Distal Femur Fracture

  • Distal femur fractures often result from high energy injuries in younger patients, but may result from low energy mechanisms   (e.g. mechanical fall) in the elderly
  • Patients generally require admission
  • Indications for immediate orthopedic consultation include:
    • Open fracture
    • Associated knee dislocation

  • Mechanism
    • Elderly - often low-energy mechanisms (e.g. fall from standing height)
    • Younger patients - high-energy axial loading with additional varus, valgus, or rotational force
  • Timing of injury
  • Other locations of pain
    • Often a distracting injury, resulting in neglecting concurrent injuries
      • Ensure you palpate the remained of the extremities, chest, pelvis, spine on exam to decrease the risk of missed injuries
  • Numbness or tingling
  • Comorbidities
    • Heart disease, diabetes, lung disease, smoking
  • Anticoagulation
    • Time of last dose
  • Last time patient last ate (NPO status)

    Vitals

  • Remove any splint/wrapping to view the distal femur
  • Basic appearance of leg (swelling, bruising)
    • Assess for poke hole/punctate wounds → open fracture
    • Do not miss this and confirm antibiotics were given
  • Pain with logroll of the extremity
  • Palpate the compartments (anterior, posterior, adductor) in the leg
    • Good to establish baseline, as subsequent bleeding and edema can develop into compartment syndrome after presentation
      • Lower risk than lower leg due to increased soft tissue space
  • Palpate remainder of the extremity to assess for ipsilateral injuries

Motor Exam:
    Motor Exam:
    • Tibialis Anterior - Dorsiflexion
    • Gastroc/Soleus - Plantar flexion
    • EHL/FHL - Extension/Flexion of the great toe
    Sensory Exam:
    • Sural (Lateral)
    • Saphenous (medial)
    • Superficial Peroneal(dorsum)
    • Deep Peroneal (1st web space)
    • Tibial (plantar)
  • Vascular Exam:
    • Dorsalis Pedis/Posterior Tibial
    • Capillary refill to toes

  • Motion at the hip and knee limited secondary to pain

  • AP/Lateral ipsilateral hip, AP/Lateral femur, AP/Lateral knee
  • CT of the distal femur/knee
    • Often helpful but this to leave to the discretion of orthopaedics
      • Recommended if concerned for intraarticular extension
      • Recommended for severe comminution

     Medical Decision Making

Closed distal femur fracture :
*** is a *** y/o ***M/F with hx of *** who presents with an injury to the ***R/L lower extremity which occurred while mechanism***, found to have a closed distal femur fracture. Associated injuries include ***. On exam, the patient is neurovascularly intact with pain on logroll. The injury was closed without any poke holes or punctate wounds that probe deep. Radiographs reveal ***. The injured extremity was placed in a knee immobilizer and orthopaedics was consulted.
Open distal femur fracture fracture :
*** is a *** y/o ***M/F with hx of *** who presents with an injury to the ***R/L lower extremity which occurred while mechanism***, found to have an open distal femur fracture. Associated injuries include ***. On exam, the patient is neurovascularly intact with a laceration on the *** side of the distal thigh that probed deep. The patient was given an immediate dose of IV ancef/gentamicin***. The laceration was irrigated at bedside of gross contaminants. Orthopaedics was consulted and the patient was made NPO. Radiographs reveal ***. Orthopaedic surgery to admit the patient and assume care.

Closed distal femur fracture:
  • Consult Orthopaedic Surgery
  • WB status: Nonweightbearing injured lower extremity
  • Diet:  NPO
  • Labs: ABG, Lactate (for high energy mechanism and polytrauma)
    • Used to assess operative timing
  • Analgesia: oral analgesia with IV narcotic for breakthrough
    • Ex: 5-10mg oxycodone q4, 0.5mg hydromorphone q4 prn, tylenol 975mg q8hr scheduled
  • Immobilization: knee immobilizer
  • Disposition: Likely admission to orthopaedics versus general surgery trauma
    • If polytraumized patient often admitted to general surgery trauma
Open distal femur fracture: :
  • Consult Orthopaedic Surgery
  • Ensure IV antibiotics were given (ancef vs. gentamicin)
    • Gustillo-Anderson chart for antibiotic type and dose
  • Diet:  NPO preop labs (type and screen, INR, aPTT,  CBC, BMP)
  • Labs: ABG, Lactate (for high energy mechanism and polytrauma)
    • Used to assess operative timing
  • Immobilization: knee immobilizer
  • Disposition: Admission to orthopaedics versus general surgery trauma
    • If polytraumized patient often admitted to general surgery trauma

Materials

Bedside Irrigation / Washout

Common ICD-10 Codes Brief Description
S72.4 Fracture of lower end of femur
S72.42 Fracture of lateral condyle of femur
S72.43 Fracture of medial condyle of femur
S72.44 Fracture of lower epiphysis (separation) of femur
S72.45 Supracondylar fracture without intracondylar extension of lower end of femur
S72.46 Supracondylar fracture with intracondylar extension of lower end of femur