A 22-year-old man (68 kg., 172 cm.), active military, with no previous history of interest, who was hit by a projectile (9 mm. calibre), from an accidental pistol shot, at close range, in the right thigh.
After primary assessment and initial care he was evacuated to the HGD "Orad y Gajías", where he was diagnosed with a fracture of the distal third of the right femur, open Gustilo type III, comminuted, and without displacement. In the rest of the examination no lesions were observed.
Exhaustive cleaning and debridement of the wounds on the right thigh was carried out, and the right lower limb was immobilised by means of a posterior cruropedic splint. Antibiotic prophylaxis, tetanus prophylaxis and antithrombotic prophylaxis were instituted.

In the tertiary assessment of the patient at the "Gómez Ulla" hospital, an axial CT scan of the right femur was performed, with multiplanar and volumetric reconstructions. A comminuted fracture of the distal third of the right femur was determined, with multiple small fragments displaced to the posterior compartment. After presentation of the case in a clinical session of the service, surgical treatment was decided using an external fixator.

Surgical intervention was performed by placing an XCaliber external fixator (Orthofix®) with four femoral pins, in static and monoplanar configuration under intradural regional anaesthesia and sedation. No surgical or anaesthetic incidents were recorded during the operation.

The injured patient had a good postoperative evolution, starting partial loading 24 hours after the operation. Five days after hospital admission, the patient was discharged home, with subsequent clinical-radiological follow-up on an outpatient basis.
Two months after the operation, the patient had limited knee joint balance and delayed healing at the fracture site. At the four-month check-up, a CT scan revealed a lack of healing at the fracture site and knee joint stiffness with a rigid stop at 30o flexion.
After removal of the external fixator at 18 weeks, the patient was reoperated on a scheduled basis, under intradural regional anaesthesia and sedation, for refreshing of the fracture site and internal fixation by means of retrograde femoral endomedullary nailing using a T2 nail (Stryker®), and for treatment of the knee extension contracture, a modified Judet technique quadriceplasty was performed, after which a gain in joint balance was observed, flexing the knee against gravity to 110o.

The immediate postoperative period was uneventful, and the patient began early rehabilitation treatment programmed by the Physical Medicine and Rehabilitation Service of the HCDGU.
In the controls after surgery, the patient presented a knee joint balance of 110o of flexion with full extension, with normal gait and without pain.
At present, the patient is fully reincorporated to his usual activities.