Orthopedics 5th year, 2nd lecture (Dr. Ali A.Nabi)

Fractures of the acetabulum

Fractures of the acetabulum

Occurs when the head of the femur is driven into the pelvis. This caused by

1. A blow on the side (fall from a height).

2. a blow from the in front of the knee ( dashboard injury ).

Fractures of the acetabulum

Fractures of the acetabulum may lead to:

1. soft tissue injury as in fracture pelvis.

2. articular cartilage damage which lead to malcongruent loading and secondary osteoarthritis.

Classification

The classification of acetabular fractures described by Letournel and Judet is the most widely used classification system. They divided acetabular fractures into two basic groups:

Classification

1. simple fracture types. Which are isolated fractures of one wall or column along with transverse fractures; this type includes fractures of the

a. posterior wall.

b. posterior column.

c. anterior wall.

d. anterior column.

e. transverse fractures.

Classification

Classification

2. complex fracture types. Which have more complex fracture geometries and include

f. combined fractures of the posterior column and wall.

g. combined transverse and posterior wall fractures.

h. T-type fractures.i. anterior column fractures with a

hemitransverse posterior fracture.j. both-column fractures.

Classification

Posterior wall and posterior column

fractures can be distinguished easily. In a posterior column fracture, the ilioischial line is interrupted, while only the retroacetabular surface is disrupted in a posterior wall fracture.

Posterior wall and posterior column

Posterior wall and posterior column

Posterior wall and posterior column

Anterior wall and Anterior column

Similarly, anterior wall and anterior column fractures can be distinguished by the additional break in the ischiopubic segment of the pelvis present in the anterior column fracture.

Anterior wall and Anterior column

Anterior wall and Anterior column

Anterior wall and Anterior column

Anterior wall and Anterior column

Transverse Fractures

A transverse acetabular fracture involves a fracture line that goes through both columns of the acetabulum, but a portion of the dome of the acetabulum remains attached to the constant fragment of the iliac wing.

Transverse Fractures

Transverse Fractures

Transverse Fractures

Transverse Fractures

Transverse acetabular fractures can be divided into transtectal, juxtatectal, and infratectal fractures, depending on the orientation of the fracture line relative to the dome or tectum of the acetabulum. Transtectal fractures are less forgiving and must be reduced anatomically, whereas infratectal fractures, if low enough, can be treated without surgery, depending on the pattern.

Transverse Fractures

A. Infratectal B. Juxtatectal C. Transtectal

T-Type Fractures

T-type fractures differ from transverse fractures by the additional fracture line that runs through the quadrilateral surface. As a result, the anterior column and posterior column are separated by fracture lines.

T-Type Fractures

T-Type Fractures

T-Type Fractures

T-Type Fractures

Both-Column Fractures

In a both-column fracture, the entire acetabulum is separated from the iliac wing. This is considered a "floating" acetabulum, and the "spur-sign," which is best seen on the obturator oblique view, is pathognomonic for the both-column fracture.

Both-Column Fractures

Both-Column Fractures

Clinical features

1. H/O severe trauma like traffic accident or fall from a height.

2. should be suspected whenever there is fracture femur, knee injury or fracture calcaneum.

3. shock and all other pelvic injury complication could be seen..

4. bruises around the hip and limb.5. the limb might be internally rotated if the hip

dislocated.6. rectal examination should be performed.7. careful neurovascular examination.

Imaging

Radiography At least four x-rays views should be

obtained in each case

1. anteroposterior view.

2. pelvic inlet view.

3. 45° left oblique view.

4. 45° right oblique view. Each view show different profile of the

acetabulum.

Imaging

Anteroposterior Radiograph Lines On anteroposterior (AP) radiographs of the

acetabulum, 6 major lines should be considered

the iliopectineal line (1) the ilioischial line (2)

Imaging

the teardrop (the medial portion of the teardrop represents the quadrilateral surface and the lateral portion represents the medial aspect of

the acetabular floor) (3) the dome (4) the anterior wall (5) the posterior wall (6)

Imaging

Imaging

C-T scan will give more detailed information for the surgical reconstruction.

Imaging

Treatment

Emergency treatment.1. ABC.

2. Skeletal traction according to body weight ( 1/10 of body weight ) to reduce any associated hip dislcation.

3. lateral skeletal traction through the greater trochanter sould be done after 3-4 days to reduce central dislocation of the hip.

4. definite treatment sould be delayed untill the general condition of the poatient permits and operation facilities are optimal.

Treatment

Non-operative treatment Indications 1. acetabular fractures with minimal displacement.2. displaced fractures that do not involved the weight

beasring zone which is the superomedial ( the roof ) of the acetabulum.

3. both column fractures with the ball and socket retained congreunt.

4. fractures in elderly where the close reduction seems tobe feasible.

5. medical contraindication for surgery like local sepsis.

Treatment

The conservative treatment

1. Closed reduction under GA.

2. skeletal longitudinal traction + lateral traction for 6-8 weeks.

3. hip movement and excercises should be encouraged during this peroid.

4. partial weight bearing for another 6 weeks.

Treatment

Operative treatment Indication

1. all unstable hips after close reduction.

2. failure of conservative treatment.

3. significant distortion of the ball and socket congruence.

4. associated femoral head fracture.

5. retained bone fragments in the joint.

Complications

1. Iliofemoral venous thrombosis.

2. sciatic nerve injury.

3. hereterotopic bone formation.

4. avascular necrosis of the femoral head.

5. loss of joint movement and secondary osteoarthritis.