Distal intraarticular femoral fracture Case for small group discussion: Management principles for the treatment of articular fractures This is a polytrauma case but the facilitators should focus on the treatment of the distal femur articular injury. Try to help the students with the parts of the case that are extraneous to the distal femur. These cases are hard to treat and they represent real life. Distal femoral fractures often represent high-energy trauma. Discussion points: Fracture classification Type of stability Patient positioning Reduction techniques (use of femoral distractor vs traction table), tips & tricks Reestablishing axis and alignment Aftertreatment Richard Buckley, CA AOT Principles Basic Course

Case description 26-year-old man Motorcycle accident Grade 2 right open intraarticular distal femoral fracture Ipsilateral femoral shaft and nondisplaced patella and minimally displaced tibial plateau fractures Neurovascular intact No other injuries

Open distal femur—clinical picture Open with small wound proximal to the patella and over the patella. The quadriceps tendon is intact. The mid femur is open as well but is not an important part of the case. Day 0

Trauma x-rays—now what ? No other x-rays of the distal femur or the proximal tibia. Right ankle exam is normal. Day 0

Classification of distal femoral fracture? To OR for debridement, irrigation, closure, and external fixation—then CT scan Classification of distal femoral fracture? External fixator was applied after the wounds were cleaned. Concentrate on the distal femur even though there is a mid femoral fracture as well: Classification is up for debate. Certainly C type and at least a 2. 33-C2.3 Day 1

Day 1 What does the CT tell us about the joint surface? What are the reasons for establishing the external fixator? What is the first goal of definitive fixation of the distal femoral fracture? Take note of the Hoffa fracture and discuss the difficulty in possible reduction tactics. External fixation: relaxes soft tissues, stabilizes the fractures, aids in obtaining a CT, allows for preoperative planning. Comment on tibial plateau fracture evident on CT. Day 1

What needs to be done before approaching the fracture of the distal femur? What types of reduction aids to reduce this fracture? Direct or indirect techniques? IM nailing of the femur must be performed first; plate fixation would be an option if justified. Day 2

Day 2 Patient positioning for second fracture? What is the priority in regard to this fracture? What types of reduction aids to reduce this second fracture? Incisions? Direct or indirect techniques? Probably need an incision in midline somewhere, medially or laterally, to reduce the Hoffa fragments and to ensure that the intercondylar split is reduced accurately. Direct reduction of the joint. Day 2

Reduction techniques to connect the shaft to the distal femoral block? Relative or absolute stability? Final x-rays after fixation of proximal tibia and patella Metaphyseal reduction with joysticks (closed reduction). There is too much comminution for absolute stability, so the fracture was bridged. Day 2

Rehabilitation plan Day 3–90 How long to use antibiotics? How long before motion to begin? Active or passive motion? How long to keep non or toe-touch weight bearing? DVT prophylaxis? Antibiotics for 1 day minimum to as long as 3 days. Usually 1-2 weeks for soft tissue healing and then early active ROM. Toe touch weight bearing. LMW heparin for about 5 weeks. Day 3–90

Final x-rays with good function of lower extremity Note that the mid femur which was stabilized with relative stability shows large amounts of callus. Note that the metaphyseal fracture which was also fixed with relative stability has healed with callus, too. 6 months

Final x-rays with good function of lower extremity Long-term prognosis of this joint should be fairly good as alignment is quite good. 6 months

Final outcome: Return to labor job at 6 months with a mild limp Satisfactory soft-tissue rehabilitation but still some quadriceps atrophy. 6 months

Summary and take-home message Open fracture takes precedence for initial treatment. Initial external fixation allows for soft-tissue stabilization and further radiologic investigation. Femoral shaft fracture is prioritized ahead of the articular distal femoral fracture as it can be a life-threatening problem. Articular reduction must be as perfect as possible with special attention to the posterior condyles which are difficult to see. Then the “end block” or articular segment is reduced in a stable fashion (absolute or relative stability) . Early ROM will help restore function for such a severe joint injury. Ask participants to summarize the case discussion. Note reference as very few good references exist in this area and no prospective randomized trials: Zlowodzki M, Bhandari M, Marek DJ, et al. Operative treatment of acute distal femur fractures: systematic review of 2 comparative studies and 45 case series (1989 to 2005). J Orthop Trauma. 2006 May;20(5):366–371. Zlowodzki M et al (J Orthop Trauma. 2006;20:366–371)