distal femur fracture

CHẤN THƯƠNG CHỈNH HÌNH

1. Supracondylar femoral fractures
Distal Femoral Fractures
Dr. le trinh

Orthopaedcis & Traumatology Department

2. Supracondylar femoral fractures
Objectives
Classification—important for decision making:
- Surgical anatomy
- Different implant choices

3. Supracondylar femoral fractures
Epidemiology
–6% of all femur fxs
–Younger / High Energy
•50% (intraarticular) Open
•1/3 Polytrauma
•1/5 Isolated
–Older / Osteoporotic
Low Energy / Prostheses

4. Supracondylar femoral fractures
Deforming forces
- Quadriceps  shortening

- Adductors  varus

- Gastrocnemius  recurvatum

5. Supracondylar femoral fractures
Müller AO classification of fractures
- 3 femur
- 33 distal femur

A1 A2 A3
B1 B2 B3
C1 C2 C3
- C complete articular
- A extraarticular



- B partial articular

6. Supracondylar femoral fractures
Hoffa fracture 33-B3
- Coronal split
- Posterior femoral condyle
- No DCS (dynamic condylar screw)
- No blade plate

7. Supracondylar femoral fractures
Lateral x-ray
Articular arcs of both condyles

8. Supracondylar femoral fractures
Traction x-ray…
CT
… better evaluates fracture

9. Supracondylar femoral fractures
Distal femoral geometry
- Mechanical axis

- Center of hip, knee, ankle

- Knee joint axis

- Anatomic axis

- 7–9° valgus

10. Supracondylar femoral fractures
Trapezoidal shape
10 ° 25°
Distal femoral geometry

11. Supracondylar femoral fractures
Trapezoidal Cross-section
–X-ray Shadow
–Medial Hardware
Protrusion
–Pain

12. Supracondylar femoral fractures
Trapezoidal Cross-section
–X-ray Shadow
–Medial Hardware
Protrusion
–Pain

13. Supracondylar femoral fractures
Trapezoidal Cross-section
–X-ray Shadow
–Medial Hardware
Protrusion
–Pain

14. Supracondylar femoral fractures
- Medial cortex slopes 25º
10 ° 25°
Distal femoral geometry

15. Supracondylar femoral fractures
- Trapezoidal shape

- Patellar sulcus
10 ° 25°
Distal femoral geometry

16. Supracondylar femoral fractures
- Trapezoidal shape

- Patellar sulcus

- Notch
10 ° 25°
Distal femoral geometry

17. Supracondylar femoral fractures
- Direct screws to avoid joint

- Too long  out medial

- AP x-ray—screws end
1 cm short of projected
medial cortex

Distal femoral geometry

18. Supracondylar femoral fractures
- Lateral cortex slopes 10º

- Must internally rotate implant
fractionally

Distal femoral geometry
10 ° 25°
W

19. Supracondylar femoral fractures
Implant options
- Lateral buttress plate (Nonlocking)

- Retrograde intramedullary nail

- Fixed angle devices:
- Dynamic condylar screw
- Blade plate
- Lateral condylar locking plate
- LISS (less invasive stabilization system) plate

20. Supracondylar femoral fractures
Blade plate
- Great resistance to bending &
torsion

- Preserves bone

- Technically demanding

21. Supracondylar femoral fractures
Dynamic condylar screw
Fixed angle device

- Allows correction in flexion /
extension plane

- Easier to use

22. Supracondylar femoral fractures
ORIF (open reduction and internal fixation) technique
DCS/blade plate
Summation wire technique:
- A K-wire along joint line
- B K-wire along anterior condyle
- C Summation K-wire parallel to A and B

23. Supracondylar femoral fractures
ORIF technique
DCS/blade entrance site
- Junction anterior & middle third

- 1.5–2 cm above joint line

24. Supracondylar femoral fractures
Wrong Entry Site
Produces Deformity
TOO POSTERIOR

Condyles Shift:
• Anterior
• Medial
• Varus

25. Supracondylar femoral fractures
Operative goals
- Anatomic articular reduction

- Axial alignment

- Stable fixation—early range of movement

- Preservation of blood supply

26. Supracondylar femoral fractures
Surgical timing
- Respect soft tissues

- If questionable, spanning external fixator

27. Supracondylar femoral fractures
Position for Surgery

28. Supracondylar femoral fractures
Lateral approach
Elevate vastus lateralis off lateral
intermuscular septum

29. Supracondylar femoral fractures
Parapatellar approach
- Better exposure of condyles

- Damage to muscle  fibrosis

30. Supracondylar femoral fractures
Lateral buttress plate
Nonlocking
- Need stable medial buttress

- Varus collapse

31. Supracondylar femoral fractures
Insufficient medial buttress
- Medial plate
- Damages blood supply
- Fixed angle device

32. Supracondylar femoral fractures
LCP—osteoprosis

33. Supracondylar femoral fractures
LISS & locking condylar
- Fixed angle device

- Locking screws

- Great benefit in osteoporotic
bone

34. Supracondylar femoral fractures
LISS—internal fixator with angled distal screws

35. Supracondylar femoral fractures
Very strong pull out strength

36. Supracondylar femoral fractures
First steps
- Reduce articular surface

- Lag screws

- Must place screws where they won’t interfere with your other fixation

37. Supracondylar femoral fractures

38. Supracondylar femoral fractures
Bridging plate

Preserve the blood supply

Mechanical

Biology

39. Supracondylar femoral fractures
Retrograde intramedullary nail
- Extraarticular fractures

- Hard to get anatomic
alignment

- May ―blow out‖ unrecognized
intercondylar fractures

40. Supracondylar femoral fractures
Retrograde intramedullary nail
- Ideal for periprosthetic
fractures

- Femoral component must
have an open notch

41. Supracondylar femoral fractures
Fracture with Prosthesis ??
Long LCP

Long DCS

Long condylar plate

Long LISS

42. Supracondylar femoral fractures
MIPO approach -
preserve biology

43. Supracondylar femoral fractures
Complications
- Malalignment—technical problems
- Recurvatum—due to gastrocnemius pull

- Loss of reduction—poor implant choice
- Varus—nonlocking buttress plate

- Failure of fixation—osteoporosis

- Nonunion

- Knee stiffness

44. Supracondylar femoral fractures
Pitfall to avoid complication
–Understand the anatomy
–Well visualized the fracture pattern
(CT scan)
–Choose your Suitable implant
–Well plan operation
–Prepare the unexpected

45. Supracondylar femoral fractures

46. Supracondylar femoral fractures
Summary
- Understand anatomy of distal femur

- Use the right implant for fracture pattern

- Respect the soft tissues