distal femur fractures classification with treatment

A brief presentation on distal femur fractures

1. Distal femur fractures Presented by UNIT 2 PGT1 Moderator - Dr Sushant Srivastava

2. Top 5 learning objectives Anatomy Fracture classification Management Post op rehabilitation Complications

3. Introduction

4. History 1960’s and earlier: Skeletal traction favored Neer et al. (JBJS 1967) advocated for closed, non-operative treatment based on poor results and high complications resulting from ORIF 1960’s: Angled blade plate introduced and subsequently the dynamic condylar screw (DCS) plate improved fixation options.

5. 4. 1990’s: ORIF established as the standard of care (Butt et al., JBJS Br 1996) 5. 2000’s: Early iterations of the lateral locking plates improved outcomes 6. 2010’s: Improved plate design and ongoing experimentation with far cortical locking (FCL) and intramedullary (IM) nail design aim to improve non-union rates and allow for early weight-bearing.

6. Injury Considerations Mechanism of injury There is a bimodal distribution • Young patient: high energy ( fall from height) • Elderly: low energy fall on flexed knee

7. 3). Associated injuries Open fracture (5-10%) Knee ligament injury (up to 20% of cases) Tibial plateau fracture Patella fracture Acetabulum fracture Fmoral neck fracture Femoral shaft fracture

8. ANATOMY

9. Basic Anatomy Of Femur The distal end is characterised by the presence of the medial and lateral condyles, which articulate with the tibia and patella, forming the knee joint. Medial and lateral condyles - Rounded areas at the end of the femur. The posterior and inferior surfaces articulate with the tibia and menisci of the knee, while the anterior surface articulates with the patella.

10. 3). Medial and lateral epicondyles - Bony elevations on the non- articular areas of the condyles. They are the area of attachment of some muscles and collateral ligaments of knee joint. 4). Intercondylar fossa - A depression found on the posterior surface of the femur, it lies in between the two condyles. It contains two facets for attachment of internal knee ligaments .

11. 5). Facet for attachment of the posterior cruciate ligament - Found on the medial wall of the intercondylar fossa, it is a large rounded flat face, where the posterior cruciate ligament of the knee attaches. 6). Facet for attachment of anterior cruciate ligament - Found on the lateral wall of the intercondylar fossa, it is smaller than the facet on the medial wall, and is where the anterior cruciate ligament of the knee attaches.

12. 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. • Lateral cortex of femur slopes = 10 degrees, whereas medial cortex slopes = 25 degrees in axial plane.

13. DYNAMIC FORCES ACTING AROUND DISTAL FEMUR Strong muscles in the front of your thigh (quadriceps) and back of your thigh (hamstrings) support your knee joint and allow you to bend and straighten your knee.

14. 2). Deformity forces • Quadriceps >> shortening • Hamstring >> shortening • Gastrocnemius >> apex posterior angulation, posterior displacement • Adductors >> varus

15. Classification

16. Prior to classifying the fracture, consider • Amount of displacement • Degree of comminution • Extent of soft tissue injury • Damage to the articular surface • Bone quality • Associated fracture of patella or tibial plateau • Associated neurovascular injury • Presence of coronal fracture line

17. NEER CLASSIFICATION

18. Fracture classification : AO/OTA

19. 33A - Extra Articular

20. 33B - Partial Articular

21. 33C - Intra-articular

22. Investigations

23. X-RAY Obtain standard AP and Lat view.

24. 2) CT SCAN - obtain saggital and 3D reconstruction

25. Angiography - 1) indicated when diminished distal pulses after gross alignment restored. 2) Consider if associated with knee dislocation.

26. Management

27. Treatment options • Relative indications for non-operative management Patient factors •Medical contraindication to surgery • Non-ambulatory Fracture factors • Non-displaced fracture • Impacted, stable fracture • Non-reconstructable fracture • Severe osteopenia

28. Non Operative treatment modalities • Long-leg cast followed by hinge knee brace • Early range of motion is key to avoid stiffness

29. Operative indications • Majority of distal femur fractures do not meet non-operative indications • Operative Goals : 1) Anatomic reduction of articular surface 2) Functional reduction of the metaphysis restoring length, alignment, and rotation 3) Restoration of anatomic and mechanical axis of the limb 4) Stable fixation 5) Early range of motion

30. Surgical treatment modalities

31. External Fixation • Temporizing measure until soft tissues permit internal fixation, or until patient is stable • In this type of operation, metal pins or screws are placed into the middle of the femur and tibia (shinbone). The pins and screws are attached to a bar outside the skin. This device is a stabilizing frame that holds the bones in the proper position until you are ready for surgery. • Precaution avoid pin placement in area of planned plate placement if possible

32. 2) Open reduction internal fixation Indications 1- displaced fracture 2- intra-articular fracture 3- nonunion Goals : 1- need anatomic reduction of joint 2- stable fixation of articular component to shaft to permit early motion.

33. ORIF with Distal Femur Plating Pre Op Xray Post Op Xray

34. ORIF with Screw Fixation Pre Op xray

35. Retrograde IM Nailing Pre Op xray Post Op xray

36. THANKYOU …