Executive Editor: Chris Colton

Authors: Florian Gebhard, Phil Kregor, Chris Oliver

Distal femur Complete articular fracture, simple articular, multifragmentary methapyseal

back to skeleton

Glossary

General considerations

All intraarticular fractures require open operative reduction and internal fixation.

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.

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 - dynamic condylar screw (DCS)
Indication summary Skill Equipment
Metaphyseal fracture more proximal Highly experienced and skilled surgeon Simple surgical and imaging resources

C-type fractures require open operative reduction and internal fixation.

The DCS, blade plate, LISS, and Condylar LCP are all viable options for complete simple articular fractures. There is no clear evidence of the superiority of one treatment option over the others. However, when dealing with osteoporosis, or a short distal femoral segment, biomechanical and clinical data suggest that locked plate/screw systems (LISS or condylar LCP) may produce more stable distal femoral fixation. The DCS is readily available, relatively inexpensive and may be inserted in a submuscular manner. Concerns with its use include sagittal plane instability (flexion/extension) and the amount of bone removed in the distal femur, which will be important if fixation failure occurs.

Indications

  • All simple articular fractures with metaphyseal fragmentation
  • Closed and open fractures
  • Some periprosthetic 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 early patient mobilization
  • Can be used in cases of pulmonary compromise
  • Reduced risk of osteoarthritis

Disadvantages

  • Demanding surgical procedure
  • Risk of infection
  • Risk of implant related complications
  • Greater blood loss
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

The DCS, blade plate, LISS, and Condylar LCP are all viable options for complete simple articular fractures. There is no clear evidence of the superiority of one treatment option over the others. However, when dealing with osteoporosis, or a short distal femoral segment, biomechanical and clinical data suggest that locked plate/screw systems (LISS or condylar LCP) may produce more stable distal femoral fixation. 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. Implants may be inserted in a submuscular manner.

Indications

  • All simple articular fractures with metaphyseal fragmentation
  • Closed and open fractures
  • Some periprosthetic 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
  • Reduced risk of osteoarthritis

Disadvantages

  • Risk of malrotation
  • Risk of condylar malreduction
  • Risk of varus and/or valgus malposition
  • 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

The DCS, blade plate, LISS, and Condylar LCP are all viable options for complete simple articular fractures. There is no clear evidence of the superiority of one treatment option over the others. However, when dealing with osteoporosis, or a short distal femoral segment, biomechanical and clinical data suggest that locked plate/screw systems (LISS or condylar LCP) may produce more stable distal femoral fixation. 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. Implants may be inserted in a submuscular manner.

Indications

  • All simple articular fractures with metaphyseal fragmentation
  • Closed and open fractures
  • Some periprosthetic 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
  • Reduced risk of osteoarthritis

Disadvantages

  • Risk of malrotation
  • Risk of condylar malreduction
  • Risk of varus and/or valgus malposition
  • Demanding surgical procedure
  • Risk of infection
  • Risk of implant related complications
  • Greater blood loss
ORIF - blade plate
Indication summary Skill Equipment
Metaphyseal fractures more proximal Highly experienced and skilled surgeon Full specialized surgical and imaging resources

The blade plate is readily available, is angularly stable, relatively inexpensive and can be inserted very distally into the femur. Concerns with its use include the technical challenge in its accurate positioning and the large surgical approach needed for its insertion.

Indications

  • All complete simple articular fractures
  • Closed and open fractures
  • Some periprosthetic 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 reduces the incidence of fat embolization
  • Fracture stabilization allows for early patient mobilization
  • Can be used in cases of pulmonary compromise
  • Reduced risk of osteoarthritis

Disadvantages

  • Demanding surgical procedure
  • Risk of infection
  • Risk of implant related complications
  • Greater blood loss
ORIF - retrograde nailing
Indication summary Skill Equipment
Articular fracture undisplaced, metaphyseal fractures proximal Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Consideration should be given to the retrograde nail’s causing significant displacement of the intercondylar fracture when it is introduced. This secondary displacement may be extremely difficult to control. Depending on the available surgical expertise, it may therefore be a safer option to consider plate fixation.
Careful consideration must be given to the entry point of the retrograde femoral nail. The planned entry point may be in an area of fracture comminution, in which case, retrograde nailing should not be undertaken

Indications

  • Simple articular fractures with metaphyseal fragmentation
  • Selected closed and open fractures
  • Obesity
  • "Floating knee" injury: can use same approach for ipsilateral tibial nail
  • Pregnancy
  • Fractures below stemmed hip prostheses

Contraindications

  • Accompanying severe pulmonary trauma
  • Local comminution at planned entry point in intraarticular fractures
  • Occluded intramedullary canal
  • Polytrauma patient in unstable condition
  • Medically unfit for surgery 
  • Stiff knee joint which does not allow the flexion necessary for intramedullary nail insertion
  • Patella baja
  • Image intensifier unavailable
  • Local soft-tissue compromise

Advantages

  • Fracture reduction
  • Allows indirect reduction
  • Good biomechanical properties
  • Definitive procedure
  • Fracture stabilization allows for early patient mobilization
  • Minimizes secondary soft-tissue damage

Disadvantages

  • Risk of secondary displacement of the reconstructed condyles
  • Risk of iatrogenic intraarticular damage to the knee joint
  • Risk of damage to the posterior cruciate ligament
  • Risk of malrotation and/or angular deformity
  • Risk of damage to the patellar tendon
  • Risk of chronic knee pain
  • Risk of infection
  • Risk of implant related complications (particularly pain around distal interlocking screws)
  • Risk of retropatellar damage (nail too long)
  • Risk of loss of fixation in osteoporotic bone
*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