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Distal Femur Fractures
Updated: Oct 9 2017

Distal Femur Fracture ORIF with Single Lateral Plate

Preoperative Patient Care
Operative Techniques

Preoperative Plan


Template fracture reductions

  • draw key fragments of fracture and plan forces required to obtain reductions
  • obtain order of reduction for fracture fragments
  • identify the main articular fragment
  • identify fracture pattern and method of plate fixation
  • for simple metaphyseal fracture pattern
  • anatomic reduction and interfragmentary compression is performed using a neutralization plate with 4 cortices above the fracture with tensioning of the plate
  • for multifragemted metadiaphyseal extension type fractures
  • the plate should be much longer
  • the plate should be two to three times the length of the fragmented section
  • 50% of the holes in the shaft component of the plate should be filled
  • apply as many screws as possible in the distal fragment to achieve stability


Template instrumentation

  • template size of instrumentation


Execute surgical walkthrough

  • resident can describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and steps to avoid them

Room Preparation


Surgical instrumentation

  • periarticular clamps
  • K wires
  • cancellous or cortical screws
  • locking femoral condylar plate


Room setup and equipment

  • radiolucent flat top table
  • c-arm fluoroscopy


Patient positioning

  • place patient supine
  • place a sterile bump or triangle under the knee

Midline Approach with an Extended Lateral Parapatellar Arthrotomy


Mark out the incision

  • mark incision directly anterior starting 5 cm proximal to the superior pole of the patella


Make the skin incision


Develop the lateral skin flap


Perform arthrotomy

  • be sure that there is a cuff of tissue on the lateral aspect of the patella as well as medially for the quadriceps


Expose the condyles

  • sublux the patella medially or invert the patella during knee flexion


Perform periosteal elevation of the capsule off of the lateral condyle to prepare for the plate

  • be sure to preserve the lateral collateral ligament
  • the dissection should be limited to the anterior 2/3 of the lateral condyle

Reduction of the Articular Surfaces and Definitive Fixation of the Condyles


Evaluate the joint line

  • determine the amount of articular comminution present
  • assess each condyle for smaller fragments


Reduce the fracture fragments

  • use large pointed reduction forceps to reduce the fragments
  • assess each reduction under direct visualization at the trochlear region of the patellofemoral joint


Place temporary fixation

  • place temporary K wires of guide pins for locking screws for provisional fixation


Place definitive fixation

  • place screws in the periphery to avoid any interference with the plate placement itself
  • if this is not possible, place screws from medial to lateral to avoid interference of plate placement

Reduction of the Shaft to the Distal Segment


Reduce the fracture with K wires

  • place bumps under the leg to reduce extension of the distal segment to align it with the shaft of the femur
  • if temporary external fixation has been placed, it should be loosened to aid in the reduction


Provisionally fix the distal segment to the shaft

  • use K wires or steinmann pins for provisional fixation

Placement of the Plate


Place K wires

  • all fixed angle plate systems are designed to restore valgus alignment of the distal femur
  • place the guidewires for the screws in the distal portion of the plate parallel to the joint line
  • placement of these screws in a parallel fashion ensures that when the shaft is brought to the plate, the anatomic axis of the femur will be restored


Insert the plate in a submuscular fashion

  • in order to place the plate, drive the guidewires to the medial side of the knee
  • place the plate submuscularly
  • drive the guidewires back through the plate laterally
  • align the plate to the distal segment and confirm that the screw trajectory is parallel to the joint


Confirm the placement of the plate proximally with fluoroscopy


Stabilize the plate to the bone distally

  • place a guidewire in the center hole of the distal aspect of the plate


Confirm placement of the plate

  • use lateral fluoroscopic imaging to confirm the anterior and posterior placement of the plate


Stabilize the plate to the bone proximally

  • if no screw targeting guide is present, a percutaneous provisional fixation pin can be used to stabilize the plate


Check reduction

  • check the flexion-extension reduction using fluoroscopy

Screw placement


Place screws

  • use partially threaded or overdrilled fully threaded screws through the plate to provide interfragmentary compression
  • once the articular surface is reduced, place two locking screws to secure the plate and the alignment


Evaluate the intercondylar notch

  • use the notch view to ensure that penetration through the intercondylar notch did not occur

Attaching the Distal Segment to the Shaft and Placement of the Additional Screws


Assess placement of the plate

  • before placing the locking screws check the length, rotation and the alignment through fluoroscopy
  • the plate can be locked to the distal segment and then used to manipulate the distal segment relative to the shaft for flexion-extension reduction


Place additional screws proximally

  • place additional screws percutaneously using freehand under fluoroscopic guidance
  • if there is a targeting guide, place locking screws percutaneously


Check the final construct with lateral radiographs


Wound Closure


Irrigation, hemostasis, and drain

  • copiously irrigate the wound
  • irrigate until backflow is clear
  • cauterize peripheral bleeding vessels


Deep closure

  • close the arthrotomy with figure of eight 0 vicryl sutures
  • reinforce with fiberwire suture


Superficial closure

  • subcutaneous with 2-0 vicryl and skin closure with 3-0 vicryl and suture or staples



  • soft incision dressings over the distal femur
Postoperative Patient Care
Private Note

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