Distal femoral fracture: Difference between revisions

(Edited and added information)
No edit summary
 
(32 intermediate revisions by 4 users not shown)
Line 4: Line 4:
</div>
</div>


== Definition/Description ==
== Introduction ==
[[Image:Femur.png|right|150px]]  
[[File:Distal-femoral-fracture.png|thumb|290x290px|Distal-femoral-fracture]]
Distal femoral [[Fracture|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 [[Falls in elderly|falling]] at home.<ref name=":4">Radiopedia Distal femoral fracture Available:https://radiopaedia.org/articles/distal-femoral-fracture (accessed 11.12.2022)</ref>Other names: Supracondylar femur fracture; Intercondylar femur fracture; Hoffa's Fracture.


Fracture that occurs at the distal end of the femur bone, that includes the femoral condyles and the metaphysis<ref name=":0">Crist B, Della Rocca G, Murtha Y. Treatment of Acute Distal Femur Fractures. ''ORTHOPEDICS.'' 2008; 31: doi: 10.3928/01477447-20080701-04</ref>. 
The majority of distal femur fractures require surgical intervention.<ref name=":5">Coon MS, Best BJ. Distal Femur Fractures. InStatPearls [Internet] 2021 Aug 9. StatPearls Publishing.Available:https://www.ncbi.nlm.nih.gov/books/NBK551675/ (accessed 11.12.2022)</ref>
== Pathology: Mechanism ==
Bimodal distribution


<br>There are different fractures; (1)<br>- Supracondylar fractures<br>- Unicondylar fractures<br>- T and Y – condylar fracture <br>- Periprosthetic fractures (2)
# '''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.
== Clinically Relevant Anatomy  ==
# '''Low energy fractures:''' mostly occur in elderly people, secondary to [[Osteoporosis disease|osteoporosis]] (predominantly in women over 65years)<ref>Streubel P., Ricci W., Wong A., Gardner M. [https://pubmed.ncbi.nlm.nih.gov/20830542/ Mortality After Distal Femur Fractures in Elderly Patients.] Clinical Orthopaedics and Related Research [Internet]. 2011 Apr 1; 469(4):1188-1196.</ref><ref name=":1">Hoskins W., Bingham R., Griffin XL. [https://www.orthopaedicsandtraumajournal.co.uk/article/S1877-1327(16)30160-9/fulltext Distal femur fractures in adults.] Orthopaedics and Trauma [Internet]. 2017;31(2):93–101. </ref><ref name=":2" />. These fractures most commonly occur with twisting motions or falls <ref>Mashru R., Perez E. [http://search.ebscohost.com.uplib.idm.oclc.org/login.aspx?direct=true&db=eoah&AN=48551848&site=pfi-live Fractures of the distal femur current trends in evaluation and management.] Current Opinion in Orthopaedics 2007;18(1):41–48. </ref> . 4-6% of all femur fractures are distal femur fractures, and more than 85%of these occurrences are low energy fractures in the elderly.
 
[[Image:Knee joint.png|right|250px]]
 
The knee is the largest weight bearing joint of the whole body. The bones of the knee are the distal part of the femur, the upper part of the tibia, and the patella. In the knee joint, there is not only bone, but also a slippery substance which is called the articular cartilage. The function of this cartilage is to protect and to cushion the bones when you move your knee, like when you jump, bend or straighten your knee.<br>Apart from the bones and the cartilage, there are certain muscles who support the joint and who allow the knee to move. There are two big and strong important muscles. The quadriceps are on the front side and the hamstrings on the back side of the knee. (6 (level of evidence 1B))<br> 
== Mechanism of Injury / Pathological Process  ==
High energy fractures: usually occurs in young adults (predominantly 30year old males) and results in intra-articular fractures. Mechanism of injury commonly includes motor vehicle accidents, high velocity missile injuries and/ or a direct blow mechanism.
 
Low energy fractures: mostly occurs in the elderly people, secondary to osteoporosis (predominantly in women over 65years)<ref>Streubel P, Ricci W, Wong A, Gardner M. Mortality After Distal Femur Fractures in Elderly Patients. Clinical Orthopaedics and Related Research [Internet]. 2011 Apr 1 [cited 2019 Apr 2];469(4):1188–96. Available from: <nowiki>http://search.ebscohost.com.uplib.idm.oclc.org/login.aspx?direct=true&db=eoah&AN=22177572&site=pfi-live</nowiki></ref><ref name=":1">Hoskins W, Bingham R, Griffin XL. Distal femur fractures in adults. Orthopaedics and Trauma [Internet]. 2017 Apr 1 [cited 2019 Apr 2];31(2):93–101. Available from: <nowiki>http://search.ebscohost.com.uplib.idm.oclc.org/login.aspx?direct=true&db=eoah&AN=40511626&site=pfi-live</nowiki></ref><ref name=":2" />. These fractures most commonly occurs with twisting motions or falls.<ref>Mashru RP, Perez EA. Fractures of the distal femur current trends in evaluation and management. Current Opinion in Orthopaedics [Internet]. 2007 Feb 1 [cited 2019 Apr 2];18(1):41–8. Available from: <nowiki>http://search.ebscohost.com.uplib.idm.oclc.org/login.aspx?direct=true&db=eoah&AN=48551848&site=pfi-live</nowiki></ref>
 
<br>Of all femur fractures, 6% exists of distal femur fractures. (4 (level of evidence 3A))<br>


== Clinical Presentation  ==
== Clinical Presentation  ==
 
[[File:Hoffa-fracture.jpeg|thumb|Distal femur fracture]]
Most common symptoms of distal femur fracture include:
History: patients commonly present after fall or traumatic event. Most common symptoms of distal femur fracture include:
* Pain with weight bearing  
* Pain with [[weight bearing|weight-bearing]]
* Swelling and bruising  
* Swelling and bruising  
* Tenderness to touch  
* Tenderness to touch  
* Deformity.<ref name=":0" /> (''Shortening of the fracture with varus and extension of the distal articular segment is the typical deformity.3 Shortening is caused by the quadriceps and hamstrings. The varus and extension deformities are due to the unopposed pull of the hip adductors and gastrocnemius muscles respectively.'')  
* Deformity.<ref name=":0">Crist B., Della Rocca G., Murtha Y. [https://pubmed.ncbi.nlm.nih.gov/18705562/ Treatment of Acute Distal Femur Fractures.] ''ORTHOPEDICS.'' 2008 Jul;31(7):681-690.</ref>
<br>  
* In the context of polytrauma<ref name=":4" />
 
== Diagnostic Procedures ==
== Diagnostic Procedures ==
'''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.


Clinical/Physical examination: the typical clinical picture during the inspection of the knee is swelling in the knee region and clear dislocation.
'''Radiographic examination:''' AP and lateral views of the femur.  


Radiographic examination: AP and lateral views of the Femur.<br>CT-scans: Highly recommended with high energy trauma and if a intra-articular fracture is suspected. (55% of distal femur fractures are intra-articular.)<br><ref name=":1" />  
'''CT-scans:''' Highly recommended with high energy trauma and if an intra-articular fracture is suspected. (55% of distal femur fractures are intra-articular.) <ref name=":1" />
== Outcome Measures  ==


add links to outcome measures here (see [[Outcome Measures|Outcome Measures Database]])
== Classification System ==
[[File:AO.jpg|Adapted from: Murphy, A., Ng, J. AO classification of distal femur fractures. Reference article, Radiopaedia.org. (accessed on 12 Aug 2022) <nowiki>https://doi.org/10.53347/rID-94057</nowiki>|alt=|right|frameless|532x532px]]
The AO classification system of distal femoral fractures is a commonly utilised system by orthopaedic surgeons.


== Management / Interventions  ==
* '''Type A:''' Extra-articular fractures
Surgical management for distal femur fractures is since the 1970s regarded superior to non-surgical management.<ref name=":2">Ehlinger M, Ducrot G,  Adam P, Bonnomet F. Minimally invasive internal fixation of distal femur fractures. Orthopaedics & Traumatology: Surgery & Research, 2017-02-01, Volume 103, Issue 1, Pages S161-S169.</ref>
* '''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


Surgical interventions:
<ref>Murphy A., Ng J. [https://radiopaedia.org/articles/ao-classification-of-distal-femur-fractures AO classification of distal femur fractures. Reference article, Radiopaedia.org.] Available: <nowiki>https://doi.org/10.53347/rID-94057</nowiki> (accessed on 09 Aug 2022)</ref>


A soft-tissue friendly attitude centered on retrograde intramedullary nailing and plate fixation by minimally invasive percutaneous plate osteosynthesis (MIPPO) and transarticular approach and retrograde plate osteosynthesis (TARPO).
== Outcome Measures ==


Nonsurgical interventions:
* [[Dynamic Gait Index]]
* [[Lower Extremity Functional Scale (LEFS)|Lower Extremity Functional Scale]]
* [[Timed Up and Go Test (TUG)|Timed Up and Go Test]]


<br>- Skeletal traction 1: 5 (level of evidence 5)<br>- Skeletal traction 2: 7 (level of evidence 1B)<br>- Casting and bracing 1: 4 (level of evidence 3A),<br>- Casting and bracing 2:&nbsp; 5 (level of evidence 5)<br>
== Management / Interventions  ==
[[File:Traction placement.jpeg|thumb|399x399px|Femur traction placement]]
Surgical management for distal femur fractures is since the 1970s regarded superior to non-surgical management. <ref name=":2">Piétu G.,  Ehlinger M. [https://pubmed.ncbi.nlm.nih.gov/27867137/ Minimally invasive internal fixation of distal femur fractures.] Orthopaedics & Traumatology: Surgery & Research, 2017; 103(1): S161-S169.</ref>


Physical Therapy Management
# 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.<ref name=":4" />
# Nonsurgical Interventions: Rare and considered in stable non-displaced fractures in non-ambulatory patients.<ref name=":4" />


=== Post operative management ===
=== Postoperative Management ===
Wound dressings
* 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. <ref name=":3">Schandelmaier P., Blauth M., Krettek C. [https://link.springer.com/article/10.1007/s065-001-8351-z Internal Fixation of Distal Femur Fractures with the Less Invasive Stabilizing System (LISS).] Orthopaedics and Traumatology 2001; 9(3):166–184.</ref>


10-14 days post-op removal of stitches
== 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. 


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)
# Postoperatively, patients should begin gentle range of motion of the knee to prevent stiffness.
# Depending on the intraoperative stability, the affected extremity may be made non-weight bearing, touchdown weight-bearing, or partial weight-bearing for 10 to 12 weeks. The physiotherapist will teach the patient how to mobilise using the correct [[Walking Aids|walking aid,]] with the correct [[weight bearing|weight-bearing]] status.
# Thorough education regarding the condition, management and rehabilitation should be given.
# Extensive physical therapy follows surgical fixation and stabilisation of the fracture. Will include a basic progressive [[Range of Motion|range of motion]] exercises, teaching of muscle strengthening exercises, circulatory exercises and mobility/ [[Gait]] activities.


Stair climbing after 7-14days
'''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


6 weeks post-op control X-ray
'''Specifically for Extra-articular fractures'''<u>:</u> 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.<ref>Smith W., Stoneback J., Morgan S., Stahel P. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5142343/ Is immediate weight bearing safe for periprosthetic distal femur fractures treated by locked plating?.] Patient Saf Surg 2016; 10:26.</ref>  
 
* Mobilisation with a walker and immediate weight-bearing (within patients tolerance levels)
Depending on the fracture type and appearance of callus formation, you can increase weight bearing. <ref name=":3">Schandelmaier P, Blauth M, Krettek C. Internal Fixation of Distal Femur Fractures with the Less Invasive Stabilizing System (LISS). Orthopaedics and Traumatology [Internet]. 2001 Sep 1 [cited 2019 Apr 2];9(3):166–84. Available from: <nowiki>http://search.ebscohost.com.uplib.idm.oclc.org/login.aspx?direct=true&db=eoah&AN=2132445&site=pfi-live</nowiki></ref>
* Straight leg raises
 
* Seated knee extension  
The aim of physiotherapeutic sessions is to gain back the full mobility of the knee and teaching the patient to walk again. At first the whole flexion and extension has to be back before we start walking. We also need to recover the power of the M. quadriceps and the M. hamstrings, this is very important because these are dynamic stabilizers of the knee. After the removal of the plaster we need to start as soon as possible with flexion and extension exercises. There is one condition before we start with the flexion exercises, pressure on the fracture is allowed.<br>Stepping can be started when there is an acceptable functional range, this means that the knee is stable enough for doing the activities of daily living. The next factors are an obstacle for the functional range. When there is a lack of extension in the knee, exercises of the M. quadriceps are recommended. There can also be a lack of flexion. When there is less than 100° of flexion, the patient has difficulties with steps, deep tread and narrow stairs. The patient needs at least 80-90° of flexion to permit sitting. It’s therefore important that the physiotherapist mobilizes the knee.
* Progressive quadriceps strengthening exercises<ref>Mohammed S., Hussain M., Steven K., Daily M., Frank R., Avilucea M. [https://pubmed.ncbi.nlm.nih.gov/29521874/ Stable fixation and Immediate weight bearing after combined retrograde inter medullary nailing and open reduction internal fixation of noncomminuted distal interprosthetic femur fractures.] Journal of Orthopaedic trauma. June 2018; 32(6):e237-e240.</ref>
 
A full recovery and a return to sports or normal daily activities usually requires 4-6 months post-surgery, depending on the severity of the injury.
<br>In supracondylar fractures the necessary degree of flexion can be obtained using pearson knee flexion peace. Or using a Tomas splint traction at the level of the fracture. Thomas Splint Traction may be used for the first 1 – 2 weeks. Mobilization of the knee should be started as early as possible to avoid tethering adhesions between M. quadriceps and fracture of the knee that cause stiffness in the knee. Unicondylar fractures are for surgical reasons better to rest in a non weight plaster for a period of 6 weeks before starting vigorous mobilization. The importance of performing frequent mobilization should be stressed to the patient. Passive mobilization of the patella in appropriate cases may be helpful. In routine cases of Distal femoral fractures a full range of flexion is achieved in the majority of all cases in the 12 months with the most gain in the first 3 months. (1)  
 
<br>According to current knowledge and evidence based recommendation, ultrasound is used to facilitate bone fracture healing. (3)(4 (level of evidence 3A))(9(level of evidence 1A)).But ultrasound hasn’t&nbsp; long-terms effects.(10(level of evidence 1A))


== Complications ==
== Complications ==
Malunion
* Pain secondary to hardware presence eg over the plate on the lateral femoral condyle where the iliotibial band may rub,  medial screw irritation secondary to excessively long screws in contact with medial soft tissues.
* [[Fracture Complications|Malunion]]: greater than 5 to 10 degrees affects knee mechanics, which may lead to arthritis of the medial and lateral compartments.
* [[Fracture Complications|Delayed union]] or Nonunion (substantial complication, with rates up to 20%).
* [[Fracture Complications|Implant failure]]<ref name=":1" />
* [[Fracture Complications|Infection (superficial infection or deep infection)]]
* Limited range of motion (common)<ref name=":5" />
* [[Leg Length Discrepancy|Leg length discrepancy]]<ref>El-Tantawy A., Atef A. [https://pubmed.ncbi.nlm.nih.gov/25427781/ Comminuted distal femur closed fractures: a new application of the Ilizarov concept of compression–distraction.] Eur J Orthop Surg Traumatolo 2015 Apr 1;25(3):555–562. </ref>
* Ligamentous instability<ref name=":3" />


Delayed union
== Resources    ==
 
Non-union (or breakage of plate)
 
Implant failure<ref name=":1" />
 
Infection (superficial infection or deep infection)
 
Limited range of motion
 
Leg length discrepancy<ref>El-Tantawy A, Atef A. Comminuted distal femur closed fractures: a new application of the Ilizarov concept of compression–distraction. European Journal of Orthopaedic Surgery & Traumatology [Internet]. 2015 Apr 1 [cited 2019 Apr 2];25(3):555–62. Available from: <nowiki>http://search.ebscohost.com.uplib.idm.oclc.org/login.aspx?direct=true&db=eoah&AN=34329802&site=pfi-live</nowiki></ref>
 
Ligamentous instability<ref name=":3" />
 
<br>


== Resources    ==
Intra-articular physeal fractures<ref>Pennock A., Ellis H., Willimon S., Wyatt C., Broida S., Dennis M., Bastrom, T. [https://pubmed.ncbi.nlm.nih.gov/29051906/ Intra-articular Physeal Fractures of the Distal Femur: A Frequently Missed Diagnosis in Adolescent Athletes.] Orthop J Sports Medi 2017 Oct 10;5(10):2325967117731567. </ref>


Intra-articular physeal fractures<ref>Pennock, AT., Ellis, HB., Willimon, SC., Wyatt, C., Broida, SE., Dennis, MM., & Bastrom, T. Intra-articular Physeal Fractures of the Distal Femur: A Frequently Missed Diagnosis in Adolescent Athletes. ''Orthopaedic journal of sports medicine'', ''5''(10). 2017. 2325967117731567. doi:10.1177/2325967117731567</ref>  
{{#ev:youtube|kXngbbqVa9g|300}}<ref>Nabil Ebraheim. Distal Femur Supracondylar Fracture - Everything You Need To Know - Dr. Nabil Ebraheim. Available from: https://www.youtube.com/watch?v=kXngbbqVa9g [last accessed 8/4/2019]</ref>


== References  ==
== References  ==


<references />
<references />
{{Qualityalert_Injury}}


'''To edit: referencing format, ?research update'''
== Resources  ==
(1) Ronald Mcrae/ Max Esser, Practical fracture treatment, Fourth edition, 2002,&nbsp; p.321-328<br>(2) Ebenbichler G. – Evidence-based medicine and therapeutic ultrasound of the musculoskeletal system – Zeitschrift für Rheumatologie – September 2009 – p.543-548<br>(3) Warden SJ et al. - Facilitation of fracture repair using low-intensity pulsed ultrasound – Veterinary and comparative orthopaedics and traumatology – December 2000 – p. 158-164<br>(4) Healio Orthopaedics - Treatment of Acute Distal Femur Fractures <br>(http://www.healio.com/orthopedics/journals/ortho/%7Bea445a00-7883-48d2-8e86-7eb7aa140d0c%7D/treatment-of-acute-distal-femur-fractures) (level of evidence 3A)<br>(5) OrthoInfo - Distal Femur (Thighbone) Fractures of the Knee <br>(http://orthoinfo.aaos.org/topic.cfm?topic=A00526#top) (level of evidence 5)<br>(6) Higgins TF - Distal femoral fractures - The Journal of Knee Surgery - 2007, 20(1):56-66<br>(6) http://europepmc.org/abstract/MED/17288091) (level of evidence 1B)<br>(7) E. M. Winant – The use of skeletal traction – New York – 1949 (level of evidence 2A)<br>(8) Dr. P.R.G. Brink et al. - Letsels van het steun- en bewegingsapparaat, 2000, p.225-231<br>(9) Markus D. Schofer et al. - Improved healing response in delayed unions of the tibia with low-intensity pulsed ultrasound: results of a randomized sham-controlled trial BMC Musculoskeletal Disorders 11:229 – 2010 (level of evidence 1A)<br>(10) Handolin L. Et al. – No long-term effects of ultrasound therapy on bioabsorbable screw-fixed lateral malleolar fracture - Scandinavian Journal of Surgery 94: 239–242 – 2005 (level of evidence 1A)
== Search Strategy  ==
Databases Searched: Google-books, Google-scholar, Pubmed, VUB-catalogus, web of knowledge<br>Keyword Searches: Distal femur fractures, femur fractures, femur , physiotherapy for femur fractures, facilitating bone fracture healing, skeletal traction femur<br>Search Timeline: 24/10/2012 – 29/11/2012
== References  ==
1) Ronald Mcrae/ Max Esser, Practical fracture treatment, Fourth edition, 2002, p.321-328<br>2) Dr. P.R.G. Brink et al. - Letsels van het steun- en bewegingsapparaat, 2000, p.225-231<br>3) Ebenbichler G. – Evidence-based medicine and therapeutic ultrasound of the musculoskeletal system – Zeitschrift für Rheumatologie – September 2009 – p.543-548<br>4) Warden SJ et al. - Facilitation of fracture repair using low-intensity pulsed ultrasound – Veterinary and comparative orthopaedics and traumatology – December 2000 – p. 158-164<br>5) Healio Orthopaedics - Treatment of Acute Distal Femur Fractures (http://www.healio.com/orthopedics/journals/ortho/%7Bea445a00-7883-48d2-8e86-7eb7aa140d0c%7D/treatment-of-acute-distal-femur-fractures) (level of evidence 3A)<br>6) OrthoInfo - Distal Femur (Thighbone) Fractures of the Knee <br>(http://orthoinfo.aaos.org/topic.cfm?topic=A00526#top) (level of evidence 5)<br>7) Higgins TF - Distal femoral fractures - The Journal of Knee Surgery - 2007, 20(1):56-66&nbsp;&nbsp;&nbsp; (http://europepmc.org/abstract/MED/17288091) (level of evidence 1B)<br>8) E. M. Winant – The use of skeletal traction – New York – 1949 (level of evidence 2A)<br>9) Markus D. Schofer et al. - Improved healing response in delayed unions of the tibia with low-intensity pulsed ultrasound: results of a randomized sham-controlled trial BMC Musculoskeletal Disorders 11:229 – 2010 (level of evidence 1A)<br>10) Handolin L. Et al. – No long-term effects of ultrasound therapy on bioabsorbable screw-fixed lateral malleolar fracture - Scandinavian Journal of Surgery 94: 239–242 – 2005 ( level of evidence 1A)
[[Category:Injury]]  
[[Category:Injury]]  
[[Category:Knee_Injuries]]  
[[Category:Knee_Injuries]]  
[[Category:Knee]]  
[[Category:Knee]]  
[[Category:Conditions]] 
[[Category:Knee - Conditions]]
[[Category:Bones]]  
[[Category:Bones]]  
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]  
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]  
[[Category:Primary Contact]]
[[Category:Primary Contact]]
[[Category:Acute Care]]
[[Category:Acute Care]]
[[Category:Bone Conditions]]
[[Category:Bone - Conditions]]
[[Category:Bone Fractures]]

Latest revision as of 08:40, 11 December 2022


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[edit | edit source]

Distal-femoral-fracture

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.[1]Other names: Supracondylar femur fracture; Intercondylar femur fracture; Hoffa's Fracture.

The majority of distal femur fractures require surgical intervention.[2]

Pathology: Mechanism[edit | edit source]

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)[3][4][5]. These fractures most commonly occur with twisting motions or falls [6] . 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[edit | edit source]

Distal femur fracture

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.[7]
  • In the context of polytrauma[1]

Diagnostic Procedures[edit | edit source]

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.) [4]

Classification System[edit | edit source]

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

[8]

Outcome Measures[edit | edit source]

Management / Interventions[edit | edit source]

Femur traction placement

Surgical management for distal femur fractures is since the 1970s regarded superior to non-surgical management. [5]

  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.[1]
  2. Nonsurgical Interventions: Rare and considered in stable non-displaced fractures in non-ambulatory patients.[1]

Postoperative Management[edit | edit source]

  • 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. [9]

Physical Therapy Management[edit | edit source]

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. Postoperatively, patients should begin gentle range of motion of the knee to prevent stiffness.
  2. Depending on the intraoperative stability, the affected extremity may be made non-weight bearing, touchdown weight-bearing, or partial weight-bearing for 10 to 12 weeks. The physiotherapist will teach the patient how to mobilise using the correct walking aid, with the correct weight-bearing status.
  3. Thorough education regarding the condition, management and rehabilitation should be given.
  4. Extensive physical therapy follows surgical fixation and stabilisation of the fracture. 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.[10]

  • Mobilisation with a walker and immediate weight-bearing (within patients tolerance levels)
  • Straight leg raises
  • Seated knee extension
  • Progressive quadriceps strengthening exercises[11]

A full recovery and a return to sports or normal daily activities usually requires 4-6 months post-surgery, depending on the severity of the injury.

Complications[edit | edit source]

Resources[edit | edit source]

Intra-articular physeal fractures[13]

[14]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Radiopedia Distal femoral fracture Available:https://radiopaedia.org/articles/distal-femoral-fracture (accessed 11.12.2022)
  2. ↑ 2.0 2.1 Coon MS, Best BJ. Distal Femur Fractures. InStatPearls [Internet] 2021 Aug 9. StatPearls Publishing.Available:https://www.ncbi.nlm.nih.gov/books/NBK551675/ (accessed 11.12.2022)
  3. ↑ Streubel P., Ricci W., Wong A., Gardner M. Mortality After Distal Femur Fractures in Elderly Patients. Clinical Orthopaedics and Related Research [Internet]. 2011 Apr 1; 469(4):1188-1196.
  4. ↑ 4.0 4.1 4.2 Hoskins W., Bingham R., Griffin XL. Distal femur fractures in adults. Orthopaedics and Trauma [Internet]. 2017;31(2):93–101.
  5. ↑ 5.0 5.1 Piétu G., Ehlinger M. Minimally invasive internal fixation of distal femur fractures. Orthopaedics & Traumatology: Surgery & Research, 2017; 103(1): S161-S169.
  6. ↑ Mashru R., Perez E. Fractures of the distal femur current trends in evaluation and management. Current Opinion in Orthopaedics 2007;18(1):41–48.
  7. ↑ Crist B., Della Rocca G., Murtha Y. Treatment of Acute Distal Femur Fractures. ORTHOPEDICS. 2008 Jul;31(7):681-690.
  8. ↑ Murphy A., Ng J. AO classification of distal femur fractures. Reference article, Radiopaedia.org. Available: https://doi.org/10.53347/rID-94057 (accessed on 09 Aug 2022)
  9. ↑ 9.0 9.1 Schandelmaier P., Blauth M., Krettek C. Internal Fixation of Distal Femur Fractures with the Less Invasive Stabilizing System (LISS). Orthopaedics and Traumatology 2001; 9(3):166–184.
  10. ↑ Smith W., Stoneback J., Morgan S., Stahel P. Is immediate weight bearing safe for periprosthetic distal femur fractures treated by locked plating?. Patient Saf Surg 2016; 10:26.
  11. ↑ Mohammed S., Hussain M., Steven K., Daily M., Frank R., Avilucea M. Stable fixation and Immediate weight bearing after combined retrograde inter medullary nailing and open reduction internal fixation of noncomminuted distal interprosthetic femur fractures. Journal of Orthopaedic trauma. June 2018; 32(6):e237-e240.
  12. ↑ El-Tantawy A., Atef A. Comminuted distal femur closed fractures: a new application of the Ilizarov concept of compression–distraction. Eur J Orthop Surg Traumatolo 2015 Apr 1;25(3):555–562.
  13. ↑ Pennock A., Ellis H., Willimon S., Wyatt C., Broida S., Dennis M., Bastrom, T. Intra-articular Physeal Fractures of the Distal Femur: A Frequently Missed Diagnosis in Adolescent Athletes. Orthop J Sports Medi 2017 Oct 10;5(10):2325967117731567.
  14. ↑ Nabil Ebraheim. Distal Femur Supracondylar Fracture - Everything You Need To Know - Dr. Nabil Ebraheim. Available from: https://www.youtube.com/watch?v=kXngbbqVa9g [last accessed 8/4/2019]
Retrieved from "https://www.physio-pedia.com/index.php?title=Distal_femoral_fracture&oldid=322910"