What is the initial management for distal femur fractures?

Initial Management of Distal Femur Fractures

Distal femur fractures require immediate surgical stabilization with open reduction and internal fixation (ORIF) using a distal femur locking compression plate (DFLCP), as surgery is the definitive treatment and non-surgical management is rarely indicated.

Immediate Emergency Department Management

Initial Stabilization and Assessment

• Immobilize the limb immediately with a long leg splint or traction device to prevent further soft tissue injury and provide pain control 1, 2
• Administer multimodal analgesia including nerve blocks, as adequate pain control is essential and surgery itself is the best analgesic for femoral fractures 3
• Assess for hemodynamic instability and activate trauma protocols if present, as these are often high-energy injuries in younger patients or fragility fractures in the elderly 2, 4
• Evaluate for associated injuries, particularly other skeletal injuries, as distal femur fractures frequently occur with polytrauma in motor vehicle accidents 2

Critical Clinical Examination Points

• Document neurovascular status of the affected limb, including distal pulses, capillary refill, and motor/sensory function 4
• Assess soft tissue integrity and classify open fractures by Gustilo-Anderson grade, as open grade 3B fractures significantly affect functional outcomes 1
• Examine for knee joint effusion or hemarthrosis, which indicates intra-articular extension requiring anatomic reduction 2

Imaging Protocol

• Obtain AP and lateral radiographs of the entire femur, including hip and knee joints 4
• Request CT scan with 3D reconstruction for all intra-articular fractures to assess articular comminution and plan surgical approach 2, 4
• Use upright films when possible rather than supine views to better demonstrate displacement 5

Pre-Operative Planning

Timing of Surgery

• Schedule surgery within 24-48 hours of hospital admission to optimize outcomes and provide definitive pain control 3
• Expedite to within 24 hours if resources allow, as high-volume centers with dedicated fracture programs show improved outcomes with earlier intervention 3

Multidisciplinary Coordination

• Initiate orthogeriatric co-management for elderly patients with multiple comorbidities, as this decreases complications and improves outcomes 3, 5
• Ensure experienced surgical and anesthesia teams are available, as complex distal femur fractures require appropriate expertise 6, 3
• Establish protocol-driven fast-track admission through the emergency department to minimize delays 6, 3

Surgical Implant Selection

Primary Implant Choice

• Use DFLCP for intra-articular (inter-condylar) fractures and highly comminuted patterns, as it provides anatomic reduction, angular stability, and multiple fixation options for both metaphyseal and articular fragments 1, 2
• Consider intramedullary supracondylar nail (IMSCN) for extra-articular fractures, as closed reduction preserves fracture hematoma and results in earlier union (7.15 months vs 8.15 months), though with comparable functional outcomes 1

Key Surgical Principles

• Achieve anatomical reduction of articular fragments with rigid fixation to restore joint congruity, limb length, alignment, and rotation 2, 4
• Expect higher intraoperative blood loss with DFLCP (average 425 ml) compared to IMSCN (243 ml), and consider tranexamic acid administration 3, 1
• Plan for bone grafting in cases with pre-operative bone loss, which occurs in approximately 12% of cases 2

Post-Operative Rehabilitation

Weight-Bearing Protocol

• Allow early weight-bearing immediately post-operatively without specific restrictions, as this enhances bone healing and does not increase risk of fracture displacement or implant failure 7
• Avoid restrictive non-weight-bearing protocols, as delayed weight-bearing may actually increase risk of fixation failure (four fracture displacements and two implant failures observed in non-weight-bearing group vs zero in early weight-bearing group) 7

Mobilization Strategy

• Begin early mobilization and aggressive physiotherapy within days of surgery to prevent knee stiffness and muscular atrophy, which are major complications of conservative treatment 3, 2
• Initiate range-of-motion exercises as soon as pain allows to minimize the 12% incidence of knee stiffness 2

Common Pitfalls to Avoid

• Delaying surgery beyond 48 hours increases complications and prolongs pain, as surgery is the best analgesic 6, 3
• Inadequate assessment of intra-articular extension leads to poor implant selection; always obtain CT for suspected articular involvement 2, 4
• Restrictive post-operative weight-bearing instructions delay healing and may paradoxically increase fixation failure rates 7
• Inadequate soft tissue management in open fractures, particularly grade 3B injuries, significantly compromises functional outcomes 1
• Failure to address osteoporosis in elderly patients with fragility fractures, as secondary prevention is essential 5

Expected Outcomes

• Bone union occurs at 4.25 months for closed fractures and 5.86 months for open fractures on average 2
• Excellent to good results are achieved in 76% of patients with DFLCP fixation using Neer's criteria 2
• Functional outcomes are comparable between DFLCP and IMSCN (46% vs 42.85% excellent results respectively) 1
• Infection rate is approximately 8% in the early post-operative period 2