2. Introduction
• Contemporary icon of pelvic
and acetabular surgery .
• Ubiquitous standard of care
of acetabular fractures for
the past 25 years.
• Complete transformation of
our understanding and
treatment of fractures of the
acetabulum
• Two textbooks are the
“Bibles” of acetabular
surgery
3. Acetabular fractures
Before Letournel
• Conflicting recommendations
on Rx.
• No classification
• No consensus on
conservative or operative
• Only AP view Pelvis obtained
• Invariably poor results –
JOINT INSTABILITY/ AVN.
After Letournel
• First systematic classification
• Phenominal concepts
• AP, 45 deg oblique views ; CT
• Concept of accurate reduction
• Surgical approaches and
management protocols
• Standard plate and screw
fixation
• Aim is congruent and stable
hip.
4.
5. Principles of acetabular fracture Rx
• Thorough understanding of 3-D anatomy of
innominate bone
• Diagnosis, Classification and operative repair
• Stable congruent hip esp. weight bearing
dome.
• Surgery is complex and done by experienced
surgeon.
• Anatomic reduction ( < 2mm ) is key to
functional outcome.
6. Mechanism of injury
• Impact of femoral head with the acetabular
surface
• Force is via GT or Axis of femur
• Fracture pattern decided by position of hip at
the time of impact
• Also force of impact and bone quality
9. Assessment – ATLS protocol
History
• Mechanism of injury
• Ask for position of hip
• Ask of axial loading or
direct injury
• Low energy trauma
• Underlying illness
Examination
• Open wounds
• Morel- Lavallee lesions
• Shortening
• Attitude of limb
• Neurological examination
• Document sciatic nerve
palsy
23. CT Scan- 2D/3D
• Extent & location
• intra- articular free
fragment / head
fragment
• orientation of # lines
• rotation of fragments
• status of posterior
pelvic ring
• Marginal Impaction
Don’t decide hip joint instability based on CT Scan.
PELVIC PLASTIC MODEL
30. Go for non operative here
• Polytrauma with sick condition
• Severe head injury
• Open wound in the planned incision site
• Morel – Lavale lesions
• Suprapubic catheter – No ilioinguinal
approach. Wait till track seals.
• Elderly with osteoporotic bone
Gull sign – poor prognosis
31. Non operative protocol
• Bed rest
• Mobilise as soon as symptoms allow
• Begin with partial weight bearing
• Assess displacement weekly for first 4 weeks
• By 6 to 12 weeks patient returns to full weight
bearing
• Joint mobilisation throughout
• Prolonged traction only for patients who needs
surgery but contraindicated due to other reasons
32. Fix if
• Displaced # in dome.
• Posterior wall # > 50 % displacement
• Positive fluoroscopy stress test
• Both column fractures with loss of parallelism
• Incarcerated fragments in the acetabulum
after closed reduction.
Ideal time – 5 to 7 days
35. Anterior Ilioinguinal
• Anterior wall, anterior column, anterior
column + posterior hemitransverse, transverse
with major displacement in anterior region
• Careful of corona mortis
• Lowest rate of heterotrophic ossification
• Risk of damage to lat.cut.N, femoral.N,
external iliac vessels and inguinal canal
62. Indications for emergency fixation
• Recurrent dislocation following reduction
despite traction
• Irreducible hip dislocation
• Progressive sciatic nerve palsy
• Associated vascular injury
• Open fractures
• Ipsilateral neck fractures
63. Posterior wall fractures
• 25 % of all acetabular fractures
• Kocher – Langenbeck approach
• Limit periosteal elevation to fracture site, don’t
release any fragment from capsule
• Distract head and remove osteochondral
fragments. May need hip subluxation
• Large fragment removal needs Modified Gibson’s
approach and troch flip osteotomy ( lateral)
• Bone grafting
• Two level reconstruction
90. Posterior column
• 3 – 5 %
• Reduced by using Schanz screw into ischium
• Reduction clamps used
• Interfragmentary screws + butress plate.
91. Transverse #
• 5 – 19 %
• medial and superior displacement of head
• Transtectal, juxtatectal and infratectal
• Reduction – Schanz screws, sciatic notch
clamp, clamp between two screws
• Anterior column screws can be placed only at
acertain angle
• ilioinguinal approach