Nerve Injuries following Acetabular Fractures

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The Incidence and Clinical Outcome of Neural

Injuries Following Acetabular Fractures

BA Rogers, R Pearce, R Walker, MD Bircher

St George¶s Hospital, London

BOA Congress,

Manchester,

Sept 2009



Benefits for surgical stabilization for displaced

acetabular fractures

Matta 1996

Fractures of the

Acetabulum: Accuracy of

Reduction



Nerve injury is a complication of acetabular

fractures and its treatment

Middlebrooks, J OrthoTrauma 2007

Once established ± Few treatment options

± Dismal outcome

Tung,J Neurosurg 2005

Letournel 1993



Aim

Do the following factors affect neural recovery?

± Time from injury to surgery

± Type of fracture

± Quality of surgical reduction

1. Quantify incidence of pre-operative nerve injuries

2. Evaluate neural recovery following surgery



Methods

� 3 year case series review of 456 referrals

� Clinical detectable nerve injuries in operatively managed

fractures

� 3.5 year mean radiographic and clinical follow-up

(range 1-6 years)

� Statistics

± Analysis of variance (ANOVA)

± Coefficient of correlation (R2)



Acetabular

Fractures456

Operative

Management

205

Non- Operative

Management

251

Neural

Injury

29

No NeuralInjury

176

6.4 % - of referrals

14.1% - of operatively managed patients



Methods

� Injury to surgery time (days)

� Classification of skeletal injury ± Letournel

� Reduction (mm) ± Maximal displacement on AP or oblique radiographs

� Ongoing sciatic nerve function

± Complete recovery ± Incomplete recovery

± Ongoing full nerve palsy



Results ± Time to Surgery

Mean time to surgery (days) comparing patients with permanent nerve

palsy with patients demonstrating full or partial nerve recovery

P<0.05, ANOVA

0

5

0

5

0

5

D a y s Permanent Palsy

Full or Partial Nerve

Recovery



Results ± Acetabular Fractures

29 out of 456 #¶s

LetournelNumber of

Patients

Mean reduction

(mm)

Simple

fractures6 1.3

Associated

fractures 23 2.4





5.6 mm



Results ± Fracture reduction

Mean reduction (mm) comparing patients with permanent nerve palsy

with those who demonstrated full or partial nerve recovery

P<0.05, ANOVA

0

0.5

.5

.5

R e d u c t i o

(

)

Permanent Palsy

Full or Partial Nerve

Recovery



Correlation to full or partial nerve recovery

Correlation

Coefficient (R2)

Short time delay to surgery

(<10 days)0.82

Less complex fracture patterns 0.79

Superior fracture reduction 0.72



DiscussionReferring orthopaedic team

± Identify

� ATLS secondary survey

� Concurrent injuries

± Document

� Sciatic

± Peroneal ± Tibial

± Prompt appropriate referral



Discussion

Acetabular Surgeon

± Identify & document nerve function

± Expediate surgery

� Aim for precise anatomical reduction

� Patient positioning

� Approach and exposure

± Follow up



Considerations

� Use of controls for comparison

� The use EMG/NCS

� CT intra- or post-op

� Clinical nerve function sole outcome assessed



No previous published studies

± Neural outcome

± Operatively managed acetabular fractures

Optimal neural recovery

± Short time to surgery, less than 10 days

(as per BOAST Dec 2008)

± Less complex fracture patterns

± Precise reduction

Conclusion



Thank you

Nerve Injuries following Acetabular Fractures

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