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Dr. Roshan D.
Introduction
Generally caused by high energy trauma Such high energy injuries usually have a high incidence of major associated injuries The fracture or fracture dislocation produced depends on the magnitude and the direction of the injuring force as well as on the strength of the bone.
Pathoanatomy
Fractures depend on the position of the femoral head at the moment of impact
Fracture location
Posterior column #
IR
Anterior column #
Superior dome #
ER
Adduction
Acetabulum - Anatomy
The articular surface is composed of and supported by two columns of bone (described by Letournel and Judet) as an inverted Y
The shorter posterior column ends at its intersection with the anterior column at the top of the sciatic notch
Acetabulum - Anatomy
The dome or roof is the weight bearing portion of the articular surface that supports the femoral head The quadrilateral surface is the flat plate of bone forming the lateral border of the pelvic cavity The iliopectineal eminence is the prominence in the anterior column that lies directly over the femoral head.
The sciatic nerve The superior gluteal Artery and Nerve Corona mortis
Classification
(Letournel and Judet)
Simple fractures
fractures of the posterior wall, posterior column, anterior wall, anterior column and transverse fractures.
Associated fractures
T-shaped fractures, fractures of the posterior column and posterior wall, transverse + posterior wall fracture, anterior fracture + hemitransverse posterior fracture and both column fracture.
Classification
Comprehensive Classification after Letournel
Classification
Comprehensive Classification after Letournel
TYPE B PARTIAL ARTICULAR TRANSVERSE ORIENTED FRACTURE Transverse types with portion of the roof attached to intact ilium
B1Transverse + posterior wall B2T types B3Anterior with posterior hemitransverse
Classification
Comprehensive Classification after Letournel
TYPE C COMPLETE ARTICULAR, BOTH COLUMN FRACTURE - both columns are fractured and all articular segments, including the roof, are detached from the remaining segment of the intact ilium, the floating acetabulum.
C1Both columnanterior column fracture extends to the iliac crest (high variety) C2Both columnanterior column fracture extends to the anterior border of the ilium (low variety) C3Both columnanterior fracture enters the sacroiliac joint
Classification
Comprehensive Classification after Letournel
Qualifiers: Additional information can be documented concerning the condition of the articular surfaces to further define the prognosis of the injury. The information should be, as additional qualifiers, identified by Greek letters.
a1) a2) a3) b1) b2) b3) g1) g2) d1) d2) d3) e1) f1) Femoral head subluxation, anterior Femoral head subluxation, medial Femoral head sublucation, posterior Femoral head dislocation, anterior Femoral head dislocation, medial Femoral head dislocation, posterior Acetabluar surface, chondral lesion Acetabular surface, impacted Femoral head, chondral lesion Femoral head, impacted Femoral head, osteochondral fracture Intra-articular fragment requiring surgical removal Nondisplaced fracture of the acetabulum
Classification
Acetabular anatomy
Acetabular anatomy
Acetabular anatomy
Acetabular anatomy
Acetabular anatomy
Transverse fracture
Acetabular anatomy
T-type fracture
fall
Radiographic Evaluation
Requires
A CT scan 3 plain radiographic views Antero-posterior view of the hip 45 iliac oblique view 45 obturator oblique view
Judet view 45 oblique view
Start evaluation with this view Iliopectineal line represents the anterior column; Ilioischial line represents the posterior column; Posterior lip represents the posterior wall; Anterior lip represents the anterior wall; Dome; Tear-drop
Anterior column fracture displacements Posterior wall fragments and their displacement
Posterior border of the posterior column and Continuity of the true posterior column can be determined.
CT Scan
3 mm interval axial cuts Include the entire pelvis to avoid missing a portion of the fracture Compare with opposite hip
Watch for Anterior and posterior wall fragments, marginal impaction, retained bone fragments in the joint, comminution, presence or absence of a dislocations and any sacroiliac joint pathology.
Management
Initial treatment follow ATLS protocols Operative treatment of acetabular fractures are usually not performed as an emergency Normally, a closed reduction Skeletal traction Even a rare true central dislocation is treated that way
Transverse fractures
Run across the acetabulum. The fractures that cross the region of the fovea are called infratectal. The fractures that cross just above the fovea are juxtatectal fractures crossing higher are transtectal.
T-type fractures
Transverse fracture with a fracture line seperating the anterior column from the posterior column
Spur sign
Surgical Approaches
Iliofemoral Ilioinguinal Kocher Langenbeck Triradiate transtrochanteric Extended iliofemoral Combined anterior and posterior approach
Iliofemoral approach
This approach is sufficient for anterior column fractures where the main displacement is cephalad to the hip joint. It doesnt give access distal to the iliopectineal eminence.
Ilioinguinal approach
It is ideal for difficult fractures with anterior displacement where access to the entire anterior column is required. The anterior approach gives access to the anterior column as far as the symphysis and includes the quadrilateral plate.
Ilioinguinal approach
It is ideal for fractures with both column injuries where in the entire outer table of the pelvis from the anterior superior iliac spine to the top of the sciatic notch can be seen.
It gives excellent visualization of the ilium, the superior dome and the posterior column. The anterior column can be seen up to the iliopectineal eminence. This exposure is similar to that provided by the triradiate approach with the additional benefit of access to the bone above the sciatic notch.
It is indicated for posterior wall injuries and posterior column injuries. It allows only to these. In all posterior approaches, the sciatic nerve is in jeopardy. The superior gluteal artery and nerve are likely to get injured in the greater sciatic notch during stripping of the periosteum.
Patient is in lateral position with no fixed support. It allows for the surgeon to roll the patient prone or supine if necessary.
B2 - T types
Posterior displacement kocher langenbeck Associated posterior wall kocher langenbeck Anterior displacement Ilioinguinal Assosiated posterior wall extensile / combined approach
Type B
B3 Anterior column and posterior hemitransverse fractures can be fixed through an anterior ilioinguinal approach.
Non displaced and minimally displaced fratures. Fractures that traverse the wt bearing dome, but with less than 2 mm displacement managed by non wt bearing and or skeletal traction for 8 weeks. Secondary congruence in displaced both column fractures. Closed treatment gives good results.
Fractures with significant displacement but, in which the region of the joint involved is judged to be unimportant prognostically. This can be determined by the roof arc measurement described by Matta and Olson as 45 degrees for each roof arc, medial, anterior and posterior. Another roof arc measurement as proposed by Vrahas, Widding and Thomas is 25 degree fro the anterior roof arc, 45 degree of the medial roof arc and 70 degree for the posterior roof arc. Most authors agree that displaced fractures through the weight bearing dome should be treated with ORIF, regardless of how they line up in traction.
Multisystem injury An open wound in the anticipated surgical field The Morel Lavalle lesion Presence of a suprapubic catheter is a contraindication for ilioinguinal approach. Elderly patients with osteoporotic bone where ORIF may not be feasible.
In the limb
Sciatic nerve injury Fracture of the ipsilateral femur Injury to the ipsilateral knee
Transverse fractures
Transtectal fractures have the worst prognosis and accurate reduction is essential. Juxtatectal fractures also usually require reduction. Typical reduction is through a posterior approach using a Farabeuf clamp to reduce the fractures while rotation is controlled by a Shanz screw in the ischium. Posterior fixation typically is with a buttress plate along the posterior column and anterior fixation using a 3.5 mm lag screw placed into the anterior column from a position above the acetabulum.
Post-operative care
Closed suction drain Antibiotic for 48 72 hours Passive motion of the hip on the 2nd or 3rd day. Touch down ambulation & crutches on 2nd to 4th day. The minimal weight bearing status is continued for 8 weeks in patients with simple fractures and 12 weeks in most others. Rehabilitation of the abductor muscle group is needed.
Complications
General
Thromboembolic disease Infection
Specific
Specific Complications
Specific Complications
Other nerves
Femoral nerve injury though rare, care to be taken during the anterior ilioinguinal approach. Superior Gluteal nerve injury is vulnerable in the greater sciatic notch, resulting in abductor paralysis. Pudendal nerve injury Injury to the lateral femoral cutaneous nerve causes sensory loss in the lateral aspect of the thigh.
Specific Complications
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