A 24-year-old male patient presented to us with severe right knee joint pain and restricted movements. He had had a road traffic accident four months before after which he refused any surgical intervention. He eventually came back to us in severe pain.
Plain radiographs show intra-articular oblique fracture traversing the lateral femoral condyle with its marked upward displacement. Distal end of femur is medially displaced with reduced joint space at lateral compartment. (Fig. 1, 2, 3)
Initial AP radiograph shows possible avulsion of lateral tibial plateau. Slightly angulated radiograph demonstrates classical Segond fracture. (Fig. 2)
MRI performed on 1.5 Tesla Philips scanner shows displaced oblique fracture of lateral femoral condyle extending from metaphysis up to the articular surface. According to Muller classification, it represents Type B1 fracture (sagittal, lateral condyle). (Fig. 4, 8)
Classical chipped off curvilinear bone fragment seen parallel to lateral tibial plateau representing Segond fracture. (Fig. 5).
Non-visualization of anterior cruciate ligament (ACL) noticed along with buckling of posterior cruciate ligament representing complete tear of ACL. (Fig. 6)
Complex tear of anterior horn and body of lateral meniscus is seen. (Fig. 7, 8)
STIR shows bone bruise at the fractured lateral femoral condyle. (Fig. 9).
Distal femoral fracture involving condyle of femur results from high and low energy injuries in young and elder patients respectively. A wide spectrum of associated soft tissue injuries are a common finding. [1]
Clinical perspective
Patients usually present with sudden, immense and sharp pain with weight bearing immediately after the injury followed by restricted movement. Later on swelling and bruising occur around the injury site. On examination, one can look for deformities, swelling, contusion or protruding bone through the skin. These fractures may be complicated by osteomyelitis, neurovascular damage, delayed consolidation / nonunion, compartment syndrome and septic arthritis. [2]
Imaging perspective
Conventional radiographs are the first line of investigation. CT is utilized in high grade injuries to assess intra-articular involvement and fracture fragments. [3] MRI is essential in all cases of intra-articular fractures to identify internal joint derangement. [4] There is a selective role of arteriography in some cases based on the history or clinical findings of ischaemia to map vascular injury, which has an incidence of around 37% in injuries involving the knee joint. [7]
Muller AO classification is the most widely used system for classifying distal femoral fractures. It was first published in 1987 by the AO Foundation as a method of categorizing injuries according to their localization and severity. Muller classification divides distal femoral fractures into 3 types, according to the localization of the fracture. [6]
Type A fractures : Extra-articular
Type B fractures : Partial articular
Type C fractures : Complete articular fractures with detachment of both condyles from the diaphysis.
These fracture types are further subdivided describing the degree of fragmentation and other, more detailed characteristics.
Fracture Type B is divided into:
B1 (sagittal, lateral condyle)
B2 (sagittal, medial condyle)
B3 (frontal, Hoffa type).
Fracture Type C is divided into:
C1 (articular simple, metaphyseal simple)
C2 (articular simple, metaphyseal multifragmentary)
C3 (multifragmentary). [5]
Outcome
Distal femoral fractures especially involving the condyles require surgery and a post-op brace to limit the range of motion. Surgical intervention includes open reduction and internal fixation using hardware to stabilize the fractured bone. A majority of fractures heal within the following 4 to 6 months, depending on the severity of the injury. When properly treated and rehabilitated most of the patients regain their full strength and range of motion in the injured leg. [4]. Our patient was also treated surgically with good outcome and minimum postoperative morbidity.
Take home massage
Distal femoral fractures need comprehensive radiological imaging to search for associated soft tissue injuries in addition to bone trauma. This provides a comprehensive road map to the orthopaedic surgeon.
Muller Type B1 (sagittal, lateral condyle) distal femoral fracture with associated Segond fracture
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From the provided right knee joint anteroposterior and lateral X-ray images, as well as MRI scans, the following can be observed:
Based on the imaging findings and the patient’s history of a high-speed injury (traffic accident), the possible diagnoses include:
Taking into account the patient’s age (24, commonly impacted by high-energy trauma), injury mechanism (traffic accident), clinical symptoms (severe knee pain and restricted mobility), and imaging that shows a fracture line involving the distal femoral articular surface in a coronal orientation, the most likely diagnosis is: Partial Intra-Articular Fracture of the Distal Femur (Hoffa Type, Müller AO B3).
Treatment Strategies:
Rehabilitation/Exercise Prescription (FITT-VP Principle):
During the early stage of fracture healing (approximately the first 6 weeks), focus on protective immobilization, followed by a gradual increase in joint mobility exercises. A suggested timeline and approach is as follows:
This report is for reference only and does not substitute for an in-person consultation or professional medical advice. If you have any concerns or experience any changes in your condition, please seek timely and direct guidance from an orthopedic specialist or appropriate medical professionals.
Muller Type B1 (sagittal, lateral condyle) distal femoral fracture with associated Segond fracture
