Broken femur @ neck: indoor bicycle trainer as therapy question

dogstar_49,

Unfortunately, the normal way of riding a bicycle (stationary or regular) places weight bearing stress across the femoral neck.

If the stationary bike is used in a modified way, then it can be used to regain range of motion in the injured hip. It is not uncommon for the stationary bike to be used this way: the foot of the injured hip is just rested on the pedal, and the uninjured limb does all of the active pedaling. The injured limb is usually placed at the lowest position, with the knee straight, at first.

The first exercises are just to move the injured limb forward about 90 degrees of the arc, then back down to straight and the opposite way to 90 degrees of the arc. So, the injured limb is passively move back and forth till that is totally comfortable. Then, the arc of motion is increased with the patient's tolerance, till the injured limb is able to go around in a complete circle. All the time, only the UNinjured limb is allowed to actively push on the pedal, the injured limb is just along for the ride.


When the surgeon allows weight bearing, then the patient can start using the injured limb to push on the pedals.

Pain is always a great guide. If there is pain at the fracture site, then the activity needs to be decreased some.

Workout pain in the soft tissues is okay, in fact needed. But, if it is intense or lasts into the next day, the activity may be a little too much, and may need to be decreased a little.


You also have to remember that femoral neck fractures can be difficult to get to heal. The fact that you are an active person will probably make it better, in that your bone is probably not osteoporotic.

You do not say what type of femoral neck fracture you had, but since it was CRIF’d (close reduction and internal fixation) with the three screws, the fracture was most likely a non-displaced, compressed fracture. Otherwise, the surgeon would probably have recommended that a prosthesis (bipolar or total hip replacement) be placed.

It is always best if you can get the patient’s own bones to heal. That usually provides the best joint possible, especially in young patients. While total joints are good, they can never provide the patient with a “normal” joint.


Also, you do NOT want to do anything to jeopardize the healing of the fracture, and thus the status of the femoral head (ball part of the joint). The blood supply to the femoral head goes up along the femoral neck. So, again, you do not want to jeopardize this blood supply.


The fact that you do not have any pain right now is a good sign. Hopefully, there will be callus formation (new bone) on the x-rays at your next appointment. If there is, then the surgeon will hopefully advance your weight bearing.


Cycling is a great exercise for hip injury patients. But, have you also tried water therapy. If you have access to a pool, you can do a lot of stuff in the pool. The water provides warmth that makes the tissues more pliant and the buoyancy makes the activities non weight bearing. You can work on gait mechanics and in some pools, even run in the deep end/diving well.

Some pools have special vests that are weighted, so that the patient can actually run in the water. A lot of elite runners do this when they are injured and are not allowed to weight bear. Something to look into. It is even great once you are allowed to weight bear.


So, when you see your surgeon, ask as to how much you are allowed to weight bear. But, remember, while you are anxious to get back to cycling and your regular activities, do not do anything that would jeopardize the blood supply to the head or cause problems with fracture healing.


Good luck. Hope you get back to cycling soon.

Hello Gaelic,
I had read several of your replies to various individuals. You are particularly informative. I hope you may be able to help.
I also fell from my bike, left side, and broke the neck of the femur on July 4th. The fracture was fully displaced, and the break almost vertical in appearance (ie pretty severe). Was taken to A&E. Due to my age (44) full hip replacement at this stage was ruled out, surgeon decided to operate immediately, and has used three cannulated screws. I have been non weight bearing since the accident. Recently started to feel more comfortable doing some partial weight bearing with use of crutches as of week 5. However I still have a lot of groin pain and pain in my knees etc, can not bend legs outwards at all, also very uncomfortable to sit for too long - constantly need to stand up. My concerns are as follows. I went back to the hospital yesterday, surgeon is away on holiday, met his assistant. The X-ray taken looked no different from initial post op X-ray, ie no new bone growth at all! Also one of the screws appeared to have moved out. Should I have new bone growth after this time? Am I best still non weight bearing if there is no new bone growth, or is a little gentle w/b with crutches alright. Is it likely the groin pain is the start of AVN? If no new bone growth evident at next X-ray which is in 4 weeks, ie 10 weeks post accident what would your advise be. Thank you

Churchi11,

Sorry about your accident.

It is unfortunate that you sustained a Garden IV femoral neck fracture (complete displacement of the fracture). These carry the highest rates of AVN of the femoral head. That is not a given, however, the incidence of AVN following displaced hip fractures can be around 80%. This is mainly because the blood vessels along the femoral neck are torn, thus nutrition to the femoral head depends basically on any remaining vessels along the neck and the functioning vessels in the ligamentum teres (a ligament that goes into the femoral head within the joint capsule). Unfortunately, this is not a lot of blood supply.

The other problem that you have to be concerned about is that of a nonunion. Nonunion is not as common as AVN and ranges from 10-30% of all femoral neck fractures. In a study by Hammer in the Journal of Orthopedic Trauma found that 2 out of 5 patients with a Garden IV, vertical fracture line, went onto nonunion (granted, these are low numbers, but it is difficult to gather a lot of these types of fractures for study).

It has been found that only about 1/3 of patients with AVN will require further surgery, whereas around 3/4 of patients with a nonunion will require additional surgery.


So, you want to try to prevent either of these from happening, if you can. A lot of things are not in your hands though. These include the timing of surgical intervention, the type of intervention, number of reduction attempts, etc. You have to focus on the post-op factors.


You must follow your surgeon’s recommendation for weight bearing. If you have instructed to be nonweight bearing, then you should not put any weight on the leg. You should also avoid doing a lot of straight leg raises, unsupported. Doing straight leg raises can put a lot of stress on the fracture site. Especially if you are having pain in the groin with similar activities.

If the surgeon feels that the fixation is such that you can do some weight bearing, then again, follow how much he/she has allowed you to do. Do not go above that amount.


It is not uncommon for callus formation to be slow around fractures that are solidly fixated. The type of healing is actually different between fractures which are surgically fixed with hardware and those that are treated by casting (such as in forearm fractures). Those fractures which have some motion around the site (casted) will produce abundant callus to prevent this motion. Fractures which are rigidly fixed heal by endosteal bone growth. Which does not produce a lot of callus. So, you may not see a lot of callus formation around the fracture site. It is going to be quite subtle.


However, if you are having one of the screws back out, that could be from subsidence at the fracture site. It also depends upon how much the screw head appeared to move. Slight differences are common when the x-ray is taken at a slightly different angle. As to if it is due to subsidence, that would have to be determined by comparing the intraoperative and post-operative films. Subsidence of the fracture is not really a big problem, as you want the fracture fragments compressed together. But, if the hardware is backing out, that may have to be addressed. Usually, if the screw threads are still in the far fragment (the femoral head) and are not across the fracture line, the screw is left in place till the fracture is healed. If it has backed out enough for the threads to be across the fracture line, then that screw is not doing much and if the head is proud, causing discomfort on the lateral side of the hip, then it may have to be removed early. But, that is up to the surgeon.


Unfortunately, continued pain in the groin, especially if it is intense, is more of a sign of a nonunion than that of AVN. Nonunion symptoms usually show up fairly early in the course of fracture healing, while AVN symptoms tend to show up later.


Again, you have to follow your surgeon’s weight bearing recommendations. But, you also have to follow the signs your own body is given you. If you are having significant pain in the groin with weight bearing or exercise, then you need to back off of those activities.

You may not see a lot of callus formation, but the surgeon is looking for other signs. So, at your next visit discuss the healing of your fracture with the surgeon.


Again, you unfortunately have a very significant injury. It is the displacement of the fracture that is the most important factor. And, completely displaced femoral neck fractures (Garden IV) have the highest rates of AVN and nonunion. Do not do anything that may compromise the healing of your fracture.

Good luck. Wishing you the best. (If you smoke, this would be a good time to quit. It you do not smoke, that’s great.) Let us know how things go with you.

Gaelic,

You are providing great help and encouragement. Broken femur neck is a terrible injury. I am 63 and on week 11 with slight non-union (1 mm x <1 cm) of a non-displaced broken femur neck, that has 2 screws. My new instructions from the surgeon are: try about 80-100 lbs weight now to see if I can stimulate bone growth for the part of the fracture that remains. In 1 more month if it's not healed, we will be discussing "options", which is clearly doc-talk for more surgery. I have seen information that union can take longer than 16 weeks and I know one other person still on crutches after 18 weeks. My surgeon is gone for 2 weeks now and I don't know how much pain I should be having or when to worry. As it is now, after a few minutes of walking with say 80 lbs, there is minor pain that subsides quickly. Any suggestions?

Candoo,

You can expect to have some discomfort in the soft tissues around the hip and pelvis region (and possibly in the lower limb also). However, you do not want to have sharp, intense (take your breath away) pain directly at the fracture site. That could mean that you are putting too much stress on the weakened area.

The idea of placing stress across the fracture site to stimulate healing is known as Wolff’s Law - bone will respond to the stresses applied to it.

If I understand your post correctly, your femoral neck is pretty much healed, except for a small 1cm area, about 1mm thick. Which would mean that the vast majority of the neck is healed, which is good. Putting some stress across the neck may just to the trick.

Again, you will probably be sore after having done some activity, mainly because your tissues are just not used to working. And, you may have some discomfort in the tissues when working, but that should not be right at the fracture site (which would be in the groin, over the femoral neck).

Good luck. Hope you go on to uneventful healing.

Gaelic,

Thanks for the help. I can't believe how many guys break their femurs bike riding!

Yea, when you are not quite as young as you used to be, one's reflexes and ability to just jump and hop off a bike is not as easy as it was when you were ten years old. And, you know, it hurts a lot more to fall down now, than it did when we were youngsters, throwing our bodies around.

I've had to give up my outdoors bike and am now relegaed to a stationary bike. I just do not trust the traffic anymore. But, I do miss getting out when the weather is nice.

Good luck with your recovery.

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i'm glad i'm not the only one that needs a little bit of help deciding on an indoor bike trainer. I'm pretty new into cycling but i've really started to love it, which is why I think I need an indoor bike trainer now, I'm addicted!! I've been looking around and I need some suggestions, I found this site and I really like the Forza F-2 Model and I was curious if any of you guys have had experience with that model or forza and if it's a pretty reliable brand. any help would be great, thanks guys.