280
Injury (1990) 21, 280-282
printedin GreatBritain
Supracondylar
fractures of the femur
J. H. Newman Bristol Royal Infirmary, Bristol, UK
Introduction
Operative management
Fractures at the upper end of the femur are occurring with ever-increasing frequency and have now reached epidemic proportions (Boyce and Vessey, 1985; Zetterberg et al., 1984). These injuries have rightly attracted a substantial amount of attention and much has been written about them in recent years. However, less attention has been paid to fractures at the distal end of the femur, which are also seen frequently and which can present formidable management problems, particularly in the elderly osteoporotic patient. Most of these occur following a blow to the flexed knee, either to a young person involved in a road accident, or in an elderly individual who falls directly on to the knee. Many patterns of injury are encountered, but the usually accepted classification is that of the A0 school (Mi.iller et al., 1979). Comminution and displacement are variable, but it must be remembered that vascular injury occurs more commonly with supracondylar fractures than with most others, so pulses must always be checked and, if necessary, the limb must be straightened in order to allow definitive assessment and urgent reconstruction where necessary. Many treatments have been advocated over the years, but there has been an increasing trend towards the recommendation of operative treatment, largely because both techniques and implants have improved so that better results can be expected in well-managed patients (Johnson and Hicken, 1987). However, as Watson Jones noted, ‘few injuries present more difficult problems than supracondylar fractures of the femur’ and it is therefore essential that the surgical circumstances are optimal before operative treatment of these difficult fractures is undertaken. If the necessary expertise or equipment is not available, then better results are likely to be obtained by conservative means. Undisplaced fractures can usually be managed by nonoperative methods, with a short spell of traction followed by mobilization in a plaster cylinder or preferably a cast brace. If there is a large haemarthrosis present, aspiration will allow easier mobilization and greater comfort for the patient. If non-operative management is selected then it is essential that satisfactory reduction of the fracture is achieved and that there is sufficient stability to allow early mobilization of the joint, because a period of immobilization will result in deleterious effects to the articular cartilage and a severe risk of adhesions and subsequent stiffness (Akeson et al., 1987). Unless the fracture is truly undisplaced, these criteria are unlikely to be met, because the fracture will tend to angulate and position will be lost. In the majority of cases, therefore, operative intervention will be required.
Fractures of the distal femur not involving the joint surface present less of a problem than intra-articular fractures. Satisfactory fixation can usually be obtained using any one of a number of devices. Rigidity is best achieved by use of a dynamic condylar screw or a condylar blade-plate, and these methods of treatment will usually allow early mobilization of the knee. If there is sufficient length of distal fragment, a good fixation can be achieved by an interlocking nail and, in the elderly osteoaorotic patient, there is a place for use of Rush pins or Enders nails which are easy to insert and will maintain fracture alignment in osteoporotic bone. However, rigid fixation cannot be achieved by this method and some form of external splintage will also be required. Intra-articular fractures present a greater challenge, but in young people with good quality bone they can usually be reconstructed anatomically by first reducing the intraarticular component of the fracture and stabilizing it with interfragmentary screws. .This articular component is then reattached to the femoral shaft using a dynamic condylar screw and plate, which is easier to insert than the previously used condylar blade-plate, which tended to disrupt the intra-articular component of the fracture complex while being hammered into hard bone. No such problem exists with the dynamic condylar screw and plate which is easier to insert; it is a rigid implant and therefore it is imperative that the condylar screw is inserted parallel to the knee joint. Rigid fixation using this device can usually be achieved in young people; early mobilization of the knee, and indeed the patient, can be started, although full weight bearing should not be allowed for a number of weeks.
0 1990 Butterworth-HeinemannLtd 0020-1383/90/050280-03
Fractures in geriatric patients In the elderly patient with porotic bone the situation is very different. Here the fracture usually involves the joint and is frequently comminuted, often with some bone loss, thus making open reduction and internal fixation difficult. However, this should not deter the surgeon from adopting an aggressive approach, since these fractures do badly when treated conservatively, and modem adjuncts have made acceptable fixation possible in almost all cases. In addition, this elderly group of patients tolerate a prolonged period of bed rest poorly. Again, the intercondylar component should be reconstructed first along the usual lines using interfragmentary cancellous screws, but care must be taken not to ‘narrow the joint’ if bone loss exists. The distal part is then fixed to the femoral shaft, but difficulties may have been encountered because of extensive comminution and bone
281
Newman: Supracondylar fractures of the femur
loss. In this case it may be possible to shorten the limb fractionally in an elderly patient in order to obtain stability, but in any case the defects should be filled with bone graft, thus improving the stability of the fixation. In the elderly patient obtaining adequate quantities of autogenous graft may be difficult, and harvesting it has its own morbidity. Instead it is acceptable to fill the defects with bank bone which ought to be readily available to all trauma units, although since the advent of AIDS extra care must to taken to ensure that the donors have been adequately screened (Buck et al., 1989) or, alternatively, irradiated bone should be used to fill the defect. Using allograft bone means that there is no shortage of bone to pack any defects securely and thus adequate fixation and stability can almost always be achieved. In the rare cases where osteoporosis or comminution are so severe that acceptable fixation cannot be achieved, then two other possibilities should be borne in mind. Firstly the defect can be filled with cement, thus conferring immediate stability and providing sclerotic material for rigid fixation with an appropriate implant. Secondly, rare instances exist where the surface of the joint is so shattered that reconstruction seems foolhardy, and in such situations a primary knee replacement can be used to overcome an otherwise insurmountable problem in an elderly patient.
Postoperative management The postoperative management of these injuries is of considerable importance. In the younger patient with good quality bone, the knee should be mobilized early, and the patient can get up non-weight bearing. In the elderly patient, where fixation is less than optimal, a more cautious postoperative approach should be adopted, because the problems presented by failure of the fixation are formidable indeed. This does not mean that the knee should be immobilized. Even with suboptimal fixation the knee itself can be moved with the aid of a continuous passive motion machine, and using this method a near normal range of knee movement can rapidly be obtained, even following severe fractures (Mooney and Stills, 1987). If the patient is not confidently able to cope with non-weight bearing, then once a good range of knee movement has been obtained, the limb should be protected in a cast-brace and the patient should continue to use crutches. Although elderly patients dislike wearing a cast-brace, the security that it provides in protecting a slightly tenuous fixation is a small price to pay in order to ensure that the integrity of the reduction is maintained; thereby the chances of fracture union and normal mobility of the knee are enhanced.
Epiphyseal injuries A few other circumstances exist where supracondylar femoral fractures can pose particular difficulties. In children it is rarely necessary to fix fractures internally; however, this rule does not apply to supracondylar fractures of the femur, since they not infrequently displace when treated conservatively. Most of these injuries in children involve the epiphyseal plate and the various patterns described by Salter and Harris (1963) are seen. However, the prognosis may be different. Elsewhere, type I and II epiphyseal injuries do not result in growth arrest, but this is not always the case in the supracondylar region, since the severity of the injury can damage the growth plate so that even with perfect reduction growth arrest can occur, with resultant angular deformity or
shortening. Because of this, Riseborough et al. (1983) noted a high incidence of growth disturbance and malunion and recommend greater use of limited internal fixation to ensure perfect reduction is maintained. Salter and Harris type III and IV injuries involve the joint surfaces so that open reduction and internal fixation will almost always be necessary in order to ensure perfect anatomical reduction. Care must be taken to avoid damaging the epiphysis with the implant. In the growing child the epiphyseal plate is a relatively weak area and can be disrupted by an injury that in an adult would cause rupture of a collateral ligament. In such cases, the initial radiograph may appear normal, and stress radiographs must be taken. These may then reveal opening of the epiphyseal plate rather than rupture of a collateral ligament.
Fractures around prostheses Over 50000 hip and knee replacements are now being inserted annually in the United Kingdom. Since most patients are elderly and have osteoporotic bone, it is not surprising that supracondylar fractures are occurring in association with these implants. Cooke and Newman (1984) found that supracondylar fractures occurring below a total hip replacement posed no special problems. However, supracondylar fractures in relation to a knee replacement can present a difficult problem, and those occurring around a stemmed prosthesis have a high incidence of problems with union (Newman, 1987). Supracondylar fractures above a resurfacing knee replacement often result from notching of the anterior cortex, though associated neurologicial disorders can also play a part (Culp et al., 1987). The same authors reviewed 61 cases treated either operatively or conservatively and concluded that such fractures are best treated by secure internal fixation and early motion, although both of their groups included cases of non-union and malunion.
Fractures in association with an arthritic knee For many years it has been appreciated that the presence of a stiff joint above or below a femoral fracture increased the incidence of non-union, because the increased lever arm resulted in excessive movement at the fracture site unless rigid fixation combined with external splintage was used. The same principle applies to a supracondylar fracture, because movement will tend to occur at the fracture site rather than at the stiff knee. In such cases, which may well be associated with porotic rheumatoid bone, it is impossible to secure the fracture adequately to allow knee movement, so adhesions are likley to develop causing further knee stiffness. In such instances a primary knee replacement with a stemmed revision prosthesis may be appropriate; or, if the fracture is too high, the fracture needs to be fixed and the knee replaced if the patient is to have a reasonable chance of regaining good knee function, although care must be taken to ensure swelling does not impede wound healing.
Conclusion Supracondylar femoral fractures in patients of any age can result in serious disability. In the past, unsatisfactory results were often obtained because of poor surgical technique and outdated implants, so that in the early 1970s most surgeons in the USA preferred non-surgical treatment (Riggins et al., 1972). However, subsequent improvements in implant
282
Injury: the British Journal of Accident Surgery (1990) Vol. Zl/No. 5
design, combined with better appreciation of the principles of operative and postoperative management, means that good results should be obtained in the majority of cases.
References W. H., Amiel D., Abel M. F. et al. (1987) Effects of irnmobilisation on joints. Chin. orthop. 219,28. Boyce W. J. and Vessey M. P. (198.5) Rising incidence of fractures of the proximal femur Lancef i, 150. Akeson
Buck B. E., Malinin T. I. and Brown M. D. (1989) Bone transplantation and human immunodeficiency virus. Clin. orfhop. 240,129. Cooke P. H. and Newman J. H. (1984) Femoral fractures in relation to cemented hip prostheses, 1. Bone Joint Strrg. 66B, 278. Culp R. W., Schmidt R. G., Hanks G. et al. (1987) Supracondylar fractures of the femur following prosthetic knee arthroplasty. Clin. orthop. 222,212. Johnson K. D. and Hicken G. (1987) Distal femoral fractures. Orthop. Clin. North Am. 18,115.
Mooney
V. and Stills M. (1987) Continuous
passive motion with
joint fractures and infections. Ckthop. Clin. North Am. 18,1. Miiller M. E., Allgiiwer M., Schneider R. et al. (1979) Manual of internal fixation. Berlin, Heidelberg, New York SpringerVerlag. Newman J. H. (1987) Fractures around knee prostheses. J. BoneJoint Surg. 69B, 849. Riggins R. S., Ganick J. G and Lipsomb P. R. (1972) Supracondylar fractures of the femur. A survey of treatment. Clin. O&q. 82, 32. Riseborough E. J., Barrett 1. R. and Shapiro F. (1983) Growth disturbance following distal femoral physeal fracture separation, J. Bone Joint Surg 65A, 885. Salter R. B. and Harris W. R. (1963) Injuries involving the epiphyseal plate. 1. Bone Joint Surg. &?A, 587. Zetterberg C., Elmerson S. and Anderson G. B. J. (1984) Epidemiology of hip fractures in Giiteborg, Sweden 1940-1983. Clin. orthop. 191,43.
Requesk forreprints should be addressed to: J. H. Newman, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 SW, UK.
Injury (1990) 21, 280-282
printedin GreatBritain
Supracondylar
fractures of the femur
J. H. Newman Bristol Royal Infirmary, Bristol, UK
Introduction
Operative management
Fractures at the upper end of the femur are occurring with ever-increasing frequency and have now reached epidemic proportions (Boyce and Vessey, 1985; Zetterberg et al., 1984). These injuries have rightly attracted a substantial amount of attention and much has been written about them in recent years. However, less attention has been paid to fractures at the distal end of the femur, which are also seen frequently and which can present formidable management problems, particularly in the elderly osteoporotic patient. Most of these occur following a blow to the flexed knee, either to a young person involved in a road accident, or in an elderly individual who falls directly on to the knee. Many patterns of injury are encountered, but the usually accepted classification is that of the A0 school (Mi.iller et al., 1979). Comminution and displacement are variable, but it must be remembered that vascular injury occurs more commonly with supracondylar fractures than with most others, so pulses must always be checked and, if necessary, the limb must be straightened in order to allow definitive assessment and urgent reconstruction where necessary. Many treatments have been advocated over the years, but there has been an increasing trend towards the recommendation of operative treatment, largely because both techniques and implants have improved so that better results can be expected in well-managed patients (Johnson and Hicken, 1987). However, as Watson Jones noted, ‘few injuries present more difficult problems than supracondylar fractures of the femur’ and it is therefore essential that the surgical circumstances are optimal before operative treatment of these difficult fractures is undertaken. If the necessary expertise or equipment is not available, then better results are likely to be obtained by conservative means. Undisplaced fractures can usually be managed by nonoperative methods, with a short spell of traction followed by mobilization in a plaster cylinder or preferably a cast brace. If there is a large haemarthrosis present, aspiration will allow easier mobilization and greater comfort for the patient. If non-operative management is selected then it is essential that satisfactory reduction of the fracture is achieved and that there is sufficient stability to allow early mobilization of the joint, because a period of immobilization will result in deleterious effects to the articular cartilage and a severe risk of adhesions and subsequent stiffness (Akeson et al., 1987). Unless the fracture is truly undisplaced, these criteria are unlikely to be met, because the fracture will tend to angulate and position will be lost. In the majority of cases, therefore, operative intervention will be required.
Fractures of the distal femur not involving the joint surface present less of a problem than intra-articular fractures. Satisfactory fixation can usually be obtained using any one of a number of devices. Rigidity is best achieved by use of a dynamic condylar screw or a condylar blade-plate, and these methods of treatment will usually allow early mobilization of the knee. If there is sufficient length of distal fragment, a good fixation can be achieved by an interlocking nail and, in the elderly osteoaorotic patient, there is a place for use of Rush pins or Enders nails which are easy to insert and will maintain fracture alignment in osteoporotic bone. However, rigid fixation cannot be achieved by this method and some form of external splintage will also be required. Intra-articular fractures present a greater challenge, but in young people with good quality bone they can usually be reconstructed anatomically by first reducing the intraarticular component of the fracture and stabilizing it with interfragmentary screws. .This articular component is then reattached to the femoral shaft using a dynamic condylar screw and plate, which is easier to insert than the previously used condylar blade-plate, which tended to disrupt the intra-articular component of the fracture complex while being hammered into hard bone. No such problem exists with the dynamic condylar screw and plate which is easier to insert; it is a rigid implant and therefore it is imperative that the condylar screw is inserted parallel to the knee joint. Rigid fixation using this device can usually be achieved in young people; early mobilization of the knee, and indeed the patient, can be started, although full weight bearing should not be allowed for a number of weeks.
0 1990 Butterworth-HeinemannLtd 0020-1383/90/050280-03
Fractures in geriatric patients In the elderly patient with porotic bone the situation is very different. Here the fracture usually involves the joint and is frequently comminuted, often with some bone loss, thus making open reduction and internal fixation difficult. However, this should not deter the surgeon from adopting an aggressive approach, since these fractures do badly when treated conservatively, and modem adjuncts have made acceptable fixation possible in almost all cases. In addition, this elderly group of patients tolerate a prolonged period of bed rest poorly. Again, the intercondylar component should be reconstructed first along the usual lines using interfragmentary cancellous screws, but care must be taken not to ‘narrow the joint’ if bone loss exists. The distal part is then fixed to the femoral shaft, but difficulties may have been encountered because of extensive comminution and bone
281
Newman: Supracondylar fractures of the femur
loss. In this case it may be possible to shorten the limb fractionally in an elderly patient in order to obtain stability, but in any case the defects should be filled with bone graft, thus improving the stability of the fixation. In the elderly patient obtaining adequate quantities of autogenous graft may be difficult, and harvesting it has its own morbidity. Instead it is acceptable to fill the defects with bank bone which ought to be readily available to all trauma units, although since the advent of AIDS extra care must to taken to ensure that the donors have been adequately screened (Buck et al., 1989) or, alternatively, irradiated bone should be used to fill the defect. Using allograft bone means that there is no shortage of bone to pack any defects securely and thus adequate fixation and stability can almost always be achieved. In the rare cases where osteoporosis or comminution are so severe that acceptable fixation cannot be achieved, then two other possibilities should be borne in mind. Firstly the defect can be filled with cement, thus conferring immediate stability and providing sclerotic material for rigid fixation with an appropriate implant. Secondly, rare instances exist where the surface of the joint is so shattered that reconstruction seems foolhardy, and in such situations a primary knee replacement can be used to overcome an otherwise insurmountable problem in an elderly patient.
Postoperative management The postoperative management of these injuries is of considerable importance. In the younger patient with good quality bone, the knee should be mobilized early, and the patient can get up non-weight bearing. In the elderly patient, where fixation is less than optimal, a more cautious postoperative approach should be adopted, because the problems presented by failure of the fixation are formidable indeed. This does not mean that the knee should be immobilized. Even with suboptimal fixation the knee itself can be moved with the aid of a continuous passive motion machine, and using this method a near normal range of knee movement can rapidly be obtained, even following severe fractures (Mooney and Stills, 1987). If the patient is not confidently able to cope with non-weight bearing, then once a good range of knee movement has been obtained, the limb should be protected in a cast-brace and the patient should continue to use crutches. Although elderly patients dislike wearing a cast-brace, the security that it provides in protecting a slightly tenuous fixation is a small price to pay in order to ensure that the integrity of the reduction is maintained; thereby the chances of fracture union and normal mobility of the knee are enhanced.
Epiphyseal injuries A few other circumstances exist where supracondylar femoral fractures can pose particular difficulties. In children it is rarely necessary to fix fractures internally; however, this rule does not apply to supracondylar fractures of the femur, since they not infrequently displace when treated conservatively. Most of these injuries in children involve the epiphyseal plate and the various patterns described by Salter and Harris (1963) are seen. However, the prognosis may be different. Elsewhere, type I and II epiphyseal injuries do not result in growth arrest, but this is not always the case in the supracondylar region, since the severity of the injury can damage the growth plate so that even with perfect reduction growth arrest can occur, with resultant angular deformity or
shortening. Because of this, Riseborough et al. (1983) noted a high incidence of growth disturbance and malunion and recommend greater use of limited internal fixation to ensure perfect reduction is maintained. Salter and Harris type III and IV injuries involve the joint surfaces so that open reduction and internal fixation will almost always be necessary in order to ensure perfect anatomical reduction. Care must be taken to avoid damaging the epiphysis with the implant. In the growing child the epiphyseal plate is a relatively weak area and can be disrupted by an injury that in an adult would cause rupture of a collateral ligament. In such cases, the initial radiograph may appear normal, and stress radiographs must be taken. These may then reveal opening of the epiphyseal plate rather than rupture of a collateral ligament.
Fractures around prostheses Over 50000 hip and knee replacements are now being inserted annually in the United Kingdom. Since most patients are elderly and have osteoporotic bone, it is not surprising that supracondylar fractures are occurring in association with these implants. Cooke and Newman (1984) found that supracondylar fractures occurring below a total hip replacement posed no special problems. However, supracondylar fractures in relation to a knee replacement can present a difficult problem, and those occurring around a stemmed prosthesis have a high incidence of problems with union (Newman, 1987). Supracondylar fractures above a resurfacing knee replacement often result from notching of the anterior cortex, though associated neurologicial disorders can also play a part (Culp et al., 1987). The same authors reviewed 61 cases treated either operatively or conservatively and concluded that such fractures are best treated by secure internal fixation and early motion, although both of their groups included cases of non-union and malunion.
Fractures in association with an arthritic knee For many years it has been appreciated that the presence of a stiff joint above or below a femoral fracture increased the incidence of non-union, because the increased lever arm resulted in excessive movement at the fracture site unless rigid fixation combined with external splintage was used. The same principle applies to a supracondylar fracture, because movement will tend to occur at the fracture site rather than at the stiff knee. In such cases, which may well be associated with porotic rheumatoid bone, it is impossible to secure the fracture adequately to allow knee movement, so adhesions are likley to develop causing further knee stiffness. In such instances a primary knee replacement with a stemmed revision prosthesis may be appropriate; or, if the fracture is too high, the fracture needs to be fixed and the knee replaced if the patient is to have a reasonable chance of regaining good knee function, although care must be taken to ensure swelling does not impede wound healing.
Conclusion Supracondylar femoral fractures in patients of any age can result in serious disability. In the past, unsatisfactory results were often obtained because of poor surgical technique and outdated implants, so that in the early 1970s most surgeons in the USA preferred non-surgical treatment (Riggins et al., 1972). However, subsequent improvements in implant
282
Injury: the British Journal of Accident Surgery (1990) Vol. Zl/No. 5
design, combined with better appreciation of the principles of operative and postoperative management, means that good results should be obtained in the majority of cases.
References W. H., Amiel D., Abel M. F. et al. (1987) Effects of irnmobilisation on joints. Chin. orthop. 219,28. Boyce W. J. and Vessey M. P. (198.5) Rising incidence of fractures of the proximal femur Lancef i, 150. Akeson
Buck B. E., Malinin T. I. and Brown M. D. (1989) Bone transplantation and human immunodeficiency virus. Clin. orfhop. 240,129. Cooke P. H. and Newman J. H. (1984) Femoral fractures in relation to cemented hip prostheses, 1. Bone Joint Strrg. 66B, 278. Culp R. W., Schmidt R. G., Hanks G. et al. (1987) Supracondylar fractures of the femur following prosthetic knee arthroplasty. Clin. orthop. 222,212. Johnson K. D. and Hicken G. (1987) Distal femoral fractures. Orthop. Clin. North Am. 18,115.
Mooney
V. and Stills M. (1987) Continuous
passive motion with
joint fractures and infections. Ckthop. Clin. North Am. 18,1. Miiller M. E., Allgiiwer M., Schneider R. et al. (1979) Manual of internal fixation. Berlin, Heidelberg, New York SpringerVerlag. Newman J. H. (1987) Fractures around knee prostheses. J. BoneJoint Surg. 69B, 849. Riggins R. S., Ganick J. G and Lipsomb P. R. (1972) Supracondylar fractures of the femur. A survey of treatment. Clin. O&q. 82, 32. Riseborough E. J., Barrett 1. R. and Shapiro F. (1983) Growth disturbance following distal femoral physeal fracture separation, J. Bone Joint Surg 65A, 885. Salter R. B. and Harris W. R. (1963) Injuries involving the epiphyseal plate. 1. Bone Joint Surg. &?A, 587. Zetterberg C., Elmerson S. and Anderson G. B. J. (1984) Epidemiology of hip fractures in Giiteborg, Sweden 1940-1983. Clin. orthop. 191,43.
Requesk forreprints should be addressed to: J. H. Newman, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 SW, UK.
