Distal femoral fractures largely occur secondary to high-energy trauma in the younger population and as osteoporotic fractures in the elderly population, including periprosthetic fractures above a TKA. Attempts to gain satisfactory axial alignment, articular congruity, and knee range of motion with conservative treatment have been largely disappointing. Operative fixation options include open reduction and internal fixation, intramedullary nailing, and bridge plating or percutaneous submuscular plating techniques. As with any fracture, treatment choice must be individualized according to the nature of the injury, bone quality, and patient demand. Regardless of treatment method, goals include restoration of articular congruity, anatomical length, rotation, and axial alignment while establishing adequate fixation to initiate early and unrestricted range of motion.