Executive Editor: Chris Colton

Authors: Florian Gebhard, Phil Kregor, Chris Oliver

Distal Femur Extraarticular fracture, wedge

back to skeleton

Glossary

General considerations

As metaphyseal wedge fractures do not have an articular component, reduction of the articular surface is not necessary so the surgeon can perform a closed reduction and use available implants via a minimally invasive, sub-muscular route.

Long leg cast then hinged knee brace
Indication summary Skill Equipment
Stabe undisplaced fracture Basic surgical experience, no specialized skills Basic equipment only

Most distal femoral fractures are treated surgically. Nonoperative treatment is reserved for exceptional cases, e.g., if the general medical condition does not allow safe anesthesia. If nonoperative treatment is selected, a long leg splint, followed by a hinged knee brace should be used to minimize limb shortening and to provide pain relief.

Indications

  • Medically unfit for surgery
  • Local soft-tissue compromise

Advantage

  • No need for anesthesia and its associated risks

Disadvantages

  • Continuing motion at the fracture site
  • Continuing soft-tissue compromise
  • Shortening of the limb
  • Increased pain
  • Risk of malunion
  • Risk of nonunion
  • Increased joint stiffness
Temporary long leg splint
Indication summary Skill Equipment
Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only

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

Indications

  • Patient in extremis
  • Significant shortening, or angulation, without operative management

Contraindications

  • Safe definitive fixation possible
  • Local soft-tissue compromise

Advantages

  • Easy to apply
  • Quick and safe procedure

Disadvantages

  • Pressure sores
  • Potential knee stiffness
  • Risk of shortening
Temporary external fixator
Indication summary Skill Equipment
Damage control Some specialized surgical experience Simple surgical and imaging resources

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 open fracture, medically unfit patient Some specialized surgical experience Simple surgical and imaging resources

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

Skeletal traction 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

  • Easy to apply
  • Quick and safe procedure

Disadvantages

  • Pressure sores
  • Potential knee stiffness
  • Increased patient discomfort and immobility
  • Pin track problems may compromise future open surgery
MIO - dynamic condylar screw (DCS)
Indication summary Skill Equipment
Displaced reducible fracture, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

DCS vs. Condylar LCP vs. LISS

Technically, the step of connecting the DCS side plate to the condylar screw in a submuscular manner is much more difficult than insertion of the LISS or the Condylar LCP.

No evidence exists proving the superiority of the use of either the DCS, the Condylar LCP, or the LISS with such fractures. The DCS may have a lesser purchase in the distal femoral fragment, if there is a short distal segment and or osteoporosis, a locking plate option may need to be considered.

Indications

  • All extra articular metaphyseal fractures
  • Closed and open fractures
  • Where a closed reduction is possible
  • Some periprosthetic fractures

Contraindications

  • Polytrauma patient in unstable condition
  • Medically unfit for surgery
  • Image intensifier unavailable
  • Early pregnancy (up to 12 weeks gestation; risks of intraoperative ionizing radiation)
  • Local soft-tissue compromise

Advantages

  • Fracture reduction
  • Less invasive procedure
  • High union rates
  • Definitive procedure
  • Fracture stabilization allows early patient mobilization
  • Can be used in cases of pulmonary compromise
  • Less visible scarring

Disadvantages

  • Closed reduction is more difficult than open reduction
  • Difficult control of distal femoral fracture fragment
  • Higher rate of malreduction
  • Technically demanding procedure
  • Frequent use of image intensifier – risk of increased exposure to ionizing radiation
  • Risk of infection
  • Risk of implant related complications
MIO - condylar locking compression plate (LCP)
Indication summary Skill Equipment
Displaced reducible fracture, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

DCS vs. Condylar LCP vs. LISS

No evidence exists proving the superiority of the use of either the DCS, the Condylar LCP or the LISS with such fractures.

Indications

  • Closed fractures where a closed reduction is possible
  • Some periprosthetic fractures

Contraindications

  • Polytrauma patient in unstable condition
  • Medically unfit for surgery
  • Image intensifier unavailable
  • Early pregnancy (up to 12 weeks gestation; risks of intraoperative ionizing radiation)
  • Local soft-tissue compromise

Advantages

  • Fracture reduction
  • Less invasive procedure
  • Minimizes secondary soft-tissue damage
  • High union rates
  • Definitive procedure
  • Fracture stabilization allows early patient mobilization
  • Can be used in cases of pulmonary compromise
  • Less visible scarring

Disadvantages

  • Closed reduction is more challenging than open reduction
  • Difficult control of distal femoral fracture fragment
  • Higher rate of malreduction
  • Technically demanding procedure
  • Frequent use of image intensifier – risk of increased exposure to ionizing radiation
  • Risk of infection
  • Risk of implant related complications
MIO - less invasive stabilization system (LISS)
Indication summary Skill Equipment
Displaced reducible fracture, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

DCS vs. Condylar LCP vs. LISS

No evidence exists proving the superiority of the use of either the DCS, the Condylar LCP or the LISS with such fractures.

Indications

  • Closed fractures where a closed reduction is possible
  • Some periprosthetic fractures

Contraindications

  • Polytrauma patient in unstable condition
  • Medically unfit for surgery
  • Image intensifier unavailable
  • Early pregnancy (up to 12 weeks gestation; risks of intraoperative ionizing radiation)
  • Local soft-tissue compromise

Advantages

  • Fracture reduction
  • Less invasive procedure
  • Minimizes secondary soft-tissue damage 
  • High union rates
  • Definitive procedure
  • Fracture stabilization allows early patient mobilization
  • Can be used in cases of pulmonary compromise
  • Less visible scarring

Disadvantages

  • Closed reduction is more challenging than open reduction
  • Difficult control of distal femoral fracture fragment
  • Higher rate of malreduction
  • Technically demanding procedure
  • Frequent use of image intensifier – risk of increased exposure to ionizing radiation
  • Risk of infection
  • Risk of implant related complications
MIO - retrograde nailing
Indication summary Skill Equipment
Closed fractures, Gustilo types I & II open fractures, stable polytrauma. “Floating knee” injury, bilateral lower extremity fractures. Pregnancy. Obesity. Ipsilateral femoral neck fracture. Concomitant ipsilateral acetabular / pelvic ring fractures. Fracture below hip prosthesis. Highly experienced and skilled surgeon Full specialized surgical and imaging resources

The introduction of a retrograde femoral intramedullary nail may need to be considered in certain circumstances. It has to be recognized that this procedure violates the knee joint and has the potential for iatrogenic compromise of later knee function.

Indications

  • Selected closed and open fractures
  • Where a closed reduction is possible
  • “Floating knee” injury
  • Pregnancy
  • Obesity
  • Concomitant ipsilateral acetabular/pelvic ring fractures
  • Fractures below stemmed hip prostheses

Contraindications

  • Polytrauma patient in unstable condition
  • Medically unfit for surgery 
  • Accompanying severe pulmonary trauma if reaming is planned
  • Narrow intramedullary canal or existing implant which does not allow for an intramedullary implant
  • Stiff knee joint which does not allow the flexion necessary for intramedullary nail insertion
  • Patella baja
  • Image intensifier unavailable
  • Local soft-tissue compromise

Advantages

  • Less invasive procedure
  • Fracture reduction
  • High union rates
  • Definitive procedure
  • Good biomechanical properties
  • Minimizes secondary soft-tissue damage
  • Fracture stabilization allows early patient mobilization
  • Good cosmetic results

Disadvantages

  • Closed reduction is more difficult than open reduction
  • Higher rate of malreduction 
  • Technically demanding procedure
  • Risk of infection
  • Risk of iatrogenic intraarticular damage to the knee joint
  • Risk of damage to the posterior cruciate ligament
  • Difficult control of distal femoral fracture fragment
  • Risk of damage to the patellar tendon
  • Risk of chronic knee pain
  • Risk of retropatellar damage (nail too long)
  • Risk of loss of fixation in osteoporotic bone
  • Implant-related pain (e.g. around distal interlocking screws)
  • Frequent use of image intensifier – risk of increased ionizing radiation exposure
ORIF - dynamic condylar screw (DCS)
Indication summary Skill Equipment
Indirect reduction not possible, image intensification not available, Surgeon's preference Highly experienced and skilled surgeon Simple surgical and imaging resources

The advantage of a DCS, when inserted in an open manner, is that the surgeon can use the implant as a reduction aid. By inserting condylar screw into the correct position in the distal femoral block, the surgeon ensures appropriate varus/valgus reduction when the plate is brought down to the bone.

The DCS may have a lesser purchase in the distal femoral fragment, if there is a short distal segment and or osteoporosis, and a locking plate option may need to be considered.

Indications

  • Closed and open fractures
  • Closed reduction impossible
  • Some periprosthetic fractures
  • Image intensifier not available
  • Early pregnancy (up to 12 weeks gestation; reduces risks of intraoperative ionizing radiation)

Contraindications

  • Polytrauma patient in unstable condition
  • Patient not medically fit for surgery
  • Local soft-tissue pathology

Advantages

  • Definitive procedure
  • Direct fracture reduction
  • Restoration of mechanical axis
  • Restoration of femoral rotation
  • Fracture stabilization allows early mobilization of patients postoperatively
  • Can be used in cases of pulmonary compromise
  • Less exposure to ionising radiation

Disadvantages

  • Risk of infection
  • Risk of implant related complications
  • Risk of greater blood loss
  • Larger operative soft-tissue trauma
  • More visible scarring
ORIF - condylar locking compression plate (LCP)
Indication summary Skill Equipment
Indirect reduction not possible, image intensification not available, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

The advantage of a condylar LCP, when inserted in an open manner, is that the surgeon can use the implant as a reduction aid. By fixing the condylar LCP in the correct position to the distal femoral block, the surgeon ensures appropriate varus/valgus reduction when the plate is brought down to the bone.

The condylar LCP is more expensive than the the DCS or the angled blade plate.

Indications

  • Closed and open fractures
  • Closed reduction impossible
  • Some periprosthetic fractures
  • Image intensifier not available
  • Early pregnancy (up to 12 weeks gestation; reduces intraoperative ionizing radiation)

Contraindications

  • Polytrauma patient in highly unstable condition
  • Patient not medically fit for surgery
  • Local soft-tissue compromise

Advantages

  • Definitive procedure
  • Direct fracture reduction
  • Fracture stabilization allows for early mobilization of patients postoperatively
  • Can be used in cases of pulmonary compromise
  • Less exposure to ionizing radiation

Disadvantages

  • Risk of infection
  • Risk of greater blood loss
  • Exposure of fracture zone
  • Larger operative soft-tissue trauma
  • More visible scarring
ORIF - blade plate
Indication summary Skill Equipment
Indirect reduction not possible, image intensification not available, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

The advantage of a blade plate, when inserted in an open manner, is that the surgeon can use the implant as a reduction aid.

By inserting the blade plate in the precisely appropriate position in the distal femoral block, the surgeon ensures appropriate varus/valgus reduction when the plate is brought down to the bone.

Indications

  • Closed and open fractures
  • Closed reduction impossible
  • Some periprosthetic fractures
  • Image intensifier not available
  • Early pregnancy (up to 12 weeks gestation; reduces intraoperative ionizing radiation)

Contraindications

  • Polytrauma patient in highly unstable condition
  • Patient not medically fit for surgery
  • Local soft-tissue compromise

Advantages

  • Definitive procedure
  • Direct fracture reduction
  • Fracture stabilization allows for early mobilization patient of patients postoperatively
  • Can be used in cases of pulmonary compromise
  • Less exposure to ionizing radiation

Disadvantages

  • Risk of infection
  • Risk of implant related complications
  • Risk of greater blood loss
  • Exposure of fracture zone
  • Larger operative soft-tissue trauma
  • More visible scarring
*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