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Average 4.2 of 59 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
Fixed-angle implants are often used for fixation of distal femur fractures. Three commonly used implants (Implants A, B and C) are shown in Figures A, B and C respectively. Which of the following statements is true reagarding these implants?
Implant B is better able to control fractures with a small distal segment than Implants A and C.
Implant C is better able to control coronal plane fractures than Implants A and B.
During insertion, Implant C results in removal of a larger amount of bone, compared with Implants A and B.
Implant A demonstrates less subsidence and greater load to failure compared with Implant C.
Implant A demonstrates lower fixation strength in torsional loading compared with Implant C
Select Answer to see Preferred Response
Implant C (locking compression plate, LCP) affords better control of coronal plane fractures than Implant A (95-degree angled blade plate, ABP) and Implant B (dynamic condylar screw, DCS).
The LCP allows for better control of coronal plane and multi-fragmented fractures because the multiple locking screws at the distal end secure the plate at multiple points and allow capture of fracture fragments in different planes. Newer polyaxial locking plates have even greater versatility in screw positioning.
Vallier et al. reviewed their experience with the ABP and LCP in distal femur fixation. They note that complications and secondary procedures (treatment of infection, nonunion, malunion, prominent implant removal) were more frequent in LCP than ABP patients.
Gwathmey et al. reviewed the fixation of distal femoral fractures. They state that the LCP is biomechanically superior to the ABP in cyclic loading and ultimate strength. However, the LCP has less fixation strength in torsional loading.
Figure A shows a 95-degree angled blade plate. Figure B shows a dynamic condylar screw. Figure C shows a locking compression plate. Illustration A shows a coronal plane fracture (Hoffa fracture, OTA 33-B3).
Answer 1: Implant C (LCP) is better able to control fractures with a small distal segment than Implants A (ABP) and B (DCS).
Answer 3: Insertion of the lag screw component of Implant B (DCS) requires removal of a greater amount of bone than Implant A (ABP) and Implant C (LCP).
Answer 4: Implant A (ABP) has greater subsidence and lower load to failure compared with Implant C (LCP).
Answer 5: Implant A (ABP) demonstrates greater fixation strength in torsional loading compared with Implant C (LCP).
Vallier HA, Immler W
J Orthop Trauma. 2012 Jun;26(6):327-32. PMID: 22183200 (Link to Abstract)
Vallier, JOT 2012
Gwathmey FW Jr, Jones-Quaidoo SM, Kahler D, Hurwitz S, Cui Q.
J Am Acad Orthop Surg. 2010 Oct;18(10):597-607. PMID: 20889949 (Link to Abstract)
Gwathmey, JAAOS 2010
Please rate question.
Average 3.0 of 21 Ratings
A 44-year-old male is involved in a motorcycle collision and presents with the radiographs shown in Figure A. A CT scan is obtained which shows intra-articular extension of the fracture, and lateral locked plating with intercondylar lag screw fixation is planned. Which of the following is important intra-operatively to ensure that the intercondylar screws are contained within the bone and are of appropriate length?
AP fluoroscopic imaging with the leg in 30 degrees of internal rotation
AP fluoroscopic imaging with the leg in 30 degrees of external rotation
AP fluoroscopic imaging with the knee in full extension
Lateral fluoroscopic imaging with the knee in 30 degrees of internal rotation
Lateral fluoroscopic imaging with the knee in 15 degrees of flexion
Figure A illustrates a comminuted distal femur fracture. AP fluoroscopic imaging with the leg in 30 degrees of internal rotation is important to prevent intercondylar screw prominence.
Hardware irritation is a common post-operative complication of distal femoral plate fixation. Two common sites of pain are laterally where the iliotibial band is in contact with the plate, and medially where intercondylar screws may penetrate the cortex if they are of inappropriate length. Iliotibial irritation most commonly presents with activities requiring knee flexion and extension. It is important to remember that the lateral metaphysis of the distal femur is angulated 10 degrees from the sagittal plane, and the medial metaphysis is angulated 25 degrees from the sagittal plane. Therefore, if a straight AP view is obtained, a distal screw can appear to be inside the bone even if it is too long. In order to assess the exact length of the screw, one must obtain an AP view with 30° internal rotation of the lower extremity.
Gwathmey et al discuss distal femoral fractures in their review article. They state that the goal of surgical management is to promote early knee motion while restoring the articular surface, maintaining limb length and alignment, and preserving the soft-tissue envelope with a durable fixation that allows functional recovery during bone healing. They describe a variety of surgical exposures, techniques, and implants developed to treat these injuries, including intramedullary nailing, screw fixation, and periarticular locked plating, possibly augmented with bone fillers.
Illustration A demonstrates the sagittal plane angulation of the medial and lateral cortex of the distal femur. Illustration B shows a knee in external rotation, with the intercondylar screw appearing to be of appropriate length. Illustration C shows the knee in internal rotation, which indicates that the screw is penetrating the medial cortex.
Average 4.0 of 41 Ratings
During surgical treatment of the most common variation of distal femoral "Hoffa" fractures, which of the following orientations for screw fixation should be used?
Medial to lateral screw placement across lateral femoral condyle
Anterior to posterior screw placement across medial femoral condyle
Medial to lateral screw placement across medial femoral condle
Anterior to posterior screw placement across lateral femoral condyle
Anterior to posterior screw placement across intercondylar notch
The most common variation of a Hoffa fracture is a coronal fracture of the lateral femoral condyle. The most appropriate screw placement of the above answer choices in the treatment of the most common Hoffa fracture variant would be anterior to posterior screws across the lateral condyle for fixation.
Hoffa fractures are coronally oriented fractures of the femoral condyles, with most occurring in the lateral condyle. They are commonly associated with high-energy fractures of the distal femur and can often be overlooked during the assessment and treatment of distal femur fractures. Hoffa fractures are best evaluated using CT scans.
Nork et al. studied the association of supracondylar-intercondylar distal femoral fractures and coronal plane fractures. Of 202 supracondylar-intercondylar distal femoral fractures, they found coronal plane fractures were diagnosed in 38%. A coronal fracture of the lateral femoral condyle was involved more frequently than the medial condyle. Eighty-five percent of these coronal fractures involved a single lateral femoral condyle.
Holmes et al. looked at five cases of coronal fractures of the femoral condyle. All cases received open reduction and internal fixation with lag screws through a formal parapatellar approach. They reported good results with all fractures healing within 12 weeks without complications with final range of motion at least 0 degrees to 115 degrees.
Illustration A shows sagittal and axial CT scan cuts showing a Hoffa fracture of the lateral femoral condyle. Illustration B shows multiple anterior to posterior, and posterior to anterior oriented screws for ORIF of the Hoffa fracture.
Nork SE, Segina DN, Aflatoon K, Barei DP, Henley MB, Holt S, Benirschke SK
J Bone Joint Surg Am. 2005 Mar;87(3):564-9. PMID: 15741623 (Link to Abstract)
Nork, JBJS 2005
Holmes SM, Bomback D, Baumgaertner MR
J Orthop Trauma. 2004 May-Jun;18(5):316-9.PMID: 15105756 (Link to Abstract)
Holmes, JOT 2004
Average 3.0 of 18 Ratings
A 68-year-old healthy active male presents after falling and sustaining an injury to his right knee. His medical history is significant only for osteoporosis. Radiographs and representative CT scan images are shown in Figures A-D. What is the most appropriate treatment method for this patient's injury?
Traction and splinting
Lag screw fixation followed by non-locking plate application
Retrograde supracondylar nail fixation
External fixation and percutaneous screw reduction of the fracture
Lag screw fixation followed by locking plate application
The injury shown in Figures A-D represents a comminuted metaphyseal distal femur fracture with a sagittally oriented intra-articular split in osteoporotic bone. Because of the intra-articular nature of this injury, the best fixation construct for treatment of this fracture in an otherwise healthy and active patient is lag screw fixation followed by locked plate application.
Egol et al performed a systematic review of the literature to compare and contrast the function and roles of conventional unlocked plates to locked plates in fracture fixation. They concluded that locked plates may increasingly be indicated for indirect fracture reduction, diaphyseal/metaphyseal fractures in osteoporotic bone, bridging severely comminuted fractures, and the plating of fractures where anatomical constraints prevent plating on the tension side of the bone.
Perren et al discuss the treatment of osteoporotic fractures in the elderly population. They state that in this group of patients, plating with locked screws improve the biology and the mechanics of internal fixation. Furthermore, when this fixation method is used as an 'internal ex fix' (bridging construct) it may stimulate early callus formation because of the inherent flexibility of the construct.
Illustrations A and B show intraoperative fluoroscopic images during fracture fixation. Illustration C shows an AP radiograph of the distal femur 3 months after fixation with a locked plate construct.
Egol KA, Kubiak EN, Fulkerson E, Kummer FJ, Koval KJ.
J Orthop Trauma. 2004 Sep;18(8):488-93. PMID: 15475843 (Link to Abstract)
Egol, JOT 2004
Perren SM, Linke B, Schwieger K, Wahl D, Schneider E.
Acta Chir Orthop Traumatol Cech. 2005;72(2):89-97. PMID: 15890140 (Link to Abstract)
HPI - history of road traffic accident , fall from bike after strucked by a car.
What should be the approach for fixation?
Title: Panel Discussion Presenter: PanelColumbia University OrthopedicsNew York,...
Average 4.0 of 24 Ratings
Which of the following treatments of an oligotrophic supracondylar femoral nonunion has been shown to have the best outcome?
Retrograde femoral nailing with adjunct BMP-4
Hybrid external fixation with adjunct BMP-4
Usage of a percutaneous locking plate with adjunct BMP-3
Open reduction and plating with autograft
Open reduction and plating with adjunct calcium phosphate
Oligotrophic femoral supracondylar nonunions have been shown to be best treated with open reduction and plating (revision if previous surgery) and usage of autologous bone grafting.
The first study by Bellabarba et al is a case series of 100% union rate (n=19) of supracondylar femoral nonunions treated with revision ORIF and autografting.
The second study by Chapman et al is a case series of 100% union rate (n=18) of supracondylar nonunions treated with single or double plating and autograft.
The referenced study by Rodriguez et al is an excellent review of the general principles and concepts of nonunions and their treatment.
Bellabarba C, Ricci WM, Bolhofner BR
J Orthop Trauma. 2002 May;16(5):287-96. PMID: 11972070 (Link to Abstract)
Bellabarba, JOT 2002
Chapman MW, Finkemeier CG.
J Bone Joint Surg Am. 1999 Sep;81(9):1217-28. PMID: 10505518 (Link to Abstract)
Chapman, JBJS 1999
Rodriguez-Merchan EC, Forriol F.
Clin Orthop Relat Res. 2004 Feb;(419):4-12. PMID: 15021125 (Link to Abstract)
Rodriguez-Merchan, CORR 2004
Average 4.0 of 17 Ratings
A 33-year-old man sustains a femur fracture in a motorcycle accident. AP and lateral radiographs are provided in Figure A. Prior to surgery, a CT scan of the knee is ordered for preoperative planning. Which of the following additional findings is most likely to be discovered?
Tibial eminence fracture
Sagittal plane fracture of the medial femoral condyle
Schatzker I tibia plateau fracture
Coronal plane fracture of the lateral femoral condyle
Axial plane fracture through the medial femoral condyle
The "Hoffa fracture" is a coronal plane fracture of the femoral condyle that is often missed on plain radiographs of supracondylar and intercondylar femur fractures. It involves the lateral condyle more frequently than the medial. Identification is important as it may impact operative planning and likely require screw fixation in the anteroposterior plane.
Nork et al. reviewed 202 supracondylar-intercondylar distal femoral fractures and found a 38% prevalence of associated coronal plane fractures. The authors recommend CT scan imaging of all supracondylar and intercondylar fractures.
Ostermann et al reported on 24 unicondylar fractures of the distal femur treated with open reduction internal fixation with a screw construct. Twenty-three patients acheived satisfactory results at 5 year follow-up. Illustrations A and B are another example of a supracondylar femur fracture with an associated Hoffa fracture identified on CT scan.
Ostermann PA, Neumann K, Ekkernkamp A, Muhr G.
J Orthop Trauma. 1994;8(2):142-6. PMID: 8207571 (Link to Abstract)
Ostermann, JOT 1994
Average 3.0 of 36 Ratings
Which of the following is the most appropriate clinical scenario to utilize locking plate and screw technology?
Oblique ulnar diaphyseal fracture
Osteoporotic periprosthetic distal femur fracture
Transverse tibial diaphyseal fracture
Spiral humeral diaphyseal-metaphyseal fracture
Conventional plating provides stable internal fixation when fractures are anatomically reduced. Stability of this type of fixation relies on the plate/bone interface and the friction that develops between this interface. Locked plates rely on the plate/screw interface, and each provides not only axial stability but also angular stability; each screw acts as a fixed angle device. Indications for locked plating for indirect reduction include: 1. metaphyseal/diaphyseal fractures 2. comminuted diaphyseal fractures 3. comminuted metaphyseal fractures. 4. short segment fixation. Locked plates are not indicated for displaced articular fractures unless anatomic rigid fixation of the articular surface is done first (locking technology cannot reduce fractures/lag segments together).
The referenced article by Gardner et al reviews locking technology and reminds us that compression technology using non-locking screws and plates is still needed for many fractures and is even required for proper treatment of some fractures.
The referenced article by Wagner is an instructional paper on how to use hybrid plating technology and reviews concepts such as the necessity of lag screw fixation before locking.
The referenced study by Egol et al is a review paper that notes that locked plates and conventional plates rely on completely different mechanical principles to provide fracture fixation and in so doing they provide different biological environments for healing. They report that locked plates are indicated for: indirect fracture reduction, diaphyseal/metaphyseal fractures in osteoporotic bone, and with bridging severely comminuted fractures.
Gardner MJ, Helfet DL, Lorich DG.
Am J Orthop (Belle Mead NJ). 2004 Sep;33(9):439-46. PMID: 15509108 (Link to Abstract)
Gardner, AJO 2004
Injury. 2003 Nov;34 Suppl 2:B31-42. PMID: 14580984 (Link to Abstract)
Wagner, INJURY 2003
Average 3.0 of 39 Ratings
We manufacture complete range of Trauma Implants & Instruments. We are the...
What is your preferred approach for bicondylar hoffas fracture.
Title: Supracondylar Femur Fracture - What Works? Presenter: Andrew Schmidt, MDC...
LISS System for stabilisation of a distal femur fracture - Arvind von Keudell, M...
Educational video describing the Hoffa fracture of the distal femoral condyles.B...
HPI - RTA
How would you definitively treat this injury?
HPI - A 74 year old female patient known to have HTN, DM, CAD, hyperthyroidism, osteoporosis and PVD S/P left below knee amputation is admitted to CCU because of diarrhea and decreased PO intake.
The patient's family reports decreased PO intake and generalized fatigue of several days duration associated with colicky abdominal pain and watery non-bloody, non-mucoisy diarrhea. The patient reports chills but no documented fever.
During her stay in ER, the patient fell down and had trauma to her leg and face. A CT brain showed only a superficial hematoma, with no other pathology.
The patient is ambulatory with a BKA prosthesis while at home doing only her activities of daily living.
The patient underwent cardiac catheterization during this admission which showed 80% stenosis in LAD, 90% stenosis in circumflex artery, 90% stenosis in right coronary artery.
Knowing her high cardiac risk for operative treatment, what is the best method of management for her fracture?
HPI - Patient fell onto left knee and had immediate pain, swelling, and deformity. Unable to bear weight
Based on the information provided, what do you think is the most likely cause for the fracture?
HPI - Fall from height; injury to the right knee. Unable to stand or move the knee
How would you classify this according to the AO classification?
HPI - Untreated Hoffa's fracture from a car accident February 2014
How would you treat this distal femur nonunion?
HPI - Grade 1 Open Distal Femoral Fracture Dec 2014. ORIF with short retrograde nail. Failure of Fixation March 2015. Exchange Retrograde Nail with synthetic bone grafting March 2015.
Referred from another centre with ongoing pain now 1 year since original injury/fixation.
CRP 11. ESR 18. No definitive evidence of infection at present.
How would you treat this potentially infected distal femoral non-union at this time (P1 xrays below)?
HPI - 21 year old involved in motorcycle crash. He reports hitting his knee against the bumper trying to avoid the stopped car in front of him.
What are the treatment options for this patient?
HPI - Type 3 C fracture distal 3rd left femur treated by debridement and external fixator application and antibiotic impregnated bone cement insertion 3 months prior to presentation.
The patient then underwent removal of external fixator and removal his antibiotic cement spacer.
There continues to be serous discharge from the lateral aspect of distal thigh
What should be the treatment plan considering that there continues to be discharge from the lateral wound?
HPI - The patient was brought two days ago with GSW, the wound is infected and bone exposed, he was shot 10 days befor,
What would be your next step in management?
HPI - MVA 3 days ago
Best treatment possible
HPI - RTA in 2012 - Open fracture distal femur with bone loss.
Initially managed with debridement, acute shortening (bone lost at the incident site) and K Wire fixation of fragments at different center ...
Later on put on Extenal fixator at another center ...
Patient consulted another center in 2013 ... Open reduction + Distal femoral locked plating was done .. bone grafting was not done.
continued to have pain and features of infection at the fracture site... Implant failure
Feb 2015 - Implant removal and debridement was done.. followed by antibiotics
Presently wound healed, no pain or discharge, ESR, CRP normal.
Ambulant with axillary crutch and brace support ... 12 cm of shortening.
How would you manage this patient at this time?
HPI - Polytrauma patient, rib fx, pneumothorax, open left femur fx, closed right femur fx. Has chest tube currently, admitted to ICU (on 5/11/15)
Definitive treatment of left femur?
HPI - 18 y/o male who presents with knee pain s/p football injury. MRI ordered by primary care doctor for evaluation of MRI - showed fracture and ACL tear. No prior injury.
How would you treat this fracture?
HPI - Vehicular Accident. Fell from a motorcycle.
How will you treat this multiply Injured patient?
HPI - RTA 3 yeas ago result in closed femoral supra-condylar # type (A III) treated by conservative management( was pregnant and refuse surgery).On physiotherapy an iatrogenic patellar tendon avulsion occur few months back.
what is your treatment plan ?
HPI - Case of 77 year old female patient previoisly known to have HTN,DL,CAD had left femur trauma s/p car accident,had DHS since 6 years on the same side where she was ambulating well with no complaints
What is the best option for treatment?
HPI - MVA with closed fracture supracondylar femur and contralateral neck femur fracture
Best method of treatment
HPI - Swelling at distal femur with obvious knee swelling and deformity
When to start knee range of motion, weight bearing
HPI - Rugby injury, 2 opponents fell on pt's knee and felt immediate pain.
What is the diagnosis?
HPI - The patient sustained a right distal femur fracture 1 year prior to presentation and underwent closed reduction and intramedullary nailing. She continues to have significant pain.
What should be further treatment plan
HPI - Child hood septic arthritis right knee joint leads to ankylosis right knee
Now right knee joint is ankylosed, and osteoporosis
previously patient was fully mobile with stiff knee joint
What will be the best treatment for her
HPI - motor cycle
HPI - Fall from standing height
How would you treat this patient?
HPI - RTA, fall from bike,
How would you treat this initially?
HPI - 21 yrs old male, active, medically free, were involved in RTA, had isolated open fracture type 3-B at right distal femur intra-articular cominuted fracture assoiciated with loss of medial condyle and right tibial plateau cominuted fracture ( Schatzker VI) , assoicited with medial plateau loss & patella alta. Neurovascular examinations were normal, & no compartment syndrom.Several depriement & irrigation was done, with I/V antibiotic, anti-tetanous were given to the patient. External fixator was applied spaning right knee to restore the length. Plastic team did skin graft at anteriomedial part over proximal tibia 2 weeks ago with excellent uptake. No sign of infection. The pateint now waiting orthopedic team to fix his fractures
Following a period of spanning external fixation what would you do for definitive management of the FEMUR fracture?
HPI - Fracture proximal end tibia and post condyle femur 4 month back .plating done for proximal end tibia ,post condyle fracture probably missed .Now presented with inability to bear weight
How to proceed with the treatment
HPI - reverse obliquity subtrochanteric fracture of the left femur three and a half months ago.subject to long gamma nail at this time.present this time with periprosthetic supracondylar fracture of left femur.
ways of surgical treatment
HPI - Pt. had bike accident 8 month back resulting in close fracture.Operated with DCS. No regular followup.Now with discharging wound and implant failure.(sorry for poor quality imaging.fracture is S/C I/C femur only).
How to treat this case?
HPI - 14 y/o hit playing football
HPI - ...
What will be your treatment
HPI - .27 years old man
.motorcycle accident on 29th July 2012.
.frontal collision with a car driving
.Open Wound + Right Distal femur Fracture with 4inch Bone loss + Right Patella fracture.
.treatment with a Ex-fix ex and IV antibiotics.
.Now No signs of infection – Wound clean and dry
• What do you expect? How do you want to treat now?
HPI - s/p MVC, open distal femur fracture and open ipsilateral tibial fracture (plateau extending to proximal metadiaphyseal junction and distal tibial metadiaphyseal fracture).
What would be your method of dealing with the bone loss?
HPI - 1 month history of knee pain after fall from ladder. Pain continues to worsen despite NSAIDS and ace wrap
How would you treat this fracture pattern?