Distal Femur Fractures: Brett D. Crist, MD

Distal Femur Fractures
Brett D. Crist, MD
University of Missouri
Columbia, Missouri
Previous Authors: Robert F. Ostrum, MD; March 2004;

Gregory J. Della Rocca, MD, PhD December 2006;
Revised November 2010
Special Thanks –
some images/illustrations from
• Robert F. Ostrum, MD
– Cooper University Hospital, Camden, NJ
• Brett D. Crist, MD
– University of Missouri, Columbia, MO
• Mark A. Lee, MD
– University of California – Davis, Sacramento, CA
• David P. Barei, MD, FRCS(C)
– Harborview Medical Center, Seattle, WA
• Mark C. Reilly, MD
– UMDNJ, Newark, NJ
Distal Femur Fractures
• Assess fracture/patient
– “Personality of the fracture”
– Other patient issues (e.g. polytrauma)
• Plan your surgery
– Implants, positioning, technique
• Reduce fracture
• Stabilize fracture
• Rehabilitation
Articular Fractures
• Overriding principles:
– Anatomical reduction of joint surfaces
– Reduction of articular segment to the diaphysis with to
restore appropriate length, alignment, rotation
– Stable fixation with safe implant placement and
minimal biological insult
• Early motion of the joint and early rehabilitation
• Principles similar for all articular fractures
• What kind of fracture is this?
• How do we decide on appropriate treatment ?
AO/OTA Classification
• Femur
– Type 3X-XX: femur
– Type 33-XX: distal
femur
• AO/OTA Type 33
– 33-AX Supracondylar
– 33-BX Unicondylar
– 33-CX Bicondylar
• See figure for further
subclassification
Evaluation of Distal Femur Fractures
• Plain radiographs
– AP/lateral knee
– AP/lateral femur
– Don’t forget to assess proximal femur!
– Insist on adequate x-rays. Don’t forget the “free look”
at the femoral neck/head often obtained on the
screening abdominopelvic CT scan in trauma patients
• Plain radiographs of contralateral (uninjured)
femur may help for planning in cases with severe
bone loss and/or comminution
• Consider traction views
• CT scan – gives details about articular surface
involvement
– May be beneficial to wait until after external fixation (if
being used)?
• Don’t forget the Hoffa fragment!
– 38% of intercondylar distal femur fractures have a
coronal plane fracture
(Nork et al, J Orthop Trauma, 87:564, 2005)
– Most precisely diagnosed via CT scanning
76% single condyle
85% lateral condyle
Open fx 2.8 x coronal

fx than closed fx
Coronal fx diagnosed
in 47% with CT and
only 21% with xray
only
• Don’t forget to evaluate the entire patient!

• ATLS
• Other orthopaedic injuries
External Fixation
• Valuable for tibial plateau fractures and
pilon fractures for temporary stabilization to
allow for soft tissue recovery
• However, distal femur fractures can often
be fixed definitively without delay,
unless…
– Patient condition precludes long procedure
– Other injuries need to be addressed earlier
– Open fractures
– Non-patient-specific factors (OR availability,
etc.)
External Fixation
• Spanning knee external fixation
– Allows for temporary stabilization of fracture if
delayed reconstruction is necessary
– Distracts fracture for ligamentotaxic reduction
and perhaps better preoperative planning
radiographs and CT scan
– External fixator as a reduction aid at time of
definitive reconstruction
• Keep pins out of planned surgical field!
Planning Definitive Reconstruction
• Know your surgical anatomy!

– Intercondylar notch
– Posterior condylar alignment
– Distal femoral valgus
– Deforming forces
– Trapezoidal shape of distal femur
Planning Definitive Reconstruction –
Intercondylar Notch
• Strategic implant
placement to
avoid notch and
concomitant
injury to cruciate
ligaments
X
Posterior Condylar Alignment with
Shaft
• Posterior condyles
project
POSTERIORLY with
regard to femoral
shaft!
Don’t do
• Too posterior leads to this!
anterior translation of
the distal segment
when fixing to shaft
Posterior Condylar Alignment with
Shaft
• Posterior condyles
project
POSTERIORLY with
regard to femoral
shaft!
• Plate too posterior
leads to medialization
of the condyles
Distal Femoral Valgus
• The distal
femoral
articular surface
has valgus of
approximately
9° relative to
the anatomical
axis of the
femur
Deforming Forces
• Recognition of Hamstrings Shorten
muscular deforming
forces allows for
reduction techniques
designed to overcome
these forces, thereby
achieving anatomical
reduction. Gastrocnemius
Extends
Trapezoidal Distal Femur
• Recognition of
this geometry
will prevent
prominent
implants and
soft tissue
irritation
“Method of Attack”
• Reduce articular surfaces first
– Direct reduction techniques
• Secure fixation of articular surfaces
– Interfragmentary screws
• Restore continuity of articular block with
shaft
– Many implants available
– Indirect reduction techniques
So Many
Implants…
Internal Fixation Options
• Condylar buttress plates
• Fixed-angle devices
– Blade plate
– Dynamic Condylar Screw (“DCS”)
– Locked plates
• Retrograde medullary nail
• All implants can work if utilized properly
Prior to Applying Implants…
• Reduce the fracture!
Surgical Technique
• Internal fixation implants
do NOT reduce the
fracture (although they
may aid reduction)
• The surgeon reduces the
fracture
Distal femur extended

Respect the Biology!
• Indirect reduction
techniques:
– External fixator
– Femoral distractor
– “Joysticks”
– Percutaneous clamps
– Bumps
Respect the Biology – Indirect
Reduction
Indirect Reduction Aids
BUMP
Indirect Reduction Aids
• Hyperextension B
deformity difficult to E
control with knee F
spanning ex-fix O
R
configuration E
– Try distal anterior to
posterior half pin as
“joystick” or build to
frame A
F
T
E
BUMP R
• Limit soft tissue dissection
– Indirect reduction techniques
– Submuscular plate application without
extensive stripping
– Preserve periosteal blood supply when able
Periosteal Endosteal
Minimally-invasive
Conventional open
Farouk and Krettek, Injury, 1997

Which Implant?
• Condylar buttress plate
• Fixed-angle device
– Blade plate
– Locked plate
Retrograde Medullary Nail
• “Advantages”
– Smaller incision
– “Percutaneous” joint fixation
– Limited exposure
– Decreased blood loss (?)
– Load-sharing device, longer lever arm (if long nail utilized)
– Soft tissues intact
• “Disadvantages”
– Arthrotomy required
– “Percutaneous” joint fixation
– Lack of alignment control (“windshield wiper” effect of implant)
– Insertion thru reconstructed cartilage
– Difficulty of insertion with total knee arthroplasty component in
place
• Don’t forget to reduce the fracture first!
– Nail will not assist with this as you are not
achieving an isthmic fit as can be achieved with
diaphyseal femoral shaft fractures
– Blocking or Pöller screws may be used to
create a false cortex and make the metaphyseal
fit of the nail better (see case example)
– Nail will happily “lock” a fracture in a
malreduced position as easily as it will “lock” a
fracture reduced
• All implants can do this
• “OIF” – open internal fixation…oops, forgot the
“R” for reduction…
Retrograde Femoral Nailing
•Medial to Small
patellar insertion
tendon site—large
enough for
(also may insertion
use trans- instruments
patellar
tendon
approach)
Retrograde Femoral Nailing
• 42 y/o male, AO/OTA 33-C2 femur, type II
open ipsilateral tibia fracture
Percutaneous Screw Fixation
+ Retrograde Nail
Retrograde IMN
Fixation Technique
Reaming & Nail Insertion
Final Result
Plate-and-Screw Constructs
– Direct visualization of joint with fixation
– Restoration of mechanical axes
– Improved fixation over nail (?)
– Blood loss (?)
– Soft tissue stripping (?)
– Screw purchase in osteopenic bone
– Load-bearing device
Which Implant?
• Condylar buttress plate
• Fixed-angle device
– Blade plate
– Locked plate
Indirect Reduction
• “Biological fixation”
• “Percutaneous” or
submuscular Plating
• “MIPO” - Minimally
Invasive Plate
Osteosynthesis
Indirect Reduction
• Not for articular surfaces
– Direct visualization and perfect reduction of
articular fracture lines necessary
• Preserves soft-tissue envelope around
metadiaphyseal fracture lines
– Achieve restoration of length, alignment, and
rotation via traction and manipulation utilizing
reduction aids that do not strip soft tissues
around the fracture site
Indirect
Reduction
(probably not a
good place for this
Clamp because it’s
}
facing medially!)
Fracture site left “undisturbed”
Plan Ahead
• Good pre-op plan
• Principles of surgical treatment:
– 1. Careful handling of soft
tissues
– 2. Indirect reduction
techniques
– 3. Anatomic reduction of
the articular surface and
restoration of limb axial
alignment, rotation, and
length
– 4. Stable internal fixation
– 5. Early rehabilitation
Plating Technique
• Incisions large enough to expose and

anatomically reduce the articular surface
• Submuscular plate application
• Fixation of implant to articular block
• Restore alignment
• Fixation of implant to shaft
• MINIMAL SOFT TISSUE STRIPPING !!!!
Dynamic Condylar Screw (DCS)
– Fixed-angle device (resists varus)
– Contour good for lateral distal femur
– Allows for sagittal plane correction after bolt placement
– Poor control of sagittal plane (flexion/extension)
deformity of distal segment
– Significant bone removal required for bolt placement
– Difficulty avoiding articular lag screw “traffic”
(especially anteroposterior) with bolt
• Injury AP x-ray
• Step 1
– Direct reduction of
articular surfaces
– Stabilization with
interfragmentary
screws
– Insertion of guide wire
for DCS bolt
• Step 2
– Placement of DCS bolt
• Step 3
– Submuscular plate
application
– Insertion of (non-
locking) diaphyseal
screws in a
percutaneous or open
fashion
DCS – final result (single case – not
all cases turn out this way!)
Screw Extension
loosening of distal
segment
Condylar Buttress Plates
– Anatomically contoured
– Submuscular application
– Good “buttress” function for unicondylar
fractures
– Do not resist varus deformation = increased
failure with medial comminution
Condylar Buttress Plates – Good
• Useful in unicondylar,
simple articular splits
• These injuries are
relatively uncommon
• No medial
comminution
Condylar Buttress Plates – Bad
• Intra-articular patterns
are frequently
comminuted
• Instability with
metaphyseal
comminution
(medially)
• Implant does not resist
varus collapse
Condylar Blade Plate
– Fixed-angle device
– Bone-sparing distally (unlike DCS)
– Anatomically contoured (but may be prominent laterally)
– Resists sagittal plane deformities (unlike DCS)
– Technically challenging
– Submuscular insertion difficult (but can still be applied in a
tissue-friendly manner without periosteal stripping)
– Difficult to avoid lag screw “traffic” stabilizing coronal
plane articular fractures.
– Force of blade insertion can disrupt articular segment
reduction
– Once placed, no ability to change position
• Single implant (unlike DCS)

– Blade
• Attached side plate of variable
lengths angled 95° to the blade.
– Placement demands proper
orientation in THREE planes:
• Sagittal
• Coronal
• Axial
• Insertion Technique
– Implant must be inserted parallel to articular surface.
– Implant must not enter the intercondylar groove or notch
– Recognize trapezoidal distal femur geometry to prevent
penetration of medial cortex with blade
– Proper insertion site
• 1.5 - 2.0 cm proximal to distal articular surface
• Centered in the anterior 2/3 of the femoral condyle
• Place interfragmentary lag screws anterior and
posterior to anticipated entry site for blade
• Reduction and fixation technique
– Reduce and fix intra-articular fracture lines first
• K-wires can be inserted as “joysticks” to manipulate pieces
• 6.5 mm or 4.5 mm lag screws placed anterior and posterior to
planned insertion site of blade
– Restore length and alignment

• Minimize soft tissue stripping
• Femoral distractor, ex-fix, and/or other reduction aids
• Fine tune sagittal and coronal alignment
– Place blade in proper position and fix plate to

shaft with nonlocking screws
Locked Plates
– Submuscular (“percutaneous”) insertion
– Anatomically contoured
– Resists varus deformation – “fixed-angle” devices
– Good fixation for osteopenic bone
– Complexity of insertion equipment (?)
– Cross-threading of screw-plate interface detrimental to
biomechanical stability
– May be difficult to avoid screw “traffic” utilized for
reduction and fixation of articular surfaces (?)
Percutaneous
Locked Plating
Locked Plating
• Locked plates can
avoid difficulty
encountered with
stabilization of coronal
splits in distal femoral
fractures that were
problematic with blade
plate fixation
Locked Plating
• CT scan reveals
multiple articular
splits in both the
sagittal and coronal
planes
Another Advantage?
• Stabilization of
articular surface
fractures utilizing
multiple lag screws
• Spanning knee
external fixator
maintains length and
alignment and can be a
reduction aid
Another Advantage?
• Submuscular plate
insertion
• Fixation of distal
segment and
diaphyseal fracture
achieved
• “Multidirectional”
locking screws in
distal aspect of plate
aid in avoidance of lag
screw “traffic”
Special Tip for Locking Plates
• The C-Arm rarely tells
the truth!
– Can’t judge
coronal/sagittal plane
alignment in small field
of view
– Get long cassette
AP/Lat views after
provisional fixation
and shaft reduction
Locked Plating
• LISS plate successful for distal femur
fractures
– 27 fractures treated with LISS plating evaluated
at 19 months’ average follow-up
– Retrospective review
– No patients with failure of fixation, varus
collapse, or nonunion.
– Weight and Collinge, JOT 18:503 (2004)
Locked Plating
• LISS plate successful for distal femur
fractures
– 103 fractures treated with LISS plating
evaluated at 14 months’ average follow-up
– Retrospective review across 3 centers
– 93% union rate, 3% infection rate, no fixation
failure (including 30 fractures in patients >65
years of age)
– Kregor et al., JOT 18:509 (2004)
Locked Plating
• Locked plates successful in periprosthetic distal
femur fractures
– 22 distal femur fractures above TKA components stabilized
with locking condylar plate
– Prospective case series
– 19/22 united after initial procedure, 20/22 with alignment
within 5° of acceptable postoperatively, 4 patients with
screw fracture (3 developed progressive coronal plane
deformity), remaining patients maintained alignment
through union
– Ricci et al, JOT 20:190 (2006)
Locked Plating - Biomechanics
• No difference in cadaveric distal femur 4-
cm fracture gap model with axial loading to
failure for LISS vs. blade plate.
– Unicortical fixation…no screw pull-out
– No advantage in “bones with high bone mineral
density”
– Zlowodzki et al, J Trauma 60:836 (2006)
Locked Plating (Osteoporosis)
• LISS plate provided improved distal femur
fixation over blade plate and retrograde nail
– This was noted especially in osteoporotic bone
– Zlowodzki et al, JOT 18:494 (2004)
Injury Films
Intraoperative Realignment using
External Fixator for Indirect
Reduction
Immediate postoperative films after
application of articular segment lag screws
and long locking plate inserted submuscularly
Respect the
biology!
Healing…
Healed
Distal Femur Fracture Literature
• Nonunion rate = 7.2%
• Fixation failure = 1.5%
• Deep infection rate = 4.3%
• Secondary surgical procedures = 30.6%
• *All case series
– Mostly single surgeon
– Less than 20 patients
Zlowodzki, et l. Operative Treatment of Acute Distal
Femur Fractures: Systematic Review of 2 Comparative
Studies and 45 Case Series (1989 to 2005)
• Retrograde IMN:
• Nonunion rate = 5.3%,

• Deep infection rate = 0.4%
• Secondary procedures = 24.2%
• Compression plates (CBP, Blade Plate,
DCS)
• Nonunion = 6.3%
• Deep infection = 4.8%
• Secondary surgery = 12.7%
• Locking Plates (All LISS)
– Nonunion = 5.5%
– Fixation failure = 4.9%
– Deep infection = 2.1%
– Secondary surgery = 16.2%
Evidence-based Summary
• Operative treatment for displaced fractures

• No difference between ex-fix, IMN, and plating
• Submuscular plating with LISS vs. conventional
plates
– Decreased infection rate
– Higher implant failure
• Increased surgeon experience (>21 fx) = decreased
revision rate
• Not enough good literature
Summary
• Have a full understanding of fracture anatomy
• Understand the benefits and limitations of each implant
• Utilize reduction techniques that are soft-tissue
friendly
• Beware of common pitfalls (sagittal plane
malreduction, etc)
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Distal Femur Fractures: Brett D. Crist, MD

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Distal Femur Fractures

Previous Authors: Robert F. Ostrum, MD; March 2004;

76% single condyle

85% lateral condyle

Open fx 2.8 x coronal

• Don’t forget to evaluate the entire patient!

• Know your surgical anatomy!

Distal femur extended

Farouk and Krettek, Injury, 1997

• Incisions large enough to expose and

• Single implant (unlike DCS)

– Restore length and alignment

– Place blade in proper position and fix plate to

• Nonunion rate = 5.3%,

• Operative treatment for displaced fractures

If you would like to volunteer as an author for

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