Orthopedics 5th year, 2nd lecture (Dr. Ali A.Nabi)


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The lecture has been given on Dec. 11th, 2010 by Dr. Ali A.Nabi.

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Orthopedics 5th year, 2nd lecture (Dr. Ali A.Nabi)

  1. 1. Fractures of the acetabulum
  2. 2. Fractures of the acetabulum <ul><li>Occurs when the head of the femur is driven into the pelvis. This caused by </li></ul><ul><li>A blow on the side (fall from a height). </li></ul><ul><li>a blow from the in front of the knee ( dashboard injury ). </li></ul>
  3. 3. Fractures of the acetabulum <ul><li>Fractures of the acetabulum may lead to: </li></ul><ul><li>soft tissue injury as in fracture pelvis. </li></ul><ul><li>articular cartilage damage which lead to malcongruent loading and secondary osteoarthritis. </li></ul>
  4. 4. Classification <ul><li>The classification of acetabular fractures described by Letournel and Judet is the most widely used classification system. They divided acetabular fractures into two basic groups: </li></ul>
  5. 5. Classification <ul><li>simple fracture types . Which are isolated fractures of one wall or column along with transverse fractures; this type includes fractures of the </li></ul><ul><li>posterior wall. </li></ul><ul><li>posterior column. </li></ul><ul><li>anterior wall. </li></ul><ul><li>anterior column. </li></ul><ul><li>transverse fractures. </li></ul>
  6. 6. Classification
  7. 7. Classification <ul><li>complex fracture types. Which have more complex fracture geometries and include </li></ul><ul><li>combined fractures of the posterior column and wall. </li></ul><ul><li>combined transverse and posterior wall fractures. </li></ul><ul><li>T-type fractures. </li></ul><ul><li>anterior column fractures with a hemitransverse posterior fracture. </li></ul><ul><li>both-column fractures. </li></ul>
  8. 8. Classification
  9. 9. Posterior wall and posterior column <ul><li>fractures can be distinguished easily. In a posterior column fracture, the ilioischial line is interrupted, while only the retroacetabular surface is disrupted in a posterior wall fracture. </li></ul>
  10. 10. Posterior wall and posterior column
  11. 11. Posterior wall and posterior column
  12. 12. Posterior wall and posterior column
  13. 14. Anterior wall and Anterior column <ul><li>Similarly, anterior wall and anterior column fractures can be distinguished by the additional break in the ischiopubic segment of the pelvis present in the anterior column fracture. </li></ul>
  14. 15. Anterior wall and Anterior column
  15. 16. Anterior wall and Anterior column
  16. 17. Anterior wall and Anterior column
  17. 18. Anterior wall and Anterior column
  18. 19. Transverse Fractures <ul><li>A transverse acetabular fracture involves a fracture line that goes through both columns of the acetabulum, but a portion of the dome of the acetabulum remains attached to the constant fragment of the iliac wing. </li></ul>
  19. 20. Transverse Fractures
  20. 21. Transverse Fractures
  21. 22. Transverse Fractures
  22. 23. Transverse Fractures <ul><li>Transverse acetabular fractures can be divided into transtectal, juxtatectal, and infratectal fractures, depending on the orientation of the fracture line relative to the dome or tectum of the acetabulum. Transtectal fractures are less forgiving and must be reduced anatomically, whereas infratectal fractures, if low enough, can be treated without surgery, depending on the pattern. </li></ul>
  23. 24. Transverse Fractures <ul><li>A. Infratectal B. Juxtatectal C. Transtectal </li></ul>
  24. 25. T-Type Fractures <ul><li>T-type fractures differ from transverse fractures by the additional fracture line that runs through the quadrilateral surface. As a result, the anterior column and posterior column are separated by fracture lines. </li></ul>
  25. 26. T-Type Fractures
  26. 27. T-Type Fractures
  27. 28. T-Type Fractures
  28. 29. T-Type Fractures
  29. 30. Both-Column Fractures <ul><li>In a both-column fracture, the entire acetabulum is separated from the iliac wing. This is considered a &quot;floating&quot; acetabulum, and the &quot;spur-sign,&quot; which is best seen on the obturator oblique view, is pathognomonic for the both-column fracture. </li></ul>
  30. 31. Both-Column Fractures
  31. 32. Both-Column Fractures
  32. 33. Clinical features <ul><li>H/O severe trauma like traffic accident or fall from a height. </li></ul><ul><li>should be suspected whenever there is fracture femur, knee injury or fracture calcaneum. </li></ul><ul><li>shock and all other pelvic injury complication could be seen.. </li></ul><ul><li>bruises around the hip and limb. </li></ul><ul><li>the limb might be internally rotated if the hip dislocated. </li></ul><ul><li>rectal examination should be performed. </li></ul><ul><li>careful neurovascular examination. </li></ul>
  33. 34. Imaging <ul><li>Radiography </li></ul><ul><li>At least four x-rays views should be obtained in each case </li></ul><ul><li>anteroposterior view. </li></ul><ul><li>pelvic inlet view. </li></ul><ul><li>45° left oblique view. </li></ul><ul><li>45° right oblique view. </li></ul><ul><li>Each view show different profile of the acetabulum. </li></ul>
  34. 35. Imaging <ul><li>Anteroposterior Radiograph Lines </li></ul><ul><li>On anteroposterior (AP) radiographs of the acetabulum, 6 major lines should be considered </li></ul><ul><li>the iliopectineal line (1) </li></ul><ul><li>the ilioischial line (2) </li></ul>
  35. 36. Imaging <ul><li>the teardrop (the medial portion of the teardrop represents the quadrilateral surface and the lateral portion represents the medial aspect of </li></ul><ul><li>the acetabular floor) (3) </li></ul><ul><li>the dome (4) </li></ul><ul><li>the anterior wall (5) </li></ul><ul><li>the posterior wall (6) </li></ul>
  36. 37. Imaging
  37. 38. Imaging <ul><li>C-T scan will give more detailed information for the surgical reconstruction. </li></ul>
  38. 39. Imaging
  39. 40. Treatment <ul><li>Emergency treatment . </li></ul><ul><ul><li>ABC. </li></ul></ul><ul><ul><li>Skeletal traction according to body weight ( 1/10 of body weight ) to reduce any associated hip dislcation. </li></ul></ul><ul><ul><li>lateral skeletal traction through the greater trochanter sould be done after 3-4 days to reduce central dislocation of the hip. </li></ul></ul><ul><ul><li>definite treatment sould be delayed untill the general condition of the poatient permits and operation facilities are optimal. </li></ul></ul>
  40. 41. Treatment <ul><li>Non-operative treatment </li></ul><ul><li>Indications </li></ul><ul><li>acetabular fractures with minimal displacement. </li></ul><ul><li>displaced fractures that do not involved the weight beasring zone which is the superomedial ( the roof ) of the acetabulum. </li></ul><ul><li>both column fractures with the ball and socket retained congreunt. </li></ul><ul><li>fractures in elderly where the close reduction seems tobe feasible. </li></ul><ul><li>medical contraindication for surgery like local sepsis. </li></ul>
  41. 42. Treatment <ul><li>The conservative treatment </li></ul><ul><li>Closed reduction under GA. </li></ul><ul><li>skeletal longitudinal traction + lateral traction for 6-8 weeks. </li></ul><ul><li>hip movement and excercises should be encouraged during this peroid. </li></ul><ul><li>partial weight bearing for another 6 weeks. </li></ul>
  42. 43. Treatment <ul><ul><li>Operative treatment </li></ul></ul><ul><li>Indication </li></ul><ul><ul><ul><li>all unstable hips after close reduction. </li></ul></ul></ul><ul><ul><ul><li>failure of conservative treatment. </li></ul></ul></ul><ul><ul><ul><li>significant distortion of the ball and socket congruence. </li></ul></ul></ul><ul><ul><ul><li>associated femoral head fracture. </li></ul></ul></ul><ul><ul><ul><li>retained bone fragments in the joint. </li></ul></ul></ul>
  43. 44. Complications <ul><li>Iliofemoral venous thrombosis. </li></ul><ul><li>sciatic nerve injury. </li></ul><ul><li>hereterotopic bone formation. </li></ul><ul><li>avascular necrosis of the femoral head. </li></ul><ul><li>loss of joint movement and secondary osteoarthritis. </li></ul>