Acetabular Fracture :Classification & Surgical Approaches

The Pioneers

Robert Judet Emile Letournel Marvin Tile

Anatomical reduction and stable

internal fixation

Column Concept

Two columns converging to form a cavity

The Acetabular Cavity Two walls – anterior and posterior Roof Floor

Plain Radiograph

Judet’s Iliac Oblique View

Judet’s Iliac Oblique View

Judet’s Obturator Oblique View

Judet’s Obturator Oblique View

CT Scan

Size of fragment Degree of displacement Amount of articular surface Site of origin of fragment Marginal impaction

CT Scan

Position of femoral head- dislocation, subluxation, perfect reduction

Incarcerated fragment

3 D CT SCAN

Letournel Classification

Most acetabular fractures fit into one of ten types

Five simple fracture patterns Five associated fracture patterns

Simple Fractures

Posterior wall fracture Posterior column fracture Anterior wall fracture Anterior column fracture Transverse fracture

Posterior wall Fracture Includes posterior

articular surface and retro acetabular surface

Posterior Column Fracture Extends from

PSIS to ischio pubic ramus

Involves posterior articular surface and ilio ischial line

Anterior Wall Fracture

Uncommon Separation of anterior part of

articular surface along with a large part of middle third of anterior column

Anterior hip dislocation can be associated

Anterior Column Fracture Extends from

symphysis pubis to iliac crest

Most commonly fracture line exits below AIIS

Often comminution into the quadrilateral plate

Transverse Fracture Across anterior and posterior columns Superior segment – ilium, acetabular roof Inferior segment – ischiopubic segment May be associated with central dislocation

Combined Fracture Types

Posterior column and posterior wall fracture

Transverse and posterior wall fracture T-shaped fracture Anterior column or wall and posterior

hemi transverse fracture Complete both-column fracture

Associated Posterior Wall and Posterior Column Fracture

Posterior column fracture is usually undisplaced or minimally displaced

Primary fracture – posterior wall

Associated Posterior Wall And Posterior Column Fracture

Anterior Column intact

Posterior dislocation Displaced posterior

wall Ilio ischial line

disrupted

Associated Transverse and Posterior Wall Fracture

Commonly posterior dislocation

Sometimes central dislocation

Highest incidence of pre op sciatic palsy and AVN of femoral head

T Shaped Fractures

Transverse and vertical components

Acetabular cavity is split into at least 3 fragments

T Shaped Fractures

Both Column Fractures All segments of

fractured acetabulum are detached from the ilium

AO Classification Type A – Fractues of a single wall or

column Type B –Fractures involve both columns Type C –Both column fractures with

articular fragments seperated from ilium

AO Classification

AO Classification

AO Classification

Injury Pattern Affecting Prognosis

High or low energy trauma Involvement of acetabular dome Comminution and displacement Joint dislocation Damage to femoral head Both-column fractures and transverse with

posterior wall fractures have worst results , primarily because of imperfect reduction

Indications For Conservative Management Non displaced or displaced

<3mm Displaced fracture in

unimportant part of acetabulum – low anterior column, low transverse

Secondary congruence in both column fractures

Indications for operative treatment Fracture Displaced >3mm Irreducible fracture dislocation Intra articular fragment

interfering with joint movement Instability of the joint To prepare the joint for hip

replacement

Contraindications to surgery Severe osteoporosis Very old patients Severe associated injuries Poor local skin condition Limited experience of the surgeon

Timing Of Surgery Urgent closed reduction of dislocation Stabilise the patient before ORIF Ideally within 7 days Poor results after 3 weeks

Kocher Langenbeck Approach Posterior wall fracture Injuries with associated

posterior wall fracture Posterior column fracture

Kocher Langenbeck Approach Transverse fracture

where major displacement is posterior

T shaped fracture with major displacement posterior

Kocher Langenbeck Approach

Ilioinguinal Approach Anterior wall

fracture Anterior column

fracture Fractures

associated with anterior wall and column fractures

Ilioinguinal Approach

Ilio inguinal Approach Incise along anterior two thirds of iliac

crest, extending to the pubic symphysis Elevate abdominal muscles from iliac

crest Open inguinal canal

Ilioinguinal Approach Detach deep abdominal

muscles from inguinal ligament and pubis

Open iliopsoas sheath Incise iliopectineal fascia Lateral retraction of

iliopsoas and medial retraction of iliac vessels

Dangers Of Ilio Inguinal Approach Lat cut nerve of thigh,

femoral nerve Corona mortis Internal iliac vein, femoral

vein Lymphatics Abdominal wall

weakness

EXTENSILE APPROACHES

Used in complex fracture patterns Triradiate Extensile Approach Carnesile Extensile approach

Extensile Ileofemoral approach

Triradiate Approach Described by Mears & Rubash Reduction & repair of Complex Acetabular fracturesAvoids ischemic necrosis Of Hip Abductors

Triradiate Approach

Carnesile approach

Carnesile approach

Complications Of Acetabular Surgery

Imperfect reduction, inadequate fixation Avascular necrosis Infection Nerve injury Heterotopic ossification Thromboembolism

Learning Curve Of The Surgeon Parallels The Suffering Curve Of The Patient

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