CASE REPORT

Depressed femoral condyle fracture

Devendra Mahadevan *, Christopher Challand, Jonathan Keenan

Department of Trauma and Orthopaedics (Level 11), Derriford Hospital, Plymouth,Plymouth Hospitals NHS Trust, Plymouth PL6 8DH, United Kingdom

Accepted 8 May 2007

Injury Extra (2008) 39, 30—33

www.elsevier.com/locate/inext

Introduction

Unicondylar intraarticular fractures of the lowerend of the femur are relatively rare and usuallyoccur in the sagittal plane.1,2 Hoffa4 described acoronal plane fracture of the femoral condyle andthese are more unusual. Femoral condyle fracturescan result from axial compression or by suddenangular strains on the knee joint and the lateralfemoral condyle is more commonly involved.6

While the sagittal and coronal intraarticularfemoral condyle fractures have been well charac-terised in the literature, we are unaware of anyreports of an isolated depressed femoral condylefracture. We report on a patient who sustained thisfracture pattern as well as the preoperative plan-ning, fixation technique and functional outcomesfollowing treatment.

Case report

An active and independent 81-year-old lady slippedand fell from a standing height. She described herknee being forced into hyperextension as sherotated on her lower leg. She developed immediatepain and was not able to weight bear.

* Corresponding author. Tel.: +44 1752763777.E-mail address: m.deven@gmail.com (D. Mahadevan).

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Clinical assessment revealed a closed injury witha neurovascularly intact extremity. A moderateeffusion was present in the knee and discrete lateraljoint line tenderness was elicited. Her knee wasstable on clinical examination.

Plain radiographs revealed a fine fracture line onthe lateral femoral condyle of the knee and anobvious lipohaemarthrosis level was seen (Fig. 1).Computer tomography delineated a significantlydepressed intraarticular fracture involving at least30% of the articular surface of the lateral femoralcondyle (Figs. 2 and 3). The fracture line did notextend into the intercondylar notch (Fig. 4).

Examination under anaesthesia confirmed astable knee through a full range of motion. A lateralparapatellar approach was used to expose the frac-ture site. Operative findings demonstrated a dis-crete impaction fracture of the anterior aspect ofthe lateral femoral condyle with at least a 5 mmstep. A lateral femoral condyle bone window wasthen created and a bone punch used to elevate thedepressed fragment. The defect under the restoredarticular surface was filled with bone graft har-vested through the same bone window, from theipsilateral distal lateral femur. Internal fixation wasachieved using the Less Invasive Stabilization Sys-tem (LISS) (Synthes Ltd., Hertfordshire, UK) withthe aid of fluoroscopy (Fig. 5).

Post-operatively, protected weight bearing withsupport from an unlocked Donjoy knee brace (DJOUK Ltd., Surrey, UK) was commenced for a period of

Femoral condyle fracture 31

Figure 1 Radiographs of left knee. Arrows trace fracture line.

3 months. She made an uncomplicated recovery. Atthe most recent clinic review (12 months), she waspain free and had a range of movement from 08 to1208 of knee flexion. She mobilised fully weightbearing with the aid of one stick and her kneeradiographs showed that the fracture reductionwas maintained (Fig. 6).

Discussion

Identification of femoral condyle fractures is impor-tant. Surgical fixation is the preferred method oftreatment as non-operative management of thesefractures may lead to malunion, nonunion and

Figure 2 CT scan images showing de

further displacement of the fracture fragment.5

The extent of the fracture in this patient was diffi-cult to appreciate on plain radiographs but couldclearly be seen on computer tomographic scans.Previous literature has advocated the use of com-puter tomographic scans as adjuncts in the diagnosisof femoral condyle fractures1,6,9 and we supportthese recommendations.

Lewis et al. postulated that an oblique or lateralforce against the lateral femoral condyle with theknee flexed results in the coronal fracture.6 Wepropose that the unusual fracture pattern seen inour patient on the anterior aspect of the femoralcondyle was a result of axial loading on a hyper-extended knee in an osteoporotic patient. The

pressed femoral condyle fracture.

32 D. Mahadevan et al.

Figure 5 Intraoperative image showing fracture inreduced position (thin arrow) and distal portion of LISSfixation (block arrow).

Figure 3 2D CT scan reconstruction of femoral condylefracture.

hyperextended knee would have exposed more ofthe anterior part of the lateral femoral condyle tothe injuring forces.

The goal in the treatment of articular fractures isto achieve anatomical reduction of the joint surfacewith stable fixation that permits early range ofmotion. In order to restore function, the articularsurface depression had to be elevated and sup-ported. The choice of implant was determined bybone quality and the capacity of the implant tosupport the anatomically reduced fracture. Poster-ior aspect femoral condyle fractures have been fixedusing screws.7,8,3 In this case, cancellous or corticallag screws were felt unlikely to hold and support thefracture because of the fracture pattern and theosteoporotic quality of the bone. The Less InvasiveStabilization System (LISS) fixation was chosen aslocked screw-plate constructs have larger pulloutstrength, particularly in osteoporotic bone, and

Figure 4 3D CT scan reconstruction of femoral condylefracture.

Figure 6 Post-operative (at 3 months) radiograph show-ing stable fixation.

fixed angle screws would support the elevated frac-ture fragment. The plate was positioned so that thedistal anterior three screws provided a raft-likesupport under the fracture fragment. This methodof fixation did not require supplemental screws fromanterior to posterior and hence there was no furtherviolation of the articular surface.

Conclusion

We have reported an unusual depressed fracture ofthe anterolateral aspect of the femoral condyle.Fractures of the femoral condyle are rare and can be

Femoral condyle fracture 33

easily overlooked. We advocate the use computertomographic scans for fracture assessment and sur-gical planning. The use of locked screw-plate con-structs may be considered in fixing depressedfractures of the femoral condyle.

Acknowledgement

The authors wish to thank Mr. Nirmal Kakani, Radi-ology Registrar at Derriford Hospital, Plymouth forhis assistance with the 2D and 3D reconstructions ofthe CT images.

References

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2. Arneson TJ, Melton LJ, Lewallen DG, O’Fallon WM. Epidemiol-ogy of diaphyseal and distal femoral fractures in Rochester,Minnesota, 1964—1984. Clin Orthop 1988;234:188—93.

3. Benirschke SK, Swintkowski MF. Knee. In: Hansen Jr ST,Swintkowski MF, editors. Orthopaedic trauma protocols.New York: Raven Press; 1993. p. 291—329.

4. Hoffa A. Lehrbuch der Frakturen und Luxationen. Stuttgart:Ferdinand EnkeVerlag; 1904. p. 453.

5. Kumar R, Malhotra R. The Hoffa fracture: three case reports. JOrthop Surg (Hong Kong) 2001;9:47—51.

6. Lewis SL, Pozo JL, Muirhead-Allwood WFG. Coronal fracturesof the lateral femoral condyle. J Bone Joint Surg Br 1989;71:118—20.

7. Liebergall M, Wilber JH, Morshelf R, Segal D. Gerdy’s tubercleosteotomy for the treatment of coronal fractures of the lateralfemoral condyle. J Orthop Trauma 2000;14:214—5.

8. Mize RD. Supracondylar and articular fractures of the distalfemur. In: Chapman MW, editor. Chapman’s orthopaedicsurgery. 3rd ed., Philadelphia: LippincottWilliams andWilkins;2001. p. 709—24.

9. Nork SE, Segina DN, Aflatoon K, Barei D, Henley MB, Holt S,et al. The association between suprocondylar-intercondylardistal femoral fractures and coronal plane fractures. J BoneJoint Surg Am 2005;87(3):564—9.