In general, operative reduction and fixation of all intraarticular fractures is mandatory in order to restore good knee function.
The eventual aim is anatomical restoration of the articular surface and early active mobilization of the joint.
|Long leg cast then hinged knee brace|
|Undisplaced fracture, low demand patient|
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. It is often used as a short-term measure, until surgery can safely be undertaken.
- Undisplaced fracture in patients not medically fit for surgery
- Risk of knee stiffness
- Risk of secondary displacement
- Risk of thrombo-embolism
|Temporary long leg splint|
|Displaced fracture, medically unfit patient|
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.
|Temporary external fixator|
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.
- Associated vascular injury
- Existing prosthesis/implant conflicting with pin tracks
- Minimally invasive
- Rapid procedure
- Potential knee stiffness
- Fixator pins may compromise sterility, future incisions, or definitive fixation
|ORIF - screw fixation|
The treatment of choice is open reduction and internal fixation.
Anterior and lateral flake fractures may be associated with patellar dislocation. These fractures may be small osteochondral fragments and may be technically unfixable. Small fracture fragments may need to be excised, or washed out of the knee joint arthroscopically.
Displaced fractures should be fixed with sunken screws, or bioresorbable pins, to achieve anatomical restoration of the articular surface, permitting early active mobilization of the joint surface. Larger fragments that are not in the femoral trochlea may be addressed arthroscopically. Reduction and cannulated screw/absorbable pin fixation is performed under arthroscopic control.
- Displaced fractures
- Additional knee ligament injury
- Additional meniscial injury
- Patient not medically fit for surgery
- Local infection
- Open surgery offers possibility of treatment of associated knee derangements
- Direct anatomical reduction
- Early mobilization of the knee joint
- Lower incidence of osteoarthritis
- Risk of nonunion and avascular necrosis
- Risk of incorrect position of screws leading to impingement on patella
- Risk of failure of bioresorbable pins
|Basic surgical experience, no specialized skills|
|Some specialized surgical experience|
|Highly experienced and skilled surgeon|
|Basic equipment only|
|Simple surgical and imaging resources|
|Full specialized surgical and imaging resources|