Fractures of the Distal Femur

“The Supracondylar Fracture”

DISTAL FEMUR FRACTURES

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

1998

Introduction

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

the Elderly (falls)

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)

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

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

Classification

• AO (Muller) seperates the fractures into 3 main types:– A:extra-articular– B: unicondylar (lat, med, hoffa)– C: bicondylar

• These are then subdivided into 3 categories• What is AO? = Arbeitsgemeinschaft fur

Osteosynthesesfragen

Classifications

• Neer: direction of condyles– I- minimal < 2mm– II a- medial – b- lateral– III- combined supra and intra

• Very basic not very helpful

Classifications

• Seinsheimer “Distal 3.5 inches”– I- < 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

Classifications

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

Radiographs

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

Management

• Cast• Traction• Hinged knee brace• Surgical

Absolute Indications

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

Relative Indications

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

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

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

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

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

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

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

Fixation Devices

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

Fixation Devices

• IM Rod– (supracondylar vs retrograde nail)

• Enders Nails• External Fixation

Post-Op Care

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

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

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

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”

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

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

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

Thank You