Coronal Plane | Often Missed | Anatomic Reduction Essential | Posterior-to-Anterior Screws
LETENNEUR CLASSIFICATION
Critical Must-Knows
- Coronal plane fracture - often missed on AP and lateral X-rays
- Lateral condyle more commonly affected (2:1 ratio)
- Complete fractures are avascular - no soft tissue attachments
- Anatomic reduction essential - articular surface fracture
- Posterior-to-anterior lag screws are gold standard fixation
Clinical Pearls
- "Look for sagittal CT - Hoffa often missed on plain films
- "Mechanism: direct blow to flexed knee or axial load
- "Gastrocnemius attachment may aid lateral fragment vascularity
- "Associated with high-energy trauma and other knee injuries
Critical Hoffa Fracture Exam Points
Easily Missed
Frequently missed on plain radiographs because the coronal fracture plane may not be visible on AP or lateral views. CT is essential for diagnosis and surgical planning. Always suspect in high-energy distal femur trauma.
Complete = Avascular
Complete Hoffa fragments have few soft tissue attachments beyond the posterior capsule and gastrocnemius origin, so they are relatively avascular. Anatomic reduction and stable fixation are critical to allow healing.
Anatomic Reduction
This is an articular fracture of the weight-bearing surface. Any step-off leads to post-traumatic arthritis. Anatomic reduction is non-negotiable. Assess under direct visualization.
P-A Lag Screws
Posterior-to-anterior lag screws are the standard fixation. They compress the fragment to the intact condyle. Countersink heads posteriorly to avoid impingement. Multiple screws provide better stability.
Hoffa Fracture Management Decision Guide
| Finding | Implication | Management |
|---|---|---|
| Undisplaced fragment | May be managed non-operatively if truly undisplaced | Very close follow-up with CT, consider fixation |
| Displaced Hoffa (any displacement) | Will not heal, high risk of displacement | Operative fixation required |
| Associated supracondylar fracture | Fix Hoffa first to restore condyle anatomy | Then address supracondylar component |
| Comminuted posterior condyle | May need buttress plate | Posterolateral or posteromedial approach |
| Open fracture | Emergent washout, staged fixation | External fixation if soft tissue concerns |
HOFFA - KHOFFA - Key Points
| H | Hidden on X-ray Coronal plane often missed on AP/lateral |
| O | ORIF required Displaced fractures need surgical fixation |
| F | Femoral condyle (posterior) Fracture through posterior condyle |
| F | Fixation P-A Posterior-to-anterior lag screws |
| A | Avascular if complete No soft tissue attachments |
| H | Hidden on X-ray Coronal plane often missed on AP/lateral | F | Fixation P-A Posterior-to-anterior lag screws |
| O | ORIF required Displaced fractures need surgical fixation | A | Avascular if complete No soft tissue attachments |
| F | Femoral condyle (posterior) Fracture through posterior condyle |
Hook:HOFFA reminds you this is Hidden, needs ORIF, involves Femoral condyle, Fixed P-A, and is Avascular
LATERAL - WLATERAL - Why Lateral More Common
| L | Lateral blow mechanism Dashboard injury to flexed knee |
| A | Anatomic prominence Lateral condyle more prominent |
| T | Tension from iliotibial band ITB may contribute to lateral forces |
| E | External rotation moment Common loading pattern |
| R | Ratio 2:1 lateral to medial Lateral condyle twice as common |
| A | Axial load plus flexion Mechanism creates coronal plane fracture |
| L | LCL and posterolateral corner may be injured Associated ligament injuries |
| L | Lateral blow mechanism Dashboard injury to flexed knee | E | External rotation moment Common loading pattern | L | LCL and posterolateral corner may be injured Associated ligament injuries |
| A | Anatomic prominence Lateral condyle more prominent | R | Ratio 2:1 lateral to medial Lateral condyle twice as common | ||
| T | Tension from iliotibial band ITB may contribute to lateral forces | A | Axial load plus flexion Mechanism creates coronal plane fracture |
Hook:LATERAL condyle is more commonly affected - 2:1 ratio
SCREW - FSCREW - Fixation Principles
| S | Screws in lag mode Compression across fracture |
| C | Countersink posteriorly Avoid posterior impingement |
| R | Reduction anatomic Articular step-off unacceptable |
| E | Enter from posterior P-A direction for optimal purchase |
| W | Weight-bearing restriction Protect fixation postoperatively |
| S | Screws in lag mode Compression across fracture | E | Enter from posterior P-A direction for optimal purchase |
| C | Countersink posteriorly Avoid posterior impingement | W | Weight-bearing restriction Protect fixation postoperatively |
| R | Reduction anatomic Articular step-off unacceptable |
Hook:SCREW reminds you of the key fixation principles
LETENNEUR CLETENNEUR Classification
| I | Posterior to Blumensaat Fragment entirely behind intercondylar roof |
| II | Crosses Blumensaat Fragment extends into weight-bearing zone |
| III | Oblique/smaller Oblique fracture plane with smaller fragment |
| I | Posterior to Blumensaat Fragment entirely behind intercondylar roof |
| II | Crosses Blumensaat Fragment extends into weight-bearing zone |
| III | Oblique/smaller Oblique fracture plane with smaller fragment |
Hook:Types I-II-III: posterior only, crossing line, oblique small
Overview and Epidemiology
Hoffa fractures are coronal plane fractures of the posterior aspect of the femoral condyle. First described by Albert Hoffa in 1904, they are relatively rare but frequently missed injuries.
Mechanism of injury:
- Direct blow to flexed knee (dashboard injury)
- Axial load with knee in flexion
- Combined shear and compression forces
- Usually high-energy trauma
Why Coronal Plane?
The fracture occurs in the coronal plane because of the loading mechanism. With the knee flexed, a direct blow or axial load creates shear forces that split off the posterior condyle. The coronal orientation is why it's easily missed on AP and lateral X-rays.
Epidemiology:
- Coronal-plane condylar fractures are rarer than sagittal-plane condylar fractures
- Male predominance; typically young adults
- High-energy trauma (motor vehicle and motorcycle collisions, falls)
- Lateral condyle is involved more often than the medial condyle
- May be isolated or associated with other injuries
Associated injuries:
- Supracondylar/intercondylar femur fractures (30-40%)
- ACL/PCL injuries
- Tibial plateau fractures
- Patellar fractures
- Neurovascular injury (rare)
Anatomy and Biomechanics
Femoral condyle anatomy:
The distal femur has two condyles that articulate with the tibia:
| Feature | Lateral Condyle | Medial Condyle |
|---|---|---|
| Prominence | More prominent | Less prominent |
| Weight-bearing | Smaller area | Larger area |
| Posterior attachment | Lateral gastrocnemius | Medial gastrocnemius |
| Hoffa frequency | More common (2:1) | Less common |
Blumensaat Line
Blumensaat line is the radiographic representation of the intercondylar roof. On lateral X-ray, it's a line along the roof of the intercondylar notch. The Letenneur classification uses this line to categorize Hoffa fractures.
Vascular considerations:
Complete Hoffa fragments are essentially avascular:
- No anterior soft tissue attachments
- No ligamentous attachments
- Only posterior periosteum/capsule
- Gastrocnemius attachment may provide some blood supply (especially lateral)
Avascular Fragment
A complete Hoffa fragment is essentially avascular free bone. Unlike many fractures where periosteal blood supply aids healing, the Hoffa fragment relies entirely on the healing from the intact condyle after fixation. This emphasizes the importance of stable fixation and anatomic reduction.
Biomechanical considerations:
- Posterior condyle is weight-bearing in flexion
- Malreduction leads to altered knee mechanics
- Any step-off causes accelerated arthritis
- Fragment may rotate or displace with knee motion
Posterior structures at risk during surgery:
- Popliteal vessels (central, protected by fascia)
- Common peroneal nerve (lateral approach)
- Saphenous nerve (medial approach)
- Gastrocnemius muscle (retracted, not cut)
Classification Systems
Letenneur Classification (based on fracture line relative to Blumensaat line)
| Type | Description | Fragment Location | Implications |
|---|---|---|---|
| I | Posterior to Blumensaat line | Behind intercondylar roof | Posterior fragment only |
| II | Crosses Blumensaat line | Extends into weight-bearing | Larger fragment, more critical |
| III | Oblique with smaller fragment | Variable | May be more comminuted |
Clinical Significance
Type II fractures involve more weight-bearing surface and may require more extensive fixation. Type III oblique fractures may have smaller fragments that are more challenging to fix.
Clinical Presentation and Assessment
History:
- Mechanism of injury (dashboard, direct blow, fall)
- High-energy vs low-energy
- Associated injuries
- Pre-injury function and activity level
Physical examination:
Physical Examination Findings
| Finding | Significance | Action |
|---|---|---|
| Knee swelling/effusion | Hemarthrosis common | Aspiration if tense |
| Posterior condyle tenderness | May localize Hoffa fracture | Palpate both condyles |
| Limited ROM due to pain | Expected finding | Examine under anesthesia if needed |
| Ligament laxity | Associated ligament injury | Document, may need staged repair |
| Open wound | Open fracture | Urgent washout, IV antibiotics |
| Neurovascular deficit | Vascular injury or compartment syndrome | Urgent intervention |
Key examination points:
- Palpate posterior condyles - may identify tenderness
- Assess ligamentous stability (may be limited by pain)
- Neurovascular examination - pulses, motor function, sensation
- Skin assessment - open wounds, abrasions, fracture blisters
- Compartment assessment if high-energy mechanism
Index of Suspicion
Have a high index of suspicion for Hoffa fracture in any high-energy knee injury. The fracture is frequently missed on initial X-rays. If the mechanism is consistent (direct blow to flexed knee), order CT even if initial X-rays appear negative.
Investigations
Radiographic assessment:
Plain radiographs:
- AP, lateral, and oblique views of knee
- Hoffa fracture may be subtle or invisible
- Look for double density sign on lateral view
- Measure fracture fragment size and displacement
Key X-ray findings:
- Coronal fracture line through posterior condyle
- Fragment may overlap with intact condyle on lateral
- Double density sign (superimposed condyle and fragment)
- Associated supracondylar fracture may be present
CT is Essential
CT with 2D reconstructions is mandatory for all suspected Hoffa fractures. It defines fracture pattern, fragment size, displacement, comminution, and allows surgical planning. Plain radiographs alone are insufficient.
CT imaging:
- Thin-slice CT with sagittal and coronal reconstructions
- Assess fracture line orientation
- Measure fragment size as percentage of condyle
- Identify comminution
- Plan screw trajectory
MRI (if indicated):
- Not routine for Hoffa fractures
- May be helpful if ligament injury suspected
- Can assess cartilage damage
- Usually obtained after fracture healing if persistent symptoms
Key imaging findings to document:
| Feature | Significance | Impact on Surgery |
|---|---|---|
| Condyle involved | Lateral vs medial | Determines approach |
| Fragment size | Percentage of condyle | Fixation method |
| Displacement | Articular step-off | Urgency of fixation |
| Comminution | Multiple fragments | May need plate |
| Associated fractures | Supracondylar component | Surgical sequence |
Differential diagnosis of the acutely painful, swollen knee after distal femoral trauma:
Hoffa Fracture - Differential Diagnosis
| Diagnosis | Distinguishing features | Key investigation |
|---|---|---|
| Hoffa (coronal condylar) fracture | Coronal-plane line through posterior condyle, often invisible on AP, tangential on lateral; lateral more common | CT with sagittal and coronal reconstructions |
| Sagittal-plane unicondylar fracture (AO/OTA 33-B1/B2) | Vertical split visible on the AP view; far more common than coronal pattern | AP radiograph, confirmed on CT |
| Supracondylar / intercondylar distal femur fracture (33-A/C) | Metaphyseal or T/Y articular pattern; may harbour an occult coexisting Hoffa fragment | CT to exclude a coronal component |
| Tibial plateau fracture / knee dislocation variant | Tibial-side bony injury, often with ligamentous instability | CT plus stress or MRI assessment |
| Ligamentous knee injury or isolated haemarthrosis | No fracture line; positive laxity tests once pain settles | MRI if radiographs and CT are normal |
Management
Indications for non-operative treatment:
- Truly undisplaced fractures (rare)
- Non-ambulatory patients
- Severe medical comorbidities precluding surgery
- Patient refusal of surgery
Non-operative protocol:
- Long leg cast or hinged knee brace
- Non-weight bearing for 6-8 weeks
- Very close follow-up with serial imaging
- CT at 2-4 weeks to assess displacement
- Low threshold for surgery if any displacement
Displacement Risk
Non-operative management carries high risk of secondary displacement. The posterior condyle bears load during knee flexion, and the fracture fragment has no soft tissue attachments to maintain position. Most surgeons favor operative fixation for all Hoffa fractures.
Surgical Technique
Patient positioning:
- Supine with bump under ipsilateral hip
- Knee flexed to 20-30 degrees over bolster
- Leg free for intraoperative flexion/extension
- Tourniquet optional
Lateral approach (for lateral Hoffa):
- Incision along distal IT band to lateral epicondyle
- Develop interval between IT band and biceps
- Incise lateral capsule to expose condyle
- Protect common peroneal nerve posteriorly
Posterolateral approach:
- Incision posterior to lateral epicondyle
- Identify and protect peroneal nerve
- Split lateral gastrocnemius if needed
- Excellent access to posterior condyle
The posterolateral approach provides direct visualization of the posterior condyle and is often preferred for Hoffa fractures.
Complications
Complications of Hoffa Fractures
| Complication | Incidence | Prevention/Management |
|---|---|---|
| Nonunion | 10-20% | Anatomic reduction, stable fixation, avoid smoking |
| Malunion | Variable | Anatomic reduction at surgery, confirm with fluoro |
| Post-traumatic arthritis | 20-30% | Anatomic reduction, no step-off acceptable |
| AVN of fragment | Rare if fixed | Stable fixation allows revascularization |
| Stiffness | 15-25% | Early ROM, physiotherapy |
| Infection | 1-5% | Antibiotic prophylaxis, atraumatic technique |
| Hardware prominence | Variable | Countersink screws, consider removal later |
Nonunion:
- Major concern due to avascular fragment
- Risk factors: inadequate fixation, smoking, displacement
- Treatment: revision fixation with bone graft
- May require plate fixation if screws failed
Malunion:
- Leads to altered knee mechanics
- Even small step-off causes cartilage wear
- Prevention is key - confirm reduction intraoperatively
- Correction requires osteotomy (difficult)
Nonunion Prevention
Nonunion is a significant concern because the Hoffa fragment is essentially avascular. Prevention requires stable fixation with good compression, anatomic reduction, and patient optimization (smoking cessation). If nonunion occurs, revision with bone grafting may be needed.
Post-traumatic arthritis:
- Occurs in 20-30% despite good treatment
- Related to cartilage damage at injury
- Malreduction increases risk
- May require arthroplasty in severe cases
Postoperative Care and Rehabilitation
Postoperative protocol:
- Knee immobilizer for comfort
- Toe-touch weight bearing with crutches
- Ice, elevation, wound care
- Gentle ROM exercises as pain allows
- CPM machine optional
- Progressive ROM (goal: 0-90 degrees by week 4)
- Continue partial weight bearing (25-50% body weight)
- Quadriceps strengthening (isometrics, SLR)
- Stationary bike when ROM allows
- Pool exercises if incisions healed
- Radiographic assessment of healing
- Progressive weight bearing based on healing
- Full weight bearing typically by 8-12 weeks
- Aggressive ROM (goal: full ROM by 12 weeks)
- Progressive strengthening
- Full activity as tolerated
- Sport-specific training
- May require ongoing physiotherapy
- Hardware removal if symptomatic
Key rehabilitation principles:
- Early motion prevents stiffness
- Delayed weight bearing protects fixation
- Monitor for loss of reduction
- Individualize based on fixation stability
- Long-term follow-up for arthritis development
Weight Bearing
Delay full weight bearing until radiographic evidence of healing (typically 8-12 weeks). The posterior condyle bears load in knee flexion, stressing the fixation. Premature weight bearing may lead to loss of reduction or nonunion.
Outcomes and Prognosis
Outcome factors:
| Factor | Better Outcomes | Worse Outcomes |
|---|---|---|
| Reduction quality | Anatomic | Any step-off |
| Fixation stability | Stable, multiple screws | Unstable, single screw |
| Associated injuries | Isolated Hoffa | Combined patterns |
| Patient factors | Non-smoker, young | Smoker, elderly |
| Fragment size | Larger | Small/comminuted |
Key to Success
The key to good outcomes is anatomic reduction and stable fixation. Any articular step-off leads to accelerated arthritis. Stable fixation allows early motion which prevents stiffness while protecting healing.
Long-term concerns:
- Post-traumatic arthritis (may develop years later)
- Stiffness (usually manageable with physiotherapy)
- Hardware prominence (may need removal)
- Functional limitations in high-demand activities
Evidence Base
- 113 studies synthesised. Lateral coronal-plane fractures are more frequent than medial, have a more vertical fracture line and concentrate on the weight-bearing zone. The Letenneur system is the most widely used classification. Posterior-to-anterior lag screws (with a posterior buttress plate for Letenneur types I and III) are biomechanically more efficient than anterior-to-posterior fixation; no consensus exists on screw number or diameter.
- 105 articles reviewed. Coronal-plane condylar fractures are rarer than sagittal-plane fractures and usually follow high-energy trauma. Letenneur, CT-based, AO and modified-AO classifications are all in use. Radiographs may be negative in questionable cases, so CT and MRI should be obtained. Non-displaced fractures carry a high risk of redisplacement, so open reduction and internal fixation is preferred with headless compression screws inserted perpendicular to the fracture line from posterior to anterior.
- 13 surgically treated isolated coronal-plane condylar fractures, mean follow-up 93 months. All united (mean 10 weeks). Post-traumatic osteoarthritis developed in 7 of 13 (54%) and avascular necrosis in 2 of 13 (15.4%). Medial Hoffa fractures had worse functional scores (mean KSS 66.5) than lateral fractures (mean KSS 83.8). Fractures may be overlooked if imaging is not scrutinised.
- 32 isolated Hoffa fractures fixed with cancellous lag screws and/or antiglide plate (lateral approach for lateral, medial for medial). All united at a mean of 11.6 weeks with no subsequent displacement, fixation failure, arthritis or avascular necrosis. Mean Knee Society Score 83.2 and mean IKDC 81.6; knee stiffness in 4 patients.
- 30 coronal-plane condylar fractures randomised between headless compression screws and cannulated cancellous (headed) screws. Good Neer outcomes in 13 of 15 (86.7%) headless versus 10 of 15 (66.7%) headed. Range of motion did not differ, but complications and implant failure were significantly higher with headed cancellous screws.
- 12 lateral Hoffa nonunions, frequently the sequel of a missed acute fracture, treated at a tertiary referral centre. All 12 united (one after re-fixation); loss of reduction 7.7% and post-traumatic arthrosis 7.7%. Mean final knee flexion 104.5 degrees with significant range-of-motion improvement.
Clinical Decision Scenarios
Use these scenarios to practise clinical reasoning and management decisions
Scenario 1: Missed Hoffa Fracture
"A 35-year-old man presents to ED after a motorcycle accident. Initial knee X-rays were reported as normal, but he has significant pain and cannot bear weight. You examine him 2 days later in fracture clinic. What is your approach?"
Scenario 2: Hoffa with Supracondylar Fracture
"CT scan of a 50-year-old woman after MVA shows a distal femur fracture with both a supracondylar component and a Hoffa fracture of the lateral condyle. How do you approach this complex injury?"
Scenario 3: Nonunion of Hoffa Fracture
"A patient presents 6 months after Hoffa fracture fixation with persistent pain and CT showing nonunion. The original fixation was with a single 6.5mm screw. What is your management?"
MCQ Practice Points
Definition Question
Q: What is a Hoffa fracture? A: A coronal plane fracture of the posterior femoral condyle. The fracture line runs in the coronal plane, separating the posterior condyle from the anterior condyle and shaft.
Imaging Question
Q: Why are Hoffa fractures frequently missed on plain X-rays? A: The fracture occurs in the coronal plane, which is parallel to the X-ray beam on AP view and tangential on lateral view. CT with sagittal reconstructions is required for diagnosis.
Anatomy Question
Q: Why is the Hoffa fragment essentially avascular? A: The fragment has no anterior soft tissue attachments (capsule, ligaments) and only posterior periosteum. It is essentially a free bone fragment relying on fixation-mediated healing.
Fixation Question
Q: Why should screws be placed posterior-to-anterior in Hoffa fracture fixation? A: P-A screw placement puts the threads in the well-vascularized intact bone rather than the avascular fragment, providing better purchase. The screw heads are also easier to countersink posteriorly.
Combined Injury Question
Q: In a combined Hoffa and supracondylar fracture, which component should be fixed first? A: Fix the Hoffa fracture first. This reconstitutes the condyle anatomy, creating a solid block to which the shaft can then be reduced and fixed.
Guidelines, Registries & Global Practice
Global epidemiology:
| Parameter | Global picture | Source |
|---|---|---|
| Frequency | Coronal-plane condylar (Hoffa) fractures are rarer than sagittal-plane condylar fractures | Zhou 2019 systematic review |
| Condyle involved | Lateral more frequent than medial; lateral fractures have a more vertical line over the weight-bearing zone | Rabelo 2023 systematic review |
| Demographics | Male predominance, typically young adults | Onay 2017; Zhou 2019 |
| Mechanism | Predominantly high-energy (road traffic and motorcycle collisions, falls); low-energy and iatrogenic cases also reported | Zhou 2019 |
| Long-term arthrosis | Post-traumatic osteoarthritis in roughly half of a small surgically treated series (7 of 13) | Onay 2017 |
Guideline and consensus position (there is no dedicated single-society Hoffa guideline):
| Body | Position relevant to Hoffa fractures | Evidence level |
|---|---|---|
| AO Foundation | Classifies as a partial articular coronal fracture of the distal femur (AO/OTA 33-B3). Recommends anatomic articular reduction and absolute stability with interfragmentary lag screws, plus a buttress/antiglide plate when comminuted | Expert/principle-based |
| AAOS / general trauma teaching (US) | CT mandatory for articular distal femur fractures; fix displaced articular fragments; fix the coronal (Hoffa) fragment before the metaphyseal component | Consensus, Level IV-V |
| NICE / BOA (UK, NG38 fractures pathway) | Generic complex articular fracture principles: CT for intra-articular involvement, senior decision-making, fixation that permits early movement | Guideline (indirect) |
| EFORT / European trauma literature | Endorses posterior-to-anterior screw orientation with posterior buttress plating for unstable patterns | Consensus, Level IV |
The recommendations converge: there is broad international agreement on CT diagnosis, anatomic reduction, lag-screw fixation and fixing the Hoffa fragment first in combined injuries.
Registry evidence:
- There is no joint or fracture registry that tracks Hoffa fractures specifically; major registries (NJR, AJRR, AOANJRR, SHAR, Norwegian, NZJR) capture arthroplasty, not coronal condylar fixation. Evidence therefore rests on systematic reviews and single-centre series.
Practice variation:
| Decision point | Variation | Reason |
|---|---|---|
| Screw direction | Posterior-to-anterior (biomechanically favoured) versus anterior-to-posterior (familiar approach, lower neurovascular risk) | Surgeon familiarity and approach choice; Rabelo 2023 |
| Screw type | Headless compression versus headed cannulated lag screws | Headless reduce prominence and implant failure; Maheshwari 2018 |
| Buttress plate use | Added for Letenneur I and III and comminuted patterns; omitted for simple osteochondral type II | Fracture geometry; Rabelo 2023 |
| Resource setting | High-resource centres use CT routinely and complex posterior approaches; limited-resource settings rely more on radiographs, increasing the missed-fracture and nonunion burden | Imaging access |
Exam Context
In any orthopaedic exam, be prepared to discuss why Hoffa fractures are missed (coronal plane poorly seen on AP and lateral X-rays), the mandatory role of CT, the AO/OTA 33-B3 designation, and the technical aspects of fixation (posterior-to-anterior lag screws, at least two screws, countersinking, buttress plate for comminution). Also know the sequence for combined injuries: fix the Hoffa fragment first.
HOFFA FRACTURES
Clinical summary
DEFINITION AND KEY POINTS
- •Coronal plane fracture of posterior femoral condyle
- •Frequently missed on initial X-rays - CT essential
- •Lateral condyle more common (2:1 ratio)
- •Complete fragments are avascular
CLASSIFICATION
- •Letenneur Type I: Posterior to Blumensaat line
- •Letenneur Type II: Crosses Blumensaat line (weight-bearing)
- •Letenneur Type III: Oblique with smaller fragment
- •Also classified by condyle: lateral, medial, or bicondylar
SURGICAL PRINCIPLES
- •Anatomic reduction is essential (articular fracture)
- •Posterior-to-anterior lag screws (gold standard)
- •Minimum 2 screws for rotational control
- •Countersink screw heads posteriorly
COMBINED INJURIES
- •Fix Hoffa FIRST to reconstitute condyle
- •Then fix supracondylar component
- •Lateral locked plate or retrograde nail for metaphysis
- •May need combined approaches for bicondylar
COMPLICATIONS
- •Nonunion (10-20%) - due to avascular fragment
- •Malunion - any step-off causes arthritis
- •Post-traumatic arthritis (20-30%)
- •Stiffness (15-25%)
TRAPS AND PEARLS
- •High-energy knee + normal X-rays = get CT
- •Single screw fixation is insufficient
- •A-P screws are inferior to P-A
- •Early motion, delayed weight bearing
- •Anatomic reduction is non-negotiable