Injury Extra (2005) 36, 289—291

www.elsevier.com/locate/inext

CASE REPORT

Union after delayed presentation ofa Hoffa fracture

Rebecca Payne*, David Clark, Simon Wall

Worthing and Southlands District General Hospital, Trauma and Othopaedics,14 North Road, Wimbledon, London SW19 1AG, UK

Accepted 14 December 2004

Report

A fit and well, 50-year-old, construction sitegroundsman presented with a history of progres-sively worsening pain and swelling in his left knee.He felt a painful ‘clunk’ on flexion and extension. Hereported locking every 20 min, but was able tocontinue with his very physical job. Thirty-fouryears previously he had sustained major traumato the knee in an 80 mile an hour motorcycle acci-dent. The only medical records remaining from thattime are held at his general practitioners, and statethat he had ‘a left Colles fracture, a dislocated leftelbow, and a lateral condyle fracture of the leftfemur’. He cannot recall being told about a fractureto the knee, or what treatment he received for it,other than that no surgery was performed. He isclear that following prolonged rehabilitation hisknee felt fully recovered, and gave him no symp-toms until about eight years prior to this presenta-tion. There was no initiating factor for theemergence of symptoms, such as re-injury.

On examination, it was noted that he had a blockto full extension, and an effusion. There was cre-pitus in the medial and lateral compartments. Thecruciate and collateral ligaments were stable.

* Corresponding author. Tel.: +44 208 543 6173.E-mail address: becky_payne@hotmail.com (R. Payne).

1572-3461/$ — see front matter # 2004 Elsevier Ltd. All rights resedoi:10.1016/j.injury.2004.12.054

McMurray’s test resulted in palpable clicks, but nopain. There was a palpable mass laterally. This wasshown on radiographs to be the inferior part of thelateral condyle, which appeared to be posteriorlydisplaced. The fragment was nearly reduced inflexion, but displaced at the limit of the patientsextension (Fig. 1). There was also marked degen-erative changes in all three compartments.

A decision was made to attempt reduction andinternal fixation, with a view to later arthroplasty.To attempt arthroplasty following excision of thefragment would require extensive augmentation ofthe posterior lateral femoral condyle.

The procedure was performed openly, through amid-lateral incision. A pseudarthrosis was evident,and this was excised. Iliac crest bone graft was used,and the fracture fragment was fixed with twoscrews. The patient was mobilised touch weight-bearing for six weeks, followed by a further sixweeks of partial weight-bearing.

The fracture progressed to satisfactory union,and now provides a stable platform for total kneereplacement, should the patients symptoms requireit (Fig. 2). The patients symptoms of giving way and‘clunking’ have resolved. He is now complaining ofpain that appears to be patello-femoral joint inorigin, and certainly has evidence of degenerationin that compartment on radiographs. He has not yetdecided to undergo total knee replacement, but as a

rved.

290 R. Payne et al.

Figure 1 (a) Reduction in flexion; (b) displacement in extension.

result of the solid union of his Hoffa fracture, he hasadequate bone stock to receive a standard uncon-strained prosthesis.

Discussion

Fractures of the femoral condyles account for lessthan 1% of femoral fractures, and are usually theresult of high energy trauma.2 Accordingly, they areoften associated with multiple injuries. Lateral con-dylar fractures are three times as common as medialones. The AO classification of fractures of the distalfemur describes three types of unicondylar fracture.Type B1 fractures are fractures in the sagital planeof the lateral condyle, B2 fractures are similar

fractures of the medial condyle. Type B3 (or Hoffafractures) are fractures in the coronal plane ofeither condyle.4 These have been further classifiedby Letenneur according to the line of the fracture.Type I have vertical fracture lines, type II are hor-izontal to the base of the condyle and type III areoblique.1 This last type was the fracture sustainedby our patient.

Hoffa fractures are inherently unstable, due tothe bony instability as well as the pull of the gastro-cneimus and popliteus. In some fractures, the pos-terior capsule may be the only soft tissueattachment, and they are also, therefore, proneto avascular necrosis. Due to these factors, therecommended treatment is open or arthroscopicreduction and internal fixation. The cruciate liga-

Union after delayed presentation of a Hoffa fracture 291

Figure 2 Post operative AP.

ments and menisci should also be assessed for asso-ciated injury.

In this case, the patient cannot recall being toldof a fracture to the knee, or even whether heunderwent treatment in a cast. The fracture hadobviously been identified, as it was mentioned in his

general practitioner’s records. He is clear that fol-lowing the prolonged rehabilitation from his inju-ries, his knee felt fully recovered, and gave him nosymptoms until approximately eight years beforethis presentation. This was now 34 years after theinjury. It is possible that the fracture had healedwith a fibrous pseudarthrosis which had eventuallyfailed. Due to the patient having joint degenerationin three compartments, it was felt that the bestoption was to attempt union at the fracture site,before proceeding to a total knee replacement ifsymptoms required it. There is one report in theliterature of non-union of a similar fracture in aneight-year-old child. There was a five-year delaybefore fixation of the fracture, and it went ontosuccessful union, and a virtually asymptomaticknee.3

Our case shows the natural history of these frac-tures in adults if they are treated conservatively. Italso demonstrates that internal fixation with bonegrafting can be a successful treatment option, evenin a case with presentation as delayed as in ours.

References

1. Letenneur J, Labour P, Rogez J, Lignon J, Bainvel J. Fracturesde Hoffa. Ann Chir 1978;32:213—9.

2. Manfredini M, Gildone A, Ferrante R, Bernasconi S, Massari L.Unicondylar femoral fractures: therapeutic strategies andlong-term results. A review of 23 patients. Acta Orthop Belgica2001;67(2):132—8.

3. McDonough PW, Bernstein RM. Non-union of a Hoffa fracture ina child. J Orthop Trauma 2000;14(7):519—21.

4. Ostermann PAW, Neumann K, Ekkernkamp A, Muhr G. Longterm results of unicondylar fractures of the femur. J OrthopTrauma 1994;8(2):142—6.