Distal femur fractures & fracture patella by dr ashutosh
1. Fracture of the patella
Distal femur Fractures &
Fracture of Patella
By:-
Dr Ashutosh Kumar
Assistant Professor
Dept. of Orthopaedics
2. Outline :
- Basic anatomy
- Introduction
- Type of fractures
- Clinical features
- Investigations
- Treatment
- surgical techniques
- Complications
3. Basic anatomy of femur
- only bone in the thigh.
- It is classed as a long bone, and is the longest bone in the
body.
- The main function of the femur is to transmit forces from
the tibia to the hip joint.
-Articulate proximally with hip bone forming hip joint And
distally with tibia & patella forming knee joint
- Divided into three areas: proximal, shaft and distal.
4. Basic anatomy ( cont… )
• The distal end is characterised by the presence of the medial and lateral
condyles, which articulate with the tibia and patella, forming the knee
joint.
• Medial and lateral condyles – Rounded areas at the end of the femur. The
posterior and inferior surfaces articulate with the tibia and menisci of the
knee, while the anterior surface articulates with the patella.
• Medial and lateral epicondyles – Bony elevations on the non- articular
areas of the condyles. They are the area of attachment of some muscles
and the collateral ligaments of the knee joint.
5. Basic anatomy ( cont… )
• Intercondylar fossa – A depression found on the posterior surface of the
femur, it lies in between the two condyles. It contains two facets for
attachment of internal knee ligaments.
• Facet for attachment of the posterior cruciate ligament – Found on the
medial wall of the intercondylar fossa, it is a large rounded flat face,
where the posterior cruciate ligament of the knee attaches.
• Facet for attachment of anterior cruciate ligament – Found on the lateral
wall of the intercondylar fossa, it is smaller than the facet on the medial
wall, and is where the anterior cruciate ligament of the knee attaches.
7. Anatomy cont…
Osteology :
• distal femur becomes trapezoidal in cross section towards knee
• medial condyle extends more distal than lateral
• posterior halves of both condyles are posterior to posterior cortex of
femoral shaft
• lateral cortex of femur slopes ~10 degrees, medial cortex slopes
~25 degrees in axial plane
8.
9. Anatomy cont …
• The knee is the largest weight bearing joint in your body.
• The distal femur makes up the top part of your knee joint.
• The upper part of the shinbone (tibia) supports the bottom part of your
knee joint.
• The ends of the femur are covered in a smooth, slippery substance
called articular cartilage. This cartilage protects and cushions the
bone when you bend and straighten your knee.
10.
11. Anatomy cont…
• Strong muscles in the front of your thigh (quadriceps) and back of your
thigh (hamstrings) support your knee joint and allow you to bend and
straighten your knee.
12.
13. Anatomy cont …
• The musculature of the thigh can be split into three sections; anterior,
medial and posterior.
• The muscles in the anterior compartment of the thigh are innervated
by the femoral nerve (L2-L4), and as a general rule, act to extend the
leg at the knee joint.
• There are three major muscles in the anterior thigh – the pectineus,
sartorius and quadriceps femoris. In addition to these, the end of the
iliopsoas muscle passes into the anterior compartment.
14.
15. Anatomy cont…
• The muscles in the posterior compartment of the thigh are collectively
known as the hamstrings. They consist of the biceps femoris,
semitendinosus and semimembranosus, which form prominent tendons
medially and laterally at the back of the knee.
• As group, these muscles act to extend at the hip, and flex at the knee.
They are innervated by the sciatic nerve (L4-S3).
16.
17. Anatomy cont …
• The muscles in the medial compartment of the thigh are collectively
known as the hip adductors. There are five muscles in this group; gracilis,
obturator externus, adductor brevis, adductor longus and adductor
magnus.
• All the medial thigh muscles are innervated by the obturator nerve,
which arises from the lumbar plexus. Arterial supply is via the obturator
artery.
18.
19. Introduction
Definition :
• Fractures of the thighbone that occur just
above the knee joint are called distal
femur fractures.
• The distal femur is where the bone flares
out like an upside-down funnel.
20. Introduction
Epidemiology :
• traditionally young patients but increasing in geriatric population
• bimodal distribution: young, healthy males, elderly osteopenic
females
• periprosthetic fractures becoming more common
21. Introduction
Mechanism :
• young patients :
high energy with significant displacement such as from a car crash.
• older patients:
low energy, often fall from standing, in osteoporotic bone, usually with less
displacement
-- In both the elderly and the young, the breaks may extend into the knee
joint and may shatter the bone into many pieces.
22. Types of fractures
Descriptive :
• supracondylar
• Intercondylar
OTA:
• A: extra articular
• B: partial articular :
portion of articular surface remains in continuity withshaft
• C: complete articular
articular fragment separated from shaft
-- Distal femur fractures can be closed — meaning the skin is intact — or can be open
23.
24. • Path mechanics :
• When the distal femur breaks, both the hamstrings and quadriceps muscles
tend to contract and shorten. When this happens the bone fragments
change position and become difficult to line up with a cast.
• gastrocnemius: extends distal fragment (apex posterior)
• adductor Magnus: leads to distal femoral Varus
25.
26. Clinical features
- The most common symptoms of distal femur fracture include:
• Pain with weight bearing
• Swelling and bruising
• Tenderness to touch
• Deformity — the knee may look "out of place" and the leg may
appear shorter and crooked
In most cases, these symptoms occur around the knee, but you may
also have symptoms in the thigh area
27. Clinical features ( cont… )
History & Physical examination :
• History >> type of falling ? , how far did you fall ? , any other injures ? , any
medical problems ? , any medications ? .
- Examination >>
- assess overall condition to make sure no other body parts have been
injured (head, belly, chest, pelvis, spine, and other extremities)
- skin integrity
- vascular evaluation :
- potential for injury to popliteal artery if significant displacement
- if no pulse after gross alignment restored then angiography is indicated
28.
29. Investigations
X-ray :
- obtain standard AP and Lateral
- traction views :
*AP,Lateral, and oblique traction views can help characterize injury
but are painful for patient
* in elderly patients, evaluate for any pre-existing knee DJD
(degenerative joint disease )
* consider views of the remainder of the extremity to rule out
associated injuries
* consider views of contralateral femur for pre-operative planning
30. Investigations ( cont..)
CT :
• obtain with frontal and sagittal reconstructions
• useful for :
* establishing intra-articular involvement
* identifying separate osteochondral fragments in the area of the
intercondylar notch
* identifying coronal plane fx (Hoffa fx):
38% incidence of Hoffa fractures in Type C fractures
* preoperative planning
-- if temporizing external fixation required, CT obtained after external fixation
31. • Hoffa fracture is : a type of supracondylar distal femoral fracture and
is characterized by an associated fracture component in the coronal plane.
• Hoffa fractures are intra-articular and are characterised by a fracture
in the coronal plane.
• Hoffa fragments are more commonly unicondylar and usually
originate from the lateral femoral condyle. They can be
occasionally bicondylar.
35. Treatment
Non - Operative :
• Skeletal traction >> Skeletal traction involves placing a pin,
wire, or screw in the fractured bone. After one of these devices
has been inserted, weights are attached to it so the bone can be
pulled into the correct position. This type of surgery may be
done using a general, spinal, or local anesthetic to keep you
from feeling pain during the procedure..
36.
37. Treatment ( cont..)
Casting and bracing for 6 weeks :
indications (rare) >>
- non displaced fractures
- non ambulatory patient
-patient with significant comorbidities presenting unacceptably high
degree of surgical/anesthetic risk
38.
39. Treatment ( cont..)
• Patients with distal femoral fractures of all ages do best when
they can be up and moving soon after treatment (such as
moving from a bed to a chair, and walking). Treatment that
allows early motion of the knee lessens the risk of knee
stiffness, and prevents problems caused by extended bed rest,
such as bed sores and blood clots.
40. Treatment ( cont..)
Operative :
1) external fixation >>
* temporizing measure until soft tissues permit internal fixation, or until
patient is stable
* avoid pin placement in area of planned plate placement if possible
* In this type of operation, metal pins or screws are placed into the middle of the
femur and tibia (shinbone). The pins and screws are attached to a bar outside the
skin. This device is a stabilizing frame that holds the bones in the proper position
until you are ready for surgery.
41.
42. Treatment ( cont..)
2) ORIF :
- indications :
1 displaced fracture
2 intra-articular fracture
3 nonunion
- goals :
1 need anatomic reduction of joint
2stable fixation of articular component to shaft to permit early motion 3-
preserve vascularity
43. Treatment ( cont..)
- Postoperative :
* early ROM of knee important
* non-weight bearing or toe touch weight-bearing for 6-8 weeks, up to
10-12 weeks if comminuted
* quadriceps and hamstring strength exercises
44. Treatment ( cont..)
3) retrograde IM nail :
- indications
* good for supracondylar fx without significant comminution
* preferred implant in osteoporotic bone
* traditionally, 4 cm of intact distal femur needed but newer implants
with very distal interlocking options may decrease this number, can
perform independent screw stabilization of intercondylar component of
fracture around nail
45.
46. Treatment ( cont..)
4) distal femoral replacement :
- indications >>
* unreconstructable fracture
* fracture around prior total knee arthroplasty with loose
component
47. These x-rays
taken from the
front (left) and
the side (right)
show a fracture
near an artificial
knee joint.
48. Fractures near knee implants may be treated with plates, rods, or with a
revision surgery (the artificial implant must be removed and replaced
with a larger implant )
49. Surgical Techniques
-- ORIF Approaches :
1) anterolateral
• fractures without articular involvement or with simple articular extension
• incision from tibial tubercle to anterior 1/3 of distal femoral condyle
• extend up midlateral femoral shaft as needed
• minimally invasive plate osteosynthesis: small lateral incision, slide plate proximally, use stab
incisions for proximal screw placement
2) lateral Para patellar
• fractures with complex articular extension
• extend incision into quad tendon to evert patella
• can be used for Hoffa fracture
50. Surgical Techniques (cont..)
3) medial Para patellar
• typical TKA (Total KneeArthroplasty ) approach
• used for complex medial femoral condyle fractures
4) 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 muscle .
• capsulotomy to visualize fracture
51. Surgical Techniques (cont..)
-- Blade Plate Fixation :
- indications
• not commonly used, technically difficult
• contraindicated in type C3 fractures
- technique
• placed 1.5 cm from articular surface
52.
53. Surgical Techniques (cont..)
-- Dynamic Condylar Screw Placement :
- indications
• identical to 95 degree angled blade plate
-technique
• precise sagittal plane alignment is not necessary
• placed 2.0 cm from articular surface
54.
55. Surgical Techniques (cont..)
-- Locked Plate Fixation
- indications:
• fixed-angle locked screws provide improved fixation in short distal femoral block
• supracondylar periprosthetic femur fractures in cruciate retaining TKA
• TKA component must be well-fixed to proceed with fracture fixation
- Technique:
• lag screws with locked screws (hybrid construct)
• useful for intercondylar fractures (usually in conjunction with locked plate)
• useful for coronal plane fractures .
• helps obtain anatomic reduction of joint
• required in displaced articular fractures
56. Surgical Techniques (cont..)
- Prosthesis :
• percutaneous lateral application can minimize soft tissue stripping and
obviate need for medial plate
• potential to create too stiff a construct leading to nonunion or plate
failure
57.
58. Surgical Techniques (cont..)
-- Retrograde interlocked IM nail:
- Approach >>
- medial Para patellar
*1) no articular extension present :
• 2.5 cm incision parallel to medial aspect of patellar tendon
• stay inferior to patella
• no attempt to visualize articular surface
*2) articular extension present :
• continue approach 2-8 cm cephalad
• incise extensor mechanism 10 mm medial to patella
• eversion of patella not typically necessary
• need to stabilize articular segments prior to nail placement
59.
60.
61. Complications
• In many cases, the devices used
to fix a fracture break or loosen
when the fracture fails to heal.
62. Complications ( cont .. )
1) 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 APradiograph of the
knee with the leg internally rotated 30 degrees
2) Malunions :
• most commonly associated with plating, usually valgus
• functional results satisfactory if malalignment is within 5 degrees in any plane
63.
64. Complications ( cont .. )
3) Nonunions :
• up to 19%, most commonly in metaphyseal area, with articular portion
healed (comminution, bone loss and open fractures more likely in
metaphysis)
• decreasing with less invasive techniques
• treatment with revision ORIF and autograft indicated
• consider changing fixation technique to improve biomechanics
66. Complications ( cont .. )
4) Infection :
• treat with debridement, culture-specific antibiotics, hardware removal
if fracture stability permits
5) Implant failure :
• up to 9%
• titanium plates may be superior to stainless steel
69. Anatomy
• Largest sesamoid bone in the body.
• Quadriceps tendon inserted on the superior pole and the
patellar ligament originates from the inferior pole.
• Funtion of the patella is to increase the mechanical
advantage and protection.
71. Mechanism of injury
Direct trauma :
• Due to direct fall over the patella
• Usually cause comminuted fractures and are the common causes
Indirect trauma (quadriceps contraction):
• Sudden forceful contraction of the quadriceps (as in sports )
• Age : common in 20 – 50 years age group
72. Clinical evaluation-
• Patient usually non
ambulatory.
• Pain, swelling
• Abrasion over the patella.
• Unable to extend the knee
• Both the active and passive
movements are restricted
78. Treatment
• Non operative
– For non displaced fracture
– Cylinder cast: extending from the groin to just above the
malleoli for 4 to 6 weeks.
– Followed by physiotherapy- quadriceps strengthening
exercise.
79. Operative-
• Tension band wiring. (figure of 8)
• Patellectomy
– Partial:for proximal pole fracture; major fragment is
preserved;.
– Complete: for comminuted fractures.
– Knee should be immobilized for 3 to 6 weeks in a long
leg cast at 10degrees flexion for both partial and
complete patellectomy.
