Published: 2022-10-27

Successful single stage management of trifocal femoral fracture associated with distal medial condyle and Hoffa’s component by a novel technique

Kumardev Arvind Rajamanya, Girish Marappa


Isolated fractures of the shaft of the femur are relatively common injuries. Ipsilateral multifocal fractures of the femur are less common with an additional proximal femoral fracture estimated to occur in up to 5% of diaphyseal fractures and additional distal femoral fracture occurring in 3-4%. Trifocal femoral fractures consisting of ipsilateral fractures of the proximal, diaphyseal, and distal femur are extremely rare. These fracture patterns are seen in the young adult population following high velocity trauma such as fall from height and road traffic accidents. The sequence of fracture type to be fixed first and the type of implant to be used are questions yet to be answered as one implant used for fixation of one fracture may not be amenable for fixation of the other fracture. These fractures are associated with significant complications and delayed rehabilitation. We describe a novel method in one such trifocal fracture pattern where the distal femoral intra-articular medial condyle with a hoffas element was stabilised by open reduction with a 4.5 proximal tibial ipsi-lateral anterolateral LCP and 2 inter-fragmentary compression screws which has not been reported in literature before. The advantages of such an implant is easy contour ability to the medial femoral condyle and adequate strength and achieving satisfactory absolute stability with options of using uni-cortical locking screws, all of which facilitates early knee ROM and rehabilitation.



Trifocal fracture, Locking compression plate, Intra-medullary interlocking nail, Hoffa’s fracture

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Käch K. Kombinierte Frakturen des Schenkelhalses mit Femurs chaft frakturen. Helv Chir Acta. 1993;59:985-92.

Müller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Springer, Berlin New York. 1990.

Dousa P, Bartonícek J, Lunacek L, Pavelka T, Kušíková E. Ipsilateral fractures of the femoral neck, shaft and distal end: Long-term outcome of five cases. Int Orthop. 2011;35:1083-8.

Barei DP, Schildhauer TA, Nork SE. Non-contiguous fractures of the femoral neck, femoral shaft, and distal femur. J Trauma. 2003;55(1):80-6.

Alho A, Ekeland A, Grogaard B, Dokke JR. A locked hip screw-intramedullary nail (cephalon-medullary nail) for the treatment of fractures of the proximal part of the femur combined with fractures of the femoral shaft. J Trauma. 1996;40:10-6.

Bartoníček J, Stehlík J, Douša P. Ipsilateral fractures of the hip, femoral shaft, distal femur and patella. Hip Int. 2000;10:174-7.

Palarčík J, Nestrojil P. Femoral reconstruction nail (in Czech). Rozhl Chir. 199574:305-12.

Tsai CH, Hsu HC, Fong YC, Lin CJ, Chen YH, CJ HSU. Treatment for ipsilateral fractures of femoral neck and shaft. Injury. 200940:778-2.

Ostermann PA, Neumann K, Ekkernkamp A, Muhr G. Long term results of unicondylar fractures of the femur. J Orthop Trauma. 1994;8(2):142-6.

Parker MJ, Das A. Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults. Cochrane Database of Systematic Rev. 2013;2:CD000339.

Becher H. Nagelung der Schenkelhalsfraktur bei gleichzei- tig bestehender Oberschenkelfraktur. Zentralbl Chir 1951;23:1609-12.

Deepak MK, Jain K, Rajamanya KA, Gandhi PR, Rupakumar CS, Ravishankar R. Functional outcome of diaphyseal fractures of femur managed by closed intramedullary interlocking nailing in adults. Ann Afr Med. 2012;11(1):52-7.

Hohman D, Affonso J, Budny J, Anders M. Calcaneal plate fixation of distal femoral fractures. Am J Orthop (Belle Mead, N.J.). 2012;41:140-3.

Hak DJ, Mauffrey C, Hake M, Hammerberg EM, Stahel PF. Ipsi- lateral femoral neck and shaft fractures: current diagnostic and treatment strategies. Orthopedics. 2015;38:247-51.

Kumar CY. Long proximal femoral nail in ipsilateral fractures of proximal femur and shaft of femur. Indian J Orthop. 2014;48:439-40.

Lambiris E, Giannikas D, Galanopoulos G, Tyllianakis M, Megas P. A new classification and treatment protocol for combined fractures of the femoral shaft with the proximal or distal femur with closed locked intramedullary nailing: Clinical experience of 63 fractures. Orthop. 2003;26:305-9.

Kang L, Liu H, Ding Z. Ipsilateral proximal and shaft femoral fractures treated with bridge-link type combined fixation system. J Orthop Surg Res. 2020;15:399.