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CASE REPORT
Year : 2015  |  Volume : 15  |  Issue : 3  |  Page : 291-294

Hoffa fracture rehabilitation


1 Department of Orthopaedics, HIMSR, Jamia Hamdard, New Delhi, India
2 Department of Rehabilitation Sciences, HIMSR, Jamia Hamdard, New Delhi, India
3 Department of Radio Diagnosis, AIIMS, New Delhi, India

Date of Web Publication2-Sep-2015

Correspondence Address:
Zuheb Ahmed Siddiqui
Department of Rehabilitation Sciences, 5th Floor, Central Library Building, HIMSR, Jamia Hamdard, New Delhi - 110 062
India
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DOI: 10.4103/1319-6308.164320

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  Abstract 

Isolated coronal fractures of the femoral condyle called as Hoffa's fracture is an uncommon injury. Hoffa fractures occur following high energy trauma with a preponderance of lateral femoral condyle. A medial condyle Hoffa fracture is even rare with very few cases reported in the literature. A careful examination along with oblique radiographs and computed tomography scan is needed for an accurate diagnosis. Conservative management is associated with poor results due to continuous shear stresses imposed on the fracture. Surgical management with anatomical reduction and rigid fixation allows early functional rehabilitation. We report a case of 19-year-old female injured during a fall and suffered medial condyle Hoffa fracture. The fracture was fixed with cannulated cancellous screws. Physiotherapy was initiated early promoting early mobilization and decreasing the risk of complications although weight bearing was graduated. After 6 months, the patient demonstrated full motion at the knee with no complaints of instability and snapping.

  Abstract in Arabic 


إعادة تأهيل المصابين بعد كسر هوفا - تقرير حالة:
يعرف الكسر التآجي للنتوء العظمي لعظم الفخذ بكسر " هوفا " وهوكسر غير شائع ، ويحدث كسر هوفا بعد التعرض لصدمة قوية في الغالب للنتوء الجانبي لعظم الفخذ وهو كسر نادر الحدوث وقد تم تسجيل حالات قليلة في المنشورات العلمية. ويتطلب التشخيص الدقيق الفحص الدقيق مع عمل صور أشعة جانبية ومغنطيسية وقد يرافق العلاج التحفظي نتائج متدنيه نتيجة لإجهاد المتواصل الذى فد يتعرض اليه موقع الكسر. أما الحل الجراحى فيسهل إرجاع الكسر وتثبيته بمتانة من ثم التأهيل الوظيفي المبكر، سجلنا حالة بكسر هوفا للنتوء الاوسط لأنثى تبلغ من العمر 19عاماً وتم تثبيت الكسر بواسطة براغي مسامية أنبوبية ثم بدأ العلاج الطبيعي مبكراً لتحفيز الحركة المبكرة والتقليل من المضاعفات. ونصح المريض بعدم تعرض مكان الكسر لحمولة الوزن الا تدريجياً. وبعد 6 أشهر أظهرت المريضة القدرة على الحركة الكاملة في مفصل الركبة من غير إي شكوى من عدم الثبات.

Keywords: Hoffa fracture, medial condyle, rehabilitation


How to cite this article:
Kumar S, Siddiqui ZA, Kumar S, Vyas S. Hoffa fracture rehabilitation. Saudi J Sports Med 2015;15:291-4

How to cite this URL:
Kumar S, Siddiqui ZA, Kumar S, Vyas S. Hoffa fracture rehabilitation. Saudi J Sports Med [serial online] 2015 [cited 2019 Nov 20];15:291-4. Available from: http://www.sjosm.org/text.asp?2015/15/3/291/164320


  Introduction Top


Unicondylar fractures of the distal femur in the coronal plane are an unusual presentation. [1] In 1904, this fracture was described by Albert Hoffa as an intra-articular fracture of the femoral condyle in coronal plane commonly affecting the lateral femoral condyle. [2] It is typically seen in adults following high energy trauma. However, the injury is overlooked if associated with supracondylar fracture or undisplaced. [3] Conservative treatment has been associated with poor functional outcomes with malunion as one of the late complications. [4],[5] Operative treatment with reduction and internal fixation is recommended to allow early functional rehabilitation and decrease the incidence of complications. [2] This case report highlights rehabilitation following surgical fixation of medial condyle Hoffa fracture in a young collegiate female.


  Case Report Top


A 19-year-old female suffered a fall while deboarding a bus and injured her left knee. Subsequently she was unable to bear weight and was taken to the trauma center immediately. She reported pain and swelling in the left knee. All movements at the knee joint were painful and restricted. A lateral view radiograph [Figure 1] of the left knee revealed coronal plane fracture of the medial femoral condyle. The patient underwent closed reduction under image intensifier and internal fixation [Figure 2] for the left knee with three cannulated cancellous screws [Figure 3] of size 6.5 mm. Physiotherapy was administered during the hospital stay. After discharge from the hospital, the patient underwent a rehabilitation program.
Figure 1: Preoperative X-ray (lateral view)

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Figure 2: Postoperative radiograph (lateral view)

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Figure 3: Postoperative radiograph (anteroposterior view)

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The rehabilitation program focused on strength improvement, a range of motion (ROM) and gait training. Physiotherapy was initiated from day 1, which consisted of isometric strengthening for quadriceps and glutei, ankle-toe movements, and gentle hip ROM exercises. Following discharge, the patient was also prescribed a home program. After 2 weeks, above knee slab was removed and the patient was given a hinged knee brace. The continuous passive motion was initiated to allow the patient to regain full ROM. Isometric muscle strengthening was performed for hamstrings, quadriceps, and glutei.

At 4 weeks postoperatively, continuous passive movement range was gradually increased to 0°-90° of knee flexion. Strengthening exercises were progressed to achieve good quadriceps strength. Heel props were initiated to increase knee extension. Ankle strengthening using resistance bands was initiated. The patient progressed to partial weight bearing after 8 weeks. Strengthening of quadriceps was progressed with weights in quadriceps table. Elastic resistance was used for hip and ankle muscle strengthening. Progress of the patient was noted with knee ROM as 135° of flexion.

Full weight bearing was initiated at 14 weeks. Patient continued to perform straight leg raise in 3 planes. Gait training and conditioning was progressed to treadmill walking.

After 6 months postoperatively, full ROM was achieved at knee and progress was noted with 140° of knee flexion and full extension with no complaints of snapping or instability. Patient was prescribed a home program designed to attain rehabilitation goals for improving strengthening, gait training, and functional limitations. Follow-up X-ray showed no signs of implant breakage and avascular necrosis [Figure 4] and [Figure 5].
Figure 4: X-ray after 6 months (lateral view)

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Figure 5: X-ray after 6 months (anteroposterior view)

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  Discussion Top


Coronal shear fractures of the distal femoral condyles, called Hoffa's fracture are rare injuries representing 0.65% of all femoral fractures. [6] The lateral femoral condyle is more commonly involved than medial femoral condyle, although bicondylar fractures have been described. [7] Nork et al. described a relative incidence of lateral condyles as high as 78%. [3] The exact mechanism of injury is not known, studies have implicated a shearing force on the posterior femoral condyle. In a flexed knee, the oblique transverse force resulting from axial loading of the knee with the transmission of ground reaction force through tibial plateau produces posterior tangential fracture patterns. [1] Physiologic valgus at the knee creates an anatomical - biomechanical vulnerability to the lateral femoral condyle. [7]

Hoffa fractures are sometimes difficult to detect on plain radiographs especially when undisplaced. [8] Oblique radiographs may be helpful although a computed tomography scan is recommended for accurate diagnosis and treatment planning. [9],[10] Letenneur et al. divided Hoffa fractures into three types based on the distance of the fracture line from the posterior cortex of the femoral shaft. [5]

Unicondylar fractures are unstable and have a tendency to displace due to the rotation caused by muscle contraction of gastrocnemius and soleus. [11] Also, the orientation of the fracture line creates a sliding force favoring upward movement of the condyle. [9],[12] Hoffa fractures can be managed either conservatively or surgically. Conservative management is usually not recommended and often leads to malunion, instability, avascular necrosis, joint contractures, and knee flexion deformity. [8],[13],[14] Medial condyle Hoffa fracture are associated with articular comminution, thereby making reduction difficult. Surgical stabilization is necessary to obtain an anatomic reduction to avoid articular incongruence and prevent axial malalignment and arthritis. [15]

In our case, a young female reported with a medial condyle Hoffa fracture. The patient underwent surgical stabilization under image intensifier with internal fixation. After slab removal, continuous passive motion was initiated focusing on increasing and maintaining knee ROM. [13] Isometric strengthening of quadriceps, hamstrings and hip muscles were performed to prevent abnormal gait patterns. [6] The patient progressed to partial weight bearing at 8 weeks. The rehabilitation goals were to improve mobility, muscle strength, and gait training. After 14 weeks, full weight bearing was initiated, and patient began performing balance and conditioning activities.


  Conclusion Top


Medial condyle Hoffa fracture is a rare injury. Operative fixation is necessary to achieve good reduction and adequate stability permitting early rehabilitation. Following surgery, the rehabilitation program should focus on achieving full knee ROM and good hip and knee muscle strength. However, weight bearing must be delayed until the fracture has united properly. A home program focusing on improving strength, balance and better performance of daily activities must be advised.

 
  References Top

1.
Lewis SL, Pozo JL, Muirhead-Allwood WF. Coronal fractures of the lateral femoral condyle. J Bone Joint Surg Br 1989;71:118-20.  Back to cited text no. 1
    
2.
Arastu MH, Kokke MC, Duffy PJ, Korley RE, Buckley RE. Coronal plane partial articular fractures of the distal femoral condyle: Current concepts in management. Bone Joint J 2013;95-B: 1165-71.  Back to cited text no. 2
    
3.
Nork SE, Segina DN, Aflatoon K, Barei DP, Henley MB, Holt S, et al. The association between supracondylar-intercondylar distal femoral fractures and coronal plane fractures. J Bone Joint Surg Am 2005;87:564-9.  Back to cited text no. 3
    
4.
Butt MS, Krikler SJ, Ali MS. Displaced fractures of the distal femur in elderly patients. Operative versus non-operative treatment. J Bone Joint Surg Br 1996;78:110-4.  Back to cited text no. 4
    
5.
Letenneur J, Labour PE, Rogez JM, Lignon J, Bainvel JV. Hoffa's fractures. Report of 20 cases (author's transl). Ann Chir 1978;32:213-9.  Back to cited text no. 5
    
6.
Manfredini M, Gildone A, Ferrante R, Bernasconi S, Massari L. Unicondylar femoral fractures: Therapeutic strategy and long-term results. A review of 23 patients. Acta Orthop Belg 2001;67:132-8.  Back to cited text no. 6
    
7.
Yucel I, De¢girmenci E, Ozturan K. Hoffa fracture - A case report. Duzce Tıp Fak Dergisi 2008;2:37-40.  Back to cited text no. 7
    
8.
Allmann KH, Altehoefer C, Wildanger G, Gufler H, Uhl M, Seif el Nasr M, et al. Hoffa fracture - A radiologic diagnostic approach. J Belge Radiol 1996;79:201-2.  Back to cited text no. 8
    
9.
Holmes SM, Bomback D, Baumgaertner MR. Coronal fractures of the femoral condyle: A brief report of five cases. J Orthop Trauma 2004;18:316-9.  Back to cited text no. 9
    
10.
Neogi DS, Singh S, Yadav CS, Khan SA. Bicondylar Hoffa fracture - A rarely occurring, commonly missed injury. Inj Extra 2008;39:296-98.  Back to cited text no. 10
    
11.
Sahu RL, Gupta P. Operative management of Hoffa fracture of the femoral condyle. Acta Med Iran 2014;52:443-7.  Back to cited text no. 11
    
12.
Cheng PL, Choi SH, Hsu YC. Hoffa fracture: Should precautions be taken during fixation and rehabilitation? Hong Kong Med J 2009;15:385-7.  Back to cited text no. 12
    
13.
Ostermann PA, Neumann K, Ekkernkamp A, Muhr G. Long term results of unicondylar fractures of the femur. J Orthop Trauma 1994;8:142-6.  Back to cited text no. 13
    
14.
Kumar R, Malhotra R. The Hoffa fracture: Three case reports. J Orthop Surg (Hong Kong) 2001;9:47-51.  Back to cited text no. 14
    
15.
Lal H, Bansal P, Khare R, Mittal D. Conjoint bicondylar Hoffa fracture in a child: A rare variant treated by minimally invasive approach. J Orthop Traumatol 2011;12:111-4.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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