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From Thomas J. Lamb
Vol. 22, No. 11November 2000
Refereed Peer Review
FOCAL POINTKEY FACTS
#
Choosing appropriate orthopedicimplants and surgical techniquesis critical to the successfulmanagement of supracondylarfemoral (SCF) fractures in adultanimals.
Supracondylar FemoralFractures in Adult Animals
University of Tennessee
David A. Lidbetter, BVSc, MVS, CertSAS, MACVSc, MRCVS
University College Dublin
Mark R. Glyde, BVSc, MVS, MACVSc, MRCVS
ABSTRACT:
Supracondylar femoral (SCF) fractures in adult animals present significantlygreater challenges to veterinary orthopedists than do fractures in immature animals in whichthe bone breaks are usually type I or II Salter-Harris physeal fractures. In adult animals, SCFfractures are often unstable because of their distal position and propensity to be comminuted.Because of the composition of the distal femur, minimal bone stock is usually available for im-plant placement. As a result, traditional implants such as intramedullary pins and dynamiccompression plates may not be adequate to stabilize fracture forces. A range of available im-plants offers additional approaches to the management of this relatively uncommon fracture.
F
emoral fractures are commonly repaired in small animals. Midshaft dia-physeal fractures are the most common femoral fractures, followed by frac-tures of the distal epiphyseum. Supracondylar femoral (SCF) fractures oc-cur infrequently in adult animals.
1
The major texts and veterinary scientificliterature cover the management of growth plate injuries in immature animalsand midshaft femoral fractures in adults in some detail; however, far less infor-mation is available on the management of the often more challenging distal frac-tures.
2–8
In humans, SCF fractures are a common fracture in which two distinctpatient populations exist: Younger people sustain these fractures as a result of high-velocity trauma, and elderly people with osteoporosis often sustain themafter minimal trauma.
9–20
Various orthopedic implants and techniques, includingintramedullary (IM) pinning, blade plating, buttress condylar plating, dynamiccompression plating, interlocking nailing, Zickel supracondylar nailing, anddouble plating, are employed in humans to repair the fractures.
9–20
Management of distal femoral fractures in young animals is typically straight-forward because of the simple nature of the fracture and the innate potential of young animals to heal rapidly. The fractures normally occur through the weak zone of hypertrophy in the physis; the surface of the fracture often interdigitatesin a
W
shape, giving the repair some inherent stability.
21
CE
V
I
SCF fractures may be morechallenging surgically in adultdogs than in immature animalsin which the fracture tends tobe through the growth plate.
I
After the fracture is thoroughlyassessed, implants and surgicaltechniques should be tailored toindividual fracture configurations.
I
Traditional repair methods suchas intramedullary pinning andstandard bone plating may notprovide ideal stability for SCFfractures.
I
Alternative devices should beconsidered to stabilize SCFfractures in adult animals.
In adult dogs, SCF fracturescan present substantial challengesbecause of the unique composi-tion of the distal femur and thefact that the fractures are oftenmore comminuted and unstable(Figure 1). These fractures aredifficult to manage because of the presence of large momentsand forces acting on them withshort segments of bone distally.SCF fractures are located near anarea of high motion due to thepresence of the knee joint andhave a small distal target for im-plant placement that is eccentri-cally placed to the bone column.In adult animals in which bio-buttress formation is slow, maxi-mum stability (which is difficultto achieve because of the smalleccentric distal target) must beobtained from the implant usedto repair the fracture. Recently,veterinary orthopedists have seenan influx of new repair devices that can be used tomanage these more difficult fractures (Table I).
ANATOMY
The shaft of the distal femur is composed of hardcortical bone, typical of the diaphysis of long bones.The femur begins to flare in its central midshaft regionand is widest in the supracondylar/epicondylar area.The condylar bone is spongy, being primarily cancel-lous with a thinner cortical rim. Cranially, the condylarregion of the femur is bordered by the medial and later-al condylar ridges and trochlear sulcus, which are cov-ered by hyaline cartilage.
22
Distally, the condyles curvecaudally with the intercondylar notch, separating themedial and lateral condyles. The intercondylar notch isthe origin of the cranial and caudal cruciate ligaments.The stifle joint is a hinge joint with limited ability torotate and is primarily stabilized by the cruciate liga-ments. Primary mediolateral stability is from the collat-eral ligaments. The lateral collateral ligament attachesthe caudal distal femoral condylar region to the head of the fibula, and the medial collateral ligament attachesthe medial epicondyle to the proximal medial tibia.
22
More cranially on the lateral side of the stifle, the longdigital extensor tendon attaches onto the distal femoralcondyle.The relevance of the local anatomy is that SCF frac-tures result in minimal bone stock in which to placeimplants to stabilize the fracture.The bone tends to have poorerholding potential because of itsmaterial properties; however, itdoes have a greater surface areafor fracture healing to occur. Im-plant placement must also avoidkey structures (e.g., articular car-tilage, collateral and cruciate lig-aments).
CLINICAL FINDINGSAND DIAGNOSIS
Animals with SCF fracturescommonly present in an unsta-ble condition and may have suf-fered concurrent injuries. They are usually non–weight-bearingin the affected leg and will haveconsiderable femoral swelling.Thorough physical, orthopedic,and neurologic examinations arenecessary. Assessment of the cru-ciate and collateral ligaments isespecially important. Instability from the fracture and local swelling can make assess-ment difficult. The cruciate ligaments in these animalsshould be assessed directly by inspection via arthroto-my during fracture repair. Initial diagnostics should in-clude a complete blood count, chemistry panel, urinal-ysis, and chest and abdominal radiography. Continuouselectrocardiography for 24 to 48 hours is advised.
FRACTURE CONFIGURATIONAND NOMENCLATURE
Fracture classification systems, which are based onthe patterns of large numbers of fractures, have beencreated for humans. These systems aid in rationalizingthe use of a particular treatment, evaluating outcome,and prognosticating. Although such systems have beendevised in veterinary orthopedics, they have not gained widespread recognition and are not used universally.
23,24
For reasons of simplicity, SCF fractures can be classifiedas supracondylar, condylar, and supracondylar/inter-condylar. Commonly used descriptive terms includesimple, multiple, comminuted, and open or closed.
SURGICAL APPROACH
Occasionally, SCF fractures that are incomplete or min-imally displaced may be treated closed without any surgi-cal approach. With the introduction of image intensifiersin veterinary surgery, closed reduction may be increasingly used with implants placed percutaneously. Most often,
Small Animal/Exotics
Compendium
November 2000
DISTAL FEMUR
I
IMPLANT PLACEMENT
I
CRUCIATE LIGAMENTS
Figure 1—
Lateral radiograph of a comminuted su-pracondylar femoral fracture.
however, either a full-open approach, mini-approach, oropen-but-do-not-touch approach is employed.
25,26
Typical-ly, because of the instability of these fractures and their dis-tal location, an approach to the shaft of the femur is com-bined with a lateral approach to the stifle as described by Piermattei and Greeley.
27
An alternative technique, which provides excellentexposure with only a minor increase in morbidity, com-bines the approach to the lateral femur with a tibialcrest osteotomy and proximal reflection of the straightpatella ligament and quadriceps group.
10,27
The firmly attached periosteum and joint capsule should be elevat-ed from the distal lateral condylar region when a boneplate repair of the femur is applied.
Compendium
November 2000Small Animal/Exotics
REPAIR DEVICES
I
LATERAL APPROACH
I
QUADRICEPS
TABLE IDevices Used to Repair Supracondylar Fractures in Adult Animals
Repair Devices
Intramedullary pinsCrossed K-wiresRush pinsLag screwsDCPReconstructionplatePlate/rodModified type IESFCustomized hook plateInterlocking nailsTibial headcompression plateHybrid circularESF
Indications
Use as adjunct fixationCats; small dogs; transverse,short oblique fracturesCats; small dogs; transverse,short oblique fracturesSmall chondrodystrophoidbreeds of dogs; very distaltransverse fracturesMany SCF fractures,particularly more proximalfracturesCats; small- and medium-sizeddogs; chondrodystrophoidbreeds of dogsMost breeds and sizes of dogsand cats; comminuted andcortical defect fractures All breeds and sizes of dogs andcats; comminuted, open SCFfracturesMost breeds and sizes of dogs;most fracture configurationsMost breeds and sizes of dogsand cats; more proximal SCFfracturesLarge-breed dogs; most fractureconfigurationsMost SCF fractures; mostbreeds and sizes of dogs andcats; very distal fractures
Relative Contraindications
Most SCF fracturesComminuted, cortical defectfracturesComminuted, cortical defectfracturesNonchondrodystrophoidbreeds of dogs; comminutedfracturesChondrodystrophoid breedsof dogs; very distal fracturesLarge dogs; comminuted orcortical deficit fracturesSome cats and small dogs;very narrow medullary canalsSCF fractures with anarticular componentUse extra care with cats andsmall dogsChondrodystrophoid breedsof dogs; some cats with very distal fractures Animals weighing <25 kgSCF fractures with anarticular component
Important Points
Poor rotational stability Simple technique; requireslimited equipmentMore difficult technique;requires specialized equipment Avoid screw placement intointercondyloid fossa; carefulcase selection Avoid trochlear ridge andintraarticular screw placement;use care with capsule closureRequires load sharing withbone; contour to distal caudalfemoral bowPlace bicortical screws inmetaphysis; place monocorticalscrews in diaphysisUse positive-profile pins; avoidquadricepsModification of existing DCPrequiredRequires specialized equipmentand trainingRight-sided plates are used forleft-sided fracturesTechnically difficult; requiresspecialized training andequipment
DCP
= dynamic compression plate;
ESF
= external skeletal fixator;
K
= Kirschner;
SCF
= supracondylar femoral.
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Supracondylar Femoral Fractures in Adult Animals
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