Executive Editor: Chris Colton

Authors: Florian Gebhard, Phil Kregor, Chris Oliver

Distal femur

back to skeleton

Glossary

Basic treatment techniques

Basic technique: Modular external fixation

Surgical procedures sorted by fracture type

Use this menu to jump directly into a specific classification (optional):
A1.1 A1.2/3 A2 A3 B1.1/2 B1.3 B2.1/2 B2.3 B3.1 B3.2/3 C1 C2 C3
A1.1

Extra-articular apophyseal fractures, simple

Please select a treatment option:
Treatment Indication summary Skill Equipment
Long leg cast then hinged knee brace Undisplaced fracture Basic surgical experience, no specialized skills Basic equipment only
Temporary long leg splint Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-spanning external fixator Damage control Some specialized surgical experience Simple surgical and imaging resources
Open reduction; lag screw(s) Displaced fracture Some specialized surgical experience Simple surgical and imaging resources
A1.2/3

Extra-articular metaphyseal fractures, simple

Please select a treatment option:
Treatment Indication summary Skill Equipment
Long leg cast then hinged knee brace Undisplaced fracture Basic surgical experience, no specialized skills Basic equipment only
Temporary long leg splint Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-spanning external fixator Damage control Some specialized surgical experience Simple surgical and imaging resources
Temporary skeletal traction Displaced open fracture, medically unfit patient Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; dynamic condylar screw - MIO (DCS) Displaced reducible fracture, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; condylar locking compression plate - MIO (LCP) Displaced reducible fracture, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; retrograde nailing 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
Open reduction; dynamic condylar screw (DCS) Indirect reduction not possible, image intensification not available, Surgeon's preference Highly experienced and skilled surgeon Simple surgical and imaging resources
Open reduction; condylar locking compression plate (LCP) Indirect reduction not possible, image intensification not available, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; angled blade plate Indirect reduction not possible, image intensification not available, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
A2

Extra-articular fractures, metaphyseal wedge

Please select a treatment option:
Treatment Indication summary Skill Equipment
Long leg cast then hinged knee brace Stabe undisplaced fracture Basic surgical experience, no specialized skills Basic equipment only
Temporary long leg splint Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-spanning external fixator Damage control Some specialized surgical experience Simple surgical and imaging resources
Temporary skeletal traction Displaced open fracture, medically unfit patient Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; dynamic condylar screw - MIO (DCS) Displaced reducible fracture, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; condylar locking compression plate - MIO (LCP) Displaced reducible fracture, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; less invasive stabilization system (LISS) Displaced reducible fracture, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; retrograde nailing 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
Open reduction; dynamic condylar screw (DCS) Indirect reduction not possible, image intensification not available, Surgeon's preference Highly experienced and skilled surgeon Simple surgical and imaging resources
Open reduction; condylar locking compression plate (LCP) Indirect reduction not possible, image intensification not available, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; angled blade plate Indirect reduction not possible, image intensification not available, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
A3

Extra-articular fractures, metaphyseal complex

Please select a treatment option:
Treatment Indication summary Skill Equipment
Long leg cast then hinged knee brace Medically unfit patient, undisplaced fracture Basic surgical experience, no specialized skills Basic equipment only
Temporary long leg splint Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-spanning external fixator Damage control Some specialized surgical experience Simple surgical and imaging resources
Temporary skeletal traction Displaced open fracture, medically unfit patient Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; dynamic condylar screw - MIO (DCS) Displaced reducible fracture, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; condylar locking compression plate - MIO (LCP) Displaced reducible fracture, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; less invasive stabilization system (LISS) Displaced reducible fracture, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; retrograde nailing 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
Open reduction; dynamic condylar screw (DCS) Indirect reduction not possible, image intensification not available, Surgeon's preference Highly experienced and skilled surgeon Simple surgical and imaging resources
Open reduction; condylar locking compression plate (LCP) Indirect reduction not possible, image intensification not available, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; angled blade plate Indirect reduction not possible, image intensification not available, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B1.1/2

Partial articular fractures, lateral condyle, sagittal; simple

Please select a treatment option:
Treatment Indication summary Skill Equipment
Long leg cast then hinged knee brace Undisplaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary long leg splint Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-spanning external fixator Damage control Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; lag screws - MIO Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Simple surgical and imaging resources
Closed reduction; cannulated lag screws - MIO Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Simple surgical and imaging resources
Open reduction; lag screws Large fragment, good bone quality, low demand patient Some specialized surgical experience Full specialized surgical and imaging resources
Open reduction; lag screws with buttress plate Large fragment, high demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; cannulated lag screws Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; cannulated lag screws with buttress plate Large fragment, high demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B1.3

Partial articular fractures, lateral condyle, sagittal; multifragmentary

Please select a treatment option:
Treatment Indication summary Skill Equipment
Long leg cast then hinged knee brace Undisplaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary long leg splint Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-spanning external fixator Damage control Some specialized surgical experience Simple surgical and imaging resources
Open reduction; lag screws Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; lag screws with buttress plate Large fragment, high demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; cannulated lag screws Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; cannulated lag screws with buttress plate Large fragment, high demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B2.1/2

Partial articular fractures, medial condyle, sagittal; simple

Please select a treatment option:
Treatment Indication summary Skill Equipment
Long leg cast then hinged knee brace Undisplaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary long leg splint Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-spanning external fixator Damage control Some specialized surgical experience Simple surgical and imaging resources
Closed reduction; lag screws - MIO Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Simple surgical and imaging resources
Closed reduction; cannulated lag screws - MIO Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Simple surgical and imaging resources
Open reduction; lag screws Large fragment, good bone quality, low demand patient Some specialized surgical experience Full specialized surgical and imaging resources
Open reduction; lag screws with buttress plate Large fragment, high demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; cannulated lag screws Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; cannulated lag screws with buttress plate Large fragment, high demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B2.3

Partial articular fractures, frontal; anterior and lateral flake fracture

Please select a treatment option:
Treatment Indication summary Skill Equipment
Long leg cast then hinged knee brace Undisplaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary long leg splint Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-spanning external fixator Damage control Some specialized surgical experience Simple surgical and imaging resources
Open reduction; lag screws Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; lag screws with buttress plate Large fragment, high demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; lag screws (cannulated) Large fragment, good bone quality, low demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; lag screws (cannulated) with buttress plate Large fragment, high demand patient Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B3.1

Partial articular fractures, frontal; anterior and lateral flake fracture

Please select a treatment option:
Treatment Indication summary Skill Equipment
Long leg cast then hinged knee brace Undisplaced fracture, low demand patient Basic surgical experience, no specialized skills Basic equipment only
Temporary long leg splint Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-spanning external fixator Damage control Some specialized surgical experience Simple surgical and imaging resources
Open reduction; screws Displaced fractures Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B3.2/3

Partial articular fractures, frontal; posterior

Please select a treatment option:
Treatment Indication summary Skill Equipment
Long leg cast then hinged knee brace Undisplaced fracture, low demand patient Basic surgical experience, no specialized skills Basic equipment only
Temporary long leg splint Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Temporary joint-spanning external fixator Damage control Some specialized surgical experience Simple surgical and imaging resources
Open reduction; screws from anterior for large fragments Displaced large fragments Highly experienced and skilled surgeon Simple surgical and imaging resources
Open reduction; screws from posterior for small fragments Displaced small fragments Highly experienced and skilled surgeon Simple surgical and imaging resources
C1

Complete articular fractures, articular simple, metaphyseal simple

Please select a treatment option:
Treatment Indication summary Skill Equipment
Temporary joint-spanning external fixator Damage control Some specialized surgical experience Simple surgical and imaging resources
Temporary skeletal traction Displaced fracture, medically unfit patient Some specialized surgical experience Simple surgical and imaging resources
Temporary long leg splint Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Open reduction; dynamic condylar screw (DCS) Metaphyseal fracture more proximal Highly experienced and skilled surgeon Simple surgical and imaging resources
Open reduction; condylar locking compression plate (LCP) Displaced articular fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; angled blade plate and lag screws Metaphyseal fracture more proximal Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; retrograde nailing Articular fracture undisplaced, metaphyseal fracture proximal Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C2

Complete articular fractures, articular simple, metaphyseal multifragmentary

Please select a treatment option:
Treatment Indication summary Skill Equipment
Temporary joint-spanning external fixator Damage control Some specialized surgical experience Simple surgical and imaging resources
Temporary skeletal traction Displaced fracture, medically unfit patient Some specialized surgical experience Simple surgical and imaging resources
Temporary long leg splint Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Open reduction; dynamic condylar screw (DCS) Metaphyseal fracture more proximal Highly experienced and skilled surgeon Simple surgical and imaging resources
Open reduction; condylar locking compression plate (LCP) More distal metaphyseal fractures, articular fracture displaced, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; less invasive stabilization system (LISS) More distal metaphyseal fractures, articular fracture displaced, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; angled blade plate and lag screws Metaphyseal fractures more proximal Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; retrograde nailing Articular fracture undisplaced, metaphyseal fractures proximal Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C3

Complete articular fractures, multifragmentary

Please select a treatment option:
Treatment Indication summary Skill Equipment
Temporary joint-spanning external fixator Damage control Some specialized surgical experience Simple surgical and imaging resources
Temporary skeletal traction Displaced fracture, medically unfit patient Some specialized surgical experience Simple surgical and imaging resources
Temporary long leg splint Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only
Open reduction; condylar locking compression plate (LCP) More distal metaphyseal fractures, articular fracture displaced, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; less invasive stabilization system (LISS) More distal metaphyseal fractures, articular fracture displaced, Surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Special considerations

Principles of management of open fractures
Complications
Infection
Compartment syndrome
*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 2016-10-19