PT Management of Fractures of Condyles of Femur

PT Management of Fractures of Condyles of Femur

1. PT Management of Fractures of Condyles of Femur

2. INTRODUCTION The fractures of condyles of Femur are classified under ‘Distal Femur Fractures’. Distal Femur fractures are the ones that occurs at the distal end of the femur bone, which includes the femoral condyles and the metaphysis. Distal femur fractures most often occur either in older people whose bones are weak, or in younger people who have high energy injuries, such as from a car crash. Most common types of distal femur fractures : Transverse fractures Comminuted fractures Intra-articular fractures

3. CLASSIFICATION Fracture of Condyles of Femur are majorly divided into Supracondylar Fracture of Femur Intercondylar Fracture of Femur

4. Supracondylar Fracture of Femur A supracondylar femur fracture involves the distal aspect or metaphysis of the femur. This area includes the distal 8 to 15 cm of the femur .

5. Conservative Treatment The fracture is reduced under general anesthesia and the limb is immobilized in a Thomas’ splint . Skeletal traction is applied through the upper end of the tibia and the knee is maintained in 30 degrees of flexion using a Pearson knee attachment. If the fracture is only slightly displaced and extra-articular, or if it reduces easily with the knee in flexion, it can be treated quite satisfactorily by traction through the proximal tibia; the limb is cradled on a Thomas’ splint with a knee flexion piece and movements are encouraged . If the distal fragment is displaced by gastrocnemius pull, a second pin above the knee , and vertical traction, will correct this. At 4–6 weeks , when the fracture is beginning to unite, traction can be replaced by a cast-brace. The limb is immobilized for 8–12 weeks.

6. FIG. Fracture of the distal femur: treatment by skeletal traction through upper tibial pin. Pearson knee attachment to the Thomas’ splint facilitates movement at the knee joint, which the patient can do himself.

7. Operative Treatment External Fixator: If the soft tissues around the fracture are badly damaged, or if it will take time before the patient can tolerate a longer surgery because of health reasons, your doctor may apply a temporary external fixator. In this type of operation, metal pins or screws are placed into the middle of the femur and tibia. 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 the patient is ready for surgery.

8. FIG. External Fixator

9. Operative Treatment Internal Fixator: The mainstay of surgical management for distal femur fractures is retrograde nailing or open reduction internal fixation (ORIF ). Retrograde intramedullary nailing is indicated in more proximal extra-articular fractures or simple intra-articular fractures, whilst an ORIF with a distal femoral plate is often indicated for more distal fractures or complex intra-articular fractures Intramedullary nailing : During this procedure, a specially designed metal rod is inserted into the marrow canal of the femur. The rod passes across the fracture to keep it in position. Plates and screws : During this operation, the bone fragments are first repositioned into their normal alignment. They are held together with special screws and metal plates attached to the outer surface of the bone . Commonly used fixator devices include the 95-degree condylar blade plate and the 95-degree dynamic compression screw.

10. A B C FIG . A. Condylar blade plate, B. Dynamic compression screw ( DCS), C. intramedullary supracondylar nail

11. Complications Arterial damage : There is a small but definite risk of arterial damage (esp. i njury to the popliteal artery) and distal ischemia. Careful assessment of the leg and peripheral pulses is essential. Malunion : Internal fixation of these fractures is difficult and malunion – usually varus and recurvatum – is not uncommon. Corrective osteotomy may be needed for patients who are still physically active. Non Union : Factors contributing to union problems include infection at the fracture site, interposition of tissue between the bone ends , excessive space between bone fragments (bone gap ) etc. Knee Stiffness : probably due to scarring from the injury and the operation – is almost inevitable. A long period of exercise is needed in all cases Secondary Knee osteoarthritis : Arthritis caused by fracture or injury is called post-traumatic arthritis. It can be treated like other forms of osteoarthritis — with physical therapy, braces, medications, and lifestyle changes.

12. Intercondylar Fracture of Femur When both condyles are fractured, the fracture line may pass through the condyles resulting in a T- or Y-shaped fracture. It generally occurs as a result of severe trauma . Since it is an intra-articular fracture, it is usually associated with haemarthrosis .

13. Conservative treatment The plan of treatment is the same as for supracondylar fractures of the femur . Skeletal traction is applied through the upper tibia and is maintained for 6–8 weeks. Knee mobilization is started after 6–8 weeks .

14. Operative treatment In all intra-articular fractures, accurate reduction of the fracture, thereby achieving congruity of the articular surfaces, is essential. Therefore, if the fracture is not too comminuted, open reduction and internal fixation of the fracture is indicated. Internal fixation is achieved by multiple screws, Kirschner wires or blade plate. Knee mobilization is started early, i.e., after 2 weeks only . A B

15. Plates that are applied to the lateral surface of the femur : traditional angled blade-plates or 95 degree condylar screw-plates. For severely comminuted ( B) fractures, the newer plate designs with locking screws appear to offer an advantage over other implants; they provide adequate stability, even in the presence of osteoporotic bone, but (as with compression plates ) unprotected weightbearing is best avoided until union is assured. Simple lag screws – these suffice for (A) fractures and are inserted in parallel, with the screw heads buried within the articular cartilage to avoid abrading the opposing joint surface. They are also used to hold the femoral condyles together in ( B) fractures before intramedullary nails or lateral plates are used to hold the main supracondylar break

16. FIG. (a ) A single condylar fracture can be reduced open and held with Kirschner wires preparatory to (b) inserting compression screws . (c) T- or Y-shaped fractures are best fixed with a dynamic condylar screw and plate (d). a b c d

17. Complications Injury to the popliteal neurovascular bundle, especially injury to the popliteal artery needs immediate repair. Postoperatively , there is a danger of infection to the superficially placed implants. This needs careful monitoring. Knee stiffness, osteoarthritis of the knee joint and malunion are possible late complications.

18. Physiotherapeutic management Objectives: Range of Motion : Improve and restore range of motion ( atleast functional) of the knee, hip , and ankle. Muscle Strength : Improve and restore the strength of the following muscles: Quadriceps , Hamstrings, Adductor magnus , longus and brevis group-hip adductors (attached to the femoral condyle) Gastrocnemius etc. Functional Goals : Normalize gait pattern and achieve proper sitting position (knee flexion of 90 degrees).

19. The common problems faced during management: 1 . Gross effusion of the knee 2. Knee stiffness – due to adhesions and involvement of the articular surfaces 3. Knee instability – the fracture, especially a comminuted one, may be associated with injuries to the soft tissues including ligaments; unless the soft tissue repair and bone architecture are properly restored, instability and stiffness of the knee are common features 4. Reflex inhibition of the quadriceps (extensor lag) – due to quadriceps insufficiency Therefore, right from the initial period, it is absolutely essential to plan appropriate physiotherapeutic measures to control these four complications . Therapeutic measures are employed to minimize effusion ; and acquire early ROM at the knee while maintaining reduction and emphasis on the early and strong isometrics to the quadriceps .

20. Management: One Week Initially, the most important aspect to check is the patient's neurovascular status. Check pulses, as well as sensation. DO NOT perform passive range of motion of the knee at any point unless absolutely rigid fixation has been achieved . Correct positioning of the fractured limb should be ensured repeatedly. Initially, when the fracture is treated with skeletal traction, the following programme is instituted: 1. Limb elevation, pressure bandage and isometrics to the quadriceps and glutei are performed . 2. Strong ankle and toe movements are given . The patient is non-weight bearing on the affected extremity for 3 months.

21. Management: 7 to 10 days Gradual knee mobilization is started after a week or 10 days. It may be started as a relaxed passive movement preceded by thermotherapy or cryotherapy . Self-controlled mobilization by continuous passive motion (CPM) is very effective. Early mobilization improves and maintains the tone and strength of the quadriceps besides facilitating gliding planes of quadriceps mechanism. Patients are encouraged to perform active range-of-motion exercises at the knee joint with the goal of full extension and 60 degrees to 90 degrees of knee flexion . Patients who are non-compliant or cannot follow orders are placed in a hinged-knee brace or cast brace to allow for protected range-of-motion exercises . The patient is instructed in stand/pivot transfers using crutches or a walker, with no weight-bearing on the affected extremity. The patient is instructed in a two-point gait using crutches or a walker with no weight bearing on the affected extremity (placing the crutches first and then hopping to the crutches on level surfaces No strengthening exercises are prescribed at this point to avoid risk of fracture displacement.

22. Management: Two weeks Check the wound for erythema or discharge. Evaluate for any crepitus or varus /valgus or sagittal angulation, which signifies loss of fixation . Check sensation, pulses, especially if there was any previous neurovascular compromise. Continue active range-of-motion exercises to the hip , knee, and ankle. If the fixation is rigid, active-assistive range-of-motion exercises are prescribed to the ankle to avoid stiffness and limitations in range of motion. Isometric exercise of the quadriceps may be prescribed when the patient is in bed, supine, with the knee in full extension. This is to avoid any pull on the fracture site and displacement of the fracture . Straight-leg-raising exercises are prescribed to strengthen the quadriceps. Continue with non-weight bearing on the affected extremity during stand/pivot transfers and ambulation. The patient uses crutches or a walker.

23. Management: Four to Eight weeks Continue active range-of-motion exercises to the knee joint with the goal of full extension and flexion of 90 degrees or greater at this time . Continue full range-of-motion exercises to the hip and ankle . Gentle active-assistive exercises to the knee are prescribed if the fracture is stable . The patient can sit in a chair and slide the foot forward on the floor to allow at least 60 degrees in extension and backward to allow more than 90 degrees of flexion. These are called stool-scoot exercises . Isometric exercise of the quadriceps and hamstrings are performed, as are ankle and gluteal isometric exercises. Continue stand/pivot transfers because the patient is still non-weight bearing on the affected extremity.

24. Management: Eight to Twelve weeks The patient should continue active and active-assistive range-of-motion exercises to the knee. By this time, more than 90 degrees flexion of the knee should be possible . Gentle passive range of motion may be allowed if there is any stiffness in the knee. Patients should work on improving quadriceps and hamstring muscle strength with isometric exercises. Isotonic strengthening exercises also are prescribed. Repetitive isotonic exercises increase strength and improve range of motion. Because patients are non-weight bearing on the affected extremity, they should continue stand/pivot transfers using crutches or a walker.

25. Management: Twelve to Sixteen weeks Check the limb for alignment and angular deformities. Check the wound for erythema or discharge . As long as bone healing is progressing properly, weight bearing may be started, beginning with toe-touch ambulation ( w eight-bearing status case-specific, but in most cases to start with PWB (15% of body weight) and progressing to full weight bearing as tolerated by the patient . If full range of motion of the knee is not obtained by this time , active-assistive range of motion can be instituted to the patient's pain tolerance . Passive range-of-motion exercises to the knee can continue if joint stiffness is present. Gentle resistance is applied to increase muscle strength. The resistance is progressively increased as are the numbers of repetitions . The patient is instructed in weight-bearing transfers on the affected extremity using crutches .

26. Management: Twelve to Sixteen weeks The patient is instructed to bear weight on the affected extremity during ambulation, beginning with toe-touch partial weight bearing and gradually progressing to full weight bearing. The patient may use a three-point or four-point gait, depending on the amount of weight borne on the affected extremity.

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