distal fracture of femur

1. DISTAL FEMUR FRACTURE
Presented by
Dr. SHUBHAM NAGDEV
Resident
Department of Orthopaedics
R.D.Gardi Medical College, Ujjain

2. Distal Femur Fractures
 involve the femoral condyles and the metaphyseal region
 commonly caused by high energy trauma such as motor
vehicle accidents or a fall from a height
 Can occur in elderly patients due to trivial trauma due to
osteoporosis and prosthesis
 Includes- supracondylar
 Intercondylar
 Hoffa’s fracture

3. PATHOLOGY
1.HIGH ENERGY
FRACTURES
• usually occur in young
adults
• result in intra-articular
fractures.
Mechanism: includes motor
vehicle accidents, high-velocity
missile injuries and/ or a direct
blow mechanism.
2. LOW ENERGY
FRACTURES
• mostly occur in elderly
people, secondary to
osteoporosis (predominantly in
women over 65years.
Mechanism: twisting motions or
falls [6]
Incidence is increasing in patients after total
knee arthroplasty

4. CLINICAL PRESENTATION
• HISTORY- patients commonly present after fall or
traumatic event. Most common symptoms of distal femur
fracture include:
• Pain with weight-bearing and knee movement
• Swelling and bruising
• Tenderness to touch
• Deformity
• In the context of polytrauma

5. Physical Examination
■ tenderness, swelling, ecchymosis of the distal thigh and knee
■ varus or valgus deformity
■ knee effusion may be present with intraarticular involvement
Neurovascular evaulation
 Check the popliteal artery if there is any significant displacement
 Ankle-brachial index (ABI) should be performed if there is a concern for
vascular injury +
■ angiography is indicated if <0.9
■ >0.9 = 99% negative predictive value
■ <0.9 = 97% specific and 95% sensitive for major arterial injury

6. DEFORMING FORCES
• hamstring and quadriceps
• cause the femur to shorten
• adductor magnus
■ leads to distal femoral varus or
valgus
■ direction of deformity is dependent on the
• location of comminution and the relation of fracture lines to the
adductor tubercle
• gastrocnemius
■ extension at the fracture site (apex posterior)
■ rotation of condyles when an intercondylar split is present

7. DIAGNOSIS
1) X-RAY
Radiograph of the entire limb is taken,
including the joint proximal and distal to site
of injury.
■ AP
■ lateral
■ Additional view- traction view -can
help characterize injury but is painful
for the patient

8. 2) CT SCAN
CT with coronal and sagittal
reconstruction is recommended
for:-
• complex fractures
• fractures with intra-articular
extension
• assessment for osteochondral
fragments in the intercondylar
notch

9. 3) ANGIOGRAPHY
Indicated in –
• decreased ipsilateral distal pulses
despite gross re-alignment
• if associated with knee dislocation
• distal pulses present with ABI
below 0.90
• Multi-slice helical CT angiography
is a highly specific and sensitive
study for the evaluation and
management of lower extremity
injuries

10. CLASSIFICATIONS
Various classification systems described for distal femur fractures
are
• 1) Neer and associates
• 2) Seinsheimer classification
• 3) AO Classification – Müller
•

11. Neer and Associates Classification
• For supracondylar femur
• Category I : Minimal displacement
Category II : Displacement of the
condyles
A) Medial condyle displacement
B ) Lateral condyle displacement
Category III : Concomitant
supracondylar and shaft fractures

12. Seinsheimer classification
•

13. Classification Description Notes
1 Nondisplaced
2A 2 part, involves patellofemoral articular surface Seen in osteoporotic patients
2B Comminuted, involves patellofemoral articular
surface
Seen in osteoporotic patients
3A Medial condyle, extending into the
intercondylar notch
Involves patellofemoral articular surface, but
not the femorotibial articular surface
3B Lateral condyle, extending into the
intercondylar notch
Involves patellofemoral articular surface, but
not the femorotibial articular surface
3C Both condyles, extending into the intercondylar
notch
Involves patellofemoral articular surface, but
not the femorotibial articular surface
4A Medial condyle, extending to the femorotibial
articular surface
4B Lateral condyle, extending to the femorotibial
articular surface
4C Complex fractures Comminuted, with any combination of the
above

14. AO Classification
33A - Extra-articular
A1 - simple
A2 - metaphyseal wedge
A3 - metaphyseal complex
33B - Partial articular (a portion of the articular surface remains
attached to the proximal shaft)
B1 - lateral condyle
B2 - medial condyle
B3 - coronal plane (Hoffa fragment)
33C - Complete articular (articular fragment separated from the shaft)
C1 – simple articular, simple metaphyseal
C2 – simple articular, metaphyseal
comminution
C3 - metaphyseal and intra-articular
comminution

15. TREATMENT
• Non - Operative :
• Skeletal traction
• Casting and bracing for 6 weeks
Indicated in –
-Non displaced fractures
- Non ambulatory patient
- Patient with significant comorbidities
presenting unacceptably high degree of
surgical/anesthetic risk

16. Operative Management
• Goals-
Anatomic reduction of the articular surface,
Restoration of limb alignment and length,
Stable internal fixation,
Rapid mobilisation and early functional rehabilitation of the
knee

17. 1) External Fixation
■ To temporarily restore length, alignment and stability
■ unstable, polytrauma
■ soft tissues not amenable to surgical incisions and
internal
• contamination requiring multiple
debridements
Definitive treatment
■ severe open and/or comminuted
fractures
■ patients unstable for surgery

18. Open Reduction and Internal Fixation
■ Indications
■ displaced fracture
■ intra-articular fracture
 periprosthetic fracture with
osteoporotic bone
• nonunion
■ fixed-angle plates required for
metaphyseal comminution
■ non-fixed angle plates are prone to
varus collapse

19. SURGERICAL APPROACHES
• Lateral
• Most common approach
• Skin incision in mid-lateral line of femoral shaft, curving slightly
anteriorly over lateral femoral condyle towards tibial tubercle
• Distal extent determined by need for joint arthrotomy if intra-articular
reduction needs to be performed
• Proximal extent determined by whether fracture will be directly or
indirectly reduced
• Divide IT band in line with its fibers
• Incise vastus lateralis fascia and elevate
fibers off septum, from distal to proximal,
ligating femoral artery perforating vessels

20. • Swashbuckler
• Indicated when more articular
reduction and fixation is needed
• No tourniquet (prevents medial
retraction of quads)
• Midline anterior incision, curving
laterally proximally
• Quadriceps fascia incised in line with skin
incision, connecting distally with a lateral
parapatellar arthrotomy
• Fascia & IT band elevated off vastus
lateralis; IT band retracted laterally and
quadriceps retracted medially

21. • Medial
• Useful for isolated medial condyle fractures or severely comminuted
fractures in which medial fixation is required
• Straight medial incision extending distally to a point just anterior to
adductor tubercle
• Fascia divided in line with skin incision, anterior to sartorius
• Vastus medialis elevated, care taken to avoid articular branch of
descending geniculate artery (DGA) and muscular branch to vastus
medialis
• Muscular branch of DGA ~5cm and adductor hiatus ~16cm proximal
to adductor tubercle

22. Types of Fixation
• Lateral pre-contoured plates
• May be used for most fracture patterns
• Retrograde intramedullary nail
• Most common for AO/OTA type A fractures
• Some simple intra-articular patterns (AO/OTA type C1 & C2)
• Dynamic condylar screw/ Angled blade plate
• Distal femoral replacement
• Elderly, pre-existing osteoarthritis, severely comminuted, with a need to immediately
mobilize
• Augmented fixation
• Bilateral plates, plate/ nail combo
• Buried screw fixation for Hoffa fractures

23. COMPLICATIONS
• Pain secondary to hardware presence eg medial screw irritation
secondary to excessively long screws in contact with medial soft tissues.
• Malunion: greater than 5 to 10 degrees affects knee mechanics, which
may lead to arthritis of the medial and lateral compartments.
• Delayed union or Nonunion
• Implant failure
• Infection
• Leg length discrepancy
• Ligamentous instability