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Distal Femur Fracture

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Other Names

  • Supracondylar femur fracture
  • Intercondylar femur fracture
  • Hoffa's Fracture

Background

  • This page refers to fractures of the distal Femur
    • Defined as regional from metaphyseal-diaphyseal junction to intra-articular surface of the knee (~15 cm)

History
Epidemiology

  • Bimodal distribution[1]
    • Seen in younger males secondary to high energy trauma
    • Elderly patients due to low energy mechanical injuries, typically a fall from standing
  • Prevalence
    • Less than 1% of all fractures[2]
    • 3-6% of all femur fractures
  • Incidence
    • Estimated to be 37 per 100,000 people in the United States[3]
  • Periprosthetic fractures
    • Primary total knee arthroplasty has been reported to be from 0.3% - 5.5%[4]
    • Revision arthroplasty may be as high as 30%
  • About 5-10% of supracondylar fractures are open fractures[5]
  • Pediatrics
    • Distal femoral physeal fractures account for 2-5% of all physeal fractures[6]
    • Predilection towards males
    • Salter Harris II represents 75-80% of distal femur fractures in children[7]

Introduction

  • General
    • Rare injury pattern requiring high energy trauma

Etiology

  • Most common mechanism is high energy, direct trauma to a flexed knee
    • E.g. Dashboard injury in MVC
  • Low energy variant can also be seen
    • Typically in elderly, osteoporotic patients
  • Patients with history of Total Knee Replacement
    • Can experience peri-prosthetic fracture
  • Deforming forces depend on fracture location

Pediatric Considerations

  • Follows the Salter Harris Classification
  • Distal femoral physis
    • Two to five times weaker than surrounding soft tissue, "weakest link in the chain"[8]
    • Thus vulnerable to forces that produce unique injuries in children compared to adults
  • High rate of growth arrest following epiphysiodesis[7]

Anatomy of the Distal Femur

  • Femoral shaft is cylindric shape, extends into two curved condyles as it approaches the joint space
  • Defined as regional from metaphyseal-diaphyseal junction to intra-articular surface of the knee (~15 cm)

Associated Injuries

Risk Factors

  • Sports
    • American Football
  • Osteopenia or Osteoporosis
    • Estimated to be present in up to 80% of distal femur fractures in patients over 35 (need citation)

Differential Diagnosis

Differential Diagnosis Thigh Pain

Differential Diagnosis Knee Pain

Clinical Features

  • History
    • Typically presenting after a high energy trauma
    • Follow ATLS protocol
    • Patient will have severe knee or thigh pain
    • Inability to bear weight
  • Physical Exam: Physical Exam Knee
    • Range of motion limited
    • Unable to bear weight
    • Effusion is typically present
    • Deformity is often obvious
    • Look for break in skin
    • Perform thorough neurovascular exam
    • In pediatric patients, the findings may be more subtle, tenderness located directly over physis

Evaluation

Lateral radiograph of distal femur fracture

Radiographs

CT

  • Important for surgical planning especially in complex fractures or intra-articular extension
    • Coronal, sagittal reconstruction
    • Look for osteochondral fragments
  • Hoffa's Fracture
    • IA distal femoral fracture in the coronal plane, most commonly involves the lateral condyle
    • Can be missed on radiographs
  • Consider angiography if any suspicion of vascular injury
    • Ipsilateral pulses can be normal in setting of vascular injury
    • Indicated if any suspicion for knee dislocation

MRI

  • Pediatrics
    • Indicated for normal or subtle findings on xray, nondisplaced fractures, other intra-articular pathology suspected
    • SH1: widening, increased signal within the physis[9]

Ankle-Brachial Index

  • Consider if any suspicion at all of vascular injury

Classification

The Orthopaedic Trauma Association Classification

  • 33A: Extra-articular
    • A1: Simple
    • A2: Metaphyseal wedge
    • A3: Metaphyseal complex
  • 33B: Partial articular (a portion of the articular surface remains attached to the proximal shaft)
    • B1: Lateral condyle
    • B2: Medial condyle
    • B3: Coronal plane (Hoffa fragment)
  • 33C: Complete articular (articular fragment separated from the shaft)
    • C1: Simple articular, simple metaphyseal
    • C2: Simple articular, metaphyseal comminution
    • C3: Metaphyseal and intra-articular comminution

Management

Nonoperative

  • Generally considered a surgical injury
    • Nonoperative management can be considered in stable, non-displaced extra-articular fractures
    • Non-ambulatory patients with significant comorbidities presenting with significant anesthesia/surgical risk
    • Elderly individuals or low-functioning individuals may be considered non-surgical at the discretion of the surgical team
  • Early pain control is important
  • Hinged Knee Brace
    • Early ROM to prevent stiffness
    • Non-weight bearing for 6 weeks
  • Long Leg Cast or Long Leg Splint
    • Can be considered acutely, not as definitive as brace
    • Thomas et al found higher rate of delayed union with splint compared to brace, no difference in malunion[10]
  • VTE prophylaxis
  • Radiographs should be obtained at fixed intervals
    • Typically 2, 4, and 6 weeks to evaluate for evidence of healing or displacement
  • Pediatric considerations
    • Can manage nondisplaced SH1, SH2 fractures nonoperatively
    • Non-weight bearing, long leg cast for 4-6 weeks
    • Repeat radiographs at 1-2 weeks to ensure no displacement has occurred
    • Younger or obese children may require a Hip Spica Cast

Operative

  • Indications
    • Most adult fractures
    • Any displaced pediatric salter harris fracture
  • Objectives: Follow AO Treatment principles
    • Anatomic reduction of the articular surface,
    • Restoration of limb alignment, length, and rotation
  • Open fracture
    • Administer tetanus, antibiotics
  • Consult vascular surgery
    • If any suspicion or objective findings of a vascular injury
  • General Principles
    • Type A: retrograde nailing or minimally invasive percutaneous plate osteosynthesis (MIPPO)
    • Type B: closed reduction and percutaneous screw fixation or MIPPO
    • Type C:
      • C1 fractures can be treated by retrograde nailing or MIPPO techniques.
      • C2, C3 and periprosthetic fractures: Minimal invasive percutaneous plate osteosynthesis
  • Technique
    • External Fixation
    • Open Reduction, Internal Fixation
    • Intramedullary Nail
    • Locking Plates

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/Work

  • At the discretion of the managing orthopedic surgeon

Prognosis and Complications

Prognosis

  • 1-year mortality rate for distal femur fractures in the elderly who undergo operative treatment has been reported to be from 13.4 to 35%[11]
  • Surgical outcomes
    • In appropriate patients, IM nail has shown good outcomes[12]
    • Distal locking plates have shown good outcomes too[13]
  • Cass looked at operative vs nonoperative management of distal femur fracture in myelopathic, nonambulatory patients[14]
    • Nonsurgical patients were at a higher risk of wound infections, 3/12 eventually required amputation
    • They concluded operative treatment of femoral fractures in nonambulatory patients with myelopathy is safe and effective
  • Butt at al compared operative to nonoperative management[15]
    • Nonoperative included skeletal traction for 6–8 weeks followed by functional bracing, operative management was dynamic condylar screw
    • Good or excellent results were obtained in 53% of the operatively treated patients versus 31% in the non-operative group
    • Nonop group had more complications: including DVT, UTI, Pneumonia, pressure ulcers, malunion, pin infections

Complications

  • Decubitus ulcers
  • Venous Thromboembolism
  • Loss of knee function
  • Surgical
    • Chronic pain from surgical hardware
    • Malunion
    • Nonunion
  • Limb shortening
  • Physeal Arrest[16]
    • Most common complication, occurs in 50% of all distal physeal femoral fractures
    • Risk increases if displaced
    • Risk varies with type: SH1 (36%), SHII (58%), SHIII (49%), SHIV (64%)

See Also

Internal

External

References

  1. ↑ Martinet O, Cordey J, Harder Y, Maier A, Bühler M, Barraud GE. The epidemiology of fractures of the distal femur. Injury. 2000 Sep;31 Suppl 3:C62-3.
  2. ↑ Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006 Aug;37(8):691-7.
  3. ↑ Zlowodzki M, Bhandari M, Marek DJ, Cole PA, Kregor PJ. Operative treatment of acute distal femur fractures: systematic review of 2 comparative studies and 45 case series (1989 to 2005). J Orthop Trauma. 2006 May;20(5):366-71
  4. ↑ Della Rocca GJ, Leung KS, Pape HC. Periprosthetic fractures: epidemiology and future projections. J Orthop Trauma. 2011 Jun;25 Suppl 2:S66-70.
  5. ↑ Dugan TR, Hubert MG, Siska PA, Pape HC, Tarkin IS. Open supracondylar femur fractures with bone loss in the polytraumatized patient - Timing is everything! Injury. 2013 Dec;44(12):1826-31.
  6. ↑ Mayer, Stephanie, Jay C. Albright, and Jason W. Stoneback. "Pediatric knee dislocations and physeal fractures about the knee." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 23.9 (2015): 571-580.
  7. ↑ 7.0 7.1 Moran, M., and M. F. Macnicol. "(ii) Paediatric epiphyseal fractures around the knee." Current Orthopaedics 20.4 (2006): 256-265.
  8. ↑ Caine, Dennis, John DiFiori, and Nicola Maffulli. "Physeal injuries in children’s and youth sports: reasons for concern?." British journal of sports medicine 40.9 (2006): 749-760.
  9. ↑ Pai, Deepa R., and Peter J. Strouse. "MRI of the pediatric knee." American Journal of Roentgenology 196.5 (2011): 1019-1027.
  10. ↑ Thomas, Tudor L., and Bernard F. Meggitt. "A comparative study of methods for treating fractures of the distal half of the femur." The Journal of bone and joint surgery. British volume 63.1 (1981): 3-6.
  11. ↑ Loosen A, Fritz Y, Dietrich M. Surgical Treatment of Distal Femur Fractures in Geriatric Patients. Geriatr Orthop Surg Rehabil. 2019
  12. ↑ Thomson AB, Driver R, Kregor PJ, Obremskey WT. Long-term functional outcomes after intra-articular distal femur fractures: ORIF versus retrograde intramedullary nailing. Orthopedics. 2008 Aug;31(8):748-50.
  13. ↑ Hartin NL, Harris I, Hazratwala K. Retrograde nailing versus fixed-angle blade plating for supracondylar femoral fractures: a randomized controlled trial. ANZ J Surg. 2006 May;76(5):290-4.
  14. ↑ Cass J, Sems SA. Operative versus nonoperative management of distal femur fracture in myelopathic, nonambulatory patients. Orthopedics. 2008 Nov;31(11):1091. PMID: 19226094.
  15. ↑ Butt, M. S., S. J. Krikler, and M. S. Ali. "Displaced fractures of the distal femur in elderly patients: operative versus non-operative treatment." The Journal of Bone and Joint Surgery. British volume 78.1 (1996): 110-114.
  16. ↑ Wall, Eric J., and Megan M. May. "Growth plate fractures of the distal femur." Journal of Pediatric Orthopaedics 32 (2012): S40-S46.
Created by:
John Kiel on 7 July 2019 06:17:37
Authors:
Last edited:
17 March 2023 17:52:23
Categories:
Knee | Lower Extremity | Trauma | Thigh | Fractures | Acute

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