STATE OF THE ART
Management of Distal Femur Fractures With Modern
Plates and Nails: State of the Art
Michael J. Beltran, MD,* Joshua L. Gary, MD,† and Cory A. Collinge, MD‡
Summary: Fractures of the distal femur, even those with articular
extension, are well suited to surgical fixation with modern precon-
toured anatomic plates and nails. Numerous adjuvant techniques are
available to the treating surgeon to obtain and maintain reduction
while preserving fracture biology. Yet despite their proven track
record and benefits over older implants, technical errors are common
and must be overcome with proper preoperative planning and
intraoperative attention to detail. This review summarizes the current
state of the art regarding distal femur fractures, with an emphasis on
relevant modern plate and nail surgical techniques, tempered by our
current understanding of implant biomechanics, fracture healing, and
long-term outcomes.
Key Words: distal femur, extreme nailing, locked plating, modern
techniques, trauma
(J Orthop Trauma 2015;29:165–172)
INTRODUCTION
The surgical management of distal femur fractures
continues to evolve. Modern implants and instrumentation,
coupled with advanced surgical techniques, have expanded
the indications for use of intramedullary nails to metaphy-
seal and even select articular fractures, while stress modu-
lation techniques for traditional plating now allow the
surgeon to manipulate construct stiffness and tailor fixation
to a given patient, all the while preserving fracture biology
through proven indirect reduction strategies. This review
will discuss the benefits and problems associated with
fixation of these difficult fractures.
Accepted for publication January 22, 2015.
From the *Department of Orthopaedics and Rehabilitation, San Antonio Mil-
itary Medical Center, Fort Sam Houston, TX; †Orthopaedic Specialty As-
sociates, Fort Worth, TX; and ‡University of Texas Health Science Center,
Houston, TX.
C. A. Collinge is a paid consultant for Biomet Trauma, Smith and Nephew,
and Stryker, receives royalties for intramedullary nailing products from
Biomet Trauma and Advanced Orthopaedic Systems, is an editor for the
Journal of Orthopaedic Trauma, and teaches courses for AO North
America and Stryker. J. L. Gary teaches courses for AO North America,
is a paid consultant for Smith and Nephew by teaching courses, and owns
stocks in RTG Scientific. The other author reports no conflict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.jorthotrauma.com).
Reprints: Michael J. Beltran, MD, Uniformed Services University for the
Health Sciences, San Antonio Military Medical Center, 3551 Roger
Brooke Dr, Fort Sam Houston, TX 78234 (e-mail: mbeltran0514@gmail.
com).
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Relevant Anatomy, Fracture Characteristics,
and Surgical Approaches
Anatomy
The distal femur has unique geometry in 3 anatomic
planes: axial, coronal, and sagittal, which must be understood
before pursuing fracture surgery.1,2 Axially, the distal femur
represents a trapezoidal shape, with a lateral slope of 108 and
a medial slope of 258 (Fig. 1). The anterior aspect of the
lateral condyle extends farther anteriorly than the medial, also
at an angle of 108. This geometry alone explains many of the
common surgical pitfalls encountered when reducing and
stabilizing fractures, especially when using anatomically pre-
contoured locked plates designed to be applied on the anterior
half of the distal femur. Intra-articular screws violating the
trochlea or notch, prominent screws encroaching on the
medial collateral ligament, and an induced golf club defor-
mity can all be avoided by understanding this axial plane
geometry.1 Coronally, the anatomic lateral distal femoral
angle measures an average of 81–8483; because this angle is
designed into available precontoured locked plates, screws
placed parallel to the joint line can be expected to reproduce
correct coronal plane angulation when the shaft is reduced to
the plate. Correct sagittal angulation is easily assessed if one
obtains a perfect lateral fluoroscopic view, by correlating
Blumensaat’s line relative to the long axis of the femur.2,3
The surgeon must remain aware that recurvatum deformity
is encountered in nearly all cases, the result of pull on the
articular block by the two heads of the gastrocnemius muscle.
Recurvatum deformity, although easily picked up with a lat-
eral view, is also readily apparent on AP imaging based on
the presence of a paradoxical notch view.4 Finally, rotational
deformity may be present and must be considered; it may be
missed or even worsened during instrumentation, for exam-
ple, while using a heavy radiolucent lateral targeting arm
during plating with MIPO technique.
Fracture Characteristics and Treatment Considerations
Distal femur fractures, like most fractures in orthopae-
dics, have a bimodal distribution, with high-energy injuries
occurring in a relatively young population and low-energy
osteoporotic injuries occurring in the elderly. High-energy
fractures of the distal femur commonly have metaphyseal
comminution, and when intercondylar extension is present,
are likely to have coronal plane fractures that can be missed
with plain radiographs.5 CT scans are required to better assess
for these so-called “Hoffa” fractures and may be helpful in
ruling out intercondylar fractures in osteoporotic elderly pa-
tients where plain radiographs may be difficult to interpret.
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 Beltran et al
FIGURE 1. Axial geometry of the distal femur. Note the lateral
slope of 108 and the 258 slope of the medial femoral condyle.
Precontoured locking plates take this slope into account; bi-
cortical screws in the anterior half of the distal femur, which
appear to be the correct length on an AP are often too long
and encroaching on the medial collateral ligament.
Although metaphyseal comminution predisposes to problems
obtaining union, articular displacement requires anatomic
reduction and lag screw fixation according to classic AO
principles, which reduces the chances of developing post-
traumatic osteoarthrosis and permits early knee ROM.6,7 In
the elderly population, intercondylar extension may not be
present, but metaphyseal comminution is prevalent and frac-
tures associated with total knee prostheses more likely to
occur. Periprosthetic fractures, even those with extension dis-
tal to the superior prosthetic flange, are typically stable and
amenable to nail or plate fixation, with arthroplasty revision
techniques rarely required.8 Careful preoperative planning is
crucial in determining whether a specific fracture is more
amenable to nailing or if plating must be performed, as many
PCL-substituting prostheses have an open box design, which
allow the use of nails; a previously published review de-
scribes the common knee arthroplasty components and which
of them permit nail passage.9 Finally, geriatric patients, unlike
young adult trauma patients, must mobilize more efficiently
and effectively to prevent the sequelae of prolonged recum-
bency, most importantly, pneumonias, decubiti, and physical
deconditioning. In this regard, the surgeon should weigh the
additional benefit of an intramedullary nail over a plate con-
struct, the former being a load-sharing device that may allow
for immediate weight-bearing. Combined plate–nail con-
structs have previously been described to afford geriatric pa-
tients the reduction benefits of plates with the immediate
weight-bearing benefits of a nail.10
Open distal femur fractures pose additional challenges.
Bone loss often occurs in the metaphysis, which can be
addressed with planned and staged bone grafting. This is
commonly done using the technique described by Masquelet,
whereby a cement spacer is used to fill the defect for a period
of 3–6 weeks before bone grafting.11 This metaphyseal bone
loss is a risk factor for failure when using a lateral locked
plate. In a series of 335 distal femur fractures, 64 (19%) had
failure with lateral locked plating; nearly half (30/64) of these
failures were associated with planned and staged bone graft-
ing for metaphyseal bone loss.12 Debridement of open frac-
tures has traditionally involved removal of all nonarticular
bony fragments without soft tissue attachment. A recent
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J Orthop Trauma  Volume 29, Number 4, April 2015
comparison of traditional debridement to a less aggressive
debridement protocol where only grossly contaminated frag-
ments were removed showed no difference in infection rates
and a statistically significant increase in bony union for a less
aggressive debridement protocol.13
Approaches
Approaches to the distal femur involve traditional open
exposures when addressing articular comminution and mini-
mally invasive percutaneous incisions when bridge plating
metaphyseal comminution alone when performing retrograde
nailing. Simple metaphyseal fracture patterns also benefit from
formal open reduction and the application of compression,
either with compression plating or lag screw fixation combined
with neutralization plating. The workhorse open approach to
the distal femur remains a lateral parapatellar arthrotomy,
where the skin incision is placed at the discretion of the
surgeon either lateral or midline.14,15 Concerns for avascular
necrosis of the patella with a later medial parapatellar arthrot-
omy for arthroplasty after a prior lateral approach appear unjus-
tified, with later conversion to total knee arthroplasty after
a well-performed articular reduction being uncommon.16 A
lateral arthrotomy allows easier plate application, which is
important as stated previously to avoid malreduction and
implant malpositioning. More recently, the “Swashbuckler”
approach has been described and a “Mini-Swashbuckler,” but
the principles remain the same, performing a thorough lateral
arthrotomy and use thoughtful retractor placement to ade-
quately visualize the articular surface.17,18 Even with a “Mini”
approach, Beltran et al18 demonstrated that coronal fractures of
the medial condyle could be adequately visualized from the
lateral side. If any concern exists intraoperatively, however, an
accessory medial incision can be performed to directly visual-
ize, reduce, and stabilize these fractures while also working
through a lateral approach.
Minimally invasive plating of extra-articular distal
femur fractures is easily performed with an incision through
skin and the iliotibial band over the lateral condyle, followed
by plate insertion through a submuscular tunnel along the
lateral femur. Correct plate application remains critical-in
these applications judicious use of fluoroscopy with perfect
AP and lateral projections minimizes the likelihood of both
fracture malreduction and plate malpositioning.1,2 Retrograde
nailing can be performed using a 3- to 4-cm incision and
performing either a tendon split or a parapatellar arthrotomy.
The authors recommend using a medial arthrotomy because
the patellar tendon and tibial tuberosity are relatively lateral
structures; obtaining the correct nail start point and trajectory
are typically done more easily using this approach.
Biomechanics of Distal Femur Fixation
Modern locked plating techniques benefit from direct
surgeon control of implant stiffness. This so-called stress
modulation allows the surgeon to choose how stiff or flexible
a construct to use for a given fracture and for a given patient.
The goal of any fixation construct is two-fold: provide stable
fixation that will support physiologic loading until union, while
also providing the flexibility necessary to allow for adequate
fracture micromotion and resultant secondary bone healing.19
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 J Orthop Trauma  Volume 29, Number 4, April 2015
Recent peer-reviewed literature and presentations at national
meetings suggests that stiff fixation constructs are a culprit in
delayed union and nonunion after distal femoral plating, and
that the quality of the callous produced is often asymmetric and
variable.20–23 Furthermore, recently reported nonunion rates
after plating of distal femur fractures are higher than previously
believed.12 Common implant factors directly under the sur-
geon’s control, which can be modulated include implant met-
allurgy, choice of locking or nonlocking screws and bicortical
or unicortical placement, as well as choosing plate length and
screw hole fill. Other less common advanced techniques can
also be used and are described further in detail.
Modern plates are made of commercially pure titanium,
titanium alloy, or 316L stainless steel, with titanium alloy
offering both improved fatigue strength and decreased stiffness.24
Commercially pure titanium, best exemplified by the original
LISS plate (Synthes, Paoli, PA), had early reported healing re-
sults that were encouraging but is not without problems, how-
ever.25,26 Common distal femoral plates in use today and their
design features are summarized in Table 1 (see Supplemental
Digital Content 1, http://links.lww.com/BOT/A304).
Surgeons also have control over screw selection and
placement, increasing the number of screws in the diaphysis,
choosing locking versus nonlocking and bicortical versus
unicortical, and the specific locations of screws all directly
affect construct stiffness.27,28 Thigh pain has been correlated
with stiffness at the end of a plate and may be the result of
a locking screw placed through a stainless plate in the terminal
plate hole; end hole locking screws also have been linked to
higher risk of periprosthetic fracture in osteoporotic bone. The
use of a nonlocking screw here to reduce this risk should be
considered.29 Furthermore, the closer one places a locking
screw to the fracture also affects stiffness by decreasing the
plate’s working length; decreased working length has been pos-
tulated to be an independent predictor of nonunion but this is
debatable. In addition to nonlocking screws at the end of a plate,
screw hole inserts have also been described to modulate stiff-
ness without the use of additional screws and prevent premature
plate failure through a plate hole.30 Finally, the use of near
cortical slotting techniques or far cortical locking screws have
also been described and recommended as a means of decreasing
construct stiffness and creating more uniform callous formation.
In both of these techniques, an increase in micromotion is al-
lowed at the near cortex adjacent to the plate, with the screw
only contacting the plate and far cortex. This, in theory, allows
for more uniform callous formation (ie, like a nail) and more
reproducible fracture healing; early clinical results with these
techniques have been encouraging.31,32
Surgeons should also modulate construct stiffness by
using a longer plate whenever possible, with well-spaced
screws. By spreading out fixation over a longer length of bone
and increasing the working length, stress concentration is
prevented and premature fixation failure less likely to occur.
When bridge plate applications are performed, we recommend
a longer plate with no more than 50% of the holes above
a fracture filled with screws, more than 4 bicortical screws in
the proximal segment are rarely required. The distal most
screw in the diaphyseal segment is most important and dictates
both working length and stiffness of the implant at the level of
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Management of Distal Femur Fractures
the fracture. Furthermore, unless lagging a simple fracture and
using the plate in neutralization mode, screws crossing the
fracture are unadvised and may be associated with nonunion.23
RETROGRADE INTRAMEDULLARY NAILING
Retrograde nailing of distal femur fractures has become
more commonplace recently as a result of improved implant
design and instrumentation. Some or all interlocking screws
can now be locked to the nail with most marketed implants,
creating fixed angle devices, which are particularly useful in
short condylar segments and osteoporotic bone. The main
advantages of retrograde nailing over plating are that these
devices may be inserted through smaller incisions than plates,
and the devices are centrally placed and therefore potentially
load-bearing; bending forces are minimized compared with
plates. Nailing distal femur fractures may be technically
difficult and requires thoughtful attention to nail starting
point, trajectory, and fracture reduction during both reaming
and nail passage. Commonly used nails and their design
features are summarized in Table 2 (see Supplemental Dig-
ital Content 2, http://links.lww.com/BOT/A305).
Relative Indications and Preoperative
Planning
Retrograde intramedullary nails may be used to treat
select distal femur fractures. Because most implants allow for
placement of many interlocking screws within a few centi-
meters of the nail end, even very far distal fractures can be
safely stabilized. The best indications for nailing include 33A
and select 33C fracture patterns, according to the fracture
classification system of the AO/OTA.33 Amenable 33C frac-
tures (ie, intra-articular fractures) can easily be managed with
nails after an open reduction and lag screw fixation of the
articular surface has been performed (similar to plating).
Thoughtful attention to lag screw position and avoiding sub-
sequent interference with interlocking screws is paramount in
very distal fracture patterns.
Planning whether a particular fracture is amenable to
nailing requires a critical assessment of the condylar segment,
especially its overall length in relation to the chosen implant
and how many independent lag screws, if any, will be
required to lag articular fracture planes. Multiple lag screws,
especially those that must be placed in A-to-P fashion for
coronal plane fractures, are likely to block distal interlocking
screw options and must be carefully planned out before nail
passage. Screws used for sagittal fracture planes should be
placed anterior or posterior to avoid potential interlocks. In
addition, nail insertion depth must be critically determined, as
overseating a nail may limit interlocking options, while
underseating a nail and leaving it prominent in the knee joint
can lead to patellofemoral pain and rapid articular erosion.
Nearly, all modern implants available include “zero” end cap
options, so that the choice to use an end cap will not affect
nail length; these end caps must be used to create a fixed-
angle construct with a number of manufacturer’s nails (see
Table, Supplemental Digital Content 2, http://links.lww.
com/BOT/A305). Finally, when addressing periprosthetic
www.jorthotrauma.com | 167
 Beltran et al
distal femur fractures above a total knee prosthesis, the sur-
geon must determine if a given implant allows for nail
passage.8
Surgical Tips and Techniques
A variety of adjuvant reduction techniques are available
to obtain and maintain metaphyseal fracture reduction during
nailing and are similar to those available during plating.
Intraoperative skeletal paralysis is paramount to ensure that
length can easily be restored before nailing; manual traction
can be used when assistants are available; however, the use of
a universal distractor is advised when available to limit surgical
traffic about the limb. In the event, a distractor is unavailable or
found to block nail passage or instrumentation, proximal tibial
skeletal traction, with weight hung over the end of the bed, can
be used to regain length. Sagittal deformity is common and is
almost always a recurvatum deformity due to the pull of the
gastrocnemius on the condylar segment. This is easily
corrected with the use of well-placed towel rolls, small bumps,
and/or Schanz pins placed into the condylar block and
manipulated with a T-handle chuck. Finally, coronal angula-
tion can be corrected by manipulating the pull angle of skeletal
traction if in use, placement of percutaneous clamps when the
fracture pattern allows, blocking wires or screws, careful use of
percutaneous bone hooks, or manual pressure alone. Rotation
can be confirmed radiographically by comparing with the
contralateral side and using the profile of the lesser trochanter
or version of the neck, or the direct measurement method can
be used.34–36
The portal of entry for the nail is in the intercondylar
notch just anterior to the femoral attachment of the posterior
cruciate ligament. This point corresponds to a point just
anterior to the distal extent of Blumensaat line on a perfect
lateral fluoroscopic view (Fig. 2). The pin is carefully inserted
in line with the femoral shaft to ensure restoration of coronal
plane alignment on both radiographic views. Once pin place-
ment is confirmed on both views, the entry reamer is
advanced to open the metaphyseal segment. Cannulated soft
tissue sleeves should be used to prevent injury to the patellar
tendon and articular surface of the patella. Care must be taken
when addressing osteoporotic bone, as correct wire placement
will not prevent errant anterior entry reaming if the hand is
FIGURE 2. AP and lateral fluoroscopic views demonstrating
correct starting point and wire trajectory. As much time as is
necessary should be spent on these 2 aspects of nailing
because errors here both can affect final reduction.
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J Orthop Trauma  Volume 29, Number 4, April 2015
allowed to fall, which predisposes to a recurvatum deformity
when the nail is seated.
Guidewire advancement before the fracture is often
aided by the use of a fracture reduction “finger” instrument,
available in the most modern nail sets. A long nail is advised
for 3 reasons: to prevent later shaft fracture at the tip of a short
nail, to increase the working length of the nail, which may
increase fracture micromotion to aid in secondary bone heal-
ing, and to use isthmal fit to increase nail stability and
decrease potential 4-point bending stress on proximal inter-
locking screws during subsequent weight-bearing. Blocking
screws are sometimes used to narrow the effective canal
diameter of the metaphysis and can prevent or correct defor-
mity in either the coronal or sagittal plane.37 When necessary,
blocking screws should be applied in the short condylar seg-
ment. A rule of thumb is to apply these screws on the concave
side of the anticipated deformity.
The fracture should be held reduced and out to length
during reaming and nail insertion. A limited reaming
technique is advised to 1–1.5 mm larger than the anticipated
nail; a nail diameter larger than 10 or 11 mm is rarely nec-
essary. Although the nail must be countersunk by at least
1 or 2 mm and confirmed by a perfect lateral view, thought-
ful attention to nail depth is critical during nailing of
extreme distal femur fractures to ensure that an adequate
number of interlocking screws can be placed in the
condylar segment, and that these screws will have adequate
room adjacent to existing lag screws. In general, we recom-
mend that the number of distal locking screws should cor-
respond with the relative amounts of fracture instability and
osteoporosis. We recommend that blocking screws be used
to gain stability by trapping the nail in place when a limited
number of distal locking screws are possible. Proximal A-to-P
interlocking is the final step. We recommend the use of 2 screws
in the setting of fracture comminution or severe osteoporosis
unless a tight isthmal fit has been obtained, in which case 1
screw is usually sufficient (Fig. 3).
PLATING OF DISTAL FEMUR FRACTURES
Modern plating techniques continue to be predicated
on the foundations of osteosynthesis: the surgeon must
obtain absolute stability for articular fractures and preserve
biology while using relative stability when addressing
metaphyseal comminution. Although new technologies
expand the armamentarium of the fracture surgeon, failure
to follow the basics inevitably leads to less optimal out-
comes when plating distal femur fractures. A recent review
summarized the pitfalls, and most importantly how to avoid
them, when addressing distal femur fractures with modern
precontoured locked plates.1
Laterally based anatomic precontoured plates are best
indicated for A- and C-type fracture patterns only. B-type
injuries (ie, partial articular fractures) are best treated with
interfragmentary compression of the articular surface and
buttress plate fixation. Although the lateral approach to the
distal femur is familiar to surgeons, the medial approach
should be used when plating medial femoral condylar
fractures. The interval between the vastus medialis and
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 J Orthop Trauma  Volume 29, Number 4, April 2015 Management of Distal Femur Fractures

FIGURE 3. Case example of 63-

year-old morbidly obese osteopo-
rotic female s/p low energy fall off
step ladder. A, Plain films and (B)
axial CT demonstrate 33-C2 distal
femur fracture. C, Fixation consist-
ing of open reduction and lag fixa-
tion of articular surface and
intramedullary nailing of commi-
nuted metaphysis. D, Fracture went
on to heal with abundant callous at
12 weeks postoperatively.

sartorius is used, and the superficial femoral artery and its Simple fracture patterns in the metaphyseal or meta-
transition to the popliteal artery are easily identified and diaphyseal regions should be addressed with absolute stability
retracted posteriorly (see Supplemental Digital Content 3, using compression plating or lag screw fixation with neutral-
http://links.lww.com/BOT/A306). ization, whereas comminuted fracture patterns benefit from

FIGURE 4. Case example of lateral

locked plating of 87-year-old patient
with periprosthetic distal femur
fracture. Stemmed femoral prosthe-
sis precludes nailing. Long plate
length is chosen to distribute stress
and to protect entire femur from
future fracture.

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 Beltran et al
indirect reduction and bridge plating to preserve fracture
biology. Although both nail and plate fixation are options for
many fracture patterns, specific indications for the use of
a plate over that of a nail include fractures with a too short
condylar segment to allow nailing, periprosthetic fractures
adjacent to an arthroplasty component with a closed box
design (most PCL-substituting designs), and preexisting total
hip arthroplasty prostheses or previous antegrade femoral
nails in place. Surgeon expertise with advanced nailing
techniques must also be weighed when determining to plate
or nail (Fig. 4).
When addressing metaphyseal comminution through
indirect reduction and preservation of biology, useful
adjuvant techniques and intraoperative assessment of mechan-
ical axes and rotation are similar to nailing. The use of a femoral
distractor to regain length is more advantageous when plating
because the Schanz pins and distractor will not impede the nail
or instrumentation. Collinge et al recently described in detail the
various technical pitfalls commonly encountered when using
precontoured lateral locked plating for distal femur fractures.
Correct attention to detail when placing these plates, in
particular, the critical importance of plate position and rotation
on the condylar segment prevents most of the problems that
have plagued precontoured plate applications since their
FIGURE 5. Case example of 45-year-
old woman with highly comminuted
distal femur fracture managed with
variable-angle lateral locked plate. A,
Injury films demonstrating severe
comminution and articular extension;
(B) intraoperative fluoroscopic views
showing restoration of mechanical
axis alignment; (C) fixation failure of
variable angle screws at 2 weeks
postoperatively. Patient elected not
to revise fixation went on to heal at
12 weeks postoperatively. Editor’s
note: A color image accompanies the
online version of this article.
170 | www.jorthotrauma.com
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J Orthop Trauma  Volume 29, Number 4, April 2015
inception. Although the use of intraoperative CT scanning
has increased recently in the field of orthopedics, this
method has not been shown to improve reduction when
compared with traditional measurement methods for rota-
tion, but it does incur increased cost, possible increased
operative time, and imparts unnecessary radiation to the
patient. It may have future use in assessing for proper hardware
placement and avoidance of articular penetration, but the
authors cannot emphasize enough the importance of surgical
planning and attention to detail intraoperatively; proper plate
application and attention to distal femoral anatomy is typically
all that is required to avoid errant screws.
More recently, precontoured plates with variable-angle
screw trajectories have become available. These plates in
theory provide 2 major benefits over traditional fixed-angle
plates: (1) screws can be angled away from the articular
surface even if the plate is applied to the bone malrotated
and (2) screws can be angled away from prostheses and
toward areas of bone cement or remaining cancellous bone
when addressing periprosthetic fractures. They can also be
used to avoid independent lag screws for C-type fracture
patterns. Despite these implied benefits, no literature to date
has been published or presented, which supports the
superiority of these plates over traditional fixed-angle screw
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 J Orthop Trauma  Volume 29, Number 4, April 2015
designs. One of the authors has experienced premature
fixation failure surmised to be because of the use of
a variable-angle plate (Fig. 5).
For fractures with increased risk for failure with lateral
locked plating (ie, open comminuted metaphyseal fractures
with bone loss), supplemental medial fixation may be consid-
ered to prevent predictable varus collapse. The addition of
a medial endosteal plate (cortical substitution technique) has
been shown to increase stability in a Sawbones model and is
a useful adjuvant to prevent medial soft tissue dissection and
plate application38; plate removal if infection develops or revi-
sion fixation is required is challenging, however. Finally, when
fracture biology is a concern acutely, especially in situations
where significant metaphyseal comminution has occurred,
acute bone grafting can be used using a retrograde femoral
harvest technique with the Reamer-Irrigator-Aspirator device
(Synthes, Paoli, PA). This technique is the subject of an ongo-
ing clinical trial and is most beneficial when the proximal shaft
segment is routinely exposed as part of the surgical plan.39
POSTOPERATIVE CARE
Postoperative management after both nailing and plating
of a distal femur fracture is similar. Gait training and knee
motion are initiated on day 1 in cooperative patients with
a physical therapist or with a continuous passive motion
machine in bed-bound patients. Weight-bearing in extra-
articular fractures is routinely encouraged once there is
radiographic evidence of callus formation, typically 6–8 weeks
postoperatively but held for intraarticular fracture patterns until
10–12 weeks postoperatively. Recently, presented evidence
suggests that displacement and fixation failure are uncommon
when patients are allowed to weight bear as tolerated immedi-
ately postoperatively after plating is performed for a low
energy, geriatric distal femur fracture, and may be associated
with decreased mortality.40 The results should be interpreted
with caution, however, given the low number of patients stud-
ied. The authors recommend that consideration be given to
immediate or early weight-bearing in geriatric patients at risk
for systemic medical complications, especially those stabilized
with a nail. Clinical and radiographic examinations are per-
formed at 4- to 6-week intervals until the fracture is healed
and patients are able to ambulate without discomfort.
CLINICAL COMPARISON OF MODERN PLATES
AND NAILS
Early studies using short first-generation nails are not
relevant today as implant technology, materials, and techni-
ques have improved. Published reports over the last decade
using long titanium alloy retrograde nails for distal femur
fractures have reported mostly good results with relatively
few complications.41–43 The results of modern plating for dis-
tal femur fractures are well supported, despite recent evidence
calling its efficacy into question.20–23,25,44
Until very recently, no large randomized studies com-
pared retrograde nailing with plating for these injuries. Tornetta
et al recently described marginally improved results with nails
over plates in a prospective, randomized, multicenter study on
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Management of Distal Femur Fractures
126 patients with distal femur fractures.45 They reported that
regardless of treatment, these patients had significant disability
at 1 year. Malalignment was present in 22% of nails and 32%
of plates, with plates having a higher rate of valgus malalign-
ment and requiring complete implant removal. Overall func-
tional results trended toward better outcomes in nails versus
plates for all measures. Three smaller series have been pub-
lished comparing the 2 implants.46–48 Hartin et al reported on 23
supracondylar femur fractures randomized to a retrograde nail
or a fixed-angle blade plate fixation. Both fixation methods
gave generally good outcomes, but there was a trend in patients
treated with a retrograde nail to require revision surgery for
removal of implants (3 vs. 0) and to experience more pain on
Short Form-36 (SF-36) outcome measures. Recently, Thomson
et al evaluated outcomes at an average of 6.7 years for 11
patients with traditional open reduction internal fixation versus
11 others treated with limited open reduction with retrograde
intramedullary nailing for OTA type-C distal femur fractures.
The rate of subsequent bone-grafting procedures (67% vs. 9%)
and malunion (42% vs. 0%) were significantly higher in ORIF
compared with the less invasive retrograde intramedullary nail-
ing treatment. A nonsignificant trend was noted for increased
infection (25% vs. 0%) and nonunion (33% vs. 9%) in the
group treated with open plating. The physical function compo-
nent of the SF-36 was approximately 2 SDs below the US
population mean and 50% of patient’s demonstrated radio-
graphic changes of post-traumatic arthritis for all patients.
There was no significant difference in any domain of the
SF-36, Short Musculoskeletal Functional Assessment, or the
Iowa knee score between the 2 treatment groups.
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