These single plane, intraarticular fractures require anatomical reduction and interfragmentary compression, sufficient to allow early joint motion. The perfection of the articular reduction is usually assessed by an open approach, but where the skills and resources are available, arthroscopically assisted reduction and percutaneous fixation may be considered. The surgeon should be prepared to find additional comminution, not evident until fracture exposure.
Note on approaches
Unless full facilities and expertise for an arthroscopic approach are available to check the closed reduction, prior to percutaneous screw insertion, the standard medial parapatellar approach is used to give an optimal view of the joint fracture reduction.
2. Patient preparation
This procedure may be performed with the patient in one of the following positions:
Closed reduction and internal fixation (CRIF) is used in minimally displaced, or undisplaced simple, medial sagittal, partial articular fractures.
Preliminary reduction As simple, medial sagittal, partial articular fractures usually result from a varus force, the application of a valgus stress may reduce the fracture. If valgus stress alone is not sufficient, arthroscopy may be helpful to assess the accuracy of the reduction.
Temporary K-wire placement
Under image intensifier control, make a stab incision over the medial aspect of the injured condyle and insert a temporary K-wire, to hold the reduction.
Make sure, that the K-wire does not conflict with the planned screw tracks.
Check of reduction Check the reduction in two planes using the image intensifier.
4. Insertion of guide wires for cannulated screws
In general, the screws are inserted at points along the midshaft axis of the femur (dotted line). The area distal to the Blumensaat’s intercondylar roof line must be avoided, in order not to violate the notch. In addition, the area of the medial knee recess should be avoided.
If you need to insert a screw in the area distal to the Blumensaat’s intercondylar roof line, direct the screw anteriorly, in order to avoid the intercondylar notch.
Insertion of guide wires
Make a separate stab incision for each screw. Bluntly dissect to the bone, avoiding the medial recess of the knee. Insert the appropriate guide wires for 7.3 mm cannulated screws, or alternatively, 4.5 mm cannulated screws. Depending on the size of the fragment, 2 to 4 screws are necessary.
Guide wire position check
Use image intensifier to make sure that the tip of the K-wire just penetrates the far cortex, slightly externally rotating the femur to profile the sloping lateral face of the lateral condyle.
5. Cannulated screw insertion
Screw length determination
Determine the appropriate screw length using the dedicated measuring device.
Manually insert the screws of appropriate lengths over the guide wires. Washers may be used. Predrilling is usually not necessary if using self-drilling/self-tapping screws.
Then remove the temporarily placed K-wire and guide wires.
Illustration 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.