Femoral

Supracondylar
fractures
Prepared by
Dr. Ramzy Sh. Shikhan
Introduction
• A.K.A distal femure fractures
• represent about 6% of all femoral fractures.
• typically occur after high-energy trauma in younger patients or after low-
energy trauma inthe elderly with osteoporotic bone.
• One-third of the younger patients have multiple-system trauma and only a
fifth of cases occur as an isolated injury.
• There is usually considerable soft-tissue damage and almost 50% of high-
energy, intraarticular distal femoral fractures are open injuries.
• With the increasing number of patients with knee joint replacement, the
incidence of periprosthetic fractures has been increasing in recent years.
Anatomy of the distal femur
• The shape of the distal femur, when viewed end on, is a trapezoid with
the posterior part wider than the anterior part, creating about 25° of
inclination on the medial surface and about 10° on the lateral surface.
• A line that is drawn from the anterior aspect of the lateral femoral
condyle to the anterior aspect of the medial femoral condyle
(patellofemoral inclination) slopes posteriorly approximately 10°.
• The normal anatomical axis of the femoral shaft relative to the knee or
the anatomical lateral distal femoral angle (LDFA) is 80–84°.
• Measured contralateral LDFA can be used as a reference for the
assessment of coronal alignment.
• Vertical axis : from wt bearing AP radio. A vertical line that extends distally from
the center of the symphysis pubis. This is used as a reference line from which
other axes are determined

• Mechanical axis : drawing a line from the centre of the femoral head to the centre
of the ankle joint. Has a 3 degree slope from the vertical axis. Subdivided to :
• Femoral mechanical axis: head of femur to the intercondylar notch of distal femur
• Tibial mechanical axis : from centre of proximal tibia to ankle centre
((the medial angle formed between the latter two form the HKAA which is slightly
less than 180 degrees
• Anatomical axis : two methods
• Line drawn proximal to distal in the intramedullary canal bisecting the
femur in one half
• Point at femoral shaft centre to a point 10cm above the knee joint
located at an equal distance between the medial and lateral cortex.
• Femoral anatomical axis deviates 5-7 degrees from the mechanical
axis (valgus)
• The normal knee joint alignment is 2-3 varus compared to mechanical
axis
Pathomechanics
• Gastrocnemius: extends distal fragment ( apex posterior)
• Hamstring and extensor mechanism :cause shortening
• Adductor magnus: leads to distal femoral varus.

• So The typical deformity is one of shortening with the proximal

fragment displaced anteriorly piercing the quadriceps (and sometimes
the skin) while the distal fragment is flexed, in Varus and rotated
posteriorly.
Positioning
Classification
Diagnosis
• AP & Lat. Views
• Traction views ( painful)
• Adjacent joints ( ass. Injuries)
• Contralateral femur( for surgical planning)
• CT coronal and sagittal ( for intra articular involvement)
• Angiography for suspected arterial injury

*Hoffa fracture : articular fracture in the coronal plane posteriorly a

Treatment
• Non operative ( rare) with hinged knee brace with immediate ROM,
NWB for 6 weeks ,

• indications:
1. Non displaced fractures
2. Non ambulatory patient
3. Patient with significant comorbidities ( ASA CLASS 4-5)
OPERATIVE
• External fixation :
Temporary until soft tissue condition permits definitive fixation
• The indications for temporary joint-bridging external fixation are:
• 1-polytrauma patients,
• 2-open fractures or dislocations
• 3-closed fractures with severe soft-tissue trauma or vascular damage.
• If possible, the articular block is reconstructed with minimal internal fixation
using 3.5 mm conventional or cannulated lag screws. Then, the joint-bridging
external fixator is mounted with Schanz screws far from the zone of injury.
• Schanz screws are inserted anteriorly in the femur to avoid
incisions for definitive treatment and anteromedially in the
tibia
Definitive fixation
• The traditional concept of open reduction and internal fixation(ORIF)
of distal femoral fractures which advocated an extended approach to
the multifragmentary fracture zone at the metaphysis is not favored
because of the high rate of nonunion and failure.
• The biological plating concept uses less traumatic approaches, with
careful handling of the soft tissue envelope and is now the gold
standard.
• It is still mandatory to perform precise reconstruction of the anatomy
of the condyles and articular surface and to restore the correct limb
axis and rotation.
Implant selection
• MIPPO ( bridge plating )
• Retro grade IM nail (extra articular , minimal displaced, elderly)
• Locking( elderly) and non locking plates ( young) and buttressing plate
( to avoid superior displacement)
• 95 degree angled blade plate and dynamic condylar screw ( rarely
used now , technically demanding , needs experience)
• Less invasive stabilization system for the distal femur
Approaches
• standard lateral approach or modified standard lateral approach.
( extra articular fractures)

• lateral or medial parapatellar or medial subvastus approach

(intra articular)

• Retrograde nailing approach

After care
• The aim of surgery is to provide stable fixation that allows early functional
rehabilitation of the injured knee.
• Active, assisted motion of the hip, knee, and ankle can be started as early as 48 hours,
provided the soft-tissue injury allows this and the patient has a good analgesia
regimen.
• Continuous passive motion may also be effective.
• In simple fractures with bone contact the internal fixation is stable enough to allow
partial weight bearing (10–15 kg) immediately after surgery.
• Multifragmentary fractures with bridge plate constructs generally require more
protection and should not bear weight initially.
• Progressive weight bearing is allowed after callus formation is seen during follow-up
at 6–12 weeks.
Complications
• Symptomatic hardware
• Malunion ( with plating, usually valgus)
• Non union more with compound fractures and extensive ORIF
• Infection
• Hardware failure ( titanium superior to stainless steel) ( using longer
plates and properly placed is advocated)
Prognosis and outcome
• The results of locking plates, inserted using MIPO techniques in elderly
patients, appear to be promising based on clinical outcomes in terms of
nonunion, implant failure, and infection
• The risk factors for reoperation include open fractures, diabetes, smoking,
increased body mass index, and shorter plate length.
• Use of longer plates can reduce the risk of fixation failure .
• Closed injuries have a higher healing rate than open injuries.
• Fewer nonunion occur in submuscular plating (10.7%) compared with
open reduction (32.0%) .
• Preexisting total knee arthroplasty increases the risk of hardware failure
Any questions ?
Knee dislocation
( principles of
emergency
management)
introduction
• The knee is one of the most complex joints of the human body.
• High- and low-energy trauma may produce a knee dislocation.
• defined as an abnormal displacement between the tibia and the femur
associated with the injury of two or more major joint ligaments.
• Motor vehicle crashes and contact sports injuries are the main causes of
these injuries but simple falls in patients with morbid obesity is an
increasing problem.
• Knee dislocations are considered to be uncommon(0.02%). However, it is
likely that these injuries were overlooked in the past because most cases
reduce spontaneously(50%)and many are associated with polytrauma.
• Male to female 4:1
• Normal range of knee is 0-140 degrees with 8-12 degrees of rotation
during flexion/extension
• Fractures present in 60% of cases
• Complication are frequent and rarely return to pre-injury state.
• Most of the cases need surgical intervention
Classification
• Descriptive ( kennedy) based on direction of displacement of Tibia:
• Anterior : most common , due to hyperextension injury, usually involves
PCL, arterial injury may happen due to an intimal tear from traction
• Posterior : dashboard injury ( axial load on flexed knee), highest rate of
vascular injury ( complete tear of popliteal artery)
• Lateral: varus or valgus forces , both ACL and PCL , highest rate of peroneal
nerve injury
• Medial: usually disrupts PCL and PCL
• Rotaional : posterolateral , usually irreducible , buttonholing of femoral
condyle through the capsule ( MCL can be interposed)
• The positional classification lacks specificity to define which knee
structures have been injured. Moreover, it is not applicable to most
cases, which reduce spontaneously before clinical and radiological
examinations.
• Therefore, Schenck proposed an anatomical classification based on
the findings of the clinical examination under anesthesia. This
classification aids in deciding which structures must be repaired or
reconstructed. This classification has become the most commonly
used scheme with five major categories:
Schenck classification
• KD I: any knee dislocation where either the (ACL) or (PCL) are intact.
• KD2: a tear of the ACL and the PCL only.
• KD III: a tear of both the ACL and PCL as well as either the
posterolateral corner (PLC) or posteromedial corner (PMC)
• KD IV: a tear of the ACL, PCL, PLC, and PMC
• KD V: an articular fracture (usually tibial plateau) associated with a
knee dislocation
Surgical anatomy
• Central pivot: This extraarticular area of the knee contains both cruciate ligaments.
The cruciate ligaments are the main static restrictors of AP translation of the tibia in
relation to the femur.

• Posteromedial corner: The PMC of the knee contains the superficial medial collateral
ligament(largest structure medially), the deep MCL, the posterior oblique
ligament(POL), the direct insertion of semimembranosus, and the medial head of the
gastrocnemius muscle. Also the medial meniscus aids in this
• Posterolateral corner: lateral collateral ligament, the popliteustendon and the
popliteofibular ligament. Also the lateral meniscus.
• Extensor mechanism : post dis. Usually disrupts this
• The popliteal fossa: vascular injury is the main concern here.
ER approach to the dislocated knee
• History : mechanism , any reduction attempts , spont. reduction.
• Exam : LOOK , FEEL , MOVE, provocative tests ( difficult in acute
settings-pain and spasm)
• The clinician must have a high index of suspicion for the presence of
multiligament knee injury with a low threshold for further evaluation
by magnetic resonance imaging (MRI) or examination under
anesthesia.
• If the knee has not been reduced before the examination,this allows
the examiner to define the direction of the dislocation.
• It is important to reduce the joint as soon as possible by means of
closed reduction.
• A delay of a few minutes to obtain an x-ray is reasonable but there
should not be a significant delay to obtain imaging.
• If the knee is dislocated and has an open wound, the reduction should
be performed as soon as possible in the operating room. Copious
irrigation is performed before reduction to avoid gross contamination
of the joint.
Closed reduction
• Ant: traction and anterior translation of femur
• Post: traction , extension and anterior translation of tibia
• Medial/lateral: traction and medial or lateral translation
• Rotatory: axial limb traction and rotation in opposite direction of
demformity
• N.B// posterolateral dislocation may have buttonholing and this should
alarm you to avoid closed reduction as there is high risk of skin necrosis.
• Afterward splint in 20-30 degrees of flexion
• Send for MRI after acute reduction but before hardware placement.
Vascular exam
• Priority is to rule of vascular injury before and after reduction
• Serial exams are mandatory.
• Palpate distal pulses:
• If present , doesn’t mean there is no vascular injury( masked by
collateral circulation) so : measure Ankle-Brachial Index( ABI)
• More than 0.9, 100% negative predictive value, keep on serial exams
• Less than 0.9….go for arterial duplex ultrasound or CT angio..whem
confirmed injury….. consult the vascular team.
• If absent or diminished :
• Confirm reduction or do immediate reduction and then reassess

• If still diminished…go for surgical exploration ( more than 8 hour delay has an 86% chance of
amputation)
• ((imaging is contra indicated if it will delay surgical revascularization.

• If pulses are present after the reduction…do ABI and consider observation versus angiography

• Do not forget to do full neurological assessment , mainly on the peroneal nerve ( big toe
dorsiflexion)
An important note
• A detailed vascular clinical examination is recommended at
admission, after 4–6 hours and at 24 and 48 hours.
• This must be clearly documented in the medical records .
• Late popliteal artery thrombosis, usually associated with an
asymptomatic intimal tear, is a recognized and devastating
complication.
• Take radiographs , compare with the normal side
• Look for avulsion fractures such as segond fracture which is avulsion
fracture of the lateral tibial condyle)
Open reduction
For :
1. Irreducible knee
2. Posterolateral dislocation
3. Open fracture dislocation
4. Vascular injury
5. Obesity ( may be difficult to obtain closed)
External fixation
For :
1. Vascular repair with fractures
2. Open fracture dislocation
3. Compartment syndrome
4. Polytrauma
Delayed ligamental repair
• Ideally within 3 weeks ( not more than 8 weeks) to allow for soft
tissue swelling and trauma to subside.
Complications
• Vascular compromise: 5-15:, post KD, KD class 4 ( treatment is
emergency repair and prophylactic fasciotomy)
• Stiffness: 38% , most common
• Laxity and instability : 37%
• Peroneal nerve injury: 25% , 50% recover partially
Any questions ?
Tibia plateau fracture
introduction
• The incidence of proximal tibial fracture is about 18.6% of all tibial
fractures
• bimodal distribution:
males in 40s (high-energy trauma)
females in 70s (falls)
• Location: unicondylar vs. bicondylar 

• frequency
• lateral > bicondylar > medial
• Mechanism: varus/valgus load with or without axial load
#high energy
• frequently associated with soft tissue injuries
#low energy
• usually insufficiency fractures
Associated conditions
• meniscal tears

• lateral meniscal tear

• more common than medial
• associated with Schatzker II fracture pattern

• medial meniscal tear

• most commonly associated with Schatzker IV fractures
 
• ACL injuries :more common in type IV and VI fractures (25%) 
• vascular injury : commonly associated with Schatzker IV fracture-dislocations
• Compartment syndrome ( specially if fracture line extends beyond the
plateaue eminence).
Anatomy
• lateral tibial plateau
convex in shape
proximal to the medial plateau
Slightly higher
More prone to fractures

• medial tibial plateau

concave in shape
distal to the lateral tibial plateau
Larger and stronger
Biomechanics medial tibial plateau bears 60% of knee's load
Approach to the patient
• History and examination
• Neurovascular assessment is crucial
• Skin condition is very important for timing of surgery
• Radiology ( standard radiographs, plateau view 10 degree caudal, CT
which has become a standard step in managing these fractures. MRI
used as well for soft tissue and ligamental problems.
Surgical approaches
• Anterolateral approach (most commonly used , Gerdy tubercle, the
tip of the fibula, and the lateral femoral epicondyle used as
landmarks)
• Posteromedial approach (directed to the posteromedial)ridge of the
proximal tibia, for medial column or medial side of post column)
• Posterolateral approach (two windows, care for CPN)
• Posterior, inverted L-shaped approach ( post column or combined
post and med col. Injuries)
Important note
• A good clinical indicator that it is safe to perform open reduction and
internal fixation (ORIF) is skin wrinkling indicating regression of
edema.
Implant selection
• External fixation with radiolucent rods is selected for staged care or
patients with soft-tissue problems.
• To fix articular fragments, lag screws are used and can be placed as a
raft to support the subchondral bone in complex articular fractures.
• Plate fixation is with a locking compression plate (LCP), which is used
for buttressing or bridging.
• Nonlocking plates (eg, low-contact dynamic compression plate) can
be used for B-type fractures with good bone quality when buttress
fixation is required.
• Smaller locking plates 2.4 or 2.7 can be used as reduction plates or
tension band plates and occasionally for fragment-specific fixation.
• Screw fixation alone can be applied (raft technique) in pure
depression fractures (Schatzker III).
• Intramedullary(IM) nails with proximal interlocking screws can be
consideredin type A fractures.
Complications
• Wound problems are the biggest concern :
Wound problems can be minimized by careful evaluation of the soft-tissue
envelope, precise timing of surgery, appropriate surgical approaches,
development of full-thickness flaps, extraperiosteal dissection of fracture
fragments, and minimal soft-tissue stripping at the fracture site.
• Malunion (Varus/valgus procarvatum deformities)
• Arthrofibrosis with severe stiffness and a flexion deformity may occur if
the knee is immobilized for long periods. These patients can also develop
an equinus deformity at the ankle, so physical therapy must address all
major joints in the leg
• Major causes of posttraumatic arthritis are:
1. Axial malalignment
2. Ligamentous instability
3. Primary damage to the articular cartilage
4. Meniscectomy
5. Articular incongruity
6. Infection
Any questions ?
Thank you