Medial Hoffa Fracture in a Young Adult: Rare Injury, Successful Fixation in a Remote Low‑Resource orthopaedic Hospital in Northern Pakistan

Medial Hoffa Fracture in a Young Adult: Rare Injury, Successful Fixation in a Remote Low‑Resource orthopaedic Hospital in Northern Pakistan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Medial Hoffa Fracture in a Young Adult: Rare Injury, Successful Fixation in a Remote Low‑Resource orthopaedic Hospital in Northern Pakistan Sohail Rehman, Zakria Rathore, Mehdi Ali Mehdivi, Nasir Hussain, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9117869/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Medial Hoffa fractures are rare coronal-plane distal femoral fractures often resulting from high-energy trauma such as road traffic accidents or falls from height; accurate diagnosis and stable fixation are essential to restore knee function and prevent long-term complications [ 1 , 2 ]. Case Presentation: We report a case of a 25-year-old male who sustained a two-part comminuted medial Hoffa fracture (CT type B) following a road traffic accident. Emergency management included analgesia, the RICE protocol, and immobilization with an above-knee back slab. Preoperative optimization included CBC, LFTs, RFTs, hepatitis B and C, HIV serology, and blood grouping. The patient underwent open reduction and internal fixation (ORIF) with six 3 mm Herbert headless screws (four posteroanterior, two anteroposterior). No postoperative complications occurred. Follow-up over three months showed progressive improvement in Knee Injury and Osteoarthritis Outcome Score (KOOS) from 42 at 2 weeks to 92 at 3 months [ 3 ]. Conclusion: This case demonstrates that meticulous perioperative planning and surgical technique can achieve excellent outcomes in rare intra-articular fractures even in remote, low-resource hospitals [ 4 , 5 ]. Orthopedic Surgery Medial Hoffa fracture Distal femoral fracture Herbert screw fixation Knee Injury and Osteoarthritis Outcome Score Remote hospital orthopaedic surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Hoffa fractures, first described by Hoffa in 1904, are coronal-plane fractures of the femoral condyles and represent a rare subset of distal femoral fractures [ 1 ]. Medial condyle involvement is particularly uncommon, and delayed or missed diagnosis can result in significant functional impairment. These fractures typically occur in young adults following high-energy trauma such as road traffic accidents, falls from height, or sports-related injuries [ 2 ]. The diagnosis of medial Hoffa fractures is often challenging due to the fracture orientation. Standard anteroposterior and lateral radiographs may not adequately demonstrate the fracture line, leading to underdiagnosis. Computed tomography (CT) scanning is considered the gold standard for detailed fracture assessment, classification, and preoperative planning, especially in comminuted or displaced fractures [ 2 ]. Management of Hoffa fractures is primarily surgical, as conservative treatment is associated with high rates of non-union, malunion, and early post-traumatic osteoarthritis [ 1 , 2 ]. Open reduction and internal fixation (ORIF) remains the standard approach. Different fixation techniques are described in contemporary orthopaedic literature, including Herbert headless screws, cannulated cancellous screws, lag screws, and buttress plating. Arthroscopic-assisted reduction has also been reported in selected cases, allowing direct visualization of the joint surface [ 4 – 6 ]. Outcomes depend on achieving anatomical reduction, stable fixation, and early rehabilitation. In remote or resource-limited hospitals, the management of rare intra-articular fractures like medial Hoffa fractures poses additional challenges. This case highlights the successful management of such a fracture in a remote, mountainous region of Northern Pakistan, emphasizing perioperative care, surgical technique, and functional outcomes. Case Presentation A 25-year-old male presented to the Emergency Department following a road traffic accident with severe right knee pain, swelling, and inability to bear weight. Examination revealed tenderness over the medial femoral condyle with significant swelling, and distal neurovascular status was intact. Emergency management included intravenous analgesia, the RICE protocol (rest, ice, compression, elevation), and immobilization with an above-knee back slab. Radiographs demonstrated a coronal fracture of the right medial femoral condyle. CT confirmed a two-part comminuted medial Hoffa fracture (CT type B) [ 1 , 2 ]. Preoperative optimization included complete blood count, liver and renal function tests, hepatitis B and C, HIV serology, and blood grouping, all within normal limits. Surgical management involved ORIF through a medial parapatellar approach. Anatomical reduction was achieved, and fixation was performed with six 3 mm Herbert headless screws: four posteroanterior and two anteroposterior. Intraoperative fluoroscopy confirmed excellent alignment and compression. The wound was closed in layers with a sterile dressing applied. Postoperatively, the patient remained non-weight-bearing for 4–6 weeks, and early passive and active knee range-of-motion exercises were initiated. Analgesia and thromboprophylaxis were continued. Follow-up revealed progressive functional recovery. KOOS improved from 42 at 2 weeks to 72 at 2 months, and 92 at 3 months, indicating near-normal knee function [ 3 ]. No postoperative complications were noted. Patient was scheduled for long term follow up. Discussion Medial Hoffa fractures are rare intra-articular injuries that can be easily overlooked, particularly in high-energy trauma scenarios. Missed diagnosis or delayed treatment may lead to non-union, malunion, chronic pain, or early post-traumatic osteoarthritis [ 1 , 2 ]. Accurate imaging, particularly CT, is essential for classification and surgical planning. Surgical fixation is the treatment of choice for displaced fractures. Herbert headless screws provide stable fixation while minimizing damage to articular cartilage. Other fixation options include cannulated screws and buttress plates depending on fracture morphology and bone quality. Arthroscopic-assisted reduction is emerging as a minimally invasive alternative in selected cases [ 4 – 6 ]. Emergency care, including adequate analgesia, soft-tissue management, and immobilization, is crucial to optimize patient outcomes before definitive surgery. Preoperative laboratory assessment ensures patient safety, particularly in regions with limited resources. In our case, all preoperative labs were within normal limits, enabling safe anaesthesia and surgery. Postoperative rehabilitation is vital for restoring knee function. Structured physiotherapy and early range-of-motion exercises contribute to the progressive improvement observed in the KOOS, from 42 at 2 weeks to 92 at 3 months [ 3 ]. These results demonstrate that even in remote, low-resource hospitals, excellent functional outcomes can be achieved with meticulous surgical planning and execution. Reporting rare medial Hoffa fractures contributes to the orthopaedic literature by highlighting optimal management strategies and outcomes in challenging settings. This case emphasizes that high-quality orthopaedic care is possible in remote, mountainous regions with careful planning, appropriate surgical technique, and structured rehabilitation [ 4 , 5 ]. Conclusion Medial Hoffa fractures are rare, intra-articular distal femoral injuries that require timely diagnosis, CT-based classification, and stable surgical fixation. ORIF with Herbert headless screws offers secure fixation, early rehabilitation, and excellent functional outcomes. Even in remote, low-resource hospitals in Northern Pakistan, meticulous perioperative care, precise surgical technique, and structured rehabilitation can achieve optimal recovery in complex intra-articular fractures [ 1 – 6 ]. Declarations Conflict of Interest The authors declare that they have no conflict of interest regarding the publication of this case report. Ethical Approval Ethical approval for this study was obtained from the Institutional Review/Ethics Committee of Regional Headquarter Hospital Skardu , approval number [No. 841/DME/RHQ] . Patient Consent Written informed consent was obtained from the patient for publication of this case report and accompanying clinical images. Acknowledgment The authors would like to express their sincere gratitude to the Head of the Department of Orthopaedics and the Dean Academic, Regional Headquarter Hospital Skardu , for their guidance and support in completing this study. Funding This research received no external funding and was conducted as part of routine clinical and academic work. References Akel A, Sarhan MY, Abu-Jeyyab M et al (2024) Medial Hoffa Fracture: A Case Report and Literature Review of Approach and Management. Am J Case Rep 25:e943136. https://www.amjcaserep.com/abstract/table/idArt/943136/id/t1-amjcaserep-25-e943136 doi:10.12659/AJCR.943136 Gavaskar AS, Bagaria V, Elhence A, Trikha V (2025) Hoffa Fractures: Current Understanding and Surgical Treatment Strategies. J Am Acad Orthop Surg 33(24):e1449–e1461. 10.5435/JAAOS-D-25-00050 . https://pubmed.ncbi.nlm.nih.gov/40550107/ Kapoor C, Merh A, Shah M, Golwala P (2016) A Case of Distal Femur Medial Condyle Hoffa Type II(C) Fracture Treated with Headless Screws. Cureus 8(9):e802. 10.7759/cureus.802 . https://pubmed.ncbi.nlm.nih.gov/27790391/ Sahoo S, Nayak M, Sahoo R (2025) A Prospective Study of Functional Outcome of Hoffa Fracture Treated with Cannulated Cancellous Screws, Herbert Screws and Buttress Plates – A Prospective Observational Cohort Study. Student’s J Health Res Afr 6(3):7. 10.51168/sjhrafrica.v6i3.1663 https://doi.org/10.51168/sjhrafrica.v6i3.1663 Krishnathas K, Mahesh U (2020) Coronal Plane Hoffa Fractures of the Distal Femoral Condyle Treatment and Outcome. Int J Orthop Sci 6(2):910–913. 10.22271/ortho.2020.v6.i2o.2159 https://doi.org/10.22271/ortho.2020.v6.i2o.2159 All Arthroscopic Management of an Hoffa Fracture of the Medial Femoral Condyle (2025) A Case Report. J Orthop Rep 4(1):100335. 10.1016/j.jorep.2024.100335 https://doi.org/10.1016/j.jorep.2024.100335 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9117869","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":606176364,"identity":"5ccb370e-4536-41e9-ae58-613b70cb7668","order_by":0,"name":"Sohail Rehman","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYLCChAoJOTb25gNApoQMcVo+nLEx5uc5lgDSwkOUDsaZbWmJM2fkGIA4hLXIt5899pi37XDihhs5n1/dqLHgYWA/fHQDPi0GZ/LSjXnOHTbecObtNuucY0CH8aSl3cCrhSHHTJqn7LDshuO524xz2IBaJHjM8GqR738D1MJ2mHHDgZxnxjn/iNDCcCPHTHJGW5rizI4c5se5bURoMbjxxkwCGshmzLl9EjxshPwi359jJgGNysefc77VyfGzHz6G32FIgE0CTBKrHASYP5CiehSMglEwCkYOAABl4Uqkv4uhbAAAAABJRU5ErkJggg==","orcid":"","institution":"Regional Headquarter Hospital Skardu, Skardu, Gilgit-Baltistan, Pakistan","correspondingAuthor":true,"prefix":"","firstName":"Sohail","middleName":"","lastName":"Rehman","suffix":""},{"id":606176507,"identity":"1030f2bb-a1db-4eeb-bf60-1e00afeb5df5","order_by":1,"name":"Zakria Rathore","email":"","orcid":"","institution":"Regional Headquarter Hospital Skardu, Skardu, Gilgit-Baltistan, Pakistan","correspondingAuthor":false,"prefix":"","firstName":"Zakria","middleName":"","lastName":"Rathore","suffix":""},{"id":606176508,"identity":"15479d2d-1632-40c6-ae9b-6e51e331c394","order_by":2,"name":"Mehdi Ali Mehdivi","email":"","orcid":"","institution":"Regional Headquarter Hospital Skardu, Skardu, Gilgit-Baltistan, Pakistan","correspondingAuthor":false,"prefix":"","firstName":"Mehdi","middleName":"Ali","lastName":"Mehdivi","suffix":""},{"id":606176509,"identity":"22c9cb84-68b5-4b53-a013-fbdcd8b4485e","order_by":3,"name":"Nasir Hussain","email":"","orcid":"","institution":"Regional Headquarter Hospital Skardu, Skardu, Gilgit-Baltistan, Pakistan","correspondingAuthor":false,"prefix":"","firstName":"Nasir","middleName":"","lastName":"Hussain","suffix":""},{"id":606176510,"identity":"79c0dca4-8c46-468b-b4cc-4bdf177b837b","order_by":4,"name":"Laiba Uroosh","email":"","orcid":"","institution":"The City School Rawalpindi, Rawalpindi, Pakistan","correspondingAuthor":false,"prefix":"","firstName":"Laiba","middleName":"","lastName":"Uroosh","suffix":""}],"badges":[],"createdAt":"2026-03-13 20:15:19","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9117869/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9117869/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104876998,"identity":"6e6f99dc-a5c9-472f-bd9f-1afe76c0da8e","added_by":"auto","created_at":"2026-03-18 08:44:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":362804,"visible":true,"origin":"","legend":"\u003cp\u003ePre Op X-Ray of the knee AP/L\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9117869/v1/71cda42a857f8a11b0f9ca03.png"},{"id":104877004,"identity":"3a070e0b-8c1f-447b-8355-909fc9910d7c","added_by":"auto","created_at":"2026-03-18 08:44:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":181224,"visible":true,"origin":"","legend":"\u003cp\u003ePre Op CT-Scan of the Knee\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9117869/v1/7830878875303146e65768bd.png"},{"id":104876957,"identity":"a400857e-2765-4465-896b-7619b91bb45b","added_by":"auto","created_at":"2026-03-18 08:44:15","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":805825,"visible":true,"origin":"","legend":"\u003cp\u003eIntra Op Clinical Photographs showing reduction of the fracture \u0026amp; temporary fixation with K-Wires\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9117869/v1/af91a5435c7fccdab00582f5.png"},{"id":104876955,"identity":"75ffdc6d-f48a-4d96-a7d1-b5cc14e10260","added_by":"auto","created_at":"2026-03-18 08:44:15","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":332892,"visible":true,"origin":"","legend":"\u003cp\u003eIntra Op Fluoroscopic Image of the knee \u0026nbsp;showing reduction \u0026amp; fixation with Herbert screws\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9117869/v1/feb741f9de02dde5c6396327.png"},{"id":104876959,"identity":"648a8701-01e0-496a-924c-234e52cf067c","added_by":"auto","created_at":"2026-03-18 08:44:15","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":804160,"visible":true,"origin":"","legend":"\u003cp\u003e2 weeks follow up showing clinical photograph of the surgical incision \u0026amp; Post Op X-ray of the knee AP/L\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-9117869/v1/917e37fb44bee6c8afb52273.png"},{"id":104876950,"identity":"62eea771-9cc4-4d0e-a8f1-1ee4b3a0c703","added_by":"auto","created_at":"2026-03-18 08:44:14","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":539839,"visible":true,"origin":"","legend":"\u003cp\u003e3 months follow up showing clinical photograph of the surgical incision \u0026amp; Post Op X-ray of the knee AP/L\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-9117869/v1/9c43e11aa3f0fa765d6c60e5.png"},{"id":104877012,"identity":"5eff1e08-3cfe-4949-a948-a6fef8ed984d","added_by":"auto","created_at":"2026-03-18 08:44:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4342119,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9117869/v1/ad6211fb-bad3-45f7-8dae-5875375776f0.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eMedial Hoffa Fracture in a Young Adult: Rare Injury, Successful Fixation in a Remote Low‑Resource orthopaedic Hospital in Northern Pakistan\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHoffa fractures, first described by Hoffa in 1904, are coronal-plane fractures of the femoral condyles and represent a rare subset of distal femoral fractures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Medial condyle involvement is particularly uncommon, and delayed or missed diagnosis can result in significant functional impairment. These fractures typically occur in young adults following high-energy trauma such as road traffic accidents, falls from height, or sports-related injuries [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe diagnosis of medial Hoffa fractures is often challenging due to the fracture orientation. Standard anteroposterior and lateral radiographs may not adequately demonstrate the fracture line, leading to underdiagnosis. Computed tomography (CT) scanning is considered the gold standard for detailed fracture assessment, classification, and preoperative planning, especially in comminuted or displaced fractures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eManagement of Hoffa fractures is primarily surgical, as conservative treatment is associated with high rates of non-union, malunion, and early post-traumatic osteoarthritis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Open reduction and internal fixation (ORIF) remains the standard approach. Different fixation techniques are described in contemporary orthopaedic literature, including Herbert headless screws, cannulated cancellous screws, lag screws, and buttress plating. Arthroscopic-assisted reduction has also been reported in selected cases, allowing direct visualization of the joint surface [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOutcomes depend on achieving anatomical reduction, stable fixation, and early rehabilitation. In remote or resource-limited hospitals, the management of rare intra-articular fractures like medial Hoffa fractures poses additional challenges. This case highlights the successful management of such a fracture in a remote, mountainous region of Northern Pakistan, emphasizing perioperative care, surgical technique, and functional outcomes.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 25-year-old male presented to the Emergency Department following a road traffic accident with severe right knee pain, swelling, and inability to bear weight. Examination revealed tenderness over the medial femoral condyle with significant swelling, and distal neurovascular status was intact. Emergency management included intravenous analgesia, the RICE protocol (rest, ice, compression, elevation), and immobilization with an above-knee back slab.\u003c/p\u003e\n\u003cp\u003eRadiographs demonstrated a coronal fracture of the right medial femoral condyle. CT confirmed a two-part comminuted medial Hoffa fracture (CT type B) [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. Preoperative optimization included complete blood count, liver and renal function tests, hepatitis B and C, HIV serology, and blood grouping, all within normal limits.\u003c/p\u003e\n\u003cp\u003eSurgical management involved ORIF through a medial parapatellar approach. Anatomical reduction was achieved, and fixation was performed with six 3 mm Herbert headless screws: four posteroanterior and two anteroposterior. Intraoperative fluoroscopy confirmed excellent alignment and compression. The wound was closed in layers with a sterile dressing applied. Postoperatively, the patient remained non-weight-bearing for 4\u0026ndash;6 weeks, and early passive and active knee range-of-motion exercises were initiated. Analgesia and thromboprophylaxis were continued.\u003c/p\u003e\n\u003cp\u003eFollow-up revealed progressive functional recovery. KOOS improved from 42 at 2 weeks to 72 at 2 months, and 92 at 3 months, indicating near-normal knee function [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]. No postoperative complications were noted. Patient was scheduled for long term follow up.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMedial Hoffa fractures are rare intra-articular injuries that can be easily overlooked, particularly in high-energy trauma scenarios. Missed diagnosis or delayed treatment may lead to non-union, malunion, chronic pain, or early post-traumatic osteoarthritis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Accurate imaging, particularly CT, is essential for classification and surgical planning.\u003c/p\u003e \u003cp\u003eSurgical fixation is the treatment of choice for displaced fractures. Herbert headless screws provide stable fixation while minimizing damage to articular cartilage. Other fixation options include cannulated screws and buttress plates depending on fracture morphology and bone quality. Arthroscopic-assisted reduction is emerging as a minimally invasive alternative in selected cases [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmergency care, including adequate analgesia, soft-tissue management, and immobilization, is crucial to optimize patient outcomes before definitive surgery. Preoperative laboratory assessment ensures patient safety, particularly in regions with limited resources. In our case, all preoperative labs were within normal limits, enabling safe anaesthesia and surgery.\u003c/p\u003e \u003cp\u003ePostoperative rehabilitation is vital for restoring knee function. Structured physiotherapy and early range-of-motion exercises contribute to the progressive improvement observed in the KOOS, from 42 at 2 weeks to 92 at 3 months [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These results demonstrate that even in remote, low-resource hospitals, excellent functional outcomes can be achieved with meticulous surgical planning and execution.\u003c/p\u003e \u003cp\u003eReporting rare medial Hoffa fractures contributes to the orthopaedic literature by highlighting optimal management strategies and outcomes in challenging settings. This case emphasizes that high-quality orthopaedic care is possible in remote, mountainous regions with careful planning, appropriate surgical technique, and structured rehabilitation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMedial Hoffa fractures are rare, intra-articular distal femoral injuries that require timely diagnosis, CT-based classification, and stable surgical fixation. ORIF with Herbert headless screws offers secure fixation, early rehabilitation, and excellent functional outcomes. Even in remote, low-resource hospitals in Northern Pakistan, meticulous perioperative care, precise surgical technique, and structured rehabilitation can achieve optimal recovery in complex intra-articular fractures [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have \u003cstrong\u003eno conflict of interest\u003c/strong\u003e regarding the publication of this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from \u003cstrong\u003ethe \u003cstrong\u003eInstitutional Review/Ethics Committee of Regional Headquarter Hospital Skardu\u003c/strong\u003e,\u0026nbsp;\u003c/strong\u003eapproval number \u003cstrong\u003e[No. 841/DME/RHQ]\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWritten informed consent\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ewas obtained from the patient for publication of this case report and accompanying clinical images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their sincere gratitude to the \u003cstrong\u003eHead of the Department of Orthopaedics\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand the \u003cstrong\u003eDean Academic, Regional Headquarter Hospital Skardu\u003c/strong\u003e\u003c/strong\u003e, for their guidance and support in completing this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received \u003cstrong\u003eno external funding\u003c/strong\u003e and was conducted as part of routine clinical and academic work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAkel A, Sarhan MY, Abu-Jeyyab M et al (2024) Medial Hoffa Fracture: A Case Report and Literature Review of Approach and Management. Am J Case Rep 25:e943136. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.amjcaserep.com/abstract/table/idArt/943136/id/t1-amjcaserep-25-e943136\u003c/span\u003e\u003cspan address=\"https://www.amjcaserep.com/abstract/table/idArt/943136/id/t1-amjcaserep-25-e943136\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e doi:10.12659/AJCR.943136\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGavaskar AS, Bagaria V, Elhence A, Trikha V (2025) Hoffa Fractures: Current Understanding and Surgical Treatment Strategies. J Am Acad Orthop Surg 33(24):e1449\u0026ndash;e1461. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5435/JAAOS-D-25-00050\u003c/span\u003e\u003cspan address=\"10.5435/JAAOS-D-25-00050\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/40550107/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/40550107/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKapoor C, Merh A, Shah M, Golwala P (2016) A Case of Distal Femur Medial Condyle Hoffa Type II(C) Fracture Treated with Headless Screws. Cureus 8(9):e802. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.802\u003c/span\u003e\u003cspan address=\"10.7759/cureus.802\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/27790391/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/27790391/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSahoo S, Nayak M, Sahoo R (2025) A Prospective Study of Functional Outcome of Hoffa Fracture Treated with Cannulated Cancellous Screws, Herbert Screws and Buttress Plates \u0026ndash; A Prospective Observational Cohort Study. Student\u0026rsquo;s J Health Res Afr 6(3):7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.51168/sjhrafrica.v6i3.1663 https://doi.org/10.51168/sjhrafrica.v6i3.1663\u003c/span\u003e\u003cspan address=\"10.51168/sjhrafrica.v6i3.1663 10.51168/sjhrafrica.v6i3.1663\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrishnathas K, Mahesh U (2020) Coronal Plane Hoffa Fractures of the Distal Femoral Condyle Treatment and Outcome. Int J Orthop Sci 6(2):910\u0026ndash;913. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.22271/ortho.2020.v6.i2o.2159 https://doi.org/10.22271/ortho.2020.v6.i2o.2159\u003c/span\u003e\u003cspan address=\"10.22271/ortho.2020.v6.i2o.2159 10.22271/ortho.2020.v6.i2o.2159\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAll Arthroscopic Management of an Hoffa Fracture of the Medial Femoral Condyle (2025) A Case Report. J Orthop Rep 4(1):100335. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jorep.2024.100335 https://doi.org/10.1016/j.jorep.2024.100335\u003c/span\u003e\u003cspan address=\"10.1016/j.jorep.2024.100335 10.1016/j.jorep.2024.100335\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Not Applicable","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Medial Hoffa fracture, Distal femoral fracture, Herbert screw fixation, Knee Injury and Osteoarthritis Outcome Score, Remote hospital orthopaedic surgery","lastPublishedDoi":"10.21203/rs.3.rs-9117869/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9117869/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eMedial Hoffa fractures are rare coronal-plane distal femoral fractures often resulting from high-energy trauma such as road traffic accidents or falls from height; accurate diagnosis and stable fixation are essential to restore knee function and prevent long-term complications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eWe report a case of a 25-year-old male who sustained a two-part comminuted medial Hoffa fracture (CT type B) following a road traffic accident. Emergency management included analgesia, the RICE protocol, and immobilization with an above-knee back slab. Preoperative optimization included CBC, LFTs, RFTs, hepatitis B and C, HIV serology, and blood grouping. The patient underwent open reduction and internal fixation (ORIF) with six 3 mm Herbert headless screws (four posteroanterior, two anteroposterior). No postoperative complications occurred. Follow-up over three months showed progressive improvement in Knee Injury and Osteoarthritis Outcome Score (KOOS) from 42 at 2 weeks to 92 at 3 months [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThis case demonstrates that meticulous perioperative planning and surgical technique can achieve excellent outcomes in rare intra-articular fractures even in remote, low-resource hospitals [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e","manuscriptTitle":"Medial Hoffa Fracture in a Young Adult: Rare Injury, Successful Fixation in a Remote Low‑Resource orthopaedic Hospital in Northern Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-18 08:43:55","doi":"10.21203/rs.3.rs-9117869/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"061b7d40-240e-491d-adfe-afa2488fcd8d","owner":[],"postedDate":"March 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":64511326,"name":"Orthopedic Surgery"}],"tags":[],"updatedAt":"2026-03-18T08:43:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-18 08:43:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9117869","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9117869","identity":"rs-9117869","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}