Executive Editor: Chris Colton

Authors: Florian Gebhard, Phil Kregor, Chris Oliver

Distal femur Partial articular fracture, lateral condyle, sagittal simple

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.

Fractures affecting the lateral femoral condyle vary in size. Unfixable, small loose fracture fragments may need to be excised, or washed out of the knee joint.

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 anesthesia. If nonoperative treatment is selected, a long leg cast/hinged knee brace should be used to minimize limb deformity 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 provisional 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
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
MIO - lag screws
Indication summary Skill Equipment
Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Simple surgical and imaging resources

If the fracture is undisplaced, or minimally displaced, closed reduction internal fixation (CRIF) techniques are often appropriate through minimal incisions. Displaced fractures are often difficult to reduce, due to interposed soft tissue, or organizing fracture hematoma. It is easier to perform CRIF techniques within the first 24-48 hours after injury, before the fracture hematoma begins to organize.

In minimally displaced fractures, reduction should be checked arthroscopically. Standard lag screws are then inserted under image intensifier guidance.

Indication

  • Minimally displaced sagittal split fractures

Contraindications

  • Patient not medically fit for surgery
  • Displaced fractures
  • Lack of arthroscopic experience or facilities

Advantages

  • Indirect articular surface reduction
  • Minimally invasive approach
  • Early mobilization of the knee joint
  • Lower risk of secondary osteoarthritis

Disadvantages

  • Imperfect reduction
  • Technically demanding
MIO - cannulated lag screws
Indication summary Skill Equipment
Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Simple surgical and imaging resources

If the fracture is undisplaced, or minimally displaced, closed reduction internal fixation (CRIF) techniques are often appropriate through minimal incisions. Displaced fractures are often difficult to reduce, due to interposed soft tissue, or organizing fracture hematoma. It is easier to perform CRIF techniques within the first 24-48 hours after injury, before the fracture hematoma begins to organize.

In minimally displaced fractures, reduction should be checked arthroscopically. Cannulated lag screws are then inserted under image intensifier guidance.

Indication

  • Minimally displaced sagittal split fractures

Contraindications

  • Patient not medically fit for surgery
  • Displaced fractures
  • Lack of arthroscopic experience or facilities

Advantages

  • Indirect articular surface reduction
  • Minimally invasive approach
  • Early mobilization of the knee joint
  • Lower risk of secondary osteoarthritis

Disadvantages

  • Imperfect reduction
  • Technically demanding
ORIF - lag screws
Indication summary Skill Equipment
Large fragment, good bone quality, low demand patient Some specialized surgical experience Full specialized surgical and imaging resources

If the fracture is displaced, open reduction internal fixation (ORIF) techniques are necessary.

Beyond 24-48 hours after injury, the fracture hematoma begins to organize. After 48 hours it is necessary to perform an open approach, even in minimally displaced fractures.

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

Indication

  • All displaced lateral sagittal split fractures

Contraindication

  • Patient not medically fit for surgery

Advantages

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

Disadvantage

  • 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

If the fracture is displaced, open reduction internal fixation (ORIF) techniques are necessary.

Beyond 24-48 hours after injury, the fracture hematoma begins to organize. After 48 hours it is necessary to perform an open approach, even in minimally displaced fractures.

It is in poor bone stock, or more vertical fracture planes that a buttress plate is added, in order to enhance stability.

Indication

  • Lateral sagittal split fractures, with poor bone stock, or more vertical fracture planes

Contraindication

  • Patient not medically fit for surgery

Advantages

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

Disadvantage

  • Wider surgical exposure
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

If the fracture is displaced, open reduction internal fixation (ORIF) techniques are necessary.

Beyond 24-48 hours after injury, the fracture hematoma begins to organize. After 48 hours it may well be easier to perform an open approach as it may be impossible to maintain an anatomical reduction by closed means.

Displaced fractures should be fixed with lag screws, which may be cannulated. 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

Disadvantage

  • 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

If the fracture is displaced, open reduction internal fixation (ORIF) techniques are necessary.

Beyond 24-48 hours after injury, the fracture hematoma begins to organize. After 48 hours it may well be easier to perform an open approach as it may be impossible to maintain an anatomical reduction by closed means.

Displaced fractures should be fixed with lag screws, which may be cannulated. In poor bone stock, or more vertical fracture planes a buttress plate is added to enhance stability.

Indication

  • All displaced 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

Disadvantage

  • 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