Authors of section

Authors

Arnold Besselaar, Daniel Green, Andrew Howard

Executive Editor

James Hunter

General Editor

Fergal Monsell

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Open reduction; plate fixation

1. General considerations

Introduction

These fractures will heal when fixed with relative stability.

A plate that bridges the growth plate will prevent further longitudinal growth.

In younger patients, this will necessitate plate removal early after fracture union.

In patients close to skeletal maturity, this may not cause a functionally important difference in leg lengths.

Plate fixation of a multifragmentary Salter-Harris II fracture of the distal femur

In some fracture patterns a large metaphyseal fragment is available for fixation and bridging the growth plate is not necessary.

Plate fixation of a multifragmentary Salter-Harris II fracture of the distal femur

Size and type of implant

The size and type of implant is determined by the size and age of the patient as well as by the fracture pattern. The range of plate sizes in pediatric femur fractures is between 2.7 and 5.0 mm.

There are anatomic condylar plates specifically designed for pediatrics which are also an option.

Adult anatomic plates may be appropriate for patients with a closing growth plate or, in rare cases, where a stable fracture fixation requires bridging (and potentially sacrificing) the growth plate.

Plate types for fixation of distal femur fractures

2. Patient preparation and approach

Patient positioning

Place the patient supine on a radiolucent table with a C-arm.

Supine patient position

Approach

The majority of the fractures are approached using the distal component of a direct lateral incision.

Confirm the location of the growth plate with image intensification and protect it, taking care not to strip the adjacent periosteum.

Direct lateral incision to approach the distal femur

3. Reduction

Removal of impediments

It may be necessary to remove interposed soft-tissue and periosteum prior to reduction of the fracture under direct vision, but not at the cost of devitalizing fragments.

Interposed periosteum

Reduction aids

Open reduction is aided by:

  • Bolsters placed posterior to the distal diaphyseal region, to correct a hyperextension deformity of the distal femoral articular block
Bolster placed posterior to the fracture
  • Manual traction, to restore length of the limb
Manual traction
  • Direct pointed reduction forceps (particularly for spiral fractures of the metaphysis)
  • A Hohmann retractor, which may be used as a lever to correct translational displacement
  • K-wires, used as a joystick, to control the distal fragment
Reduction with K-wire and forceps

Temporary fixation with K-wires

Once the metaphyseal component of the fracture is roughly reduced insert multiple K-wires through the fracture for temporary fixation.

Temporary K-wire fixation

4. Plate fixation

In the following example, the plate is placed across the growth plate.

Plate placement

Plate contouring is often required to match the anatomy of the femur.

Secure the plate with bone holding forceps.

Plate placement

Insertion of screws

Prior to screw insertion make sure that both ends of the plate are well aligned and have good contact with the bone. Check the femoral alignment with image intensification before screw placement.

Start with insertion of a screw on both ends of the plate and then insert further screws.

Insert two screws through the plate distal to the growth plate.

Insert two or three screws through the plate proximal to the fracture zone.

Insertion of screws

Final construct with different fracture morphology and plate application

Final construct with different fracture morphology and plate application

5. Final assessment

Check implant position and fracture reduction with image intensification.

Use clinical examination to check lower extremity alignment.

Clinical examination of lower extremity alignment

6. Aftercare

Immediate postoperative care

The patient should get out of bed and begin ambulation with crutches on the first postoperative day.

In most cases the postoperative protocol will be touch-weight bearing for the first 4 weeks.

Touch-weight bearing with immobilization

Analgesia

Routine pain medication is prescribed for 3–5 days postoperatively.

Neurovascular examination

The patient should be examined frequently to exclude neurovascular compromise, particularly following displaced, high-energy fractures, when deterioration may be delayed.

Compartment syndrome, although rare, should be considered in the presence of severe swelling, increasing pain, and changes to neurovascular signs.

Discharge care

Discharge from hospital follows local practice and is usually possible after 1–3 days.

Mobilization

The patient should continue ambulation with crutches.

After ORIF, fractures are sufficiently stable for the knee to be immobilized in a removable brace and range-of-motion exercises can begin early in the postoperative phase.

For the more unstable or comminuted fractures, range-of-motion exercises will begin at a slower rate.

Follow-up

Clinical and radiological follow-up is usually undertaken 2 weeks postoperatively.

Follow-up for growth deformity

All patients with physeal fractures of the distal femur should have clinical and radiological examination 8–12 weeks postoperatively to assess for signs of physeal growth disturbance or resumption of growth.

Examination should be repeated at intervals until resumption of normal growth is documented. This can be seen as a horizontal growth line (Harris line) that is parallel to the entire physis on both AP and lateral views.

A growth line that converges towards the growth plate may be the earliest sign of growth arrest and should prompt investigation/treatment or referral as appropriate.

X-ray of the knee showing growth lines

Clinical assessment of leg length and alignment is recommended at one-year.

Clinical assessment of leg length uses a tape measure from the ASIS to the medial malleolus.

Clinical assessment of leg length

If there is any concern about leg length discrepancy or malalignment, long leg x-rays are recommended.

Leg length is measured from the femoral head to the ankle joint.

Radiological assessment of leg length

Implant removal

If symptoms develop, plate and screws can be removed once the fracture is completely healed, usually 6–12 months postoperatively.

If K-wires are used, they are typically removed after 4–6 weeks.