Nonoperative treatment
Nonoperative treatment has a limited role.
Consider a hinged knee brace for:
- Stable nondisplaced fracture
- Nonambulatory patient
- Patient whose operative risk is prohibitive.
Prolonged immobilisation produces stiffness, muscle loss and complications of immobility and should be avoided where possible.
Temporary external fixation
Use spanning external fixation when:
- The patient is physiologically unstable
- Severe swelling or soft tissue injury prevents definitive internal fixation
- Open contamination requires repeated debridement
- Temporary restoration of length and alignment is required.
Operative principles
The sequence in an articular fracture is:
- Reconstruct the joint surface
- Restore the condylar block
- Restore femoral length, alignment and rotation
- Connect the reconstructed articular segment to the shaft
Avoid varus alignment.
Lateral locking plate
A precontoured lateral locking plate is useful for:
- Metaphyseal comminution
- Osteoporotic bone
- Intra articular fractures
- Very distal fractures
The construct should provide adequate working length and avoid unnecessarily dense locking screw placement that creates an excessively stiff construct and contributes to nonunion.
Medial comminution with poor cortical support can require additional medial fixation.
Retrograde intramedullary nail
Useful for:
- Extraarticular fractures
- Simple articular fractures after independent fixation of the joint split
- Selected periprosthetic fractures with an open femoral component box
The distal segment must be large enough to accept sufficient locking fixation.
Hoffa fracture
A coronal plane femoral condyle fracture is inherently unstable and should usually undergo anatomical reduction and screw fixation, often supplemented with a buttress plate in large or unstable fragments.
Nonoperative management of a displaced Hoffa fracture produces poor articular results.
Severe osteoporotic fracture
In an elderly patient with extreme comminution, severe bone loss or a nonreconstructible articular surface, distal femoral replacement may permit immediate stable reconstruction and early weight bearing.
It is a major arthroplasty procedure and should not replace reconstructive fixation when satisfactory osteosynthesis is achievable.
Rehabilitation
Stable fixation should permit early knee motion.
Prolonged knee immobilisation leads rapidly to arthrofibrosis.
Weight bearing depends on construct stability, fracture morphology and bone quality. Increasingly robust constructs can permit early weight bearing in selected patients.
Complications
Major complications are:
- Nonunion
- Varus collapse
- Implant failure
- Infection
- Knee stiffness
- Post traumatic osteoarthritis
- Malalignment
