Distal Femur Fractures

AO Classification




Distal Femoral FractureSupracondylar Femur Fracture Retrograde Nail0002


Distal femoral fractureDistal Femur Fracture Lateral




Distal Femur Fracture Medial




Distal Femur Fracture


Distal Femur Fracture Intercondylar 1Distal Femur Fracture Intercondylar  2Distal Femur Fracture Intercondylar CT




Non operative Management





- cannot immobiise joint above

- need to keep knee stiff


Operative Management




1.  Retrograde nail

2.  Plate

3.  Tumour prosthesis


1.  Retrograde Nail


Supracondylar Femur Fracture Retrograde Nail0001Supracondylar Femur Fracture Retrograde Nail0001



- small incision

- good for floating knee

- load sharing


Supracondylar Femur Fracture Retrograde Nail0003Supracondylar Femur Fracture Retrograde Nail0004



- more difficult for intra-articular fractures

- technically difficult to perfectly restore alignment



- distal 1/3

- floating knee




Set up

- patient supine

- put knee over radiolucent triangle / bundle of gowns

- allows entry to knee

- ensure II for AP and lateral of knee and AP of hip for proximal locking screw


Entry point

- medial parapatella approach

- entry above ACL origin

- slightly medial

- ensure central in AP and lateral

- awl / 3.2 mm guide wire

- ream for enlarged end of retrograde nail


Pass guide wire

- measure length


Ream & Insert nail

- distal locking performed

- proximal AP locking under II control


Retrograde Nail Proximal0001Retrograde Nail Proximal0002




Iannacone et al J Orthop Trauma 1994

- 41 distal femur fractures treated with retrograde nail

- 4 non unions requiring revision fixation

- 4 fatigue fractures of the IMN; changed to using minimum 12 and 13 mm rods


Case Nonunion


Retrograde Nail Nonunion0003Retrograde Nail Nonunion0004Retrograde Nail Nonunion0001Retrograde Nail Nonunion0002


Supracondylar Nonunion TKR0001Supracondylar Nonunion TKR0002


2.  Plate


Distal Femur Fracture Medial ORIFSupracondylar Plate ORIFSupracondylar Plate Lateral




- easier to fix intracondylar extension

- can be done MIPO / minimally invasive plate osteosynthesis

- plates anatomically contoured so can restore mechanical axis





- patient supine on radiolucent table with II

- place distal femur over radiolucent triangle / drapes

- reduces fracture



- incision over lateral distal femoral condyle

- longitudinal

- through skin and soft tissue

- divide ITB

- elevate vastus lateralis

- down to bone


Reduce intra-articular portion if required

- can elevate patella to assess reduction

- compress with bone reducing forcep

- 6.5 mm cannulated screws

- anterior and posterior to plate

- ensure not in joint / above blumensaat's

- ensure not in PFJ (distal femur is trapezoidal)


MIPO plate technique

- percutaneously elevate muscle off femur with elevator

- insert appropriate length plate (4 cortical screws above) with targeter

- temporarily fix distal plate to distal fragment

- if place screws parallel to joint line, the plate will be in correct valgus

- temporarily fix proximal plate percutaneously with temporary fixation screws

- obtain an indirect reduction

- check aligment and plate position AP and lateral

- attach plate with screws




Schutz et al Arch Orhop Traum Surg 2005

- 62 patients average age 52 years treated with LISS plate

- union achieved in 85% patients

- 6 required bone grafting, 3 required revision of components


Tumour Prosthesis


Elderly osteoporotic patient

- unreconstructable distal femur

Femoral Shaft Fractures



Usually young patients

- 15 - 40


15% compound




High velocity injury



- pedestrian v car

- fall from height


Emergency Managment


EMST principles

- need for transfusion not uncommon

- hypotension from isolated closed femoral fracture unlikely



- ipsilateral NOF / pelvic fracture / acetabular fracture / dislocation

- knee injury

- floating knee / ipsilateral tibial fracture


Thorough neurovascular exam

- incidence vascular injury 1%


Temporary femoral traction splints

- ring against ischium

- velcro around foot

- pneumatic traction

- can only be applied for 12 hours or so


Thomas Splint


Compound wound


Betadine pack




Winquist Classification


Type 1

- minimal or no comminution


Femoral Shaft Fracture No comminution


Type 2

- < 50% comminution


Type 3

- 50 - 100% comminution

- inherently unstable as < 50% contact between major fragments

- need supplemental fixation / must be locked


Femoral Fracture Type 3


Type 4

- segmental comminution

- no contact or inherent stability between proximal and distal fragments


Associated injuries


Femoral Shaft Fracture with Neck Fracture


Up to 10% concurrence

- can be missed on plan film

- splints can obscure



- carefully review pelvic xrays

- order CT if required

- assess carefully on II when intra-operatively




De Campos et al 1994 Clinical Orthopedics

- 5% ACL, 2.5% PCL

- 20% LM tears, 12% MM tears


Always assess knee after femoral stabilisation


Femoral Fracture + ACL Reconstruction


Floating Knee


Ipsilateral Femur + tibial fracture


Floating Knee 1Floating Knee 2


Operative Management Issues


Surgical Timing


Bone et al JBJS Am 1989

- stabilisation within 24 hours

- decreased pulmonary complications

- decreased length hospital stay


Damage Control Orthopaedics



- avoid second hit to severely injured patients

- stabilise femoral fracture as quickly as possible

- usually simple external fixator

- allow return to ICU for warming / stabilisation

- when stable, definitive fixation



- head injuries

- thoraco-abdominal injuries

- multiple injuries



- cytokine shown to be elevated in multitrauma

- suggested delay definitive treatment until drops

- approximately day 6




Pape et al J Orthop Trauma 2002

- retrospective study of polytrauma patients at risk of multi-organ failure

- patients treated with ETC (early total care)(IMN femur) v

- DCO (early stabilisation femur external fixation with later IMN)

- significant reduction in incidence of multiorgan failure

- significant reduction ARDS (15% down to 9%)

- no increased rate of local complications (infection, non union)


Bhandari J Orthop Trauma 2005

- external fixator converted to IMN within 2 weeks

- 1.7% infection rate


Surgical Options


ORIF / plate

External fixation

IMN - antegrade / retrograde / reamed / unreamed


External Fixation



- severely contaminated wound

- Damage Control Orthopaedics

- complex femoral fracture with vascular injury



- 2 x half pins proximally

- 2 x half pins distally

- 2 x bars


Timing of conversion to IMN


Harwood et al J Orthop Trauma 2006

- compared 111 femur fractures treated with immediate IMN to 81 DCO

- DCO femurs more likely to be grade 3 compound

- increased pin site infections in external fixation

- no significant increase in deep infection rates if converted within 2 weeks


Plate v IMN




Bosse et al JBJS Am 1997

- compared plate v reamed IM nail (117 v 104)

- patients multiply injured (femur + thoracic injury)

- no evidence that a reamed femoral IMN increased risk of ARDS in this group





- associated proximal / distal femoral fracture

- vascular injury

- medulla too narrow for IMN

- paediatric population



- tension side / load bearing

- significant disruption to blood supply required

- plate will break early if union not achieved




Giessler et al Orthopedics 1995

- 71 femurs diaphyseal fractures

- 93% union at 16 weeks

- recommended bone grafting at same time



- large fragment plate

- minimum 8 cortices each side of fracture

- need periord of NWB


Reamed v Unreamed IMN


Femoral Nail0001Femoral Nail0002




Non union / Canadian Study Group JBJS Am 2003

- multicentred randomised trial

- non union rates reamed v unreamed IMN

- 8 / 106 (7.5%) smaller unreamed femoral nail nonunion

- 2 / 121 (1.7%) larger reamed femoral nail nonunion


ARDS / Canadian Study Group J Orthop Trauma 2006

- multicentred randomised trial reamed v unreamed

- incidence ARDS in multiply injured patients

- 151 unreamed v 171 reamed nails within 24 hours

- very low incidence of ARDS in both groups

- not statistically significant

- need some 35 000 patients to detect difference


Locked v Unlocked IMN


Unusual not to lock distally

- gives rotational stability


If stable transverse fracture / > 50% cortical apposition

- can dynamically lock


Retrograde nail


Retrograde Femoral NailRetrograde Femoral Nail Lateral



- floating knee (single incision for femoral and tibial nail

- obesity - difficult access to trochanter

- pregnancy - minimise radiation to pelvis

- patella fracture (able to ORIF with same incision)

- ipsilateral pelvic / acetabular / NOF fracture



- similar rates union

- may have slightly higher incidence knee pain


Floating Knee 1Floating Knee 2Floating Knee 3


NOF (Neck of Femur) + Femoral shaft fracture


Must pay attention first to meticulous NOF ORIF



1.  Pin and Plate NOF / Retrograde Nail

2.  Pin and Plate NOF / Plate femur

3.  Reconstruction Nail

- difficult to anatomically reduce NOF

- increased incidence NOF non union

4.  Antegrade IMN in place before diagnosis of NOF fracture

- if undisplaced, can place screws anterior to nail

- if displaced must remove nail


Dislocated Hip + Femoral shaft fracture


1.  Simple dislocation

- may be able to reduce hip with proximal steinman pin

- then IMN femur / retrograde or antegrade

- or plate femur


2.  Dislocation with Pipkin

- may need anterior approach to ORIF femoral head fracture

- may be best to plate / retrograde nail femur


3.  Dislocation with posterior acetabular fracture

- may need posterior approach to acetabulum

- consider plating femur / distal femoral or tibial steinman pin

- delayed ORIF posterior wall


Distal femoral condylar fracture + shaft fracture



1.  Screws anterior and posterior to retrograde nail

2.  Distal Locking plate


Bilateral Femur Fractures


High risk of complications

- blood loss

- nerve injury

- ARDS (double risk unilateral)

- mortality risk (5x unilateral)

- non union



- IMN one femur

- assess patient stability

- IMN nail other femur or external fixation / delayed nail




Nerve Palsy


Pudenal nerve palsy most ommon

- up to 15%

- usually transient

- related to longer traction times

- may be related to the use of smaller posts







- need attention to patella and foot position prior to distal locking




A.  Clinically

- point both patellas to the ceiling

- foot internally or externally rotated compared to uninjured leg


B.  CT


Femoral Nail Malrotation CT 1Femoral Nail Malrotation CT 2



- remove distal locking screws

- correct rotation

- insert new distal locking screws


Distal femoral breach


Distal femoral breachDistal Breach ORIF


Non union



- uncommon

- increased with unreammed nails



- not united after 6 months

- no progression for 3 months



1.  Dynamisation

2.  Exchange nailing +/- bone graft

3.  Remove nail / plate + bone graft

4.  Augmentation with plating and bone grafting

5.  External Fixation


1.  Dynamisation



- stable fractures

- non comminuted / non segmental


Wu J Trauma 1997

- 24 nails dynamised 4 - 12 months

- union in 50%


2.  Exchange nailing


Femoral Non unionExchange Nail Bone Graft



- remove old nail

- ream up to larger size

- insert new larger nail


Weresh et al J Orthop Trauma 2000

- 19 patients at least 6 months post

- union in only 50%


3.  Removal Nail / Plating / Bone Graft


Bellabarab J Orthop Trauma 2001

- 100% union rate

- augment with bone graft


4.  Augment with Plate + Bone Graft


Ueng J Trauma 1997

- 17 patients, 100% union


Infected Non union



- removal of nail

- irrigation +++

- antibiotic nail / cover IMN with antibiotic cement

- 6 weeks IV antibiotics

- definitive nail / External fixator


Infected Femoral Nail 1Infected Femoral Nail2Infected Femoral Nail3Infected Femoral Nail4


Infected Femoral Nail United APInfected Femoral Nail United Lateral




No evidence increased risk if nail removed > 1 year

Femoral Stress Fractures

Femoral Shaft Stress Fracture




Usually mid or lower femur






Lateral femur

- can progress to fracture

- high rate of non-union

- should ORIF


Stress Fracture Lateral


Femoral stress fractureFemoral Stress Fracture IMN




Medial femur

- rare

- usually unite



Stress Fracture Medial


Femoral Neck Stress Fractures




Athletes with increase activity / distance

Women with eating disorders /  amenorrhea




Compression / inferior neck

- < 50% protective weight bear

- > 50% emergent ORIF


Tension side / superior neck

- emergent ORIF


Hip stress fractureFemoral Neck Stress Fracture


Hip Stress Fracture Axial CTHip Stress Fracture Coronal CT


Hip Stress FractureHIp Stress FractureHip Stress Fracture 3




Hoffa fracture



Coronal plane fracture of distal femoral condyle

- intra-articular

- often only attachment is posterior capsule








Usually a severe valgus trauma




Usually lateral femoral condyle


Hoffa Fracture Xray





- aids surgical planning



- excludes associated LCL / MCL injury


Hoffa Fracture MCL Avulsion MRI 1Hoffa Fracture MCL Avulsion MRI 2






Usually unstable

- needs ORIF

- can be associated with LCL injuries


Must preserve the posterior soft tissue for vascularity




1.  Buttress screws + AP screws


Hoffa Fracture ORIF APHoffa Fracture Lateral


2.  Headless compression 6.5mm PA screws


Hoffa Fracture ORIF PA screws








Infected Femoral Fracture



ABx coated IM nail + External Fixator


Infected Femoral Nail 1Infected Femoral Nail 2Infected Femoral Nail 3Infected Femoral Nail 4






Surgical Techniques

Surgical TechniquesAntegrade Femoral Nail


1.  Trochanteric Entry Antegrade Femoral Nail



- GA, IV ABx

- traction table

- patient legs adducted, torso adducted

- allows access to GT

- flex and abduct other hip for II access



- incision proximal to GT

- split abductors in line

- palpate tip of GT

- check entry point on AP II view

- check entry point on lateral II view (junction anterior 1/3 posterior 2/3)

- entry with awl or 3.2 mm guide wire

- ensure wire doesn't penetrate medial cortex

- use proximal reamer for thickened proximal portion of nail


Pass guide wire

- ball tipped

- femoral fractures difficult to reduce with traction

- use reduction tool to reduce in AP and lateral views to pass guidewire

- if having difficulty +++, can perform miniopen incision to pass guide wire

- measure guide wire to determine nail length


Note typical deformity of proximal fragment which needs to be corrected

- flexed by psoas

- abducted by G medius

- externally rotated


Femoral Shaft Fracture Standard Displacement Lateral



- tight fit best

- nails come in 8.5, 10, 11 and 12 mm

- need to ream 1 - 2 mm larger than nail


Pass nail

- attach to proximal locking jig

- ensure drill passes through jig into proximal nail holes

- insert nail

- visualise with II at fracture site

- ensure nail doesn't get caught on one cortex

- excessive hammering in this position can cause fracture





- usually proximal locking first

- screw should purchase cortex of lesser trochanter


Femoral Nail Proximal Locking0001Femoral Nail Proximal Locking0002



- straighten out other leg / lower so can obtain lateral II

- perfect circle technique

- distal locking performed


Femoral Nail Distal Locking0001Femoral Nail Distal Locking0002


2.  Retrograde Nail


Retrograde Femoral NailRetrograde Femoral Nail Lateral



- distal 1/3

- floating knee

- obesity


Set up

- patient supine

- put knee over radiolucent triangle / bundle of gowns

- allows entry to knee

- can remove to allow proximal locking

- ensure II for AP proximally locking


Entry point

- medial parapatella approach

- entry above ACL origin

- slightly medial

- ensure central in AP and lateral

- awl / 3.2 mm guide wire

- ream for enlarged end of retrograde nail


Pass guide wire

- measure length


Ream & insert nail

- distal locking performed

- proximal AP locking under II control