Classification And Treatment in Supracondylar Fracture of Femur:

Supracondylar region extends from the femoral condyles to the junction of metaphysis with femoral shaft .The distal fragment is displaced and angulated posteriorly due to the pull of gastrocnemius muscle.

Mechanism of Injury

It is due to severe valgus or varus forces with axial loading and rotation due to RTA, fall, etc.

Classification

1. Nears’s Classification

• Undisplaced Fracture
• Displaced Fracture
• Medial Displacement
• Lateral Displacement
• Comminuted Fracture

2. Muller’s AO Classification

• Type A: Extra-articular Fractures.
• Type B: Unicondylar Fractures.
• Type C: Bicondylar Fractures.

Each is further subdivided into 1-3 depending on the severity of comminution.

3. OTA Classification of Supracondylar Fractures of Femur

Supracondylar Fractures of Femur

• Type A: Extra-articular.
• Type B: Partial articular (Unicondylar).
• Type C: Total articular (Bicondylar).

4. Further Subdivisions

Type A

• Simple
• Metaphyseal  Wedge
• Metaphyseal Comminution

Type B

• Fracture lateral condyle.
• Fracture medial condyle.
• Frontal fracture.

Type C

• Articular and metaphyseal simple.
• Articular simple and metaphyseal comminution.
• Total comminution.

Clinical Features

It consists of the usual features of fractures, but what is specific to this fracture is the flexion deformity caused by the pull of gastrocnemius. Hemarthrosis is commonly seen, especially with fractures extending into the joint.

Radiographs

Radiograph helps to study the fracture pattern more accurately. Routine AP, lateral and oblique (45degree) views are required.

Arteriography: This should be performed in suspected vascular damage or in associated dislocation of the knee joint.

Treatment

The treatment usually consists of conservative methods, traction and operative methods.

• Conservative Methods: This has a limited role and is usually useful in impacted and undisplaced fractures. In the former, a long leg or Spica cast is sufficient and in the latter, a long above knee cast after an initial period of skin or skeletal traction is all that is required.
• Traction Methods: The choice is mainly skeletal traction and two methods are described.
• Upper Tibial Traction: Here the skeletal traction is applied through the upper end of tibia. Initial weight used is around 15-20 lbs and is subsequently reduced. The traction is given for a period of 8-12 weeks and the patient is put on cast braces. To prevent the knee stiffness from developing, the patient is encouraged to carry out the knee movements during the traction itself.
• Two-Pin Traction Method: In this method, traction is added through the distal femur apart from the traction given through the upper end of tibia. This helps in accurate reduction of the fracture and maintains the reduction so obtained. The disadvantage of this technique is that it is cumbersome and may cause neurovascular compressions in and around the knee.
• Operative Methods: This consists of DRIP and is preferred as the closed reduction is associated with troublesome complications like limited knee motion, residual varus and internal rotation deformities. The advantages of open reduction are early mobilization of the knee joint and an accurate reduction and rigid fixation.
• Fixation Methods: The choice is between medullary fixation and blade plate fixation.
• Intramedullary Fixations: Rush pins, Ender’s nail, medullary nails, split nails, static locking nails, etc. are some of the commonly used medullary fixation methods. They offer biological fixation but the fixation offered is less stable.
• Trigen (Third generation) Knee Nail: Inserted in a retrograde fashion. It is a titanium nail and has two holes for oblique screws and one for transverse screw at the insertion end. At the opposite locking end two holes are present in the anteroposterior plane and 2 holes in the lateral plane. The results are encouraging.

Complications

The complications commonly encountered in supracondylar fractures are delayed union, mal union, nonunion, injury to the popliteal vessels and common peroneal nerves, knee stiffness, deep vein thrombosis, infection, implant failure, etc.

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