Principles and Management

Before we begin

ATLS – life and limb threatening first

Acetabular fracture may be an indicator of significant trauma

Acetabular fractures should be discussed with a pelvic surgeon.

Important points

1. Acetabular fractures are different to pelvis fractures

2. Comprises of anterior & posterior walls and columns.

3. Classifications: Letournel, 1981 Muller, 1991 Tile, 1995

Acetabular Fractures

Acetabular Fractures

There are also combined types (complex):

Posterior wall / column Transverse / posterior wall T type Both column

Acetabular Fractures

Iliopectineal line – Anterior column

Ilioischial line – posterior column

Anterior & Posterior walls

Anterior & Posterior walls

Posterior Wall Fracture

Common. Motor vehicle accident Really, it’s a partial posterior column

fracture Associated with a dislocation and

knee injuries (dashboard)

Mechanism of fracture

Posterior Wall fracture mechanism

Posterior Wall fracture radiograph

Posterior Wall fracture radiograph

Obturator Oblique: Post. wall & ant. col ObOb-POWAC

Iliac Oblique: Ant. wall. & post. col. (can’t see obturator foramen)

Posterior Wall Fracture

Kocher Langenbeck

Kocher Langenbeck

Indications:Posterior wallPosterior columnPosterior wall & columnTransverseT-shaped fractures

PSIS – GT – 12cm distally.Split through Fascia Lata & Glut Max.Detatch short ext rot 1.5cm from their insertions.75mg Aspirin for 6/52 prevents H.O.

Ilioinguinal approach

Indicated for: Anterior wall / column fractures Transverse fractures Both column fractures

Supine. Urinary Catheter At risk:

Lateral cutaneous nerve of thigh Corona mortise (ext iliac + obt. a.

anastomosis) Femoral artery & vein.

Ilioinguinal approach

OSI radioluscent table Pillow under knees to take pressure

off femoral n. Operate through 4 windows

Very low incidence of H.O. with this approach

Heterotopic Ossification Ectopic bone. Trabecular bone formation, outside

skeletal structures & between muscle planes.

Acetabular surgery accounts for 25% Score:

Brooker Grade 1-4 on xray Alonso Grade 1-3 on CT

Tx: excision after 1 year. Prophylaxis NSAID or Radiotherapy, or both.

Bone scan checks if still active

Outcome of acetabular fractures Controllable & non-controllable

factors If fixed, consider TTWB post-op and

don’t allow flexion past 90 degrees When fixing elderly hip fractures,

consider ORIF + THR. Percutaneous surgery indicated if:

Polytrauma, poor skin, simple fractures Contraindicated if fracture displaced

Summary

Trauma principles (ATLS) Advice from regional trauma centre Anterior and posterior columns Fracture classification Kocher Langenbeck and Ilioinguinal