Posted: Nov 23 2020 #(C101632) 2021 Orthopaedic Trauma & Fracture Care: Pushing the Envelope

Distal Femur Fracture in 75F

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HPI

A 75-year-old female presents to the ED after a ground level fall in which she tripped over a dog gate. After the fall she was unable to ambulate, and reports pain localized to the right knee. At baseline she is a community ambulator without any assistive devices.

PMH

No significant past medical history

Focused exam of the right lower extremity reveals a 2 cm superficial abrasion to the anterolateral knee without open wounds. A palpable effusion is present. Moderate TTP diffusely about the right distal femur. Sensation is intact to all distributions of the RLE. Motor exam is grossly intact to EHL/FHL/GSC. PT and DP pulses are palpable. Compartments to the lower leg and thigh are soft and easily compressible.

Poll

1 of 11

1. In addition to the plain film radiographs, would you obtain any additional imaging to guide management?

No - current radiographs are sufficient

16%

209/1250

Yes - additional radiographic views (aXR)

17/1250

Yes - CT scan of the femur (CT)

72%

911/1250

Yes - MRI scan of the femur (MRI)

10/1250

Yes - aXR + CT

59/1250

Yes - aXR + MRI

2/1250

Yes - CT + MRI

13/1250

Yes - aXR + CT + MRI

2/1250

Outside my area of expertise - best if I don't vote

27/1250

2. Would you use a classification system for this injury to guide management?

No - a classification system would not help me

45%

554/1207

Yes - AO/OTA

46%

563/1207

Yes - Seinsheimer

24/1207

Yes - Other

3/1207

Outside my area of expertise - best if I don't vote

63/1207

3. How would you manage this patient?

Nonoperative

22/1227

Operative

96%

1189/1227

Outside my area of expertise - best if I don't vote

16/1227

4. If you choose Operative management, what technique would you use?

I would not choose Operative management

2/1205

External fixation (ExFix) only (includes monoplanar, ringed circular fixation, etc)

12/1205

Open reduction internal fixation (ORIF)

91%

1102/1205

Intramedullary nail fixation (IMN) (includes percutaneous fixation)

36/1205

Arthroplasty (includes total knee and distal femur replacement)

9/1205

ORIF + IMN

20/1205

Outside my area of expertise - best if I don't vote

24/1205

5. If you choose Open reduction internal fixation (ORIF), what approach would you use?

I would not choose ORIF

3/1218

Lateral only

39%

487/1218

Minimally invasive lateral only

26%

321/1218

Modified anterior (swashbuckler) only

99/1218

Lateral parapatellar only

16%

204/1218

Medial parapatellar only

18/1218

Medial only

9/1218

Combination of those listed above

35/1218

Outside my area of expertise - best if I don't vote

42/1218

6. If you choose Open reduction internal fixation (ORIF), which technique would you utilize?

I would not choose ORIF

1/1184

Screws only

11%

140/1184

Non-locking (non-fixed angle) plate

78/1184

Locking plate

73%

874/1184

Dynamic condylar screw

48/1184

Blade plate

12/1184

Outside my area of expertise - best if I don't vote

31/1184

7. If you choose Open reduction internal fixation (ORIF) with a lateral plate, how proximal would you extend the plate?

I would not choose ORIF with a lateral plate

17/886

Distal 1/3rd femur

38%

337/886

Middle 1/3 femur (approx. midshaft)

47%

423/886

Proximal 1/3 femur Distal to LT

56/886

Proximal 1/3 femur AT level of LT

30/886

Outside my area of expertise - best if I don't vote

23/886

8. If you choose Operative management and attain the construct shown below, how would you immobilize the patient postoperatively?

I would not choose Operative management

2/1058

Soft dressing only

40%

428/1058

Hinged knee brace

40%

433/1058

Knee immobilizer

14%

157/1058

Above-knee cast

20/1058

Outside my area of expertise - best if I don't vote

18/1058

9. If you choose Operative management and attained the construct shown below, what would be your postoperative weight-bearing status?

I would not choose Operative management

2/1089

Weight-bearing as tolerated (WBAT)

107/1089

Partial/protected (25-50%) weight-bearing (PWB)

21%

231/1089

Touch-down weight-bearing (TTWB)

35%

387/1089

Non-weight bearing (NWB)

31%

343/1089

Outside my area of expertise - best if I don't vote

19/1089

10. If you choose Operative management and attained the construct shown below, what would be your immediate postoperative motion restrictions?

I would not choose Operative management

3/1075

ROM as tolerated

55%

601/1075

ROM 0-45 degrees

18%

196/1075

ROM 0-90 degrees

17%

188/1075

No ROM at all

68/1075

Outside my area of expertise - best if I don't vote

19/1075

11. If you choose ORIF and made the patient non weight bearing after surgery, what DVT prophylaxis would you prescribe?

I would not choose ORIF

1/1059

None - I would not prescribe DVT prophylaxis

26/1059

Aspirin

21%

224/1059

Low molecular weight heparin (Lovenox)

57%

609/1059

Heparin

33/1059

Xa inhibitors (Xarelto etc.)

14%

151/1059

Outside my area of expertise - best if I don't vote

15/1059

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