1. Acetabular fracturesDr. Roshan D.

2. Introduction Generally caused by high energy trauma Such high energy injuries usually have ahigh incidence of major associated injuries The fracture or fracture dislocationproduced depends on themagnitude and the directionof the injuring force as wellas on the strength of the bone. 3. Acetabulum - Anatomy Incomplete hemisphericalsocket with an inverted horse-shoeshaped articular surface non articulating cotyloidfossa. The articular surface iscomposed of andsupported by twocolumns of bone(described by Letourneland Judet) as aninverted Y 4. Acetabulum Anatomy The Column Concept Used in the classification of the fractures The anterior column Iliac crest, iliac spines, the anterior half of theacetabulum and the pubis. The posterior column Ischium, ischial spine, posterior half of theacetabulum and the dense bone forming the sciaticnotch The shorter posterior column ends at itsintersection with the anterior column at the top ofthe sciatic notch 5. Acetabulum - Anatomy The dome or roof is the weight bearingportion of the articular surface thatsupports the femoral head The quadrilateral surface is the flat plate ofbone forming the lateral border of thepelvic cavity The iliopectineal eminence is theprominence in the anterior column that liesdirectly over the femoral head. 6. Acetabulum AnatomyNeurovascular structures The sciatic nerve The superior gluteal Artery and Nerve Corona mortis 7. Classification(Letournel and Judet) Simple fractures fractures of the posterior wall, posteriorcolumn, anterior wall, anterior column andtransverse fractures. Associated fractures T-shaped fractures, fractures of the posteriorcolumn and posterior wall, transverse +posterior wall fracture, anterior fracture +hemitransverse posterior fracture and bothcolumn fracture. 8. ClassificationComprehensive Classification after Letournel TYPE A - PARTIAL ARTICULAR ONECOLUMN FRACTURE A1Posterior wall A2Posterior column A3Anterior wall and/or anterior column 9. ClassificationComprehensive Classification after Letournel TYPE B PARTIAL ARTICULARTRANSVERSE ORIENTED FRACTURE -Transverse types with portion of the roofattached to intact ilium B1Transverse + posterior wall B2T types B3Anterior with posterior hemitransverse 10. ClassificationComprehensive Classification after Letournel TYPE C COMPLETE ARTICULAR, BOTHCOLUMN FRACTURE - both columns arefractured and all articular segments,including the roof, are detached from theremaining segment of the intact ilium, thefloating acetabulum. C1Both columnanterior column fracture extendsto the iliac crest (high variety) C2Both columnanterior column fracture extendsto the anterior border of the ilium (low variety) C3Both columnanterior fracture enters thesacroiliac joint 11. Classification Comprehensive Classification after Letournel Qualifiers: Additional information can be documentedconcerning the condition of the articular surfaces tofurther define the prognosis of the injury. The informationshould be, as additional qualifiers, identified by Greekletters. a1)Femoral head subluxation, anterior a2)Femoral head subluxation, medial a3)Femoral head sublucation, posterior b1)Femoral head dislocation, anterior b2)Femoral head dislocation, medial b3)Femoral head dislocation, posterior g1)Acetabluar surface, chondral lesion g2)Acetabular surface, impacted d1)Femoral head, chondral lesion d2)Femoral head, impacted d3)Femoral head, osteochondral fracture e1)Intra-articular fragment requiring surgical removal f1)Nondisplaced fracture of the acetabulum 12. Classification 13. Acetabular anatomyAnterior column fracture Anterior column with ananterior wall fracture 14. Acetabular anatomyAnterior wall fracture Associated anterior wall andtransverse fractures 15. Acetabular anatomyClassic posterior wall Posterior column fracture fracture 16. Acetabular anatomyPosterior wall with posterior Posterior wall fracture with a column fracturetransverse fracture 17. Acetabular anatomySuperior dome fracture Transverse fracture 18. Acetabular anatomyT-type fracture Anterior wall fracture with dislocation 19. Signs and symptoms Apart from local examination Look out for associated life threateninginjuries (intra-abdominal injuries) A, B, C first before the rest Older patients Arrhythmia, transient ischemic attacks may have led to thefall SDH can occur when older patients fall. 20. Radiographic Evaluation Requires A CT scan 3 plain radiographic views Antero-posterior view of the hip 45 iliac oblique view 45 obturator oblique viewJudet view 45 oblique view 21. Plain Radiographs 1 - AP View Start evaluation with this view Iliopectineal line represents the anterior column; Ilioischial line represents the posterior column; Posterior lip represents theposterior wall; Anterior lip represents the anterior wall; Dome;Tear-drop 22. Plain Radiographs2 - The obturator oblique view Anterior columnfracturedisplacements Posterior wallfragments and theirdisplacement 23. Plain Radiographs 3 - The iliac oblique view Posterior border ofthe posterior columnand Continuity of the trueposterior column canbe determined. 24. CT Scan 3 mm interval axial cuts Include the entire pelvisto avoid missing aportion of the fracture Compare with oppositehip Watch forAnterior and posterior wall fragments, marginalimpaction, retained bone fragments in the joint,comminution, presence or absence of adislocations and any sacroiliac joint pathology. 25. Management Initial treatment follow ATLS protocols Operative treatment of acetabularfractures are usually not performed as anemergency Normally, a closed reduction Skeletaltraction Even a rare true central dislocation istreated that way 26. Operative Surgical anatomy Posterior wall fragments vary in the size and degree of comminution Well appreciated in a CT scan. Unrecognized fracture lines maybe detectedat surgery So the posterior wall fracture should never befixed with lag screw alone. The posterior wall fragment receives its bloodsupply from the capsule avoid detachingthe capsule from its blood supply. 27. Operative Surgical anatomy Posterior Column fractures Can occur anywhere along the posteriorcolumn from the ischial spine to the sciaticnotch. Typically, the column fragment rotates. It is necessary to derotate the fragment andcheck the reduction. 28. Operative Surgical anatomy Anterior Column fractures Occur at various levels along the anteriorcolumn. Although the pubic ramus is part of theanterior column, ramus fracture usuallyindicates the presence of a pelvic fracturerather than an acetabular fracture. 29. Operative Surgical anatomy Transverse fractures Run across the acetabulum. The fractures that cross the region of the fovea arecalled infratectal. The fractures that cross just above the fovea arejuxtatectal fractures crossing higher are transtectal. T-type fractures Transverse fracture with a fracture line seperating theanterior column from the posterior column 30. Operative Surgical anatomy Anterior and posterior hemi-transversefractures This is an anterior column fracture with andadditional fracture line that runs transverselyacross the posterior column. Here, the displacement is usually anterior andthe posterior column not significantlydisturbed. Thus reducing the anterior column usuallyreduces the posterior column. 31. Operative Surgical anatomy Both column fractures Entire acetabulum is separated from the axialskeleton. Sometimes, it is called as a floating acetabulum. Since the entire acetabulum is separated from theilium, the actual joint can appear congruent. This radiographic appearance is called thesecondary congruence. Spur sign 32. Spur sign Pathognomonic ofboth column fratures.see in obturatoroblique view 33. Surgical Approaches Iliofemoral Ilioinguinal Kocher Langenbeck Triradiate transtrochanteric Extended iliofemoral Combined anterior and posterior approach 34. Indications for non-operativetreatment Non displaced and minimally displaced fratures. Fractures that traverse the wt bearing dome, butwith less than 2 mm displacement managedby non wt bearing and or skeletal traction for 8weeks. Secondary congruence in displaced both columnfractures. Closed treatment gives good results. 35. Indications for non-operative treatment Fractures with significant displacement but, in which theregion of the joint involved is judged to be unimportantprognostically. This can be determined by the roof arc measurementdescribed by Matta and Olson as 45 degrees for eachroof arc, medial, anterior and posterior. Another roof arc measurement as proposed by Vrahas,Widding and Thomas is 25 degree fro the anterior roofarc, 45 degree of the medial roof arc and 70 degree forthe posterior roof arc. Most authors agree that displaced fractures through theweight bearing dome should be treated with ORIF,regardless of how they line up in traction. 36. Medical contraindications to surgery Multisystem injury An open wound in the anticipated surgicalfield The Morel Lavalle lesion Presence of a suprapubic catheter is acontraindication for ilioinguinal approach. Elderly patients with osteoporotic bone where ORIF may not be feasible. 37. Indications for operative treatment In fracture incongruity due to Posterior column or wall injuries Displaced fractures of the superior dome Retained bony fragments In the limb Sciatic nerve injury Fracture of the ipsilateral femur Injury to the ipsilateral knee In the patient polytraumatised patient 38. Treatment of specific fracture patterns Posterior wall fractures Posterior Langenbeck approach with the patientpositioned either prone or lateral using lag screw anda reconstruction plate placed from the ischium overthe retro acetabular surface onto the lateral ileum. (Ifthe fracture extends superiorly into the dome, atrochanteric osteotomy may be performed to allowadditional exposure) To avoid AVN of the posterior wall, the posterior wallfragments must not be detached from the posteriorcapsule. The knee must be kept flexed throughout theprocedure to avoid injury to the sciatic nerve. 39. Treatment of specific fracture patterns Posterior column fracture Though uncommon if significantly displaced, requiresORIF (Kocher Langenbeck approach). Typical fixation is with a lag screw combined with acontoured reconstruction plate along the posteriorcolumn. Rotational deformity must be corrected by placing aShanz screw in the ischium to control rotation whilethe fracture is reduced with a reduction clamp 40. Treatment of specific fracture patterns Anterior wall and anterior column fracture Isolated anterior wall fractures are uncommon. Sometimes, they are associated with anterior hipdislocation. Fractures requiring surgery are fixed with a buttressplate applied through an ilioinguinal or iliofemoralapproach. Anterior column fractures are approach similarly withfixation by a contoured plate along with a pelvic brim. 41. Treatment of specific fracture patterns Transverse fractures Transtectal fractures have the worst prognosis andaccurate reduction is essential. Juxtatectal fractures also usually require reduction. Typical reduction is through a posterior approachusing a Farabeuf clamp to reduce the fractures whilerotation is controlled by a Shanz screw in the ischium. Posterior fixation typically is with a buttress platealong the posterior column and anterior fixation usinga 3.5 mm lag screw placed into the anterior columnfrom a position above the acetabulum. 42. Treatment of specific fracture patterns Posterior Column fracture with associatedposterior wall fracture A Kocher-Langenbeck approach is used with or without a trochanteric osteotomy. The column fracture is reduced first. A short reconstruction plate is placed posteriorlyalong the posterior edge of the column. A separateplate is used for the wall fragment. T screws through the plate secure rotational reductionon the posterior column fragment. 43. Treatment of specific fracture patterns Transverse fracture with associatedposterior wall fracture The common fracture can be difficult toreduce. The posterior wall component requires aposterior exposure, but reduction of theanterior part of the transverse fracture can bedifficult through a Kocher-Langenbeckapproach and extensile or combinedapproach is frequently necessary. 44. Treatment of specific fracture patterns T-type and anterior column-posterior Hemi-transverse fracture They are treated through an ilioinguinal approach witha contoured plate placed along the pelvic brim and lagscrews extending into the posterior column. For a T-type fracture with severe posteriordisplacement but minimal anterior displacement,posterior approach alone may be sufficient withplacement of anterior column lag screw. If both the anterior and posterior components of thefracture are significantly displaced, an extensive orcombined approach are required. 45. Treatment of specific fracture patterns Both column fractures These have varying degrees of comminution and canbe extremely complex and difficult to treat. Many both column fractures can be treated throughan anterior ilioinguinal approach. But a posterior or extensile exposure is required forinvolvement of the sacroiliac joint, significant posteriorwall fracture, or intraarticular comminution. Reduction is begun from the most proximal portion ofthe fracture and proceed towards the joint. 46. Implants for acetabular fractures 47. 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 to4th day. The minimal weight bearing status is continuedfor 8 weeks in patients with simple fractures and12 weeks in most others. Rehabilitation of the abductor muscle group isneeded. 48. Complications General Thromboembolic disease Infection Specific 49. Specific Complications Sciatic nerve injury Thirty percentage of acetabular fractures haveassociated sciatic nerve injury. In 2 6 % of patients, it occurs as a result of surgeryand is more often associated with posterior fracturepattern treated through a Kocher-Langenbeck andextensile exposures. The peroneal component of sciatic nerve is moreoften involved than the tibial component. Complete peroneal palsies have the worst prognosis.Tibial component has greater chances of recovery. 50. Specific Complications Other nerves Femoral nerve injury though rare, care to be takenduring the anterior ilioinguinal approach. Superior Gluteal nerve injury is vulnerable in thegreater sciatic notch, resulting in abductor paralysis. Pudendal nerve injury Injury to the lateral femoral cutaneous nervecauses sensory loss in the lateral aspect of the thigh. 51. Specific Complications Post-traumatic arthritis Heterotopic ossification Chondrolysis AVN 52. Thank You