These difficult fractures can be approached for reduction and fixation from the anterior aspect. If the posterior condylar fragments are large, the fracture lines will usually be accessible by the parapatellar approach.
For shallower fragments the standard lateral/anterolateral approach is necessary to gain more posterior access: alternatively, a posterior approach should be considered.
For the medial side, a straight medial approach can be used, taking care to avoid injury to the infrapatellar branch of the saphenous nerve.
Achieve reduction using periosteal elevators and a large pointed reduction forceps. The joystick technique, in which a small Schanz screw is inserted from the extraarticular surface, is also useful (as illustrated).
Insert the guide wires as perpendicularly as possible to the fracture plane.
Check guide-wire placement
Check the correct guide-wire insertion under fluoroscopic image intensifier control. The condylar surface must not be perforated.
Countersink manually, deeply enough to allow for fully buried screw heads.
Pitfall: countersinking too deeply Be aware of countersinking too deeply into the cancellous bone, which often happens using a power tool.
Do not perform countersinking when planning the use of headless compression screws.
Screw length determination
Determine the appropriate screw lengths, inserting the dedicated measuring device into the countersunk hole.
Insert the screws using the cannulated screw driver and check under image intensifier control in the lateral and oblique views that the screw length was chosen correctly.
X-ray showing the completed osteosynthesis.
6. Aftercare following screw (and plate) fixation of partial articular fractures
Introduction Impediments to the restoration of full knee function after distal femoral fracture are fibrosis and adhesion of injured soft tissues around the metaphyseal fracture zone, joint capsular scarring, intra-articular adhesions and muscle weakness.
Continuous passive motion is a low load method of restoring movement and is a useful tool n the early post operative phase. It must be used in combination with muscle strengthening programs. With stable fracture fixation, the surgeon and the physical therapy staff will design an individual program of progressive rehabilitation for each patient.
The regimens suggested here are for guidance only and not to be regarded as proscriptive.
Functional treatment Unless there are other injuries, or complications, joint mobilization may be started immediately postoperatively. Both active and passive motion of the knee and hip can be initiated immediately postoperatively. Emphasis should be placed on quadriceps strengthening and straight leg raises. Static cycling without load, as well as firm passive range of motion exercises of the knee, allow the patient to regain optimal range of motion.
Weight bearing Touch-down weight bearing (10-15 kg) may be started immediately with crutches, or a walker. This will be continued for 6-8 weeks postoperatively. After that, touch-down weight bearing progresses to full weight bearing gradually over a period of the next 2 to 3 weeks. In general, patients are full weight bearing without devices (e.g., cane) by 10-12 weeks.
Follow up Wound healing should be assessed at 2 to 3 weeks postoperatively. Subsequently 6 week, 12 week, 6 month, and 12 month follow-ups are usually made. Serial x-rays allow the surgeon to assess the healing of the fracture.
Implant removal Implant removal is not essential, unless there are implant-related symptoms after consolidation.
Thrombo-embolic prophylaxis Consideration should be given to thrombo-embolic prophylaxis, according to local treatment guidelines.