Fractures of the Distal Femur

1. Fractures of the Distal Femur “The Supracondylar Fracture”

2. DISTAL FEMUR FRACTURES J.E.BURKHARDT D.O. GARDEN CITY HOSPITAL 1998

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

4. 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)

5. 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

6. 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

7. 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

8. Classifications • Neer: direction of condyles • I- minimal < 2mm • II a- medial • b- lateral • III- combined supra and intra • Very basic not very helpful

9. 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

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

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

12. Management • Cast • Traction • Hinged knee brace • Surgical

13. Absolute Indications • displaced intraarticular fxs • open fxs • vascular injury • floating knee • bilateral femoral fractures • pathologic fractures

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

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

22. Fixation Devices • IM Rod • (supracondylar vs retrograde nail) • Enders Nails • External Fixation

23. Post-Op Care • Bracing • CPM • Ambulation • Weight bearing status • Bone graft at 6-8 weeks if needed

24. 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

25. 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

26. 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”

27. 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

28. 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

29. 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

30. Thank You