Executive Editor: Chris Colton

Authors: Florian Gebhard, Phil Kregor, Chris Oliver

Distal femur Partial articular fracture, lateral condyle, sagittal fragmentary

back to skeleton

Glossary

General considerations

In general, operative reduction and fixation of all intraarticular fractures is mandatory in order to restore good knee function.
The aim is absolute stability, with anatomical restoration, of the articular surface and early active mobilization of the joint.

Long leg cast then hinged knee brace
Indication summary Skill Equipment
Undisplaced fracture, medically unfit patient 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 anaesthesia. 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.

Indication

  • Undisplaced fractures in patients not medically fit for surgery

Disadvantages

  • Risk of knee stiffness
  • Risk of secondary displacement
  • Risk of thrombo-embolism
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.

Indications

  • Patient in extremis
  • Significant angulation, without operative management

Contraindications

  • Safe definitive fixation possible
  • Severe 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

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
ORIF - lag screws
Indication summary Skill Equipment
Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Displaced fractures should be fixed with lag screws. Small intermediate fragments may be fixed with bioresorbable pins, so that anatomical restoration of the articular surface can be achieved and early active mobilization of the joint undertaken.

In poor bone stock, or more vertical fracture planes a buttress plate is added to enhance stability.

Indication

  • All lateral sagittal split fractures

Contraindication

  • Patient not medically fit for surgery

Advantages

  • Direct articular surface reduction
  • Early mobilization of the knee joint
  • Lower incidence of osteoarthritis

Disadvantages

  • Risk of failure of bioresorbable pins
  • Risk of knee joint stiffness
ORIF - lag screws with buttress plate
Indication summary Skill Equipment
Large fragment, high demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Displaced fractures should be fixed with lag screws. Small intermediate fragments may be fixed with bioresorbable pins, so that anatomical restoration of the articular surface can be achieved and early active mobilization of the joint surface can be undertaken.

In poor bone stock, or more vertical fracture planes a buttress plate is added to enhance stability

Indication

  • All lateral sagittal split fractures with poor bone quality

Contraindication

  • Patient not medically fit for surgery

Advantages

  • Direct articular surface reduction
  • Early mobilization of the knee joint
  • Lower incidence of osteoarthritis

Disadvantages

  • Risk of failure of bioresorbable pin
  • Risk of knee joint stiffness
ORIF - cannulated lag screws
Indication summary Skill Equipment
Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Displaced fractures should be fixed with lag screws, which may be cannulated. Small intermediate fragments may be fixed with bioresorbable pins, so that anatomical restoration of the articular surface can be achieved and early active mobilization of the joint surface can be undertaken.

In poor bone stock, or more vertical fracture planes a buttress plate is added to enhance stability.

Indication

  • All lateral sagittal split fractures

Contraindication

  • Patient not medically fit for surgery

Advantages

  • Direct articular surface reduction
  • Early mobilization of the knee joint
  • Lower incidence of osteoarthritis

Disadvantages

  • Risk of failure of bioresorbable pin
  • Risk of knee joint stiffness
ORIF - cannulated lag screws with buttress plate
Indication summary Skill Equipment
Large fragment, high demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Displaced fractures should be fixed with lag screws. Small intermediate may be fixed with bioresorbable pins, so that anatomical restoration of the articular surface can be achieved and early active mobilization of the joint surface can be undertaken.

In poor bone stock, or more vertical fracture planes a buttress plate is added to enhance stability.

Indication

  • All lateral sagittal split fractures with poor bone stock

Contraindication

  • Patient not medically fit for surgery

Advantages

  • Direct articular surface reduction
  • Early mobilization of the knee joint
  • Lower incidence of osteoarthritis

Disadvantages

  • Risk of failure of bioresorbable pin
  • Risk of knee joint stiffness
*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