Bicondylar Hoffa Fracture of Distal Femur In Skeletally Immature

Afiq Fawwaz
Department Of Orthopaedic, Hospital Sultan Abdul Halim

Abstract

Hoffa fractures are the fractures of the femoral

condyles in the coronal planes. These are
uncommon in adults and notably rarer in
skeletally immature patient.. We report a
variant of bicondylar hoffa fracture in 14-year-
old boy treated with open reduction and
internal fixation using partial threaded screws.

Introduction

The hoffa fracture may involve one or both

condyles. These fractures are classified as
33B3.2 and 33B3.3 respectively as per AO
classification. Un displaced or minimally
displaced fractures often get missed in routine
radiographs of distal femur. The treating Image 1a (AP view knee)
clinician must have high index of suspicion to
diagnose these fractures. The details on
configuration of fracture provided by
Computed Tomography (CT) scan are
mandatory to plan out surgical procedures.

Case Presentation

A14-year-old boy alleged motor vehicle

accident. He was riding motorbike and
skidded. Immediately he was bring to
emergency department. He was treated as per
Advanced Trauma Life Support (ATLS)
protocols. He sustained injury to his right knee
and unable to bear weight.
On examination, his knee was swollen and
tender. Any attempted movement at the right
knee were severely painful and restricted. No
signs of external wound. Distal pulses were
good comparable to contralateral and no distal
neurology deficit. Antero-posterior and lateral
plain radiograph of the right knee revealed
bicondylar Hoffa fracture (image 1). CT scan of
the right knee was performed to understand
fracture configuration. The patient was
immobilised with above knee posterior slab.
Image 1b (lateral view knee)
The patient was posted for open reduction and
internal fixation on the next day. Patient under
general anaesthesia and was positioned
supine on radiolucent operation table.
Tourniquet was applied. The knee was
exposed using swashbuckler approach. The
knee was fully flexed to allow delivery of the
hoffa fragments. Then the fragments were
anatomically reduced and compressed with a
large, pointed reduction clamp. Multiple
Kirschner wires were inserted for temporal
reduction and stabilisation. Reduction was
confirmed with imaging intensifier and direct
visualisation of the articular surface. Four (two
per fragment) partial threaded screws size
4.0mm was inserted from anterior to posterior.
Screw was countersunk to prevent screw head
projected above articular surface.
The patient was kept in above knee posterior
slab for initial 2 weeks. Gradual active knee
mobilisation was started after 2 weeks.
Radiographs taken at 3rdmonth (image 2)
follow up showed signs of union with range of
motion knee 0-120. The patient still under
follow up.
Image 2
Discussion
The Hoffa fracture which is a coronal plane
fracture of the femoral condyle was first
described by Friedrich Busch in 1869 and later
by Albert Hoffa in 1904. It has been
hypothesized that an axial load to the femoral
condyle with the knee in 90 degrees or a
greater amount of flexion produces coronal
fracture of femoral condyle. Among paediatric
age group, the most common coronal fracture
is lateral condyle followed by bicondylar
fracture and medial femoral condyle is the
least common. The aforementioned trend is
similar in adults. Lateral condyle is mostly
fractured due to presence of physiological
genu valgum.
Hoffa fractures involve important load-bearing
areas of the knee joint surface. Most authors
recommend open reduction to restore normal
condylar anatomy and rigid internal fixation,
allowing functional recovery. Conservative
treatment generally led to poor outcomes
associated with malunion, non-union, and
avascular necrosis. We used the swashbuckler
approach which has been shown to give good
access to both the condyles while causing less
injury to the quadriceps mechanism, lesser
fibrosis and early return of quadriceps strength
and range of motion. Fixation was done using
multiple lag screws perpendicular to the
fracture plane from anteriorposteriorly (AP).
Jarit et al showed that fixation with
posteroanteriorly (PA) oriented lag screws was
biomechanically superior to AP-oriented lag
screws when subjected to vertical
loads. Headless compression screws can
reduce the degree of required cartilage
damage compared to countersunk lag screws.
The distal femoral physis is responsible for
approximately 70% of the growth of the femur
and 35% of the total length of the lower
extremity. It has an average growth of 1.0
cm/year, which makes it the fastest growing
physis. Thus, patient can have a high
incidence of long-term complications such as
growth disturbances, with subsequent
development of limb length discrepancy and
angular deformities. Continuous follow up is
mandatory to address this issue.
Conclusion
To conclude, we are reporting a bicondylar
Hoffa fracture in a paediatric age group. Good
surgical exposure by swashbuckler approach,
accurate reduction, stable fixation and early
mobilisation resulted in good functional
recovery. However, follow up is needed to
figure out long term complications.
References
1. Nork, S. E., Segina, D. N., Aflatoon, K.,
Barei, D. P., Henley, M. B., Holt, S., et al.
(2005). The association between
 supracondy- lar-intercondylar distal
femoral fractures and coronal plane frac-
tures. The Journal of Bone and Joint
Surgery of America, 87(3), 564–569.
2. Harna B, Goel A, Singh P, Sabat D.
Pediatric conjoint Hoffa’s fracture: An
uncommon injury and review of literature. J
ClinOrthop Trauma 2017; 8:353-4
3. M. H. Arastu, M. C. Kokke, P. J. Duffy, R.
E. Korley, and R. E. Buckley, “Coronal
plane partial articular fractures of the distal
femoral condyle: current concepts in
management,” The Bone & Joint Journal,
vol. 95, no. 9, pp. 1165–1171, 2013.
4. G. J. Jarit, F. J. Kummer, M. J. Gibber, and
K. A. Egol, “A mechanical evaluation of
two fixation methods using cancellous
screws for coronal fractures of the lateral
condyle of the distal femur (OTA type
33B),” Journal of Orthopaedic Trauma, vol.
20, no. 4, pp. 273–276, 2006
5. Raja BS, Gowda AKS, Baby BK,
Chaudhary S, Meena PK. Swashbuckler
approach for distal femur fractures: A
systematic review. J Clin Orthop Trauma.
2021 Nov 19; 24:101705.
6. McKenna SM, Hamilton SW, Barker SL.
Salter Harris Fractures of the Distal Femur:
Learning Points from Two Cases
Compared. J Investig Med High Impact
Case Rep. 2013 Jul
29;1(3):2324709613500238
7. Pritchett JW. Longitudinal growth and
growth-plate activity in the lower
extremity. J PediatrOrthop. 1992;2(4):557.