fractures of the distal femur
DESCRIPTION
Fractures of the Distal Femur. “The Supracondylar Fracture”. DISTAL FEMUR FRACTURES. J.E.BURKHARDT D.O. GARDEN CITY HOSPITAL 1998. Introduction. 4-7% of all femur fractures Excluding the hip, 31% of femur fractures Two populations: Young (high energy) and the Elderly (falls). Anatomy. - PowerPoint PPT PresentationTRANSCRIPT
Introduction
• 4-7% of all femur fractures• Excluding the hip, 31% of femur fractures• Two populations: Young (high energy) and
the Elderly (falls)
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)
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
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
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
Classifications
• Neer: direction of condyles– I- minimal < 2mm– II a- medial – b- lateral– III- combined supra and intra
• Very basic not very helpful
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
Classifications
• Seinsheimer IV– A. Medial condyle comminuted– B. Lateral condyle comminuted– C. Total disaster of comminution
Absolute Indications
• displaced intraarticular fxs• open fxs• vascular injury• floating knee• bilateral femoral fractures• pathologic fractures
Relative Indications
• All patients that do not want to be immobilized for a prolonged period of time and can withstand the operation
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
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
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
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
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
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
Fixation Devices
• 95 degree DCS (Sanders, JOT, 1989)• 95 degree Blade Plate (Schatzker&Mueller)• Condylar Plate (Johnson, 1987)• LISS• Bolhofner Plate
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
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
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”
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
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
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