A femur broken in a scooter accident: walking again with an intramedullary nail
A patient in his late teens came in with severe pain in the left thigh after falling off an electric scooter. The femur is the longest and strongest bone in the body, so a break in its shaft means a very large force was applied. This article follows the course, in real images, from surgery until the bone had fully healed and the metal was removed.
Diagnosis: a fracture with a butterfly fragment
The X-ray showed a widely displaced fracture of the femoral shaft, and CT let me examine the shape of the fragments in three dimensions. It was a fracture in which a butterfly-wing-shaped wedge fragment had broken off between the large upper and lower pieces.
By the AO/OTA classification widely used for fractures, this is a type B (wedge) fracture.
| Class | Shape | Meaning |
|---|---|---|
| Type A, simple fracture | Two bone pieces | Subdivided into spiral, oblique and transverse fractures |
| Type B, wedge fracture | An additional butterfly-shaped fragment | When the wedge fragment is fitted back, the large upper and lower pieces touch each other (this patient) |
| Type C, complex fracture | Multiple fragments, or a whole segment | Even when fitted together, the large upper and lower pieces do not touch |
Electric scooters have small wheels, so riders easily fall on small curbs or ice, and a fall at speed produces a high-energy injury close to a motorcycle accident. Fractures with a butterfly fragment or several pieces, as here, are common.
Treatment: why an intramedullary nail
For femoral shaft fractures in adults and in adolescents who have almost finished growing, surgery is the rule, and the standard treatment is intramedullary nailing, in which a long metal rod is placed in the marrow canal inside the bone.
- The fracture site is not opened. Because the nail is inserted through small incisions at the hip and knee, the blood clot (hematoma) at the fracture and the surrounding blood supply are preserved, which favors healing.
- It acts as a pillar inside the bone. The nail shares the body weight with the bone, so walking can begin early.
- The results have been verified for a long time. In the large 1984 study that established this method, 99.1% of 520 femoral fractures healed and 0.9% became infected.
Depending on the entry point, a nail can be inserted through the greater trochanter, the bony prominence on the outer side of the hip, or through the piriformis fossa, the hollow just inside it. In a study comparing the two, healing rates and functional results were similar, but the trochanteric approach had shorter intraoperative fluoroscopy time (average 95 versus 153 seconds) and, in obese patients, shorter operating time. In adolescents with open growth plates, entering through the piriformis fossa risks injuring the blood supply to the femoral head, so I choose the trochanteric entry. For this operation I used a 10 mm diameter, 380 mm long nail inserted through the greater trochanter, and filled the gap between fragments with artificial bone graft.
Why it heals even if the fragment is not perfectly fitted
Honestly, looking at the images right after surgery I felt some regret that the butterfly fragment was not an exact anatomical fit. But the heart of femoral shaft fracture surgery is not fitting the fragments 100%, like gluing them. It is correcting length, rotation and alignment, and creating an environment in which the bone can heal on its own. This is called biological fixation.
How the bone healed over one year
In the 1-, 2- and 4-month images, white callus fills in around the fracture, and at one year it had healed so solidly that the fracture line was almost invisible. It is the result of nail fixation that protects the blood supply, combined with a young patient's capacity to recover.
Removing the metal after the bone healed
I removed the nail after confirming that the bone had healed enough. Whether metal has to be removed, and when, depends on age, site and symptoms. The details are in Do you have to remove the metal plate in your body?.
Rehab after surgery: walking again
The main goal of nail fixation goes beyond getting the bone to heal: it is to get up and walking as soon as possible. The table below is a general example and is adjusted to the fracture pattern and the rate at which callus forms.
| Period | Goal | Main content |
|---|---|---|
| Just after surgery to 2 weeks | Control pain and swelling, prevent joint stiffness | Ankle pumps to prevent blood clots, tightening the thigh with the knee straight, starting to bend and straighten the knee |
| 2–6 weeks | Walking with crutches | Starting at 20–30% of body weight while checking stability on X-ray. In young patients, increase faster if callus fills in quickly |
| 6 weeks to 3 months | Off crutches, normal walking | If callus is sufficient, full weight bearing, hip and thigh strengthening, stationary bike |
| From 3–6 months | Return to sports | Start with light jogging, then jumping and cutting sports. Discuss contact sports with your doctor |
I am often asked, “Do I have to lie in bed until the bone has fully healed?” The answer is no. Appropriate weight bearing stimulates bone cells and in fact helps the bone heal. This patient also rehabilitated actively, and a year later he walks and runs as he did before the accident.
In closing
- A femoral shaft fracture is caused by a large force, and in adults and adolescents intramedullary nailing is the standard treatment.
- The goal of surgery is less to fit the fragments perfectly than to restore length, rotation and alignment and protect the environment in which the bone heals.
- The nail lets you walk early, and steady rehab puts the finishing touch on treatment.
- When riding an electric scooter, always wear protective gear and be careful on ice and curbs.
This article is general medical information. Treatment and rehab can differ depending on the fracture pattern, age and associated injuries, so please confirm with an examination.
References
- Winquist RA, Hansen ST Jr, Clawson DK. Closed intramedullary nailing of femoral fractures: a report of five hundred and twenty cases. J Bone Joint Surg Am. 1984;66(4):529–539.
- Ricci WM, Schwappach J, Tucker M, et al. Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures. J Orthop Trauma. 2006;20(10):663–667.
- Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium—2018. J Orthop Trauma. 2018;32(Suppl 1):S1–S170.