The document discusses the anatomy and classification of acetabular fractures. It notes that Judet and Letournel analyzed the anatomy of the innominate bone and established planes and angles. Acetabular fractures are classified using the Judet and Letournel or Orthopaedic Trauma Association systems. Treatment may involve non-operative management with traction or surgery depending on the fracture pattern and stability. Surgical approaches are dependent on the specific fracture location and goal is anatomic reduction to restore a congruent joint. Complications can include arthritis, heterotopic ossification, nerve injuries and infection.
12. Hip flexed –Posterior wall # Dislocation
Internal rotation & adduction – Dislocate without
fracture.
Neutral hip - # posterior wall
Abducted position – Transverse # with posterior wall
13. Magnitude of force / displacement –
degree of comminution
Degree of articular impaction
Strength of the bone.
14. Clinical Evaluation:ABCD
Life threatening injuries
HEMODYNAMIC STABILITY
Superior gluteal A. or V.
Selective angeography
Head, chest, abdomen
57% have other associated injuries.
Secondary survey – knee, patella, ligaments.
15. Morel Lavalle lesion
Skin
Subcutaneous degloving, hematoma.
Fluid wave, fluctuent
Circumscribed area of anaesthesia / Echymosis
Culture
Significance in surgical treatment.
16. Neurological injuries
30% partial injuries to sciatic N.
More commonly peroneal division.
Superior gluteal N.
Impossible to assess abductor strength in acute
fractures.
17. Dislocation may be missed on examination
X rays needed
Dislocation – Urgently reduced
Osteonecrosis femoral head.
Wearing of head against intra articular fragments
Urgent skeletal traction.
18. 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 #s
Intraop traction not used
Concurrent symphysis dislocations.
19. Radiographic evaluation:
Pelvis AP view
Judet views – 45 degree oblique
Aid in classification
Identify # displacements.
OUT OF TRACTION
Painful – premedication.
Pelvic inlet / Outlet views – useful but not
mandatory
20. Pelvis AP viewX ray
view
Information
regarding
1Iliopectin
eal 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
21. 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
22. Obturator oblique
X ray view Information
regarding
1Iliopectinea
l line / Pelvic
brim
Anterior column
2Posterior
rim or lip
Posterior
column or wall
Obturator
ring
Column
involvement
Roof Superior
articular surface
23. C. T. ScanRotational displacements
Intra articular fragments
Marginal articular
impaction
Associated femoral head
injuries
Size of posterior wall
fragment.
3-D RECON
Relationship of multiple sites
of injury
24. Dry bone model or Line drawing:
Fracture pattern
Drawing the fracture lines from X ray landmarks
Should be drawn always before surgery.
Fracture pattern truly appreciated.
28. Non-operative treatment
Unlike most articular #s having specific operative
indications acetabular #s are
generally considered requiring operative treatment
Unless certain non-operative criteria are met.
Other factors – fracture displacement and location,
stability of hip & patient related factors.
29. 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
30. 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 CT
Not applicable in
ABC
Posterior wall
31. Other factors
ABC
No intact acetabulum left to measure
Perfect secondary congruence
Posterior wall
>50% width all unstable hips
<25% width all stable
32. 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).
34. Operative Treatment:
Earlier the better once decided to operate.
After 3 wks – results not good.
Not an emergency except
Irreducible hip dislocation
Progressing neurological deficits
Open #s
Vascular injuries
35. Surgery
ORIF - treatment of choice
GOAL
Anatomic reduction of articular surface
Avoiding complications
Restoring congruent joint
Stable hip
Maximize the potential for long term survival of hip.
37. Closed reduction and percutaneous fixation –
proposed for
elderly patients &
Simple fractures with minimal displacements.
No long term results available yet.
38. Methods of Non Operative care:
Skeletal traction
Mainly historical importance in displaced, unstable #s.
Acute situation.
Polytraumatized sick patient
Supracondylar femur traction (Never trochanteric –
infection).
Early ambulation, Limited and progressive weight
bearing
39. Early ambulation, Limited and progressive
weight bearing
Mobilization with protected wt bearing – 10-30Lb
TDWB
If bilateral – transferred in bed to chair manner.
Early CPM
Weight bearing at min 8 weeks
Certain of stability if any doubt – Dynamic stress
views.
Serial X-rays – late subluxation or loss of position
of articular fragments.
40. 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.
41. Other factors favoring operative
intervention:
Sciatic N lesion developing
following closed reduction or
while in traction.
Associated fracture of femur
Traction not possible
Ipsilateral knee disruption
Patellar fracture or posterior ligamentous injuries.
42. Indications for Emergency ORIF
Irreducible dislocation, usually by
Large fragments of bone within the joint
Soft tissue interposition.
Head buttonholed through capsule.
Unstable hip following reduction
Increasing neurologic deficit
Before reduction–Urgent closed reduction
After reduction-Urgent Open reduction.
Associated Vascular injury – mc anterior column
fractures.
Open fractures.
44. Role of THR
Should not be used for fractures best treated by ORIF
Older pateints, with poor bone or extensive
comminution with probable poor results.