Distal femoral fracture


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Introduction

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

The majority of distal femur fractures require surgical intervention.

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

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.
• In the context of polytrauma

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.

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

Adapted from: Murphy, A., Ng, J. AO classification of distal femur fractures. Reference article, Radiopaedia.org. (accessed on 12 Aug 2022) https://doi.org/10.53347/rID-94057

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 is a clinical tool used to assess a person's ability to modify gait in response to changing task demands, including variations in speed, head movements, and obstacles. It is widely used in individuals with balance and mobility issues, particularly in neurological and geriatric populations.
• Lower Extremity Functional Scale is a self-reported questionnaire designed to evaluate the functional status of the lower extremities, covering activities such as walking, squatting, and climbing stairs. It is commonly used to assess progress in rehabilitation for lower limb conditions.
• Timed Up and Go Test is a simple and quick measure of functional mobility, balance, and fall risk. It involves timing how long it takes for an individual to rise from a chair, walk 3 meters, turn, return, and sit down, often used to monitor mobility in older adults and individuals with various impairments. Together, these outcome measures provide valuable insights into balance, gait, and lower extremity functionality, aiding clinicians in tracking patient progress and planning interventions.

Management / Interventions

Femur traction placement

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 for Orthopedic Surgery (Based on Recent Evidence)

1. Wound Management:

• Initial Dressings: Modern practice emphasizes using advanced wound dressings such as hydrocolloids or alginates, which promote a moist wound-healing environment, reducing infection risks and aiding faster healing .
• Frequency: Dressings should be reviewed within 48-72 hours post-op, and subsequent changes can be made every 3-5 days unless there is drainage or signs of infection . Negative-pressure wound therapy (NPWT) is recommended for complex or larger wounds to enhance healing and reduce complications .
• Suture Removal: Stitches are typically removed 10-14 days post-op unless there is delayed healing, in which case they can remain for longer.

2. Weight-Bearing and Mobility:

• Early Mobilization: Early movement is critical to prevent complications like deep vein thrombosis (DVT) or pulmonary embolism. Partial weight-bearing (PWB) is usually allowed as soon as tolerated (typically 10-20% of body weight). The latest evidence supports early ambulation even on postoperative day 1 with proper aids .
• Progression of Weight Bearing: Depending on the type of fracture and the patient’s healing progress (as seen on follow-up X-rays or bone scans), weight-bearing can gradually increase over 6-12 weeks. Studies suggest that early full weight-bearing (FWB) can be introduced after 4 weeks if healing is satisfactory .

3. Gait Training:

• Initial gait training with two elbow crutches is recommended, progressing to one crutch or a cane as tolerated. Emphasis is placed on normalizing gait patterns early to prevent long-term compensatory patterns.
• Balance and Proprioceptive Training should be incorporated early, as these have been shown to enhance functional recovery post-fracture surgery .

4. Stair Climbing and Functional Mobility:

• Depending on pain tolerance and balance, patients can start stair climbing with supervision after 7-10 days post-op. Recent protocols advocate for early functional rehabilitation to enhance confidence and mobility .

5. Follow-Up and X-ray Monitoring:

• Control X-rays or CT scans should be done at 6 weeks post-op to evaluate callus formation. Recent studies recommend earlier imaging (within 4 weeks) to check for complications such as hardware failure .
• Based on radiological findings, a progressive increase in weight-bearing status is determined. If there is strong callus formation, patients can transition to full weight-bearing from 6-8 weeks post-op .

6. Pain Management and Complications:

• The use of multimodal analgesia is encouraged to reduce opioid consumption. This includes NSAIDs, acetaminophen, and in some cases, regional nerve blocks for pain control .
• Patients should be screened for early signs of complications like infection, DVT, or malunion, with follow-ups typically scheduled for 2 weeks, 6 weeks, 3 months, and 6 months .

7. Physiotherapy and Rehabilitation:

• Structured rehabilitation, focusing on range of motion (ROM), strength training, and functional exercises, should begin as early as 2 weeks post-op for most cases. Prolonged immobilization is generally avoided to prevent stiffness and atrophy .
• By 12 weeks post-op, patients should aim for significant functional improvement with the goal of returning to daily activities. Further evidence supports aquatic therapy and accelerated rehab programs as part of modern protocols .

• 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. 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.

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

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

• 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.
• Malunion: greater than 5 to 10 degrees affects knee mechanics, which may lead to arthritis of the medial and lateral compartments.
• Delayed union or Nonunion (substantial complication, with rates up to 20%).
• Implant failure
• Infection (superficial infection or deep infection)
• Limited range of motion (common)
• Leg length discrepancy
• Ligamentous instability

Resources

Intra-articular physeal fractures also known as Salter-Harris fracture