Acetabular fractures.ppt

Acetabular fractures
MODERATOR : Dr.Ashwani Ummat
PRESENTER : Dr.Nishat Setia

INTRODUCTION
 Typically occur in young adults secondary to high-
energy trauma
 In trauma, there is a 50% chance of associated injuries:
spine fractures, abdominal and chest trauma,
genitourinary injury, extremity fractures, knee
ligamentous disruptions, joint dislocations, neuro and
head injury, pelvic fractures.
 Surgical treatment is often needed to restore the
anatomic shape of the hip joint, thus allowing normal
pressure distribution

Anatomy
 Formed as a portion of the innominate bone
 Junction of three bones: ilium, ischium, and pubis joined by the
tri-radiate cartilage
 The acetabulum is divided into 2 columns: anterior and posterior
 The 2 columns are described as having the shape of an inverted
Y, or of the Greek letter lambda (l).
 Anterior column: iliac crest,anterior border of the iliac wing, the
entire pelvic brim, the anterior wall, and the superior pubic
ramus
 Posterior column: the ischial portion of bone ( lesser and
greater sciatic notches), posterior wall, and the ischial tuberosity

Radiography
 Five (5) Pelvic X Ray views
 The anteroposterior (AP) view
 Bilateral 45 degree oblique views, or Judet views
of the pelvis
 Inlet and Outlet Pelvis X ray views
 Computed tomography, CT scans, can be
obtained to provide additional information on
fracture configuration

Pelvis XRay
 Inlet view:
 Pt is supine with XRay beam parallel to plane of
sacrum, sacrum is seen on end with vertebral body
anteriorly and sacral lamina posteriorly
 AP of pelvis with beam tilted 25-30 degrees caudally
 Outlet view:
 Pt is supine with XRay beam perpendicular to plane of
sacrum
 AP of pelvis with beam tilted 35-45 degrees cephalad

Judet hip XRay
 Iliac oblique:
 Patient is supine with involved side of pelvis rotated
anteriorly 45 deg, beam directed vertically toward
affected hip
 shows iliopectineal line, Anterior Column and Posterior
Wall
 Obturator oblique:
 Patient is supine with uninvolved side of pelvis rotated
ant. 45 degrees, beam directed vertically toward the
affected hip
 shows ilioischial line, Posterior Column and Anterior
Wall.

Teardrop
 Internal limb = outer wall
of obturator canal
 External limb = middle
1/3 of cotyloid fossa
 Inferior border =
ischiopubic notch

Classification
 Initially published by Judet in 1964, and later modified
by Letournel
 Judet and Letournel classification system: elementary
and associated types
 Elementary: posterior wall (PW), posterior column
(PC), anterior wall (AW), anterior column (AC),
transverse
 Associated: posterior column and wall (PC-PW),
transverse posterior wall (T-PW), anterior column and
posterior hemitransverse (AC-PHT) , T-Shaped, both-
column (BC),

Elementary types
Post wall Post
column
Ant wall Ant column Transver
se

Associated types
Post. Wall
& post.
column
Transverse
& post.
Wall or
column
T-shaped Ant column or
wall & post
hemitransverse
Both
columns

Radiographs of a
posterior wall fracture. A.
Anteroposterior view
shows all radiographic
landmarks to be intact
except the posterior rim
(arrow). B. The obturator
oblique view shows the
displaced posterior wall
fracture (arrow). C. The
iliac oblique view shows
an intact posterior border.

Radiographic appearance
of the posterior column
fracture. A. On the
anteroposterior view, the
displacement of the
ilioischial line (arrow) is
apparent while the
iliopectineal line is seen to
be intact (black
arrowheads). As typical, the
ilioischial line (arrow) is
displaced relative to the
radiographic U (white
arrowhead). B. The
obturator oblique view
confirms the anterior
column to be intact
(arrowheads) and
demonstrates the fracture
of the ischial ramus
(arrow). C. The iliac oblique
view shows the disruption
of the greater sciatic notch
and the displacement of the
posterior column (arrow).
D. The computed
tomography section shows
a fracture line typical of a
posterior column fracture.

Radiographic appearance
of the anterior wall
fracture, as described by
Letournel and Judet.76 A.
On the anteroposterior
(AP) view, the disruption
of the iliopectineal line is
seen in two locations. B.
The obturator oblique
confirms this and
demonstrates that the
femoral head remains
congruent to the anterior
wall segment. C. The iliac
oblique view confirms the
posterior border of the
bone to be intact and that
the ilioischial line
disruption seen on the AP
view is because of a
fragment of quadrilateral
surface comminution and
does not represent a
fracture through the
posterior border of the
innominate bone. This
explains the normal
position of the ischium
despite the ilioischial line
displacement.

Radiographic appearance of
the anterior column fracture.
A. The AP view demonstrates
the fracture from the iliac
crest to the hip joint with
disruption of the roof. A
small area of comminution at
the pelvic brim is noted. The
ischial ramus fracture is also
noted. B. The obturator
oblique demonstrates a single
break in the iliopectineal line
where the anterior column
fracture crosses the pelvic
brim. Although difficult to
see, the disruption of the
ilium can be appreciated as a
reduplication of the cortical
lines of the internal iliac and
fossa and external wing of the
ilium. C. The iliac oblique
view confirms the posterior
border of the bone to be
intact.

Radiographic appearance of the
associated posterior column and
posterior wall fracture. A. The
anteroposterior pelvis radiograph
shows the disruption of the ilioischial
(black arrow) but not the iliopectineal
lines (black arrowheads), and the
ischial ramus fracture is present (white
arrowhead), and the posterior wall
fragment can be appreciated overlying
the roof of the acetabulum (white
arrow). B. The obturator oblique view
shows the displaced posterior wall
fragment (white arrow), the ischial
ramus fracture (white arrowhead), and
the intact iliopectineal line (black
arrowhead). C. The iliac oblique
demonstrates the disruption of the
greater sciatic notch and the posterior
wall fragment superimposed on the
roof of the acetabulum (black arrow).
D. This computed tomography section
shows the posterior wall fracture
(arrow) with a column fracture line
typical of a posterior column fracture
(black arrowheads).

Radiographic appearance of the associated
transverse and posterior wall fracture
(transtectal pattern). A. The appearance on
the anteroposterior radiograph is quite
similar to that of the pure transverse
fracture with disruption of five of the six
radiograph landmarks; only the
radiographic U (which maintains its normal
relationship to the ilioischial line) remains
intact. The posterior wall fragment is seen
as an oblique cortical line overlying the
intact roof (arrowhead). B. The obturator
oblique shows the transverse fracture, the
subluxation of the femoral head with the
ischiopubic fragment, as well as the
posterior wall fragment. It is easy to see on
this view how the femoral head may abrade
against the fracture edge while the hip is
subluxated. C. The iliac oblique view
highlights the fracture line exiting the
greater sciatic notch as well as the posterior
wall fragment superimposed on the roof
of the acetabulum (black arrow).

Radiographic appearance of the
associated anterior wall and posterior
hemitransverse fracture. A. The
anteroposterior pelvis radiograph
demonstrates the medial subluxation
of the femoral head with segmental
displacement of the iliopectineal line.
The ilioischial line displacement is
noted and, unlike the anterior wall
fracture, the relationship of the
ischium to the ilioischial line is
preserved. Wear of the femoral head is
seen laterally where the head is
articulating with the edge of the intact
roof. B. The obturator oblique
radiograph appears similar to that seen
in the isolated anterior wall fracture but
the fracture is seen to be
multifragmentary with impaction.
Disruption of the posterior rim line is
appreciated. C. The iliac oblique shows
the disruption of the posterior border
of the innominate and displacement
through the greater sciatic notch.

Radiographic appearance of the T-
shaped fracture of the patient shown in
Figure 45-5. A. The appearance on the
anteroposterior pelvis radiograph may be
distinguished from the transverse
fracture by the presence of the fracture
of the ischial ramus (white arrow).
Displacement of the stem of the T may
cause the ilioischial line to appear
duplicated (black arrowheads). Likewise,
the relationship between the ilioischial
line, which remains with the posterior
column, and the teardrop, which remains
with the anterior column, may be
disrupted (black arrow). B. The
obturator oblique shows the break in the
iliopectineal line (black arrow). It also
allows better visualization of the stem of
the T (white arrow) as it enters the roof
of the obturator foramen and is
associated with the ischial ramus fracture
(arrowhead). C. The iliac oblique view
demonstrates the disruption of the
greater sciatic notch and subluxation of
the femoral head.

Radiographic appearance of a both-
column fracture. A. Despite disruption of
all six of the radiograph landmarks, the
femoral head is seen to remain congruent
to the roof and anterior column fragment.
The position of the head on the
anteroposterior radiograph is medialized as
well as superiorly displaced. Fracture of
the contralateral pubic body because of
the displacement of the superior pubic
ramus fragment is noted. B. The obturator
oblique demonstrates the spur sign
(arrowhead) as well as confirming the
congruence between the femoral head and
acetabulum. C. The iliac oblique view
reveals loss of congruence between the
femoral head and the posterior column;
therefore, this fracture is indicated for
surgical treatment. D. The computed
tomography section shows the anterior
column (white arrow), the superior extent
of the posterior column (white
arrowhead), the spur sign of the iliac wing
(black arrow), and a large posterior wall
fracture (black arrowhead).

AO Classification
 Type A - # single wall or column
 Type B - # both anterior and posterior
columns(transverse or T-type fractures)
 Type C - # both anterior and posterior columns
but all articular surfaces are detached from
remaining intact ilium.

AO classification of acetabular
fractures. Type A: fracture
involves only one of two
columns of acetabulum; type A1:
posterior wall fracture and
variations; type A2: posterior
column fracture and variations;
type A3: anterior wall and
anterior column fracture. Type
B: transverse fractures, portion
of roof remains attached to
intact ilium; type B1: transverse
fracture and transverse plus
posterior wall fracture; type B2:
T-shaped fracture and variations;
type B3: anterior wall or column
plus posterior hemitransverse
fracture. Type C: fractures of
anterior and posterior columns,
no portion of roof remains
attached to intact ilium; type C1:
anterior column fracture
extending to iliac crest; type C2:
anterior column fracture
extending to anterior border of
ilium; type C3: fractures enter
sacroiliac joint.

Nonoperative treatment
 Nondisplaced fractures, <5mm, or articular step-off of
<2mm
 Operative contraindications: local or systemic
infection, severe osteoporosis
 Operative relative contraindications: advanced age,
associated medical conditions (ESRD on dialysis,
ESLD, Seizure Disorder, uncontrolled DM, CHF,
Neurological Disorder), associated soft tissue and
visceral injuries, or a multiply injured patient not stable
for a big acetabular surgery
 Displaced fractures: large portion of acetabulum
remains intact with a congruous femoral head, or
secondary congruence with a both-column fracture.

 Posterior Wall: if less than 50% of the width of the
articular cartilage is displaced , some authors say less
than 25%
 Many low Anterior Wall fractures
 A minority of low T-shaped fractures.
 Infratectal transverse fractures
 In assesing the intact portion of acetabulum, it is useful
to obtain roof arc measurements
 Matta first described these angles in 1986
 Stable fractures=all roof arc angles >45 degrees
 CT subchondral arc technique of Olson: no
involvement of the upper 10mm of the acetabulum by
CT corresponds to an intact 45 degrees roof arc on all 3
plain XRays

Roof Arc Angles
 A vertical line is drawn from
roof of acetabulum to
geometric center of the
femoral head, and second
line is drawn from fracture to
the geometric center
 1. Medial Roof Arc (AP pelvis)
 2. Anterior Roof Arc
(Obturator oblique)
 3. Posterior Roof Arc (Iliac
oblique)

Operative treatment
 Any displaced fracture > 5mm, or articular step-off of
>2mm
 Allows early ambulation and decreases chance of post-
traumatic arthritis
 Usually undertaken 2-3 days after injury, when initial
fracture and intrapelvic vessel bleeding has subsided
 Ideally performed before 10 days, so fracture fragments
remain mobile
 Three weeks after injury, a bony callus has formed,
making reduction more difficult (typically not done)

Surgical approaches
 Kocher-Langenbeck: best access to posterior column
(prone)
 Ilioinguinal: best access to anterior column and inner
aspect of innominate bone (supine)
 Extended iliofemoral: best simultaneous access to the
two columns (lateral)
 Combined approaches performed concurrently or
successively is less desirable
 Extended iliofemoral approach has the highest
incidence of ectopic bone formation (Heterotrophic
Ossification) and longest postoperative recovery

Kocher-Langenbeck approach
 Posterior wall fractures
 Posterior column fractures
 Posterior column-posterior wall fractures
 Juxta-tectal/Infra-tectal transverse or transverse-
posterior wall fractures
 Some T-shaped fractures

Ilioinguinal approach
 Anterior column fractures
 Anterior wall fractures
 Some anterior column-posterior hemitransverse
fractures
 May also be used for both column fractures with large
single posterior fragment, with reduction being
achieved indirectly through reduction of the
quadrilateral plate
 Fractures with associated superior ramus and symphysis
pubis fractures

Extended Iliofemoral approach
 T-shaped fractures
 Transverse fractures with extended posterior wall
 T-shaped fractures with wide separations of the
vertical stem of the "T" or those with associated
pubic symphysis dislocations
 Certain associated both column fractures
 Associated fracture patterns or transverse fractures
which are operated greater than 21 days following
injury

Other approaches
 Stoppa approach (supine): Cole and Bolhofner
 Allows access to the medial wall of the
acetabulum, quadrilateral surface, and sacroiliac
joint
 Triradiate approach (prone):
 Alternate exposure to the external aspect of the
innominate bone, with almost same exposure as
iliofemoral but visualization of the posterior part
of the ilium is not as good

Postoperative care
 If the fracture has been reduced accurately, 90% of
normal ROM will be obtained without difficulty by the
patient
 Pt is placed on bedrest initially, allowing ambulation
when symptoms allow
 Iliofemoral approach= 5 days of absolute bedrest, to
allow for edema to subside and initial wound healing
 ROM of the hip can be instituted by Physiotherapy.

 The patient is encouraged to ambulate with a step-
through gait and a heel-toe walking motion, using
crutches or walker
 Patient is instructed on active flexion, abduction, and
extension exercises to be performed at the hip while
standing
 AP Pelvis XRay should be obtained after gait training
and before discharge to confirm that loss of reduction
has not occurred
 Iliofemoral approach: active abduction and passive
adduction are not allowed for the first 3 weeks
 Limited weight bearing is continued for 8 weeks.
 Patient is directed at regaining muscle strength at the
hip, particularly the abductors

Complications
 Operative wound infection: decreased with the liberal use of
drains, and intraoperative hemostasis
 Iatrogenic nerve palsy: Peroneal branch of Sciatic N (Kocher-
Langenbeck), Sciatic N (Iliofemoral), Femoral N (Ilioingiunal)
 Periarticular ectopic bone formation: greatest with lateral
exposure of the innominate bone, highest with iliofemoral
approach, followed by Kocher-Langenbeck, and almost
nonexistent with ilioingiunal or Stoppa approaches
 Indomethacin 25mg TDS post operatively or a localized single-
dose of radiation therapy significantly decreases risk (both
equally effective)
 Thromboembolic complications (DVT,
PulmonaryEmbolism): Coumadin started 48 hours postop and
continued for 6 weeks, or LMW Heparin started POD#1 and
continued for 3 weeks

Morel-Lavallee lesion
 A closed degloving injury over the greater trochanter
 Results from the blunt trauma that caused the fracture
 The subcutaneous tissue is torn away from the underlying fascia,
and a significant cavity results
 Cavity contains hematoma and necrossed fat
 These areas must be drained and debrided before or during
surgery to decrease the chance of infection
 Advisable to leave this area open through the surgical incision or
a separate incision
 Dressing changes and wound packing are sometimes needed for
a prolonged period of time
 Primary excision of the necrotic fat and closure over a drain has
not been routinely successful

Acetabular fractures.ppt

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