Femur, distal: partial articular fracture of the medial condyle—33-B2 and spiral wedge shaft fracture—32-B1
10.1055/b-0034-87644
Femur, distal: partial articular fracture of the medial condyle—33-B2 and spiral wedge shaft fracture—32-B1
Suthorn Bavonratanavech
Case description
A 30-year-old male motorcyclist sustained a right femoral shaft fracture with a spiral wedge and an additional coronal fracture of the medial femoral condyle. There was no other injury.
Indication for MIPO
If there is only a shaft fracture, closed intramedullary nailing would be the preferred fixation method. However, with this combination of extraarticular and intraarticular fracture types, a condylar plate or a dynamic condylar screw (DCS) with a long side plate is recommended so that fixation of both fractures can be achieved with a single implant. Instead of conventional plate application, which often involves extensive dissection of soft tissue, MIPO technique is favored as it tends to minimize the damage to the soft tissue and blood supply.
a–d X-rays show a fracture of the midshaft of the femur, and a long spiral wedge associated with a medial condyle fracture.
Preoperative planning
In the case of an intraarticular fracture, anatomical reduction with absolute stability is mandatory. It requires direct reduction with adequate exposure of the joint. As there is a coronal split of the medial condyle, a medial parapatellar approach is selected because it gives better access and will simplify the fixation technique. After the coronal fracture is fixed with a malleolar lag screw the medial condyle will be reduced and fixed with a lateral condyle using a one-third tubular plate. The standard surgical technique for condylar blade plating is performed by making the seating chisel tunnel following the placement of a guide wire in the correct position both in AP and lateral views. The condylar plate is introduced under the muscle and bypasses the fracture zone to bridge the shaft fracture with the spiral wedge fracture in order to achieve relative stability. The proximal part of the femur is fixed with a side plate of adequate length. A 16-hole, 70 mm blade is prepared (Fig 18.2-2).
a–j Preoperative planning.a Preoperative images show the wedge fracture at the shaft and the coronal fracture of the medial condyle.b The skin incision is made one finger‘s breadth medial to the lateral border of the patella. After exposure of the joint by the medial parapatellar approach the patella can be everted and flipped laterally to enable better access to the medial femoral condyle. The coronal fracture of the medial condyle is reduced and maintained with a K-wire before this is replaced with a malleolar screw. A one-third tubular plate is used to fix the medial border of the supracondylar area to add more stability. The patella is then flipped back into the patellofemoral groove.c–d The patella is then flipped back and with the condylar guide, a guide wire is inserted from the lateral condyle, parallel with the knee joint axis and inclination slope from lateral to the medial condyle to indicate the plane for the condylar blade. The chisel blade is introduced, its length determined by measuring the length of the guide wire after insertion into the bone, or from measuring the length on the x-ray.e–f The 16-hole 70 mm condylar blade is introduced from the distal femur through the prepared tunnel with the blade pointing laterally. The blade is rotated after the side plate is fully engaged under the muscle. The guide wire is kept in place to show the direction the blade enters the seating chisel tunnel.g An additional cancellous and cortex screw is fixed to secure the plate at the distal femur. Manual traction is performed to gain length and the cortex screw is inserted at the center of the bone of the proximal fragment with the screw directly perpendicular to the shaft axis. This screw will function as a reduction screw to keep the plate close to the bone without using bone forceps. The alignment is checked for length, axis, and rotation.h–i Length can be adjusted using the push-pull technique with the anchorage screw and bone spreader until the correct length is achieved. The screw in the proximal plate hole must be removed while performing this procedure, as generally, the wedge fracture will be reduced with ligamentotaxis. The screw is reinserted into the last hole of the plate if the length is correct, or another hole may be drilled for screw fixation.j After obtaining the correct femoral length the screw is inserted to fix the proximal fragment. In case the wedge fracture is severely displaced, screw fixation to bring the wedge fragment close to the fracture can be performed.
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Jul 2, 2020 | Posted by drzezo in ORTHOPEDIC | Comments Off on Femur, distal: partial articular fracture of the medial condyle—33-B2 and spiral wedge shaft fracture—32-B1
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