Anatomy of the distal femur
The distal femur has a unique anatomical shape. Seen from an end-on view,
the lateral surface has a 10° inclination from the vertical, while the medial
surface has a 20–25° slope. A line drawn from the anterior aspect of the
lateral femoral condyle to the anterior aspect of the medial femoral condyle
(patellofemoral inclination) slopes approximately 10°. These anatomical details
are important when inserting screws, or blade plates. In order to avoid joint
penetration, these devices should be placed parallel to both the patellofemoral
and femorotibial joints planes.
The muscle attachments to the distal femur are responsible for the typical
displacement of the distal articular block following a supracondylar fracture,
namely shortening with varus and extension deformity. Shortening is due to the
pull of the quadriceps and hamstring muscles, while the varus and extension
deformity is caused by the unopposed pull of the adductors and gastrocnemius,
The popliteal vessels, the tibial nerve and the common peroneal nerve lie in
close proximity to the posterior aspect of the distal femur. Because of this,
vascular injuries occur in about 3% and nerve injuries in about 1% of fractures
of the distal femur.
There are no significant arteries, veins, or nerves on the lateral side of
There may be bleeding from the lateral genicular arteries, which will need
to be controlled using diathermy.
At the posterior aspect of the knee lie the popliteal artery, nerve and
vein. It must be borne in mind that these structures can be damaged by the
injury, or can be damaged by the surgeon during the reconstruction.
Reduction of the metaphyseal/diaphyseal fracture component
Consideration must be given to fracture reduction in:
- Internal/external rotation
Reduction can be performed with a single reduction tool (e.g., large
distractor), or by combining several steps (for example fracture table +/-
external fixator, +/- reduction via the implant, etc.) to achieve the final
The preferred method depends on the fracture and soft-tissue injury pattern,
the chosen stabilization device and the experience and skills of the
If a large fragment has separated from the fracture zone and impaled the
adjacent muscle, direct reduction of that fragment may be required.
It is very important to restore the biomechanical axis of the lower limb.
The normal biomechanical axis follows a line from the center of the femoral
head, through the center of the proximal tibia and then through the center of
the ankle joint. This axis can be checked intraoperatively by using a piece of
cable, such as the diathermy cord, to give an approximate estimate of the axis,
The biomechanical axis must be restored and care should be taken to ensure
that there is no malrotation of the distal femur on the proximal femur.
If no traction table is used (i.e., using the freehand technique) the cable
method may be used. In this technique, the electrocautery cord is held from the
iliac spine across the patella to the cleft between the first and second toes.
If rotation is correct, this cord will pass over the midline of the patella,
and slightly medial to the tibial eminence.
Another method of assessing rotational reduction is to compare the cortical
thickness above and below the fracture. If a shaft fracture is
multifragmentary, the image intensifier cannot be used to compare cortical
diameters on each side of the fracture.
This Illustration shows the longitudinal axes of the lower limb.
Two main steps
In the treatment of complete articular fractures distal femoral fractures, the surgeon first reconstructs the distal femoral articular block. A reduction of the metaphysis/diaphysis is then performed before the DCS plate is positioned along the femoral shaft.
Choice of implant
For retrograde femoral nailing to achieve adequate fracture stabilization, the fracture should be at least 6 cm from the joint line to achieve distal locking with two transverse screws or a screw and a spiral blade. In contrast, more distal fixation can be achieved with plates, or locked fixators. For example the distal most screws in a LISS plate, or a condylar plate, may be subchondral.
The distal-most fixation for various implants are:
LISS plate: subchondral
Condylar plate: subchondral
95° angled blade plate: 1.5 – 2 cm
95° dynamic condylar screws: 2 cm
Retrograde intramedullary nail: 6 cm (for 2 locking screws, or one locking screw and a spiral blade)
This procedure may be performed with the patient in one of the following positions:
For this procedure the following approaches may be used:
Reduction of the articular block
The chosen approach must adequately expose the articular surface of the
distal femoral condyle. Reduction aids that are helpful include:
- A 5.0 mm or 6.0 mm Schanz pin in the medial and/or lateral femoral condyle
to act as a joystick.
- Pointed reduction forceps, or large pelvic reduction clamps, to clamp from
medial to lateral across the intercondylar split.
Pearl: combination of reduction aids
Attempts at reduction of the intercondylar split with the pointed reduction
forceps alone are often unsuccessful, as rotational control of the femoral
condyle is also needed. The use of the Schanz pin in conjunction with the
pointed reduction forceps is therefore preferred.
Before definitive fixation is undertaken, more than one clamp is applied.
Usually, one to two additional K-wires are inserted, either from medial to
lateral, or lateral to medial.
If the K-wires are inserted from medial to lateral, they may either go
through small stab incisions in the skin, or through the parapatellar
Definitive articular surface fixation
Screws may be placed along the periphery of the articular surface of the
lateral femoral condyle going from lateral to medial to compress the
These screws may be fully threaded 3.5 mm lag screws (shown with gliding
hole), 6.5mm partially threaded lag screws, or 4.0/4.5 mm cannulated, partially
threaded lag screws.
Insertion of screws in this manner leaves a „free zone“ of bone into which a
laterally based plate system can be inserted (dotted circle).
This end-on view demonstrates the screw trajectories from lateral to
On occasions, it is acceptable to insert screws through the articular
surface, when no other option is available. These screws must be countersunk
and recessed beneath the articular surface.
Preparation for correct positioning
The DCS is a two part device with a stable linkage, used to attach the distal femoral condylar mass to the diaphysis. Correct orientation of the knee joint plane requires meticulous placement of the screw device.
Determine the correct position for the DCS with the help of guide wires around the joint. Under image intensifier control, pass one guide wire lateral to medial along the tibio-femoral joint line (red). Pass a second guide wire over the anterior surface of the knee to indicate the plane of the patello-femoral condyles (green).
The ideal position of the DCS is shown by the yellow wire. Note that it is inserted parallel to both the red wire in the frontal plane and is parallel to the green line on the end-on view on the femur. This latter orientation ensures that the plate comes to lie flush with the lateral cortex.
The ideal entry point for the DCS is shown on the diagram. The guide wire
for the DCS is positioned at 2 cm proximal to the distal end of femur. On the
lateral view, the distal femur is divided into thirds and the DCS entry site is
located at the junction of the anterior and middle thirds.
Insert the guide wire at the chosen entry site of the DCS. Insert the guide
wire under image intensifier control all the way across the femur. Check the
position of the guide wire carefully to ensure it has been correctly
positioned, with the parallelism already described.
Correct depth of guide-wire insertion
The depth of guide-wire insertion is crucial. Remember that the cross
section of the distal femoral condylar mass is trapezoidal and slopes markedly
on the medial side. The tip of the guide wire should just engage the medial
cortex, and so will appear short of the medial condylar cortex on the AP
Pitfall: too long a guide wire
It is important to remember that the distal femur tapers from the
posterior to the anterior. Therefore, if a straight AP view is obtained, the
guide wire can appear to be inside the bone. If it appears to be outside the
bone, it is most likely too long and the DCS will cause pain and possibly
heterotopic ossification. In order to assess the exact length of the guide wire
obtain an AP view with 30° internal rotation of the lower extremity.
In this illustration, internal rotation by 30° reveals that the guide wire
length was chosen inappropriately.
Screw length measurement
Next, slide the direct measuring device over the guide wire and determine
guide-wire insertion depth and, thereby, the length of the DCS required.
After assembling the DCS triple reamer and setting the reamer to the correct
depth, ream the hole for the DCS over the guide wire.
After tapping, insert the DCS over the guide wire, so that its outer end is
still visible 2-3 mm outside the lateral cortex of the distal femur.
In order for the plate barrel to slide over the screw, the T-handle should
be parallel, on the lateral view, to the long axis of the distal fragment.
Pearl: omit tapping in osteoporotic bone
In osteoporotic bone, tapping should be omitted.
Detach the T-handle and pass the plate barrel over the screw shank.
Alternative: reconnect T-handle to screw
Some surgeons reconnect T-handle to the screw to help to adjust the
position the plate. However, this maneuver is not absolutely necessary and some
surgeons do not perform it.
Use the impactor to bring the plate down to the bone, with the barrel
sliding over the screw shank.
The compression screw may be utilized to couple the screw to the plate.
Additionally, the compression screw will provide additional compression
across the intraarticular split.
Pearl: do not use compression screw in osteoporotic patients
Do not use the compression screw in osteoporotic patients – it can cause
the DCS thread to strip out from the soft cancellous bone of the medial femoral
Final screw placement in distal fragment
A cancellous screw can then be inserted into the most distal screw hole of
the plate to prevent rotation of the distal femoral articular block around the
axis of the DCS.
Reduction of metaphyseal fracture component
The key concept in reduction of the metaphyseal fracture component when
utilizing a DCS is that insertion in the distal femur allows the surgeon to use
the plate to assist the metaphyseal fracture reduction. The surgeon must
control for length, rotation and sagittal plane deformity
(hyperextension/hyperflexion). When performed in an open manner, length can be
restored by manual traction. The sagittal plane deformity correction can be
aided by a supracondylar bolster.
Loosely secure the plate to the proximal femur with a Verbrugge clamp.
Take care to restore the mechanical axis of the femur in all planes. Give
consideration to fracture reduction in:
- Internal/external rotation
Use of the articulated tension device
Secure the articulated tension device to the proximal femur with a
The articulated tension device is very useful to apply controlled
compression to the fracture site. It should be used when possible in fracture
patterns where there is contact between the proximal and distal main fragments.
It may not be used in situations of severe metaphyseal comminution and/or
Insertion of first screw into proximal fragment
Tighten the articulated tension device with the spanner so that the
indicator on the tension device is in the green zone, checking the fracture
site carefully to ensure that no unwanted displacement occurs.
Insert a screw through the plate close to the compression device to secure
the fixation. Insert the screw eccentrically in the plate hole to maintain the
Complete the fixation of the plate to the femur with sufficient screws,
using neutral insertion of the screws in the plate holes.
Additional screw insertion
Lastly remove the articulated tension device and complete the fixation by
inserting additional screws according to the preoperative plan.