Distal Femur (Sandeep Sir)

Distal femur FracturesPlating pearls and pitfalls
Dr Sandeep Gupta
Assistant Professor
G.M.C.H , Chandigarh
Biomechanics of distal femur

Factors under the surgeon's control :
implant metallurgy
screws ( locking/non locking,uni/bicortical)
plate length
screw hole fill
Cortical slotting techniques or far cortical locking screws :
decrease construct stiffness
create more uniform callous formation
Distal most screw in the diaphyseal segment is most important
dictates working length
dictates stiffness of the implant
Recommendation
Use a long plate(8-10 holes in proximal fragment)
Staggered fixation in proximal frag. with 50%

holes filled is enough
Screw near to fracture in prox. fragment preferably

be cortical(helps as reducing agent and
decreases stiffness)
optimise distal fixation with proper plate

positioning and proper screw orientation
Role of medial plate
Generally should not be used in acute fracture
Has a role in management of delayed /nonunion of fractures with medial comminution
Potential pitfalls
Almost all are because of incorrect plate placement !
Can be described by the Rule of Toos:!
too valgus
too anterior
too rotated
too distal
too flexed or extended
too far off bone.
Potential pitfall-1
Fracture alignment that is too

valgus
Results in coronal plane

deformity of the articular
surface
Easily preventable (as modern

plates are designed to
reproduce the anatomic lateral
distal femoral angle of 81 to
85)
Pitfall-2
Plate placed too anterior either proximally
on the diaphysis or distally on the condyles!
Leads to compromised fixation leading to

failure, because eccentrically placed screws
Plate applied too anterior near the knee !
Painful encroachment on the extensor

mechanism
Screw placement into the patellofemoral joint
Plate applied too posterior distally !
screws into the intercondylar notch causing

injury to the cruciate ligaments and knee
motion limitation
Pitfall-3
Plate applied too distal !
intra-articular screw placement

into the intercondylar notch or
patellofemoral joint
painful implant prominence

(iliotibial band syndrome)
the golf club deformity can

result as the plate convexity
abuts the condyles, effectively
medializing the entire articular
block.
Pitfall-4
Plate applied too rotated !
rotational deformity
screws may be aimed into

unintended areas anteriorly or
posteriorly around the knee
Pitfall-5
Plate applied too flexed or too
extended !
lead to compromised fixation
prominent hardware
sagittal plane (curvatum)

fracture deformity
Pitfall - 6
Plate applied too far off the
bone
may cause symptoms as a

result of implant prominence
under the iliotibial band
may be associated with

malediction increased risk of
implant failure.
Tips to optimise plating
Avoidance of implant-related problems is largely

preventable
Important to understand the local anatomy, the

implants and how they are designed to be used
Thorough preoperative planning
Computed tomography scan of the distal femur

(so as not to miss occult hoffas fracture)
TIP -1
Understand the Relevant Anatomy and Its
Radiographic Appearance!
Articular surfaces of the medial and lateral

condyles coalesce to form the trochlea
anteriorly
Trochlea's subchondral arc is well seen on

lateral radiographic images
Posteriorly intercondylar fossa houses the

ACL & PCL
Blumensaat's line on lateral imaging

represents the anterior and proximal limit of
the intercondylar notch
Medial condyle extends distally than its

lateral counterpart, resulting in a valgus
limb axis (94 and 100)
TIP - 2
Shape of the distal
femur is trapezoidal!
angle of inclination of
the medial surface ~25
lateral surface of the

condylar segment is
internally rotated relative
to the sagittal plane by
approximately 10
TIP - 3
Use plate design to recreate
anatomy!
distal locking screws are

inserted with a vector parallel
to the distal femoral condyles
proximal shaft of the plate is

apposed to the femoral
diaphysis
result is coronal plane

fracture alignment of 5 to 8
of valgus
TIP - 4
Quality Radiography and Interpretation of Images!
Optimal intraoperative imaging with C-arm fluoroscopy and

radiographic interpretation is mandatory
Optimal AP can be achieved by obtaining a quality AP image of

the knee (where the fibula is partly overlying the tibia) and the
patella centered over the condyles
Optimal lateral view is obtained by superimposing the femoral

condyles on one another
The notch view can demonstrate screws that cross the

intercondylar notch
TIP - 5
Enough emphasis cannot be placed on the
importance of fracture reduction !
formal arthrotomy to adequately visualize the

articular surface for reduction and fixation of
complex articular injuries
the universal femoral distractor (or external fixator,

if present) is useful for restoring length, sagittal
plane reduction and maintains the reduction
during plate application
TIP - 6
Plate Positioning!
Centered along midlateral line and applied

within a centimeter of the vermillion border
(anterior edge) of the lateral condylar surface
Plate should match the lateral contour of the

supracondylar flare and end at a point 1 or
1.5 cm above the joint line(AP view)
Joint axis wire should be close to parallel

with the articular line of the femoral condyles
Plate well centered distally with the distal

screw cluster near but not beyond the
radiographic junction of Blumensaat's line
and the subchondral margin of the trochlea
TIP - 7
Accurate Joint Axis Pin or Screw
Placement Is Essential!
cannulated wire guide is applied

through the joint axis reference hole
pin should be parallel to the joint axis

of the distal femoral condyles on a AP
image
lateral view, pin will be seen as aimed

slightly posteriorly (eg, 1020) and
distal (6)
Sagittal alignment of the condyles

relative to the shaft is often best
assessed on a lateral image using the
alignment along the posterior cortex
TIP - 8
Optimal AP and lateral

images of the distal
femur should be
obtained before
leaving the operating
room
Oblique views and the

notch view may be
helpful, as outlined
previously
Conclusion
major complications with plate and screw fixation

of distal femur fractures are underappreciated
use of anatomically contoured plating systems

presents a risk for fracture malreduction and
implant-related problems if not applied improperly
use of current surgical technique and avoidance

of the pitfalls discussed can minimize implantrelated complications and improve patient
outcomes
THANK YOU

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Distal femur FracturesPlating pearls and pitfalls

Biomechanics of distal femur

screws ( locking/non locking,uni/bicortical)

screw hole fill

Cortical slotting techniques or far cortical locking screws :

decrease construct stiffness

create more uniform callous formation

Distal most screw in the diaphyseal segment is most important

dictates working length

dictates stiffness of the implant

Use a long plate(8-10 holes in proximal fragment)

Staggered fixation in proximal frag. with 50%

Screw near to fracture in prox. fragment preferably

optimise distal fixation with proper plate

Role of medial plate

Generally should not be used in acute fracture

Has a role in management of delayed /nonunion of fractures with medial comminution

too flexed or extended

too far off bone.

Fracture alignment that is too

Results in coronal plane

Easily preventable (as modern

Leads to compromised fixation leading to

Plate applied too anterior near the knee !

Painful encroachment on the extensor

Screw placement into the patellofemoral joint

Plate applied too posterior distally !

screws into the intercondylar notch causing

intra-articular screw placement

painful implant prominence

the golf club deformity can

screws may be aimed into

lead to compromised fixation

sagittal plane (curvatum)

may cause symptoms as a

may be associated with

Tips to optimise plating

Avoidance of implant-related problems is largely

Important to understand the local anatomy, the

Thorough preoperative planning

Computed tomography scan of the distal femur

Articular surfaces of the medial and lateral

Trochlea's subchondral arc is well seen on

Posteriorly intercondylar fossa houses the

Blumensaat's line on lateral imaging

Medial condyle extends distally than its

lateral surface of the

distal locking screws are

proximal shaft of the plate is

result is coronal plane

Optimal intraoperative imaging with C-arm fluoroscopy and

Optimal AP can be achieved by obtaining a quality AP image of

Optimal lateral view is obtained by superimposing the femoral

The notch view can demonstrate screws that cross the

formal arthrotomy to adequately visualize the

the universal femoral distractor (or external fixator,

Centered along midlateral line and applied

Plate should match the lateral contour of the

Joint axis wire should be close to parallel