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August 1994, Volume 44, Issue 8

Original Article

Fractures of the Distal Femur in Adults

Modood Ali  ( Department of Surgery, College of Medicine, King Saud University, P.O. Box 641, Abha, Saudi Arabia. )
Mohammed Rafique-ul-Hassan Khan  ( Department of Surgery, College of Medicine, King Saud University, P.O. Box 641, Abha, Saudi Arabia. )

Abstract

Nineteen adults sustaining 20 distal femoral fractures were followed for 18 months. Majority (70%) of the patients were males  between the ages of 17 to 70 years and 68% sustained other injuries too. Fractures were classified by AO classification; most  of them were intrarticular CI type. Open reduction and internal fixation was carried out in 60% cases. Assessment of results  taking into consideration the parameters of pain, deformity and range of movement were compared with the conservatively  treated group (JPMA 44:188,1994).

Introduction

Fracture of the distal femur has always been considered a difficult injury to trea1,2. Orthopaedic surgeons have been  dismayed by the eventrual unsatisfactory outcome and treatment. Many forms of treatment have been advised1. In the past  conservative treatment was reported to have good results. Charles Neer et al3. considered that these fractures were not  suitable for open reduction and internal fixation and Mooney4, advocated the use of functional bracing for fractures at this level.  These observations were attributed to the non-availability of satisfactory implants during that time1-3. Lately there has been an  increased trend towards operative treatment of these injuries1,5,6,7. This was mostly due to the introduction of better implants  and operative techniques. Good results are now being reported with open reduction and internal fixation. This study reports the  results of 20 distal femoral fractures in 19 adults treated at Asir Central Hospital, Abha.

Patients and Methods

From 1988 to 1991, 19 adults with 20 fractures of the distal femur were admitted to Asir Central Hospital at Abha. These  patients had either been directly brought to the emergency room or referred from peripheral hospitals. Fractures were classified  according to AO classification8. Fourn treatment methods were used , i.e., condylar plates, Buttress plate, plaster cylinder  and skeletal traction. All patients were operated under general anaesthesia and tourniquet control. A standard extended lateral  approach6 was used to expose the fracture. Cancellous bone-graft was used in one case. Peroperative X-rays were taken,  during fixation of condy lar element, to ensure proper placement of implant. Postoperatively, patients were nursed with their legs elevated on a Braun Bohler frame. Active knee movements were encouraged as soon as pain allowed. Mobilization,  nonweight bearing with crutches, was started after a week under the supervision of a physiotherapist Partial weight bearing was allowed at not less than 6 weeks progressing to full weight bearing. Patients were followed up for an avenge of 18 months, (range 12 months to 3 years). The results of treatment were assessed by considering the parameters of range of movement, pain and clinical deformity (valgus orvarus) at the knee joint. Outcome of various treatment modalities regarding flexion is shown in Table II. Patients who were treated conservatively suffered prolonged pain, restricted movement and deformity as compared to the ones treated by open reduction and internal fixation.

Results

There were 14 males and 5 females whose ages ranged from 17-70 years (mean 40 years). Most (8 cases) of the patients were in the age group 28-38 years. Road traffic accidents were the most common cause (13 casds) of injury followed by fall (6 cases), over two thirds of the patients had other injuries (Table I).

Only one fracture was compound in nature (type 1). Fractures were classified according to A.O. classification8, the most common type being CI; there were no B2 or B3 fractures (Table II).

Follow-up ranged from 12 months to three years (mean 18 months). Four methods of treatments were used to treat these patients (Table II). Majority of the patients had been treated by condylar plate and one by a Butress plate (Figures 1 and 2).



One elderly lady had to be treated in a plaster cylinder due to her associated serious medical condition. All fractures united. The average period of union was 12.1 weeks (range 8-18 weeks). Full extension was achieved in 16 (84%) patients. There was limitation of less then 10 degrees in 2 patients and more than 10 degrees in 1. These three patients had been treated conservatively, later being the elderly lady who had been treated in plaster. The average flexion was 110.5 degrees. Maximum flexion was achieved in patients treated by A.O. eondylar plate. Three patients could not flex more than 60 degrees. All had been treatedconservatively. None of the patients developed a valgus or varus defermity. A 28 years old Yemeni lady developed a 2 ems shortening. She had initially been treated on skeletal traction and had beenreferred to us with gross over-riding and a painful stiff knee; bone had to be trimmed to obtain properalignment. She required a shoe raise but had no residual limitation of movement of the knee joint.

Discussion

Fractures of the distal femur present various manage­ment problems due to inherent instability of the condylar fragment and frequent intra-articular involvement. This re­sults in deformity, subsequent stiffness and osteoarthritis of the knee joint. Unlike some reported western series5,7 supra­condylar fractures of the femur in our series involved younger patients following road traffic accidents and were usually associated with other musculoskeletal trauma. Restoration of joint anatomy and early mobilization, therefore demand operative fixation. Previous reports of satisfactory outcome from conservative treatment3 were mainly ma relatively older age group of patients sustaining low velocity trauma. The available implants were not good enough for internal fixation in these patients. In addition, this could also be due to the lesser demand placed on their knees. The results of such studies are therefore not necessarily applicable inayounger age group. In our study most of the patients belonged to ayounger age group (mean age 40 years) who had a satisfactory result in an operatively fixed cohort. Moreover, most (68%) of our patients had associated musculoskeletal injuries. This is at variance with the recently reported series5,7 where them were either no associated injuries or the number of associated injuries was small. The overriding importance of early mobilization of a polytraumatized patient was another indica­tion for stabilization of supracondylar fractures to reduce associated morbidity. Although the follow-up period is relatively short to exclude the possibility of future osteoarthritis, early outcome is promising in relation to function. Absence of non or malunion in the operative group allowed early regain of function and is expected to reduce joint stiffness leading to degeneration. This is in concordance with the recently published reports5,7. However, even in a clearly defined situation the indication of primary bone grafting and choice of implant is dictated by the magnitude of trauma and type of fracture. Newer design of implants, e.g., Dynamic condylar screw, may add to the stability of fixation, but in the absence of these condylar or Buttress plate supplemented by leg screw fixation could also ensure satisfactory results.

References

1. Newman, J.H. Supracondylar fractures of the femur. Injury, 1990;21:280-82
2. Rockwood, CA. and Green, OP. (eds). Fractures in adults, 2nd ed. Philadel­phia, Lippincott, 1984, p. 1429.
3. Neer, S., Grantham, S.A., Shelton, ML. Supracondytar fractures of the adult femur. A study of one hundred and ten eases. J.Bone Joint Surg.. 196 7;49A: 591-613.
4. Mooney, V., Nickel, V.L., Harvey, J.P. et sl. Cast-brace treatment for fractures of the distal part of the femur. J.Bone Joint Surg., 1970;52A:1563­-78.
5. Mize Roby, D. Surgical management of complex fractures of the distal femur. Clin.Orthop., 1989;240:77-86.
6. Ruedi. 1., Von Hochatetter, A.H.C., Achlumpf, R. Surgical approaches for internal fixation. Berlin, Heidelberg, Springer- Verlag, 1984, p. 131.
7. Shewring, D.J. and Meggit, S.F. Fractures of the distal femur treated with the A.O. dynamic eondylar screw. J.Bone Joint Surg., I 992;74B; 122-25.
8. Muller. ME., Allgower, M., Schneider, R. et at. Manual of internal fixation. 3rd ed. Berlin, Heidelberg, Springer-Verlag, 1991, pp. 140-41.

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