Distal Femur Fractures

David J. Stockton, MD MASc

University of British Columbia
Department of Orthopaedics

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Top 5 Learning Objectives

1) Osteology & deforming

forces
2) Fracture classification
3) Treatment options and
considerations
4) Surgical approaches
5) Fixation options (Collinge CA, Wiss DA. Distal Femur Fractures. In: Tornetta P, Ricci WM, eds. Rockwood and Green’s Fractures in Adults,
9e. Philadelphia, PA: Wolters Kluwer Health, Inc; 2019.)

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Introduction
• Account for 7% of all femur fractures
• Bimodal distribution: High-energy injuries in the young, low-energy in the elderly
• Historical treatment
• 1960’s and earlier: Skeletal traction favored
• Neer et al. (JBJS 1967) advocated for closed, non-operative treatment based on poor results
and high complications resulting from ORIF
• 1960’s: Angled blade plate introduced and subsequently the dynamic condylar
screw (DCS) plate improved fixation options
• 1990’s: ORIF established as the standard of care (Butt et al., JBJS Br 1996)
• 2000’s: Early iterations of the lateral locking plates improved outcomes (Weight &
Collinge, JOT, 2004)
• 2010’s: Improved plate design and ongoing experimentation with far cortical
locking (FCL) and intramedullary (IM) nail design aim to improve non-union rates
and allow for early weight-bearing
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Osteology
• Shaft of femur aligned with
anterior half of lateral condyle
• Anatomic axis 9° valgus (range 7-
11°)
• anatomic lateral distal femoral angle
(aLDF) 81° (79°- 83°)
• mechanical lateral distal femoral
angle (mLDF) 87° (85° - 90°)
• Sectioned axially, distal femur is
trapezoidal
• Ramifications for:
• Implant placement
• Screw prominence (Collinge CA, Wiss DA. Distal Femur Fractures. In: Tornetta P, Ricci WM, eds. Rockwood and
Green’s Fractures in Adults, 9e. Philadelphia, PA: Wolters Kluwer Health, Inc; 2019.)

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Injury Considerations
• Mechanism of injury
• Young patient: high energy (MVC,
fall from height)
• Elderly: low energy fall on flexed
knee
• Deforming forces
• Quadriceps  shortening
• Hamstring  shortening
• Gastrocnemius  apex posterior
angulation, posterior
displacement
• Adductors  varus (Collinge CA, Wiss DA. Distal Femur Fractures. In: Tornetta P, Ricci WM, eds. Rockwood and
Green’s Fractures in Adults, 9e. Philadelphia, PA: Wolters Kluwer Health, Inc; 2019.)

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Injury Considerations
• Associated injuries
• Open fracture (5-10%)
• Knee ligament injury (up to 20% of cases)
• Tibial plateau fracture
• Patella fracture
• Acetabulum fracture
• Femoral neck fracture
• Femoral shaft fracture

Courtesy of Jeff Potter, MD

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Injury Considerations
• History
• Mechanism of injury
• Ambulatory status
Indications for CT angiogram:
• Pre-existing knee arthritis 1) Diminished/ absent pulse
• Physical exam 2) Expanding hematoma
3) ABI <0.9
• If high energy injury: ATLS
4) Persistent arterial bleeding
• Examine for other injuries 5) Damage to associated nervous
• Neurovascular status of limb structures
• Ankle-brachial index/ CT angiogram
if any discrepancy in pulses
• Inspect for soft tissue injury

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Injury Considerations Double density sign Paradoxical notch view

• Workup
• Orthogonal X-Rays
• Double-density on AP X-Ray: Hoffa
fragment
• ‘Paradoxical notch view’ on AP X-Ray:
articular fragment in recurvatum
• Image joint above and below Hoffa fracture
• Low threshold for CT scan Courtesy of Jeff Potter, MD
• Demonstrates intra-articular
involvement
• Reveals coronally oriented Hoffa
fracture
• 38% incidence (Nork et al., JBJS 2005)
• Lateral > medial condyle
• Missed ~31% of the time

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Injury Considerations
• Prior to classifying the fracture, consider:
• Amount of displacement
• Degree of comminution
• Extent of soft tissue injury
• Damage to the articular surface
• Bone quality
• Associated fracture of patella or tibial plateau
• Associated neurovascular injury
• Presence of coronal fracture line

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Fracture Classification: AO/OTA

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(Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. AO/ OTA fracture and dislocation
classification compendium 2018. J Orthop Trauma. 2018;32 Suppl 1:S1-S170.)
Fracture Classification: AO/ OTA

(Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. AO/ OTA fracture and dislocation
classification compendium 2018. J Orthop Trauma. 2018;32 Suppl 1:S1-S170.)
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 33A:
Extra-articular

(Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. AO/ OTA fracture and dislocation
classification compendium 2018. J Orthop Trauma. 2018;32 Suppl 1:S1-S170.)
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 33B:
Partial articular

(Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. AO/ OTA fracture and dislocation
classification compendium 2018. J Orthop Trauma. 2018;32 Suppl 1:S1-S170.)
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 33C:
Complete articular

(Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. AO/ OTA fracture and dislocation
classification compendium 2018. J Orthop Trauma. 2018;32 Suppl 1:S1-S170.)
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Treatment options
• Relative indications for non-operative management
• Patient factors
• Medical contraindication to surgery
• Non-ambulatory
• Fracture factors Though non-operative treatment is
• Non-displaced fracture rare, outcomes may be superior to
• Impacted, stable fracture poorly conceived and executed
• Non-reconstructable fracture operative treatment
• Severe osteopenia
• Surgeon factors
• Lack of experience with operative treatment
• Lack of appropriate instrumentation or facilities available

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Treatment options
Evidence
• Non-operative treatment • Butt et al., JBJS Br 1996
• Long-leg cast followed by hinged • RCT of 42 patients >60yrs old with
knee brace displaced fractures to treatment with a
Dynamic Condylar Screw versus skeletal
• Early range of motion is key to traction with knee flexion exercises at 3-4
avoid stiffness weeks
• 53% of patients in operative group had
excellent or good results, versus 32% in
non-op group
• Significantly more complications in the
non-op group, many related to extended
period of immobility (UTI, pressure sores,
DVT, and pressure sores)

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Treatment options
• Operative indications:
• Majority of distal femur fractures do not meet non-operative indications

• Operative Goals:
1) Anatomic reduction of articular surface
2) Functional reduction of the metaphysis restoring length, alignment, and
rotation
3) Restoration of anatomic and mechanical axis of the limb
4) Stable fixation
5) Early range of motion

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Surgical Approaches
• Lateral
• Most common approach
• Skin incision in mid-lateral line of femoral
shaft, curving slightly anteriorly over lateral
femoral condyle towards tibial tubercle
• Distal extent determined by need for joint
arthrotomy if intra-articular reduction needs
to be performed
• Proximal extent determined by whether
fracture will be directly or indirectly reduced
• Divide IT band in line with its fibers
• Incise vastus lateralis fascia and elevate (Collinge CA, Wiss DA. Distal Femur Fractures. In: Tornetta P, Ricci WM, eds. Rockwood and
Green’s Fractures in Adults, 9e. Philadelphia, PA: Wolters Kluwer Health, Inc; 2019.)
fibers off septum, from distal to proximal,
ligating femoral artery perforating vessels

Video demonstration: https://otaonline.org/video-library/45036/procedures-and-

techniques/multimedia/16731389/lateral-distal-femur-plate-for-periprosthetic
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Surgical Approaches
• Swashbuckler
• Indicated when more articular
reduction and fixation is needed
• No tourniquet (prevents medial
retraction of quads)
• Midline anterior incision, curving
laterally proximally
• Quadriceps fascia incised in line with
skin incision, connecting distally with
a lateral parapatellar arthrotomy (Starr AJ, Jones AL, Reinert CM. The "swashbuckler": a modified anterior approach

• Fascia & IT band elevated off vastus for fractures of the distal femur. J Orthop Trauma. 1999;13(2):138-140)

lateralis; IT band retracted laterally

and quadriceps retracted medially
Video demonstration: https://otaonline.org/video-library/45036/procedures-and-
techniques/multimedia/16776605/distal-femur-swashbuckler-exposure Core Curriculum V5
 Surgical Approaches
• Medial
• Useful for isolated medial condyle fractures
or severely comminuted fractures in which
medial fixation is required
• Straight medial incision extending distally to
a point just anterior to adductor tubercle
• Fascia divided in line with skin incision,
anterior to sartorius
• Vastus medialis elevated, care taken to avoid
articular branch of descending geniculate (Sirisreetreerux N, Shafiq B, Osgood GM, Hasenboehler EA. Medial knee approach: An anatomical study
artery (DGA) and muscular branch to vastus of minimally invasive plate osteosynthesis in medial femoral condylar fracture. J Orthop Trauma.

medialis
2016;30(11):e357-e361)

• Muscular branch of DGA ~5cm and adductor

hiatus ~16cm proximal to adductor tubercle
Video demonstration: https://otaonline.org/video-library/45036/procedures-and-
techniques/multimedia/16731423/medial-femur-dissection Core Curriculum V5
 Surgical Approaches
• Limited anterior approach for IM
nailing
• Trans-patellar tendon incision or
medial to tendon
• Start point just anterior to femoral
origin of PCL
• Centered in shaft on AP Xray
• Anterior edge of Blumensaat’s line
on perfect lateral Xray (Beltran MJ, Gary JL, Collinge CA. Management of distal femur fractures with modern plates and nails: state of the
art. J Orthop Trauma. 2015;29(4):165-172)

Video demonstration: https://otaonline.org/video-library/45036/procedures-and-

techniques/multimedia/16731387/percutaneous-retrograde-supracondylar-femoral
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Reduction Tools
• Chemical paralysis
• Bump placed under knee corrects
apex posterior deformity by relaxing
gastrocnemius muscle
• Adequate exposure
• Femoral distractor
• ‘Pre-load’ Shanz pins (angle them slightly
away from fracture) to account for
angular deformity induced by distraction
• K-wires
• Reduction clamps
• Large Weber clamps
• Large peri-articular reduction clamp Courtesy of Claude Sagi, MD
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Types of Fixation
• Lateral pre-contoured plates
• May be used for most fracture patterns
• Retrograde intramedullary nail
• Most common for AO/OTA type A fractures
• Some simple intra-articular patterns (AO/OTA type C1 & C2)
• Dynamic condylar screw/ Angled blade plate
• Distal femoral replacement
• Elderly, pre-existing osteoarthritis, severely comminuted, with a need to
immediately mobilize
• Augmented fixation
• Bilateral plates, plate/ nail combo
• Buried screw fixation for Hoffa fractures
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 Bridge plate fixation

Fixation Options
• Lateral pre-contoured plates
• Modes of fixation:
• Simple fractures: neutralization plate Courtesy of Jeff Potter, MD
for an anatomically reduced fracture
with lag screw fixation
• Comminuted fractures: bridge plate Buttress plate fixation
• Vertical shear fracture fixation:
buttress plate
• Available with variable-angle
locking, fixed-angle locking, and
non-locking options
• Have largely replaced the dynamic
condylar screw and blade plate
Courtesy of Claude Sagi, MD

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Fixation Options
• Pre-contoured lateral plates
• Stress modulation: the concept of manipulating bridge plating
variables to optimize the flexibility of the construct to allow
callus formation (Beltran et al. JOT 2015)
• Titanium vs. stainless steel
• Locking vs. non-locking
• Unicortical vs. bicortical screws
• Plate length
• Screw hole fill
• Working length

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Fixation Options
• Far-cortical locking plates
• Biomechanical and animal studies show
increased and more evenly distributed callus
• Plumarom et al., JOT 2019
• Retrospective cohort of AO/OTA type A, C, and
periprosthetic fractures
• 42 treated with far-cortical locking plates and 15
with lateral locked plates
• mRUST scores from blinded radiographs
statistically higher in FCL group at 6, 12, and 24
• 91% union for FCL group vs. 82% for LLP group at
one year
(Bottlang M, Feist F. Biomechanics of far cortical
locking. J Orthop Trauma. 2011;25 Suppl 1:S21-28)

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Case Example
• 59 year old male,
workplace injury where
a 250lb marble slab fell
on his leg
• Pre-existing severe knee
osteoarthritis

Courtesy of Jeff Potter, MD

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 Final 1 year follow-up X-Ray
2 week post-op X-Ray

Courtesy of Jeff Potter, MD

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Fixation Options
Dynamic
Condylar Screw
• Dynamic Condylar Screw (DCS) plate (DCS) plate
• Less Invasive Stabilization System (LISS)
• Evidence:
• COTS group, JOT 2016
• RCT comparing LISS (28 patients) vs the DCS
(24 patients)
• 52% of LISS group healed at 12 months vs.
91% in the DCS group
Less Invasive
• Both have largely been replaced by Stabilization
modern implants that have variable System (LISS)
angle/ fixed angle, and non-locking
options

(Collinge CA, Wiss DA. Distal Femur Fractures. In: Tornetta P,

Ricci WM, eds. Rockwood and Green’s Fractures in Adults, 9e.
Philadelphia, PA: Wolters Kluwer Health, Inc; 2019.)
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Fixation Options
• Limitations of lateral locked distal femur plates: non-union
• Up to 31%
• Rodriguez et al., JOT 2016
• Retrospective study including 271 supracondylar femur fractures
• Nonunion rate 13%
• Plate material (stainless steel) and those with high rigidity scores were associated with
nonunion
• Rigidity score included: plate material, presence of screws across main fracture, and
proximal screw density
• Ricci et al., JOT 2014
• Retrospective study including 335 AO/OTA Type A or C fractures
• Nonunion rate 19%
• Risk factors for reoperation to promote union include open fracture, diabetes,
smoking, increased BMI, and shorter plate length

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Fixation Options
• Intramedullary nail
• Minimizes disruption of soft tissues
• Improved designs (multiple distal screw
options and ability to lock distal screws
to the nail) have expanded their
indications
• Retrograde nail should extend to the
level of the lesser trochanter, or at least
allow two proximal interlocking screws
• Antegrade nails may be an option for
high supracondylar fractures or
segmental fractures
• Reduce fracture prior to reaming (Collinge CA, Wiss DA. Distal Femur Fractures. In: Tornetta P, Ricci WM, eds.
Rockwood and Green’s Fractures in Adults, 9e. Philadelphia, PA: Wolters Kluwer
Health, Inc; 2019.)

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Fixation Options
• Dynamic condylar screw/ angled blade plate
• Currently, used at times for nonunion/ revision scenarios
• Stiff constructs (stainless steel)
• Condylar screw & blade must be inserted parallel to joint
• Position in the articular fragment is critical to avoid malreduction

(Collinge CA, Wiss DA. Distal Femur Fractures. In: Tornetta P, Ricci
Blade positioning WM, eds. Rockwood and Green’s Fractures in Adults, 9e. Philadelphia,
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PA: Wolters Kluwer Health, Inc; 2019.)
Case Example
• 68 year old man, left leg
crushed when trailer fell
off a jack and onto his leg
• Open left segmental,
comminuted distal femur
fracture

Courtesy of Mike Moran, MD

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2 week follow-up X-Rays

Courtesy of Mike Moran, MD

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• Distal femur & shaft fracture
nonunion established at one year
• Persistent pain, no infectious
symptoms, skin healed with no
draining sinus, CRP normal

Courtesy of Mike Moran, MD Core Curriculum V5

 Union by 6 months
post-op

Intra-op image confirming DCS placement

Courtesy of Mike Moran, MD Core Curriculum V5

Fixation Options
• Distal femur replacement
• Advantages
• Immediate weight-bearing, eliminates risks of nonunion, malunion,
fixation failure, and post-traumatic OA (Meluzio et al. Injury 2020)
• Disadvantages
• Limited salvage options in cases of osteolysis, loosening, peri-
prosthetic fracture, or infection

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 Fixation Options
• Lateral plate augmented fixation with
• Medial pre-contoured distal tibia plate
• Medial 3.5mm recon plate
• Retrograde IM nail
• May be useful to avoid varus failure
and permit early weight-bearing
• Fontenot et al. J Orthop Trauma 2019
• Biomechanical study using 28 synthetic
femora
• Both Lateral plate plus medial recon plate
& lateral plate plus nail exhibited higher
stiffness and load to failure
(Wright DJ, DeSanto DJ, McGarry MH, Lee TQ, Scolaro JA. Supplemental fixation of

• Wright et al. J Orthop Trauma 2020 supracondylar distal femur fractures: A biomechanical comparison of dual-plate and plate-nail
constructs. J Orthop Trauma. 2020;34(8):434-440)

• Dual plate fixation had slightly higher

torsional and axial stiffness Core Curriculum V5
Fixation Options
• Hoffa fracture fixation
• Caused by shear moment through posterior
condyle
• Do not miss these fractures
• Require independent screw fixation-prior to
plate- in the sagittal plane
• Flexion of knee helps to reduce fragment
• Fixation outside articular margin when
possible; buried/ headless screw when not
• Very small posterior fragment may require
posterior to anterior screw

(Holmes SM, Bomback D, Baumgaertner MR. Coronal fractures of the femoral

condyle: A brief report of five cases. J Orthop Trauma. 2004;18(5):316-319)

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Post-surgery Rehabilitation
• Traditional had been NWB for up to 12 weeks
• New evidence suggests immediate or early weight-bearing does not
increase fixation failure rate
• Poole et al., BJJ 2017
• Case series of 127 fractures in patients with mean age 73 years old fixed with lateral distal
femur locking plate
• 84% were allowed to weight-bear immediately. At minimum 1 year follow-up, 95% united
and only 3% required re-operation for failure of fixation
• Lieder et al., JOT 2020
• Retrospective cohort of 135 patients with AO/OTA Type A and periprosthetic femur
fractures allowed to either weight bear immediately or touch-down weight bear
• No difference in adverse events (11% WBAT vs. 19% TDWB) including early fixation failure,
nonunion, or infection
• Range of motion initiated immediately post-op
• Involve primary care physician and/or endocrinologist if osteoporosis is a
concern
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References
1) Neer CS, 2nd, Grantham SA, Shelton ML. Supracondylar fracture of the adult femur. A study of one hundred and ten cases. J
Bone Joint Surg Am. 1967;49(4):591-613.
2) Butt MS, Krikler SJ, Ali MS. Displaced fractures of the distal femur in elderly patients: Operative versus non-operative
treatment. J Bone Joint Surg Br. 1996;78(1):110-114.
3) Weight M, Collinge C. Early results of the less invasive stabilization system for mechanically unstable fractures of the distal
femur (AO/OTA types A2, A3, C2, and C3). J Orthop Trauma. 2004;18(8):503-508.
4) Collinge CA, Wiss DA. Distal Femur Fractures. In: Tornetta P, Ricci WM, eds. Rockwood and Green’s Fractures in Adults, 9e.
Philadelphia, PA: Wolters Kluwer Health, Inc; 2019.
5) Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. AO/ OTA fracture and dislocation classification compendium 2018. J
Orthop Trauma. 2018;32 Suppl 1:S1-S170.
6) Nork SE, Segina DN, Aflatoon K, et al. The association between supracondylar-intercondylar distal femoral fractures and
coronal plane fractures. J Bone Joint Surg Am. 2005;87(3):564-569.
7) Starr AJ, Jones AL, Reinert CM. The "swashbuckler": A modified anterior approach for fractures of the distal femur. J Orthop
Trauma. 1999;13(2):138-140.
8) Sirisreetreerux N, Shafiq B, Osgood GM, Hasenboehler EA. Medial knee approach: An anatomical study of minimally invasive
plate osteosynthesis in Medial Femoral Condylar Fracture. J Orthop Trauma. 2016;30(11):e357-e361.
9) Canadian Orthopaedic Trauma Society. Are locking constructs in distal femoral fractures always best? A prospective multicenter
randomized controlled trial comparing the Less Invasive Stabilization System with the minimally invasive Dynamic Condylar
Screw system. J Orthop Trauma. 2016;30(1):e1-6.
10) Beltran MJ, Gary JL, Collinge CA. Management of distal femur fractures with modern plates and nails: state of the art. J Orthop
Trauma. 2015;29(4):165-172

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References
11) Rodriguez EK, Zurakowski D, Herder L, et al. Mechanical construct characteristics predisposing to non-union after locked lateral
plating of distal femur fractures. J Orthop Trauma. 2016;30(8):403-408.
12) Ricci WM, Streubel PN, Morshed S, Collinge CA, Nork SE, Gardner MJ. Risk factors for failure of locked plate fixation of distal
femur fractures: An analysis of 335 cases. J Orthop Trauma. 2014;28(2):83-89.
13) Gwathmey FW, Jr., Jones-Quaidoo SM, Kahler D, Hurwitz S, Cui Q. Distal femoral fractures: Current concepts. J Am Acad Orthop
Surg. 2010;18(10):597-607.
14) Bottlang M, Feist F. Biomechanics of far cortical locking. J Orthop Trauma. 2011;25 Suppl 1:S21-28.
15) Plumarom Y, Wilkinson BG, Marsh JL, et al. Radiographic healing of far cortical locking constructs in distal femur fractures: A
comparative study with standard locking plates. J Orthop Trauma. 2019;33(6):277-283
16) Meluzio MC, Oliva MS, Minutillo F, Ziranu A, Saccomanno MF, Maccauro G. The use of knee mega-prosthesis for the
management of distal femoral fractures: A systematic review. Injury. 2020;51 Suppl 3:S17-S22.
17) Fontenot PB, Diaz M, Stoops K, Barrick B, Santoni B, Mir H. Supplementation of lateral locked plating for distal femur fractures:
A biomechanical study. J Orthop Trauma. 2019;33(12):642-648.
18) Wright DJ, DeSanto DJ, McGarry MH, Lee TQ, Scolaro JA. Supplemental fixation of supracondylar distal femur fractures: A
biomechanical comparison of dual-plate and plate-nail constructs. J Orthop Trauma. 2020;34(8):434-440
19) Holmes SM, Bomback D, Baumgaertner MR. Coronal fractures of the femoral condyle: A brief report of five cases. J Orthop
Trauma. 2004;18(5):316-319
20) Poole WEC, Wilson DGG, Guthrie HC, et al. 'Modern' distal femoral locking plates allow safe, early weight-bearing with a high
rate of union and low rate of failure: five-year experience from a United Kingdom major trauma centre. Bone Joint J. 2017;99-
B(7):951-957.
21) Lieder CM, Gaski GE, Virkus WW, Kempton LB. Is immediate weight-bearing safe following single implant fixation of elderly
distal femur fractures? J Orthop Trauma. 2020.

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