2. Introduction
ā¢ Treatment of acetabular fractures is a complex area
of orthopaedics that is being continually refined.
ā¢ Caused by high energy trauma and associated
injuries are frequent.
ā¢ Management of entire patient should follow
accepted ATLS protocol.
3. Anatomy
ā¢ Acetabulum; Incomplete hemispherical socket with
an inverted horseshoe shaped articular surface
surrounding the nonarticular cotyloid fossa.
ā¢ Articular socket supported by two columns of bone,
described by Letournel and Judet as an inverted Y.
13. Roof Arc
ā¢ Matta et al developed a system for roughly
quantifying the acetabular dome after fracture, which
they called the āRoof arcā measurement.
14. ā¢ Determines if the remaining intact acetabulum is sufficient to
maintain a stable and congruous relationship with femoral head.
ā¢ If any of the roof arc measurements in a displaced fracture are
less than 45 degrees, operative treatment should be considered
15. ā¢ CT scan is invaluable in the treatment of acetabular
fractures.
21. Both column Fracture
ā¢ 23% of all acetabular fractures
ā¢ Acetabulum completely disconnected from axial skeleton.
ā¢ Central dislocation of femoral head
22. ā¢ Spur Sign; External cortex of most caudal portion of
intact ilium.
24. Treatment Protocol
ā¢ Radiographs allow proper fracture classification
ā¢ Fracture location and displacement determine need
for surgery
ā¢ Fracture Pattern determines Approach.
25. Non Operative ; Indications
ā¢ Nondisplaced and minimally displaced fractures (<2 mm)
ā¢ Fractures with significant displacement but in which the region of the joint
involved is judged to be unimportant prognostically (roof arc).
ā¢ Secondary congruence in displaced both column fractures
ā¢ Medical contraindications to surgery
ā¢ Local soft tissue problems, such as infection, wounds and soft tissue lesions
ā¢ Elderly patients with osteoporotic bone in whom open reduction may not be
feasible
26. Non Operative Treatment Techniques;
ā¢ Bed Rest with joint mobilisation.
ā¢ When there is adequate fracture healing , usually by
6-12 weeks , gradually progress to full weight
bearing..
ā¢ Prolonged traction treatment for those patients with
operative indications related to fracture displacement
but having contraindications to surgical intervention.
27. Indications for operative treatment
Fracture characteristics:
ā¢ With 2 mm or more of displacement in the dome of acetabulum as
defined by any roof arc measurements of less than 45 degrees
ā¢ any subluxation of the femoral head from a displaced acetabular
fracture noted on any of the three standard radiographic views
ā¢ Posterior wall fractures with more than 50% involvement of the
articular surface of the posterior wall.
ā¢ Incarcerated fragments in the acetabulum after closed reduction of
hip dislocation
28. ā¢ Urgent surgical interventions
-Irreducible hip dislocation
-Open fracture
-Vascular compromise
-Worsening neurologic deficit
ā¢ No delay beyond 15 days for elementary fractures and 10 days
for associated types
30. Selection of Surgical approach
ā¢ Fracture type
ā¢ Elapsed time from injury to operative intervention
ā¢ Magnitude and location of maximal fracture
displacement
31. Fracture Reduction & Fixation;
ā¢ First reduce and stabilise the
displaced columns , if present and
then reduce any wall fracture.
ā¢ After definitive fixation of the
reduced fragments, the entire
construct is stabilised with
buttress plates.
32. Percutaneous Treatment
ā¢ Mini open exposure through lateral window of ilioinguinal
incision.
Indications;
ā¢ To prevent potential further fracture displacement.
ā¢ Displaced fractures in elderly.
ā¢ Simple fractures with minimal displacement
ā¢ As an adjunct to standard ORIF techniques
ā¢ Severe injuries that prevent formal ORIF
50. Modified Stoppa Approach
ā¢ Exposes internal surface of the anterior column and
the quadrilateral surface.
ā¢ It can be used for many fractures previously treated
through ilioinguinal approach.
56. ā¢ Use of Stoppa Approach with the Lateral window of
the ilioinguinal approach has been promoted as a
way of avoiding the dissection of the middle window
of the ilioinguinal approach and thus exposure of
femoral vessels and nerve.
57. Complications
ā¢ Overall mortality rates (0 - 2.5%)
ā¢ Post traumatic arthritis & osteonecrosis of femoral head
ā¢ Infections
ā¢ Sciatic nerve palsy (10-15% ;2-6%)
ā¢ Heterotopic ossification
ā¢ Thromboembolic complications
ā¢ Intra articular hardware
58. THR
ā¢ In older patients with extremely poor prognoses.
ā¢ Indications include intraarticular comminution,
full thickness abrasive loss of articular cartilage,
impaction of femoral head, impaction of dome,
associated femoral neck fracture and
preexistent arthritis.
ā¢ Fractures can be fixed with percutaneous
screws, plates or cables and fixation augmented
with multiple screw fixation of the ingrowth cup.