Femur Break

FemurCarlos,

Dynamizing the nail (removing the screws at one end) is a method to get the bone to heal. However, it usually has to be done before the bone goes on to an established non-union. Dynamization is usually done at around the 4 to 6 month mark in femur fractures.

Unfortunately, doing this after the fracture has on established nonunion is usually not successful. But, it is an easy procedure, so if it does happen to do the trick, great.

By removing the interlocking screws at one end of the nail, it allows more stress to go through the bone. When the nail is statically locked the nail becomes a stress shielding construct. Unfortunately, fractures sometimes need stress to heal. So, by dynamizing, the nail then becomes a load sharing construct and more of the stresses with weight bearing go through the bone.

Bone will respond to the stresses applied to it. This is called Wolff's Law. So, when someone lifts weights his/her bones become stronger and stouter. And, likewise, if the bones are not stressed (age, injury, space flight) then osteoporosis sets in.


The problem in your case is that you probably has a well established nonunion by this time. Nonunions do not have the biological capacity to heal. So, usually, surgery has to be done to jump start that capacity again.

In femur fractures that can be done one of two ways. The traditional method is to do an open procedure. This is a big operation. The nonunion is opened and all of the fibrous tissue is removed from between the bone ends. The bone ends are freshened up, so that they are bleeding. The ends are then reapproximated and fixed with internal hardware. The area around the ends of the bones is packed with autologous bone graft. This methods brings in new cells (graft) and provides stability to the bone (internal fixation).

Another method that is sometimes tried, is to remove the current IM nail. Then to ream the intramedullary canal again. This removes some of the fibrous tissue and also causes the bone to bleed. Then a new nail is placed.

Choice between the two procedures has to be based on the fracture construct and whether the nonunion is hypertrophic or atrophic in nature. That is something that would have to be determined by the surgeon, in pre-op planning.


So, for now, you probably just have to wait and see if the bone is going to get its act together and start to lay down new callus. But, at almost a year out from the initial injury, the nonunion is most likely established and it no longer has the biological ability to heal.

If, after several weeks, there has been no change in the nonunion site, then you are going to have to discuss your options with your surgeon.


Hang in there, you have made it this far. Good luck.

Thanks very much for your advice! It's difficult to describe because the pain since the screw removal has Definatley reduced somewhat, but as most people who have suffered this injury will know, there are up days and down days. What has struck me as odd is that after some research not many people are still suffering as badly as I am 11 months post break. I can walk around the house etc in no pain what so ever, driving is not a problem neither is light lifting. But walking a distance of over say 20 yards sends shooting pains up the leg and therefore causes the limp etc. but as I said the pain has reduced since the screw removal and also has changed the pain, yet what u said to me about removing the screws to, if you like, kick start the bone growth again, I was not told this what ever! The mothod that you have informed me of is much more understandable than when they told me it was to let the bone move so it hits the metal causing the bone to fuse!

P.S I thank you very much for your latest reply it was very helpfull

FemurCarlos,

When the nail is dynamized, the stress of weight bearing now goes mostly through the bone. The nail is just basically on internal splint now. When you weight bear, the stress now goes normally down the bone, so the ends of the bones, where the fracture is, now get pushed together. Hopefully, the compression at the fracture site will stimulate the bone to start laying down callus again and heal the fracture once and for all.

It is a good sign that the pain is getting less and less.

Hang in there. Hopefully, dynamizing the nail will do the trick. But, as always, hope for the best, plan for the worst. Good luck.

Gaelic,

It's been a few weeks on and I've noticed the pain increasing somewhat could this be a good sign to show that my bone is bleeding again and it could be healing??

FemurCarlos

FemurCarlos,

It is now uncommon for patients to have some increased pain around the fracture site after dynamization. The stresses are now going almost completely through the bone. Thus, there is probably some slight movement at the fracture site.

Hopefully, this movement will cause the body to start laying down some osteiod and then callus around the fracture site, to stop this movement. That is the idea behind the dynamization.

As long as the pain is not a sharp, intense, or "take-your-breath-away" type of pain, it is probably okay. Hopefully, again, this will decrease as the body stabilizes the fracture. So, you may be on your way to healing.


Hope you do well and the fracture finally gets its act together and unites. Good luck. Hope you have a happy holiday season.

Gaelic,

After continuing pain the hospital have set an X-ray date of Friday 23rd of December to determine whether said screw removal has been successfull. However they said that if the bone is non union still they will start proceedings for a bone graft. To your knowledge can you advise me as to the procedure of the bone graft ie whether it would be existing bone or the new plastic type and also a time scale for recovery etc.

Thanks for your help.

Carlos

Carlos,

There are a couple of ways of treating a femoral nonunion.

One is to do a nail exchange. Basically, here they take the old nail out, ream the intramedullary canal again, and reinsert a new nail. Sometimes, by reaming the inside of the bone, which takes out some of the fibrous tissue and makes the bone bleed, this can jump start the healing process. And this would be all that is needed.

However, sometimes, the surgeon will also pack bone graft directly in the fracture site, after removing the fibrous tissue. This requires opening the fracture site.


There are basically three types of bone graft. Autologous bone graft is taken from somewhere in your body. These sites are usually the iliac crest, either anterior or posterior, or the proximal tibia. Many surgeon feel this is the best graft. It provides both the scaffolding needed for the new bone to grow on, but also, the progenitor cells from the bone marrow, needed to help heal the bone.

The is cadaver, or banked, bone. This is usually used when large solid blocks of bone are needed. It also comes in several shapes and sizes. It provides excellent support, but since it has been cleaned of any cells in it, it does not provide the progenitor cells needed.

The there are the bone substitutes. These are many different forms of these from the use of coral, to man made bone. Sometimes these constructs are injected with BMP (bone morphogenic protein), which is one of the bodily substances needed for fracture healing.


All of these have their own pros and cons.


The best thing to do, is to sit down with your surgeon and ask him/her what the plan is for treating the nonunion. How is it going to be done? What type of fixation will be used afterwards? What type of bone grafting material will be used?


Good luck.

I broke my Femur right near the middle about 8 months ago. I had a Rod put in near my hip and screws near my knee and hip. The Femur break its self has almost fully healed and olny gives me problems when I walk a long distance or try to lift something over ten pounds and walk with it. However my hip is killing me and I dont understand why. It honestly feels like the screw or rod itself is chipping away my hip. I have no insurance and my orthapedic surgen just tells me I have Bercidis and gave me a Quarter Zone shot. It helped with some of the pain for about two weeks but the sharp pain of something chipping away at my bone is still there and never went away. I'm only 24 and I understand breaking a femur is a LONG healing process but every one I ask never mentions any pain in their hip. I don't know what exactly I can do or should do. I just want the pain to go away and for me to have some kind of knowledge on why exactly I broke my femur and now I have horrible problems with my hip.

I broke my Femur right near the middle about 8 months ago. I had a Rod put in near my hip and screws near my knee and hip. The Femur break its self has almost fully healed and olny gives me problems when I walk a long distance or try to lift something over ten pounds and walk with it. However my hip is killing me and I dont understand why. It honestly feels like the screw or rod itself is chipping away my hip. I have no insurance and my orthapedic surgen just tells me I have Bercidis and gave me a Quarter Zone shot. It helped with some of the pain for about two weeks but the sharp pain of something chipping away at my bone is still there and never went away. I'm only 24 and I understand breaking a femur is a LONG healing process but every one I ask never mentions any pain in their hip. I don't know what exactly I can do or should do. I just want the pain to go away and for me to have some kind of knowledge on why exactly I broke my femur and now I have horrible problems with my hip.

a232A,

The IM nail is buried within the central canal of the femur. If it is statically locked proximally (towards the top) and distally (just above the knee), then the nail cannot get out of the bone.

It is also placed through the piriformis fossa, by the greater trochanter, so it is not close to the true hip joint.

However, greater trochanteric bursitis is quite common after an IM nailing.



But, if your pain is not getting better with the cortisone injections, and the pain is located in the groin, then you may have injured the acticular cartilage inside of the hip joint at the time of your injury. It is also possible that you have a labral tear, around the outside of the acetabulum (socket). Both of these would give you pain in the groin region.


So, if you think that you have something else going on, and your current surgeon is not taking you seriously, seek a second opinion. See a different surgeon.

Good luck.

Gaelic,

It has been some time since we last spoke. The surgeons have called my fracture a non union and are planning a bone Graft from the hip and placing it in the bone etc. before I broke my femur in two places I was a keen footballer ( soccer if your in USA). After speaking to the surgeons they have told me that I will be able to return to play football as it is nigh on impossible to break your femur whilst playing football as most breaks are below the knee etc. but my doctor has said he thinks this is wrong and I should need play football again. How much my doctor knows about the sport and the fact that he is no bone specialist like the surgeons that say it is possible is up fr debate. I don't know if you know anything about football aka soccer but I cannot personally recall anyone breaking their femur playing football and I have watched and played football since I was 5 now 22. I seek your personall opinion on this matter. People may think I am ma and should be greatfull to be alive but I hate the thought of never being able to play the game I love again. I was also told by other surgeons that the bone would be even stronger than before after graft and healing time because of the metal being in there and he said I would be absolutely fine! Please reply ASAP. Look forward to hearing from you or anyone here!

FemurCarlos

Hi FemurCarlos,

I just came across this thread and your story as I was researching dynamization which I will be having tomorrow in the hope of kicking my femur into action and stimulating some bone growth. I am 21 and suffered a compound femur fracture in the right leg and tib plateau (knee) and fib in the left during a snowboarding accident 5 months ago. I had an IM nail put into my femur with 2 screws at the knee and 1 at the hip, and also I think three screws put into hold my left knee in place.

Thanks to my awesome physio I have been able to walk unaided for about the last month and spent only 2 months in a wheelchair, shocking all the surgeons/ specialists who thought I'd be stuck in one for 4. However, when I went for my 12 weekly X-rays, I was told that my femur wasn't healing very much at all, hence why they've decided to take the screws out of my knee. I guess I will report back once it's had a chance to grow! Dreading the thought of a bone graft but am I right in thinking that they won't declare a non union until the 9 month mark?

Anyway, the reason I wanted to write to you was to say i KNOW HOW YOU FEEL, with the football thing, that is. I was (/am?!) a snowboard instructor and have spent the past 3 years travelling the world doing what I love. I actually had my accident during a training session for an exam I was supposed to be taking later that week. The thought of not doing it again is horrible. They say i'll make a 'full recovery' but I'm thinking that means able to walk, drive, run... but for very active folk like us? What is the latest with your surgery/ femur recovery?

All the best and I hope to hear from you soon