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Fracture, Distal Femur

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Fracture, Distal Femur
Sandeep Johar
Basics
Description
  • Fracture involves the distal 15 cm of the femur.
  • Fractures may be
    • Supracondylar: Zone is from the femoral condyles to the junction of the metaphysis and femoral shaft.
    • Intracondylar
    • Condylar
  • Many classification systems (Neer, Stewart, Schatzker, etc.): AO/OTA is the most commonly used and complete classification system.
Epidemiology
  • Distal femur fractures represent ∼7% of all fractures of the femur (1).
  • No data on the incidence in the athletic population
Pediatric Considerations
  • Up to 60% of femoral fractures in children 3 yrs old or younger may be the result of nonaccidental trauma (2).
  • Spiral fractures of the femur strongly suggest child abuse (2).
Risk Factors
  • High-energy sports such as motor sports and downhill skiing
  • Osteoporosis
Etiology
  • Fractures generally occur from significant axial loading with associated varus, valus, or rotation force.
  • May occur from direct trauma as well
  • In young adults, fractures are usually associated with high-energy trauma such as:
    • Motor vehicle accidents, falls from heights, direct impact
    • Motor sports, downhill skiing
  • In older individuals, a slip and fall may be enough force to cause injury.
  • Muscle attachments, quadriceps, hamstring, and gastrocnemius cause the observed deformity in distal femur fractures.
Commonly Associated Conditions
  • Fractures are generally from high-energy mechanism, so a full trauma survey should be performed.
  • Complications may include:
    • Proximal or shaft fractures of the femur
    • Ligament and cartilage injuries of the knee
    • Proximal tibia fractures
    • Open fractures: 5–10% of all supracondylar fractures
    • Quadriceps tendon injury
    • Vascular injuries are relatively uncommon.
Diagnosis
Pediatric Considerations
  • Cartilaginous components of the proximal and distal ends of the developing femur alter the fracture patterns seen in hip and knee injuries in children.
  • Essential workup:
    • Radiographs
    • Assess distal pulses, palpate compartments, and evaluate sensation and motor function.
      • If pulses are not equal or palpable, bedside Doppler may be necessary.
    • Search for associated injuries.
    • In suspected child abuse, obtain skeletal survey or bone scan.
History
  • History will help to guide examination and workup.
  • High-energy injuries require full examination and search for associated injuries.
  • Direct trauma and low-energy mechanism do not necessarily require a more comprehensive evaluation.
Physical Exam
  • Tenderness on examination, deformity, thigh shortening, swelling (secondary to hematoma), and crepitus with movement
  • Limited movement of hips and knees
  • Commonly presents with associated injuries: Chest or abdominal trauma, hip or knee injury, direct blow to the extremity
  • Vascular compromise (arterial injury): Expanding hematoma, absent or diminished pulses, progressive neurologic deficits in a closed fracture
  • Hypotension and tachycardia secondary to significant blood loss
Diagnostic Tests & Interpretation
  • Radiographs:
    • Anteroposterior (AP) view of pelvis, true lateral of hip, AP and lateral views of femur, and complete knee series
    • Other imaging as indicated by trauma protocols
  • CT scan: Complex intraarticular injuries generally necessitate CT scan for operative planning.
  • Arteriography: Should be performed for evidence or suspicion of vascular compromise
Lab
CBC, type, and crossmatch
Differential Diagnosis
  • Hip fracture or dislocation
  • Knee dislocation
  • Proximal tibia fracture
  • Thigh contusion or hematoma
Treatment
Pediatric Considerations
  • Assess markers for nonaccidental trauma.
    • Delay in presentation; history of mechanism inconsistent with the injury
    • Isolated trauma to the thigh; associated burns, bruises, or linear abrasions
  • Assess for dislocation of the femoral capital epiphysis.
  • Depending on the age of the patient and the fracture type, pediatric femoral fractures may not require operative treatment.
Pre-Hospital
  • Long-leg splint should be applied to the extremity in the position it was found.
  • If signs of neurovascular compromise, reduce limb with in-line traction.
  • Use analgesia when possible.
  • Do not attempt to reduce open fractures in the field.
    • Apply wet sterile dressing over an open fracture.
    • If wound is grossly contaminated, use sterile saline irrigation.
  • Apply wet sterile dressing over an open fracture.
  • If wound is grossly contaminated, use sterile saline irrigation.

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ED Treatment
  • Primary and secondary trauma surveys
  • If surgical treatment will be delayed or for selected patients in whom nonoperative management is the treatment of choice, consider fracture reduction.
  • Reduce fractures to near-anatomic alignment by using in-line traction (Hare, Buck, or long posterior splint): Reduces pain and helps to prevent hematoma formation.
  • Pain management: Parenteral or IV opiate-type analgesia
  • Infection prophylaxis: With open fractures, tetanus toxoid if indicated, cefazolin with gentamicin
  • For injuries with highly contaminated wounds, add penicillin G to cover Clostridium spp.
  • Emergently consult an orthopedic surgeon
  • Femur fractures with vascular (expanding hematoma, absent or diminished pulses) or progressing neurologic compromise require immediate angiography or vascular consultation for femoral artery exploration.
  • Consider transferring patients with a femur fracture if:
    • Necessary orthopedic consults are not available.
    • There are associated serious injuries that may require a trauma center for management.
Medication
  • Cefazolin: Adult: 2 g IM/IV; children: 20 mg/kg IM/IV
  • Gentamicin: 1.5 mg/kg IV
  • Penicillin G: Adult: 2 million IU IV; children: 25,000 IU/kg/day IV divided q8h
Surgery/Other Procedures
  • Surgical reconstruction should be performed as soon as possible (3)[C].
  • If surgery will be delayed more than 24 hr (closed fractures), tibial pin traction should be applied to maintain limb length (3)[C].
  • Multiple surgical techniques can be performed to obtain reduction and fixation and depend on both surgeon experience and the specific fracture.
  • Anatomic reduction of the fracture with particular attention to the articular surface is more closely related to positive outcomes than the actual surgical technique.
  • Children aged 6 mos to 5 yrs with a diaphyseal fracture and <2 cm of shortening may be treated with early spica casting or traction and delayed spica casting (4)[B].
  • There is unclear benefit of surgery versus casting in fractures with >2 cm shortening or varying degrees or rotation and angulation (4)[C].
In-Patient Considerations
Initial Stabilization
Monitor heart rate and BP continuously because large volumes of blood (ie, 4–6 units) may be contained within the thigh.
Admission Criteria
  • Most femur fracture patients should be admitted.
  • Conservatively treated fractures in a pediatric patient may not require hospitalization.
Ongoing Care
Prognosis
  • Depends on multiple factors:
    • Fracture type
    • Associated injuries
    • Patient comorbidities
  • Fracture with intra-articular involvement carries a high risk of posttraumatic arthritis.
Complications
  • Hemorrhagic shock secondary to significant blood loss
  • Neurovascular injury
  • Infection secondary to open fractures
  • Fat embolism and adult respiratory distress syndrome can cause respiratory failure.
References
1. Arneson TJ, Melton LJ, Lewallen DG, et al. Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 1965–1984. Clin Orthop Relat Res. 1988;188–194.
2. Hui C, Joughin E, Goldstein S, et al. Femoral fractures in children younger than three years: the role of nonaccidental injury. J Pediatr Orthop. 2008;28:297–302.
3. Albert MJ. Supracondylar fractures of the femur. J Am Acad Orthop Surg. 1997;5:163–171.
4. Kocher MS, Sink EL, Blasier RD, et al. Treatment of pediatric diaphyseal femur fractures. J Am Acad Orthop Surg. 2009;17:718–725.
Additional Reading
Macnicol MF. Fracture of the femur in children. J Bone Joint Surg Br. 1997;79:891–892.
Starr AJ, Hunt JL, Reinert CM. Treatment of femur fracture with associated vascular injury. J Trauma. 1996;40:17–21.
Codes
ICD9
  • 821.20 Fracture of lower end of femur, unspecified part, closed
  • 821.21 Fracture of femoral condyle, closed
  • 821.22 Fracture of lower epiphysis of femur, closed
Clinical Pearls
  • Be aware of potential associated injuries in all femur fractures.
  • Evaluate for signs of child abuse in children <3 yrs.


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