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https://upload.orthobullets.com/topic/1041/images/Xray - Lat - Hoffa fragment_moved.jpg
https://upload.orthobullets.com/topic/1041/images/distal femur fracture vascular injury.jpg
https://upload.orthobullets.com/topic/1041/images/hoffa fracture.jpg
https://upload.orthobullets.com/topic/1041/images/radiographs blade plate.jpg
Introduction
  • Epidemiology
    • traditionally young patients but increasing in geriatric population
    • bimodal distribution: young, healthy males, elderly osteopenic females
    • periprosthetic fractures becoming more common
  • Mechanism
    • young patients
      • high energy with significant displacement
    • older patients
      • low energy, often fall from standing, in osteoporotic bone, usually with less displacement
Anatomy
  • Osteology
    • distal femur becomes trapezoidal in cross section towards knee
    • medial condyle extends more distal than lateral
    • posterior halves of both condyles are posterior to posterior cortex of femoral shaft
    • anatomical axis of distal femur is 6-7 degrees of valgus 
    • lateral cortex of femur slopes ~10 degrees, medial cortex slopes ~25 degrees in axial plane 
  • Pathomechanics
    • gastrocnemius: extends distal fragment (apex posterior)
    • hamstring and extensor mechanism: cause shortening
    • adductor magnus: leads to distal femoral varus
Classification
  • Descriptive
    • supracondylar
    • intercondylar
  • OTA: 33 
    • A: extraarticular
    • B: partial articular
      • portion of articular surface remains in continuity with shaft
      • 33B3 is in coronal plane (Hoffa fragment)
    • C: complete articular
      • articular fragment separated from shaft
Presentation
  • Physical exam
    • pain, deformity, swelling localizing to distal thigh/knee
    • evaluate skin integrity
    • vascular evaluation 
      • potential for injury to popliteal artery if significant displacement
      • if no pulse after gross alignment restored then angiography is indicated
  • Full trauma evaluation if high energy mechanism
Imaging
  • Radiographs
    • recommended views
      • AP
      • lateral
    • optional views
      • traction views
        • AP, lateral, and oblique traction views can help characterize injury but are painful for patient
      • adjacent joints
        • consider views of the remainder of the extremity to rule out associated injuries
      • contralateral femur
        • consider views of contralateral femur for pre-operative planning and templating
    • findings
      • Hoffa fracture 
        • intra-articular distal femoral fracture in the coronal plane
        • may be seen on lateral view
      • in elderly patients, evaluate for any pre-existing knee DJD
  • CT
    • obtain with coronal and sagittal reconstructions
    • useful for
      • establishing intra-articular involvement
      • identifying separate osteochondral fragments in the area of the intercondylar notch
      • identifying coronal plane fracture (Hoffa fracture  post
        • 38% incidence of Hoffa fractures in Type C fractures 
      • preoperative planning
    • if temporizing external fixation required, CT obtained after external fixation
  • Angiography
    • indicated when diminished distal pulses after gross alignment restored
    • consider if associated with knee dislocation
Treatment
  • Nonoperative
    • hinged knee brace with immediate ROM, NWB for 6 weeks
      • indications (rare)
        • nondisplaced fractures
        • nonambulatory patient
        • patient with significant comorbidities presenting unacceptably high degree of surgical/anesthetic risk
  • Operative
    • external fixation
      • temporizing measure until soft tissues permit internal fixation, or until patient is stable
      • avoid pin placement in area of planned plate placement if possible
    • open reduction internal fixation
      • indications
        • displaced fracture
        • intra-articular fracture
        • nonunion
      • goals
        • need anatomic reduction of joint
        • stable fixation of articular component to shaft to permit early motion
        • preserve vascularity
      • technique (see below)
      • postoperative
        • early ROM of knee important
        • non-weight bearing or toe touch weight-bearing for 6-8 weeks, up to 10-12 weeks if comminuted
        • quadriceps and hamstring strength exercises 
    • retrograde IM nail 
      • indications
        • good for supracondylar fx without significant comminution
        • preferred implant in osteoporotic bone
        • traditionally, 4 cm of intact distal femur needed but newer implants with very distal interlocking options may decrease this number, can perform independent screw stabilization of intercondylar component of fracture around nail
    • distal femoral replacement
      • indications
        • unreconstructable fracture
        • fracture around prior total knee arthroplasty with loose component
Surgical Techniques
  • ORIF Approaches
    • anterolateral
      • fractures without articular involvement or with simple articular extension
      • incision from tibial tubercle to anterior 1/3 of distal femoral condyle
      • extend up midlateral femoral shaft as needed
      • minimally invasive plate osteosynthesis: small lateral incision, slide plate proximally, use stab incisions for proximal screw placement
    • lateral parapatellar
      • fractures with complex articular extension
      • extend incision into quad tendon to evert patella
      • can be used for Hoffa fracture
    • medial parapatellar 
      • typical TKA approach
      • used for complex medial femoral condyle fractures
    • medial/lateral posterior
      • used for very posterior Hoffa fragment fixation
      • patient placed in prone position
      • midline incision over popliteal fossa
      • develop plane between medial and lateral gastrocnemius m.
      • capsulotomy to visualize fracture
  • Blade Plate Fixation 
    • indications
      • not commonly used, technically difficult
      • contraindicated in type C3 fractures
    • technique
      • placed 1.5 cm from articular surface
  • Dynamic Condylar Screw Placement 
    • indications
      • identical to 95 degree angled blade plate
    • technique
      • precise sagittal plane alignment is not necessary
      • placed 2.0 cm from articular surface 
    • cons
      • large amount of bone removed with DCS
      • difficult to place
  • Locked Plate Fixation 
    • indications
      • fixed-angle locked screws provide improved fixation in short distal femoral block   
      • supracondylar periprosthetic femur fractures in cruciate retaining TKA 
        • TKA component must be well-fixed to proceed with fracture fixation
    • technique
      • lag screws with locked screws (hybrid construct)
        • useful for intercondylar fractures (usually in conjunction with locked plate) 
        • useful for coronal plane fractures q
        • helps obtain anatomic reduction of joint
        • required in displaced articular fractures q
    • pros
      • percutaneous lateral application can minimize soft tissue stripping and obviate need for medial plate
    • cons
      • potential to create too stiff a construct leading to nonunion or plate failure
  • Non-fixed angle plates
    • indications
      • now largely obsolete due to tendency for varus malalignment
  • Retrograde interlocked IM nail  
    • indications
      • good for supracondylar fractures without significant comminution
      • preferred implant in osteoporotic bone
      • short nail rarely indicated, implant should at least reach lesser trochanter
    • approach
      • medial parapatellar
        • no articular extension present
          • 2.5 cm incision parallel to medial aspect of patellar tendon
          • stay inferior to patella
          • no attempt to visualize articular surface
        • articular extension present
          • continue approach 2-8 cm cephalad
          • incise extensor mechanism 10 mm medial to patella
          • eversion of patella not typically necessary
          • need to stabilize articular segments prior to nail placement
    • pros
      • requires minimal dissection of soft tissue
    • cons
      • less axial and rotational stability
      • postoperative knee pain
Complications
  • Symptomatic hardware
    • lateral plate
      • pain with knee flexion/extension due to IT band contact with plate
    • medial screw irritation
      • excessively long screws can irritate medial soft tissues
      • determine appropriate intercondylar screw length by obtaining an AP radiograph of the knee with the leg internally rotated 30 degrees
  • Malunions 
    • most commonly associated with plating, usually valgus
    • functional results satisfactory if malalignment is within 5 degrees in any plane
  • Nonunions 
    • up to 19%, most commonly in metaphyseal area, with articular portion healed (comminution, bone loss and open fractures more likely in metaphysis)
    • decreasing with less invasive techniques
    • treatment with revision ORIF and autograft indicated 
    • consider changing fixation technique to improve biomechanics
  • Infection
    • treat with debridement, culture-specific antibiotics, hardware removal if fracture stability permits
  • Implant failure
    • up to 9%
    • titanium plates may be superior to stainless steel
    • most likely due to improper bridge plating techniques 
 

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Technique Guides (2)
Questions (11)

(OBQ12.56) During surgical treatment of the most common variation of distal femoral "Hoffa" fractures, which of the following orientations for screw fixation should be used? Review Topic

QID: 4416
1

Medial to lateral screw placement across lateral femoral condyle

4%

(140/3475)

2

Anterior to posterior screw placement across medial femoral condyle

27%

(945/3475)

3

Medial to lateral screw placement across medial femoral condle

7%

(255/3475)

4

Anterior to posterior screw placement across lateral femoral condyle

58%

(2009/3475)

5

Anterior to posterior screw placement across intercondylar notch

3%

(94/3475)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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(OBQ08.196) Which of the following treatments of an oligotrophic supracondylar femoral nonunion has been shown to have the best outcome? Review Topic

QID: 582
1

Retrograde femoral nailing with adjunct BMP-4

12%

(66/570)

2

Hybrid external fixation with adjunct BMP-4

2%

(9/570)

3

Usage of a percutaneous locking plate with adjunct BMP-3

4%

(21/570)

4

Open reduction and plating with autograft

80%

(454/570)

5

Open reduction and plating with adjunct calcium phosphate

3%

(17/570)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ13.57) 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? Review Topic

QID: 4692
FIGURES:
1

Implant B is better able to control fractures with a small distal segment than Implants A and C.

1%

(53/3862)

2

Implant C is better able to control coronal plane fractures than Implants A and B.

59%

(2288/3862)

3

During insertion, Implant C results in removal of a larger amount of bone, compared with Implants A and B.

2%

(77/3862)

4

Implant A demonstrates less subsidence and greater load to failure compared with Implant C.

12%

(453/3862)

5

Implant A demonstrates lower fixation strength in torsional loading compared with Implant C

25%

(970/3862)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ06.70) 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? Review Topic

QID: 181
FIGURES:
1

Tibial eminence fracture

2%

(20/1077)

2

Sagittal plane fracture of the medial femoral condyle

13%

(142/1077)

3

Schatzker I tibia plateau fracture

3%

(28/1077)

4

Coronal plane fracture of the lateral femoral condyle

79%

(850/1077)

5

Axial plane fracture through the medial femoral condyle

3%

(29/1077)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ12.33) 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? Review Topic

QID: 4393
FIGURES:
1

AP fluoroscopic imaging with the leg in 30 degrees of internal rotation

61%

(3292/5391)

2

AP fluoroscopic imaging with the leg in 30 degrees of external rotation

18%

(948/5391)

3

AP fluoroscopic imaging with the knee in full extension

6%

(330/5391)

4

Lateral fluoroscopic imaging with the knee in 30 degrees of internal rotation

9%

(504/5391)

5

Lateral fluoroscopic imaging with the knee in 15 degrees of flexion

5%

(275/5391)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ05.145) Which of the following is the most appropriate clinical scenario to utilize locking plate and screw technology? Review Topic

QID: 1031
1

Intra-articular fracture

10%

(59/570)

2

Oblique ulnar diaphyseal fracture

4%

(20/570)

3

Osteoporotic periprosthetic distal femur fracture

83%

(473/570)

4

Transverse tibial diaphyseal fracture

2%

(9/570)

5

Spiral humeral diaphyseal-metaphyseal fracture

1%

(8/570)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ11.44) 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? Review Topic

QID: 3467
FIGURES:
1

Traction and splinting

0%

(11/2803)

2

Lag screw fixation followed by non-locking plate application

3%

(73/2803)

3

Retrograde supracondylar nail fixation

5%

(127/2803)

4

External fixation and percutaneous screw reduction of the fracture

1%

(28/2803)

5

Lag screw fixation followed by locking plate application

91%

(2552/2803)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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