Distal femoral fracture

Original Editor ­ - Leen Wyers

Top Contributors - Mande Jooste, Laura Ritchie, Evan Thomas, Kim Jackson and Daphne Jackson

Definition/Description

Femur.png

Fracture that occurs at the distal end of the femur bone, that includes the femoral condyles and the metaphysis[1].

Most common types of distal femur fractures:

  • Transverse fractures
  • Comminuted fractures
  • Intra-articular fractures

Clinically Relevant Anatomy

The femur, also known as the thigh bone, is the longest bone in the body. Distally, the lateral and medial condyles articulates with the Tibial plateau of the Tibia forming the Tibiofemoral joint, and the patellar surface of the femur articulates with the patella, forming the patellofemoral joint. Together these two joints form the knee joint, which is the largest weight bearing joint in the body. During flexion and extension the patella and Tibia act as one structure in relation to the femur.
Knee joint.png

The knee is a hinge type synovial joint, consisting of ligaments, bones, tendons and cartilage.
The two main muscle groups that play a role in knee flexion and extention is the Quadriceps and Hamstrings.

Mechanism of Injury / Pathological Process

Distal femur fractures are mainly caused by high- and low energy types of injuries.

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)[2][3][4]. These fractures most commonly occurs with twisting motions or falls.[5]


4-6% of all femur fractures is distal femur fractures, and more than 85%of these occurrences is low energy fractures in the elderly.

Clinical Presentation

Most common symptoms of distal femur fracture include:

  • Pain with weight bearing
  • Swelling and bruising
  • Tenderness to touch
  • Deformity.[1] (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.)

Diagnostic Procedures

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.
CT-scans: Highly recommended with high energy trauma and if a intra-articular fracture is suspected. (55% of distal femur fractures are intra-articular.)
[3]

The most common classification system used for distal femur fractures is the AO/OTA system.

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. [4]

Surgical interventions:

A soft-tissue friendly attitude centered on:

  • Retrograde intramedullary nailing
  • Plate fixation by minimally invasive percutaneous plate osteosynthesis (MIPPO)
  • Transarticular approach and retrograde plate osteosynthesis (TARPO).[4]

Nonsurgical interventions:

  • Skeletal traction 1 (level of evidence 5)
  • Skeletal traction 2 (level of evidence 1B)
  • Casting and bracing 1 (level of evidence 3A)
  • Casting and bracing 2 (level of evidence 5)

Post operative 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. [6]

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.

Whilst the patient is admitted in 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.

Extensive physical therapy will follow surgical fixation and stabilisation of the fracture. Extensive physical therapy will include basic progressive range of motion exercises, teaching of muscle strengthening exercises, circulatory exercises and mobility/ gait training 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 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: (Post operative- 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.[7]

  • Mobilisation with a walker and immediate weight bearing (within patients tolerance levels)
  • Straight leg raises
  • Seated knee extension
  • Progressive quadriceps strengthening exercises[8]

Complications

  • Malunion
  • Delayed union
  • Non-union (or breakage of plate)
  • Implant failure[3]
  • Infection (superficial infection or deep infection)
  • Limited range of motion
  • Leg length discrepancy[9]
  • Ligamentous instability[6]

Resources

Intra-articular physeal fractures[10]

[11]

References

  1. 1.0 1.1 Crist B, Della Rocca G, Murtha Y. Treatment of Acute Distal Femur Fractures. ORTHOPEDICS. 2008; 31: doi: 10.3928/01477447-20080701-04
  2. 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: http://search.ebscohost.com.uplib.idm.oclc.org/login.aspx?direct=true&db=eoah&AN=22177572&site=pfi-live
  3. 3.0 3.1 3.2 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: http://search.ebscohost.com.uplib.idm.oclc.org/login.aspx?direct=true&db=eoah&AN=40511626&site=pfi-live
  4. 4.0 4.1 4.2 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.
  5. 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: http://search.ebscohost.com.uplib.idm.oclc.org/login.aspx?direct=true&db=eoah&AN=48551848&site=pfi-live
  6. 6.0 6.1 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: http://search.ebscohost.com.uplib.idm.oclc.org/login.aspx?direct=true&db=eoah&AN=2132445&site=pfi-live
  7. Smith WR, Stoneback JW, Morgan SJ, Stahel PF. Is immediate weight bearing safe for periprosthetic distal femur fractures treated by locked plating?. Patient safety in surgery. 2016. 10:26.
  8. Mohammed S, Hussain MD, Steven K, Daily MD, Frank R, Avilucea MD. 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).
  9. 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: http://search.ebscohost.com.uplib.idm.oclc.org/login.aspx?direct=true&db=eoah&AN=34329802&site=pfi-live
  10. 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 medicine5(10). 2017. 2325967117731567. doi:10.1177/2325967117731567
  11. 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]