Operative

Treatment

of

Supracondylar

Condylar

Fractures
TECHNIQUE BY From tile Departments SVEN of AND OLERUD, and

of
RESULTS M.D.*, Orthopedic

the
IN UPPSALA,

Femur
FIFTEEN CASES SWEDEN University Hospital, Uppsala

Surgery

Surgery,

Supracondylar-condylar faces ment,

may be very difficult

fractures
to treat,

of the
either by

femur
closed

which
or open

involve
methods.

the among

articular
Closed

surtreat-

advocated stiffness may

because

by Watson-Jones of the knee also occur. of technical

( I 955)

and

Charnley

( I 963)

others,

may

produce angulation
trophe

joint. Deformity Internal fixation difficulties and

in the form of shortening or even some on the other hand may lead to catasinadequate fixation. This method had, advocated closed and open reduction and final condylar results in have
6#{149}

therefore, treatment

been condemned and Neer, Grantham, and Shelton on the basis of a comparison of cases in which traction

and internal fixation had been used in the femoral fractures. Internal fixation in their almost 50 per cent of the cases. During recent years new concepts and developed 2 which permit better of this article is, first, to describe

treatment of supracondylar series had given very poor techniques of osteosynthesis previously which is based

been

internal fixation than a method of treatment

The purpose on the prinso in a

ciples recommended by the Swiss AO school and provides stable osteosynthesis that early active exercises can be performed and, second, to describe the results small series
of cases.

Material The patients included were those

and Methods
with supracondylar fractures of the femur with

articular involvement and disruption of the joint surfaces. No pathological fractures or fractures in children were included. The sixteen patients were all treated in the Departments of Surgery and Orthopedics of the University Hospital in Uppsala between the years 1 965 and 1 970. At the time of treatment the youngest patient was sixteen years old and the oldest was seventy-seven. Six were less than thirty years old; four, between the ages of thirty and fifty; and six, over fifty. Ten were male, and six were female. All of the women were over the age of thirty. The fractures were
caused by playing a traffic ice accident hockey in twelve, in one. Eight by a fall on stairs in three, and by an injury

while shaft
of age.

of the femur laterally. Five patients

had

penetrated

were the quadriceps

open fractures. In seven muscle anteriorly, and occurred Fourteen

of these the in one it had years were by me

penetrated

All of the open fractures had other severe injuries. examinations accident. One

in patients less than fifty of the sixteen fractures performed

treated by me. one to six years Classification In this

tion

Follow-up after the

of fifteen patient was

patients were lost to follow-up.

of the Supracondylar-Condylar
series

Fractures into three

of the Femur main groups using a classificadisplace-

the patients

were

divided

based on that used by Neer, Group I (two patients) was

*

Grantham, composed
14 Uppsala

and Shelton of fractures

14, Sweden.

(Fig. I). with relatively

little

Akademiska
NO.
5, JULY

Sjukhuset,
1972

750

VOL.

54-A.

1015

1016

SVEN

OLERUD

MINIMAL

DISPLACEMENT I

MEDIAL

DISPLACEMENT

LATERAL

DISPLACEMENT

cONJOINED 0NDYLAR

SUPRAC SHAFT

OF CONDYLES hA FIG.

OF CONDYLES UB

1
fractures. In Group II the shaft may

The

anatomical

be dislocated

medially

classification (II A)

of

or laterally

supracondylar-condylar (II B) (reprinted

from
1967).

Supracondylar

Fractures
A. Grantham,

of the
and

Adult
M.

Femur.

A Study
J. Bone

of One
and Joint

Hundred
Surg.,

and Ten
49-A: 592,

Cases
June

by C. S. Neer,

II, S.

L. Shelton.

ment,
divided

in

which condylar
II

the

metaphyseal
This type

part
of

of

the

masses.

fracture

shaft was

was wedged firmly relatively stable.

between
were

the
di-

Group (five patients) included the fractures in which the condyles vided and dislocated and the shaft of the femur was displaced either laterally, ly or dorsally; one of these patients had an open fracture (Case 7).
Group
III

medialthere patients
frag-

was had
ments:

considerable open fractures

in two In three

(nine patients) metaphyseal with lateral perforation condyle

of the Group-Ill

comprised the and diaphyseal of the

fractures

intercondylar comminution. muscle

were

fractures Seven (Fig.

divided

in which

of these 6).

quadriceps
the condyles

into three

the

was

divided
in the

by a fracture
sagittal plane,

in the
and

frontal
third

plane
the

in adlateral

dition condyle

to the was

intercondylar

fracture

in the

divided by a second vertical In some of the Group-Il fractures

fracture in the sagittal plane. with anterior displacement, muscle associated of the femoral
Open

there

was

per-

foration and suprapatellar

type of soft-tissue especially

laceration of the quadriceps bursa caused by the protrusion

injury was often III. very in Group

with shaft.
fractures

laceration In Group
appeared

of the III this

to be

pronounced.

common

Of the years
only

seven two
over

patients were
fifty, four since

with under
of

Group-I thirty. Of
between

and the

Group-Il nine
thirty fractures are the

fractures, with
fifty, in the result and

five Group-Ill
four

were
were

over fractures,
less

fifty
than

old
one

and
was

patients
and

were more these

thirty.
have

The
been

higher
anticipated
I11OC

incidence
COflhIllOfl

severe fractures

younger of high

patients energy

might injuries

which

are

in younger

people. Treatment

Indication.s
The main indication

for

surgical

treatment

was

incongruence

of the joint backward reason for

sur-

faces tion
tures.

sufficient to jeopardize indication in the two Group-I

future articular function. Angulation fractures. In older patients a further of confinement to bed. considered advantageous, especially

was the for operaopen frac-

was to shorten the duration Immediate operation was

Of the eight patients with open despite multiple injuries and two had tiple injuries and severe shock. Ten

fractures, six were operated their osteosynthesis deferred patients were treated with
THE JOURNAL OF BONE AND

on immediately because of mulskeletal traction

JOINT SURGERY

OPERATIVE

TREATMENT

OF

SUPRACONDYLAR-CONDYLAR

FRACTURES

1017

through an open
stance

the tibial fracture

operation

tuberosity was operated

was performed

during the on more

twenty

preoperative period. than ten days after days after injury.

Only one the accident.

patient with In this in-

FIG.

The
between

broken
the

line indicates
patella and the

the location
tibial tuberosity.

of the Y-shaped

skin incision,

the

center

of which

lies

Operative A large
2). Osteotomy a chisel,

Technique Y-shaped
of the may split

incision
tibial the

was
bone)

made
was after

and
then first

the tibial
performed drilling

tuberosity
with a hole

was
an oscillating

exposed
saw all

(Fig.
(not the

tuberosity

which

anteroposteriorly

FIG. Osteotomy anteroposteriorly with a screw. By means of easily accessible.

VOL. 54-A. NO.

of

the tibial through The patellar this incision

tuberosity has been performed, but prior to this a hole was drilled the tibia to ensure an exact replacement and fixation of the fragment retinaculum has been divided, as well as the fat pad and synovium. the distal end of the femur anterior to the intermuscular septa

is

5. JULY

1972

101 8

SVEN

OLERUD

FIG.

4-A considerable separation of the two femoral

Supracondylar condyles.

fracture,

Group

II.

Note

the

way

through

the

dorsal

cortex

for

subsequent

exact

repositioning

and

fixation

of the

tubercle with The patellar tion on both was lifted in was freed to
3), while on for

a screw which gripped both the cancellous bone and the dorsal cortex. retinaculum and synovium were then divided in the longitudinal direcsides of the joint, and the fat pad was severed transversely. The patella a dorso-cranio-medial direction, and the extensor apparatus of the knee a limited extent along the intermuscular septum on the medial side (Fig.
the lateral side a fairly extensive dissection in the cranial direction along

the

lateral

side

of the

femur

was

often

required

in order limit applied

to make

room

to insert

the

apparatus low enough minutes After the The

tion

internal fixation. However, to allow use of a tourniquet, surfaces, together

the upper which was the and

of the incision for a maximum fragments screws (Figs. (and, 4-A

was always of ninety if need and be, 4-B).

during the operation. clearing of the fracture fragments) more were condyles than fitted

condylar with

shaft

fixed

fractures

reconstituted with

could then two condylar (Fig. blade

be aligned fragments,

primarily with the femoral extra screws were needed and

shaft. In for fixa-

nel the
of

of these fragments in the condyles, the

5). After accurate ofthe AO angulated

very careful chiseling of a chanblade-plate was hammered in with

blade parallel the femur there

to the articular surface. After the reconstruction of the distal end was a large cavity in the metaphysis as the result of compression In all of them the fracture fractures abandoned
inserted in the

of the cancellous bone in no fewer than six patients. filled with cancellous bone graft, regardless of whether initially pression
compression

the had

cavity been with

was open com-

or not. in the
(the

In several longitudinal
compression

of the

severely had

comminuted to be
by screws

fixation and
cases different

direction
achieved

interfragmentary

to suffice. The bone graft from the iliac crest which was fitted into the defect where it increased
screw

had

was in some the stability was excised vacuum

OF

fragments) taken as a block achieved by the final as in a synovectomy. drainage.

AND JOINT

fixation. importance

In most was

cases attached

the suprapatellar to establishing

bursa

Great

effective
THE JOURNAL

The

tibial

BONE

SURGERY

OPERATIVE

TREATMENT

OF

SUPRACONDYLAR-CONDYLAR

FRACTURES

1019

FIG. After osteosynthesis the fragments have been

4-B restored to the anatomical position almost cx-

actly.

tuberosity
screws.

was

finally

fitted

into

its bed

and

fixed

with

one

or two

cancellous

bone

Postoperative

Care period the extremity was elevated on a splint with the of 90 degrees (Fig. 6). By this means the site of the of blood and exudate, which otherwise would be-

In the early postoperative knee and hip held at an angle suprapatellar bursa was drained
come

organized, form adhesions and inhibit movements of the knee joint. In some patients this position caused discomfort, and a position with a smaller angle of flexion was used. After six to ten days the patients were encouraged to carry out active move-

ments,

increasing

them

progressively.

Throughout

the

whole

postoperative

convales-

cence and therapist.

ity to extend

rehabilitation For the first

program, the patients exercises were supervised by a physiothree or four weeks attention was focused on gaining the abil-

the knee. After this time more energetic attempts were made to increase Manipulation was never used to gain motion, only active exercises. Crutch-walking without weight-bearing was started as soon as the patients general condition would allow it, usually seven to ten days after operation. Once the patient was used to walking with crutches he was told to put his foot on the floor and as he walked with crutches to move the limb in a normal fashion without bearing more flexion.
VOL. 54-A, NO. 5, JULY 1972

1020

SVEN

OLERUD

FIG.

5 III because primary of the severe roentgenogram comminution of points to a step-off the in

Supracondylar metaphyseal

fracture region (Case

classified 14). The

as Group arrow on

the

articular

surface

of the

lateral

femoral

condyle,

where
bone

this

condyle
which

has

been
are

split

in the
visible

frontal

plane. The reconstruction was started by attaching condyle to the anterior one with two cancellous lateral view. The second and third pairs of films one year after the osteosynthesis. than five to ten kilograms of weight on

the posterior
screws,

fragment
fracture

of the lateral
clearly

femoral
on the

illustrate

the

immediately

after

and

it as determined

by an

ordinary

bathroom

scales. After three limb and to increase

months the patients were instructed to put more weight on the the weight gradually until full weight was being put on the limb after another month, that is four months after operation. The average duration of hospitalization of the patients with no other injuries was twenty-eight days. For the patients of working age with no complications the average length of time on the sick list was six months. For the two patients with serious complications the
time time on the sick list all was those thirty the who months who followed were (Case were 5) and already returned twenty-three retired to productive and months on work. (Case pension 6), at rethe

spectively.
of injury,

Excluding

patients

The

blade-plate

and

screws

were

eventually
THE

removed
JOURNAL OF

from
BONE

all
AND

patients
JOINT

under
SURGERY

OPERATIVE

TREATMENT

OF

SUPRACONDYLAR-CONDYLAR

FRACTURES

1021

FIG.

6 knee and hip

it

For

the

first

six

to

ten

days

after

operation

the

joint
has

are
been

angled
initially.

position.

The

knee

is more

easily

mobilized

when

maintained held in

this

in a rightposition

fifty eration.

years

of age,

but

not

before

one

and

one-half

to two

years

after

the

primary

op-

Complications
In eleven patients the wound and the fracture healed uneventfully and at four months there was ing. In five patients,
Osteornyelitis

sufficient however,
of the

consolidation there were

developed

at the fracture to permit full weight-beardisturbances in healing as follows:

in one patient with a Group-Ill fracture

femur

who another

had

sustained

a severe,

open,

soft-tissue

injury

(Case

5, Fig.

7-A).

fixation of the metaphyseal component of the fracture occurred in with a Group-Ill fracture, but after bone-grafting and further internal fixation the final result was satisfactory (Case 6). Septic arthritis ofthe knee developed in a patient with a Group-I closed fracture and osteoarthritis of the knee (Case 10). The infection in the joint resolved after draining and antibiotic therapy, and the femoral fracture united without evidence of
infection, but knee motion was poor.

Unstable patient

One organism
removal

patient (Case 1 1 ) had so-called metallosis or perhaps an infection with an of low virulence. Repeated cultures from the secretion were negative. After of the metallic implants, twelve months after the accident, the inflammatory
resolved completely. of

process

Osteitis

the

tibial

tuberosity

occurred

in a patient

with

a Group-Il

fracture

I 3). The infection here probably originated in the tract of the pin inserted the tuberosity during primary treatment in traction. After removal of the screw from the tibial tuberosity along with a sequestrum, uneventful healing ensued. Reduced strength of knee extension was the only residual symptom. As previously mentioned, the metallic implants were only removed from patients below fifty years of age (nine of the fifteen patients). This operation for extraction of the implants was performed twelve to twenty-seven months (mean, twenty months) after the accident. In one patient with a Group-Ill open fracture, from whom
VOL. 54-A. NO.
5. JULY 1972

(Case through

1022

SVEN

OLE

RUD

the plate was removed twenty-three special trauma occurred at the was treated with intramedullary
final result.

months reaming healing

after and

metaphyseodiaphyseal

refracture without any This complication K#{252}ntscher nailing, with a very good
junction.

the

accident,

The

following

patients

with

disturbances Reports
accident

are

of special

interest.

Case
CASE

5. A nineteen-year-old (Fig. 7-A), a tibial

man

in a traffic

sustained

an

open

Group-Ill

fracture

of the

femur

fracture

and a Monteggia

fracture,

all on the

right

side,

as well

FIG.

7-A man had Note an open Group-Ill end of the suprafern-

Figs. Fig. oral-shaft

7-A 7-A:

through

7-G:

Case

5. This

nineteen-year-old

condylar-intercondylar
Appearance intermediate

fracture of the femur. of limb on admission

fragment.

See case
to the

report.
hospital. protruding

FIG.

7-B
Group III fracture. Note

Initial femoral

roentgenograms shaft immediately

show a severely in front of the

comminuted patella.
THE

fragments

of

JOURNAL

OF

BONE

AND

JOINT

SURGERY

OPERATIVE

TREATMENT

OF

SUPRACONDYLAR-CONDYLAR

FRACTURES

1023

FIG.

7-C fragment and the condylar

fragments have been by cancellous screws. With been bent to fit the lateral the femoral condyles to act
is

Photograph

during

reconstruction.

The

shaft

reconstructed separately, the shaft and condylar surface and has been

the various fragments being held together fragments aligned, the angulated plate has laid in position with its blade in contact with

as a guide while a tract for the blade is chiseled through the place. Note the large defect in the metaphyseal area. At a later will be filled with cancellous bone grafts.

condyles. The chisel stage of the operation

shown in this defect

FIG.

7-D The
tibial

Roentgenograms of the supracondylar fracture after reconstruction. tibia are some of those used for the compression osteosynthesis of the
VOL. 54-A, NO. 5. JULY 1972

extra
fracture.

screws

in the

1024
as a pulmonary contusion and slight

SVEN

OLERUD

concussion.

The

femoral

fracture

was

treated

by on

open

re-

duction, fixation with an angulated plate, and a bone graft (Figs. 7-B through fracture was fixed with screws and the Monteggia fracture with a compression The postoperative course was characterized by a coagulation consumption

7-D).
plate

The
the

tibial
ulna.

defect or fat em-

FIG.

7-E

FIG.

7-F
dorsal bridge

Fig. of bone Fig.

These
pletely faces
is

7-E: After d#{233}bridement of infected bone there is a large defect with a small visible on the lateral roentgenogram. 7-F: The metallic implants were removed two years and four months after roentgenograms were made five months after removal. The bone defect has filled with now almost mature bone. The plane of the femoral condylar

the accident. become cornarticular sur-

correct.

FIG.

7-G

The mal

final alignment

condition of the

four limb

grees).
No further

Depressed
drainage

scars

are

occurred

years after the accident shows almost full extension and nearly noras viewed from in front. Flexion is completely satisfactory (125 devisible where there had been sinuses as the result of the infection. after removal of the metal.
THE JOURNAL OF BONE AND JOINT SURGERY

OPERATIVE bolism After aureus. excision surgical area filled during was on all characterized four The of weeks the there infected infection

TREATMENT by
was

OF

SUPRACONDYLAR-CONDYLAR cutaneous femoral and medullary and cavity bone despite about in the grafts. the fracture, drainage fibrous one The infection. and tissue year metaphyseal metallic Gradually petechiae, and cultures when was after

FRACTURES and it had performed. the bone implants accident (Fig. a callus were a persistent grew
Staphylococcus

1025
fever. localized, Despite the 7-E). left bridge This in this infected was situ was years disapwith after of years function

pulmonary drainage treated infection resulting with by bone

infiltrations, from and the incision

was the

become

cortical

intervention again several of these debrided,

persisted, in a large cancellous procedures

occasions operative

formed
Throughout and peared. the the the four

and

osseous
this period had

continuity
there elapsed had been He after was the

between
intermittent metal with his

the
was to work wound

shaft
purulent removed,

and

condyles
discharge after which Fucidine, worker dry

of the
from all two and signs and he

femur
of

was
When infection beginning

restored.
two

a sinus. alternately, had

months The patient of Four (Fig. 6. the 7-G). A 8-A)

treated returned injury

Ekvacillin had

and remained

first signs
accident. knee CASE

infection. years

as a forestry

one-half good

thirty-five-year-old and distal multiple end over of the the distal fractures femur

man was

sustained of the facial reconstructed

an

open using

supracondylar in a traffic an of accident. angled

fracture In an blade-plate

of

the and

left bone

femur procedure,

(Fig.

bones

emergency

grafts.
was

The
some

primary
swelling

postoperative

stage
end of

was
the

completely
femur and

satisfactory.
signs effusion

After

four
in the

months
left knee

there
joint.

Roentgenograms

revealed

that two of the screws

roentgenographic it was clear
8-B). patient was

fixing

the plate

to the condylar

fragment

were

displaced and there was blade. After four months

sis

that
kept

evidence of motion of the condyles in relation to the a pseudarthrosis had developed between the metaphyoperation in bed for the was six performed, weeks and area his or combined activity with was a further limited for

and

the

condyles bone graft.

(Fig. The

A stabilizing

cancellous

a further
could be

month.
removed.

Two
No

years
signs

after
of

the
irritation

accident
around

the work

fracture

was

completely
in

healed
the knee

and

the
joint

plate
were

fracture

noted. The patient knee function was

returned to his previous normal (Fig. 8-C).

as a shop

assistant.

Four

years

after

injury

Results
The results were assessed on the basis of seven variables which were used to

FIG.

8-A

Figs. 8-A through 8-C: Case 6. This thirty-five-year-old man sustained an open Group-Ill fracture and multiple fractures of the facial bones in a traffic accident. See case report. Fig. 8-A: The initial roentgenograms show that the condyles and the tibia are externally tated 90 degrees and displaced laterally so that the shaft fragment projects medially.
VOL. 54-A, NO. 5. JUI.Y 1972

ro-

1026

SVEN

OLERUD

FIG.

8-B
there is satisfactory alignment and the plate to the condylar fragment the condylar are displaced

Eight fractures

months after are healed.

is

emergency Two of the bone

osteosynthesis screws holding

and there
fracture

roentgenographic
was exposed, the condyles.

evidence
grafts

of motion
were placed
in

of the
about
a

condyles
the site

in relation
of non-union,

to the blade.
and the

The
supra-

site across

condylar
the blade

fracture

was stabilized

by hammering

straight

four-hole

plate

along

the

tract

of

analyze
variables

the

studied

subjective, are

functional, listed in Table

and anatomical I, which also that used variable for by was each

condition of each shows the point system Neer given of the and associates, a minus value seven variables

patient. The used to rate

but knee in-

the results. This systeni resembles stability was rated in addition. This had Table and had
tient stairs

and are

therefore given points) patient One

walking

a negative The total II along Eight seven pain The

had

effect point with

on the scores other were only

final and

result. scores data.

in

end-result

patients had pain

completely free during changes

from pain in the knee in the weather (sixteen pain. in ten

points) and

joint (twenty points). No points). stated them

with fatigue or function-limiting walking capacity was satisfactory

reduced ability points). to run (sixteen

patients
another

(twenty
had

paon

difficulty

(twelve

used
security.

a cane The not

when

Two patients, both over seventy years walking out of doors (eight points) because (ten points) of the injury. two of them

of age, it gave

that they a sense of

were do

capacity retired

for work at the time but

was only assessed for the ten The nine who were working had changed
THE JOURNAL

patients who were able to of occupaSURGERY

so without

handicap,

to a different
OF BONE AND

type
JOINT

OPERATIVE

TREATMENT

OF

SUPRACONDYLAR-CONDYLAR

FRACTURES

1027

FIG.

8-C of the metal knee is the implants, same as that normal anaof the op-

Four years after tomical relationships posite normal knee.

the

injury and two have been restored

years and

after removal motion of the

tion.

A farmer
worker

(Case
(Case

I 2) had
1 1 ) had

changed
changed

to the
from

lighter
ajob

work
requiring

of an electrician,
walking and

and
standing

an into

dustrial one patient

where

appeared

she could work sitting down. that she had changed her job
I ) in this if he had

Herjoint primarily that However,

function was extremely good and for psychological reasons. Another capacity this young was man less than had it would completed

it

(Case been

group had

thought the
and was

his working

have
his

not

accident.

training

as a restauranteur

of follow-up.

A tenth

patient

(Case

playing tennis regularly every I 6), a student, had no complaint

week at the time at all to the knee walking. (fifteen

joint,

but had been advised not to choose work requiring much With regard to the objective findings, normal anatomical

standing and relationships

points) were completely restored in thirteen of the fifteen patients who were followed up. Of the other two patients, one had a Group-Ill fracture (Case I 2) which could not be reduced and fixed anatomically because too long a period had elapsed prior to operation so that shortening of two centimeters (Case including had to be accepted had healed patient with (nine points) and valnot folthe other had gus angulation Postoperative
lowed

a Group-Ill fracture (twelve points). roentgenograms 8) showed in thirteen

I 5) which those

a 5-degree who was

of the

(fifteen formed
points).

up (Case points)

a practically exact reconstruction of the end of the femur patients. Only in Case I 2, in which operation was per-

at a late stage, was there some rotation of the lateral femoral condyle (twelve In Case I 5, the condyles were restored but there was a valgus angulation evident roentgenographically (twelve points). Only slight signs of arthrosis were evident in the five patients observed for more than four years after operation. Examination of the range of knee motion showed that fourteen patients had a full active extension and one (Case I 3) lacked 10 degrees of extension. Seven patients,
VOL.

all under
54-A, NO.
5,

fifty
JULY

years
1972

of age,

had

a practically

normal

range

of movement,

that

1028

SVEN

OLERUD

TABLE
CRITERIA FOR EVALUATION OF THE RESULTS

I
(ACCORDING TO NEER
AND ASSOCIATES)*

Pain

(20

points)

Anatomy

(15 points) enlargement

angulation or 0.5-centimeter 12 9 15

None Intermittent or in weather

When
Limits

20
during changes

Only
5-degree

16
12 8 4-0

shortening
10-degree angulation or rotation, 2.0-centimeter shortening
15-degree angulation or rotation, 3.0-centimeter shortening

fatigued
function

Constant
Walking Same Clearly

or at night
Capacity

(20 points)
accident 20

as before limited

Healed with deformity

considerable

Some limitation Uses cane or severely limited Uses crutches or other walking
Joint Movement

3 or chronic
0

aid

16 12 8 4-0

Pseudarthrosis
infection

Roentgenogram

(15 points)
15

(20 points)
135 degrees

Normal
100 degrees

or

Almost normal 5-degree angulation

20 16 12 8
4 0

or

0.5-

80 degrees
60 degrees 40 degrees

centimeter lateral displacement 10-degree angulation or 1.0centimeter displacement 15-degree

centimeter Healed but

12
9

angulation
displacement

or 2.06 3 0

20 degrees or less
Work Regular Changed Capacity

(10 points)

with

considerable

Same as before

accident

10

deformity Pseudarthrosis or chronic

but with handicap occupation

Light work Not working

* Excellent,

2-0
more than 85 points ; satisfactory,

infection
70 to 85 points; unsatisfactory, 55 to 69 points;

and poor,
is more

less than than

55 points. (twenty 1 1 0 degrees points). One patient (sixteen (Case points). 5) had Of I 25 degrees the others, and three

I 35 degrees 3 and 1 3),

two

(Cases

of flexion

had flexion to 80 to 90 degrees (twelve points) and one (Case 8), flexion to 70 degrees (eight points). Only one patient (Case 10) had flexion limited to 25 degrees (zero points) because of septic arthritis. Instability of the knee joint was found in four patients (minus five points). One (Case 4) had hyperextension of about I 0 degrees and valgus instability of 5 degrees. The other three showed a varus-valgus instability of 5 to 7 degrees when the knee
was

tested

in the

extended

position. 9) had

There

were drawer

no subjective sign of considerable

was then

symptoms severity
reconstructed

associated includopera-

with ing

this instability. One patient (Case

lateral instability.

a positive
cruciate

The

anterior

ligament

tively,

full stability was restored. Therefore this patient did not lose points for instability in the follow-up rating (Table II). The total numerical scores could be determined for the fifteen patients who were followed. Of these, nine were of working age and one was too young to work. Among the nine of working age, seven had excellent and two had satisfactory results (seventy to eighty-five two points (downgraded because of loss of motion)
(downgraded because

and

results
points):

(more
Case

than

85 eighty

points)
eighty-

9 with

and

Case

I 2 with patient capacity

points still points).

re-

of loss of motion and shortening). The student had an excellent result ( 100 points). Five patients were retired and were not rated for working One of these suIting from

who

was (ten

patients (Case 2) was disabled prior to injury because of paralysis poliomyelitis and hence had a very low total score. For the other
THE JOURNAL OF BONE AND JOINT

four,

SURGERY

OPERATIVE

TREATMENT

OF

SUPRACONDYLAR-CONDYLAR TABLE II SCORES)

FRACTURES

1029

RESULTS

(PoINr

a c: a
V 0 D.
. -

.9
.

a j
-.. L 0 ,,,
0
-,

p
3 a
0.
>

.irI-

3
0. a

..

0. a

,,,

a a
(I)

C.)
. .-

-D O,-.lla C)
I)

LI., #{176}/%&
c,
-

U a
b1

a
;u

.9

.aE

on1
1.
2.E.S.

a
20

2
0

n 0
C0.

a
0.
0

a L.B. 20
54

F_

:
8

<
15 15

<

.fl
, ,

-0

E 0 0.
()

0 z

4
SIC

1110(1)

6 16 5.516--

15

20

94
-

15

-5

60 27

Graft Retired
polio(8) synthesis

due
;

to
osteonot

3. 4.

E.F.

66

K.W.

16

4 4

110 Hc

5
5

20
20

20
20

10

15 15

15 15

16 20

+ -5

95

33 21

reliable Retired
Hyperextension and valgus(8) deformity Graft Graft

5. 6.

T.A.
A.L.

19
35

16
7

1110(1) 1110(1)
110 110

20 20

20 20

10 10

15 15

15 15

16 20

96

+
+

7.

Y.N.

25
77 31
-

20
162010

20

10

15
15

15
1512

20

100 100
82

(2) (3)

8. O.M. 9.B.J.

41110(1)4

60 39 30 30 75

No follow-up
Graft; anterior

cruciate struction
instability
years

reconfor
two

before follow-up
l0.L.G. 69 510

11. AL.

40

4 111#{176}3.5
1110 lIe 35 2

16 16
16 20

820
20 12
-

8
8

15 15
9 15

15 15
12 15

#{216}(4)_5

20
12 16

+
+ -5

94
80
-

42 19 (5)

Retired(8) Graft

12.
13.

H.L.
K.N.

44
74

4
4

Shortening,
70 layed Retired; degrees

deoperation lack 10
(8)

(6)

extension
14. K.E.

15.

A.Y.

25 75

4 4
-

111#{176} 1110

2 1,5

20 16

16 8

10
-

15

15

20
12

+
+

96
-

24 (7)
20 150

Graft
Retired

12
15

12
15

16. M.H.

16

HI#{176} 1

20

20

10

20

100

Leg shortening

due to tibial fracture, not

affecting capacity c
0
=

work

closed
open

fracture
fracture

dash
(1) (2)

available

data incomplete

(3)
(4) (5) (6) (7) (8)

graft = cancellous bone graft One to three severe fractures of other bones in addition to femur. Deep infection, which required drainage, d#{233}bridement, and several cancellous bone-graft procedures. Metaphyseal pseudarthrosis treated by further stabilization and bone grafting. Septic arthritis treated successfully by drainage and antibiotics. Sterile (several negative cultures) abscess which required operative drainage. No signs of inflammation after plate removal. Infection and sequestration of part of the tibial tuberosity. After sequestrectomy complete healing

occurred.
Healed uneventfully. straight knee joint The hospital varus-valgus time, however,

was prolonged
of about 5 degrees.

because

of an

open

severe

tibial

fracture
With

in the same limb.

instability

the scores with in the satisfactory

VOI_. 54-A. NO.

no points range
1972

for working capacity were: (Case I 3); in the unsatisfactory

in the excellent range (Case

range (Case 3); I 5); and in the

5, JULY

1030 poor
tients

SVENOLERUD

range
lost

(Case
points

I 0),
primarily

the

patient
because

with

septic

arthritis

of the

knee.

These

elderly

pa-

in large points

measure
because

to their
ofdecreased

age

rather
knee

of impaired walking capacity which was related than to residua of their fracture. They also lost
motion.

Discussion Supracondylar garded

from surgeons with work, have great and often

fractures
concern result

because

to resort hardly form in the

to operative been of

femur with articular involvement are always rethey are difficult to treat, cause a long absence in permanent disablement. These facts have encouraged treatment with internal fixation, but the results of this
.

of the

method
trophe

encouraging osteomyelitis,

Internal

fixation and

can

easily delayed

result healing.

in catasNeer,

septic

arthritis,

Grantham, and Shelton stated that Group-Ill injuries are especially unfavorable for surgical treatment. For the other two types of fracture, primary plaster immobilization in Group I and traction therapy in Group II should, as a rule, give fully satisfactory results, and Neer, Grantham, and Shelton recommended a conservative apin the Successful joints, requires
surfaces. therefore, Traction

proach

treatment of these fractures. treatment of intra-articular restoration and maintenance

fractures, especially of the congruence of such should

in weight-bearing of the two articular In principle, surgically. An is effective in the screws be performed swelling. with open From fractures apand in

can hardly guarantee restoration all intra-articular distal fenioral fractures

congruence. be treated

essential paratus angular

prerequisite for the success of such treatment, however, for stable osteosynthesis. Such apparatus is now available plates designed by the AO group. Theoretically, especially for open fractures, operation should stage. small The tissues even main are then at their that best, the with risk no appreciable of infection series high, of the it would appear

the acute
the present

is not especially operation. One

when cancellous bone grafts advantages of an immediate

are inserted at the primary operation is the earlier and

more complete mobilization of the patients knee made possible by decreasing the hematoma and edema which must be resorbed before the tissue becomes mobile. Osteoporotic bone is often unsuitable for osteosynthesis, and therefore in elderly patients internal fixation is usually not considered advisable. The results in the present series, which admittedly is small, show that even in elderly persons stable internal this

fixation
operative

can

be achieved

with

some

success.

One

of the

great

advantages

of

approach for treatment

more
necessary

important,

is the possibility that a long period of confinement with traction can

exercises can be started in bed and the long However,

early and, even hospitalization

be avoided.

the contraindications The

frac-

to operation in elderly patients often outweigh its advantages. Traffic accidents were the predominant cause of the fractures in this series. high level of energy involved is manifested by the large number of comminuted tures fractures
often

with

both is also

metaphyseal characteristic for healing, described was

and

diaphyseal

involvement.

The

high

incidence

of open

unfavorable

of violent trauma. The conditions but this effect was hardly evident found to be
was sufficiently

in such fractures are in the present series. In all but one early exercises, patient despite

The
(Case

technique
2) the

osteosynthesis

highly reliable

successful. to allow

the often extensive comminution. Large metaphyseal bone cavities were filled with cancellous bone grafts at the primary operation in many cases. Despite this potential cause of instability, early postoperative active exercises could still be initiated, indicating satisfactory stability and good anchorage of the osteosynthesis apparatus. The right-angle position of the knee postoperatively and the early mobilization quickly
operation

resulted
required.

in a satisfactory

range

of movement.

In no patient

was

a knee-release

THE

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OPERATIVE

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SUPRACONDYLAR-CONDYLAR

FRACTURES

1031

The retraction damage

in all cases.

extensive of the to the extensor

dissection, entire extensor muscles,

with but

osteotomy such a large

of the of the knee,

tibial gave

tuberosity good is probably supply was

and exposure not

proximal without necessary

apparatus

exposure

Obviously this operative technique damages the blood of the distal end of the femur. Nonetheless, no bone collapse tensive wound surfaces exposed during the procedure must infection, especially when the operation must be performed erating the tibial theater.
Four become serted patients

portions The exalso increase the risk of in an old-fashioned opinfections, the one in

to large observed.

in this can
infected

series

had

infections.

One

of these

tuberosity,
primarily

be attributed

through treatment the

the

tibia of the

to the traction pin since the tracts of such pins quite frequently. For this reason the pin should be inmore distally than is usual when extensive dissection is patient with provided femoral osteomyelitis anchored illustrates in the bone, the value until of bone

anticipated. The maintaining

internal

fixation,

it is well

union has occurred. Despite the presence of infection a fairly extensive metaphyseodiaphyseal bone bridge may be formed, and later, on a suitable occasion, the metal implants can be removed to promote definitive cure of the infection and healing of the fracture. The results when and
and

in the anatomical

series

presented the

here of the

indicate distal for

the end practically

value of the

of

stable can articular

internal be acmo-

fixation,
complished,

reconstruction

femur

thereby reducing
surfaces.

providing

requirements

normal

bility
articular rapidly

the risk of post-traumatic A postoperative infection

arthrosis due may be disastrous,

to incongruence of the but if it is dealt with

adequately it should be controllable until bone healing has occurred. The implant can then be removed and the infection eliminated. As can be seen from Table I I in this series the results for the Group-I and GroupII fractures were somewhat inferior to those with the more severe Group-Ill fracture. This finding is surprising, but may be accidental and related to the small nummetal
ber of patients studied.

the
only tion

seven one is not

patients of the

with nine
as may

The age of the patients Group-I and II fractures

be

might were

be another more than

factor since five of fifty years old and

with Group-Ill fractures the case with osteoporotic not be successful and early postoperative functional Furthermore elderly patients have difficulty regaining fact they do not need. Young patients, on the other
stable,

patients

was in this age group. If fixabone, the osteosynthesis may training may not be possible. full knee motion, which in hand, need more knee flexion

and are more apt to do their The strongest indication Group-Ill fracture, although open reduction. These
Elderly people
are

exercises until for operative some fractures

subjected

they

attain the motion they need. treatment of the type described is a of this type are impossible to treat by

usually occur in young and middle-aged patients. to high energy trauma. Since the operative treatment can restore normal anatomical relationships and function, Group-Il fractures should be included in the operative indications, except in older patients, in whom extensive osteoporosis constitutes a clear contraindication.
seldom Group-I fractures,

fractures

patellar pouch, may sometimes The

tions erative reduction.
VOL. 54-A. NO.

which are not displaced and should be treated with conservative be an indication for surgery. state On and
operative

probably do not affect methods. Angulation,

the suprahowever,

mental
choosing

when

traindications. treatment,

physical capacity of the patient are important consideratreatment in elderly patients and may constitute conthe other hand, since the bed-bound time is very short after opthis reduced time in bed may be a relative indication for open
1972

5, JULY

1032
It

SVENOLERUD

should

be emphasized

that

satisfactory not

osteosynthesis be attempted until

of fractures one has

of this mastered

type the

is a difficult

procedure

which the series achieved heal in most

should

technique.
stable

Although osteosynthesis will

presented by the right cases without

here is small, it seems approach and correct loss ofjoint function.

to show that after surgical technique,

these

fractures

Summary Sixteen
by the

patients

with

supracondylar-condylar by the Swiss AO group.

fractures The end

of the femur results were

were

treated in

technique

developed

analyzed

fifteen
tients

of these patients who were available for follow-up. Two patients had a Group-I fracture and five, a Group-Il fracture. had Group-Ill fractures of which three were open and six needed
grafts to fill

Nine pacancellous further marked paper-

bone

All stabilization
Three limitation tients mitted

fractures and
patients of the

bone defects present after anatomical reduction. united although one had a pseudarthrosis and bone grafting before it healed. had infections but only one
motion revealed very as a consequence. good and satisfactory results

required and
in fourteen

had

severe

symptoms

kneejoint study

Follow-up

and a poor result in one. The good end results were

early postoperative function.

attributed

to the

stable

osteosynthesis

which

References
1. CHARNLEY, JOHN: The Closed Treatment of Common Fractures. Ed. 3, pp. 166-196. Edinburgh, E. and S. Livingstone, 1961. 2. MULLER, M. E.; ALLG#{212}WER, M.; and WILLENEGGER, H.: Technique of Internal Fixation of Fractures. New York, Springer-Verlag, 1965. 3. NEER, C. S., II; GRANTHAM, S. A.; and SHELTON, M. L.: Supracondylar Fracture of the Adult Femur. A Study of One Hundred and Ten Cases. J. Bone and Joint Surg., 49-A: 591-613, June 1967. 4. NEFF, G.: Zur Behandlung der supracondyl#{227}ren und tiefen Oberschenkelfrakturen. Monatsschr. Unfallh., 69 151-159, 1966. 5. OLERUD, SvEN: Rekonstruktion av distala femur vid komminut fraktur. Svensk Kir. For. FOrh., 24: 93-94, 1966. 6. SLATIS, P.; Rv#{246}PpY, S.; and HUITTINEN, V.-M.: AOl Osteosynthesis of Fractures of the Distal Third ofthe Femur. Acta Orthop. Scandinavica, 42: 162-172, 1971. 7. STEWART, M. J.; SISK, T. D.; and WALLACE, S. L., JR.: Fractures of the Distal Third of the Femur. A Comparison of Methods of Treatment. J. Bone and Joint Surg., 48-A: 784-807, June 1966. 8. WATSON-JONES, SIR REGINALD: Fractures and Joint Injuries. Ed. 4, Vol. II, pp. 744-745. Edinburgh and London, E. and S. Livingstone, 1955.

THE

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