doing strengthening exercises, you may be able to maintain, but not rebuild, your muscle mass.


Again, if your knee is just not getting any more motion at all, see your surgeon sooner rather than later. Getting the motion is difficult, but you should see at least some progress with continued stretching exercises.

Good luck.

Thanks a million!!! I have my first PT session Tuesday the 31st. I talked with her over the phone today and she said something similar that, it might just be too soon for the knee to bend through the inflammation and the quad may be too stiff and may not be strong enough to support a bend yet. I just thought by 1 month I'd be bending my knee because I've read so many posts about people bending their knees after a few days, weeks and I feel like I'm behind not being able to sit in a chair.

mcoulstring,

Everyone heals at their own rate. But, you are right, most patients will have around 90 degrees of knee flexion by 30 days post injury. So, it is a little concerning that you have only 30 degrees of flexion.

Do speak with the physical therapist. They are the first line against arthrofibrosis and do see it often. The therapist should also be able to look at the knee joint. There are a few problems in the knee, such as a displaced buckethandle tear of one of the meniscal cartilages, that cause the knee to not be able to move past a certain point. A torn ACL can flip into the joint, preventing motion. So, the knee joint also needs to be examined.

Good luck. Keeping my fingers crossed that you do not develop arthrofibrosis, as that can be a real big problem. Again, work hard in PT. Best wishes.

Hey Galiec,
Just for some reason this past week I made huge progress...My pain has subsided a lot so I started stretching more (mainly my knee trying to get it to bend more) I also accidentally put weight on it (I'm 4 month out but was told no weight bearing for 6- and found that it didn't hurt at all, so I've been basically walking gently with about 50-80% pressure and although it's tiring it feels more comfortable then trying to bend my knee and crutch on one leg.

Well, I had my first PT session yesterday. I went in there and she measured my knee and it was bending at 45 degrees at the beggining of the session. She said my incisions, and screws are right on my t-band so she said I'm going to have to work a bit harder as that's already a tight tissue. By the end of the session, I was able to bend my knee at 65 degrees (after working my ass off and pushing it) I also walked on the bars for awhile and she told me to put as much weight on it as I can stand from here on out. My knee still feels like it wants to hyperextend every time I stand up straight and she said that's normally because my joints are waking back up.

I think in retrospect, I may not have pushed myself enough in the early stages of my recovery (specifically trying to bend my knee). I get new X-rays and see my ortho on Friday. Should I hold off on asking for an MRi? I'd rather not spend the money if I don't have to and I'm now scheduled for PT twice a week for the next month and I'm going to religiously do the regiment she gave me. My knee feels like the very weak link but, that doesn't necessarily mean there's damage in there right? My ortho did say I have early stages of arthritis and I'm knocked kneed which she said doesn't help (but I've also never had any knee probs before and I'm extremely active.). Is there anything that she can look for on the X-rays that would indicate other knee injuries like torn ligs? Any info would be greatly appreciated!
Thanks,
Mark

Mark,

When you do see the orthopedic surgeon, have him/her examine the knee thoroughly, just to make sure there is nothing going on with it. If the surgeon thinks further imaging of the knee/thigh is warranted, he/she will order it. X-rays only look at the bone, of course, and some inferences can be made about the cartilage, ligament, tendons, etc, but that's about it. Again, a good exam in the best thing, and then if the surgeon wants more information, he/she will order more tests.


It sound like you are starting to make some progress. It does take around 63 degree of knee flexion to clear the toes during walking. So, you are almost there. The fact that you do not have any pain at the fracture site with weight bearing is a great sign. Weight bearing will help stimulate the body to heal the fracture faster, this is called Wolff's Law: bone will respond to the stresses applied to it. And, it is easier to regain motion when you are weight bearing.

But, you still have a ways to go. It takes about 90 degrees to walk up stairs and to sit in a regular chair. It takes more than 90 degrees to walk down stairs and to rise from low chairs.

As stated before, usually patients will have around 90 degrees by a month out, but every patient is different. Since you are starting to get more motion it is not quite as concerning, but you will have to stay of top of it. You will have to work hard on your own between therapy sessions. And, if you do not continue to make steady progress, the surgeon may want to see you back sooner, rather than later. The therapist should keep track of your progress and notify the surgeon if she has any concerns.


As to the knee wanting to hyperextend when you stand, that is due to the quad atrophy. The quads are the main postural muscles of the lower extremities. They keep us upright. So, when the quads of weak or they are not used to working, it is easy for the knee to either hyperextend or give way. That feeling will go away as your quads regain strength.


So, have the surgeon fully examine your knee. Work hard in therapy to regain and maintain motion. Sounds like the bone is healing (no pain with weight bearing).

Good luck.

So here's a quick and confusing update thus far, I had an MRI three weeks ago on my knee and was told that I have a small tear in my lateral meniscus (not effect my motion), small tear in my mcl and a sprained acl. After the MRI my surgeon assessed my knee that still won't bend past 65 degrees and determined that arthfibrosis is possible and that the first step is to go harder in PT. So, I did... I started walking over my knee as if I would normally and it hurt really bad but I just powered through it. I went to push off on the ball of my foot as if I would in a normal stride and all of a sudden, I felt an unreal pain on the outside of my knee at the top of my tibia that traveled up to the screw above my knee. I immediately feel to the ground in agony. After getting my bearings I noticed that I would start to get this terrible pain everytime a put weight on the ball of my foot (or right when my arch flattens out)...Hands down worst pain I've ever felt next to breaking my femur of course...So I went in to the ER because I figured something was getting caught on my hardware and they took X-rays and the surgeon said that everything looked fine and the screw had not backed out or moved at all.

Went to PT and my PT seems to think it may be my Tband being irrated. My question is, would an irrated tband cause excruciating pain? I was putting 75-100% weight on my leg with no issues now, if I step down with my knee bent even the slightest, I get a crippling pain. So I've been told I'm free to weight bear but even the PT said it looks like I've taken 10 steps backwards as, I can on step down with my knee completely locked. Why would the pain start below my screw as I step down and then travel up to my screw then to mid thigh?

mcoulstring,

Sorry about all of your troubles.

Unfortunately, it is often difficult to determine where the pain is being generated from, even with an examination. The findings on the MRI usually do not cause the type of pain you are describing. The MCL tear would cause focal pain right on the medial side of the knee. ACL tears, themselves, do not cause pain, but rather if incompetent, they cause instability. (It's everything else that is injured during an ACL rupture that usually causes all the pain associated with that injury.) A small tear in the body of the meniscus is usually not painful. If the tear is large and causes part of the meniscus to flip into the joint, it causes a locked knee. But, the meniscus itself has no nerve fibers in it.


In arthrofibrosis, the knee joint becomes a huge scar ball. Remember, the knee joint is the largest joint in the body. Its capsule is usually very giving and stretchable, allowing the knee to go through a very large arc of motion. When you think about it, the knee can go from about 5 degrees of hyperextension to around 160 degrees of flexion (bringing the heel to the buttocks). When the knee is scarred down, the usual gliding of the tissues does not occur, the normal biomechanics of the joint are all messed up.

The knee is not actually a true hinge joint (like the elbow). As the knee flexes, the femur rolls and glides on the tibial plateau. When it goes into full extension, it there is a "screw-home mechanism" where the tibia actually rotates on the femur slightly, so that the condyles of the femur sit deeply in the depressions on the tibial plateau. This is so you can lock your knees when standing, to preserve energy.

So, when everything is glued down with scar tissue, the knee will act more like a hinge, rather than gliding and rolling like it should. The capsule is contracted, socked in, squeezing the joint very tightly. The joint is just not happy.

This can cause abnormal pulling and stretching of tissues all over the place. If you look at a picture of the joint capsule, you will notice that it starts on the top of the tibia and actually goes all the way up onto the distal femur, about a hand's breadth above the patella (suprapatellar pouch). It also goes around into the posterior aspect of the knee. (This is why it is recommended that patients with knee injuries elevate the leg with the knee straight, fully extended, rather than draping it over a pillow. This prevents contracture of the posterior capsule and a flexion contracture.)


With arthrofibrosis, the external tendons can also become adhered to the outer layer of the capsule and ligament. So, the ITB on the lateral side of the knee does slide like it should, the pes anserine on the medial side can develop bursitis, and the big one, the patellar tendon becomes shortened, thickened, and scarred down.


So, with all of this going on, it is no wonder that you have pain. But, trying to pinpoint exactly which one or ones is causing it, may not be possible.


Arthrofibrosis is really big problem. While PT is the mainstay of early treatment, be sure to stay on your surgeon. The optimum treatment has not yet been found. Surgeons who treat a lot of arthrofibrosis feel that early surgical treatment is necessary. Surgery is a two edged sword. It can cut the adhesions (lysis of adhesions) and take out some of the scar tissue, but it also causes scar tissue to form. This is why the conventional thinking is to stay with PT as long as possible and avoid surgery if possible. But, in some cases, surgery is necessary.

This is where the two sides get into it. The ones who advocate surgery say do it early, don't wait too long. The other side, says wait as long as possible.


I am not advocating that you have surgery. Just trying to give you both sides. If the physical therapy is just not cutting it, you might want to push your surgeon a little. If you have not already, you might want to Google "treatment of arthrofibrosis of the knee". There is actually a lot of information, from several large institutions which treat college and pro athletes with this problem. You can get an idea of the spectrum of treatments.


Again, sorry for all of your trials and tribulations. I know it is a real pain. Hang in there. Try to work as much as you can on stretching the tissues out. But, don't hurt yourself.

Good luck.



(PS: I have been on both sides (both as a professional and as a patient). I developed arthrofibrosis and ended up having to have surgical treatment. It did not give me a normal knee, but at least enough to drive my stick shift car. Wishing you the best.)

Thanks for all of the info! I was actually just in the gym doing seat leg extensions with no weight and I can tell you for certain that when I try to extend my effected leg, two things happen: Firstly, I can't get a full locked extension. It feels as though mechanical I just won't go. But if I guide it with my free hands slowly, it will almost lock. I'm attributing that to the swelling o the capsule and my quads are probably not strong enough yet. And two, after doing about five reps, I can feel my tband snap over my knee like its supposed to and then BAM! I can feel something get caught right on my screw. It feels like a nerve getting plucked like a guitar string. Extremely painful, and I imagine I'm just aggravating what's already injured. I can put my thumb right over my screw and feel the reaction of whatever tissue is being aggravated...

Here's my issue, I'm a full time student and senior about to finish up my undergrad. The only health insurance I have is VA. I am very thankful to be 100% covered because my helicopter bill alone was $32,000...But my surgeon at the va is just a resident working under a licensed ortho surgeon and this poor guys case load is probably ridiculous as, it is social medicine. He seems to have had the same thoughts on my my injuries that you have although his take on the arthrofibrosis is different. He measured my knee at a mere 54 degrees where it has been since January 1st only this time he's making it official. He wants to take another reading in 6 weeks and if it's better than 54% (at least by 5 degrees) he wants to wait another 6 weeks and so on and so fourth. So they seem to be on the opposite end of the spectrum. And I'm still a little confused because the measurements are taken "passively" and I can push my brains out and really get to 65-70 in the chair (almost passing out) but when I sit on the table, my passive bend is always 54 give or take a few degrees...Im a pretty tough kid : I broke my collarbone and had level 3 seperation in the same half pipe I injured my leg on last year and I rode down the mountain and drove 3 hours to the hospital in San Diego last year. Hell, I even refused morphine when they got me to the ambulance with my broken femur until my body started convulsing an they said I had to have it. I went about 1.5 hours with no meds.

In your professional opinion, should try to take out an insurance policy through my school and go see a specialist? I'm not looking to be cut open at all but something has to give my knee doesn't feel mechanically sound and as you can tell, it seems to be causing damage in other places? When it comes to my mobility, I can't even put a price on it...

mcoulstring,

By convention, all range of motion measurements are the passive range of motion. But, usually, the physician will mark down both active and passive (or they should).


Usually, the distal screws are placed above the flare of the femoral condyles. The tenor fascia lata muscle comes down from the lateral hip to the lateral knee as the outer most structure (just under the skin and subQ). So, there is actually quite a bit of muscle (vastus lateralis) between the screw heads and the ITB (which is the distal tendon of the tensor muscle). This is not to say that you don't have some type of scar band snapping over the screw head, and it may be connected to the ITB. When the screws of put in, the ITB is split in line with it fibers (an inch or so), the the muscle underneath is bluntly dissected down to the bone using a pair of forceps. Then a soft tissue protector is placed through this area (just sort of a big tube that the drill bit, screw, and screw driver can be put down through). The protector keeps the drill and screw from chewing up the muscle tissue. But, that little defect still has to heal and it can heal with scar bands. So, again, you may have something in there snapping around the screw heads.


The VA provides the best care they can, with the resources they have. But, they are just so overwhelmed with the number of patients they are trying to take care of. And, they are always short staffed.


If you can get insurance, it will probably be to your benefit. Just be aware, that many health insurance policies will not cover "pre-existing" conditions. Or, you have to pay extra for them to be covered. If you can get a policy to cover your residual problems that would be great.


Yes, unfortunately, orthopedic surgeons will try to do everything not to operate on stiff joints. They are taught that surgery will usually just make things worse. And, it is better to just keep pushing in physical therapy, to obtain as much as possible. Then whatever you get, well, that's what you get.

I wasn't happy with what I had and I had been trying to get more motion for almost two years. Luckily, I found a surgeon who, though he did not do the surgery, knew a colleague who was trying a new technique to get more motion in late arthrofibrosis cases. I was put off twice by this surgeon, who said, try more PT. I just became a pest basically. I kept showing up back in his office. He'd give me the speel of the risks and that the amount I would gain would not be great. But, I kept saying I would be happy if he could just get me to 90 degrees. So, finally, he relented.

I had what is called a tibial tubercle cephlad slide, with lysis of adhesions. They actually cut the connection where the patellar tendon attaches to the tibia and move it up towards the knee. This can really mess up the quad mechanism, so it is a real balancing act. And, he cleaned out as much scar tissue from inside the knee as he could. Then, I was kept in the hospital and placed in a CPM machine (continuous passive motion) for almost five days, around the clock. I got my 90 degrees, but it took me awhile to regain control of my quads (before surgery I only had around 45-50 degrees). Would I do it again, yes, because it worked in my case. It doesn't in all cases.

And, this was for well established arthrofibrosis with severe patella baja. Usually, if it is gotten to fairly early, the sportsmedicine guys will do an arthroscopic lysis of adhesions and manipulation under anesthesia, with CPM after. Bony procedures are usually reserved for late cases.



But, you are the one living with the knee and know how it is doing. If you can get insurance, it would probably be best. You might even in the next few months, see if you could get in to see one of the orthopedic sportsmedicine guys in your area for an evaluation and recommendation. Unfortunately, the VA may just never get around to doing anything, not because they don't want to, but because they just don't have the resources.


Oh, just a thought on the snapping around the lateral distal thigh. Sometimes, an injection of cortisone will help to breakdown scar bands. Again, just a thought. I'm sure your PT has probably also recommended friction massage to see if that could break it up. It's not generally recommended to use ultrasound around metal implants, or that could also be used (some PT's will do ultrasound over screw heads, if the US head is kept in continuous motion, while others are very rigid on the contraindications. It's really up to the PT.)


Hang in there. Wish you the best on the rest of your college days (they are truly some of the best times of your life).

Good luck.

Well, I know this may sound crazy but, last night that excruciating pain was driving me insane. So throwing a small temper tantrum, I started standing on my leg sweating and shaking just fed up. I took a long step and put all my weight on it nearly in tears. In my upper thigh (in the break area) I could pin point a hard mass in my quad that all of the pain was radiating from. I pressed down with my hand and nearly fainted and felt something move shift. All of a sudden the pain was gone. It was like a small miracle. I very gently took a few steps nervous that the pain would just come back. It didn't...I had pt today and walked in there with no crutches and very little pain. After seeing how much pain I was in the previous weeks, my pt called my ortho surgeon who just happen to be on break...both in awe, neither of them could give me an explanation. They said it was likely one of the 7 pieces of bone floating around the rod. Which is what I originally thought...but I guess it's still a mystery?

Anywho, ecstatic about this miracle, I pushed my knee as hard as I could today and got 80 degrees comfortably at the end of my session. I'm still so confused but also excited that I may finally be able to push through this stiff joint capsule. At the end of my session both My PT and I were just speechless. I was able to walk, squat, everything. I'll be so happy if I don't have to endure another major surgery.

From completely devastated and painfully frustrated to walking strongly in one day?
-Mark

Mark,

That's excellent.

It could be one of the small bone fragments. If it was up around the fracture site, it could also be associated with scar again.

If you think about it, the area around the fracture is going to have a lot of soft tissue damage. The periosteum is ripped apart and off the bone, the muscles get torn off their bony attachments and their muscle bellies get cut from the sharp edges of the bone fragments, the fascia, nerves, blood vessels all get stretched and twisted while the thigh is not supported. All of this damage causes extensive bleeding in that area. Besides all of the soft tissue damage, bone bleeds like stink. Remember, the bone marrow is where the blood cells are actually made.

So, once the femur is nailed and generally in the shape it is supposed to be, you still have this big hematoma and chewed up tissue around the fracture site. The body then starts to heal the bone and the soft tissues, resorbing the old blood from the hematoma. But, when doing that, a lot of collagen (scar) gets laid down to heal the soft tissues.

Some patients actually scar the quad muscles down to the femur. This can limit the amount a knee flexion. But, usually, patients will have pain and pulling right in the center of the quads, over the fracture site.


You may have had a small scar ball, attached to the fracture fragments, whatever, but whatever it was, you basically did a lysis on yourself. You tore that tethering structure. As long as you keep your motion going, so it doesn't tether down again, you should be golden.


Whatever it was, don't look a gift horse in the mouth. Keep the motion going and don't let things get tethered down.


Excellent, just keep going. Good luck.

Haha will do! I've been stretching every few hours...And I can now bend to about 80-90 comfortably. Getting past there is going to be tough but, I feel like my quads may be hindering the motion as well as that joint capsule. I can feel the stretching in my break area o my quads but the pain feels more like a sore muscle then sharp jabbing pain so I'm just holding long stretches for minutes at a time and I can feel it lossening up. Thanks for all of the info! I'm the type of person that likes to know things about my injuries and not getting to talk to my ortho about it frustrating.
Thanks again!