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Supracondylar Femoral Frx: Operative Treatment

- Pertinent Surgical Anatomy

- Operative Treatment: Choice of Hardware:
    - 95 deg. condylar blade plate:
    - dynamic screw and side plate:
    - condylar buttress plate:
    - IM nails for supracondylar fractures:
    - zickel nail:
         - may be used for extra-articular transverse supracondylar fractures
         - good for osteoporotic bone;

- Preoperative Planning:
    - template for fracture fragments;
    - must r/o a Hoffa extension (coronal plane fracture) in which case, a condylar buttress plate is required; (see classification);
    - w/ a blade plate, the angulation of the screws in the plate (to avoid fracture lines on the other side) may be determined;
    - determine anatomic axis from the uninjured knee;
    - select implant;
    - consent pt for ICBG;

- Surgical Strategy: (for intra-articular fractures)
    - restoration of articular anatomy:
            - restoration of articular surface w/ direct visualization of fracture using a limited medial para-patellar arthrotomy (keep skin incision 
                   medial and distal inorder to avoid a narrow skin bridge) - see blood supply to the knee;
            - after adequate exposure, femoral condyles are reduced & fixed w/ K wires;
            - then definitively fix with large cancellous screws;
            - use washers with poor bone stock;
            - cancellous screws are placed anterior & posterior in condyles, allowing sufficient space between them for insertion of condylar blade plate;
    - restoration of extra articular anatomy:
            - simple bump: round bump under the frx site assists reduction of the supracondylar fracture by reversing the typical recurvatum deformity;

    - restoration of ligamentous stability:
            - once knee is stabilized, ligamentous injury about knee is assessed;
            - before stabilization of fracture, it is difficult to determine extent ofinjury to the ligaments;
            - medial instability is commonly present w/ supracondylar frxs;

- Positioning:
    - supine, foley, sterile tournequet, hip bump, and operative knee elevated on towels (so that the opposite leg is not visualized when the flouro is obtained);
    - flourotable w/ flouro on opposite side of table;
    - ensure that pt is prepped and consented for ICBG;

- Frx Reduction:
    - consider use of femoral distractor
    - femoral condyles are reduced w/ K wires;
    - 2 cannulated screws are inserted, one screw as anterior as possible and one screw placed as posteriorly as possible w/o going into the notch;
          - hence, placement of these screws will allow sufficient space between them for subsequent insertion of the condylar blade plate or screw;
          - due to the trapezoidal shape of the femoral condyles, which are narrower anteriorly than posteriorly, the cannulated screws should be 1 cm
                    short of the medial femoral cortex;
          - following insertion of cancellous screws, the extra-articular portion of the fracture is reduced and stabilized


- Post Op Care