Distal femoral fracture


Original Editor ­ - Leen Wyers

Top Contributors - Mande Jooste, Angeliki Chorti, Kim Jackson, Laura Ritchie, Lucinda hampton, Evan Thomas, Daphne Jackson, Admin, Leen Wyers, Karen Wilson and Claire Knott

Introduction

Distal femoral fractures involve the femoral condyles and the metaphyseal region, commonly caused by high energy trauma such as motor vehicle accidents or a fall from a height. In the elderly, they may occur from falling at home.

Most common types of distal femur fractures:

• Transverse fractures : when the bone breaks straight across
• Comminuted fractures: when the bone breaks into many pieces
• Intra-articular fractures: when the bone extends into the knee joint

Pathology: Mechanism

Bimodal distribution

1. High energy fractures: usually occur in young adults (predominantly 30year old males) and result in intra-articular fractures. Mechanism of injury commonly includes motor vehicle accidents, high-velocity missile injuries and/ or a direct blow mechanism.
2. Low energy fractures: mostly occur in elderly people, secondary to osteoporosis (predominantly in women over 65years). These fractures most commonly occur with twisting motions or falls . 4-6% of all femur fractures are distal femur fractures, and more than 85%of these occurrences are low energy fractures in the elderly.

Clinical Presentation

History: patients commonly present after fall or traumatic event. Most common symptoms of distal femur fracture include:

• Pain with weight-bearing
• Swelling and bruising
• Tenderness to touch
• Deformity.
• In the context of polytrauma

Diagnostic Procedures

AP and lateral views of an extra-articular distal femur fracture.

Clinical/Physical examination: the typical clinical picture during the inspection of the knee is pain of distal femur that is made worse with knee movement and inability to weight-bear.

Radiographic examination: AP and lateral views of the femur.

CT-scans: Highly recommended with high energy trauma and if an intra-articular fracture is suspected. (55% of distal femur fractures are intra-articular.)

Classification System

The AO classification system of distal femoral fractures is a commonly utilised system by orthopaedic surgeons.

• Type A: Extra-articular fractures
• Type B: Partial articular fratures, one part of the articular surface is involved and the rest of the joint is still attached to the metaphysis and diaphysis
• Type C: Complete articualr fractures, the fracture is crossing the joint surface and separated from the diaphysis

Outcome Measures

Dynamic Gait Index

Lower Extremity Functional Scale

Timed Up and Go Test

Management / Interventions

Surgical management for distal femur fractures is since the 1970s regarded superior to non-surgical management.

1. Surgical Interventions: Usually require open reduction and internal fixation (especially in cases of displaced or intraarticular fractures). Extra-articular or simple intra-articular fractures may be treated with intramedullary nailing and screw fixation. Simple unicondylar or epicondyle fractures may be treated with simple screw fixation. Extremely comminuted, non-reconstructable fractures or patients with pre-existing osteoarthritis might need arthroplasty.
2. Nonsurgical Interventions: Rare and considered in stable non-displaced fractures in non-ambulatory patients.

Postoperative Management

• Wound dressings post-op as well as 2days post-op, or as directed by the operating doctor.
• 10-14 days post-op removal of stitches
• Mobilise with two elbow crutches; gait training; Usually PWB (15kg) (WB status is to be confirmed by the operating doctor as it is patient/ case specific)
• Stair climbing after 7-14days
• 6 weeks post-op control X-ray
• Depending on the fracture type and appearance of callus formation, you can increase weight-bearing.

Physical Therapy Management

The main aim of Physiotherapy post distal femur fracture is to get the patient back to his/ her baseline function and to prevent complications.

1. Whilst the patient is admitted to hospital, the Physiotherapist will teach the patient how to mobilise using the correct walking aid, with the correct weight-bearing status as discussed with the doctor. Thorough education regarding the condition, management and rehabilitation should be given.
2. Extensive physical therapy will follow surgical fixation and stabilisation of the fracture. Extensive physical therapy will include a basic progressive range of motion exercises, teaching of muscle strengthening exercises, circulatory exercises and mobility/ Gait activities.

Physical therapy management summary:

• Education (Regarding condition, surgery, complications, rehabilitation, and importance of frequent mobilisation during the day)
• Management of swelling (Ice and elevation)
• Mobilise patient out of bed and teach the patient on correct assistive device usage
• Gait training (Weight-bearing status case-specific, but in most cases to start with PWB (15% of body weight))
• Progressive Gluteal, Quadriceps and Hamstring muscle strengthening
• Progressive Knee range of motion exercises
• Patellar mobility
• Ankle movements and foot-pumps to aid with circulation

Specifically for Extra-articular fractures: after the fracture has been surgically stabilised by locked plating or retrograde inter medullary nailing. Physiotherapy is indicated from Day 1 post-op. Early mobilisation without any weight-bearing limitations have good morbidity and mortality outcomes in the elderly; and also have accelerated functional recovery.

• Mobilisation with a walker and immediate weight-bearing (within patients tolerance levels)
• Straight leg raises
• Seated knee extension
• Progressive quadriceps strengthening exercises

Complications

• Malunion
• Delayed union
• Non-union (or breakage of the plate)
• Implant failure
• Infection (superficial infection or deep infection)
• Limited range of motion
• Leg length discrepancy
• Ligamentous instability

Resources

Intra-articular physeal fractures