CASE REPORT ACETABULAR FRACTURE GOA.pptx

health and trauma related

1. CASE REPORT OF MANAGEMENT OF POSTERIOR WALL ACETABULAR FRACTURE WITH OPEN REDUCTION AND INTERNAL FIXATION WITH RECONSTRUCTION PLATE Dr. SUNIL KUMAR CHAUDHARY Pg YEAR iii GMCTH

2. Patient Profile Bal Bahadur Magar 43 Year/ Male Annapurna 06, Kaski Hindu Married Date of presentation: 2080/09/22

3. Chief Complaints Pain and deformity of the right hip, following impact by a falling wooden log, approximately 6 hours prior to the presentation at our center Inability to bear weight

4. History of Presenting Illness Following alleged history of fall of a wooden log directly over the right hip while cutting branches from the tree, the patient complained of pain and deformity of the right hip Pain was acute on onset, continuous in nature, non-radiating and has no relieving factors The patient was unable to bear weight Pain was associated with minimal swelling. There were no external injuries

5. Past History Not significant Personal history Non- alcoholic Non- smoker Non- vegetarian by diet

6. Clinical Examination General condition Ill looking Vitals BP: 130/80 mm of Hg in right arm in supine position Pulse: 98 bpm , regular rhythm, normal character and euvolemic RR: 22 bpm SPO 2 : 96% in RA Systemic Examination Chest/ CVS: WNL PA: Soft, non tender

7. Local Examination Minimal swelling present No ecchymosis or external injuries seen Diffuse tenderness present over the right inguinal region Attitude of Right limb: Flexed, adducted, internally rotated and apparently shortened.

8. X- Ray X ray at the time of presentation Posterior dislocation of right hip Posterior wall fracture of the right acetabulum

9. Pain management along with fluid resuscitation was done in the emergency room The patient was admitted with the diagnosis of posterior dislocation of right hip with right acetabular fracture ( Leutornel & Judet , Elementary type, Posterior Wall) Patient shifted to the OT for reduction for posterior dislocation of the right hip Closed reduction was done by Allis method under SAB (in 2 hours from the time of presentation in our center, total time elapsed following trauma 8 hours) Skeletal traction (Proximal tibial) applied and kept for 12 days

10. Post reduction X-ray Femoral head reduced Posterior wall of the acetabulum fracture

11. CT Scan (Post Reduction) Femoral head reduced Posterior wall of the right acetabulum fracture

12. Definitive Management ORIF with Reconstruction plate fixation (titanium) was done on 2080/10/02 (12 th day of admission) under SAB. Position: Lateral Approach: Kocher Langenbeck Approach

13. Intra- Op

14. Immediate Post Op X-ray Reduction satisfactory Screws not encroaching the articular surface Intra-articular space clear

15. Post Op Status Vitals: Stable Systemic Examination: WNL Complications: None

16. Follow- Up (4 week) No fresh complains Non weight bearing crutch walking X- ray in AP and lateral cross table views Reduction maintained Plates and screws in position

17. Follow- Up (6 week) No fresh complains Partial weight bearing allowed X- ray in AP and lateral cross table views Reduction maintained Plates and screws in position

18. Follow- Up (12 week) No fresh complains Complete weight bearing allowed X- ray in AP and lateral cross table views Reduction maintained Plates and screws in position

19. Harris Hip Score 85 (Good)

20. Range of Motion Flexion: 110° Extension: 15°

21. Range of Motion ER: 60° IR: 40°

22. Range of Motion Adduction: 20° Abduction: 40°

23. Discussion Incidence of acetabular fracture : 3/ lakh population per year Neurologic injuries occur in up to 30% of cases In case of sciatic nerve injury, partial injury is more common, of which peroneal division more than tibial Rockwood and Green 8 th edition

24. Anterior column ( Iliopubic component) Posterior column ( Ilioischial component) Acetabular dome: Superior weight bearing portion of acetabulum at the junction of anterior and posterior column.

25. Radiographic Evaluation AP view Iliac oblique view (45 degree external rotation) Obturator oblique view (45 degree internal rotation) Computed tomography

26. Treatment Goals Anatomic restoration of the articular surface Joint stability to prevent post traumatic arthritis

27. Non Operative Treatment Non- displaced fractures with no hip instability Maintenance of medial, anterior and posterior roof arc greater than 45 degrees For posterior wall fracture, size is a major determinant for operative treatment, fragments < 20% non- operative and >50% always operative.

28. Operative Treatment Displaced acetabular fractures Inability to maintain congruent joint out of traction Large posterior wall fragment Removal of an interposed intra- articular loose fragments Fracture dislocation irreducible by closed methods.

29. Surgical Approaches Kocher- Langenbeck Indications Posterior wall fractures Posterior column fractures Posterior column/ wall Juxtatectal / infratectal transverse or transverse with posterior wall fractures Some T – types fractures (more displaced posteriorly than anteriorly)

30. Limitations Superior acetabular region Anterior column Fractures high in greater sciatic notch Trochanteric osteotomy required to extend exposure

31. Complications Sciatic nerve palsy:10% Infection: 3% Heterotopic ossification: 8-25% Avascular necrosis: 6.6% with posterior types associated with dislocations Post traumatic osteoarthritis Rockwood and Green 8 th edition

32. Take Home Message Acetabular fractures fixation surgery is a complex and demanding. Has the potential for many serious complications . Anatomic reduction of weight bearing dome, congruent reduction of the femoral head and timely surgical intervention are the keys to success.

33. Reference Campbell Operative orthopedics, 14 th edition Rockwood and Greens fractures in Adults, 8 th edition Handbook of fractures by J. Koval

34. THANK YOU!!!