For the intra-articular fractures, the medial or lateral parapatellar approach is used as it gives excellent exposure of the possible distal femoral articular surface. The lateral approach can be utilized more commonly but if in case the medial femoral condyle is in major comminution then the medial parapatellar approach is used. A straight incision in the skin is made with approximately 1 cm lateral to the patella. The dissection is carried out to extensor retinaculum. To enter the knee joint, a medial or lateral parapatellar curvy linear retinacular incision is made.

In the lateral parapatellar approach it can be extended proximally in between the vastus lateralis and rectus femoris. The medial retinacular incision, in the medial parapatellar approach, can be extended proximally along the one-third medial of the quadriceps tendons. To the patella side, a cuff of attached tissue is left to facilitate the later repairing.

The distal articular surface of the femur is then exposed by the flexing of knee and eversion of the patella which enables the fixation and reduction of the articular fracture with the help of the intramedullary rod. The patella is repositioned when this is completed. Along the lateral cortex, the Implant is then slipped in the submuscular tunnel which is followed by the screws that are inserted to complete fixation.

Whatever the purpose of incision is, it is required to ensure the proximal plate end which lies against the center of the lateral cortex of the femoral shaft. The proper alignment for the plate fixation of the fracture can be ensured.

Operative Procedure (cont.) 

• Reduction and fixation of the articular fractures.
• In the type C fractures, the next step is internal fixation and the anatomical reduction of the articular fractures.
• To obtain the reduction of fragments of articular fractures, various aids can be used.
• In the medial and lateral femoral Condyles, Schantz screws can be inserted which serves as the joystick for securing the fracture reduction. The screws are majorly used in the case of type C1 and C2 fractures.
• For holding the lateral and medial femoral condyles the pelvic reduction clamps or large pointed reduction forceps can be useful together after the reduction.
• For the temporary fixation of the reduced condylar fragments, the K-wires can also be useful.
• Followed by the articular fracture reduction, the fixation through lag screws is carried out with the small fragments of the 3.5 mm cortex screws or 4.0 mm partially threaded cancellous bone screws. In the lateral or medial directions, the lag screws can be inserted in the case of the intercondylar fractures and in the case of the frontal plane to the direction of anterior to posterior.

The lag screws position should be planned so that it does not interfere with the subsequent placement of the definitive ortho implants for the fixation of the supracondylar fracture component.

Reduction of the metaphyseal/ diaphyseal fracture component 

The next step consists of the reduction of the articular block to the distal femoral metaphysis/ diaphysis. If the LISS DF is going to be used as the fixation device, then it is important. In the case of fixed-angle devices like 95° condylar plate and Locking Plate for Hand Fracture, the devices can be used as the reduction aid for standard screws than being used for drawing the bone to the plate and is helpful for re-establishing the axial, normal and sagittal alignment of the distal femur.

The goal is to achieve closed indirect reduction. The various reduction aids can be used.

To keep the knee flexed at 60 to 70 degrees the pads are placed posterior towards the supracondylar region which helps in relaxing the gastrocnemius and the frequent hypertension deformity can be corrected for the particular blocks.

If the manual traction is applied to the ankle with vector force then it is directed towards the posterior which utilizes the supracondylar pads as the fulcrum which results in reducing the fracture and restoring limb length along with the axial and rotational alignment.

From the anterior to posterior direction a Schantz screw is inserted in the articular block just proximal to the margin that can be used as the joystick for derogating the hyperextended distal fragment in the properly aligned proximal fragment.

To obtain and maintain the fracture reduction, the external fixator or femoral distractor can be used.