Strategies for Preventing Malreduction in Distal Femoral Comminuted Fractures: A Case Report
Abstract
Background: Comminuted distal femur fractures pose a significant challenge to achieving precise reduction and stable fixation. Achieving proper alignment is critical, as malreduction can lead to functional impairment and altered gait. Careful preoperative planning and precise intraoperative technique are essential to optimize fracture reduction and ensure favorable postoperative outcomes.
Case Report: A 39-year-old man sustained a comminuted distal femur fracture [AO Foundation/Orthopedic Trauma Association (AO/OTA) 33-C2] after a 9-meter fall. Surgical fixation was performed one week later using a precontoured anatomic lateral locking plate via minimally invasive plate osteosynthesis (MIPO). Postoperative imaging demonstrated a recurvatum deformity of the knee. At three months, fracture union was achieved with functional knee motion. This case underscores careful planning and implant positioning in complex distal femur fractures.
Conclusion: Optimal management of comminuted distal femur fractures requires precise anatomical reduction, careful plate positioning, and intraoperative verification to restore alignment, length, and rotation, while avoiding intercondylar notch violation. Immediate correction of malposition is essential to prevent postoperative deformity and preserve function, even if it modestly prolongs operative time.
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2. 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. doi: 10.5435/00124635- 201010000-00003. [PubMed: 20889949].
3. 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):110-4. [PubMed: 8898139].
4. Von Keudell A, Shoji K, Nasr M, Lucas R, Dolan R, Weaver MJ. Treatment Options for Distal Femur Fractures. J Orthop Trauma. 2016;30 Suppl 2:S25-7. doi: 10.1097/bot.0000000000000621. [PubMed: 27441931].
5. Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. 2018;32 Suppl 1:S1-s170. doi: 10.1097/bot.0000000000001063. [PubMed: 29256945].
6. Sain A, Sharma V, Farooque K, V M, Pattabiraman K. Dual Plating of the Distal Femur: Indications and Surgical Techniques. Cureus. 2019;11(12):e6483. doi: 10.7759/cureus.6483.
[PubMed: 31903313]. [PubMed Central: PMC6935741].
7. Imam MA, Torieh A, Matthana A. Double plating of intra- articular multifragmentary C3-type distal femoral fractures through the anterior approach. Eur J Orthop Surg Traumatol. 2018;28(1):121-30. doi: 10.1007/s00590-017-2014-9. [PubMed: 28710534].
8. Yang RS, Liu HC, Liu TK. Supracondylar fractures of the femur. J Trauma. 1990;30(3):315-9. doi: 10.1097/00005373-199003000-00009. [PubMed: 2313750].
9. Schatzker J, Mahomed N, Schiffman K, Kellam J. Dynamic condylar screw: a new device. A preliminary report. J Orthop Trauma. 1989;3(2):124-32. doi: 10.1097/00005131-198906000- 00007. [PubMed: 2637681].
10. Kontakis MG, Giannoudis PV. Nail plate combination in fractures of the distal femur in the elderly: A new paradigm for optimum fixation and early mobilization? Injury. 2023;54(2):288-91. doi: 10.1016/j.injury.2022.11.035. [PubMed: 36400628].
11. Krettek C, Miclau T, Stephan C, Tscheme H. Transarticular Approach and Retrograde Plate Osteosynthesis (TARPO): An Alternative Surgical Approach for Complex Distal Intra- Articular Femur Fractures. Tech Orthop. 1999;14(3):219-29.
12. Lin CC, Parody N, Anil U, Egol KA. Effect of Implant Linkage on Axial and Rotational Stiffness of Nail-Plate Constructs for Comminuted Distal Femoral Fractures. J Orthop Trauma. 2023;37(7):351-5. doi: 10.1097/bot.0000000000002594. [PubMed: 36862986].
13. Fisher JS, Kazam JJ, Fufa D, Bartolotta RJ. Radiologic evaluation of fracture healing. Skeletal Radiol. 2019;48(3):349-61. doi: 10.1007/s00256-018-3051-0. [PubMed: 30238139].
14. Iannacone WM, Bennett FS, DeLong WG, Jr., Born CT, Dalsey RM. Initial experience with the treatment of supracondylar femoral fractures using the supracondylar intramedullary nail: a preliminary report. J Orthop Trauma. 1994;8(4):322-7. doi: 10.1097/00005131-199408000-00008. [PubMed: 7965294].
15. Hussain MS, Dailey SK, Avilucea FR. Stable Fixation and Immediate Weight-Bearing After Combined Retrograde Intramedullary Nailing and Open Reduction Internal Fixation of Noncomminuted Distal Interprosthetic Femur Fractures. J Orthop Trauma. 2018;32(6):e237-e40. doi: 10.1097/bot.0000000000001154. [PubMed: 29521874].
16. Garala K, Ramoutar D, Li J, Syed F, Arastu M, Ward J, et al. Distal femoral fractures: A comparison between single lateral plate fixation and a combined femoral nail and plate fixation. Injury. 2022;53(2):634-9. doi: 10.1016/j.injury.2021.11.011. [PubMed: 34836629].
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):642-8. doi: 10.1097/bot.0000000000001591. [PubMed: 31335505].
18. Sanders R, Swiontkowski M, Rosen H, Helfet D. Double-plating of comminuted, unstable fractures of the distal part of the femur. J Bone Joint Surg Am. 1991;73(3):341-6. [PubMed: 2002071].
19. Liporace FA, Yoon RS. Nail Plate Combination Technique for Native and Periprosthetic Distal Femur Fractures. J Orthop Trauma. 2019;33(2):e64-e8. doi: 10.1097/bot.0000000000001332. [PubMed: 30277982].
20. Aggarwal S, Rajnish RK, Kumar P, Srivastava A, Rathor K, Haq RU. Comparison of outcomes of retrograde intramedullary nailing versus locking plate fixation in distal femur fractures: A Systematic Review and Meta-analysis of 936 patients in 16 studies. J Orthop. 2023;36:36-48. doi: 10.1016/j.jor.2022.12.007. [PubMed: 36591439]. [PubMed Central: PMC9800249].
21. Stoffel K, Sommer C, Lee M, Zhu TY, Schwieger K, Finkemeier C. Double fixation for complex distal femoral fractures. EFORT Open Rev. 2022;7(4):274-86. doi: 10.1530/eor-21-0113. [PubMed:
35446259]. [PubMed Central: PMC9069857].
22. Rupp M, Popp D, Alt V. Prevention of infection in open fractures: Where are the pendulums now? Injury. 2020;51 Suppl 2:S57-s63. doi: 10.1016/j.injury.2019.10.074. [PubMed: 31679836].
23. Wong MK, Leung F, Chow SP. Treatment of distal femoral fractures in the elderly using a less-invasive plating technique. Int Orthop. 2005;29(2):117-20. doi: 10.1007/s00264-004-0609-3. [PubMed: 15703938]. [PubMed Central: PMC3474502].
24. 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):503-8. doi: 10.1097/00005131-200409000- 00005. [PubMed: 15475845].
25. Kregor PJ, Stannard JA, Zlowodzki M, Cole PA. Treatment of distal femur fractures using the less invasive stabilization system: surgical experience and early clinical results in 103 fractures. J Orthop Trauma. 2004;18(8):509-20. doi: 10.1097/00005131-200409000-00006. [PubMed: 15475846].
26. Smith TO, Hedges C, MacNair R, Schankat K, Wimhurst JA. The clinical and radiological outcomes of the LISS plate for distal femoral fractures: a systematic review. Injury. 2009;40(10): 1049-63. doi: 10.1016/j.injury.2009.01.005. [PubMed: 19486966].
27. Sommer C, Gautier E, Müller M, Helfet DL, Wagner M. First clinical results of the Locking Compression Plate (LCP). Injury. 2003;34 Suppl 2:B43-54. doi: 10.1016/j.injury.2003.09.024. [PubMed: 14580985].
28. Vallier HA, Immler W. Comparison of the 95-degree angled blade plate and the locking condylar plate for the treatment of distal femoral fractures. J Orthop Trauma. 2012;26(6):327-32. doi: 10.1097/BOT.0b013e318234d460. [PubMed: 22183200].
2. 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. doi: 10.5435/00124635- 201010000-00003. [PubMed: 20889949].
3. 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):110-4. [PubMed: 8898139].
4. Von Keudell A, Shoji K, Nasr M, Lucas R, Dolan R, Weaver MJ. Treatment Options for Distal Femur Fractures. J Orthop Trauma. 2016;30 Suppl 2:S25-7. doi: 10.1097/bot.0000000000000621. [PubMed: 27441931].
5. Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. 2018;32 Suppl 1:S1-s170. doi: 10.1097/bot.0000000000001063. [PubMed: 29256945].
6. Sain A, Sharma V, Farooque K, V M, Pattabiraman K. Dual Plating of the Distal Femur: Indications and Surgical Techniques. Cureus. 2019;11(12):e6483. doi: 10.7759/cureus.6483.
[PubMed: 31903313]. [PubMed Central: PMC6935741].
7. Imam MA, Torieh A, Matthana A. Double plating of intra- articular multifragmentary C3-type distal femoral fractures through the anterior approach. Eur J Orthop Surg Traumatol. 2018;28(1):121-30. doi: 10.1007/s00590-017-2014-9. [PubMed: 28710534].
8. Yang RS, Liu HC, Liu TK. Supracondylar fractures of the femur. J Trauma. 1990;30(3):315-9. doi: 10.1097/00005373-199003000-00009. [PubMed: 2313750].
9. Schatzker J, Mahomed N, Schiffman K, Kellam J. Dynamic condylar screw: a new device. A preliminary report. J Orthop Trauma. 1989;3(2):124-32. doi: 10.1097/00005131-198906000- 00007. [PubMed: 2637681].
10. Kontakis MG, Giannoudis PV. Nail plate combination in fractures of the distal femur in the elderly: A new paradigm for optimum fixation and early mobilization? Injury. 2023;54(2):288-91. doi: 10.1016/j.injury.2022.11.035. [PubMed: 36400628].
11. Krettek C, Miclau T, Stephan C, Tscheme H. Transarticular Approach and Retrograde Plate Osteosynthesis (TARPO): An Alternative Surgical Approach for Complex Distal Intra- Articular Femur Fractures. Tech Orthop. 1999;14(3):219-29.
12. Lin CC, Parody N, Anil U, Egol KA. Effect of Implant Linkage on Axial and Rotational Stiffness of Nail-Plate Constructs for Comminuted Distal Femoral Fractures. J Orthop Trauma. 2023;37(7):351-5. doi: 10.1097/bot.0000000000002594. [PubMed: 36862986].
13. Fisher JS, Kazam JJ, Fufa D, Bartolotta RJ. Radiologic evaluation of fracture healing. Skeletal Radiol. 2019;48(3):349-61. doi: 10.1007/s00256-018-3051-0. [PubMed: 30238139].
14. Iannacone WM, Bennett FS, DeLong WG, Jr., Born CT, Dalsey RM. Initial experience with the treatment of supracondylar femoral fractures using the supracondylar intramedullary nail: a preliminary report. J Orthop Trauma. 1994;8(4):322-7. doi: 10.1097/00005131-199408000-00008. [PubMed: 7965294].
15. Hussain MS, Dailey SK, Avilucea FR. Stable Fixation and Immediate Weight-Bearing After Combined Retrograde Intramedullary Nailing and Open Reduction Internal Fixation of Noncomminuted Distal Interprosthetic Femur Fractures. J Orthop Trauma. 2018;32(6):e237-e40. doi: 10.1097/bot.0000000000001154. [PubMed: 29521874].
16. Garala K, Ramoutar D, Li J, Syed F, Arastu M, Ward J, et al. Distal femoral fractures: A comparison between single lateral plate fixation and a combined femoral nail and plate fixation. Injury. 2022;53(2):634-9. doi: 10.1016/j.injury.2021.11.011. [PubMed: 34836629].
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):642-8. doi: 10.1097/bot.0000000000001591. [PubMed: 31335505].
18. Sanders R, Swiontkowski M, Rosen H, Helfet D. Double-plating of comminuted, unstable fractures of the distal part of the femur. J Bone Joint Surg Am. 1991;73(3):341-6. [PubMed: 2002071].
19. Liporace FA, Yoon RS. Nail Plate Combination Technique for Native and Periprosthetic Distal Femur Fractures. J Orthop Trauma. 2019;33(2):e64-e8. doi: 10.1097/bot.0000000000001332. [PubMed: 30277982].
20. Aggarwal S, Rajnish RK, Kumar P, Srivastava A, Rathor K, Haq RU. Comparison of outcomes of retrograde intramedullary nailing versus locking plate fixation in distal femur fractures: A Systematic Review and Meta-analysis of 936 patients in 16 studies. J Orthop. 2023;36:36-48. doi: 10.1016/j.jor.2022.12.007. [PubMed: 36591439]. [PubMed Central: PMC9800249].
21. Stoffel K, Sommer C, Lee M, Zhu TY, Schwieger K, Finkemeier C. Double fixation for complex distal femoral fractures. EFORT Open Rev. 2022;7(4):274-86. doi: 10.1530/eor-21-0113. [PubMed:
35446259]. [PubMed Central: PMC9069857].
22. Rupp M, Popp D, Alt V. Prevention of infection in open fractures: Where are the pendulums now? Injury. 2020;51 Suppl 2:S57-s63. doi: 10.1016/j.injury.2019.10.074. [PubMed: 31679836].
23. Wong MK, Leung F, Chow SP. Treatment of distal femoral fractures in the elderly using a less-invasive plating technique. Int Orthop. 2005;29(2):117-20. doi: 10.1007/s00264-004-0609-3. [PubMed: 15703938]. [PubMed Central: PMC3474502].
24. 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):503-8. doi: 10.1097/00005131-200409000- 00005. [PubMed: 15475845].
25. Kregor PJ, Stannard JA, Zlowodzki M, Cole PA. Treatment of distal femur fractures using the less invasive stabilization system: surgical experience and early clinical results in 103 fractures. J Orthop Trauma. 2004;18(8):509-20. doi: 10.1097/00005131-200409000-00006. [PubMed: 15475846].
26. Smith TO, Hedges C, MacNair R, Schankat K, Wimhurst JA. The clinical and radiological outcomes of the LISS plate for distal femoral fractures: a systematic review. Injury. 2009;40(10): 1049-63. doi: 10.1016/j.injury.2009.01.005. [PubMed: 19486966].
27. Sommer C, Gautier E, Müller M, Helfet DL, Wagner M. First clinical results of the Locking Compression Plate (LCP). Injury. 2003;34 Suppl 2:B43-54. doi: 10.1016/j.injury.2003.09.024. [PubMed: 14580985].
28. Vallier HA, Immler W. Comparison of the 95-degree angled blade plate and the locking condylar plate for the treatment of distal femoral fractures. J Orthop Trauma. 2012;26(6):327-32. doi: 10.1097/BOT.0b013e318234d460. [PubMed: 22183200].
| Files | ||
| Issue | Vol 12 No 3 (2026) | |
| Section | Case Report | |
| Keywords | ||
| Distal Femur Fractures Comminuted Fracture Minimally Invasive Surgery | ||
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How to Cite
1.
Zolghadr H, Soleymani M. Strategies for Preventing Malreduction in Distal Femoral Comminuted Fractures: A Case Report. J Orthop Spine Trauma. 2026;12(3):151-4.
