Acetabular fractures

Everything need to know about acetabulum fractures.
History, classification, ATLS protocol, investigations and management.

1. Acetabular fractures By Dr Arshad Shaikh Credits Dr Anand

2. Introduction Contemporary icon of pelvic and acetabular surgery . U biquitous 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

3. 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.

4. 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.

5. 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

6. Mechanism of injury

7. Mechanism of injury

8. 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

9. 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

10. Anatomy & Osteology hemisphere recess quadrilateral surface transverse acetabular ligament Dome of acetabulum iliopectineal eminence sciatic nerve relation

11. Anatomy & Osteology

12. Two column concept

13. Radiology of acetabular fractures

14. Radiology of acetabular fractures Superior weight bearing surface

15. Radiology of acetabular fractures Iliac oblique view Obdurator oblique view

16. Radiology of acetabular fractures Iliac oblique view Obdurator oblique view

17. Roof arc measurement

18. Roof arc measurement

19. Dynamic stress view Dynamic hip instability

20. 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

21. Classification – Letournel

22. 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

23. 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

24. 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 unstable Both column # Secondary congruence

25. Secondary congruence

26. Secondary congruence

27. 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

28. 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

29. 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

30. Orthopedic trauma association

31. Approaches Anterior Ilioinguinal Iliofemoral Extended Iliofemoral Modifications of Ilioinguinal Modifications of iliofemoral Posterior Kocher- Langenbeck Modifications Trochantric flip osteotomy Modified Gibson Modified Stoppa Intrapelvic

32. 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

33. Ilioinguinal approach

34. Ilioinguinal approach

35. Ilioinguinal approach

36. Ilioinguinal approach

37. Ilioinguinal approach

38. Ilioinguinal approach

39. Ilioinguinal approach

40. Ilioinguinal approach

41. Ilioinguinal approach

42. Ilioinguinal approach

43. Iliofemoral approach

44. 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

45. Kocher- Langenbeck approach

46. Kocher- Langenbeck approach

47. Kocher- Langenbeck approach

48. Kocher- Langenbeck approach

49. Kocher- Langenbeck approach

50. Kocher- Langenbeck approach

51. Kocher- Langenbeck approach

52. Kocher- Langenbeck approach

53. Kocher- Langenbeck approach

54. Modified Stoppa’s approach

55. Extended Iliofemoral approach

56. Trochantric flip osteotomy

57. Modified Gibson’s approach

58. Choice of approach

59. 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

60. 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

61. Extended posterior wall

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

63. 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

64. Transverse #

65. Transverse #

66. Transverse #

67. Anterior Wall and column 1 – 2 % quadrangular clamp screws and plate

68. Anterior column # Very low low intermediate high

69. 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

70. 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

71. 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

72. 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

73. Spur sign

74. Anterior column

75. Anterior column

76. Anterior column

77. Anterior column

78. Anterior column

79. Anterior column

80. Anterior column

81. Anterior column

82. Anterior column

83. Anterior column

84. Anterior column

85. Anterior column

86. Anterior column

87. Anterior column

88. Both column

89. Both column

90. Both column

91. Both column

92. Both column

93. Both column

94. Both column

95. Perioperative care Thromboembolism prophylaxis Active mobilisation by 6 – 12 weeks Indomethacin to prevent heterotropic ossification X 4 – 6 weeks PWBW – 10 to 12 weeks

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

97. Heterotopic ossification

98. Results

99. THR in acetabular # Elderly patient Post traumatic Patients with poor prognosis Cementless cup in fractured acetabulum is a concern

100. Associated injuries Acetabulum + Posterior hip dislocation Acetabulum + Pelvic ring Acetabulum + Femoral head Acetabulum + Femoral neck in young Acetabulum + Shaft femur/ IT