![• 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]](https://image.slidesharecdn.com/distalhumerusfractures-220522163613-7ac269fe/95/Distal-Humerus-Fractures-pptx-21-638.jpg)
![• 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](https://image.slidesharecdn.com/distalhumerusfractures-220522163613-7ac269fe/95/Distal-Humerus-Fractures-pptx-41-638.jpg)
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Distal Humerus Fractures.pptx
The document provides a comprehensive overview of distal femur fractures, covering epidemiology, anatomy, classification, clinical presentation, imaging, and management strategies. It emphasizes the importance of pre-operative planning and proper implant selection to address this complex fracture type, with detailed descriptions of various surgical approaches and techniques. The document concludes by highlighting the role of modern implant designs and adjunctive fixation in improving fixation outcomes.
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Distal Humerus Fractures.pptx
- 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 ofthe 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 than1% 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 most10- 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 lateralsurface 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 • Shorteningis 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 bundlelie 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.
- 10. CLINICAL PRESENTATION • Highenergy 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 – operativePlanning ‘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 – operativePlanning • Other devices and instruments – Image intensifier – Femoral distractor – Reduction clamps • Pointed clamps • Collinear clamp – Schanz pins – K wires
- 17. • DFLP fixationof 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 RAFNconstructs 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 loadsare better tolerated by LISS plate than IMN. • IMN less deformation at fracture site.
- 20. THEATRE SET-UP • Patientpositioning – Supine; knee flex 30° – Bump under ipsilateral hip
- 21. • Contralateral limbimages 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 / Medialparapatella Modified Swashbuckler Olerud approach(Extensile ant. Approach with T. tuberosity osteotomy)
- 23. Antero-Lateral approach • Midlateral 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 • Askin 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 Jof Knee Surgery. 2019. • 57.1% had excellent/good functional outcomes (n =72) • Complications - infections, tibial tuberosity non union & post op pain.
- 30. REDUCTION TECHNIQUES • Converttype 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 • Hoffafracture – 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 lockingplate – 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 positionof 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 lateralplacement of the plate can cause external rotation of the distal fragment and patella mal-alignment.
- 36. • Too posteriorplacement 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 • Bridgeplating • For distal screw insertion • LISS is a system which helps MIPO
- 38. ADJUNCTIVE FIXATION • Severemedial 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 buttresscan 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 • Intramedullarynail with lateral plate • Indicated for both native and periprosthetic fractures
- 41. • J OrthopTrauma .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 • Hoffafractures - slightly under-contoured 3.5 mm narrow plate
- 43.
- 44. RFN-ADVANCED™ Retrograde Femoral NailingSystem • 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 NailingSystem • 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 NailingSystem 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
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- 51. SUMMARY • The treatmentof 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.