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Acetabular Fracture Postgraduate
Acetabular Fracture Postgraduate
Acetabular Fracture Postgraduate
BY
Tarek EL-KHADRAWE
Ass. Prof. of Orthopaedics and
Traumatology
Overview
Radiographs
Classification
Treatment Options
Surgical Approaches
Radiographic Evaluation
From the lateral,
acetabulum is
inverted Y
Anterior column
Posterior column
Sciatic notch through
obturator and inferior
pubic ramus
AP
6 Lines
Iliopectineal
Ilioischial
Posterior wall
Anterior wall
Dome
Teardrop
Radiographs
6 Lines
Iliopectineal
Ilioischial
Posterior wall
Anterior wall
Dome
Teardrop
AP
Oblique
Iliac Oblique
Posterior column
Anterior wall
Iliac Oblique
Posterior column
Anterior wall
Iliac Oblique
Posterior column
Anterior wall
Oblique
Obturator
Anterior column
Posterior Wall
Obturator Oblique
The Dome
The Dome
Classification: Letournel and Judet
Classification: Special Notes
Both column
essentially a T
type occurring
proximal to the
joint
No portion of the
articular surface
is attached to
axial skeleton
SPUR SIGN
Division of
both columns
ABOVE the
acetabulum
Secondary
congruence
Posterior Wall
AP view
Posterior Wall
Blood supply
is from
capsule: do
not detach
Flip over
leaving
capsule if
possible
Anterior column + posterior
hemitransverse vs. T type
Reducing anterior column
usually reduces posterior
column, post capsule is
not usually disrupted
In contrast, in the T type,
reducing the anterior
does not reduce the
posterior and the post
capsule is disrupted
T type
T type
T type
Must involve
obturator foramen
Both Column
Both Column
Treatment options
Nonoperative Operative
Traction ORIF
NWB ORIF w/ THA
Indicated if Absolute indication is
displacement < 2mm hip instability /
subluxation out of
traction
Operative vs. Non-op
Classic Articles Current Literature
Rowe and Lowell: non- Rowe and Lowell
op is preferred 2 groups of fractures
Judet et. al: 90% good High energy forces,
result if anatomic incongruous joint
Operative
reduction, 74% good management is better
result overall Low energy, minimal
displacement
Non-op management
is satisfactory
Surgical Considerations
Timing Approaches
Surgery should be Iliofemoral
completed within 7 d Ilioinguinal
results deteriorate Kocher-Langenbach
after 3 weeks Triradiate
Extended Iliofemoral
Combined
Iliofemoral
Sling 1: iliopsoas
Sling 2: external iliac
artery and vein (aka
femoral sheath)
Sling 3: spermatic
cord
Kocher-Langenbach
Isolated posterior wall Complications:
or posterior column Sciatic nerve 2-10%
injuries only Damage to femoral
Exposure limited head blood supply via
superiorly by superior medial femoral
gluteal vessels and circumflex a.
greater trochanter
High incidence of HO
and sciatic injury
May consider troch
osteotomy
Approach by fracture type
Kocher-Langenbach Anterior column +
Posterior column posterior
Prone is best hemitransverse
Weight of leg in lateral Ilioinguinal approach
position causes rotation usually adequate
of posterior column
Posterior wall
Lateral is OK Transverse fxs
Posterior column + Depends on location of
posterior wall displacement
Prone is best T type is most difficult
Approach by fracture type
Both Column
If posterior column is a
single large fragment, then
ilioinguinal approach is
preferred
If posterior column is not
reduced, then add Kocher-
Langenbach
If significant posterior wall
fracture, choose extensile
or combined approach
Reduction
Traction 5 or 6 mm Schanz
Fracture table threaded pin through
Direct pull on femoral the ischial tuberosity
neck as joystick for T type
Corkscrew into femoral or posterior column
neck
fxs
T handled bone hook
on greater troch Farabeuf clamps on
External distractors screws inserted on
either side of fx
Fixation
Interfrag lag screws 3.5 mm recon plate
3.5 mm cortical contoured
screws, even in
cancellous bone
No tap necessary
except in dense bone
of sciatic butress
Outcomes
THA after ORIF of
acetabulum does
better than THA after
unreduced
acetabulum fx
Complications
Thromboembolism: 60% Post-traumatic DJD
of cases Abductor weakness
HO
Use XRT or indomethacin
Intra-articular
peri/post op for prophylaxis hardware
w/ Kocher-Langenbach
approach
Neurologic injury
AVN
18% of posterior fracture
patterns
THANK YOU