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Classification and Treatment of Distal Femoral Fractures
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Posted on: 11/17/2010
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Fractures just above or even through the knee joint are called distal femoral fractures. In this review article, several surgeons with expertise in computer-assisted surgeries present current concepts about these fractures. Classification of the fracture, clinical evaluation, and treatment (both surgical and nonsurgical) are covered in depth.
Let's start by taking a quick look at the classification scheme used to describe these fractures. In your mind's eye, imagine one of three fracture locations: 1) at the bottom of the femur (long bone in the thigh) but just above the knee joint, 2) through one of the femoral condyles (round bony knobs at the bottom of the femur), and 3) through both condyles and through the joint.
The second type (through the condyle) is termed unicondylar because it only goes through one of the two condyles. The unicondylar femoral fracture also affects part of the joint, so it's also referred to as a partial articular unicondylar fracture. If the fracture goes through both condyles, then it is classified as a complete articular/bicondylar femoral fracture and is part of the third group listed.
Any of the fractures can be simple (a single fracture line that is undisplaced -- meaning it doesn't separate or move) or comminuted. Comminuted fractures have tiny fragments of bone because there are so many fracture lines.
What's the best way to treat each of these classifications of distal femoral fractures? Well, that's a very good question and one for which there isn't one single answer. The surgeon actually has quite a few options to choose from based on the type and severity of the fracture.
For example, a nail could be put down through the entire length of the bone to stabilize and hold all the pieces together. Or a locking plate, screw fixation, wires, or other bone fixation devices can be used. In many cases, the bone has been so damaged or is so osteoporotic (brittle) that the surgeon must fill in between the cracks with a bone filler like bone grafts or bone cement.
The majority of this review article focuses on surgical approaches, techniques, and implants used to repair all kinds of distal femoral fractures. The surgery selected is designed to promote early knee motion, restore the joint articular surface, and maintain proper limb length and alignment.
The surgeon also aims to save the surrounding soft tissues so that the patient can have a full functional recovery. Fixation (holding all the bone fragments together) during healing is a key part of the surgical procedure and gets close attention in this article.
Patient status is an important consideration. In the case of traumatic accidents, orthopedic stabilization may be all that's accomplished until the patient's life is stabilized. When sufficient recovery of health has occurred, then the patient can be taken back to surgery to repair or reconstruct the knee.
Today's fixation devices are new and improved. Some are specifically designed to be used in patients who have thin, brittle bones. Locking plates offer improved management in that they can provide a rigid hold on the many tiny (comminuted) pieces of bone.
The newer, updated fixation devices are stronger, accept more load, and resist pulling out of the bone. Not only that, but many of the improved fixation devices are designed so that the surgeon doesn't have to cut through so many important soft tissue structures on the way to the bone. The metal plates are even shaped like the natural bone to allow for a closer fit. The plate can be slipped under the skin and muscle and placed against the bone using just a small incision.
As with any surgery, even with new and improved techniques and devices, problems and complications can occur. There can be infections. The fixation devices can come loose. Even with the holding power of these nails, plates, screws, and wires, the bone may fail to close. The result is a nonunion fracture.
Older adults with bone loss, arthritis, or who have a long history of using steroids (antiinflammatory drugs) are at risk of additional bone fractures around the fixation devices. Malalignment of any healing fracture can present significant problems later with loss of motion, instability, and deformity.
But for those patients who get past all that to the end result, the outcomes can be very good (even excellent!). More studies are needed to compare different types of fixation devices for each type of fracture. The information gained from studies like this would help guide surgeons in choosing the best treatment approach for each patient.
In summary, distal femoral fractures are seen by orthopedic surgeons in young adults as a result of motor vehicle accidents or other high-energy trauma. A second group include the older adults with poor bone quality who fracture from a simple fall. In either group, the fractures can be complex, requiring careful operative and post-operative management.
Results can be quite good with careful evaluation of the fracture, the patient characteristics, and the surgical tools and techniques available. The surgeon who keeps up with what's available in terms of modern implants and techniques has the best chance of achieving optimal results. This article summarizes all aspects of evaluation and management of distal femoral fractures for all age groups.
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References:
F. Winston Gwathmey, Jr, MD, et al. Distal Femoral Fractures: Current Concepts. In Journal of the American Academy of Orthopaedic Surgeons. October 2010. Vol. 18(10):597-607.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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