acetabular fractures

$: Acetabular fractures$
Acetabular fracturesBy Dr Arshad Shaikh

CreditsDr Anand

Introduction• Contemporary icon of pelvic

and acetabular surgery .• Ubiquitous standard of care of

acetabular fractures for the past 25 years.

• Complete transformation of our understanding and treatment of fractures of the acetabulum

• Two textbooks are the “Bibles” of acetabular surgery

Acetabular fractures

Before Letournel• Conflicting recommendations

on Rx.• No classification• No consensus on

conservative or operative• Only AP view Pelvis obtained• Invariably poor results –

JOINT INSTABILITY/ AVN.

After Letournel• First systematic classification• Phenominal concepts• AP, 45 deg oblique views ; CT• Concept of accurate reduction • Surgical approaches and

management protocols• Standard plate and screw

fixation• Aim is congruent and stable hip.

Principles of acetabular fracture Rx

• Thorough understanding of 3-D anatomy of innominate bone

• Diagnosis, Classification and operative repair• Stable congruent hip esp. weight bearing

dome.• Surgery is complex and done by experienced

surgeon.• Anatomic reduction ( < 2mm ) is key to

functional outcome.

Mechanism of injury

• Impact of femoral head with the acetabular surface

• Force is via GT or Axis of femur• Fracture pattern decided by position of hip at

the time of impact• Also force of impact and bone quality

Mechanism of injury

Assessment – ATLS protocol

History• Mechanism of injury• Ask for position of hip• Ask of axial loading or

direct injury• Low energy trauma• Underlying illness

Examination• Open wounds• Morel- Lavallee lesions• Shortening• Attitude of limb• Neurological examination• Document sciatic nerve

palsy

Associated injuries

• Extremity ( 35%)• Head ( 19 %)• Chest ( 18 %)• Nerve palsy ( 13 % )• Abdominal ( 8 % )• Genitourinary ( 6 % )• Spine (4 %)

• Pelvic injury• Fracture neck of femur• Fracture shaft of femur• Bladder injuries• Morel Lavalle lesions• Knee ligament injuries

Anatomy & Osteology

• hemisphere recess• quadrilateral surface• transverse acetabular

ligament• Dome of acetabulum• iliopectineal eminence• sciatic nerve relation

Anatomy & Osteology

Two column concept

•

Radiology of acetabular fractures


Superior weight bearing surface


Iliac oblique viewObdurator oblique view


Iliac oblique view Obdurator oblique view

Roof arc measurement

Dynamic stress view

Dynamic hip instability

CT Scan- 2D/3D

• Extent & location• intra- articular free

fragment / head fragment

• orientation of # lines• rotation of fragments• status of posterior

pelvic ring• Marginal Impaction

Don’t decide hip joint instability based on CT Scan.

PELVIC PLASTIC MODEL

Classification – Letournel

Management options-NON-SURGICAL

Stable nondisplaced & minimally displaced Selected displaced fractures where intact

acetabulum maintains stability & congruity – Low anterior column, Low transverse , low T-shaped

Both column fractures with secondary congruence

Wall fractures not compromising hip stability Local wound issues/ Medically unfit/ Elderly

Stable fracture

• Acetabular fracture < 2 mm of displacement in dome

• Roof arc measurement greater than 45 degree on three views

• Recently , Medial roof arc > 45 degree Anterior roof arc > 25 degree Posterior roof arc > 70 degree• Axial CT – superior 10 mm acetabulum

articular surface

Don’t apply roof arc here

Posterior wall # - • Assess hip stability here.( Whether+/-

dislocation )• > 50 % post. Wall is unstable • < 50 % wall - Dynamic stress fluoroscopy • If in doubt – assume hip is unstableBoth column #• Secondary congruence

Secondary congruence

Go for non operative here

• Polytrauma with sick condition• Severe head injury • Open wound in the planned incision site• Morel – Lavale lesions• Suprapubic catheter – No ilioinguinal

approach. Wait till track seals.• Elderly with osteoporotic bone

Gull sign – poor prognosis

Non operative protocol

• Bed rest• Mobilise as soon as symptoms allow• Begin with partial weight bearing • Assess displacement weekly for first 4 weeks• By 6 to 12 weeks patient returns to full weight

bearing• Joint mobilisation throughout• Prolonged traction only for patients who needs

surgery but contraindicated due to other reasons

Fix if

• Displaced # in dome.• Posterior wall # > 50 % displacement• Positive fluoroscopy stress test• Both column fractures with loss of parallelism• Incarcerated fragments in the acetabulum

after closed reduction.

Ideal time – 5 to 7 days

Orthopedic trauma association

Approaches

Anterior• Ilioinguinal• Iliofemoral• Extended Iliofemoral• Modifications of Ilioinguinal• Modifications of iliofemoral

Posterior• Kocher- Langenbeck• Modifications• Trochantric flip osteotomy• Modified Gibson• Modified Stoppa Intrapelvic

Anterior Ilioinguinal

• Anterior wall, anterior column, anterior column + posterior hemitransverse, transverse with major displacement in anterior region

• Careful of corona mortis• Lowest rate of heterotrophic ossification• Risk of damage to lat.cut.N, femoral.N,

external iliac vessels and inguinal canal

Ilioinguinal approach

Iliofemoral approach

Kocher- Langenbeck approach

• Posterior wall, column, t type, transverse• Access to sciatic notches, hip capsule• Damage to sciatic.N, gluteal vessels and

intermediate risk of heterotrophic ossification• Lateral/ Prone• Prone + traction• Knee flexion

Kocher- Langenbeck approach

Modified Stoppa’s approach

Extended Iliofemoral approach

Trochantric flip osteotomy

Modified Gibson’s approach

Choice of approach

Indications for emergency fixation

• Recurrent dislocation following reduction despite traction

• Irreducible hip dislocation• Progressive sciatic nerve palsy• Associated vascular injury• Open fractures• Ipsilateral neck fractures

Posterior wall fractures

• 25 % of all acetabular fractures• Kocher – Langenbeck approach• Limit periosteal elevation to fracture site, don’t

release any fragment from capsule• Distract head and remove osteochondral fragments.

May need hip subluxation• Large fragment removal needs Modified Gibson’s

approach and troch flip osteotomy ( lateral)• Bone grafting• Two level reconstruction

Extended posterior wall

Posterior column

• 3 – 5 %• Reduced by using Schanz screw into ischium• Reduction clamps used• Interfragmentary screws + butress plate.

Transverse #

• 5 – 19 %• medial and superior displacement of head• Transtectal, juxtatectal and infratectal• Reduction – Schanz screws, sciatic notch

clamp, clamp between two screws• Anterior column screws can be placed only at

acertain angle• ilioinguinal approach

Transverse #

Anterior Wall and column

• 1 – 2 % • quadrangular clamp • screws and plate

Anterior column #

Very low low

intermediate high

Anterior column/wall + Posterior hemitransverse

• 7%• Gull Wing sign – poor prognosis• Reduce anterior column through ilioinguinal

approach• Confirm posterior column reduction by

palpating quadrilateral surface• screws + butress plate

Anterior column/wall + Posterior hemitransverse

• 7%• Gull Wing sign – poor prognosis• Reduce anterior column through ilioinguinal

approach• Confirm posterior column reduction by

palpating quaadrilateral surface• screws + butress plate

T - shaped

• 7 %• Kocher Langenbeck with prone• Sequential anterior ilioinguinal approach• Simultaneous access• Reduction difficult without screws passing

through stem of T• If associated posterior wall , low rate of

excellent reductions

Both columns

• 23%. Most common. Spur sign• No portion of cartilage remains attached to

pelvic bone• Secondary congruence• Spur sign• Surgical malreduction - Secondary congruence• Anterior and posterior approach

Spur sign

Anterior column

Both column

Perioperative care

• Thromboembolism prophylaxis• Active mobilisation by 6 – 12 weeks• Indomethacin to prevent heterotropic

ossification X 4 – 6 weeks• PWBW – 10 to 12 weeks

Complications

• Infection• Iatrogenic nerve injuries• Intra articular hardware• Venous thromboembolism• Heterotopic ossification• Post traumatic arthosis and Osteonecrosis

Heterotopic ossification

Results

•

THR in acetabular #

• Elderly patient• Post traumatic• Patients with poor prognosis• Cementless cup in fractured acetabulum is a

concern

Associated injuries

• Acetabulum + Posterior hip dislocation• Acetabulum + Pelvic ring• Acetabulum + Femoral head • Acetabulum + Femoral neck in young• Acetabulum + Shaft femur/ IT

acetabular fractures

Health & Medicine