acetabular fraacture management with surgical approaches
TRANSCRIPT
The Pioneers
Robert Judet Emile Letournel Marvin Tile
Anatomical reduction and stable
internal fixation
CT Scan
Size of fragment Degree of displacement Amount of articular surface Site of origin of fragment Marginal impaction
Letournel Classification
Most acetabular fractures fit into one of ten types
Five simple fracture patterns Five associated fracture patterns
Simple Fractures
Posterior wall fracture Posterior column fracture Anterior wall fracture Anterior column fracture Transverse fracture
Posterior Column Fracture Extends from
PSIS to ischio pubic ramus
Involves posterior articular surface and ilio ischial line
Anterior Wall Fracture
Uncommon Separation of anterior part of
articular surface along with a large part of middle third of anterior column
Anterior hip dislocation can be associated
Anterior Column Fracture Extends from
symphysis pubis to iliac crest
Most commonly fracture line exits below AIIS
Often comminution into the quadrilateral plate
Transverse Fracture Across anterior and posterior columns Superior segment – ilium, acetabular roof Inferior segment – ischiopubic segment May be associated with central dislocation
Combined Fracture Types
Posterior column and posterior wall fracture
Transverse and posterior wall fracture T-shaped fracture Anterior column or wall and posterior
hemi transverse fracture Complete both-column fracture
Associated Posterior Wall and Posterior Column Fracture
Posterior column fracture is usually undisplaced or minimally displaced
Primary fracture – posterior wall
Associated Posterior Wall And Posterior Column Fracture
Anterior Column intact
Posterior dislocation Displaced posterior
wall Ilio ischial line
disrupted
Associated Transverse and Posterior Wall Fracture
Commonly posterior dislocation
Sometimes central dislocation
Highest incidence of pre op sciatic palsy and AVN of femoral head
T Shaped Fractures
Transverse and vertical components
Acetabular cavity is split into at least 3 fragments
AO Classification Type A – Fractues of a single wall or
column Type B –Fractures involve both columns Type C –Both column fractures with
articular fragments seperated from ilium
Injury Pattern Affecting Prognosis
High or low energy trauma Involvement of acetabular dome Comminution and displacement Joint dislocation Damage to femoral head Both-column fractures and transverse with
posterior wall fractures have worst results , primarily because of imperfect reduction
Indications For Conservative Management Non displaced or displaced
<3mm Displaced fracture in
unimportant part of acetabulum – low anterior column, low transverse
Secondary congruence in both column fractures
Indications for operative treatment Fracture Displaced >3mm Irreducible fracture dislocation Intra articular fragment
interfering with joint movement Instability of the joint To prepare the joint for hip
replacement
Contraindications to surgery Severe osteoporosis Very old patients Severe associated injuries Poor local skin condition Limited experience of the surgeon
Timing Of Surgery Urgent closed reduction of dislocation Stabilise the patient before ORIF Ideally within 7 days Poor results after 3 weeks
Kocher Langenbeck Approach Posterior wall fracture Injuries with associated
posterior wall fracture Posterior column fracture
Kocher Langenbeck Approach Transverse fracture
where major displacement is posterior
T shaped fracture with major displacement posterior
Ilioinguinal Approach Anterior wall
fracture Anterior column
fracture Fractures
associated with anterior wall and column fractures
Ilio inguinal Approach Incise along anterior two thirds of iliac
crest, extending to the pubic symphysis Elevate abdominal muscles from iliac
crest Open inguinal canal
Ilioinguinal Approach Detach deep abdominal
muscles from inguinal ligament and pubis
Open iliopsoas sheath Incise iliopectineal fascia Lateral retraction of
iliopsoas and medial retraction of iliac vessels
Dangers Of Ilio Inguinal Approach Lat cut nerve of thigh,
femoral nerve Corona mortis Internal iliac vein, femoral
vein Lymphatics Abdominal wall
weakness
EXTENSILE APPROACHES
Used in complex fracture patterns Triradiate Extensile Approach Carnesile Extensile approach
Extensile Ileofemoral approach
Triradiate Approach Described by Mears & Rubash Reduction & repair of Complex Acetabular fracturesAvoids ischemic necrosis Of Hip Abductors
Complications Of Acetabular Surgery
Imperfect reduction, inadequate fixation Avascular necrosis Infection Nerve injury Heterotopic ossification Thromboembolism
Learning Curve Of The Surgeon Parallels The Suffering Curve Of The Patient