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Acetabulum fractures

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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.

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1

Acetabulum fractures

2

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

3

Judet & Letournel Analysed inominate bone anatomy. Plane of Ilium & Obturator foramen ~ 90o 450 to frontal plane X rays at 45 oblique views.

4

Anatomy of acetabulum: Incomplete hemispherical socket Horse shoe shaped articular facet Non articular condyloid fossa

5

Anatomy: Anterior Column - longer Posterior Column - shorter Sciatic notch

6

Dome or roof – weight bearing portion Goal of treatment Anatomic restoration of dome Concentric reduction of femoral head within dome

7

Acetabulum fractures

8

Neurovascular structures External iliac A.

9

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

10

Mechanism of Injury: Transmitted Force Femur Femoral head Pelvis and acetabulum

11

Fracture pattern Dependent upon: Position of hip Direction & magnitude of Impact Osteoporotic bones Other injury patterns. DIAGS

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. ScanRotational 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.

25

Fracture Classification: Judet and Letournel Classification Orthopaedic Trauma Association Classification

26

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%

27

Treatment options: Non surgical treatment Operative treatment

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).

33

Patient related factors Age Preinjury activity level Functional demands Medical comorbidities Old patients Planned arthroplasty once arthritis develops.

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.

36

Accuracy of reduction Correlates with clinical outcome. <1mm Excellent results 1-3mm good/fair. >3mm poor results.

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.

43

Contraindications In Patient Very osteoporotic Severe associated injuries In Fracture Very comminuted inoperable fracture In Surgical team Not experienced in such surgeries No expert help available.

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.

45

Surgical approaches: FRACTURE TYPE APPROACH ELIMENTARY FRACTURES 1 Posterior wall Kocher-Langenbeck 2 Posterior column Kocher-Langenbeck 3 Anterior wall Ilioinguinal 4 Anterior column Ilioinguinal 5 Transverse Infratectal/Juxtatectal Transtectal Kocher-Langenbeck Extended iliofemoral or Kocher-Langenbeck

46

Surgical Approaches: ASSOCIATED FRACTURES 1 Posterior column + wall Kocher-Langenbeck 2 Anterior + posterior Hemitransverse Ilioinguinal 3 Transverse + posterior wall Infratectal/Juxtatectal Transtectal Kocher-Langenbeck Extended iliofemoral or Kocher-Langenbeck 4 T – shaped Infratectal/Juxtatectal Transtectal Kocher-Langenbeck or combined Extended iliofemoral or combined 5 Associated both column ABC Ilioinguinal.

47

Complications:Post traumatic arthrosis Heterotrophic Ossification Venous 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.

48

Acetabulum fractures

More Related Content

Acetabulum fractures

  • 2. Acetabular supports: 2 Columns (Inverted “Y”) & Sciatic buttress Judet & Letournel
  • 3. Judet & Letournel Analysed inominate bone anatomy. Plane of Ilium & Obturator foramen ~ 90o 450 to frontal plane X rays at 45 oblique views.
  • 4. Anatomy of acetabulum: Incomplete hemispherical socket Horse shoe shaped articular facet Non articular condyloid fossa
  • 5. Anatomy: Anterior Column - longer Posterior Column - shorter Sciatic notch
  • 6. Dome or roof – weight bearing portion Goal of treatment Anatomic restoration of dome Concentric reduction of femoral head within dome
  • 9. Sciatic N. Superir gluteal A. & N. Greater sciatic notch
  • 10. Mechanism of Injury: Transmitted Force Femur Femoral head Pelvis and acetabulum
  • 11. Fracture pattern Dependent upon: Position of hip Direction & magnitude of Impact Osteoporotic bones Other injury patterns. DIAGS
  • 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. ScanRotational 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.
  • 25. Fracture Classification: Judet and Letournel Classification Orthopaedic Trauma Association Classification
  • 26. 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%
  • 27. Treatment options: Non surgical treatment Operative treatment
  • 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).
  • 33. Patient related factors Age Preinjury activity level Functional demands Medical comorbidities Old patients Planned arthroplasty once arthritis develops.
  • 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.
  • 36. Accuracy of reduction Correlates with clinical outcome. <1mm Excellent results 1-3mm good/fair. >3mm poor results.
  • 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.
  • 43. Contraindications In Patient Very osteoporotic Severe associated injuries In Fracture Very comminuted inoperable fracture In Surgical team Not experienced in such surgeries No expert help available.
  • 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.
  • 45. Surgical approaches: FRACTURE TYPE APPROACH ELIMENTARY FRACTURES 1 Posterior wall Kocher-Langenbeck 2 Posterior column Kocher-Langenbeck 3 Anterior wall Ilioinguinal 4 Anterior column Ilioinguinal 5 Transverse Infratectal/Juxtatectal Transtectal Kocher-Langenbeck Extended iliofemoral or Kocher-Langenbeck
  • 46. Surgical Approaches: ASSOCIATED FRACTURES 1 Posterior column + wall Kocher-Langenbeck 2 Anterior + posterior Hemitransverse Ilioinguinal 3 Transverse + posterior wall Infratectal/Juxtatectal Transtectal Kocher-Langenbeck Extended iliofemoral or Kocher-Langenbeck 4 T – shaped Infratectal/Juxtatectal Transtectal Kocher-Langenbeck or combined Extended iliofemoral or combined 5 Associated both column ABC Ilioinguinal.
  • 47. Complications:Post traumatic arthrosis Heterotrophic Ossification Venous 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.