Orthopaedics & Traumatology: Surgery & Research (2013) 99, 353360

Available online at

www.sciencedirect.com

REVIEW ARTICLE

Distal femur fractures. Surgical techniques and a

review of the literature
M. Ehlinger , G. Ducrot , P. Adam , F. Bonnomet
Department of Orthopaedics and Trauma Surgery, Hautepierre Teaching Hospital Center, Strasbourg Academy Hospital Group, 1,
avenue Molire, 67098 Strasbourg cedex, France
Accepted: 29 October 2012

KEYWORDS
Distal femur;
Fracture;
Supracondylar and
intercondylar
fracture;
Internal xation;
Biomechanics

Summary Fractures of the distal femur are rare and severe. The estimated frequency is 0.4%
with an epidemiology that varies: there is a classic bimodal distribution, with a frequency peak
for men in their 30s and a peak for elderly women; however, at present it is found predominantly
in women and in the elderly with more than 50% of patients who are over 65. The most common
mechanism is an indirect trauma on a bent knee, and more rarely direct trauma by crushing.
The anatomy of the distal femur explains the three major types of fracture. Because of the
anatomy of the distal femur, only surgical treatment is indicated to stabilize the fracture. A
non-surgical treatment is a rare option. The aim of this report was to provide an update on the
existing surgical solutions for the management of these fractures and describe details of the
surgical technique applicable to these injuries. Recent radiological, clinical and biomechanical
data published in the literature are reported to compare different surgical options.
2013 Elsevier Masson SAS. All rights reserved.

Introduction
Fractures of the distal femur are rare and severe. The
estimated frequency is 0.4% of all fractures and 3% of
femoral fractures [1]. A classic bimodal distribution is
found with a peak in frequency in young men (in their
30s) and elderly women (in their 70s). The usual context is a high energy trauma in a young patient and a
domestic accident in an elderly person [1]. The gender

Corresponding author.
E-mail address: matthieu.ehlinger@chru-strasbourg.fr
(M. Ehlinger).

ratio has changed and today there is a majority of women

(1 man/2 women), and the population is also increasingly
older; mean 61 years old at fracture and over 65 in more
than half the cases [1]. Sufcient stabilization to withstand
static loading forces on bone and dynamic muscular forces
can only be obtained with surgery. An orthopedic treatment is rare: it is proposed in bedridden patients and/or in
patients with reduced autonomy in fractures with little or no
displacement.
The goal of this study was to provide an update on
the management of these fractures. The basic points
of treatment are summarized. The technical details and
the indications of the different surgical treatments are
then described. Finally, recent radiological, clinical and

1877-0568/$ see front matter 2013 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.otsr.2012.10.014

354
biomechanical results published in the literature are
reported to compare the techniques.

Management and therapeutic principles

Initial management
Besides a clinical examination and a standard radiological
examination, a CT scan is recommended because 55% of
these fractures are intra-articular [1]. If there is a doubt
about the presence of vascular injury, appropriate tests
should be performed. It should be remembered that the
presence of a distal pulse does not exclude vascular injury.
Femoral nerve block is indicated and recommended by same
authors in the emergency room [2]. These fractures are serious with a high mortality rate in elderly populations which is
comparable to that found in the proximal femur. It has been
shown that a delay in surgery by more than 4 days (whatever the cause) is associated with an increase in mortality
at 6 and 12 months of follow-up [3]. The known risk factors are dementia as well as cardiac and kidney disorders
[3]. To reduce perioperative morbidity and mortality in this
age group, Kammerlander et al. [4] advise appropriate initial medical management and taking measures to prevent
complications that may compromise functional results. In a
series of 43 patients in their 80s, they reported 50% mortality
at the 5-year follow-up, a frequent loss of independence,
and only 18% of patients who can walk without help.

The major principles of treatment

Fractures of the distal femur are severe and medical
management and treatment are difcult. The 1988 SOFCOT symposium reported [5]: infection and septic nonunion
in 13% (29% of open fractures), aseptic nonunion in
14%, residual stiffness in 35%, secondary post-traumatic
osteoarthritis in 50%, with initial chondral injury as well as
incomplete reduction.
The main therapeutic principles are as follows. If the
fracture is intra-articular, joint reconstruction is the rst
step. The knee must remain free and mobile at the surgical
site. Exposure of epiphyseal fracture lines is obtained with
the knee bent, especially with frontal lines. Stabilization
on the frontal plane is usually not difcult, while saggital
plane stability with rotation of the condyles is much more
difcult. The metaphyseal portion, in particular of the anterior cortex can serve as a reference point. The second step
includes reducing the epiphysis on the metaphyso-diaphysis:
this is performed with the leg in extension. In case of a comminutive fracture, rotation and length should be carefully
controlled.

Surgical options
For an extra-articular fracture, all therapeutic options are
possible and mini-invasive surgery can be performed. In case
of an intra-articular fracture, open reduction and internal
plate xation should be performed with the patient on a
standard operating table.

M. Ehlinger et al.

External xation
External xation is not indicated for denitive treatment
of these fractures, in particular in displaced intra-articular
fractures. It is difcult to control alignment, the stability
of this technique is poor (lever arm of the leg), there is
no xation of the articular component and stabilization of
the fracture requires bridging the knee, which increases the
risk of stiffness. The indications are more often for temporary xation. If there is a complex fracture, the fracture can
be evaluated and a therapeutic strategy can be determined
using this solution. A bilateral fracture or a oating knee
are typical examples of these complex fractures (Fig. 1).
External xation provides medical management and a Damage Orthopedic Control approach which reduces pain and
facilitates treatment. Local monitoring of an open fracture
is facilitated. Finally, in case of associated vascular injury,
the fracture must be stabilized rapidly.
External xation should bridge the knee when there is
intra-articular involvement. The femoral pins should be at
a distance from the fracture site and the joint to prevent
infection. Anterior femoral pins can be a good choice if internal xation with a lateral plate is used later: in that case
external xation is maintained during the procedure to facilitate control of alignment during internal xation. Although
temporary external xation has certain advantages, there
are still certain risks. Control of the fracture is limited,
and there is a risk of skin damage from a protruding bone
fragment. Oh et al. [6] reported results of a series of 59
complex intra-articular fractures with temporary bridging
external xation. There were seven complications including four that developed in distal femoral fractures. The
authors explain this rate of infection and the unsuccessful
control of length that occurred by the abundant femoral leg
muscles and the presence of the suprapatellar pouch. On
the other hand, Parekh et al. [7] reported good results in
the two-step management of complex intra-articular fractures around the knee (with 16 distal femoral fractures in a
series of 47 cases). Finally, Bonnevialle et al. [8] reported a
series of 27 fractures of the femoral diaphysis and 26 fractures of the distal femur treated with a lateral external
monoplane xator with a high rate of infection and knee
stiffening in the distal fracture group. They concluded
that denitive external xation is only indicated in stable
distal metaphyseal-diaphyseal fractures when the epiphysis
has rst been stabilized.

Anterograde intramedullary nailing

The indications for anterograde intramedullary nailing are
essentially extra-articular fractures. Certain intra-articular
fractures without or with very little displacement can be
treated with this technique as long as the epiphyseal part
of the fracture has been stabilized with isolated screws to
avoid opening of the fracture site during nailing. Finally, in
the rare cases of bi- or trifocal fractures of the distal femur,
nailing is often the only therapeutic alternative (Fig. 2).
This solution is contraindicated in complex intra-articular
fractures.
The advantages of this technique are that it is closed
with conservation of heamatoma and that the implant is

Treatment of distal femur fractures in adults

355

Figure 1 Bilateral oating knee: a: clinical appearance; b: AP X-ray; c and d: postoperative X-ray, left side; e and f: postoperative
X-ray, right side.

extra-articular which is relatively easy to remove. The

patient should be installed on a traction table. If condylar
traction is being performed (extra-articular fracture), this
should be as anterior as possible. If there is intra-articular
involvement, a traction boot is indicated. Recurvatum deformity of the distal fragment is controlled by providing
distal support attached to the traction table (Fig. 3). Additional internal xation of an epiphyseal fragment should
take into account the position of the future nail. The nail
should descend as deeply as possible into the condyle for
maximum stability. Antekeier et al. [9] dened the minimum distance between the fracture site and the most
proximal screw for distal xation of the nail. Anterograde
intramedullary nailing is possible when the fracture is
located more than 3 cm from the proximal screw, which can
resist one million cycles of loading. The diameter of the
nail is also important. For Huang et al. [10], distal cortical contact increases stability of the system while reducing
strains which are absorbed by the nail and the locking
screws.

Retrograde nailing
The indications for retrograde nailing are classic: extraarticular fracture, simple intra-articular fractures with
little or no displacement. This technique may be
indicated in cases of oating knee with a single
surgical approach for stabilization of both fracture
sites.
Passing a nail near the fractured trochlea can worsen
the situation by opening the fracture site, thus if there
is an intra-articular fracture line, initial screw xation is
indicated. Retrograde nailing has the advantages of being a
closed technique, but because it is intra-articular, there is
a risk of septic arthritis in case of infection. Removal is also
more difcult. The patient can be installed on a standard
or a fracture table. On a standard table, the knee is in 30
exion and the distal femur is supported. On a fracture
table, reduction is obtained by skeletal traction at the
proximal tibia with the leg hanging slightly. The nail should
be inserted deep enough to avoid any impingement with the

356

M. Ehlinger et al.

Figure 2 Example of a bifocal fracture of the femur treated with anterograde intramedullary nailing: a, b, c: preoperative X-rays;
d, e, f: immediate postoperative X-rays.

Simple screw xation

Simple screw xation is proposed in the presence of a frontal
or sagittal unicondylar fracture.
A medial or lateral parapatellar approach is often
necessary, however, in case of a fracture with no or little displacement, a percutaneous procedure is possible and
reduction is controlled by ligamentotaxis. A recent study
showed that osteosynthesis using two 6.5 mm screws were
more effective than osteosynthesis using two or four 3.5 mm
screws [11]. A load of 4056% more was required with
6.5 mm screws to cause system failure. In frontal fractures,
the direction of the screws changes the mechanical stability.
Double screws using cancellous lag screws in a posterior to
anterior direction provide better mechanical strength during loading than those in an anterior to posterior direction
[12].

Blade plate
Figure 3 Distal support attached to a traction table to control
tilting of the distal fragment.

patella and should not be used as a lever to prevent

creating an intercondylar fracture line. Epiphyseal
xation can be improved by using a screw and counter
screw.

Classic indications are extra-articular fractures, sagittal

unicondylar fractures or supracondylar and intercondylar
fractures.
This is a monoblock, preshaped implant that is adapted to
the anatomy of the distal femur. The system is very stable
allowing compression of the epiphyseal-metaphyseal fracture site. In osteoporotic bone, placement of the blade
can be traumatic and have little resistance to breakage.
Mechanically, the plate functions like a dynamic tension

Treatment of distal femur fractures in adults

band and creates medial compression. The 95 blade plate is
placed on a femur whose articular surface is in 13 valgus.
In this way, the difference in angle between the plate and
the distal end of the femur results in medial compression
of the metaphyseal fracture site after diaphyseal xation,
thanks to the deformation of the blade plate. For an optimal
effect, the medial pillar must be perfectly reconstructed.
The diaphyseal position of the plate is determined by the
position of the blade which must be precisely dened. It
should be located 2 cm from the joint line (AP and lateral
view), along the axis of the femoral diaphysis and in the middle of the anterior half of the largest diameter of the condyle
in prole. Thus the blade is inserted in front of the Blumensatt line (avoiding the cruciate ligaments) and behind the
groove of the trochlea (avoiding the patellofemoral joint
line). The path is perpendicular to the lateral cortex, aimed
approximately a dozen degrees towards the back to prevent
internal rotation and medial translation of the distal fragment. The blade should not extend beyond the medial cortex
to prevent injuries of the medial collateral ligament.

Dynamic compression plate

The indications are classic: extra-articular fractures,
sagittal unicondylar fractures or supra- and intercondylar
fractures.
This solution includes dynamic epiphyseal screw xation
(lag screw) for compression of the fracture site. Epiphyseal xation is obtained by a single screw which the plate
pivots upon for sagittal adjustment. The 95 angle between
the plate and the screw facilitates frontal placement and
positions the ephiphyseal screw parallel to the joint. This
system has the advantage of being fairly easy to position,
because the screw is cannulated, to limit bone trauma and
to have good resistance to screw failure. However the screw
hole is large, there may be rotational instability in the distal screw before diaphyseal xation and the insertion site of
the screw may be located near a frontal fracture. The insertion guide is positioned according to the same criteria as the
blade plate, and its direction on the axial plane is parallel to
the anterior trochlear rims, or 10 downwards and inwards.

Locking compression plate

The classic indications are extra-articular fractures, sagittal
unicondylar fractures or supra- and intercondylar fractures.
The goal of locking plate is to provide better stability in
fragile bone. Primary stability of the plate is independent
of the friction effect as the screw presses the plate, and is
obtained by locking the screw into the plate. Plate design is
usually anatomical which allows it to be used as a reduction
mold, molding the bone to the plate.
The locking plate can be used during an open procedure
when there is intra-articular involvement, or with miniinvasive surgery using the ancillary less invasive stabilization
system (LISS) in case of an extra-articular fracture or in the
presence of a simple non- displaced fracture [13]. Combination use is possible, with mini-invasive proximal diaphyseal
xation combined with open distal internal xation. Miniinvasive surgery reduces postoperative pain, and facilitates
functional recovery [14]. Its main disadvantage is the lack

357
of epiphyseal compression with locking screws, requiring
prior placement of standard additional screws. These screws
should not interfere with the plate. The rules for xation of
this system must be strictly followed, in particular during
mini-invasive surgery to prevent malunion and mechanical
failure [15]. The patient can be installed according to the
surgeons preference. If the patient is installed on a traction
table, traction should be moderate and a certain degree of
impaction of the fragments should be preserved, especially
in elderly patients to promote union. The rst step of the
mini-invasive surgery is to mark the skin with references
(fracture, joint line, patella, femoral stems of an existing
implant, femoral axis, incision) which will help reduce the
amount of radiation to the patient, choose the length of the
plate and facilitate the procedure. The lateral paracondylar
approach is used. The length of the plate is chosen to leave
at least ve holes above the fracture. The goal is to obtain
coverage that is as long as possible to absorb and distribute
strains and stresses. It is necessary to remain extra-articular
by raising the suprapatellar pouch. The beveled tip of the
plate allows minimally traumatic submuscular and extraperiosteal insertion. The plate should be parallel to the lateral
cortex in front, centered on the femoral diaphysis in prole,
with the racket of the distal femoral plate located behind
the base of the trochlea and in front of the Blumensatt line.
The anatomical plate can be used as a reduction mold if and
only if the plate is, rstly, parallel to the lateral cortex of
the femur (parallel to the cortex does not mean in contact
with bone), secondly, the epiphyseal screws are parallel to
the joint line. The second part of the procedure includes
placing a 2 mm pin along the path of the central screw of
the LISS system which should be parallel to the joint line.
The bone can then be pulled towards the plate with a traction screw or by using the LISS system. To obtain a perfect
reduction, different technical tricks can be used (lag screw
from the bone to the plate, temporary intrafocal pinning,
temporary screws, joystick pin) [1315].
Numerous biomechanical studies have been performed
to evaluate and dene locking plate xation systems.
The LCP (Synthes, Etupes, France) system is usually the
reference and is compared to classic internal xation systems. Dougherty et al. [16] suggest that bicortical screws
should be systematically used to provide three points of
xation (2 cortical + the plate) to limit breakage. The position of the screw in relation to the fracture line depends on
the type of fracture. If the fracture is unstable (long fracture line, comminutive fracture) locking screws are placed
near the fracture line to stabilize the fracture site. If it is
a simple fracture, locking screws are placed further away
with an open hole on each side of the fracture to create
elasticity in the system, which will promote union [17]. For
Ahmad et al. [18], the internal xation system should be
close to the fracture. A distance of less than 2 mm provides
better resistance to compression and torsion, while there
is signicant plastic deformity with more than 5 mm. LCP
plates have combination screw holes making it possible to
use a locked system, a dynamic compression plate (DCP)
system or a combination system. Stoeffel et al. [19] compared these three systems. The locking system results in
less loss of reduction under axial compression with less plastic deformity and the DCP system provides better strength
under torsion. The authors propose combination xation.

358

M. Ehlinger et al.

Bottlang et al. [20] propose the use of a standard screw at

the end of the plate in case of a fracture in osteoporotic bone
to limit strains and prevent a stress fracture. This type of
system increases strength during bending without changing
strength under compression or torsion. The implant must be
parallel at a 10 angle to the cortex and the lateral condyle.
Indeed Khala et al. [21] have shown that these parallel systems are stronger under axial compression and cyclic loading
than systems in which the plate is not parallel to the lateral
cortex. Beingessner et al. [22] compared titanium plates
to steel plates as well as unicortical to bicortial screws in
these indications. They showed that strength under torsion
is reduced in titanium plates and strength is improved
with bicortical screws. On the other hand, there is no difference for axial compression strains and plastic deformity.
Lujan et al. [23] concluded that titanium plates favor
the formation of calluses by increasing elasticity in xation
material. Finally, for Wilkens et al. [24], the placement of
polyaxial screws increases strength under axial compression
and torsion and reduces deformation observed under cyclic
loading.

was increased in locking plates, however failures were more

severe with opening of the proximal femoral fragment.
Zlowodzki et al. [29] compared LCP, blade plates, and retrograde nailing in extra-articular fractures. Strength under
axial compression was better with the LCP system than with
the blade plate or nailing, by 34 and 13% respectively, but
strength under torsion was reduced. The authors observed
better distal xation with the LCP system with loss of distal xation in only one LCP plate (6%), three blade plates
(38%) and eight losses with retrograde intramedullary nailing (100%). These same authors compared the blade plate to
the LCP system in cadavers with high bone density and did
not nd any signicant difference in compression strength
[30]. Finally, Hingins et al. [31] concluded that the locking
plate system was better than the blade plate with increased
strength under axial compression and cyclic loading whatever the quality of cadaveric bone. To our knowledge, no
studies have been performed to compare anteretrograde
intramedullary nailing to locking plates. Overall, biomechanical results showed that locking plates are better.

Total knee arthroplasty

Clinical results

As in complex fractures of the proximal humerus, the distal humerus and fractures of the femoral neck, total knee
arthroplasties can be included as a therapeutic option in
elderly patients.
This is a difcult procedure in a fragile population requiring extensive expertise in arthroplasty. The main technical
point is to restore the height of the joint line when there
is no longer any possibility of reduction. An intact lateral
or medial pillar facilitates adjustment of the replacements.
A constrained knee replacement is usually chosen and even
in certain cases a megaprosthesis such as that used after
tumor resection. Postoperative morbidity-mortality is high.
In a series of 54 fractures in patients in their 80s, Appleton et al. [25] reported a mortality of 40% and a morbidity
of 15% at 1 year with 11% of surgical revisions and 4% of
implant revisions. Patient selection is essential to guarantee
the best results. Finally, certain authors propose a hinged
prosthesis to treat nonunion of the distal femur in elderly
patients. After a mean follow-up of 4 years in a series of 10
patients mean age 74 years old, Vaishya et al. [26] reported
satisfactory functional results with a very low morbidity in
eight patients. Haidukewych et al. [27] proposed a total
knee replacement for nonunion of the distal femur as well as
for early failure of internal xation. Survival was 91%, after
5 years in 15 patients with perioperative complications in
29%, postoperative complications in 29%, and poorer results
than for primary replacements.

Results in the literature

Biomechanical data
Several biomechanical studies have shown that locking systems are better than classic internal xation (DCP plate,
retrograde nailing, blade plate) [2830]. Fulkerson et al.
[28] compared locking plates to classic large fragment plates
with cables. Strength under axial compression and torsion

Vallier and Immler [32] compared the 95 blade plate

and LCP locking plates in a retrospective series of 71
intra-articular and extra-articular fractures. The rates of
complications, surgical revisions and nonunion were statistically higher with LCP plates. On the other hand, Nayak et al.
[33] support the use of LCP locking plates for extra-articular
fractures, reporting union in all cases, good recovery of
alignment and high quality function. An autologous graft was
not necessary with the mini-invasive technique, postoperative pain was reduced and the rate of union was high. Kolb
et al. [34] conrmed these results in a retrospective series
of 50 fractures. Functional recovery was found to be very
good with 80% of good and very good results. They concluded
that the locking plate system allows early mobility, rapid
functional recovery and good radiological results with low
morbidity, even though these were intra-articular fractures.
Kanabar et al. [35] and Kavali et al. [36] proposed xation of
complex fractures of the distal femur with locking plates by
mini-invasive approach emphasizing the limited blood loss
and low rate of complications. Kavali et al. [36] did not nd
any statistical difference in functional recovery between
patients treated for single or multiple fractures. Comparisons in the literature between retrograde intramedullary
nailing and blade plate by a mini-invasive approach have
not shown any difference between intra-articular or extraarticular fractures. Markmiller et al. [37] did not report
improved results for any particular implant for identical
indications. Hierholzer et al. [38] conrmed these results
in a retrospective series of 115 fractures comparing retrograde nailing (n = 59) and mini-invasive locking plate (n = 56).
The authors describe the indications for each technique:
the plate can be adapted to all fractures, while retrograde
nailing is better adapted to extra-articular fractures. They
emphasize that high quality results are more dependent
upon the surgical technique than the choice of implant.
On the other hand, results comparing retrograde nailing
and classic open internal xation are clear. For Thompson et al. [39], statistical results for the rate of surgical

Treatment of distal femur fractures in adults

revision and the rate of malunion are better for retrograde
intramedullary nailing. The rates of infection and nonunion
were higher in the open internal xation group. After a
mean follow-up of 6 years nearly 50% of intra-articular
fractures showed progression to arthritis on radiological
imaging. Acharya et Rao [40] reported a prospective series
in 28 patients treated with retrograde nailing with union
in 93%, malunion in 14% and excellent or good functional
results in 75% of cases. There was no difference between
results for retro- and anteretrograde nailing. For Salem
et al. [41], results in length, torsion, alignment and function
were comparable. The only reported difference was in hip
range of motion which was more limited with anteretrograde
intramedullary nailing, and knee range of motion which
was more limited with retrograde nailing. Hartin et al. [42]
did not observe any difference in functional recovery in a
randomized comparison of the treatment of extra-articular
fractures by retrograde intramedullary nailing and blade
plate. The only element observed was more frequent pain
in the knee in the retrograde nailing group, so that xation material had to be removed in 25% of the cases. The
results in the literature do not provide any consensus on the
technique only closed techniques seem to make a difference. It is important to remember that the best results are
obtained with techniques in which the surgeon has the most
experience.

Conclusion
The quality of the surgical technique is the primary factor, and the only guarantee of obtaining good radiological
and clinical results in distal femoral fractures. Mini-invasive
treatment (nailing or plates) seems to provide better results.
All types of fractures can be treated with locking plates
and a classic or mini-invasive surgical approach is possible. Although the overall mid-term results are satisfactory,
there are no studies evaluating the long-term functional and
radiological results of fractures of the distal femur. However,
there seems to be a tendency towards progression to arthritis in intra-articular fractures. Recent biomechanical studies
have shown that results are better with locking plates. The
surgical technique must be rigorous and the biomechanical
qualities of these implants must be understood to prevent
the development of major complications.

Disclosure of interest
ME, PA: occasional consultant for Synthes .

Appendix A. Supplementary data

Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/
j.otsr.2012.10.014.

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