Case Report Open Access
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World J Clin Cases. Dec 26, 2022; 10(36): 13458-13466
Published online Dec 26, 2022. doi: 10.12998/wjcc.v10.i36.13458
Hoffa's fracture in a five-year-old child diagnosed and treated with the assistance of arthroscopy: A case report
Zhi-Hao Chen, Hai-Fan Wang, Hao-Yu Wang, Fei Li, Jian-Long Ni, Zhi-Bin Shi, The First Department of Orthopaedics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an Jiaotong University, Xi'an 710004, Shaanxi Province, China
Xue-Feng Bai, Department of Orthopaedics, Xi’an Daxing Hospital, Xi'an 710016, Shaanxi Province, China
ORCID number: Zhi-Hao Chen (0000-0002-7499-7507); Fei Li (0000-0002-7282-1938); Zhi-Bin Shi (0000-0002-4488-080X).
Author contributions: Shi ZB provided this case and provided the relevant fund; Chen ZH and Wang HF drafted the majority of the manuscript; Wang HY, Li F, Bai XF and Ni JL collected all the materials; All authors have read and approved the final version.
Informed consent statement: Informed written consent was obtained from the patient.
Conflict-of-interest statement: All the authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Zhi-Bin Shi, MD, Professor, The First Department of Orthopaedics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an Jiaotong University, No. 157 Xiwu Road, Xi'an 710004, Shaanxi Province, China. zbshixjtu@163.com
Received: October 17, 2022
Peer-review started: October 17, 2022
First decision: October 27, 2022
Revised: November 5, 2022
Accepted: November 22, 2022
Article in press: November 22, 2022
Published online: December 26, 2022
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Abstract
BACKGROUND

Hoffa's fracture is a coronal-oriented fracture of the femoral condyle. It is rarely observed in pediatric patients that isolated coronal fracture of the medial femoral condyle accompanies an intact lateral femoral condyle. Only a few cases involving Hoffa's fracture of the medial femoral condyle have been reported in patients with undeveloped skeletons. Such a fracture cannot be observed by routine imaging examinations, thus resulting in possible misdiagnosis and further treatment challenges.

CASE SUMMARY

A 5-year-old boy with Hoffa's fracture of the medial femoral condyle suffered from right knee pain and severe swelling after being hit by a heavy object. The patient was misdiagnosed and initially treated in a local primary healthcare center. No improvement in his right knee’s extension was observed following conservative treatment for 2 wk. The patient was transferred to our hospital, re-diagnosed using arthroscopy, and underwent open reduction and internal fixation. The therapeutic outcome was satisfactory with the screws removed 7 mo after fixation. At the final follow-up of 40 mo, the range of motion in the knee had recovered. There was no varus-valgus instability.

CONCLUSION

Hoffa's fracture is rarely seen in children aged 5 years, let alone in the medial condyle, and can easily be misdiagnosed due to limited physical and imaging examinations. Suspected Hoffa's fracture in preschool children should be confirmed based on arthroscopic findings. Open reduction and internal fixation should be performed to protect the articular surface and prevent long-term complications.

Key Words: Hoffa's fracture, Pediatrics, Medial femoral condyle, Missed diagnosis, Arthroscopy, Open reduction-internal fixation, Case report

Core Tip: Hoffa’s fracture is a rare fracture pattern of femoral condyle, it has special coronal fracture slice. When it happens in children, this fracture is very easy to be missed. The medial condyle Hoffa’s fractures are especially uncommon. We report Hoffa’s fracture of the medial condyle in a 5-year-old child, the youngest patient ever reported, who was misdiagnosed in the first place. Eventually, we diagnosed the disease with arthroscopy and completed the operation with its assistance, successfully avoiding the radiation damage caused by computed tomography scans to toddler. Meanwhile, a clear and concise review of literature is also included in our study.



INTRODUCTION

Hoffa's fracture, named after Albert Hoffa in 1904 following his detailed research on this disease[1], is an unusual fracture type on the coronal plane of the femoral condyle. Hoffa's fractures of the lateral femoral condyle are commonly seen, while Hoffa's fractures of the medial femoral condyle are rare, especially in individuals with undeveloped skeletons. The latest case was a 16-year-old girl with Hoffa's fracture of the medial femoral condyle reported by Jiang et al[2] in 2022. This type of fracture is an intra-articular fracture and is clinically treated under the same principles as a typical intra-articular fracture. But this type of injury is often misdiagnosed due to a lack of clinical suspicion and radiographic examinations. In this report, we present the case of a 5-year-old boy with unusual type of injury misdiagnosed in a local hospital. Arthroscopy was performed to confirm the medial Hoffa's fracture. Later, open reduction and internal fixation were successfully applied to the patient for treatment.

CASE PRESENTATION
Chief complaints

A 5-year-old boy was transferred to the Department of Orthopedics in our hospital due to right knee pain and swelling, and an inability to bear weight and extend the right knee.

History of present illness

The patient had right knee pain and an inability to extend the knee following 2 weeks of conservative treatment.

History of past illness

The boy had no history of severe diseases, surgery or long-term medication.

Personal and family history

The patient’s family had no related diseases.

Physical examination

His right knee was swollen, skin was intact with tenderness on palpation, and limited mobility. No distal neurovascular deficits were observed. He was alert, articulate, and a reliable reporter. No other weakness, stiffness, or edema was found.

Laboratory examinations

Results of laboratory examinations were unremarkable.

Imaging examinations

X-Ray showed a stable fracture in the medial femoral condyle with no displacement (Figure 1). A local orthopedist suggested conservative treatment. Computed tomography (CT) is considered efficient in the diagnosis of adult Hoffa's fracture. However, in this case, the thick cartilage of the distal femoral epiphyseal area made it difficult to evaluate the fracture[1,3,4]. The area of high signal on magnetic resonance imaging (MRI) also indicated no severe displacement (Figure 2).

Figure 1
Figure 1 X-ray before surgery shows a stable fracture in the medial femoral condyle with no displacement. A: Anterior-posterior view of X-ray; B: Lateral view of X-ray.
Figure 2
Figure 2 Magnetic resonance imaging before surgery indicated no severe displacement. A: Sagittal slice of lateral condyle of femur; B: Most lateral slice of femoral intercondylar notch; C: Most medial slice of femoral intercondylar notch; D: Sagittal slice of medial condyle of femur.
FURTHER DIAGNOSTIC WORK-UP

Arthroscopy was performed to confirm the diagnosis. Different from the findings on the imaging examinations, obvious fracture displacement of the cartilage was found (Figure 3).

Figure 3
Figure 3  Arthroscopy showed obvious fracture displacement of the cartilage.
FINAL DIAGNOSIS

Hoffa's fracture of the medial femoral condyle.

TREATMENT

Arthroscopic exploration and diagnosis were performed at the beginning of the operation. The presence of steps and micromovement at the fracture ends could be seen during arthroscopy. However, due to instability of the bone mass caused by the now old injury (more than 2 wk), it was difficult to achieve a satisfactory reduction via arthroscopy. Therefore, open reduction was scheduled (Figure 4). Two 3.0 mm partially-threaded cancellous screws placed perpendicular to the fracture line were used to reduce the fracture. To avoid epiphyseal injury, a screw of appropriate length was placed through the metaphysis. Countersunk screws were also placed through the articular cartilage.

Figure 4
Figure 4  The operation was completed using the medial parapatellar approach.
OUTCOME AND FOLLOW-UP

Following open reduction and internal fixation, the patient wore a knee brace with 30° of knee flexion for approximately 2 wk. Afterwards, gradually begin to work on the range of motion of the knee. The patient was strictly instructed to avoid any weight-bearing bending until the sixth week, in order to minimize the shear force on his coronation. Partial weight-bearing began after the sixth week, then progressing to full weight-bearing (FWB) by the tenth week. At the six-month follow-up, he could walk without support. The knee range of motion was 5° to 100° (Figure 5). No angular deformity or limb-length discrepancy was observed. X-ray showed that the fracture healed well and there was no sign of femoral condyle collapse (Figure 6). The screws were removed after 7 mo. At the final follow-up of 40 mo, the KSS score was 100. The patient had full range of motion, with no varus-valgus instability (Figure 7).

Figure 5
Figure 5 Six months after surgery, the range of motion of the knee joint reached 5°-100°. A: Maximum flexion position; B: Maximum extension position.
Figure 6
Figure 6 Plain radiographs showed a well-healed fracture with no evidence of collapse of the femoral condyle. A: Anterior-posterior view of X-ray; B: Lateral view of X-ray.
Figure 7
Figure 7 At the final follow-up of 40 months, the patient had full range of motion. A: Maximum flexion position; B: Maximum extension position
DISCUSSION

Coronal plane fracture of the femoral condyle was named after Hoffa following his detailed research on this fracture in 1904[3]. Letenneur et al[5] classified this fracture into three different types. Accordingly, our patient developed a Type III fracture. This rare injury can also be classified into a medial, lateral and conjoint Hoffa's fracture based on the location of the fracture[6]. According to a review of the literature on Hoffa’s fracture in the pediatric population (Table 1), 16 cases of Hoffa’s fracture in pediatric patients were reported. Only 5 were located on the medial femoral condyle. Bali et al[7] first described an isolated Hoffa's fracture of the medial condyle in a patient with an undeveloped skeleton. Ranjan et al[6] described a Hoffa’s fracture of the medial condyle in a 6-year-old girl. To date, only four cases of Hoffa’s fracture of the medial condyle in pediatric patients has been reported. We aimed to report the fifth case in a 5-year-old patient, the youngest ever diagnosed.

Table 1 Review of the literature on Hoffa’s fracture in the pediatric population.
No.
Ref.
Sex
Age (yr)
Injury
Diagnostic tool
Location of fracture
Approach
Outcome
1Agrawal et al[8], 2021M18Road side accidentX-ray, CTConjointMedial parapetallar approach, with 2 (6.5 mm) PTCS in 1 condyle and one 6.5 and 4.5 mm PTCS in another condyle0°-130° ROM
2Kondreddi et al[9], 2014-17Road traffic accidentX-rayLateral parapatellar arthrotomy, with four 4-mm cancellous screws (2 for each condyle) introduced antero-posteriorly through the non-articular surface, in a di-rection perpendicular to the fracture line120° ROM
3Julfiqar et al[20], 2019M12Fall from height when his left knee was in the flexed positionX-rayOpen reduction and intraepiphyseal internal fixation using a 4.5 mm cannulated cancellous screw0°-120° ROM
4Chaudhary et al[12], 2020M11Fall from a treeX-rayOpen reduction and internal fixation using the Swashbuckler approach, lag screw technique with two 4 mm cancellous screws placed antero-posteriorly in the lateral condyle and one antero-posterior 4 mm cancellous screw and one Herbert screw placed postero-anteriorly in the medial condyle0°-120° ROM
5Lal et al[15], 2011-9Fall from heightX-rayArthroscopy assisted internal fixation, with 4.5-mm cannulated cancellous screws, inserted from anterior to posterior just distal to the femoral physisCure
6Harna et al[22], 2017M7Hit by a speeding motor vehicleCTSwashbuckler approach, with 2.9 mm Herbert screws for compression0°-130° ROM
7Kumar et al[13], 2001F17Fall from ladderX-rayLateral femoral condyleReduction and fixation with two antero-posterior lag screwsFull ROM
8Flanagin et al[10], 2011M14WrestlingArthroscopyHeadless compression screwsFull ROM
9Potini et al[14], 2015M14Direct blow over kneeX-rayOpen reduction and rigid fixation with countersunk interfragmentary screws5°–110° ROM
10Tripathy et al[19], 2013M12Fall while playingCTOpen reduction and fixation with two partially threaded cancellous lag screwsCure
11Ashraf[16], 2019M12Motor vehicle accidentX-ray, CTEvaluation of the cruciateligaments and antero-posterior stability with arthroscopy, open reduction and internal fixation using two cannulated screwsFull ROM
12McDonough et al[11], 2000M8Road traffic accidentX-rayOpen reduction and internal fixation using two partially threaded cancellous lag screwsFull ROM
13Jiang et al[2], 2022F16Knee injury in a sprint raceX-ray, CTMedial femoral condyleOpen reduction and fixation using three 3.5 mm partially threaded cancellous screws0°-135° ROM
14AlKhalife et al[3], 2018M12Object droppedCTOpen reduction and internal fixation through a medial parapatellar approach with the aid of a bone clamp and two 4.0 mm partially threaded cancellous screws, the screw heads placed through the articular cartilage were countersunk15°–130° ROM
15Bali et al[7], 2011M12Traffic accidentCTOpen reduction and internal fixation with two large-fragment cannulated screws, which were buried under the articular surface of the kneeCure
16Ranjan et al[6], 2021F6FallCTOpen reduction and fixation through the medial approach with two 4.5 mm partially threaded cannulated cancellous screws0°–110° ROM
17Current Study, 2022M5Hit by objectArthroscopyOpen reduction and internal fixation through the medial parapatellar approach, using two 3.0 mm partially threaded cancellous screwsFull ROM

Hoffa’s fractures are mostly triggered by high-energy damage[8,9], and are more commonly seen in young adults. This injury is mainly caused by axial shear force affecting the posterior part of the femoral condyle when the knee is flexed[6]. Due to the anatomical features of the ectropion angle at the distal femur, when high-energy violence acts on the distal femur, it often acts firstly on the lateral condyle. As a result, lateral condyle fractures are more common than medial condyle fractures. Commonly, the cause of Hoffa's fractures in adults is vehicle accidents[7] while in pediatric Hoffa's fracture are usually caused by trivial injury or sports injury[10]. In this case, the injury was caused by a heavy object falling on the right knee. Since only a few cases have been reported, little is known about Hoffa's fractures in children, and McDonough et al[11] reported the first case of a non-healing Hoffa's fracture in an eight-year-old boy. According to our research (Table 1), X-ray is the most effective diagnostic tool for confirming pediatric Hoffa’s fracture, followed by CT[12-14]. However, as the fracture is barely visible on routine anteroposterior radiographs, misdiagnosis often occurs even in the lateral view. The fracture can be obscured by the intact anterior condyle in the anterior and posterior projections, if it is minimally displaced[15-17]. Therefore, it is wiser to carry out the gold standard investigation, which is CT[18]. However, in pediatric patients, the fracture line can be easily ignored, even on CT and MRI due to thick cartilage. In young patients, the diagnosis of Hoffa’s fracture is often omitted based on past clinical experience. Three cases of misdiagnosed Hoffa’s fracture in eight-year-old and two twelve-year-old boys were identified in previous literature, which were fixed with cannulated screws and successfully treated[11,16,19]. In this study, we report another case of nonunion of Hoffa’s fracture in the medial condyle in a five-year-old boy who was initially misdiagnosed as having a stable fracture with no displacement. The patient was finally diagnosed with Hoffa’s fracture by arthroscopy. Therefore, it is noteworthy that arthroscopy is critical in the diagnosis of pediatric Hoffa’s fracture with inconclusive radiographs[10]. In our case, a CT scan was not performed on the injured knee due to difficulty in evaluating the fracture, thick cartilage of the distal femoral epiphysis and the patient’s immature skeleton[1,3,4]. Avoiding CT exams can also prevent greater radiation exposure during CT scans than X-rays[20].

Conservative treatment of these fractures is unsatisfactory as the reduction in fracture fragments is difficult to achieve and to maintain by closure. This may lead to multiple complications such as avascular necrosis, nonunion, and malunion[4,15,21]. Therefore, as the ideal treatment[19], surgical stabilization and internal fixation are required to achieve a satisfactory clinical outcome. There is also controversy regarding the surgical approaches for pediatric Hoffa’s fracture. The approaches described in previous literature include the lateral, medial and Swashbuckler approach (Table 1). It is generally accepted that surgical stabilization is necessary for a satisfactory clinical outcome after the treatment of Hoffa’s fracture. The reason for this is that, closure reduction and cast/traction techniques are difficult to achieve and sustain the reduction of fracture fragments without soft tissue attachment. Therefore, this kind of injury is also prone to vascular necrosis and bone nonunion, which should be prevented by stable anatomical compression reduction and internal fixation. This can only be achieved by open/arthroscopic approaches[15]. In our case, we performed open reduction and internal fixation with the assistance of arthroscopy using a medial parapatellar approach. The outcome was satisfactory. The advantages of the guidance of arthroscopy include avoidance of soft tissue, decreased blood loss, and intraarticular visualization. Acute Hoffa’s fracture with minimal communition and large fragments can also get benefit from arthroscopic fixation[21,22].

CONCLUSION

We report Hoffa’s fracture of the medial condyle in a 5-year-old child, the youngest patient ever reported, who was diagnosed and treated with the assistance of arthroscopy. We maintain that this rare fracture can be misdiagnosed easily. Healthcare practitioners should note of this when dealing with children’s knee fractures. It is better to diagnose this fracture by arthroscopy in patients with skeletal immaturity. Treatment of this fracture with open reduction and internal fixation can prevent further long-term complications. However, arthroscopy-guided reduction and internal fixation may be a good option for patients who have a fresh fracture.

Footnotes

Provenance and peer review: Unsolicited article; Externally peer reviewed.

Peer-review model: Single blind

Specialty type: Anatomy and morphology

Country/Territory of origin: China

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P-Reviewer: Hakimi T, Afghanistan; Paparoupa M, Germany S-Editor: Liu JH L-Editor: A P-Editor: Liu JH

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