Introduction

Fractures of femur whether supracondylar or intercondylar in a T or Y shaped configuration have historically been difficult to treat because of their unstable nature and their degree of comminution. The proximity of these fractures to the knee joint makes regaining full knee motion and function difficult. The incidence of mal-union, non-union and infection is also very high. Dissatisfied with the results of earlier used methods of treatment, surgeons started looking for newer ways of treatment. With the development of improved internal fixation devices by AO group, Healy and Brooker in 1983 had good functional results with open reduction and internal fixation with plate and screws.

The dynamic condylar screw (DCS) is an impressive method of treatment of these fractures with various advantages of early active knee motion, full range of movement preserved, stable internal fixation and maintenance of joint congruity.

Material and Methods

The present study consisted of 25 cases of fractures of distal femoral region in age group of 20 years and above of either sex, treated with ORIF with dynamic condylar screw. After spinal anaesthesia, placing patient on traction table fracture site was exposed via lateral approach. A K-wire was inserted perpendicular to distal femur and parallel to joint surface at the junction of anterior 1/3^rd and posterior 2/3^rd of longest AP dimension, using k-wires in joint and patellar groove as guide. An appropriate length lag screw after proper reaming and tapping was inserted over guide wire. Once the lag screw was in place appropriate side plate was applied so that at least eight cortices were purchased in proximal fragment. Additional one or two cancellous screw anterior and posterior to the proposed site of insertion of the lag screw was put in intercondylar fractures after anatomical reduction, axial compression was provided with tensioning device and plate was fitted to shaft femur with 4.5 mm cortical screws.

Postoperatively limb was maintained in elevated position while patient was in bed antibiotics and analgesia was given as per need. Patients were discharged with non weight bearing for three weeks and allowed to walk with pair of crutches when they achieved quadriceps power and flexion upto 90* and radiographic examination showed consolidation. Patients were followed monthly and physiotherapy advised. AP and lateral X-rays of lower femur including knee were taken at monthly intervals and once fracture showed union patient were allowed partial and subsequently full weight bearing. Assessment of results was compared with the criteria laid down by Schatzker and Lambert (1979) for supracondylar femoral fractures, as given below.

Figure 1

Observations

The present study is based on 25 cases of supracondylar and intercondylar fractures of femur admitted to the department of orthopaedics, GMC Jammu. All these cases were treated by open reduction and internal fixation using dynamic condylar screw at the earliest possible. These fractures are more common in fourth and fifth decades of life(Table 1).Males(80%) outnumbered females(20%) in such fractures (Table 2). Injury was more common on right limb(52%) (Table3). In most of cases, the mode of injury was road traffic accidents(84%). Half of rest of the cases occurred because of fall from height whereas other half occurred because of slipping (Table 4).

Figure 2

Table 1: Showing age incidence.

Figure 3

Table 2: Showing sex incidence

Figure 4

Table 3: Showing limb involved

Figure 5

Table 4: Showing mode of injury

8 cases (32%) were with associated injuries (Table 5).The average time taken for union in all cases was 12.6 weeks (Table 7). The range of motion was more than 110* in morev than 80% of cases (Table 6). It was seen that the most common complications were knee stiffness (8%) and loss of length(<1.2cm)(8%) (Table 8).

Figure 6

Table 5: Showing nature of associated injuries

Figure 7

Table 6: Showing range of movements

Figure 8

Table 7: Showing time take for union

Figure 9

Table 8: Showing complications

To assess the results of treatment of supracondylar/intercondylar fracture of femur criteria laid down by Schatzker et all (1979) were used. Excellent to good results were obtained in 84% of cases (Table9).

Figure 10

Table 9: Showing results of suupracondylar/intercondylar fractures of femur.

Figure 11

Fig 1: Preoperative radiograph showing fracture distal femur.

Figure 12

Fig 2: Immediate post operative radiograph of same fracture fixed with DCS

Figure 13

Fig 3: Post operative radiograph at 24 weeks

Figure 14

Fig 4: Patient showing extension at 3 weeks.

Figure 15

Fig 5: Same patient showing flexion at 3 weeks.

Figure 16

Fig 6: Same patient at 24 weeks sitting cross-legged.

Discussion

From review of literature and present study it has been concluded that operative treatment or these fractures requires careful preparation and meticulous attention to intraoperative details. This includes careful handling of soft tissues, anatomic reduction of articular surface and bone grafting where needed and correct application of stable internal fixation. A poor reduction and internal fixation was sole reason for poor results. Substantial amount of external callus was observed in all cases where union occurred suggesting that DCS didn’t provide rigid fixation. The dynamic compression screw has advantages of accurate reduction and fixation, has good purchase in osteoporotic bones, and can be easily mastered and positioned over guide wire under image intensification. As the DCS is fixed angled device, so proper insertion of lag screw is at 95* and parallel to joint line after reduction is recommended. Hence we strongly recommend open reduction and internal fixation with DCS in fracture of distal femur at earliest possible.

Conclusion

It was concluded that dynamic condylar screw is an effective and technically undemanding method for treatment of supracondylar and intercondylar fractures of femur.