Edited by Theodore Guild and Matt Fury - 7/1/2021
Descriptors
Open vs closed
Location: supracondylar, intercondylar, condylar
Articular involvement
Comminution
Angulation or rotational deformity
Shortening or translation
Exam Pearls
Look for indications of open injuries
Always document a good neurovascular exam. May be associated with popliteal artery injury.
If concern for vascular injury, obtain ABI’s.
If <0.9, obtain angiography.
Workup
Radiographs: AP and lateral of knee, traction view may be useful. AP and lateral of ipsilateral full length femur and hip.
Other imaging:
CT scan of the knee to assess for intra-articular extension, intra-articular fragments, Hoffa’s fracture (intra-articular distal femur fracture in coronal plane).
Angiography if ABI <0.9 or other concern for vascular injury
Labs: Preop CBC/BMP/Coags/T&S/COVID
Other: CXR, EKG pre-op if indicated
Management
Need for acute intervention: Yes, immobilization with mild reduction (can attempt to pull out to length, does not require formal reduction with sedation)
Weight-bearing and range of motion: NWB, range of motion as tolerated at hip and ankle
Type of immobilization: Knee immobilizer. Skeletal traction through proximal tibia (lateral to medial to avoid peroneal nerve) if significant shortening.
Admission or discharge status: Admit. If 2+ system involvement, admit to ACS. If medically unwell, admit to medicine.
Anticoagulation: per HOTI protocol - usually LVX before 8 pm. If poor kidney function, SQH.
Antibiotics: None if closed.
Surgical Indications
Absolute: Nearly all distal femur fractures with the following exceptions:
Stable, non-displaced or incomplete fractures
Poor surgical candidates (medically ill)
Relative: n/a
Not an indication: n/a
Surgical Options
ORIF: Indications: Displaced or intra-articular fracture Periprosthetic fracture with poor bone quality
Retrograde intramedullary nail:
Indications:
Extra-articular or simple articular fractures
Periprosthetic fractures when the implant has an “open-box” design
Historically required 4 cm of intact distal femur although not necessarily true with newer implants
Arthroplasty: Indications: Pre-existing osteoarthritis with appropriate fracture pattern
Distal femoral replacement: Indications: Low demand patients with non-reconstructable fracture pattern, periprosthetic fracture with aseptic loosening
External fixation: Indications: Typically temporizing measure in unstable polytrauma patient or in patient with soft tissue injury or contamination not amenable to definitive fixation