Fractures of the Distal Femur

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Fractures of the Distal Femur

• The Supracondylar Fracture

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DISTAL FEMUR FRACTURES

• J.E.BURKHARDT D.O.
• GARDEN CITY HOSPITAL
• 1998

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Introduction

• 4-7 of all femur fractures
• Excluding the hip, 31 of femur fractures
• Two populations Young (high energy) and the
  Elderly (falls)

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Anatomy

• Supracondylar infraisthmus to condyles
• Metaphyseal- wide canal, thin cortices, and poor
  bone stock
• Anterior at the condyles is the trochlear groove,
  posterior is the intercondylar fossa
• Medial is wider and more distal
• Posterior condylar area wider (trapezoid)

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Anatomy

• Anterior half of condyles is in line with femoral
  shaft
• Normal mechanical axis is 3 degrees and valgus
  angle usually between 7 and 11 degrees

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Anatomy

• Fracture patterns quads and hams shorten,
  gastroc causes posterior condylar displacement
  and apex posterior angulation (aka extension)
• DANGER SFA popliteal fossa 10cm proximal to the
  knee thru the adductor magnus

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Classification

• AO (Muller) seperates the fractures into 3 main
  types
• Aextra-articular
• B unicondylar (lat, med, hoffa)
• C bicondylar
• These are then subdivided into 3 categories
• What is AO? Arbeitsgemeinschaft fur
  Osteosynthesesfragen

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Classifications

• Neer direction of condyles
• I- minimal lt 2mm
• II a- medial
• b- lateral
• III- combined supra and intra
• Very basic not very helpful

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Classifications

• Seinsheimer Distal 3.5 inches
• I- lt 2mm of displacement
• II - Distal Metaphysis only
• A. Two part
• B. Comminuted
• III- Into the Intercondylar notch
• A. medial condyle separate
• B. lateral condyle separate
• C. both separate from shaft

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Classifications

• Seinsheimer IV
• A. Medial condyle comminuted
• B. Lateral condyle comminuted
• C. Total disaster of comminution

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Radiographs

• AP and lateral then traction views
• 45 degree obliques
• CT scan
• Tomogram

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Management

• Cast
• Traction
• Hinged knee brace
• Surgical

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Absolute Indications

• displaced intraarticular fxs
• open fxs
• vascular injury
• floating knee
• bilateral femoral fractures
• pathologic fractures

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Relative Indications

• All patients that do not want to be immobilized
  for a prolonged period of time and can withstand
  the operation

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Contraindications

• If the surgery is going to kill the patient, ie
  unstable myocardium the patients injuries should
  be treated closed. Life is not worth returning
  function to one limb.
• Massive comminution with osteoporotic bone which
  would do better in a cast

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Surgical Treatment

• Traction films
• Contralateral films
• Tracings of the fracture
• Stepwise dialogue of the procedure
• Important to know the fracture well and treat it
  once before entering the OR
• know the implants needed and if your hospital
  carries them

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Timing

• Should be performed within the first 24-48 hours
  of injury (NOT ELECTIVELY)
• This should be done during the day when a skilled
  team is present and the appropriate planning is
  performed
• If the surgery is not performed within 48 hours,
  tibial traction is needed and the pin is placed
  at least 10cm distal to the tibial tubercle away
  from the surgical field

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Principles of Surgery

• careful soft tissue handling
• indirect reduction techniques
• femoral distractor, traction, resident
• anatomic reduction of articular surface, correct
  alignment and rotation to shaft
• stable fixation, bone graft where needed
• early and active functional rehab

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Surgical Exposures

• Drape entire lower extremity free
• Patient supine with bump under hip
• Keep sterile tourniquet available
• Single lateral incision for ORIF
• Stay anterior to insertion of LCL
• To see intraarticular you may curve the distal
  portion anteriorly to the lateral border of the
  tibial tubercle

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Tips to the Approach

• Carefully dissect the superior lateral geniculate
  and ligate it
• Avoid damaging the lateral meniscus
• To see intraarticular one can do either an
  infrapatellar z plasty or a tibial tubercle
  osteotomy (pre-drill osteotomy)
• Standard midline incision if retrograde nail

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Fixation Devices

• 95 degree DCS (Sanders, JOT, 1989)
• 95 degree Blade Plate (SchatzkerMueller)
• Condylar Plate (Johnson, 1987)
• LISS
• Bolhofner Plate

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Fixation Devices

• IM Rod
• (supracondylar vs retrograde nail)
• Enders Nails
• External Fixation

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Post-Op Care

• Bracing
• CPM
• Ambulation
• Weight bearing status
• Bone graft at 6-8 weeks if needed

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Bibliography

• Skeletal Trauma
• JOT Vol 3, No 3, 1989, Sanders, etal
• JAAOS May/June 97, M J. Albert
• JOT Vol 9, No 3, 1995 Freedman, etal
• JOT Vol 9, No 4, 1995 Ostrum Geel
• JOT Vol 9, No 4, 1995 Koval, etal
• CORR, 296, Lucas, etal

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Sanders, etal., JOT, Vol 3, 1989

• 35 patients treated with DCS
• results were fair to excellent in 83
• place bone graft medially if proximal extension
• very nice device for revision nonunions

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Lucas, etal., CORR 296, 1993

• Preliminary report of GSH
• 25 fractures in 24 patients
• Decreased op time and blood loss to ORIF
• All fxs healed clinically and radiographically
• A WONDERFUL NEW CONCEPT

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Freedman, etal., JOT, 1995

• 5 patients (3 nonunions 2 fractures)
• 4 good to excellent results with total knees as
  salvage procedure for difficult fracture and
  difficult nonunion
• 1 infection led to AKA
• Howmedica system
• Theory- Old people have previous gonarthrosis and
  ORIF and nail do not treat this

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Ostrum and Geel, JOT, 1995

• 30 ORIF indirect reduction on lateral side only,
  no medial stripping, no bone grafting
• Prospective study, implants picked by surgeon
• 87 excellent and satisfactory results with NEER
  rating system
• 3 Failures, two elderly, one renal transplant
  patient with bilateral quad ruptures

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Koval, etal., JOT, 1995

• 16 distal femoral nonunions treated with GSH nail
• Reamed nail
• 4 united with index sx, 1 after dynamization
• 2 more unitied after exchange nailing
• at 16 months 9 still nonunions
• Do NOT recommend this procedure

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Thank You