Hoffa Fracture: Recognition, Management, and Key Surgical Principles

Hoffa fracture is a rare but clinically important injury involving a coronal plane fracture of the femoral condyle, most commonly affecting the lateral femoral condyle. Because it extends into the knee joint, delayed diagnosis or inadequate fixation can lead to long-term disability, pain, and post-traumatic arthritis.

What Causes a Hoffa Fracture?

Hoffa fractures usually occur after high-energy trauma, such as:

• Road traffic accidents

• Sports injuries

• Falls from height

The injury mechanism often involves axial loading on a flexed knee, creating shear forces across the femoral condyle.

Clinical Presentation

Patients commonly present with:

• Severe knee pain

• Swelling and hemarthrosis

• Restricted range of motion

• Difficulty or inability to bear weight

Standard X-rays may miss the fracture because of its coronal orientation.

Diagnosis

Initial evaluation includes:

• AP and lateral knee radiographs

• CT scan with 3D reconstruction (often essential for surgical planning)

CT imaging helps identify:

• Fragment size

• Degree of displacement

• Associated distal femur injuries

Management

Non-operative Treatment

Reserved only for:

• Rare, non-displaced fractures

• Patients unfit for surgery

However, conservative treatment has limited indications because displacement and instability are common.

Surgical Treatment (Preferred)

Open Reduction and Internal Fixation (ORIF) is considered the standard approach.

Principles of fixation:

• Anatomical reduction of the articular surface

• Stable fixation using headless compression screws or cancellous screws placed perpendicular to the fracture line

• Additional plate support when needed for comminuted patterns

Early postoperative rehabilitation focuses on:

• Controlled range of motion

• Gradual weight bearing according to fixation stability

Complications

Potential complications include:

• Knee stiffness

• Nonunion or malunion

• Post-traumatic osteoarthritis

• Avascular necrosis (uncommon)

Key Takeaway

Hoffa fractures are uncommon but easy to overlook. Early recognition, CT-based assessment, and stable surgical fixation are essential to restore joint congruity and optimize long-term knee function.