Acetabular fractures

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Acetabular fractures

• Christopher M. Stewart, MD
• PGY III
• LSU-HSC

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Background

• Typically occur in young adults secondary to
  high-energy trauma
• In trauma, there is a 50 chance of associated
  injuries spine fx, abdmonial and chest trauma,
  genitourinary injury, extremity fx, knee
  ligamentous disruptions, joint dislocations,
  neuro and head injury, pelvic fx
• Surgical tx is often needed to restore the
  anatomic shape of the hip joint, thus allowing
  normal pressure distribution

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Anatomy

• Formed as a portion of the innominate bone
• Junction of three bones ilium, ischium, and
  pubis joined by the tri-radiate cartilage
• The acetabulum is divided into 2 columns
  anterior and posterior
• The 2 columns are described as having the shape
  of an inverted Y, or of the Greek letter lambda
  (l).
• Anterior column ant border of the iliac wing,
  the entire pelvic brim, the ant wall, and the
  superior pubic ramus
• Posterior column the ischial portion of bone (
  lesser and greater sciatic notches), post wall,
  and the ischial tunerocity

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Radiography

• Five (5) Pelvic XRs
• The anteroposterior (AP) view
• Bilateral 45 degree oblique views, or Judet views
  of the pelvis
• Inlet and Outlet Pelvis XR
• Computed tomography, CT scans, can be obtained to
  provide additional information on fx configuration

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Pelvis XR

• Inlet view
• Pt is supine with XR beam parallel to plane of
  sacrum, sacrum is seen on end with vertebral
  body anteriorly and sacral lamina posteriorly
• AP of pelvis with beam tilted 25-30 degrees
  caudally
• Outlet view
• Pt is supine with XR beam perpendicular to plane
  of sacrum
• AP of pelvis with beam tilted 35-45 degrees
  cephalad

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Judet hip XR

• Iliac oblique
• Pt is supine with involved side of pelvis rotated
  anteriorly 45 deg, beam directed vertically
  toward affected hip
• shows iliopectineal line, AC and PW 
• Obturator oblique
• Pt is supine with uninvolved side of pelvis
  rotated ant. 45 degrees, beam directed vertically
  toward the affected hip
• shows ilioischial line, PC and AW  

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AP Pelvis XR
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Teardrop

• Internal limb outer wall of obturator canal
• External limb middle 1/3 of cotyloid fossa
• Inferior border ischiopubic notch

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Inlet Pelvis XR
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Outlet Pelvis XR
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Iliac oblique
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Obturator oblique
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Classification

• Initially published by Judet in 1964, and later
  modified by Letournel
• Judet and Letournel classification system simple
  and complex types
• Simple posterior wall (PW), posterior column
  (PC), anterior wall (AW), anterior column (AC),
  transverse
• Complex T-shaped, anterior column and posterior
  hemitransverse (AC-PHT) , both-column (BC),
  posterior column and wall (PC-PW), transverse
  posterior wall (T-PW)

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Simple types
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Complex types
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PW
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PC
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AW
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Transverse
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T-PW
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AC-PHT
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BC
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PC-PW
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Nonoperative tx

• Nondisplaced fx, lt5mm, or articular step-off of
  lt2mm
• Operative contraindications local or systemic
  infection, severe osteoporosis
• Operative relative contraindications advanced
  age, associated medical conditions (ESRD on
  dialysis, ESLD, Seizure Disorder, uncontrolled
  DM, CHF, Neurological Disorder), associated soft
  tissue and visceral injuries, or a multiply
  injured pt not stable for a big acetabular sx
• Displaced fx large portion of acetabulum remains
  intact with a congruous femoral head, or
  secondary congruence with a both-column fx

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• PW if less than 50 of the width of the
  articular cartilage is displaced (ST), some
  authors say less than 25
• Many low AW fx
• A minority of low T-shaped fx
• Infratectal transverse fx
• In assesing the intact portion of acetabulum, it
  is useful to obtain roof arc measurements
• Matta first described these angles in 1986
• Stable fxall roof arc angles gt45 degrees
• CT subchondral arc technique of Olsen no
  involvement of the upper 10mm of the acetabulum
  by CT corresponds to an intact 45 degrees roof
  arc on all 3 plain XRs

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Roof Arc Angles

• A vertical line is drawn from roof of acetabulum
  to geometric center of the femoral head, and
  second line is drawn from fracture to the
  geometric center
• 1. Medial Roof Arc (AP pelvis)
• 2. Anterior Roof Arc (Obturator oblique)
• 3. Posterior Roof Arc (Iliac oblique)

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Roof arc measurement
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Operative tx

• Any displaced fx, gt 5mm, or articular step-off of
  gt2mm
• Allows early ambulation and decreases chance of
  post-traumatic arthritis
• Usually undertaken 2-3 days after injury, when
  initial fx and intrapelvic vessel bleeding has
  subsided
• Ideally performed before 10 days, so fx fragments
  remain mobile
• Three weeks after injury, a bony callus has
  formed, making reduction more difficult
  (typically not done)

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Surgical approaches

• Kocher-Langenbeck best access to posterior
  column (prone)
• Ilioinguinal best access to anterior column and
  inner aspect of innominate bone (supine)
• Extended iliofemoral best simultaneous access to
  the two columns (lateral)
• Combined approaches performed concurrently or
  successively is less desirable
• Extended iliofemoral approach has the highest
  incidence of ectopic bone formation (HO) and
  longest postoperative recovery

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Kocher-Langenbeck approach

• Posterior wall fractures
• Posterior column fractures
• Posterior column-posterior wall fractures
• Juxta-tectal/Infra-tectal transverse or
  transverse-posterior wall fractures
• Some T-shaped fractures

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Ilioinguinal approach

• Anterior column fractures
• Anterior wall fractures
• Some anterior column-posterior hemitransverse
  fractures
• May also be used for both column fractures with
  large single posterior fragment, with reduction
  being achieved indirectly through reduction of
  the quadrilateral plate
• Fractures with associated superior ramus and
  symphysis pubis fractures

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Extended Iliofemoral approach

• T-shaped fractures
• Transverse fractures with extended posterior wall
  
• T-shaped fractures with wide separations of the
  vertical stem of the "T" or those with associated
  pubic symphysis dislocations
• Certain associated both column fractures
• Associated fracture patterns or transverse
  fractures which are operated greater than 21 days
  following injury

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Other approaches

• Stoppa approach (supine) Cole and Bolhofner
• Allows access to the medial wall of the
  acetabulum, quadrilateral surface, and sacroiliac
  joint
• Triradiate approach (prone)
• Alternate exposure to the external aspect of the
  innominate bone, with almost same exposure as
  iliofemoral but visualization of the posterior
  part of the ilium is not as good

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Postoperative care

• If the fx has been reduced accurately, 90 of
  normal ROM will be obtained without difficulty by
  the pt
• Pt is placed on bedrest initially, allowing
  ambulation when symptoms allow
• Iliofemoral approach 5 days of absolute bedrest,
  to allow for edema to subside and initial wound
  healing
• PROM of the hip can be instituted by PT or by a
  CPM
• Gait training can usually begun on POD2
• 15kg WB is allowed

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• The pt is encouraged to ambulate with a
  step-through gait and a heel-toe walking motion,
  using crutches or walker
• Pt is instructed on active flexion, abduction,
  and extension exercises to be performed at the
  hip while standing
• AP Pelvis XR should be obtained after gait
  training and before discharge to confirm that
  loss of reduction has not occurred
• Iliofemoral approach active abduction and
  passive adduction are not allowed for the first 3
  weeks
• Limited weight bearing is continued for 8 weeks,
  then WBAT with external support is begun
• PT is directed at regaining muscle strength at
  the hip, particularly the abductors
• Note NWB for 12 weeks is typically performed at
  LSU

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Complications

• Operative wound infection decreased with the
  liberal use of drains, and intraoperative
  hemostasis
• Iatrogenic nerve palsy Peroneal branch of
  Sciatic N (Kocher-Langenbeck), Sciatic N
  (Iliofemoral), Femoral N (Ilioingiunal)
• Periarticular ectopic bone formation greatest
  with lateral exposure of the innominate bone,
  highest with iliofemoral approach, followed by
  Kocher-Langenbeck, and almost nonexistent with
  ilioingiunal or Stoppa approaches
• Indomethacin 25mg POTID or a localized
  single-dose of XRT significantly decreases risk
  (both equally effective- Burd et.al JBJS 2001)
• Thromboembolic complications (DVT, PE) Coumadin
  started 48 hours postop and cont for 6 wks, or
  LMW Heparin started POD1 and cont for 3 wks

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Morel-Lavale lesion

• A closed degloving injury over the greater
  trochanter
• Results from the blunt trauma that caused the fx
• The subcutaneous tissue is torn away from the
  underlying fascia, and a significant cavity
  results
• Cavity contains hematoma and liquified fat
• These areas must be drained and debrided before
  or during surgery to decrease the chance of
  infection
• Advisable to leave this area open through the
  surgical incision or a separate incision
• Dressing changes and wound packing are sometimes
  needed for a prolonged period of time
• Primary excision of the necrotic fat and closure
  over a drain has not been routinely successful