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