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Acetabular fraacture management with surgical approaches
- 1. Acetabular Fracture : Classification & Surgical Approaches
- 2. The Pioneers Robert Judet Emile Letournel Marvin Tile Anatomical reduction and stable internal fixation
- 3. Column Concept Two columns converging to form a cavity
- 4. The Acetabular Cavity Two walls – anterior and posterior Roof Floor
- 6. Judet’s Iliac Oblique View
- 7. Judet’s Iliac Oblique View
- 9. Judet’s Obturator Oblique View
- 10. CT Scan Size of fragment Degree of displacement Amount of articular surface Site of origin of fragment Marginal impaction
- 11. CT Scan Position of femoral head- dislocation, subluxation, perfect reduction Incarcerated fragment
- 12. 3 D CT SCAN
- 13. Letournel Classification Most acetabular fractures fit into one of ten types Five simple fracture patterns Five associated fracture patterns
- 14. Simple Fractures Posterior wall fracture Posterior column fracture Anterior wall fracture Anterior column fracture Transverse fracture
- 15. Posterior wall Fracture Includes posterior articular surface and retro acetabular surface
- 16. Posterior Column Fracture Extends from PSIS to ischio pubic ramus Involves posterior articular surface and ilio ischial line
- 17. Anterior Wall Fracture Uncommon Separation of anterior part of articular surface along with a large part of middle third of anterior column Anterior hip dislocation can be associated
- 18. Anterior Column Fracture Extends from symphysis pubis to iliac crest Most commonly fracture line exits below AIIS Often comminution into the quadrilateral plate
- 19. Transverse Fracture Across anterior and posterior columns Superior segment – ilium, acetabular roof Inferior segment – ischiopubic segment May be associated with central dislocation
- 20. Combined Fracture Types Posterior column and posterior wall fracture Transverse and posterior wall fracture T-shaped fracture Anterior column or wall and posterior hemi transverse fracture Complete both-column fracture
- 21. Associated Posterior Wall and Posterior Column Fracture Posterior column fracture is usually undisplaced or minimally displaced Primary fracture – posterior wall
- 22. Associated Posterior Wall And Posterior Column Fracture Anterior Column intact Posterior dislocation Displaced posterior wall Ilio ischial line disrupted
- 23. Associated Transverse and Posterior Wall Fracture Commonly posterior dislocation Sometimes central dislocation Highest incidence of pre op sciatic palsy and AVN of femoral head
- 24. T Shaped Fractures Transverse and vertical components Acetabular cavity is split into at least 3 fragments
- 26. Both Column Fractures All segments of fractured acetabulum are detached from the ilium
- 27. AO Classification Type A – Fractues of a single wall or column Type B –Fractures involve both columns Type C –Both column fractures with articular fragments seperated from ilium
- 31. Injury Pattern Affecting Prognosis High or low energy trauma Involvement of acetabular dome Comminution and displacement Joint dislocation Damage to femoral head Both-column fractures and transverse with posterior wall fractures have worst results , primarily because of imperfect reduction
- 32. Indications For Conservative Management Non displaced or displaced <3mm Displaced fracture in unimportant part of acetabulum – low anterior column, low transverse Secondary congruence in both column fractures
- 33. Indications for operative treatment Fracture Displaced >3mm Irreducible fracture dislocation Intra articular fragment interfering with joint movement Instability of the joint To prepare the joint for hip replacement
- 34. Contraindications to surgery Severe osteoporosis Very old patients Severe associated injuries Poor local skin condition Limited experience of the surgeon
- 35. Timing Of Surgery Urgent closed reduction of dislocation Stabilise the patient before ORIF Ideally within 7 days Poor results after 3 weeks
- 36. Kocher Langenbeck Approach Posterior wall fracture Injuries with associated posterior wall fracture Posterior column fracture
- 37. Kocher Langenbeck Approach Transverse fracture where major displacement is posterior T shaped fracture with major displacement posterior
- 39. Ilioinguinal Approach Anterior wall fracture Anterior column fracture Fractures associated with anterior wall and column fractures
- 41. Ilio inguinal Approach Incise along anterior two thirds of iliac crest, extending to the pubic symphysis Elevate abdominal muscles from iliac crest Open inguinal canal
- 42. Ilioinguinal Approach Detach deep abdominal muscles from inguinal ligament and pubis Open iliopsoas sheath Incise iliopectineal fascia Lateral retraction of iliopsoas and medial retraction of iliac vessels
- 43. Dangers Of Ilio Inguinal Approach Lat cut nerve of thigh, femoral nerve Corona mortis Internal iliac vein, femoral vein Lymphatics Abdominal wall weakness
- 44. EXTENSILE APPROACHES Used in complex fracture patterns Triradiate Extensile Approach Carnesile Extensile approach Extensile Ileofemoral approach
- 45. Triradiate Approach Described by Mears & Rubash Reduction & repair of Complex Acetabular fractures Avoids ischemic necrosis Of Hip Abductors
- 49. Complications Of Acetabular Surgery Imperfect reduction, inadequate fixation Avascular necrosis Infection Nerve injury Heterotopic ossification Thromboembolism Learning Curve Of The Surgeon Parallels The Suffering Curve Of The Patient
- 50. Thank YouThank You For YourFor Your KindKind AttentionAttention