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1. Distal Femur Fractures Assoc. Prof. Dr.MD.Tajul Islam Unit Chief Blue Unit 2 National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR)

2. Learning Objectives Define distal femur fractures Review epidemiology and mechanisms Understand classification systems Learn imaging and surgical management Discuss complications and rehabilitation

3. Epidemiology Account for ~0.4% of all fractures Bimodal: young (high-energy trauma) and elderly (low-energy, osteoporotic) Slight female predominance in elderly

4. Mechanism of Injury High energy: RTA , falls from height Low energy: osteoporotic fractures Often associated with polytrauma

5. Anatomy Distal femur = metaphysis + condyle Medial and lateral condyles form knee joint Trochlear groove, intercondylar notch Popliteal vessels posteriorly

6. Blood Supply & Soft Tissue Supplied mainly by femoral and popliteal arteries Close proximity to neurovascular bundle Soft tissue envelope critical for healing

7. Classification Overview AO/OTA classification (33): - 33A: Extra-articular - 33B: Partial articular - 33C: Complete articular Special: Hoffa (coronal plane)

8. AO/OTA 33A (Extra-articular) Simple or comminuted metaphyseal fracture Does not involve articular surface

9. AO/OTA 33B (Partial articular) Involves one condyle only May include coronal (Hoffa) fracture

10. AO/OTA 33C (Complete articular) Bicondylar fracture with articular involvement High complexity, requires CT for planning

11. AO Classification

12. A for extra-articular A1: Simple A2: Metaphyseal wedge A3: Metaphyseal complex B for partial articular Lateral condyle sagital Medial condyle sagital Coronal

13. C for intra-articular C1: Articular simple, metaphyseal simple C2: Articular simple, metaohyseal multifragmentary C3: Articular multifragmentary

14. Hoffa Fracture Coronal plane fracture of femoral condyle Often missed on X-ray Best seen on CT scan

15. Clinical Features Pain, swelling, deformity Inability to bear weight Hemarthrosis common Assess for distal neurovascular status

16. Plain Radiographs AP and lateral of knee Must include joint above and below Merchant/notch view for posterior condyles

17. Notch view x-ray knee

18. CT Scan Essential for intra-articular fractures Helps define fragments and plan fixatio n

19. MRI (rare use) Rarely indicated Useful for ligamentous/meniscal injury May show occult fracture lines

20. Non-operative Management Indications: non-displaced, medically unfit Immobilization: cast or brace Risks: stiffness, malunion

21. Operative Principles Goals: restore articular surface, length, alignment Stable fixation to allow early ROM Choice depends on fracture pattern

22. Locking Plate Fixation Lateral LCP most common Angular stability Minimally invasive techniques (MIPO)

23. Retrograde Intramedullary Nail Entry: intercondylar notch Indicated in simple, extra-articular Contraindicated in severe comminution/articular fractures

24. Dual Plating / Hybrid Fixation Indicated in severe metaphyseal comminution Increases stability

25. Lateral Surgical Approach Standard for lateral plate fixation Good exposure of lateral condyle

26. Medial Surgical Approach Used for medial condyle/Hoffa fractures Careful dissection to protect neurovascular structures

27. Minimally Invasive (MIPO) Small incisions, indirect reduction Preserves blood supply Requires fluoroscopy

28. Post-operative Protocols Early ROM when fixation stable Weight-bearing delayed (6–8 weeks) DVT prophylaxis, wound care

29. Rehabilitation Quadriceps strengthening exercises Progressive ROM Full weight bearing at ~10–12 weeks

30. Complications Early- Arterial damage- There is little chance but definite risk of arterial damage & distal ischemia. Late- Joint stiffness- is almost inevitable Malunion- varus malunion & recurvatum is not uncommon Non-union- can be avoided by minimal soft tissue damage & exposing only those part that are required for reduction.

31. Key Takeaways Distal femur fractures are complex Classification and CT essential Stable fixation enables early ROM Complications are common and must be anticipated

32. Wh en the knee joint is fully extended , the pull of the gastrocnemius muscle on the one hand and of the adductor magnus muscle on the other hand leads to genu recurvatum and shortening. With the knee flexed approximate ly at 60 degree over a knee support this mal-alignment of the distal fragments can easily be corrected. The shortening is best approached by manual traction or with a distractor . Nice to know

33. Thank you all