What is the step-by-step procedure for treating a comminuted fracture of the distal femur using distal femur plates?

Step-by-Step Procedure for Comminuted Distal Femur Fracture Fixation Using Distal Femur Plates

The distal femoral locking compression plate (DFLCP) is the preferred implant for comminuted distal femur fractures, particularly for intra-articular fractures, as it provides anatomic and stable fixation with better functional outcomes compared to other methods. 1

Preoperative Assessment and Planning

1. Imaging Evaluation

   • Obtain standard radiographs (anteroposterior, lateral views) 2
   • Consider CT scan for complex fractures to assess fragment size and displacement 2
   • Evaluate for associated injuries including distal radioulnar joint abnormalities 2

2. Patient Optimization

   • Assess comorbidities and optimize medical conditions
   • Consider orthogeriatric co-management for elderly patients 2
   • Evaluate for osteoporosis in elderly patients 2
   • Smoking cessation counseling (increases nonunion rates) 2

Surgical Procedure

1. Patient Positioning and Preparation

• Position patient supine on radiolucent table
• Place a bolster under the affected knee for slight flexion (30°)
• Prepare and drape the entire limb circumferentially
• Administer appropriate prophylactic antibiotics

2. Surgical Approach

• Make a lateral approach to the distal femur
• Create a straight incision along the lateral aspect of the thigh extending from the lateral femoral condyle proximally
• Develop the plane between the vastus lateralis and the lateral intermuscular septum
• Elevate the vastus lateralis off the lateral intermuscular septum and retract anteriorly

3. Fracture Reduction

• Perform careful soft tissue handling to preserve blood supply 3
• Use indirect reduction techniques when possible to preserve fracture hematoma 1
• For intra-articular fractures, achieve anatomic reduction of the articular surface first
• Use K-wires for provisional fixation of articular fragments
• Restore limb length, rotation, and alignment
• Confirm reduction with fluoroscopy in multiple planes

4. Plate Application

• Select an appropriate length distal femoral locking plate (generally >10 holes) 3
• Position the plate on the lateral aspect of the distal femur
• Ensure proper plate positioning with fluoroscopy:
  • Plate should be centered on the lateral femoral condyle
  • Distal end should be parallel to the joint line
  • Proximal end should align with the femoral shaft

5. Fixation Technique

• Secure the plate to the distal fragment first using locking screws
• Place multiple locking screws in the distal fragment to achieve stable fixation
• Use a targeting guide for accurate screw placement
• For the shaft, create adequate working length by skipping holes near the fracture site 3
• Place combination of locking and non-locking screws in the shaft as needed
• For highly comminuted fractures, consider double-plating technique (steel plate and polyethylene plate) for enhanced stability 4
• Confirm final fixation with fluoroscopy in multiple planes

6. Wound Closure

• Irrigate the wound thoroughly
• Close the fascia with absorbable sutures
• Close subcutaneous tissue and skin in layers
• Apply sterile dressing

Postoperative Management

1. Immediate Care

   • Monitor neurovascular status
   • Pain management with appropriate analgesics
   • Consider early mobilization with physical therapy

2. Rehabilitation Protocol

   • Begin early finger and knee range of motion exercises to prevent stiffness 2
   • Protected weight-bearing for 6 weeks 3
   • Progressive weight-bearing based on radiographic evidence of healing
   • Implement home exercise program focusing on active and passive range of motion 2

3. Follow-up Schedule

   • First follow-up at 2 weeks for wound check
   • Subsequent follow-ups at 6 weeks, 3 months, and 6 months with radiographs
   • Monitor for:
     • Fracture healing (average union time: 8.15 months for DFLCP) 1
     • Hardware-related complications 2
     • Knee range of motion and function

Potential Complications and Management

• Nonunion: Consider bone grafting or revision fixation
• Malunion: May require corrective osteotomy if symptomatic
• Hardware failure: Revision surgery with stronger construct
• Infection: Debridement, antibiotics, and possible implant removal
• Joint stiffness: Aggressive physical therapy; consider manipulation under anesthesia
• Post-traumatic arthritis: Long-term complication requiring monitoring 2

Clinical Pearls

• Longer plates (>10 holes) with adequate working length provide better stability 3
• Careful soft tissue handling and preservation of fracture hematoma promote healing 1
• For elderly patients with osteoporosis, consider calcium and vitamin D supplementation 2
• DFLCP shows better results for intra-articular and highly comminuted fractures compared to intramedullary nailing 1
• Expected blood loss with DFLCP is approximately 425 ml 1