A 91-year-old obese woman presents to the emergency department by ambulance with right leg pain after a fall at home. She lost balance while walking and landed on her right knee. She had immediate pain and an inability to bear weight after the fall. Anteroposterior and lateral radiographs (Figures 1 and 2) show a comminuted supracondylar distal right femur fracture. Coronal and sagittal CT views (Figures 3 and 4) confirm there is no fracture extension distally to the articular surface.
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This patient sustained an osteoporotic-related right supracondylar femur fracture. Patients with comminuted supracondylar fractures such as this should have a CT to rule out fracture extension to the articular surface. Determining fracture extension is crucial, as it can change the type of implant used for fixation. The patient’s bone quality also plays a role regarding which implant is used. Patients with osteoporotic bone should have the longest implant possible to avoid a stress riser to the midfemur where a future fracture can occur. Long implants are used to protect the entire femur.
The disadvantage of a lateral locking plate in this patient is a large incision that spans the majority of the femur. Retrograde nailing has the benefit of reduced surgical time, less blood loss, and less radiation exposure over lateral locking plates. Retrograde nails are also ideal for comminuted fractures as they can span the comminuted area. Access to the entry point for an antegrade nail (tip of the greater trochanter) can also be challenging in obese patients. Union rates between antegrade and retrograde nails are similar. Retrograde nails generally should not be used if the fracture extends distally past the supracondylar flare or within 4 cm of the joint line. Distal fractures (distal to the supracondylar flare) and fractures with articular extension are best treated with a lateral locking plate.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Horwitz DS, Kubiak EN. Surgical treatment of ostoporotic fractures about the knee. J Bone Joint Surg Am. 2009;91:2970-2982.
- Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: current concepts. J Am Acad Orthop Surg. 2009;17:296-305.