Review Article
Managements of Supracondylar femur fractures
Zenat khired MD
Abstract
Supracondylar and intracondylar fractures of the distal femur historically
have been difficult to treat , As it is frequently comminuted and intraarticular, and it often involve osteoporotic bone. Surgery is the standard of
care for displaced fractures and for patients who must obtain rapid return of
knee function. A different surgical exposures, techniques, and implants has
been developed including ;fixed angle plates, Dynamic condylar screw and
plate, intramedullary nailing, and periarticular locked plating, possibly
augmented with bone graft. A warrness of indications and applications of the
principles of modern implants and techniques is critical in achieving optimal
outcomes and good results.
Supracondylar fractures represents
between 4% and 7% of all femoral
fractures; however their incidence
likely Will increase as the
population ages.1,2 Their treatments
are associated with a significant rate
of complications.3 An elderly
patient with poor bone quality may
sustain a supracondylar femoral
fracture in a simple fall, whereas, A
high-energy mechanism, such as a
motor vehicle crash, is generally
required to produce such injury in a
younger patient with good bone
quality. The goals of management
of supracondylar fractures are
correction of axial alignment,
length, and rotation; restoration of
motion; and rapid union so as to
return the patient to normal
function.3 In selected cases, closed
treatment can accomplish these
goals.
Early definitive fixation may not be
suitable for the polytraumatized or
under-resuscitated patient. In these
cases, it may be appropriate to use
damage-control orthopaedics with
spanning external fixation to restore
length and stabilize the extremity to
allow systemic stabilization. Careful
a traumatic surgical technique is
necessary to minimize soft-tissue
injury and periosteal stripping. The
surgical
goals
are
anatomic
alignment and stable fixation of the
fracture to allow motion of the limb
and early rehabilitation. A variety
of surgical methods are available
for definitive fixation. Selection is
based on the characteristics of the
fracture and patient status. An
understanding of the normal
anatomy of the distal femur and the
axial alignment of the knee joint is a
prerequisite to the operative
fixation of distal femoral fractures.
Fixed-angle Blade Plate and
condylar plate sliding system
The blade plate furnishes the greatest
resistance to bending and torsional stresses
and produces the most secure fixation of the
distal fragment. 4,5 The blade plate is
difficult to use, and meticulous attention to
surgical technique is required.6 It has been
reported to give good results (yang et al
1990), but the technique is demanding and
the need to hammer the implant into
position risks separating the femoral
condyles. Compression-screw systems are
technically easier to use than the angled
blade plate. Since sagittal-plane adjustments
can be made in plate position, correct
orientation is required in only two planes.
Although compression-screw systems are
suitable for most supracondylar fractures.
there are exceptions Due to the large size of
the lag screw, a minimum of 4 cm of intact
bone is required in the distal fragment.5 A
6.5-mm cancellous screw must also be
inserted into the distal fragment to gain
rotational stability figure 1. Shewring et al
treated 21 cases of supracondylar and
intercondylar femur fractures there was 2
nonunion and no deaths. 6 The problems
associated with this kind of fixation
included nonunion, varus collapse , high
rates of bone grafting, and arthrofibrosis.7
poor fixation in osteoporotic bone and an
inability to control coronal plane fracture .
The large lateral shoulder of this device may
irritate the iliotibial band and necessitate
hardware removal after the fracture has
healed. A long-term study with an average
follow up of 9.5 years reported satisfactory
to excellent results in 82% of fractures
managed with the condylar plate .8
Similar outcomes have been reported with
the dynamic condylar screw, with 81% good
or excellent results.8
Condylar Buttress Plate
It may be used for the fixation of minimally
displaced fractures, but is most useful in
fractures with articular extension in the
sagittal and coronal planes. It must be
correctly positioned with the lateral flare of
the plate seated directly over the lateral flare
of the condyle. If the plate is placed
proximal or distal to the flare, varus or
valgus malalignment may occur.4 In very
comminuted fracture to avoid collapse of
the medial columon , reduction can be
maintained with the combined use of medial
and lateral plates.5
Intramedullary Nailing
Newer designs of retrograde nails offer multiple
distal screw position options that allow articular
reconstruction and sturdy fixation even in intraarticular fractures. 9 Laboratory studies have
shown the superiority of this implant over
traditional plating techniques in maintaining
blood supply to the bone.10 Clinical studies have
suggested that these theoretical advantages have
translated into higher rates of union and reduced
the
requirement
for
primary
bone
11
,
12
,
13
grafting.
An antegrade nail may be
used in proximal supracondylar fractures.
Regardless of nail type, multiple distal
locking screws are required to control sagittal
alignment of the distal fragment . Knee pain
was a common symptom reported by most
authors. Considering the results of three
studies14,15,16
Papadokostakis et al.17did a systemic review
of the literature on retrograde nailing of
femoral fractures. An analysis of 544 distal
femoral fractures demonstrated an overall
union rate of 96.9% at a mean time to union
of 3.4 months. Average knee ROM was
104.6°. Reported complications included
knee pain 16.5%, infection 1.4%, and
malunion 5.2%. Reoperation was done in
17% of patients. Poor hold of the distal
interlocking screws in osteoporotic bone is a
problem. 18 Previous studies have shown
significant rates of component removal for
patella impingement.19,20
Although this
complication is sometimes caused by technical
error in placement, it is clear that nails have the
capacity to migrate distally as the fracture settles,
especially in osteoporotic bone.21,22 concern
exists that the intra-articular entry used for distal
femoral nails may predispose patients to higher
levels of knee pain over time.19 Previous studies
have shown significant rates of component
removal for patella impingement.19,20
Locking Plate
The first commercially available locked plate
designed for periarticular fracture fixation, The
LISS system relies on unicortical shaft fixation
and self-drilling, self-tapping screws To
perform targeted percutaneous fracture
fixation. These plates have significant
advantages over earlier designs in that they
allow placement of bicortical locking screws
providing a longer working length while
allowing a range of insertion angles.23
Locked screws augment the stability of the
construct because they secure the plate at
multiple points, thereby eliminating motion
at the plate-bone interface and best owing
greater strength to resist pullout. A number
of polyaxial interfaces are available. One
uses an expanding bushing contained within
the plate (PolyAx; DePuy Orthopaedics,
Warsaw, IN), another uses freely rotating
rings that are snapped into the screw holes
(Numelock; Stryker, Mahwah, NJ), whereas
a third uses a locking cap placed after screw
insertion that converts a standard cortical or
cancelous screw into a fixed-angle screw via
frictional interface (NCB; Zimmer, Warsaw,
IN). A recent biomechanical study
comparing a polyaxial locking plate with a
conventional locking plate demonstrated
greater axial and torsional stiffness with the
former as well as less irreversible
deformation and higher load to failure.
Earlier studies have shown reduced nonunion
rates for locked plating of distal femoral
fractures compared to non-locking plates
.23,24,25
,but more recent studies found
nonunion rates up to 20 % .26,27 In recent
study, 18% of the fractures showed signs of
delayed or non-union. Multiple reasons
influence union rates. Higher stiffness of
locking plates has been related to suppressing
interfragmentary movement and callus
formation .26,28 But in a systemic review by
Zlowodski , 29 comparing traditional plating ,
intramedullary nails, and locking plates, no
observed differences were found between
implants regarding the rate of nonunion
,infection , fixation failure ,or revision
surgery.30
External Fixation
External
fixation
is
an
invaluable
management option for distal femoral
fractures because it offers rapid stabilization
and restoration of length with minimal softtissue disruption.
Half-pin hybrid, and
circular wire frame constructs provide
relative stability, with the advantage of
shorter operating time, minimal blood loss,
and minimal periosteal stripping. External
fixation should be considered in patients
with open wounds, poor skin healing
potential, and multiple injuries as well as
in fractures that cannot be reconstructed
with open reduction and internal fixation .31
The Ilizarov external fixator when used for
the
treatment
of
comminuted
supracondylar and intercondylar fractures
of the distal femur has considerable
advantages . With the Ilizarov system the
diverging olive wires offer good stability and
a firm compression effect on the condyles .
Several authors report acceptable overall
results with external fixation, describing union
rates ranging from 92.3% to 100% at an
average
of
4
to
6
months
,14,15,16,32
postoperatively.
Periprosthetic Fracture of the
Distal Femur
The incidence of peripros- thetic distal
femoral fracture has been reported to
be 0.9% after primary TKA and 1.6%
after revision TKA. Risk factors for
Supracondylar periprosthetic femoral
fractures include rheumatoid arthritis,
osteoporosis, neurologic
disorders,
chronic steroid therapy, anterior
cortical notching of the femur, and
revision knee arthroplasty.35 In the
presence of a stable implant, periprosthetic
supracondylar femoral fractures are
preferably managed with reduction and
internal fixation, as anatomical alignment
and stable fixation of the distal articular
component allows for early movement of
the knee and patient mobilization . Several
surgical options have evolved, including
hybrid external fixation, intra-medullary
nailing, and conventional and locked plate
fixation.34 The complication rate for
conventional, non-locked plating is high.
Using conventional plating, Figgie et al35
had a 50% nonunion rate in ten
supracondylar periprosthetic femoral
fractures. As comminution is frequently
present at the fracture site, angular
stability is crucial to resist varus
deformity.36 Although biomechanical
studies have shown intramedullary
nailing to achieve increased resistance to
varus stress compared with locked
plating,37 this difference has not been
shown to be clinically significant.34,37
Furthermore, Intramedullary nailing is
limited by the availability of distal bone
stock, as well as the size and position of
the
femoral
component
notch.39
Therefore, enlargement of the notch
with a diamond burr is often required,
raising concern about possible third-body
wear.38 Locked plating, on the other hand ,
allows for distal fixation regardless of the
design of the femoral component and the
presence of intramedullary implants
Adequate clinical results have been
reported
with
both
retrograde
intramedullary
nailing
and
locked
38,39
plating.
Revision arthroplasty with a
long stemmed component should be
considered
for
fractures
that
compromise the stability of the femoral
component. Distal femoral replacement
may be indicated in fractures with
massive bone loss.
POST OPERATIVE CARE:
When the fixation is solid and bone quality
good, some patients can be allowed early
weight bearing and motion. If bone quality
is good but not enough to allow early
weight bearing, the patient may be placed
in a hinged knee brace to allow early
motion but kept off full weight bearing
until radiographs show bone healing (at
about 12 wk). If bone quality is poor, more
rigid splinting may be required for about 6
weeks and then switched to a hinged brace.
Some surgeons use a CPM machine to
facilitate gradual advancement in knee
flexion.
Summary:
Fractures of the Supracondylar femur
are serious injuries that frequently result
in varying degrees of permanent
disability Careful patient evaluation and
fracture characterization is critical when
choosing a treatment plan. Unstable or
displaced fractures should be managed
surgically. Many implants have been
developed to implement these kind of
fracture . Management priorities include
restoration of the articular surface as
well as length, rotation, and alignment.
Locked plating and IM nailing are
mainstays of surgical treatment because
of their ability to obtain sturdy fixation,
even in osteoporotic bone, and their
resistance to inherent deforming forces.
References
1- Nieves JW,Bilezikian JP,Lane JM,at
al.Fragility Fractures of the hip and
femur:
incidence
and
patient
characteristics.
Osteopros
Int
2010;21:399-408
2- Court –Brown CM.Ceaser B:
Epiemiology of adult fractures : A
review. Injury 2006;37(8) : 691-697.
3- Schatzker J, Tile M: The rationale of
operative Fracture Care .New York :
Springer –Verlag ,1987.
4-Marsh JL, Jansen H,Yoong HK,Found EM Jr.
Supra-condylar fractures of the femur by
External
fixation
.J
Orthop
Trauma
1997;11:405-11.
5- Schatzker J, Tile M: The Rational of
Operative fracture care .New York: SpringerVerlag, 1987.
6-SHEWRING D.J.,B. F. MEGGITT :Fractures of
the distal femur treated with the AO Dynamic
Condylar screw
7-Davison BL. Varus collapse of comminuted
distal femur fractures after open reduction
and internal fixation with a lateral condylar
butteress plate .Am J Orthop.2003;32(1):2730
8-Huong HT, Huang PJ, Su JY, Lin Sy :Indirect
Reduction
and
Bridge
plating
of
supracondylar fractures of the femur . Injury
2003; 34(2) : 135-140.
5-Marshal JL ,Slongo TF ,Agel J, et al :Fracture
and dislocation classification compedium2007:Orthopedic
Trauma
Association
Classificaton
,database
and
outcomes
committee .J Orthop Trauma 2007;21(10
Suppl): S1-S133
9-M Pekmezci,E. McDonald, J. Buckley, U.
Kandemin. Retrograde intramedullary nails
with distal screws locked to the nail have
higher fatigue strength than locking plates in J
Bone Joint Surg (Br )2014;96-B:114-21.
10- Farouk O,Krettek C, Miclau T ,et al.
Minimally invasive plate osteosynthesis: does
percutaneous plating disrupt femoral blood
supply less than traditional technique ? J.
Orthop. Trauma 1999;B: 401-6.
11- Henry SL, Supracondylar femur fractures
treated percutaneously . Clin. Orthop .
2000;375:51-9.
12-Schutz M, Muller M, Krettek C et al.
Minimally invasive fracture stabilization of
distal femoral fractures with the LISS:
aprospective multicenter study .Injury
2001;32 S3 :48-54.
13-Seifert J,Stengel O,Methes G et al
.Retrograde fixation of distal femoral
fractures : Results using a new nailing
system .J .Orthop .Trauma 2003;17:48895.
14-Ostrum RF, Agarwal A, Lakatos R,Poka
A.Prospective comparison of retrograde
and antegrade femoral intramedullary
nailing. J Orthop Trauma 2000;14:496501.
15-Ricci WM,Bellabarba C, Evanoff B, et al
.Retrograde versus antegrade nailing of
femoral shaft fractures .J Orthop Trauma
2001;15:161-9.
16 - Torentta P,Tiburzi D. Antegrade or
retrograde reamed femoral nailing : a
prospective randomized trail 15:192-6.
17 - Papadokostakis G, Papakostidis C,
Dimitriou R, Giannoudis PV;The role and
efficacy of retrograding nailing for the
treatment of diaphyseal and distal femoral
fractures: A systemic review of the
literature .Injury 2005; 36(7) :813-822.
18-Janzing HM, Stockman B, Van Damme
G, et al. The retrograde intramedullary
supracondylar nail :an alternative in the
treatment of distal femoral fractures in the
elderly
?
Arch
Orthop
Trauma
Surg.1998;118:92-95
19- Leggon RE,Feldmann DD. Retrograde
femoral nailing: a focus on the knee. Am. J.
Knee Surg.2001;14:109-18.
20-Moed BR,Watson JT, Cramer KE et al.
Unreamed intramedullary nailing of the
fractures of the femoral shaft J. Orthop.
Trauma 1998;12:334-42.
21-I tok,Hungerbuhler R, Wahl D,Grass
R,Improved
intramedullary
nail
interlocking in osteoporotic bone .
J.Orthop. Trauma 2001; 15:192-6.
22- Kumar A, Jasani V, Butt MS.
Management of distal femoral fractures in
elderly patients using retrograde titanium
supracondylar nails. Injury 2000;31:16973.
23-Gautier E ,Sommer C, Guidelines for the
clinical application of the LCP. Injury
.2003;34(suppl 2):B 63-B76.
24-Kregor PJ, Stannord J, Zlowodzki M, Cole
PA, Alonso J: Distal femoral fracture fixation
utilizing the less invasive stabilization system
(L.I.S.S):the technique and early results. Injury
2001, 32 (suppl 3): SC32-SC47.
25- weight M, Collinge C: Early results of the
less invasive stabilization system for
mechanically unstable fractures of the distal
femur (AO/OTA Types A2,A3,C2 and C3) J
Orthop Trauma 2004,18:503-508.
26-Henderson CE, Kuhl LL, Fitzpatrick DC,
Marshal JL: Locking plates for distal femur
fractures Is there a problem with fracture
healing ? J Orthop trauma 2011,25(Suppl 1):
S8-S14.
27-Kubiak EN, Fulkerson E , Strauss E, Egol
KA: The evolution of locked plates .J Bone
Joint Surg Am 2006, 88 (suppl4): 189-200.
28-Martin F Hoffman ,Clifford B Jones ,Debra L
Sietsema ,Paul Torentta and Scott JKoening
:Clinical outcomes of locked plating of distal
femoral fractures in a retrospective cohort
.Journal of Orthopaedic Surgery and Research
2013,8:43.http://wwwJosr-online.com/
content/8/1/43.
29-Zlowodzki M, Bhandari M, Marek DJ, Cole
PA, Kregor PJ: Operative Treatment of Acute
distal femur fractures : Systematic review of 2
comparative Studies and 45 case Series (1989
to 2005). J Orthop Trauma 2006,20: 366 371.
30-Henderson
CE
,Lujan
TBottlang
M,Fitzpatrick DC, Madey SM, Manson JL
:Stabilization of distal femur fractures with
intramedullary nails and locking plates :
Differences in callus formation. Lowa Orthop J
2010,30:61-68.
31- Parekh AA, Smith WR,Sliva S,etal:
Treatment of comminuted intra-articular
distal femur fractures with limited internal
and External tensioned wire fixation .J
Orthop Trauma 2000; 14 (6): 405-413.
32- Ali F, Saleh M: Treatment of isolated
complex distal femoral fractures by
external fixation .Injury 2000 ;31(3) 139146.
33-Culp RW, Schmidt RG, Hanks G,Mak A,
Esterhai
JL
Jr,
Heppenstall
RB:
Supracondylar Femur fractures following
prosthetic knee arthroplasty .Clin Orthop
1987;222:212-222.
34- Herrera DA,Kregor PJ ,Cole PA et al
.Treatment of acute distal femur fractures
above a total knee arthroplasty
:Systematic review of 415 cases (19812006).Acta Orthop 2008;79:22-7.
35-Figgie MP Goldberg VM,Figgie HE 3rd
,Sobel M. The results of Treatment of
Supracondylar Fracture above Total knee
arthroplasty .J Arthroplasty 1990:5267-76.
36-Zuurmond RG,Pilot P, Verburg AD.
Retrograde
bridging
nailing
for
supracondylar fracture around total knee
replacement: a copatibilility study using
the trigen supracondylar nail .Knee
2007;14:208-11.
37-ricci WM,Loftus T,Cox C,Borrelli J.
Locked plates combined with minimally
invasive insertion technique for the
treatment of periprosthetic supracondylar
femur fractures above total knee
arthroplasty
.J
Orthop
Trauma
2006;20:190-6.
38- Schatzker J, Tile M: The rationale of
operative Fracture Care .New York :
Springer –Verlag ,1987.