Acetabular supports:2 Columns (Inverted “Y”) & Sciatic buttress

Judet & Letournel

Judet & LetournelAnalysed inominate bone anatomy.Plane of Ilium & Obturator foramen ~ 90o

450 to frontal planeX rays at 45 oblique views.

Anatomy of acetabulum:Incomplete

hemispherical socket

Horse shoe shaped articular facet

Non articular condyloid fossa

Anatomy:Anterior Column -

longerPosterior Column -

shorterSciatic notch

Dome or roof – weight bearing

portion

Goal of treatmentAnatomic restoration

of domeConcentric reduction

of femoral head within dome

Neurovascular structuresExternal iliac A.

Sciatic N.Superir gluteal A. & N.Greater sciatic notch

Mechanism of Injury:Transmitted Force

Femur

Femoral head

Pelvis and acetabulum

Fracture patternDependent upon:

Position of hipDirection & magnitude of ImpactOsteoporotic bonesOther injury patterns.

DIAGS

Hip flexed –Posterior wall # DislocationInternal rotation & adduction – Dislocate

without fracture.Neutral hip - # posterior wallAbducted position – Transverse # with

posterior wall

Magnitude of force / displacement – degree of comminutionDegree of articular impaction

Strength of the bone.

Clinical Evaluation:ABCDLife threatening injuriesHEMODYNAMIC STABILITY

Superior gluteal A. or V.Selective angeographyHead, chest, abdomen

57% have other associated injuries.Secondary survey – knee, patella, ligaments.

Morel Lavalle lesionSkinSubcutaneous degloving, hematoma.Fluid wave, fluctuentCircumscribed area of anaesthesia /

EchymosisCultureSignificance in surgical treatment.

Neurological injuries30% partial injuries to sciatic N.More commonly peroneal division.Superior gluteal N.Impossible to assess abductor strength in

acute fractures.

Dislocation may be missed on examinationX rays neededDislocation – Urgently reduced

Osteonecrosis femoral head.Wearing of head against intra articular

fragmentsUrgent skeletal traction.

Associated injuries:Posterior pelvic ring disruption –

reduction and fixation prior to acetabular # treatment.

Recreate a stable posterior pelvis to reduce the acetabulum to.

Contralateral rami #sIntraop traction not used

Concurrent symphysis dislocations.

Radiographic evaluation:Pelvis AP viewJudet views – 45 degree oblique

Aid in classificationIdentify # displacements.

OUT OF TRACTIONPainful – premedication.

Pelvic inlet / Outlet views – useful but not mandatory

Pelvis AP viewX ray view

Information regarding

1Iliopectineal line

Anterior column

2 Ilioischial line

Posterior column

3 Tear drop

Relationship of columns

4 Roof (Sourcil)

Superior articular surface

5 Anterior Lip

Anterior column or wall

6 Posterior lip

Posterior column or wall

Iliac ObliqueX ray view Information regarding

1 Greater & Lesser sciatic notch

Posterior column (Posterior border of innominate bone)

Quadrilateral surface of ischium

Posterior column (Posterior border of innominate bone)

2 Anterior lip Anterior column or wall.

Iliac wing Anterior column

Roof Superior articular surface

Obturator obliqueX ray view Information

regarding

1Iliopectineal line / Pelvic brim

Anterior column

2Posterior rim or lip

Posterior column or wall

Obturator ring

Column involvement

Roof Superior articular surface

C. T. ScanRotational

displacementsIntra articular

fragmentsMarginal articular

impactionAssociated femoral

head injuriesSize of posterior wall

fragment.3-D RECON

Relationship of multiple sites of injury

Dry bone model or Line drawing:Fracture patternDrawing the fracture lines from X ray

landmarksShould be drawn always before surgery.Fracture pattern truly appreciated.

Fracture Classification:Judet and Letournel ClassificationOrthopaedic Trauma Association

Classification

Fracture Classification of Letournel and Judet A ELIMENTARY FRACTURES

1 Posterior wall 30%

2 Posterior column 3-5%

3 Anterior wall 1-2%

4 Anterior column 3-5%

5 Transverse 5-19%

B ASSOCIATED FRACTURES

1 Posterior column + wall 3-4%

2 Anterior + posterior Hemitransverse 7%

3 Transverse + posterior wall 20%

4 T – shaped 7%

5 Associated both column ABC 23%

Treatment options:Non surgical treatmentOperative treatment

Non-operative treatmentUnlike most articular #s having specific

operative indications acetabular #s are generally considered requiring operative

treatmentUnless certain non-operative criteria are met.Other factors – fracture displacement and

location, stability of hip & patient related factors.

Criteria for Non-operative Management (Four)Roof arcs >45 degrees.No fracture involvement in cranial 10 mm of

joint on CT (CT subchondral arc).No femoral head subluxation on three x-rays,

taken out of traction.For posterior wall fractures: less than 40% of

width of wall on CT .

Criteria by Olson & Matta

Roof arch measurements:Way to quantify the intact weight bearing

articular surface (WBD).In AP, Obturator and Iliac views.Correlates with 10mm of acetabular WBD on

CTNot applicable in

ABCPosterior wall

Other factorsABC

No intact acetabulum left to measurePerfect secondary congruence

Posterior wall>50% width all unstable hips<25% width all stable

Displacement <2mm – non-operative treatment regardless of location.In WBD – careful X ray follow up.Stress views may be needed (Tornetta

modified criteria of Olson & Matta).

Patient related factorsAgePreinjury activity levelFunctional demandsMedical comorbidities

Old patientsPlanned arthroplasty once arthritis develops.

Operative Treatment:Earlier the better once decided to operate.After 3 wks – results not good.Not an emergency except

Irreducible hip dislocationProgressing neurological deficitsOpen #sVascular injuries

SurgeryORIF - treatment of choiceGOAL

Anatomic reduction of articular surfaceAvoiding complicationsRestoring congruent jointStable hipMaximize the potential for long term survival

of hip.

Accuracy of reductionCorrelates with clinical outcome.<1mm Excellent results1-3mm good/fair.>3mm poor results.

Closed reduction and percutaneous fixation – proposed for elderly patients &Simple fractures with minimal displacements.No long term results available yet.

Methods of Non Operative care:Skeletal traction

Mainly historical importance in displaced, unstable #s.

Acute situation.Polytraumatized sick patientSupracondylar femur traction (Never

trochanteric – infection).Early ambulation, Limited and progressive

weight bearing

Early ambulation, Limited and progressive weight bearingMobilization with protected wt bearing – 10-

30Lb TDWBIf bilateral – transferred in bed to chair

manner.Early CPMWeight bearing at min 8 weeksCertain of stability if any doubt – Dynamic

stress views.Serial X-rays – late subluxation or loss of

position of articular fragments.

Surgical indications:Loss of congruence (Subluxation) of hip on

any view (AP or Judet x-rays) Displacement of >2 mm within the superior

articular surface (weightbearing dome) Retained intraarticular fragments, Greater than 25% of the width of the

posterior wall on CT or demonstrable instability.

Lack of secondary congruence for an associated both column fracture.

Other factors favoring operative intervention:Sciatic N lesion developing

following closed reduction orwhile in traction.

Associated fracture of femurTraction not possible

Ipsilateral knee disruptionPatellar fracture or posterior ligamentous

injuries.

Indications for Emergency ORIFIrreducible dislocation, usually by

Large fragments of bone within the jointSoft tissue interposition.Head buttonholed through capsule.

Unstable hip following reductionIncreasing neurologic deficit

Before reduction–Urgent closed reductionAfter reduction-Urgent Open reduction.

Associated Vascular injury – mc anterior column fractures.

Open fractures.

ContraindicationsIn Patient

Very osteoporoticSevere associated injuries

In FractureVery comminuted inoperable fracture

In Surgical teamNot experienced in such surgeriesNo expert help available.

Role of THRShould not be used for fractures best treated

by ORIFOlder pateints, with poor bone or extensive

comminution with probable poor results.

Surgical approaches:FRACTURE TYPE APPROACHELIMENTARY FRACTURES

1 Posterior wall Kocher-Langenbeck2 Posterior column Kocher-Langenbeck3 Anterior wall Ilioinguinal4 Anterior column Ilioinguinal5 TransverseInfratectal/JuxtatectalTranstectal

Kocher-LangenbeckExtended iliofemoral or Kocher-Langenbeck

Surgical Approaches:ASSOCIATED FRACTURES

1 Posterior column + wall Kocher-Langenbeck2 Anterior + posterior Hemitransverse

Ilioinguinal

3 Transverse + posterior wallInfratectal/JuxtatectalTranstectal

Kocher-LangenbeckExtended iliofemoral or Kocher-Langenbeck

4 T – shaped Infratectal/JuxtatectalTranstectal

Kocher-Langenbeck or combinedExtended iliofemoral or combined

5 Associated both column ABC Ilioinguinal.

Complications:Post traumatic arthrosisHeterotrophic OssificationVenous thromboembolism - 61%Neurologic injury

Sciatic – 30% of acetabular #s 2 -3% iatrogenic after surgery.

LFCN (m.c. N. injury after surgery)Infection 1-10% after surgery.