Acetabular Fractures
Maj Hrishikesh Pande
Introduction
• Major challenge
• Operative management in specialised centre
• Important to recognize fractures that require
operative treatment
• Importance of anatomical reduction for good
functional outcome
Bony Anatomy
Bony Anatomy
Biomechanics
• Weight-bearing area is primarily posterior and
superior - necessary to maintain hip stability.
• Fractures < 20% of the posterior wall do not
affect stability ; > 40% always render the hip
unstable.
• Excessive pain when the hip is flexed with the
patient awake suggests instability.
• The hip should be stable through flexion to
100 degrees in 10 degrees of adduction.
Pathoanatomy
Patient Evaluation
• Acetabular fractures do not occur without
trauma.
• Lookout for associated injuries, particularly
those that are life threatening
Radiographic Evaluation
• Three plain radiographic views:
– Anteroposterior hip
– 45-degree iliac oblique
– 45-degree obturator oblique.
• CT scan
Anteroposterior Hip
45-degree iliac oblique
45-degree iliac oblique
45-degree obturator oblique
45-degree obturator oblique
CT Scan
• Useful but should not replace the standard
radiographs.
• The 3D scan with femoral head subtraction better understanding of overall fracture
pattern.
Radiographic Evaluation
• Radiographic roof-arc angle is frequently used
to define the weight-bearing dome.
• Fracture crosses the weight-bearing area if
– Anterior roof-arc is less than 25 degrees
– Medial roof-arc is less than 45 degrees
– Posterior roof-arc is less than 70 degrees
Roof Arc Angle
Weight Bearing Area
Anatomical Classification
Letournel and Judet's classification
AO comprehensive
fracture classification
TREATMENT OPTIONS
• The ultimate decision based on
– analysis of the fracture
– overall health
– associated injuries
– surgical risks.
• Surgeons should be realistic about their
abilities.
• Dislocation of hip should be reduced as an
emergency.
Indications for conservative
treatment
• Nondisplaced and minimally displaced fractures.
• Fractures with significant displacement of
unimportant region.
• Secondary congruence in displaced both-column
fractures.
• Medical contraindications to surgery.
• Local soft tissue problems.
• Elderly patients with osteoporotic bone in whom
open reduction may not be feasible.
Indications for surgical treatment
• Failure to meet the criteria for closed
treatment
• Incarcerated fragments in the acetabulum
after closed reduction of the hip dislocation
• Multiple or ipsilateral injuries that require
mobilization of the patient or the extremity
• Prevention of nonunion and retention of
sufficient bone stock for later reconstructive
surgery
Surgical Approach
• When possible, anterior approaches are
preferred to posterior approaches because of
the lower incidence of heterotopic
ossification. The full triradiate, the extended
iliofemoral, and combined approaches are
now primarily used for late cases.
Illiofemoral Approach
• For fractures of the anterior column in which
the main displacement is cephalad to the hip
joint.
Illioinguinal Approach
This approach allows access
to the anterior column as far
as the symphysis and includes
the quadrilateral plate. Most
both-column fractures can
also be managed through this
approach, but only if the
posterior fragment is large and
in one piece.
Kocher-Langenbach Approach
For isolated posterior
wall injuries as well
as posterior column
injuries
Triradiate Approach
Offers excellent exposure of
the entire outer table of the
pelvis from the anteriorsuperior spine to the top of
the sciatic notch.
Extended Illiofemoral
• Excellent visualization of the outer table of the
ilium, the superior dome, and the posterior
column . The anterior column can be
visualized to the iliopectineal eminence.
Implants
Post-Op care
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Indomethacin
DVT prophylaxis
Traction +/Nonweight bearing 6-8 weeks
Partial weight bearing 4 weeks
Active and assisted exercises
Complications
• Nerve injuries
– Sciatic
– Femoral
– Superior gluteal
– Lateral cutaneous nerve of thigh
• Heterotropic ossification
• Infection
• Chondrolysis
Thank You