Fractured Femur Recovery

dyrlac

[This is mostly for my own benefit, but I remember frantically googling "femur fracture cycling" whilst in hospital, so perhaps it will be useful to others -- tl; dr version: breaking your leg hurts, but 6 months will get you back most of the way with luck and lots of exercise]


Crash:
I was (am) a reasonably fit 40yo with a 250km/week cycling habit. On 15 July 2016, when riding on Lambeth Palace Road in an intermittent bus/cycle lane at about 25kph, the car to my right in the general traffic lane stopped to allow an oncoming car to turn across our lane(s); the oncoming car accelerated through the resulting gap in the motor traffic but ploughed through me, striking me on the outside of my right thigh at c. 20kph. Happily, this occurred 50 metres from the entrance to St. Thomas' A&E. Everyone stopped, police were duly summoned, one fellow cyclist stopped my garmin, another called my missus. Ultimately no charges were filed :roll: , but the driver's insurers have been superb.

Injury:
A transverse/comminuted fracture of the right distal femur (that big bone in your leg, snapped in half just above the knee, with a couple of extra bits floating around). Non compound, but I knew I was in a bad way when my leg started bending of its own accord in an unnatural direction. This was my only injury, not a scratch anywhere else. Had the impact occurred 3 inches lower, I would have needed a new knee; 8 inches higher, and I would have been in the market for a new pelvis. Bike was a write-off as were my custom bibshorts and jersey (which had to be cut off me).

Surgical treatment:
Was put into traction straightaway, but did not go into the operating theatre until the next morning. Traction was awful as my cyclist's quads, which were spasming all over the place, easily overpowered the meagre counterweight in the traction frame. In surgery, the orthos performed an antegrade intramedullary nailing: essentially they drill a hole length-wise through the femur from hip to knee (how they lined up the broken bits remains a mystery), stick a titanium rod through the hole(s), like a string through beads, then torque the whole assembly down with three locking screws at either end. End result is a 3 cm scar at my hip and three screw-hole scars near my knee and another trio at my hip. Took 4 hours under general anaesthesia. Woke up with my left leg (the uninjured one) totally numb because of nerve compression during surgery; which sorted itself out over the course of the next few days but was more than a little worrying.

Post-surgery:
I spent a week in the orthopaedic ward at St. Thomas' (patients comprised drunks who fell down, old ladies with broken hips, young chaps who crashed their motorcycles, and me). An intramedullary nail is meant to be immediately weight bearing. There is no cast or plaster (other than bandages on the surgical incisions), and you're meant to put as much weight through your foot as pain allows. Once my left leg recovered from the nerve compression on S+2 (two days post surgery), I got a zimmer frame to shuffle round the ward. The next day I was on crutches. The hospital physios checked me out on climbing stairs and using the toilet, and finally let me leave on S+5 (five days post surgery). I donated the fan my wife had brought to the ward, naturally it had been the hottest week of the year.

Drugs:
I was on morphine and paracetamol for the first two weeks, then tramadol and co-codomol (for pain), and amitriptyline (a mild antidepressant, but an effective sleep aid) for the next 3 weeks. My pain was never terribly well controlled (and is actually still present as a low-level ache, kind of like DOMS), but I am never taking an opiod again if I can avoid it. Tramadol withdrawal is the worst: spent a weekend in bed with the shakes and sweats. Ibuprofen was contraindicated early on as an inhibitor to bone regrowth.

Legals:
I am a member of British Cycling, who put me in touch with Leigh Day to start the claims process on a no-fee basis. Leigh Day have been ace, from handling the initial police report and subsequent dealings with the police to liaising with the insurers and securing interim payouts. The driver's insurers subscribed to the Rehabilitation Code, which means they appoint a rehab specialist (even before they admit fault) to arrange for physio, psychiatric and other medical care; idea is to get you into rehab treatment asap so as to ultimately minimise the amount of time you are out of work (lost earnings for which the insurer would be on the hook for). The insurer has since admitted full liability, but the total claim amount is still being determined: a full and final settlement will need to take into account all future claims, including eg, costs associated with removing the metalwork if I ever need to do so.

[contd.]

dyrlac

[contd. from above]

Early rehab:
The NHS will take several weeks to get you set up with a physio. I wanted to move quicker, so I saw my first physio (on my own dime: ultimately reimbursable from the insurer) on S+6 (six days after surgery). Was referred to hydrophysio in the pool to supplement the land-based physio, so from S+10 I was doing 2 sessions of land based physio and 2 sessions of hydrophysio per week (funded by the insurer under the Rehabilitation Code), along with half an hour daily on exercises at home. Walking was hard, for the first month (still using two crutches), a walk of more than a kilometre was very difficult if not impossible. While I was off work, I did manage to watch *all* of the Olympics. Go Team GB! I went back to work on S+25, taking Ubers (funded by the insurer), then the train.

Early cycling:
I was advised that I could start gentle cycling on the turbo (no more than 15m) in late August on S+24 (24 days after surgery). Unfortunately, I don't do gentle very well and once I discovered zwift, and it was game on for three weeks (I set a new max HR and LTHR, although with a measured FTP of 175 Watts :oops: ). I got banned again on S+50 by my horrified medicos who concluded that I had totally compromised my ability to walk. Shamefacedly, I locked up my shed for a couple more months.

Middle rehab:
Was down to one crutch by early September (S+50). Land based exercises largely centred around resistance band-knee extensions, hydrophysio was largely running in the water against a current with your feat touching down against a steeply inclined slope (this is great, by the way, I'd do it even if not injured). No crutches past S+75. Walking without crutches represented a step back in mobility, but was necessary to get rid of the limp I was cultivating. Unfortunately during this period, I had never quit eating like a cyclist, so I went from 70kg on the day of the crash in July to 80kg by mid November. I had a brief scare when my right knee kept crackling and popping, but an MRI--performed by the NHS, who by this point were desperate to discharge me--ruled out any undiagnosed ACL/MCL trouble. Started going to the gym around the same time for resistance work 2x per week (steps with barbells, squats, etc), replacing one session of hydro and one session of land based physio.

Middle cycling:
I got back onto cycling outside (still banned from the turbo) in October on S+90, with a boris bike ride from Waterloo to my office. These increased in frequency and length (I started boris biking to/from Vauxhall, then Clapham Junction). On S+105, I started commuting from work again on my winter bike (with gears). During that first week back on the bike I cycled 194km, very slowly (avg of 125 watts). By the end of November, I was making forays back into Richmond Park and toward the end of the month had started some wattbike work (L2 for 60m twice weekly), focusing on L/R balance. Managed 1,013km in November, none of it very fast and a lot of it on boris bikes.

Mental health:
Part of my assessment under the Rehabilitation Code was an assessment for, among other things, post traumatic stress disorder. When I got back on the bike, I did notice that I would fixate on things in my right side peripheral vision, which obviously isn't very helpful as I really needed to look where I was going. Cue 8 sessions of eye movement desensitisation therapy and things seem back to normal.

Late rehab:
In December (S+130), my land based physio and gym work was almost exclusively directed at plyometric training (jumping, etc) to drive impact work through my right leg. By this point my orthopaedic consultant reluctantly agreed that I was approaching sufficient fitness that I could go skiing in January (and February, and March) subject to a final xray that showed sufficient union of the bits of bone. A quick trip to the Hemel Hampstead Snow Centre established that I could persuade myself to point my skis downhill, but my form was totally lost. I did manage to ski in January, my promise to stick to the blue pistes lasted all of 84 minutes, more skidding than carving on the reds, but I'll take it.

By the end of December, hydrophysio was essentially done, I'll miss the nice warm pool, but we had reached diminishing marginal returns. To replace it, my land physio prescribed treadmill work. (I came to cycling after wrecking my legs running, so this is just coming full circle.) 3x week, 30 minutes of run/walk. Last night, on S+199, I ran 5 whole kilometres in a time of 34:25. :? Once I can run a sub 25m 5k, I'll rejoin the ranks of the non-runners.

Late cycling:
In December I allowed myself back on Zwift and the regular commute took me to 1,149 kilometres in the month. Zwift was a haphazard weekend/holiday thing, 60m here, 90m there. In January, I decided to make it a bit more structured. I bought a Wahoo Kickr fancy smart turbo trainer and started a strict Tuesday/Thursday rota of sweet spot training and 2x20s, with a longer session at the weekend. Measured FTP is back up to 236 watts (about 3.1 W/kg, not at all special, but given where I was ...). Down to 75kg, hope to get that down to sub-70kg by the summer and push the FTP up to 280. Now back to commuting on fixed gear; not setting the world alight in SCR, but not pootling either. Hit 1,545 km for January (including pseudo kilometres on Zwift).

Current status:
Nearing 7 months on, I reckon I'm about 90% in terms of function, 75% in terms of performance compared to the day of the crash (when I was probably in the best shape of my life). Sitting for more than 20m is guaranteed to result in a bit of a limp for 20 paces or so, and the leg is more or less continually sore but not in any debilitating way, just as a reminder to pay attention to the numpties.

keef66

Well that's another thing to add to my very long list of things to avoid. Sounds horrific. At least you had the sense to do it near a hospital, and the driver's insurers were cooperative...

Carry on healing.

Do you get any kind of documentary evidence to wave when you set off the metal detector at the airport?

Mikey23

Thanks very much for sharing your experiences. My broken femur was not picked up till two weeks after the accident which caussed it to be displaced and impacted ro the point where a THR was the only realistic option and you will find me in the threads below! . So you have explained why my non operated leg was numb then. Never figured that one out. And PTSD was something i had not thought of but can see it could be an issue. I think i will try not to get back on the turbo yet as i dont think im ready and dont want to go bonkers. But i could get some aquafit type physio...

dyrlac

Glad to be of some use, had to get that off my chest.

Re: airports. I set the detectors off about 50% of the time. They usually make me go in the whole body scanner, and then wave me through.

Re: hydro - if based in South West London, I have nothing but good things to say about Aquaphysio (http://www.aqua-physio.co.uk/). A block of self-help sessions is relatively cheap if you're paying your own way.

peteco

Thanks for taking the time to put that together.
I guess everyone here is praying they don't have to refer to it, but I am sure it will help someone in the future.

Pete

herzog

Great posts Dyrlac!

I'm 3y on from pretty much the same injury and don't even think about it anymore. I would say the recovery, in terms of discomfort, was complete by 12 months and my FTP is now higher than it was before the injury (when, like you, I was in the form of my life).

Providing the op was done correctly, you should get back to 100% in terms of both function and performance.

the_cyclist_of_catan

Herzog wrote:

Providing the op was done correctly, you should get back to 100% in terms of both function and performance.

I can't agree with that.

The surgery on my leg left it incredibly straight ant has healed nicely (though it took the best part of 12 months) - but it was clearly a tough operation from a traction point of view - the surgeon said he'd never pulled so hard, I lost so much blood I was in the ICU for a week, and the traction post crushed my perineal nerve (don't google it. Just accept that it took mine about ten weeks to recover and I was mightily relieved when it did).

The fracture itself causes all sorts of nerve and muscle damage, and the surgery can cause more. They're pretty good at missing most of the important stuff with the distal and proximal pins, but they needed to open my leg up somewhat to perform a proper reduction. Which means that my left Vastus Lateralis is now about 50% of its pre-op length, and the scarring is pretty much one long line from knee to hip. What with the accident damage and surgical damage, I reckon that 18 months on my leg is about 80% what it was. I can still ride okay, but I reckon that I've lost about 1.5mph off my average speed. I dare say that if I worked twice as hard as I did before I could get back to 90%, but there's a reason why this injury is "career ending" for almost all pro athletes who snap their femurs.

https://drive.google.com/open?id=0ByzVNqCc6XQYdmhYTThWd1VsdW8

I didn't have any problems with opiod withdrawal, but the morphine made me itch and all of them gave me severe constipation - which with a broken leg to deal with was by far the worst part of the ordeal. I was non-weight bearing for 7 weeks (which sucks), and on crutches for 5 months. The surgeon made me stay off the bike for nine months (although I did some static recumbent and then turbo work, starting at about 8 weeks; I couldn't get my leg over the saddle of a proper bike for 5-6 months though). I managed to make it back on the bike in time to complete the 100-mile audax I'd crashed out of on the 12-month "femurversary", but there's no way my cycling is as strong as it was. And I'm left with that constant fear that another heavy fall might result in some pretty catastrophic damage - those bolts into the neck of my femur look like they'd make great stress risers to propagate cracks.

Oh, and I had nobody to sue. Three months off work, and all the costs associated with Physio, prescriptions, appointments etc all dented the bank balance quite alarmingly. And three months with lots of pain (despite industrial strength quantities of ibuprofen and paracetamol), with little or no sleep during those weeks. I did get to watch a lot of Sweeney on ITV4 though.

herzog

I think I was lucky to have the guy that runs the leg trauma surgical training for SE England on duty when I did mine...Sunday afternoon around Brighton. My docs in Switzerland where I was living at the time said it was a world class job.

Aftercare on the NHS was a different story though.

dyrlac

Catan: yikes. Sorry to hear about your complications, being immediately weight bearing made things much, much easier for me. My thigh circumference is back to parity between both legs and I'm putting out similar power numbers for each leg (using the admittedly inexact wattbike estimates). So I'm feeling pretty good about the bike. Running is also steadily improving; my 5k time now stands at 30:18, 4 minutes quicker than last week, but I still hide the speed on the treadmill--too embarrassing plodding along in single-digit kph. Where I'm still struggling is in lateral plyometric movements: fancy footwork at my kids' rugby training generally results in me on my arse or limping off the pitch. Going skiing again (!) next week, so we'll see if a couple more weeks of recovery have made any improvement to my form (unlikely).

Herzog wrote:

I think I was lucky to have the guy that runs the leg trauma surgical training for SE England on duty when I did mine...Sunday afternoon around Brighton. My docs in Switzerland where I was living at the time said it was a world class job.

Aftercare on the NHS was a different story though.

I was similarly impressed by my surgeons: the team was literally high-fiving each other when they came to see me in recovery. The ward where I was a prisoner for 5 days post-op did leave quite a bit to be desired, but I accept that I'm a difficult (or more charitably, motivated) patient.

the_cyclist_of_catan

In terms of the NHS, I formed a VERY positive view of things from my bed in the ICU (I have no real idea how I got there; I was nowhere near as poorly as anyone else on the unit that week, I had one next-door neighbour that didn't last twelve hours). The NHS Physio was good, too - including hydrotherapy (though I think I scared him with my desire to always push further and faster).

It was only after the 6-month mark that I started to get a bit fed up; with the physio and surgical follow-up both over, I didn't realise that that was it - the progress over the previous six months would come to a grinding halt, and all those little niggles and issues would remain. Like the rod. I swear I can feel the pins catching on something in the knee every time I climb a stair. Though I am not fond of climbing stairs anymore - I've gone from bounding up them two or three at a time to sort-of struggling up each one. It's not a major battle, but the sort of effort that a staircase is the day after a really, really tough ride. Only in my case it never gets any better. I keep oscillating between wanting the rod out and putting up with it being a permanent feature. But the consultant was pretty sure that it ought to be in for good, and the way the NHS is these days they're not going to volunteer to remove it for me.

Oh well. It could have been worse. I could have been a fatal head injury (would have been, if I hadn't been wearing my helmet - according to the paramedic. Which was a bit odd, I thought, as I never actually hit my head during my crash).

dyrlac

The Cyclist of Catan wrote:

I keep oscillating between wanting the rod out and putting up with it being a permanent feature. But the consultant was pretty sure that it ought to be in for good, and the way the NHS is these days they're not going to volunteer to remove it for me.

If you don't asks, you don't gets. My consultant was agnostic about it coming out (at least 12 months post, and more like 36), if I establish that it needed to come out--even for daft reasons, like I thought the rod was impinging performance in marathon training--he was happy to do so via the NHS (and in any event my final settlement from the drivers' insurance is bloody well going to include a contingency fund for having it out privately). My hesitation is that I really don't want to be cut open again if I can avoid it.

The Cyclist of Catan wrote:

Oh well. It could have been worse. I could have been a fatal head injury (would have been, if I hadn't been wearing my helmet - according to the paramedic. Which was a bit odd, I thought, as I never actually hit my head during my crash).

Heard this a lot too, the persistent faith in the magical properties of helmets. First thing anyone ever asks: "were you wearing a helmet?" even after I explain the *only* impact was the leg.

fvh1

Thanks for a great post Dyrlac.
You have covered in such good detail your road back to recovery from your fractured femur, and has given me hope that in the end, after all the PT and exercise, I will make a return to walking without limping and running outdoors again.
I am S+100 days now for my left femur.

Looking at the last x ray, I would say I am 50% in terms of the bone healing and laying down new tissue.
I'm not having any flexibility or mobility issues, and my limp is getting better with more effort in PT on the quads and glutes.
My next x ray is S+158 days. Cannot speak highly enough of our public health system in Perth, Western Australia, I have been looked after very well since I was in ED, ortho surgery the next day, and all the follow ups.