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