**5. Essentials of surgical technique**

Our preference for all cases requiring internal fixation, is positioning in supine. A sterile and discardable torniquet is a useful adjunct which can be used to facilitate exposure, and can be later removed if needed, so it does not interfere with insertion of plates and/or retrograde nails. Whenever RIMN becomes part of the fixation method, we advocate the use of long nails, extending proximally to the metaphysis, in between the two trochanters. This may provide protection of the entire bone segment, therefore minimizing the risk of periprosthetic fractures.

If open reduction is indicated, whether the fracture is intraarticular or extraarticular, we have progressively shifted our choice to a lateral para-quadricipital approach. It was originally described as a trans-articular approach for fracture fixation with plates [60]. This allows excellent exposure of both femoral condyles, facilitating direct visualization and reduction of articular fragments, if present. Deep flexion of the knee allows for the whole contour of the articular surface to be assessed. At times, in cases of metaphyseal comminution (A3 or C2/C3 fractures), this approach allows the surgeon to directly reduce the condyles to the diaphysis, and use small plates or K wires for provisional fixation. Access to the femoral diaphysis can be undertaken by dividing longitudinally the quadriceps between the rectus anterior and vastus lateralis very proximally, to expose the intact proximal diaphysis. Direct assessment -and/or indirect assessment with fluoroscopy- of overall alignment can be done. The same approach allows for placement of a lateral locking plate onto the condyles, which is then slid proximally in a closed manner, to be finally attached to the proximal diaphysis with percutaneous screws.

For the combined use of RIMN and locking plates ("augmented RIMN"), and depending on the details of the fracture pattern as seen during exposure, at times the first implant to be used is the plate, which is fixed to bone with short (usually 30 or 32 mm long) locking screws distally and monocortical (14 mm long) locked screws to the diaphysis (**Figure 12**), in order to allow unobstructed insertion of a RIMN. Whenever possible, we attempt to have at least one locking screw inserted from the plate engaging one of the interlocking holes of the nail. This results in a much stronger construct distally. We should outline that, at the end of the procedure, and in light that proximal monocortical screws might toggle and loosen due to repetitive cantilever forces towards varus, the two most proximal screws in the plate are replaced with bicortical 4.5 large fragment screws. These usually have a trajectory tangential to the intramedullary nail, which enhances their resistance to pull out. Closure of the longitudinal quadriceps split is done with non-absorbable suture in order to restore continuity of the muscular unit, and to allow prompt full passive range of motion and active isometric muscle contraction.

*Management of Distal Femoral Fractures DOI: http://dx.doi.org/10.5772/intechopen.110692*

#### **Figure 12.**

*(a–c) Direct approach and reduction of the fracture by means of a lateral locking plate. Monocortical locked screws proximally and 30 mm-long locked screws distally were used for reduction and provisional fixation, allowing unobstructed insertion of a RIMN.*
