Background: Intramedullary nail rupture is a known mechanical complication of femoral non-union, resulting from fatigue of the material from prolonged cyclic weight-bearing in the absence of bone consolidation. Focal extracorporeal shock wave therapy (f-ESWT) represents a non-invasive option, with efficacy reported in the literature comparable to surgery in hypertrophic non-union.

Clinical case: A 65-year-old man, subjected to intramedullary nailing for a diaphyseal fracture of the left femur, develops a delay in consolidation and subsequently transverse rupture of the nail at the foci level, in the absence of infectious signs. Given the patient's desire to delay a second major surgery, the multidisciplinary team proposed a course of f-ESWT as a first-line option, reserving surgical revision for a later time.

Intervention: Three sessions in one month of f-ESWT (3000 pulses/session, energy flux density 0.822 mJ/mm²) associated with protected partial weight-bearing and rest.

Results: Radiographically confirmed bone tissue improvement approximately 1 month after the beginning of treatment, with resumption of partial weight-bearing using a single elbow crutch and improvement in pain.

Conclusions: In selected cases of hypertrophic non-union with nail failure but moderate residual stability, f-ESWT may constitute a reasonable non-invasive alternative to immediate surgical revision, to be evaluated in a multidisciplinary setting.