What is the management plan for a patient with a closed, complete transverse fracture of the distal femur due to a road traffic collision?

Management of Distal Femur Fracture

Early surgical fixation with a distal femur locking compression plate (DFLCP) is the recommended treatment for this young patient with a complete transverse fracture of the distal third femur due to road traffic collision. 1

Initial Management

• Provide adequate analgesia including regular paracetamol and carefully titrated opioids (with caution if renal dysfunction is present) 2
• Consider femoral nerve block or fascia iliaca block for immediate pain relief while awaiting surgery 2
• Ensure proper immobilization of the fracture to prevent further displacement 2
• Initiate intravenous fluid therapy to maintain adequate hydration 2
• Implement warming strategies to prevent hypothermia 2
• Obtain complete radiographic assessment, including CT imaging to determine fracture extent, displacement, and associated injuries 3

Surgical Planning

• Schedule surgery as soon as possible, ideally within 24-48 hours, as early fixation provides the most effective analgesia and improves outcomes 2
• For this complete transverse fracture of the distal femur, open reduction and internal fixation (ORIF) with DFLCP is preferred over intramedullary supracondylar nailing 1, 4
• DFLCP provides angular stability with multiple options to secure fixation of metaphyseal fragments, allowing for anatomical reduction and stable fixation 4

Surgical Considerations

• Surgery should be performed by an experienced surgeon to minimize operative time and optimize outcomes 2
• Ensure appropriate antibiotic prophylaxis within one hour of skin incision 2
• Implement thromboprophylaxis measures including pharmacological agents (LMWH) and mechanical methods (compression devices) 2
• Use active warming strategies throughout the procedure to prevent hypothermia 2
• Consider the need for blood loss management, as DFLCP fixation may result in average blood loss of approximately 425ml 1

Postoperative Care

• Continue regular analgesia with paracetamol and carefully titrated opioids as needed 2
• Maintain thromboprophylaxis with LMWH and mechanical methods 2
• Implement early mobilization protocol as tolerated to prevent complications 2
• Provide supplemental oxygen for at least 24 hours postoperatively 2
• Monitor fluid balance and encourage early oral intake 2
• Begin aggressive motion exercises when appropriate to achieve optimal outcomes 3

Rehabilitation Protocol

• Initiate early physical therapy focusing on range of motion exercises and quadriceps strengthening 3, 4
• Progress to partial weight-bearing according to fracture stability and fixation strength 1
• Expect union time of approximately 8-9 months with DFLCP fixation 1, 4
• Include long-term balance training and fall prevention in the rehabilitation program 3
• Educate the patient about potential complications and expected outcomes 3

Potential Complications to Monitor

• Infection (reported in approximately 8% of cases) 4
• Knee stiffness (reported in approximately 12% of cases) 4
• Delayed union or nonunion 1, 4
• Hardware failure 1

Prognosis

• Expected excellent to good results in approximately 76% of patients with distal femur fractures treated with ORIF 4
• Young age (19 years) is a positive prognostic factor compared to elderly patients with osteoporotic bone 1, 5
• Early surgical intervention and appropriate rehabilitation are key factors in achieving optimal functional outcomes 1, 4