Executive Editor: Chris Colton

Authors: Florian Gebhard, Phil Kregor, Chris Oliver

Distal femur Complete articular fracture, multifragmentary articular

back to skeleton

Glossary

General considerations

All intraarticular fractures require open operative reduction and internal fixation.
The DCS, the angled blade plate and the retrograde IM nail are contraindicated in these injuries because their insertion into the condylar mass may disrupt the complex articular injury.

Temporary external fixator
Indication summary Skill Equipment
Damage control Some specialized surgical experience Simple surgical and imaging resources

Intraarticular fractures should be anatomically reduced when this is possible.

In occasional cases, a period of nonoperative treatment may be necessary before the patient’s general condition, or the local status of the soft-tissues, will permit safe surgery. In these patients, temporary external fixation may be useful.

Further indication

  • Associated vascular injury

Contraindication

  • Existing prosthesis/implant conflicting with pin tracks

Advantages

  • Minimally invasive
  • Rapid procedure

Disadvantages

  • Potential knee stiffness
  • Fixator pins may compromise sterility, future incisions, or definitive fixation
Temporary skeletal traction
Indication summary Skill Equipment
Displaced fracture, medically unfit patient Some specialized surgical experience Simple surgical and imaging resources

In occasional cases, a period of temporary skeletal traction may be necessary before the patient’s general condition, or the local status of the soft-tissues, will permit safe surgery.

The eventual aim is anatomical restoration of the articular surface and early active mobilization of the joint.

Skeletal traction does not allow for mobilization of the patient and may give rise to soft-tissue concerns about future incisions.

Indications

  • Patient in extremis
  • Severe local soft-tissue compromise
  • Significant shortening, or angulation, without operative management

Contraindications

  • Safe definitive fixation possible
  • Associated vascular and/or neurological injury

Advantages

  • Straightforward to apply
  • Quick and safe procedure

Disadvantages

  • Pressure sores
  • Potential knee stiffness
  • Increased patient discomfort and immobility
Temporary long leg splint
Indication summary Skill Equipment
Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only

In occasional cases, a period of temporary splintage may be necessary before the patient’s general condition, or the local status of the soft-tissues, will permit safe surgery.

Shortening or significant angulation are risks with splints.

Indication

  • Patient in extremis

Contraindications

  • Safe definitive fixation possible
  • Severe local soft-tissue injury or pathology

Advantages

  • Easy to apply
  • Quick and safe procedure

Disadvantages

  • Pressure sores
  • Potential knee stiffness
  • Risk of shortening
ORIF - condylar locking compression plate (LCP)
Indication summary Skill Equipment
More distal metaphyseal fractures, articular fracture displaced, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Condylar LCP vs. LISS
The LISS, and Condylar LCP are the only viable options for these injuries. There is no clear evidence of the superiority of one implant option over the other.  Both the LISS and condylar LCP are “internal” locked fixators. They provide excellent biomechanical stability of the distal femoral segment, even in osteoporosis. The surgeon must be familiar with the techniques of locked plating.

Indications

  • All complete multifragmentary articular  fractures
  • Closed and open fractures

Contraindications

  • Polytrauma patient in unstable condition
  • Patient not medically fit for surgery

Advantages

  • Definitive procedure
  • The articular surface can be reduced
  • Restoration of mechanical axis
  • Restoration of femoral rotation
  • Fracture stabilization allows for early patient mobilization
  • Can be used in cases of pulmonary compromise
  • May reduce risk of osteoarthritis

Disadvantages

  • Risk of condylar malreduction
  • Demanding surgical procedure
  • Risk of infection
  • Risk of implant related complications
  • Greater blood loss
ORIF - less invasive stabilization system (LISS)
Indication summary Skill Equipment
More distal metaphyseal fractures, articular fracture displaced, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Condylar LCP vs. LISS
The LISS, and Condylar LCP are the only viable options. There is no clear evidence of the superiority of one implant option over the other.  Both the LISS and condylar LCP are “internal” locked fixators. They provide excellent biomechanical stability of the distal femoral segment, even in osteoporosis. The surgeon must be familiar with the techniques of locked plating.

Indications

  • All complete multifragmentary articular 
  • Closed and open fractures

Contraindications

  • Polytrauma patient in unstable condition
  • Medically unfit for surgery

Advantages

  • Definitive procedure
  • The articular surface can be reduced
  • Restoration of mechanical axis
  • Restoration of femoral rotation
  • Fracture stabilization allows early patient mobilization
  • Can be used in cases of pulmonary compromise
  • May reduce risk of osteoarthritis

Disadvantages

  • Risk of condylar malreduction
  • Demanding surgical procedure
  • Risk of infection
  • Risk of implant related complications
  • Greater blood loss
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2008-12-03