Distal Femur Fractures

Topic updated on 04/09/16 10:08pm
  • 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
  • Osteology
    • anatomical axis of distal femur is 6-7 degrees of valgus 
    • lateral cortex of femur slopes ~10 degrees, medial cortex slopes ~25 degrees 
  • 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
  • Physical exam
    • vascular evaluation 
      • potential for injury to popliteal artery if significant displacement
      • if no pulse after gross alignment restored than angiography is indicated
  • 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
  • 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
  • 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


Please Rate Educational Value!
Average 4.0 of 41 Ratings

Qbank (10 Questions)

(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

(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

(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

(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

(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

(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

(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

This is a Never-Been-Seen Question that can only be seen in Milestone Exams
for Virtual Curriculum members.

Click HERE to learn more and purchase the Virtual Curriculum today!

HPI - Patient fell onto left knee and had immediate pain, swelling, and deformity. Una...
7113 responses
HPI - Fall from height; injury to the right knee. Unable to stand or move the knee
588 responses
HPI - Untreated Hoffa's fracture from a car accident February 2014
835 responses
HPI - Grade 1 Open Distal Femoral Fracture Dec 2014. ORIF with short retrograde nail....
425 responses
HPI - 21 year old involved in motorcycle crash. He reports hitting his knee against t...
545 responses
HPI - Type 3 C fracture distal 3rd left femur treated by debridement and external fixa...
293 responses
HPI - The patient was brought two days ago with GSW, the wound is infected and bone ex...
poll What is the definitive management for this kind of fracture.
41 responses
HPI - MVA 3 days ago
poll Best treatment possible
163 responses
HPI - RTA in 2012 - Open fracture distal femur with bone loss. Initially managed wi...
poll Management options
158 responses
HPI - Polytrauma patient, rib fx, pneumothorax, open left femur fx, closed right femur...
poll Several questions: How you will remove the bent nail and screws from left f...
7 responses
HPI - 18 y/o male who presents with knee pain s/p football injury. MRI ordered by pri...
poll How would you treat this fracture?
101 responses
HPI - Vehicular Accident. Fell from a motorcycle.
poll How will you treat this multiply Injured patient?
229 responses
HPI - RTA 3 yeas ago result in closed femoral supra-condylar # type (A III) treated by...
poll what is your treatment plan ?
75 responses
HPI - Case of 77 year old female patient previoisly known to have HTN,DL,CAD had left...
poll What is the best option for treatment?
350 responses
HPI - MVA with closed fracture supracondylar femur and contralateral neck femur fractu...
poll Best method of treatment
146 responses
HPI - Swelling at distal femur with obvious knee swelling and deformity
poll When to start knee range of motion, weight bearing
110 responses
HPI - Rugby injury, 2 opponents fell on pt's knee and felt immediate pain.
poll What is the diagnosis?
50 responses union distal end femur.jpg
HPI - The patient sustained a right distal femur fracture 1 year prior to presentation...
poll What would be your next step in treatment of this patient?
113 responses
HPI - Child hood septic arthritis right knee joint leads to ankylosis right knee Now...
poll what will be the best treatment for her
230 responses
HPI - motor cycle
poll type of fixatin
2418 responses
HPI - Fall from standing height
poll What is the treatment?
384 responses ap.jpg
HPI - RTA, fall from bike,
poll opinion
19 responses
HPI - 21 yrs old male, active, medically free, were involved in RTA, had isolated open...
poll what are the surgical options which will provide best outcome for this youn...
1475 responses
HPI - history of road traffic accident , fall from bike after strucked by a car.
poll what should be the approach for fixation?
160 responses
HPI - Fracture proximal end tibia and post condyle femur 4 month back .plating done fo...
poll How to proceed with the treatment
81 responses
HPI - reverse obliquity subtrochanteric fracture of the left femur three and a half mo...
poll ways of surgical treatment
1194 responses
HPI - Pt. had bike accident 8 month back resulting in close fracture.Operated with DCS...
poll How to treat this case?
20 responses
HPI - 14 y/o hit playing football
poll treatment
67 responses 1..jpg lat..jpg
HPI - ...
poll What will be your treatment
324 responses ray.jpg op day 1.jpg op day 2.jpg
HPI - .27 years old man .motorcycle accident on 29th July 2012. .frontal collision w...
poll • What do you expect? How do you want to treat now?
156 responses
HPI - s/p MVC, open distal femur fracture and open ipsilateral tibial fracture (platea...
poll What would be your method of dealing with the bone loss?
377 responses medial condyle fracture.jpg distal femur fracture.jpg medial condyle fracture.jpg
HPI - 1 month history of knee pain after fall from ladder. Pain continues to worsen de...
poll Type of fixation? When do you begin motion post op?
56 responses
See More Cases


Educational video describing the Hoffa fracture of the distal femoral condyles.B...
See More Videos


What is your preferred approach for bicondylar hoffas fracture.
31 responses
See More Posts



Topic Comments