OT notes · Orthopaedics

Distal femur fixation (DCS / distal femoral locking plate)

Usual anaesthesia
Spinal or general
Position
Supine on a radiolucent table with a hip bump, knee flexed over a sterile removable bump or triangle, C-arm from the opposite side
Setting
emergency

Operative note template for plate fixation of a distal femoral fracture with a lateral locking plate or a dynamic condylar screw (DCS), with a filled example for a limited lateral approach and submuscular locking plate for a closed AO type C1 fracture. The assigned books give the locking plate technique step by step; for the DCS they give only its indications and limits, so DCS-specific insertion steps are kept general.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • malunion (valgus, varus, rotation, shortening)
  • non-union, need for bone graft
  • implant failure or loosening
  • infection
  • knee stiffness
  • post-traumatic arthritis of the knee
  • DVT, pulmonary embolism, fat embolism
  • nerve or vessel injury

Pre-operative details for this operation

  1. Fracture classification (OTA/AO 33)A1A2A3B1B2B3 (Hoffa)C1C2C3open or closed; if open, grade and wound
  2. CT findingsintercondylar split, coronal (Hoffa) fragment, comminution
  3. Intact condylar bone above the notchin cm; DCS and blade plate need at least 3-4 cm of intact condyle
  4. Distal neurovascular status and soft tissuespulses, sensation, movement; swelling, blisters; temporary external fixator in place or not
  5. Associated injuriesipsilateral hip / shaft / tibial plateau fracture; knee arthroplasty above which fracture lies
  6. Templating and implants availableplate length and type, screw sizes, bone graft or substitute
  7. Blood arrangedgroup, units

Anaesthesia and position

  1. AnaesthesiaSpinalCombined spinal-epiduralGeneral
  2. Table and positionradiolucent table, supine, hip bump; rotation matched to other side using lesser trochanter profile and patella-up knee
  3. Knee bumpsterile bump or triangle under knee to relax gastrocnemius
  4. TourniquetNot usedSterile tourniquetpressure, time up and down
  5. C-armfrom opposite side; notch view available

Operative findings

  1. Articular surfacenumber of fragments, intercondylar split, coronal fragment, cartilage damage
  2. Metaphysiscomminution, bone loss
  3. Bone qualityGoodOsteoporotic
  4. Final alignment on C-armlength, rotation, varus / valgus, flexion / extension; notch view: no screw in notch

Procedure (steps)

  1. ApproachLimited lateral (5-6 cm) with submuscular plateStraight lateralMidline with lateral parapatellar arthrotomyMedial / subvastus (B2, B3, or second plate)incision length; iliotibial band incised in line; LCL preserved; medial soft tissue not stripped
  2. Length and rotation restoredManual tractionFemoral distractorTemporary external fixator used as distractor
  3. Articular reductiondirect view; pointed reduction clamp; K-wires or guide pins kept outside the plate zone
  4. Articular fixationlag screws outside the plate (size, number, headless / countersunk) or through the plate
  5. Metaphysis to shaft reductionK-wires / Steinmann pins / bumps to correct extension of distal fragment; comminution left undisturbed
  6. ImplantDistal femoral locking plate (fixed-angle)Variable-angle locking plateDynamic condylar screw (95 degree) with side plate95 degree blade plateCondylar buttress plate (non-locking)number of holes, side, make
  7. Distal fixationfirst guide wire through central hole parallel to the joint (joint wire as reference); number and size of distal locking screws; notch view checked
  8. Plate position on shaftsubmuscular slide with Cobb elevator; lateral C-arm to confirm plate on bone proximally and not too posterior or distal
  9. Proximal fixationreduction screw to pull shaft to plate if needed; number of proximal screws (locking / non-locking); working length; percutaneous stab incisions with targeting guide
  10. Bone graft / substituteNot neededAutograft (site)Bone substitute (type, volume)
  11. Final checkAP and lateral C-arm; mechanical axis with diathermy cord; knee put through full range; images saved

Closure, drains and dressing

  1. Wash and drainirrigation; drain in knee or under fascia, brought out laterally
  2. Arthrotomy / iliotibial bandsuture material and technique
  3. Subcutaneous tissuesuture
  4. Skin and stab incisionsStaplesInterrupted sutures
  5. Dressing and bracehinged knee brace / splint and position
  6. Distal pulses at end

Specimens and implants

  1. Platetype, side, number of holes, material (steel / titanium), make, lot, sticker
  2. Screwsfor each: type (locking / cortical / cancellous / headless), diameter, length, position
  3. DCS (if used)lag screw length, side plate angle and holes, compression screw
  4. Bone substitutetype, volume, lot
  5. C-arm images savednumber

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Limb elevation and neurovascular checks
  2. Drainremove by 48 h
  3. Knee brace and motione.g. hinged brace locked in extension till wound healed, then full motion; CPM if available
  4. Weight bearingplate fixation: toe-touch for 6-8 weeks, then partial for 4-6 weeks, then full, adjusted to fracture and X-ray
  5. DVT prophylaxisLMWH if obese, multiply injured, previous DVT or poorly mobile; drug, dose, duration
  6. Analgesia and cold therapy
  7. Check X-rayAP and lateral femur with knee
  8. Physiotherapyrange of motion and strengthening; quadriceps and ankle pumps from day 1
  9. Stitches / staplesremoval date

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. S.D., 46 years, 70 kg, fall from a two-wheeler. Closed fracture of the right distal femur, AO 33-C1: undisplaced simple intercondylar split with a simple supracondylar fracture. No Hoffa fragment on CT. Distal pulses normal.

Case details

Date: 19/08/2026. Elective trauma list, injury day 3. OT 3.

In OT 09:00. Spinal 09:12. Incision 09:40. Closure 11:55.

Surgeon: Dr A. (consultant). Assistant: Dr B. (3rd-year resident, Orthopaedics), who did the approach, articular screws and closure.

Anaesthetist: Dr C. Scrub nurse: Sr D. Radiographer: Mr E.

Indication and pre-op

AO 33-C1 fracture right distal femur, closed, soft tissue swelling settled. Plan: articular lag screws and lateral distal femoral locking plate through a limited lateral approach.

Pre-op: pulses palpable, sensation and toe movement normal. Hb 11.8 g/dl. 2 units cross-matched.

Templated on X-ray: 13-hole plate. Implant set, C-arm and radiolucent table checked.

Consent in Hindi. Right thigh marked. WHO checklist done. Inj cefazolin 2 g IV at 09:25, before incision.

Anaesthesia and position

Spinal anaesthesia. Supine on radiolucent table, bump under right hip adjusted so lesser trochanter profile matched the left side with patella facing up.

Sterile triangle under the knee. No tourniquet. C-arm from the left side.

Painted with povidone-iodine and draped, whole leg free.

Procedure

Lateral incision 6 cm from joint line upwards, curved slightly towards the tibial tubercle distally. Iliotibial band incised in line. Lateral femoral condyle exposed; lateral collateral ligament preserved.

Findings: intercondylar split undisplaced, joint surface intact. Supracondylar fracture transverse with a small medial wedge. Bone quality good.

Condyles compressed with a large pointed reduction clamp. Two guide wires placed anteriorly and posteriorly, outside the plate area. Two 6.5 mm partially threaded cannulated cancellous screws with washers, 70 mm and 75 mm, across the condyles.

Length and rotation restored with manual traction. Extension of the distal fragment corrected with a bump under the fracture. Temporary Steinmann pin across the fracture outside the plate zone.

Submuscular plane made up the lateral shaft with a Cobb elevator. 13-hole right lateral distal femoral locking plate slid under vastus lateralis.

Joint reference wire placed. Guide wire through the central distal hole parallel to the joint. Lateral C-arm: plate on bone proximally. Proximal end held with a guide wire through the targeting guide.

Length, rotation and sagittal alignment rechecked. Five 5.0 mm locking screws in the distal segment; notch view: no screw in the notch or joint.

Proximal end: one 4.5 mm cortical screw first to pull the shaft to the plate, then four 5.0 mm locking screws through stab incisions with the targeting guide, leaving holes empty next to the fracture for working length.

Final C-arm AP and lateral: length and rotation equal to left side, alignment restored, plate central on the shaft. Mechanical axis checked with the diathermy cord through the centre of the knee. Knee moved through full range. 10 images saved.

Closure

Wound washed with saline. Suction drain under the iliotibial band brought out laterally.

Iliotibial band closed with polyglactin 910 (Vicryl) 1. Subcutaneous tissue Vicryl 2-0. Skin and stab incisions with staples.

Dressing. Hinged knee brace locked in extension. Pulses palpable at end.

Specimens and implants

13-hole right lateral distal femoral locking plate, titanium. 5 distal and 4 proximal 5.0 mm locking screws (lengths on implant sheet), one 4.5 mm cortical screw 40 mm. Two 6.5 mm partially threaded cannulated cancellous screws, 70 and 75 mm, with washers.

Make, lot and batch as on packets; stickers pasted in case sheet and implant register.

No specimen. 10 C-arm images saved.

End of procedure

Estimated blood loss 350 ml. No transfusion. Mop, needle and instrument count correct. No intra-operative complications.

Shifted to recovery, stable. Pulse 84/min, BP 128/80 mmHg.

Post-op orders

Right leg elevated. Distal pulses and toe movement 2-hourly for 12 h.

Drain output charted; remove at 48 h.

Hinged knee brace locked in extension for 2 weeks, then full motion. Quadriceps sets and ankle pumps from POD 1.

Toe-touch weight bearing with walker for 6 to 8 weeks.

DVT prophylaxis as per unit protocol after risk assessment.

Check X-ray right femur with knee, AP and lateral, on POD 1. Staples out at 2 weeks.

Signature

Dr B., JR-3, Orthopaedics, for Dr A. Reg. no. ________. 19/08/2026, 12:15.

Must document for this operation

  • Fracture type (OTA/AO), including any coronal (Hoffa) fragment and how it was fixed. A missed coronal fragment is a known cause of poor results, and the next surgeon needs to know what was fixed.
  • How rotation and length were checked (other-side lesser trochanter profile, C-arm) and the final result. Malrotation after distal femoral plating is common; the note shows it was checked.
  • Plate length, number of screws in each fragment, and which holes were left empty. Construct length and working length affect healing and failure; they are needed if the plate fails.
  • Notch view confirming no screw in the joint or notch. Protects against a claim of intra-articular screw and shows the check was done.
  • Implant make, lot and stickers, including the articular screws. Needed for implant traceability, recall, and removal later.
  • Whether medial soft tissue was left undisturbed and whether bone graft was used. These affect the chance of union and the need for later grafting.

Common mistakes in these notes

  • Writing 'distal femur plating done' with no plate length or screw count.
  • No record of rotation check.
  • Articular lag screws not listed separately from the plate screws.
  • Weight-bearing instruction left as 'as advised'.
  • Not stating whether the fracture was intra-articular and how the joint was seen.

Indian practice and paperwork

  • Record batch and serial numbers of the plate and screws in the case sheet, the implant logbook and the discharge summary. (NABH Accreditation Standards for Hospitals, 5th ed. (2020), MOM.10(d))
  • Under PM-JAY, stratification can depend on anaesthesia type and technique, so the note should state both and match the booked package. (NHA Health Benefit Package 2.2 user guidelines)

Sources

  • Wiesel SW, Albert TJ, eds. Operative Techniques in Orthopaedic Surgery. 3rd ed. Vol 1. Wolters Kluwer; 2022, Trauma ch 13, Open reduction and internal fixation of the distal femur (Agarwal A), e-book PDF pp. 1245-1275.
  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2027, Ch 59, Fractures of the lower extremity: distal femur, plate and screw fixation, dynamic condylar screw fixation, condylar plate fixation, pp. 2627-2628.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Implantation of internal fixation devices: cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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