What is the best treatment approach for a patient with an impacting fracture of the medial femoral condyle, assuming stability and no signs of neurovascular compromise or significant displacement?

Treatment of Impacting Fracture of Medial Femoral Condyle

Surgical Fixation is the Definitive Treatment

For impacting fractures of the medial femoral condyle, open reduction and internal fixation (ORIF) is the preferred treatment approach, as anatomical restoration of the articular surface is essential for intra-articular injuries, followed by lag screw fixation and buttress plating to counteract vertical shear forces. 1, 2

Surgical Approach and Technique

Exposure and Reduction

• Access the fracture through a medial or anteromedial parapatellar approach, which provides optimal visualization of the medial femoral condyle 1
• Achieve anatomical reduction of the articular surface under direct visualization, as any step-off in the weight-bearing surface leads to post-traumatic arthritis 1, 2
• For minimally displaced fractures in young, compliant patients, arthroscopic-assisted reduction with navigated guidance can minimize soft tissue morbidity 3

Fixation Strategy

• Insert lag screws perpendicular to the fracture line from posterior to anterior (anteroposterior direction) to achieve interfragmentary compression 1, 2
• Use headless compression screws when possible to avoid prominent hardware 2
• Apply a buttress plate to counteract vertical shear forces, as lag screws alone are insufficient for fractures with vertical fracture lines 4

Plate Selection Challenge

• No anatomical plates exist specifically for the medial femoral condyle, unlike the lateral side 4, 5
• Use a locking compression plate designed for the proximal tibia (4.5/5.0) as a buttress plate, which fits well on the medial femoral condyle 4
• Alternatively, contour a low-profile mesh plate to fit around the fracture site for complex fracture patterns with medial wall involvement 5
• For patients with osteoporosis or high body mass index, combine cannulated screws with antigliding plate fixation for enhanced stability 2

Perioperative Management

Anesthesia

• Either spinal or general anesthesia is appropriate, with spinal anesthesia potentially reducing postoperative confusion in elderly patients 6, 7
• Administer multimodal analgesia with peripheral nerve blockade (femoral nerve block) preoperatively 7

Prophylaxis and Monitoring

• Give prophylactic antibiotics within one hour of skin incision 8
• Administer fondaparinux or low molecular weight heparin for DVT prophylaxis 6, 8
• Implement active warming strategies to prevent hypothermia 8

Postoperative Protocol

• Continue regular paracetamol throughout the perioperative period 8
• Use opioids cautiously, especially in patients with renal dysfunction; avoid codeine due to constipation and cognitive dysfunction risk 8
• Initiate early mobilization protocols with protected weight-bearing until radiographic union is confirmed, typically at 3-5 months 1

Critical Pitfalls to Avoid

• High risk of missed diagnosis: These fractures are frequently overlooked on initial radiographs, requiring a high index of suspicion 1
• Order CT and MRI if radiographs are negative but clinical suspicion remains high, as plain films may not reveal the fracture line 2
• Inadequate reduction before fixation leads to malunion, hardware failure, and post-traumatic arthritis 1, 2
• Conservative management of displaced fractures carries high risk of redisplacement and poor outcomes 2

Expected Outcomes

• Bone union typically occurs at 3-5 months postoperatively with appropriate fixation 4, 1
• Patients can expect return to normal activities with good functional outcomes when anatomical reduction is achieved 5
• Range of motion of 0° to 120° is achievable with proper surgical technique and rehabilitation 4