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Distal Femur Fractures

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Topic updated on 04/09/16 10:08pm
Introduction
  • Defined as fxs from articular surface to 5cm above metaphyseal flare
  • Mechanism
    • young patients
      • high energy with significant displacement
    • older patients
      • low energy in osteoporotic bone with less displacement
Anatomy
  • Osteology
    • anatomical axis of distal femur is 6-7 degrees of valgus 
    • lateral cortex of femur slopes ~10 degrees, medial cortex slopes ~25 degrees 
Classification
  • Descriptive
    • supracondylar
    • intercondylar
  • OTA: 33 
    • A: extraarticular
    • B: partial articular
      • portion of articular surface remains in continuity with shaft
      • 33B3 is in coronal plane (Hoffa fragment)
    • C: complete articular
      • articular fragment separated from shaft
Presentation
  • Physical exam
    • vascular evaluation 
      • potential for injury to popliteal artery if significant displacement
      • if no pulse after gross alignment restored than angiography is indicated
Imaging
  • Radiographs
    • obtain standard AP and Lat
    • traction views
      • AP, Lat, and oblique traction views can help characterize injury
  • CT
    • obtain with frontal and sagittal reconstructions
    • useful for
      • establish intra-articular involvement
      • identify separate osteochondral fragments in the area of the intercondylar notch
      • identify coronal plane fx (Hoffa fx  post
        • 38% incidence of Hoffa fx's in Type C fractures 
      • preoperative planning
  • Angiography
    • indicated when diminished distal pulses after gross alignment restored
Treatment
  • Nonoperative
    • hinged knee brace with immediate ROM, NWB for 6 weeks
      • indications (rare)
        • nondisplaced fractures
        • nonambulatory patient
        • patient with significant comorbidities
  • Operative
    • open reduction internal fixation
      • indications
        • displaced fracture
        • intra-articular fracture
        • nonunion
      • goals
        • need anatomic reduction of joint
        • stable fixation of articular component to shaft
        • preserve vascularity
      • technique (see below)
      • postoperative
        • early ROM of knee important
        • non-weight bearing or touch toe weight-bearing for 6-8 weeks
        • quadriceps and hamstring strength exercises 
    • retrograde IM nail 
      • indications
        • good for supracondylar fx without significant comminution
        • preferred implant in osteoporotic bone
    • distal femoral replacement
      • indications
        • unreconstructable fracture
        • fracture around prior total knee arthroplasty with loose component
Surgical Techniques
  • ORIF Approaches
    • anterolateral
      • fxs without or with simple articular extension
      • incision from tibial tubercle to anterior 1/3 of distal femoral condyle
      • extend up midlateral femoral shaft as needed
    • lateral parapatellar
      • fxs with complex articular extension
      • extend incision into quad tendon to evert patella
    • medial parapatellar 
      • typical TKA approach
      • used for complex medial femoral condyle fractures
    • medial/lateral posterior
      • used for very posterior Hoffa fragment fixation
      • patient placed in prone position
      • midline incision over popliteal fossa
      • develop plane between medial and lateral gastrocnemius m.
      • capsulotomy to visualize fracture
  • Blade Plate Fixation 
    • indications
      • not commonly used, technically difficult
      • contraindicated in type C3 fractures
    • technique
      • placed 1.5cm from articular surface
  • Dynamic Condylar Screw Placement 
    • indications
      • identical to 95 degree angled blade plate
    • technique
      • precise sagittal plane alignment is not necessary
      • placed 2.0cm from articular surface 
    • cons
      • large amount of bone removed with DCS
  • Locked Plate Fixation 
    • indications
      • fixed-angle locked screws provide improved fixation in short distal femoral block
      • supracondylar periprosthetic femur fractures in cruciate retaining TKA 
    • technique
      • lag screws with locked screws (hybrid construct)
        • useful for intercondylar fractures (usually in conjunction with locked plate) 
        • useful for coronal plane fractures q
        • helps obtain anatomic reduction of joint
        • required in displaced articular fractures q
  • Non-fixed angle plates
    • indications
      • now largely obsolete due to tendency for varus malalignment
  • Retrograde interlocked IM nail  
    • indications
      • good for supracondylar fx without significant comminution
      • preferred implant in osteoporotic bone
    • approach
      • medial parapatellar
        • no articular extension present
          • 2.5cm incision parallel to medial aspect of patellar tendon
          • stay inferior to patella
          • no attempt to visualize articular surface
        • articular extension present
          • continue approach 2-8cm cephalad
          • incise extensor mechanism 10mm medial to patella
          • eversion of patella not typically necessary
    • pros
      • requires minimal dissection of soft tissue
    • cons
      • less axial and rotational stability
      • postoperative knee pain
Complications
  • Symptomatic hardware
    • lateral plate
      • pain with knee flexion/extension due to IT band contact with plate
    • medial screw irritation
      • excessively long screws can irritate medial soft tissues
      • determine appropriate intercondylar screw length by obtaining an AP radiograph of the knee with the leg internally rotated 30 degrees
  • Malunions 
    • most commonly associated with plating
    • functional results satisfactory if malalignment is within 5 degrees in any plane
  • Nonunions 
    • treatment with revision ORIF and autograft indicated 
    • consider changing fixation technique to improve biomechanics

 

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Qbank (10 Questions)

TAG
(OBQ13.57) Fixed-angle implants are often used for fixation of distal femur fractures. Three commonly used implants (Implants A, B and C) are shown in Figures A, B and C respectively. Which of the following statements is true reagarding these implants? Topic Review Topic
FIGURES: A   B   C      

1. Implant B is better able to control fractures with a small distal segment than Implants A and C.
2. Implant C is better able to control coronal plane fractures than Implants A and B.
3. During insertion, Implant C results in removal of a larger amount of bone, compared with Implants A and B.
4. Implant A demonstrates less subsidence and greater load to failure compared with Implant C.
5. Implant A demonstrates lower fixation strength in torsional loading compared with Implant C

PREFERRED RESPONSE ▶
TAG
(OBQ12.33) A 44-year-old male is involved in a motorcycle collision and presents with the radiographs shown in Figure A. A CT scan is obtained which shows intra-articular extension of the fracture, and lateral locked plating with intercondylar lag screw fixation is planned. Which of the following is important intra-operatively to ensure that the intercondylar screws are contained within the bone and are of appropriate length? Topic Review Topic
FIGURES: A          

1. AP fluoroscopic imaging with the leg in 30 degrees of internal rotation
2. AP fluoroscopic imaging with the leg in 30 degrees of external rotation
3. AP fluoroscopic imaging with the knee in full extension
4. Lateral fluoroscopic imaging with the knee in 30 degrees of internal rotation
5. Lateral fluoroscopic imaging with the knee in 15 degrees of flexion

PREFERRED RESPONSE ▶
TAG
(OBQ12.56) During surgical treatment of the most common variation of distal femoral "Hoffa" fractures, which of the following orientations for screw fixation should be used? Topic Review Topic

1. Medial to lateral screw placement across lateral femoral condyle
2. Anterior to posterior screw placement across medial femoral condyle
3. Medial to lateral screw placement across medial femoral condle
4. Anterior to posterior screw placement across lateral femoral condyle
5. Anterior to posterior screw placement across intercondylar notch

PREFERRED RESPONSE ▶
TAG
(OBQ11.44) A 68-year-old healthy active male presents after falling and sustaining an injury to his right knee. His medical history is significant only for osteoporosis. Radiographs and representative CT scan images are shown in Figures A-D. What is the most appropriate treatment method for this patient's injury? Topic Review Topic
FIGURES: A   B   C   D    

1. Traction and splinting
2. Lag screw fixation followed by non-locking plate application
3. Retrograde supracondylar nail fixation
4. External fixation and percutaneous screw reduction of the fracture
5. Lag screw fixation followed by locking plate application

PREFERRED RESPONSE ▶
TAG
(OBQ08.196) Which of the following treatments of an oligotrophic supracondylar femoral nonunion has been shown to have the best outcome? Topic Review Topic

1. Retrograde femoral nailing with adjunct BMP-4
2. Hybrid external fixation with adjunct BMP-4
3. Usage of a percutaneous locking plate with adjunct BMP-3
4. Open reduction and plating with autograft
5. Open reduction and plating with adjunct calcium phosphate

PREFERRED RESPONSE ▶
TAG
(OBQ06.70) A 33-year-old man sustains a femur fracture in a motorcycle accident. AP and lateral radiographs are provided in Figure A. Prior to surgery, a CT scan of the knee is ordered for preoperative planning. Which of the following additional findings is most likely to be discovered? Topic Review Topic
FIGURES: A          

1. Tibial eminence fracture
2. Sagittal plane fracture of the medial femoral condyle
3. Schatzker I tibia plateau fracture
4. Coronal plane fracture of the lateral femoral condyle
5. Axial plane fracture through the medial femoral condyle

PREFERRED RESPONSE ▶
TAG
(OBQ05.145) Which of the following is the most appropriate clinical scenario to utilize locking plate and screw technology? Topic Review Topic

1. Intra-articular fracture
2. Oblique ulnar diaphyseal fracture
3. Osteoporotic periprosthetic distal femur fracture
4. Transverse tibial diaphyseal fracture
5. Spiral humeral diaphyseal-metaphyseal fracture

PREFERRED RESPONSE ▶
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