The document discusses distal femur fractures, including: 1) The anatomy of the distal femur and knee joint. 2) Types of distal femur fractures including supracondylar, intercondylar, and complete articular fractures. 3) Treatment options including casting/bracing, external fixation, open reduction internal fixation using various plate techniques, and retrograde intramedullary nailing. 4) Potential complications from treatment including malunion, nonunion, infection, and implant failure.

1. Distal femur Fractures
Prepared by : Dr.Loay Aburaiya
2016-2017

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.

6. Posterior view anterior view

7. Amatomy 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

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.

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.

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.

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).

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.

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 with shaft
• C: complete articular
articular fragment separated from shaft
-- Distal femur fractures can be closed — meaning the skin is intact — or can be
open

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

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

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.

32. Hoffa fracture

33. Investigations ( cont..)
Angiography :
• indicated when diminished distal pulses after gross alignment
restored
• consider if associated with knee dislocation

34. CT view

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..

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

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.

42. Treatment ( cont..)
2) ORIF :
- indications :
1- displaced fracture
2- intra-articular fracture
3- nonunion
- goals :
1- need anatomic reduction of joint
2- stable 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

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 Knee Arthroplasty ) 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

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

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

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

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 AP radiograph
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

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

65. Complications ( cont .. )

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