Femoral Supracondylar Fractures: Prepared by Dr. Ramzy Sh. Shikhan
Femoral Supracondylar Fractures: Prepared by Dr. Ramzy Sh. Shikhan
Femoral Supracondylar Fractures: Prepared by Dr. Ramzy Sh. Shikhan
Supracondylar
fractures
Prepared by
Dr. Ramzy Sh. Shikhan
Introduction
• A.K.A distal femure fractures
• represent about 6% of all femoral fractures.
• typically occur after high-energy trauma in younger patients or after low-
energy trauma inthe elderly with osteoporotic bone.
• One-third of the younger patients have multiple-system trauma and only a
fifth of cases occur as an isolated injury.
• There is usually considerable soft-tissue damage and almost 50% of high-
energy, intraarticular distal femoral fractures are open injuries.
• With the increasing number of patients with knee joint replacement, the
incidence of periprosthetic fractures has been increasing in recent years.
Anatomy of the distal femur
• The shape of the distal femur, when viewed end on, is a trapezoid with
the posterior part wider than the anterior part, creating about 25° of
inclination on the medial surface and about 10° on the lateral surface.
• A line that is drawn from the anterior aspect of the lateral femoral
condyle to the anterior aspect of the medial femoral condyle
(patellofemoral inclination) slopes posteriorly approximately 10°.
• The normal anatomical axis of the femoral shaft relative to the knee or
the anatomical lateral distal femoral angle (LDFA) is 80–84°.
• Measured contralateral LDFA can be used as a reference for the
assessment of coronal alignment.
• Vertical axis : from wt bearing AP radio. A vertical line that extends distally from
the center of the symphysis pubis. This is used as a reference line from which
other axes are determined
• Mechanical axis : drawing a line from the centre of the femoral head to the centre
of the ankle joint. Has a 3 degree slope from the vertical axis. Subdivided to :
• Femoral mechanical axis: head of femur to the intercondylar notch of distal femur
• Tibial mechanical axis : from centre of proximal tibia to ankle centre
((the medial angle formed between the latter two form the HKAA which is slightly
less than 180 degrees
• Anatomical axis : two methods
• Line drawn proximal to distal in the intramedullary canal bisecting the
femur in one half
• Point at femoral shaft centre to a point 10cm above the knee joint
located at an equal distance between the medial and lateral cortex.
• Femoral anatomical axis deviates 5-7 degrees from the mechanical
axis (valgus)
• The normal knee joint alignment is 2-3 varus compared to mechanical
axis
Pathomechanics
• Gastrocnemius: extends distal fragment ( apex posterior)
• Hamstring and extensor mechanism :cause shortening
• Adductor magnus: leads to distal femoral varus.
• indications:
1. Non displaced fractures
2. Non ambulatory patient
3. Patient with significant comorbidities ( ASA CLASS 4-5)
OPERATIVE
• External fixation :
Temporary until soft tissue condition permits definitive fixation
• The indications for temporary joint-bridging external fixation are:
• 1-polytrauma patients,
• 2-open fractures or dislocations
• 3-closed fractures with severe soft-tissue trauma or vascular damage.
• If possible, the articular block is reconstructed with minimal internal fixation
using 3.5 mm conventional or cannulated lag screws. Then, the joint-bridging
external fixator is mounted with Schanz screws far from the zone of injury.
• Schanz screws are inserted anteriorly in the femur to avoid
incisions for definitive treatment and anteromedially in the
tibia
Definitive fixation
• The traditional concept of open reduction and internal fixation(ORIF)
of distal femoral fractures which advocated an extended approach to
the multifragmentary fracture zone at the metaphysis is not favored
because of the high rate of nonunion and failure.
• The biological plating concept uses less traumatic approaches, with
careful handling of the soft tissue envelope and is now the gold
standard.
• It is still mandatory to perform precise reconstruction of the anatomy
of the condyles and articular surface and to restore the correct limb
axis and rotation.
Implant selection
• MIPPO ( bridge plating )
• Retro grade IM nail (extra articular , minimal displaced, elderly)
• Locking( elderly) and non locking plates ( young) and buttressing plate
( to avoid superior displacement)
• 95 degree angled blade plate and dynamic condylar screw ( rarely
used now , technically demanding , needs experience)
• Less invasive stabilization system for the distal femur
Approaches
• standard lateral approach or modified standard lateral approach.
( extra articular fractures)
• Posteromedial corner: The PMC of the knee contains the superficial medial collateral
ligament(largest structure medially), the deep MCL, the posterior oblique
ligament(POL), the direct insertion of semimembranosus, and the medial head of the
gastrocnemius muscle. Also the medial meniscus aids in this
• Posterolateral corner: lateral collateral ligament, the popliteustendon and the
popliteofibular ligament. Also the lateral meniscus.
• Extensor mechanism : post dis. Usually disrupts this
• The popliteal fossa: vascular injury is the main concern here.
ER approach to the dislocated knee
• History : mechanism , any reduction attempts , spont. reduction.
• Exam : LOOK , FEEL , MOVE, provocative tests ( difficult in acute
settings-pain and spasm)
• The clinician must have a high index of suspicion for the presence of
multiligament knee injury with a low threshold for further evaluation
by magnetic resonance imaging (MRI) or examination under
anesthesia.
• If the knee has not been reduced before the examination,this allows
the examiner to define the direction of the dislocation.
• It is important to reduce the joint as soon as possible by means of
closed reduction.
• A delay of a few minutes to obtain an x-ray is reasonable but there
should not be a significant delay to obtain imaging.
• If the knee is dislocated and has an open wound, the reduction should
be performed as soon as possible in the operating room. Copious
irrigation is performed before reduction to avoid gross contamination
of the joint.
Closed reduction
• Ant: traction and anterior translation of femur
• Post: traction , extension and anterior translation of tibia
• Medial/lateral: traction and medial or lateral translation
• Rotatory: axial limb traction and rotation in opposite direction of
demformity
• N.B// posterolateral dislocation may have buttonholing and this should
alarm you to avoid closed reduction as there is high risk of skin necrosis.
• Afterward splint in 20-30 degrees of flexion
• Send for MRI after acute reduction but before hardware placement.
Vascular exam
• Priority is to rule of vascular injury before and after reduction
• Serial exams are mandatory.
• Palpate distal pulses:
• If present , doesn’t mean there is no vascular injury( masked by
collateral circulation) so : measure Ankle-Brachial Index( ABI)
• More than 0.9, 100% negative predictive value, keep on serial exams
• Less than 0.9….go for arterial duplex ultrasound or CT angio..whem
confirmed injury….. consult the vascular team.
• If absent or diminished :
• Confirm reduction or do immediate reduction and then reassess
• If still diminished…go for surgical exploration ( more than 8 hour delay has an 86% chance of
amputation)
• ((imaging is contra indicated if it will delay surgical revascularization.
• If pulses are present after the reduction…do ABI and consider observation versus angiography
• Do not forget to do full neurological assessment , mainly on the peroneal nerve ( big toe
dorsiflexion)
An important note
• A detailed vascular clinical examination is recommended at
admission, after 4–6 hours and at 24 and 48 hours.
• This must be clearly documented in the medical records .
• Late popliteal artery thrombosis, usually associated with an
asymptomatic intimal tear, is a recognized and devastating
complication.
• Take radiographs , compare with the normal side
• Look for avulsion fractures such as segond fracture which is avulsion
fracture of the lateral tibial condyle)
Open reduction
For :
1. Irreducible knee
2. Posterolateral dislocation
3. Open fracture dislocation
4. Vascular injury
5. Obesity ( may be difficult to obtain closed)
External fixation
For :
1. Vascular repair with fractures
2. Open fracture dislocation
3. Compartment syndrome
4. Polytrauma
Delayed ligamental repair
• Ideally within 3 weeks ( not more than 8 weeks) to allow for soft
tissue swelling and trauma to subside.
Complications
• Vascular compromise: 5-15:, post KD, KD class 4 ( treatment is
emergency repair and prophylactic fasciotomy)
• Stiffness: 38% , most common
• Laxity and instability : 37%
• Peroneal nerve injury: 25% , 50% recover partially
Any questions ?
Tibia plateau fracture
introduction
• The incidence of proximal tibial fracture is about 18.6% of all tibial
fractures
• bimodal distribution:
males in 40s (high-energy trauma)
females in 70s (falls)
• Location: unicondylar vs. bicondylar
• frequency
• lateral > bicondylar > medial
• Mechanism: varus/valgus load with or without axial load
#high energy
• frequently associated with soft tissue injuries
#low energy
• usually insufficiency fractures
Associated conditions
• meniscal tears