Can read freely here https://sethiortho.blogspot.com/ DISTAL FEMUR FRACTURES OVERVIEW • INTRODUCTION • EPIDEMIOLOGY • ANATOMY AND IT’S RELEVENCE • CLASSIFICATION • CLINICAL PRESENTATION • IMAGING • MANAGEMENT – Operative – Approaches – Implants – Tips and tricks INTRODUTION • Fractures of the supracondylar and intercondylar region of the femur. • Bimodal distribution, – Younger patients – High energy – Elderly patients – Low energy • A challenging fracture type to treat. EPIDEMIOLOGY • Less than 1% of all fractures • 3 – 6% of femoral fractures • Incidence – 37 per 100,000 population in USA. • Non union rate 10 – 20% after plate fixation. • Coon MS, Best BJ. Distal Femur Fractures. National Library of Medicine. August 2021. • Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006 Aug;37(8):691-7. ANATOMY • Distal most 10- 15 cm of the femur. supracondylar and condylar region. • Medial condyle extends more distally and is more convex than the lateral femoral condyle. This accounts for the physiologic valgus of the femur. • The lateral surface has a 10° inclination from the vertical, while the medial surface has a 20–25° slope. • Patello-femoral inclination approximately 10° • In order to avoid joint penetration, screws should be placed parallel to both the patellofemoral and femorotibial joints planes. Muscle attachments • Shortening is due to the pull of the quadriceps and hamstring muscles • Varus and extension deformity is caused by the pull of the adductors and gastrocnemius. • Neuro-vascular bundle lie near the posterior aspect of the distal femur. • Vascular injuries occur in about 3% and nerve injuries in about 1% of fractures of the distal femur. CLASSIFICATION • AO/OTA CLINICAL PRESENTATION • High energy trauma • Older patients – low energy • Swelling , Deformity • Open fractures • Neuro-vascular complications not uncommon IMAGING • Plain radiography – AP – Lateral • CT – Intra-articular fracture assessment – Pre-op planning – Identify osteochondral fragments • Angiography – ABI < 0.9 MANAGEMENT • Non operative – Non-displaced type A fractures – Non- ambulatory / Inoperable – Splint care / knee immobilizer / hinged knee brace • Operative – Any displacement / malalignment – Intra-articular involvement SURGICAL MANAGEMENT • ORIF • Retrograde IM nail • External fixation • Arthroplasty Open Reduction & Internal Fixation • Indications – Intra-articular fractures – Low Type A fractures – Metaphyseal comminution – Non-union – Osteoporotic bones Pre – operative Planning ‘Failing to plan is planning to fail’ • Implants • Anatomical lateral locking plate • Condylar variable angle locking compression plate (VA-LCP) • 95° angled blade plate • 95° dynamic condylar screws • lag screws / headless screws • Other plates for adjunctive fixation Pre – operative Planning • Other devices and instruments – Image intensifier – Femoral distractor – Reduction clamps • Pointed clamps • Collinear clamp – Schanz pins – K wi

1. DISTAL FEMUR FRACTURES
DR. THILINA JAYASEKARA
REGISTRAR IN ORTHEPAEDIC SURGERY
NHSL

2. OVERVIEW
• INTRODUCTION
• EPIDEMIOLOGY
• ANATOMY AND IT’S RELEVENCE
• CLASSIFICATION
• CLINICAL PRESENTATION
• IMAGING
• MANAGEMENT
– Operative
– Approaches
– Implants
– Tips and tricks

3. INTRODUTION
• Fractures of the supracondylar and
intercondylar region of the femur.
• Bimodal distribution,
– Younger patients – High energy
– Elderly patients – Low energy
• A challenging fracture type to treat.

4. EPIDEMIOLOGY
• Less than 1% of all fractures
• 3 – 6% of femoral fractures
• Incidence – 37 per 100,000 population in USA.
• Non union rate 10 – 20% after plate fixation.
• Coon MS, Best BJ. Distal Femur Fractures. National Library of Medicine.
August 2021.
• Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review.
Injury. 2006 Aug;37(8):691-7.

5. ANATOMY
• Distal most 10- 15 cm of the femur. supracondylar
and condylar region.
• Medial condyle extends more distally and is more
convex than the lateral femoral condyle. This
accounts for the physiologic valgus of the femur.

6. • The lateral surface has a 10° inclination from the
vertical, while the medial surface has a 20–25° slope.
• Patello-femoral inclination approximately 10°
• In order to avoid joint penetration, screws should be
placed parallel to both the patellofemoral and
femorotibial joints planes.

7. Muscle attachments
• Shortening is due to the pull of the quadriceps
and hamstring muscles
• Varus and extension deformity is caused by
the pull of the adductors and gastrocnemius.

8. • Neuro-vascular bundle lie near the posterior aspect
of the distal femur.
• Vascular injuries occur in about 3% and nerve injuries
in about 1% of fractures of the distal femur.

9. CLASSIFICATION
• AO/OTA

10. CLINICAL PRESENTATION
• High energy trauma
• Older patients – low energy
• Swelling , Deformity
• Open fractures
• Neuro-vascular complications not uncommon

11. IMAGING
• Plain radiography
– AP
– Lateral
• CT
– Intra-articular fracture assessment
– Pre-op planning
– Identify osteochondral fragments
• Angiography
– ABI < 0.9

12. MANAGEMENT
• Non operative
– Non-displaced type A fractures
– Non- ambulatory / Inoperable
– Splint care / knee immobilizer / hinged knee brace
• Operative
– Any displacement / malalignment
– Intra-articular involvement

13. SURGICAL MANAGEMENT
• ORIF
• Retrograde IM nail
• External fixation
• Arthroplasty

14. Open Reduction & Internal Fixation
• Indications
– Intra-articular fractures
– Low Type A fractures
– Metaphyseal comminution
– Non-union
– Osteoporotic bones

15. Pre – operative Planning
‘Failing to plan is planning to fail’
• Implants
• Anatomical lateral locking plate
• Condylar variable angle locking
compression plate (VA-LCP)
• 95° angled blade plate
• 95° dynamic condylar screws
• lag screws / headless screws
• Other plates for adjunctive fixation

16. Pre – operative Planning
• Other devices and instruments
– Image intensifier
– Femoral distractor
– Reduction clamps
• Pointed clamps
• Collinear clamp
– Schanz pins
– K wires

17. • DFLP fixation of the distal femur fractures resulted in
stronger construct than the DCS fixation in both
cyclic loading and ultimate strength in
biomechanical testing of a simulated A3 distal femur
fracture.

18. • The RAFN constructs experienced greater subsidence and
reduced axial stiffness compared with the LCP in the
supracondylar fracture model when subjected to simulated
simplified six-week postoperative weight bearing.

19. • Cyclical loads are better tolerated by LISS plate
than IMN.
• IMN less deformation at fracture site.

20. THEATRE SET-UP
• Patient positioning
– Supine; knee flex 30°
– Bump under ipsilateral hip

21. • Contralateral limb images as templates
A. Lesser trochanter profile to assess rotation
B. AP image [50% overlap of the fibular head by
the tibia] – trochlear notch contour
C. Lateral image [overlaping femoral condyles]

22. APPROACHES
Antero-lateral
Lateral
Medial
Lateral / Medial parapatella
Modified Swashbuckler
Olerud approach(Extensile ant. Approach with
T. tuberosity osteotomy)

23. Antero-Lateral approach
• Mid lateral line to the Gerdy’s tubercle.
• Incision through ITB along the musle fibre
orientation.
• V. Lateralis is elevated.
• Joint capsulotomy to visualize the articular surface.

24. Medial approach
• A skin incision is made in the line of the tendon of
adductor magnus from the adductor tubercle.
• Plane between the V. medialis and sartorius
• Posterior retraction of the A. magnus
• Blunt dissection follows to avoid neuro-vascular
bundle

25. Lateral parapatellar approach
• Land marks - Tibial tubercle and the patella. The incision can
be either directly midline, or preferably, slightly lateral to
midline.
• longitudinal incision through the lateral parapatellar
retinaculum and the quadriceps tendon.
• Flexion of the knee and medial traction on the extensor
mechanism, the patella is dislocated medially.

26. Modified Swashbuckler approach
• A midline skin incision above the
fracture laterally across the patella.
• Lateral parapatella arthrotomy done
2cm lateral to the patella border.
• At the base of the incision is deviated
aiming the post. depression of V.
lateralis.

27. • Swashbuckler approach – excellent outcome in terms of
post op knee ROM, pain tolerance, infection rate.
• Excellent approach to manage complex type C fractures

28. Olerud (Extensile Anterior) Approach
• A large Y-shaped incision or
a linear incision.
• Tibial tuberosity osteotomy.
• An arthrotomy incision is
then made on both sides of
the patella, and the patella
is lifted superiorly.

29. • The J of Knee Surgery. 2019.
• 57.1% had excellent/good functional outcomes
(n =72)
• Complications - infections, tibial tuberosity non
union & post op pain.

30. REDUCTION TECHNIQUES
• Convert type C to Type A.
• In the absence of metaphyseal comminution reduce
the largest articular fragment to the metaphysis
( C → B) and the fix the rest.
• Femoral distractor is used in reduction of the articular
block to the shaft.
• A well placed bump under the knee – hyper extended
distal part relative to the shaft.

31. REDUCTION TECHNIQUES
• Hoffa fracture
– Medial Hoffa fragments are addressed first.
– Schanz pins can be used to joystick the medial Hoffa.
– Posterior Hoffa - Extreme hyperflexion of the knee joint
with hyperextension of the metaphyseal segment.

32. FIXATION
• Articular segments
– Lag screws
• Fully threaded 2.7 or 3.5 mm lag screws
• Partially threaded 6.5mm lag screws
• Cannulated partially threaded 4.0/4.5 mm
– Headless compression screws

33. FIXATION
• Lateral locking plate
– Post. Distal hole above the Blumensaat’s line.
– Ant. Distal hole above the trochlear groove.
– AP – plate should be 1 – 1.5cm cranial to the joint line
– Plate should seat antero-lateraly on the shaft

34. • Ideal position of the distal screws
– Plane of the tibio-femoral joint line (Red)
– Plane of the patellofemoral condyles (Green)
– Screw should parallel to both lines in two views
• This orientation ensures that the plate comes to lie
flush with the lateral cortex.

35. • Direct lateral placement of the plate can cause
external rotation of the distal fragment and
patella mal-alignment.

36. • Too posterior placement of the plate causes
“Golf clubbing” of the distal segment.
• Hyperextension or internal rotation of the
distal segment can cause similar problem.

37. MIPO technique
• Bridge plating
• For distal screw insertion
• LISS is a system which helps MIPO

38. ADJUNCTIVE FIXATION
• Severe medial metaphyseal comminution
– Medial plating in the antero-medial aspect of the distal
femur
• 3.5mm recon plate
• Proximal tibial LCP
– From adductor tubercle to 15cm below the LT is the “Safe
zone”

39. • Medial buttress can also provide with bone
grafts.
– Fibula graft
• Ipsilateral or cadaveric
– Bi-cortical strut graft
• Grafting is done before compress with the
plate.

40. ADJUNCTIVE FIXATION
• Intramedullary nail with lateral plate
• Indicated for both native and periprosthetic
fractures

41. • J Orthop Trauma .February 2019
• Better option in osteoporotic distal femur fractures
[relatively high nonunion rate with or without
subsequent plate failure]
• Technique can offer stable, balanced fixation allowing for
immediate weight bearing and early mobilization

42. ADJUNCTIVE FIXATION
• Hoffa fractures - slightly under-contoured 3.5
mm narrow plate

43. New Developments..

44. RFN-ADVANCED™ Retrograde Femoral
Nailing System
• Designed to improve fixation
by reduced toggle and loss of
reduction for distal femur
fractures.
• Two descending oblique
screws target denser posterior
condyles.
• Locking Attachment Washer
increases the fixation strength
by 44% compared to nailing
alone.

45. RFN-ADVANCED™ Retrograde Femoral
Nailing System
• Locking Polymer is built into the
nail for angular stability.
• Designed to avoid the challenges
associated with cross-threading
and cold-welding.
• Locking Polymer reduces screw
toggle by 80% and holds the screw
in position relative to the nail,
increasing pull out strength up to
128%.

46. RFN-ADVANCED™ Retrograde Femoral
Nailing System
The RFN-A System is intended to stabilize fractures of the distal femur
and the femoral shaft, including:
• Supracondylar fractures, including those with intraarticular
extension
• Combination of ipsilateral condylar and diaphyseal fractures
• Ipsilateral femur/tibia fractures
• Femoral fractures in multiple trauma patients
• Periprosthetic fractures
• Fractures in the morbidly obese
• Fractures in osteoporotic bone
• Impending pathologic fractures
• Malunions and nonunions

47. • https://approvedsolutions.aofoundation.org/app
rovedsolutionsfolder/2020/rfn-advanced-
retrograde-femoral-nailing-system#tab=details;

48. Our Experience…

49. Our Experience…

50. Our Experience…

51. SUMMARY
• The treatment of distal femur fracture needs careful pre-
operative planning.
• In ORIF with LCP, proper placement of plate is important
to avoid fragment displacement and subsequent non
union.
• Adjunctive fixation is useful to prevent failures.
• Modern implant designs are useful in combating the
many challenges in distal femur fracture fixation.

52. REFERENCES
1. Lee C, Dane B, Ajay G. Surgical Tips and Tricks
for Distal Femur Plating. J of the American
Academy of Orthopaedic Surgeons.
2021;29(18) : p 770-779.

53. REFERENCES
2. Ehlinger M, Ducrot G, Adam P, et al. Distal femur
fractures. Surgical techniques and a review of
the literature. Orthopaedics & Traumatology:
Surgery & Research.2013; 99(3):353-360.
3. AO surgery reference
https://surgeryreference.aofoundation.org.
4. Campbell’s operative Orthopaedics. 14th ed.
2021.

54. THANK YOU !