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Me and My Intramedullary Nail (2mths since the op)

Me and my IM Nail Part 2 (3mths since the op)>>>

Me and my IM Nail Part 3 (4mths since the op)>>>

Just over 2 months ago I had a fall and broke my left Tibia (at the shin) and Fibula bones (the lower leg bones) and had to have an operation so they could put a big metal rod (known technically as an intramedullary nail or rod) down the bone to help the healing process. There is not much information available on the internet about this procedure, particularly the healing process, so I thought I would share my experiences in case it is of help or comfort to others going through the same thing.

Tibia Break

Fibula Break

My fall did not seem like a major one and so it was a shock that I had broken a bone, let alone 2 bones and a massive unwelcome surprise that the breaks were so severe I would need an operation?! I was told that they would likely do one of three options: 1) put in a metal rod inside the length of the tibia bone; 2) put a metal plate across the shin area or 3) put in some sort of metal screw/nail horizontally through the shin.

I asked what the risks were and they said the intramedullary nail does have some risks and if I was having circulation issues before or during the surgery then it could lead to them having to amputate. I thought this was just a normal disclaimer but when I pressed the issue the doctor said there was a significant risk, although small in percentage terms of about 5%. The alternative would be not to have the surgery and have a cast, which would not guarantee the bones would heal okay and would also double the recovery time from 6mths to 12mths. I gave written consent that I was alright with them going ahead with the surgery.

It was only as I was being wheeled down to theatre that I was told they were going to do the more risky option 1. I told myself that 19 times out of 20 it would be fine, but couldn’t help but wonder if I would be the unlucky 1 in 20 and looked down at my left foot (well toes, as I had a cast pre-operation) and thought it might be the last time I would see it. When I stirred in recovery afterwards, my first action was to see if I still had my leg and was very relieved to still see it there.

My leg after the operation

Looking back on it, the hospital (St.George’s Hospital in Tooting, South London, UK) did not give me much information about what would happen to me and I was pleased to discover that I didn’t have a cast. Apparently, the point of intramedullary (IM) nails are that they help the bone heal a lot quicker by keeping it in position and also partly carry the strain the bone normally endures. As the ankle and knee joints are not restricted by a cast with this approach, it means partial weight can be applied and then increased when the bone and leg have sufficiently healed.

The technique was developed by German surgeon Gerhard Küntscher and first performed in 1939 to treat soldiers and helped get them back to health (and to fight again) much quicker. Having a cast and therefore a totally inactive leg for a minimum of 4 months or so requires a great deal of time and physio work to get back to normality. Whereas the IM nail approach would sometimes have soldiers back fighting within 6 months.

I found this You Tube video clip of an operation showing the insertion of the IM nail which would have been very similar, but not identical to the one I had. Note: It’s not particularly graphic but if you are a little squeamish, then probably best not to watch it.

I was told the metal used was a stainless steel alloy. People keep asking me if that means I will set off metal detectors at the airport and to be honest I still don’t know as I keep forgetting to ask. This article here suggests I probably will, but it won’t be a big deal and that airport security staff are quite used to it.

For the first day or so after operation, with a very swollen lower leg, I was on a morphine drip in the hospital and then was given Tramadol as a painkiller along with Paracetamol.  I was taking two Tramadol at a time, every 4 hours, and they made very drowsy as well as making me feel quick sick in the stomach. I let the doctors know and they reduced my intake to one every 4 hours, but I still hated the way they made me feel so decided after about day 3 to stop taking them, but kept them just in case I needed them.

I hate being in hospitals and could not wait to get out. I am in my early thirties and was in a 6-bed ward full of much older men with various issues more significant and serious than my own. Alfred, who was in the bed opposite me, was the undisputed wet fart champion of the ward. One evening there seemed to be an unconscious competition between the others as to who could fart and snore the loudest. Alfred was again the winner. One of the men was quite friendly and chatty but kept wanting to show me his stomach, which I was not so keen to do.

My view in hospital and wearing hospital slippers

I was admitted to the hospital late Saturday night and had the operation the following evening. I was told that some people, particularly the elderly, need to stay in hospital for a couple of weeks to recover but by the Thursday the doctors said they were happy for me to go home as long as the physio gave me the all clear that I was safe and competent on crutches.

I was desperate to get out of the hospital and could not stand to be there any longer than I had to so I needed to pass this crutches test with the physio. I’d been given the crutches late on Wednesday by a physio but unfortunately my first attempt was not a great success and only managed a few feet before having to lie down again. This was partly due to being very woozy from the painkillers, it also was my first attempt at being vertical since the operation and most likely due to me accidentally ripping out a poorly inserted cannular with the crutch and then started bleeding down my arm.

My swollen leg - taken when they were changing the bandages

The following day I stopped taking the painkillers and felt more awake and alert. The stomach guy on my ward had done the crutches test before and in return for finally showing me his stomach he told me what I needed to do to pass. You needed to go up and down the ward with confidence and then go up and down some stairs after they showed you the safe method of doing it.

The truth was it was an effort to get out of bed and even using the crutches to visit the toilet was a major ordeal. Having to wee into a container for several days was degrading enough, but I had refused to do a ‘number 2’ and so when I got the crutches I was able to go in a proper toilet for the first time in 4 days and boy did that feel good! Anyway, I had done a couple of practice runs on the crutches down the ward corridor and was not quick but felt I was competent.

The doctors had said I was allowed to put partial weight onto my left leg which meant when I walked with crutches I could put my left foot on the floor but not put any real weight on it. This is rather tricky at first as every instinct you have says not to put your painful foot (or rather leg) onto the floor. Keeping your leg raised in the air is a lot easier on crutches and you are assured that you are not doing any damage.  When putting the foot on the floor you have to time pushing down on the crutch handles ensuring your weight is carried by your shoulders and not your damaged leg.

My crutches

The physios wander the hospital visiting different patients and so you never know what time they will come round. Whenever I went to the loo on the Thursday I would do so as quickly as I could in case I missed the physio and would have to wait another day. He finally arrived in the afternoon and was a different person to the day before. He looked at my file and wasn’t sure if I was allowed to put partial weight on the foot or not. I told him the doctors had said it was okay and he asked a nurse who said she didn’t know. He then disappeared for ages and came back and confirmed I was allowed to. We went up and down the ward and he seemed okay with that and said that was enough for today. I told him that I wanted to go up and down the stairs and he said he wasn’t sure and went off to check something. I never saw him again that day and had to stay another night.

Poor old Alfred shat himself during the night. As in he properly shat himself and stank out the entire ward. Elsewhere along the corridor I heard a woman screaming in pain needing attention. I had to get out! I decided that whatever happened the next day, whether the physio showed up or not, I was going to leave in the evening.

A close up of just below the knee

I waited patiently for him to arrive and he did so just after lunch. Being off the painkillers (I only took them at night to help me sleep) made me feel a lot better and alert and when the physio arrived I felt confident I would pass the test. I asked him if we would be doing the stairs today and he said we will see how it goes. I then made it very clear to him that he was the only person preventing me from going home and that my bed could be used by someone more deserving than me. I gave him a look that made it clear we would definitely be doing the stairs.

We got to the stairs and he asked me if there were any stairs at my home and if so, were there any hand rails? I live in a flat so the kitchen, toilet and bedroom are all on the same level so that was fine, but I live on the top floor which means going up 7 flights of steps, plus a stoop at the bottom. I could not remember if it had handrails or not but needed to get out of the hospital so told him I had 3 flights of stairs and there were handrails on both sides!

I got my wish and passed the crutches test and could go home. My parents kindly gave me a lift from the hospital back to my flat which also turned out to be a bit of an ordeal. The U.K. had been hit by snow whilst I was I was recovering from the operation and so it meant the pavements and roads were very slippy. Not ideal for someone uneasy on crutches and a broken leg.

My ward seemed to be miles away from the exit of the hospital where I could get picked up by my parents’ car, but I was determined. My parents were stressing and fretting, getting annoyed with each other and I with them. When parking outside my building, my Dad preferred to use the side street from the main road but that was far too slippy and so he had to reverse onto the main road. Walking from the car onto the pavement was really quite tricky and very cold! I wasn’t able to put shoes on (my left foot and ankle in particular was very swollen) and so was wearing these pathetic and most unsexy hospital slippers.

Hospital Slipper

My parents were either side of me looking very anxious and every unsteady movement I made they over-reacted putting their arms out to catch me and making ‘aargh’ noises. They were just worried and wanted to help and make sure I was okay. However, it wasn’t helping me and I was in pain and quite cold so I got rather impatient with them and was quite rude to my poor Dad at one point. I got through the gate and to the stoop when I first had to start going up steps. I had forgotten the exact order of the method the physio had told me, but after step 3 or 4 I remembered and was able to get up stairs a lot easier and quicker than I thought I would, albeit one step at a time.

The safe method of going upstairs (or down) with crutches is to hold the hand rail with one hand and then both of the crutches in the other hand. One of which is used as a crutch and the other is horizontal as you are just carrying it, effectively. This is a safe method, but it is slow. It is also cumbersome when going up flights of stairs as when you have got to the top of one flight, you revert back to 2 crutches as you go round the corner and then have to change back to one crutch as you go up again. The alternative is to hop round, with the 2 crutches still in the one hand, which is what I ended up doing. After a few weeks you may feel confident to abandon this safe method altogether and use both crutches going up and down the stairs. I have been doing this for the last month, although I am sure physios would disapprove.

I got into my flat and lay on my bed, in my own clothes (not the horrible hospital gown) surrounded by my stuff in my bedroom that would not be disturbed by some nurse in the middle of the night asking if they could take a swab of my nose and groin. To which my response was initially okay and then as I realised what she had asked, “Hang on, you want to do what? Why do you need to do that? You do realise it’s my leg that has the problem?”

Being at home felt great and I was so relieved to be out of the hospital. My parents tried hard to persuade me to go and be with them in Somerset (2-3hrs drive from London) whilst I was convalescing. As the bedrooms are upstairs in their home it would mean them converting the living room into a bedroom for me. It would not be ideal and also, more importantly, it wouldn’t be my home. It wouldn’t be my bed and I wouldn’t have my stuff or my independence. It was better, although harder work for me, that I was in my flat. I don’t regret that decision in any way.

I’m still single at the moment and quite an independent, self-reliant sort so it was quite hard to be in my position where I did actually need a bit of help. My parents had been to the supermarket so I was stocked up with food and would not need to go to the supermarket for a while. A lot of the supermarkets do internet ordering and home deliveries and my flatmate offered to get stuff for me too so I knew I would be okay on that regard.

My first day at home alone was interesting. It’s the day the full realisation of your situation hits you as you figure out all the stuff that you are no longer able to do. So much of what you do in life depends on you having two able arms and legs.

Showering suddenly is a very precarious activity as you are balancing really on one leg and cannot move around. You can only wash yourself with one hand as the other is needed to hold on to the wall. It was only a few weeks ago someone suggested that you don’t actually have to stand up and you could sit on the floor in the shower/bath, I wished I’d known that at the beginning! As you have bandages, you need to have something to protect them from getting wet and my mum sent me the below which worked quite well.

Lower-leg guard

I am pleased my kitchen is quite small and so I can hop from one side to the other and rest on the counter without having to use the crutches. I was very pleased when I made my first meal for myself … some toast and a cup of tea. However, to get this from the kitchen to my room necessitates only using one crutch and carefully holding said plate or cup of tea and hopping gently without dropping or spilling anything. So transporting a simple plate of toast and a cup of tea turns into a palaver of two trips and even a third one to get the other crutch if you did not think of this when you first left your bed.

Going to the toilet is a bit tricky too and you have to be quite careful initially at lowering yourself down and standing up. It helps my loo is nearby and very narrow so there is always something to lean on or hang on to. I’ve also had to go from being a scruncher-stander to a scruncher-sitter.

As important as the physical side of things, is your mental attitude. After my operation in early January I was told it would be a minimum of 3 months until I was better and actually more like 6 months before I could “do the things you want to do”. Basically, all the plans and expectations I had for 2010 had just been thrown out of the window. I was hoping to get back into my jogging routine (having abandoned it for 3mths) and now I was being told that it would likely be July before I could think about doing something like that.

I feel I have approached the whole scenario quite well and in good humour. In fact, I have been quietly proud of myself in this area. I haven’t been angry about the situation or thought about ‘why me?’ or that is really unfair. It has happened and so you just have to get on with it.

I have focused on short-term goals rather than the end goal finish line. These goals were getting though the operation okay, then getting out of the hospital and then my first hospital check up about 2 and half weeks later. The next milestone was the following check up about 5 weeks later (a couple of days ago as I write this). More of this a bit later on.

The first week at home was the toughest week by far. The leg was still very swollen and very painful when not in a well-cushioned elevated position. Whenever I stood up, it felt as if blood was rushing in to the lower leg all and would be extremely painful for about 5-10mins. The kind of pain that leaves you out of breath and so I had to psyche myself up for every trip to the toilet or to the kitchen. It would be such a relief to get back to my bed and get my leg back on the pillows.

The swelling of the lower leg, ankle and foot meant that the leg seemed distorted and when I put the foot on the floor and tried to straighten it, I could only get my foot flat by standing at an odd angle with my other leg slightly bent. I was quite concerned that maybe something was wrong and that the metal rod was misaligned. However, when the swelling went down, all was fine.

After the first week at home, the swelling in the leg went down and it started to look quite normal and the pain gradually subsided. The 5-10mins of tremendous pain every time I stood up got less and less in time and intensity and I felt a lot better and was motivated to be more mobile.

I had been house-bound for over week and felt it was now time to venture outdoors. I planned a trip to my local shop to get a few sundry items, something that previously would be a nothing task that would take only 10mins to do. Now I had to plan this carefully as I felt sure I could get down the 7 flights of stairs and then the 50 yards to the shop without any problems. However, I was concerned about the actual shopping part as I would not have a free hand to carry the items I wanted to buy.

My solution to this was to use a rucksack which when in the shop would come off my back and, using the small top handle, would rest on one of the crutch handles. That way I could walk around and simply put in the items as if it were a basket. When full of items it does become a little difficult to walk about with, but overall has been more satisfactory than the hassle of putting the rucksack on and off again throughout the shop.

When I ventured outside onto the street I felt very vulnerable on my crutches and was really wary that someone would accidentally bump into me and I would fall over and damage my leg more. That feeling of vulnerability reduces the more you heal and the more confidence you gain on the crutches.

I was more than a little chuffed at having got to the shop and back with my shopping. I felt independent and quite knackered! Two days later I went with a housemate to meet a mutual friend at a nearby pub for a drink. The pub is a 7mins walk, but on crutches it seemed to take forever and was quite uncomfortable. I had got some padded bike gloves to use with the crutches but still managed to develop blisters. Some people wrap bandages or padding around the handles and I think this may be a better approach.

In the pub we sat on stools and had a drink and it felt good to be doing something normal again. It was my first social engagement since having the operation 3 weeks previously. It was not a comfortable experience as at that point whenever the leg was not elevated it became sore quite quickly and so I was always readjusting my position to try and make it more comfortable.

The elbow crutches I have are really quite good, but the one issue I have with them is that it is very difficult to keep them standing upright when resting against something. It only takes a slight nudge and they will fall over, something that happened many times when at the pub. However, it did act as a good ice-breaker to talk to people (women) who would ask what I had done.

Not having a cast was really good but sometimes it would have been useful to have one. People would notice the crutches and then look at the leg and because there is no cast they are less sympathetic, like I’ve just sprained my ankle or something.  Once the swelling went down it was easy to put on shoes and socks so apart from the crutches I look quite normal and able-bodied. So out an about on buses and trains people don’t give you as much space and are less wary about bumping you as they would if you had a cast.

My first hospital check up appointment was an important milestone I was working towards and I would need to get a bus for the first time whilst on crutches. Buses in London have a big step up to get on and I was worried about finding a seat in time before the bus started moving, not getting hit by other people and then getting off as you cannot stand up until the bus has stopped.

The bus experience was not as bad as I thought on the way there, early afternoon, and I was able to get on the bus without a major jump up or anything and found a seat relatively easily. However, the journey back was at rush hour and I had to fight a swarm of people to get on and then find a seat. It was okay, but I wasn’t comfortable.

The hospital check up went well, apart from the ridiculous waiting time and had an X-ray done and then spoke to a consultant who confirmed the IM nail was aligned exactly as it should be and that I should come back again in 5 weeks time. He said if I started to feel better that I could start putting a little more weight on the leg.  Rather than stitches, I had metal clips and these were removed at the visit. They have a little device a bit like a fancy staple remover that takes them out and is mostly painless.

Metal clips below the knee, just before they were removed

Bottom left is the bruise and mark on the shin from where the bone almost came through the skin

It was the first time I got to actually see the metal in my leg and was a little shocked as I saw more metal than I expected! When I was told that I would have a metal rod in my leg I had pictured in my head a thin rod and some small screws at each end to hold it in place. As you can see the IM nail is quite substantial and the screws holding it in place are the width of the leg, seeming like they may pop through the skin at any moment! The doctor let me take a photo of the X-rays.

X-Ray of IM Nail in my leg - top left is my knee and the whitest parts are the nail and screws holding it in place

Another angle - showing the IM nail just below the knee

Passing that first big milestone was a real motivator and confidence boost as all the worries I’d had were now gone and I was feeling more comfortable and less in pain as each day went by. Thankfully I work for myself and so it meant I could now start to get back to work and earn some money. Unfortunately, I am self-employed and so I had no income at all for January and I was not cash-rich when the accident happened and so it has left me in a difficult financial position, one that I have not yet resolved.

The next few weeks I ventured out a bit more, went to a few work meetings, to a friend’s birthday celebrations and even travelled by train on my own to Birmingham (2hrs from London) for another friend’s 30th birthday. Actually that latter trip was a tough day as it was a Saturday but I was doing some work for a client in West London and the plan was to finish up there and then head straight to Marylebone to catch my pre-booked train. I realised as I left my client that I had left my train tickets and wallet in my flat so had to go all the way back to South London to pick up my wallet and then travel across London again and buy a new much more expensive ticket to get to Birmingham. I was so annoyed with myself.

Using the London Underground is not the easiest thing in the world as most stations are not geared up for people with disabilities. To get through the turnstile you have to swipe your oyster card and quickly get through the gate before it shuts on you. You feel a bit vulnerable on the escalators and it is a bit hairy if the person in front of you decides to get off at the very last moment. So far people on crowded buses and trains have been really good and someone has offered up their seat when it has been busy.

My next milestone was a couple of days ago with my second hospital check up. I have been getting really bored and tired of being on crutches and the pain has pretty much gone, just a little soreness. In the week leading up to the appointment I had felt a lot better and had been putting a bit more weight on my leg, but not too much as I still have a bruise and swelling where the tibia break was (the shin). I was eager to start physio and start the process of being able to walk again and did not want another 5 weeks of being on crutches.

The appointment went well and was told I was healing fine and that I can start putting more weight on the leg. I showed the consultant that I could stand on tip-toes unaided and could walk without crutches, well, I can do this rather slow pathetic hobble walk. The consultant made a ‘lame’ joke about is that how people walk in Clapham (where I live) and said I needed to start physio and putting weight on the leg would aid the healing process. The nurse told me that when I started putting more weight on the leg and doing the physio my leg and foot would swell up, but this was normal.

I left feeling very happy. I had passed the milestone and was onto the next phase. I now only use one crutch when moving about the flat and although it is not a fluid movement and still a bit of a hobble, it is a lot better than before. I can now put the used tea bag straight into the bin from the cup (as you need two hands to do this) rather than putting it on a plate and emptying it later.

When I was waiting at the hospital I saw another guy who had crutches. He could walk without them and had a very slight limp and walked into his appointment carrying the crutches and then came out without them. That is my next goal, to be like that guy at my next appointment in 6 weeks or so.

My ultimate goal is to be able to do a 10mins jog. Once I can do that I will feel like I have recovered, but that is a long way away and I am just focusing on the next goal.

If you have your own experiences to share or know of useful information or resources online please add them in the comments below.

Me and my IM Nail Part 2 (3mths since the op)>>>

Me and my IM Nail Part 3 (4mths since the op)>>>

Jake McMillan