Acetabulum fractures, judet

1. Dr Subodh Pathak
Acetabular Fractures

2. INTRODUCTION
BRIEF ANATOMY
CLASSIFICATION OF FRACTURE
CLINICAL FEATURES
PRE OPERATIVE EVALUATION
MANAGEMENT
COMPLICATION
CONCLUSIONS

3. INTRODUCTION
The treatment of acetabular fractures is a
complex area of orthopedics that is being
continually refined
Experience in handling these injuries is a
vital determinant in the positive outcome
of treatment.
The quality of acetabular fracture
reduction is the single most important
factor in the long-term outcome

4. The quality of acetabular fracture reduction is the single most
important factor in the long-term outcome of these
patients,and such surgery should be undertaken only by
surgeons with sufficient experience.

6. ANATOMY
 Incomplete
hemispherical
socket with an
inverted
horseshoe-shaped
articular surface
surrounding the
non-articular
cotyloid fossa

7. COLUMN THEORY
Inverted “Y”
two column
concept (1966)
Judet and Letournel

8. Anterior Column
 Anterior (iliopubic)
column
 Extends from anterior iliac
crest → symphysis pubis
 3 segments
Iliac
segment
Acetabular
segment
Pubic
segment

9. Posterior Column
 Posterior (ilioischial) column
 Extends from greater sciatic
notch → inferior ischium
 The upper end of the posterior
column attaches to the posterior
aspect of the anterior column
forming an angle of about 60
degrees.
 Anatomical roof of the
acetabulum forms keystone of
arch

11. ANATOMY contd.
 The dome, or roof, of the acetabulum is
the weight-bearing portion of the articular
surface
 The quadrilateral surface is the flat plate
of bone forming the lateral border of the
true pelvic cavity
 The iliopectineal eminence is the
prominence in the anterior column that
lies directly over the femoral head.

14. ANATOMY contd.
 The neurovascular structures passing
through the pelvis are at risk during the
original injury and subsequent treatment
 The sciatic nerve exits the greater sciatic
notch inferior to the piriformis muscle, and
is at risk of being injured in posterior
fracture-dislocations
 The superior gluteal artery and nerve also
exit the greater sciatic notch at its most
superior aspect and remain tethered to
the bone at this level; may be injured in
fractures that enter the superior portion of
the greater sciatic notch

16. ANATOMY contd.
 Corona mortis – an occasional large anastomosis that
occurs between the external iliac or inferior epigastric
artery and the obturator artery
 Failure to ligate this vascular connection during the
ilioinguinal approach can lead to significant haemorrage

18. Mechanism of injury
 Femoral head acts like a hammer impacting
against the acetabulum
 Femoral head in IR – posterior column is affected
 Femoral head in ER – anterior column is affected
 Femoral head in Adduction –superior dome
 Femoral head in abduction – inferior dome

19. INITIAL TREATMENT
 High-energy trauma, and associated injuries are
frequent
 Advanced Trauma Life Support (ATLS) protocol
 Operative treatment of an acetabular fracture should not
be performed as an emergency

20. Initial treatment contd.
 In associated hip dislocations, closed reduction
should be carried out under sedation in the ER or
with General anesthesia and fluoroscopy
 Patient should be put on skeletal traction and
planned for definitive treatment
 If closed reduction is unsuccessful, rapid CT scan
of the pelvis should be obtained to highlight the
cause for the obstruction to reduction

21. RADIOGRAPHIC
EVALUATION
 Anteroposterior view of the pelvis
 Judet views – 45 degree oblique views of the pelvis

22. Obturator
oblique view
•45 degree internal rotation
view
•Radiographic beam is
roughly perpendicular to
the obturator foramen
•Best for delineating
anterior column and
posterior wall of the
acetabulum

23. Iliac oblique view
•45 degree external
rotation view
•Best for delineating the
posterior column and
the anterior wall of the
acetabulum along with
the iliac wing

25. Medial tear
drop visualised
on AP
radiograph of
the pelvis

26. ANATOMY contd.
 Concept of acetabular roof arc measurements
has been laid down by Matta et al.
 It is a system of determining how much of the
roof stays intact or uninvolved on each of the
three standard x-ray views
 Medial roof arc is measured on the AP view,
Anterior roof arc on the obturator oblique view
and Posterior roof arc on the Iliac oblique view
 If any of the roof arc measurements in a
displaced fracture are less than 45 degrees,
operative treatment should be considered

27. Medial roof arc
 The medial roof arc is
measured on the
anteroposterior view by
drawing a vertical line
through the roof of the
acetabulum to its
geometric center. A
second line is then drawn
through the point where
the fracture line intersects
the roof of the acetabulum
and again to the
geometric center of the
acetabulum. The angle
thus formed represents
the medial roof arc.

28. CT scan
 Useful modality in cases where roof arc
measurements are inconclusive, or in complex
fracture patterns, or where fracture lines
cannot be exactly delineated
 In an axial CT scan cut, the transverse
fracture lines and fractures of the anterior and
posterior walls are in the sagittal plane
 Anterior and posterior column fractures
usually extend through the quadrilateral
surface and into the obturator foramen with a
more coronal orientation

30. CT scan contd.
 Axial CT scan showing the superior 10 mm of the
acetabular roof to be intact corresponds to a routine
radiographic roof arc measurement of 45 degrees.
 Three-dimensional CT reconstructions may be useful in
unique and complicated fracture patterns and can help in
pre-op planning

32. Classification
 Letournel and Judet classification system – most widely
followed
 AO classification system

33. Letournel and Judet classification
SIMPLE FRACTURE PATTERNS

34. Letournel and Judet contd.
ASSOCIATED FRACTURE PATTERNS

35. AO classification
 TYPE A: Fractures of a single wall or column

36. TYPE B: Fractures involving both
anterior and posterior columns

37. TYPE C: Fracture involving both columns,
with all articular segments detached from
the remaining segment of intact ilium

38. Indications for Nonoperative
Treatment
 Nondisplaced and minimally displaced
fractures
 Some fractures with displacement
 Secondary Congruence in Displaced Both-
Column Fractures
 Medical Contraindications to Surgery
 Local Soft Tissue Problems

40.  as an emergency –
-irreducible dislocation of the hip
- when it is part of open fracture
management

41. SURGICAL APPROACHES-
 Iliofemoral-
 Anterior wall fractures
 # anterior coloumn, displacement cephalad to hip joint
 Plates up to iliopectineal eminence

43.  Ilioinguinal approach-
 For difficult anterior displacements
 Access to entire anterior column, quadrilateral plate,
pubic symphysis.
 Approach of choice for both column #

45.  Kocher Langenback-
 Access to posterior column
 Sciatic nerve injury & heterotopic ossification

47.  Triradiate approach-
 Excellent exposure of outer table of pelvis from ASIS to
sciatic notch

49.  Extended iliofemoral approach-
 Anterior column up to iliopectineal eminence
 Outer table of ilium, superior dome & posterior column

51.  Combined approaches-
 Late cases
 Complication rates are no different

53. Reduction
Most difficult part of acetabular surgery
Traction, special clamps, cerclage wires
Traction-
Fracture table
Corckscrew in femoral neck, hook on the
greater trochanter, schanz pin into ischial
tuberosity

55.  Special clamps-
 Pointed clamps
 Farabeuf clamps
 Double pronged pelvic clamps

58.  Cerclage wires-
 Through the lesser or greater sciatic notch

59. Implants
 Interfragmental lag screws, 3.5 mm
cortical screws of lengths up to 120 mm
 3.5 mm reconstruction plates

61. Sites of application
 Anterior column- from inner table to
symphysis pubis
 Posterior column- distal end to be secured
to ischial tuberosity
 Screws to be directed away from the joint
 Buttressing small posterior wall fragments
with spring plate
 Scews alone can provide the only fixation

62. Treatment of specific fracture
patterns
Posterior wall fracture-
Kocher Langenbeck approach
Patient in prone or lateral
Lag screws and reconstruction plate
Spring plate in comminuted
fractures

64. Posterior column fracture-
Relatively uncommon
Kocher-Langenbeck approach
Rotational deformity
Lag screw combined with a
contoured reconstruction plate along
the posterior column

66. Anterior Wall and Anterior
Column Fractures
Isolated anterior wall fractures are
uncommon
ilioinguinal or iliofemoral approach
fixation by a contoured plate along
the pelvic brim

68.  Transverse Fractures
 Present a spectrum of difficulty
 Transtectal fractures, above the cotyloid
fossa, have the worst prognosis
 Juxtatectal fractures,at the junction of the
cotyloid fossa with the articular surface,
also usually require reduction,
 Infratectal fractures can be treated
nonoperatively

69.  Typical reduction is through a posterior
approach
 Palpating the reduction of the quadrilateral
surface
 Posterior fixation- buttress plate along the
posterior column
 Anterior fixation, using a 3.5-mm lag
screw placed into the anterior column
from a position above the acetabulum.

71. Posterior Column Fracture with
Associated Posterior Wall
Fracture
Kocher-Langenbeck approach
The column fracture is reduced first,
and a short reconstruction plate
A separate plate is used for the wall
fragment

73.  Transverse Fracture with Associated Posterior Wall
Fracture
 difficult to reduce.
 An extensile or combined approach frequently is
necessary

75.  T-Type and Anterior Column–
Posterior Hemitransverse Fractures
 ilioinguinal approach
 Plate placed along the pelvic brim and lag
screws extending into the posterior
column
 T-type fracture with severe posterior
displacement
 Posterior approach with placement of an
anterior column lag screw.

78.  Both-Column Fractures
 T-type fractures with transverse
component above the dome of the
acetabulum
 Varying degrees of comminution and can
be extremely complex and difficult to treat
 ilioinguinal approach
 Reduction is begun from the most
proximal portion of the fracture and
proceeds toward the joint

80. POSTOPERATIVE CARE
 Closed-suction drainage
 Antibiotic therapy is continued for 48 to 72 hours
 Indomethacin
 Low molecular weight heparin
 Passive motion of the hip on the second or third day
 Touch-down ambulation with crutches usually is
allowed by the second to fourth day

81. Complications
Overall mortality rates after
acetabular fractures- 0 to 2.5%
Nerve injury
Sciatic nerve
30% of acetabular fractures
Peroneal division more common

82.  Femoral and superior gluteal nerve
injury- rare
 Infections
 Incidence of infection related to surgeon’s
experience
 Letournel – overall 4.2%
 First 22 ilioinguinal approaches- 32%
next 146 cases- 1.4%
 Early recognition and aggressive
management

83. Avascular necrosis
 Fractures associated with posterior
dislocation.
Letournel - 7.5% after posterior
dislocation
 Other fractures- 1.6%.
Avascular necrosis of the posterior
wall by excessive fracture site
exposure

84.  Heterotopic ossification
 After most extensile approaches
 14% to 50% of patients when no
prophylaxis
 Rare after the ilioinguinal approach
 Indomethacin 25mg tid - 4 to 6 weeks
 Low-dose radiation 700 cGy

85.  Chondrolysis
 Infection or metal inside the joint
 Thromboembolic complications
 8% to 61% of patients with acetabular fractures
 Risks of pulmonary embolism range from 2% to
6%.
 Subcutaneous enoxaparin and intermittent
compression boots while patients are awaiting
surgery.
 Postoperatively- enoxaparin followed by warfarin
for 6 weeks

86. Posttraumatic arthritis
Letournel's series - 17%
After perfect reduction - 10.2%
After imperfect reduction - 35.7%
Both-column and transverse–
posterior wall fractures worse
results

87. Conclusion
 Factors determining prognosis-
- injury related
- surgeon related
 Fractures with hip instability or joint incongruity –
accurate reduction , stable fixation and early motion
 The surgery is demanding,
long learning curve
fraught with complications.