Fracturas Fracturas AcetabularesAcetabulares

Dr Pérez Dr Pérez

Ortopedia HCGOrtopedia HCG

Tipicamente ocurren de gente joven, son Tipicamente ocurren de gente joven, son secundarias a traumas de alta energia.secundarias a traumas de alta energia.

Hay màs de 50 %de probabilidades de tener Hay màs de 50 %de probabilidades de tener lesiones asociadas: fx de columna, trauma lesiones asociadas: fx de columna, trauma abdominal y toràcico, lesiones genito abdominal y toràcico, lesiones genito uninarias, fx de extremidades, lesiones de uninarias, fx de extremidades, lesiones de los ligamentos de las rodillas,luxaciones, los ligamentos de las rodillas,luxaciones, trauma craneoencefalico.trauma craneoencefalico.

El tratamiento quirùrgico es frecuente para El tratamiento quirùrgico es frecuente para restaurar la anstomìa articular. restaurar la anstomìa articular.

AnatomíaAnatomía

Está formado por el hueso innominado.Está formado por el hueso innominado. La unión de 3 huesos: ilium, ischium, and pubis joined La unión de 3 huesos: ilium, ischium, and pubis joined

by the tri-radiate cartilageby the tri-radiate cartilage El acetábulo está dividido en 2 columnas: anterior y El acetábulo está dividido en 2 columnas: anterior y

posteriorposterior Las 2 columnas se describen tiene la forma de unaLas 2 columnas se describen tiene la forma de unaY Y

invertida,invertida, o la letra Griega lambda (l). o la letra Griega lambda (l). Columna anteriorColumna anterior: ant border of the iliac wing, the : ant border of the iliac wing, the

entire pelvic brim, the ant wall, and the superior pubic entire pelvic brim, the ant wall, and the superior pubic ramusramus

Columna posteriorColumna posterior: the ischial portion of bone : the ischial portion of bone ( lesser and greater sciatic notches), post wall, and the ( lesser and greater sciatic notches), post wall, and the ischial tunerocityischial tunerocity

RadiologíaRadiología

Five (5) Pelvic XRsFive (5) Pelvic XRs Proyección anteroposterior (AP) Proyección anteroposterior (AP) Oblicuas Bilateral 45 grados, o Oblicuas Bilateral 45 grados, o

proyecciones de Judet de la pelvis.proyecciones de Judet de la pelvis. Inlet y Outlet Inlet y Outlet Tomografía computarizada, TAC, Tomografía computarizada, TAC,

provee información adicional de la provee información adicional de la configuracion delas fracturas.configuracion delas fracturas.

Pelvis XR: Pelvis XR:

Inlet:Inlet: Pt supino con XR paralelo al plano del Pt supino con XR paralelo al plano del

sacro.sacro. AP de pelvis con inclinación 25-30 grados AP de pelvis con inclinación 25-30 grados

caudalmente. caudalmente. Outlet:Outlet: Pt en supine con XR perpendicular al plane Pt en supine con XR perpendicular al plane

del sacrodel sacro AP de pelvis con inclinación 35-45 grados AP de pelvis con inclinación 35-45 grados

cefálico. cefálico.

Judet hip XR Judet hip XR Iliac oblique:Iliac oblique: Pt is supine with involved side of pelvis Pt is supine with involved side of pelvis

rotated anteriorly 45 deg, beam directed rotated anteriorly 45 deg, beam directed vertically toward affected hipvertically toward affected hip

shows iliopectineal line, AC and PW shows iliopectineal line, AC and PW  Obturator oblique:Obturator oblique: Pt is supine with uninvolved side of pelvis Pt is supine with uninvolved side of pelvis

rotated ant. 45 degrees, beam directed rotated ant. 45 degrees, beam directed vertically toward the affected hipvertically toward the affected hip

shows ilioischial line, PC and AW  shows ilioischial line, PC and AW  

AP Pelvis XRAP Pelvis XR

TeardropTeardrop

Internal limb = Internal limb = outer wall of outer wall of obturator canalobturator canal

External limb = External limb = middle 1/3 of middle 1/3 of cotyloid fossacotyloid fossa

Inferior border = Inferior border = ischiopubic notchischiopubic notch

Inlet Pelvis XRInlet Pelvis XR

Outlet Pelvis XROutlet Pelvis XR

Iliac obliqueIliac oblique

Obturator obliqueObturator oblique

ClassificaciónClassificación Inicialmete publicado por Judet en 1964,y Inicialmete publicado por Judet en 1964,y

despues modificado por Letourneldespues modificado por Letournel Judet and Letournel sistema de Judet and Letournel sistema de

clasificación: tipos simples y complejossclasificación: tipos simples y complejoss SimplesSimples: posterior wall (PW), posterior : posterior wall (PW), posterior

column (PC), anterior wall (AW), anterior column (PC), anterior wall (AW), anterior column (AC), transversecolumn (AC), transverse

ComplejosComplejos: T-shaped, anterior column and : T-shaped, anterior column and posterior hemitransverse (AC-PHT) , both-posterior hemitransverse (AC-PHT) , both-column (BC), posterior column and wall column (BC), posterior column and wall (PC-PW), transverse posterior wall (T-PW)(PC-PW), transverse posterior wall (T-PW)

Simple typesSimple types

Complex typesComplex types

PWPW

PCPC

AWAW

TransverseTransverse

T-PWT-PW

AC-PHTAC-PHT

BCBC

PC-PWPC-PW

Nonoperative txNonoperative tx Nondisplaced fx, <5mm, or articular step-off of Nondisplaced fx, <5mm, or articular step-off of

<2mm<2mm Operative contraindicationsOperative contraindications: local or : local or

systemic infection, severe osteoporosissystemic infection, severe osteoporosis Operative relative contraindicationsOperative relative contraindications: :

advanced age, associated medical conditions advanced age, associated medical conditions (ESRD on dialysis, ESLD, Seizure Disorder, (ESRD on dialysis, ESLD, Seizure Disorder, uncontrolled DM, CHF, Neurological uncontrolled DM, CHF, Neurological Disorder), associated soft tissue and visceral Disorder), associated soft tissue and visceral injuries, or a multiply injured pt not stable for injuries, or a multiply injured pt not stable for a big acetabular sxa big acetabular sx

Displaced fx: large portion of acetabulum Displaced fx: large portion of acetabulum remains intact with a congruous femoral head, remains intact with a congruous femoral head, or secondary congruence with a both-column or secondary congruence with a both-column fxfx

PW: if less than 50% of the width of the PW: if less than 50% of the width of the articular cartilage is displaced (ST), some articular cartilage is displaced (ST), some authors say less than 25%authors say less than 25%

Many low AW fxMany low AW fx A minority of low T-shaped fxA minority of low T-shaped fx Infratectal transverse fxInfratectal transverse fx In assesing the intact portion of In assesing the intact portion of

acetabulum, it is useful to obtain roof arc acetabulum, it is useful to obtain roof arc measurementsmeasurements

Matta first described these angles in 1986Matta first described these angles in 1986 Stable fx=all roof arc angles >45 degreesStable fx=all roof arc angles >45 degrees CT subchondral arc technique of Olsen: no CT subchondral arc technique of Olsen: no

involvement of the upper 10mm of the involvement of the upper 10mm of the acetabulum by CT corresponds to an acetabulum by CT corresponds to an intact 45 degrees roof arc on all 3 plain intact 45 degrees roof arc on all 3 plain XRsXRs

Roof Arc AnglesRoof Arc Angles A vertical line is drawn A vertical line is drawn

from roof of acetabulum from roof of acetabulum to geometric center of to geometric center of the femoral head, and the femoral head, and second line is drawn second line is drawn from fracture to the from fracture to the geometric center geometric center 1. Medial Roof Arc (AP 1. Medial Roof Arc (AP

pelvis) pelvis) 2. Anterior Roof Arc 2. Anterior Roof Arc

(Obturator oblique)(Obturator oblique) 3. Posterior Roof Arc 3. Posterior Roof Arc

(Iliac oblique)(Iliac oblique)

Roof arc measurementRoof arc measurement

Operative txOperative tx Any displaced fx, > 5mm, or articular step-off Any displaced fx, > 5mm, or articular step-off

of >2mmof >2mm Allows early ambulation and decreases Allows early ambulation and decreases

chance of post-traumatic arthritischance of post-traumatic arthritis Usually undertaken 2-3 days after injury, Usually undertaken 2-3 days after injury,

when initial fx and intrapelvic vessel bleeding when initial fx and intrapelvic vessel bleeding has subsidedhas subsided

Ideally performed before 10 days, so fx Ideally performed before 10 days, so fx fragments remain mobilefragments remain mobile

Three weeks after injury, a bony callus has Three weeks after injury, a bony callus has formed, making reduction more difficult formed, making reduction more difficult (typically not done)(typically not done)

Surgical approachesSurgical approaches Kocher-LangenbeckKocher-Langenbeck: best access to : best access to

posterior column (prone)posterior column (prone) IlioinguinalIlioinguinal: best access to anterior column : best access to anterior column

and inner aspect of innominate bone (supine)and inner aspect of innominate bone (supine) Extended iliofemoralExtended iliofemoral: best simultaneous : best simultaneous

access to the two columns (lateral)access to the two columns (lateral) Combined approaches performed Combined approaches performed

concurrently or successively is less desirableconcurrently or successively is less desirable Extended iliofemoral approach has the Extended iliofemoral approach has the

highest incidence of ectopic bone formation highest incidence of ectopic bone formation (HO) and longest postoperative recovery(HO) and longest postoperative recovery

Kocher-Langenbeck Kocher-Langenbeck approachapproach

Posterior wall fracturesPosterior wall fractures Posterior column fracturesPosterior column fractures Posterior column-posterior wall Posterior column-posterior wall

fracturesfractures Juxta-tectal/Infra-tectal transverse or Juxta-tectal/Infra-tectal transverse or

transverse-posterior wall fracturestransverse-posterior wall fractures Some T-shaped fractures Some T-shaped fractures

Ilioinguinal approachIlioinguinal approach Anterior column fracturesAnterior column fractures Anterior wall fracturesAnterior wall fractures Some anterior column-posterior Some anterior column-posterior

hemitransverse fractureshemitransverse fractures May also be used for both column May also be used for both column

fractures with large single posterior fractures with large single posterior fragment, with reduction being achieved fragment, with reduction being achieved indirectly through reduction of the indirectly through reduction of the quadrilateral platequadrilateral plate

Fractures with associated superior ramus Fractures with associated superior ramus and symphysis pubis fracturesand symphysis pubis fractures

Extended Iliofemoral Extended Iliofemoral approachapproach

T-shaped fractures T-shaped fractures Transverse fractures with extended Transverse fractures with extended

posterior wall posterior wall T-shaped fractures with wide separations T-shaped fractures with wide separations

of the vertical stem of the "T" or those with of the vertical stem of the "T" or those with associated pubic symphysis dislocationsassociated pubic symphysis dislocations

Certain associated both column fracturesCertain associated both column fractures Associated fracture patterns or transverse Associated fracture patterns or transverse

fractures which are operated greater than fractures which are operated greater than 21 days following injury21 days following injury

Other approachesOther approaches Stoppa approachStoppa approach (supine): Cole and (supine): Cole and

BolhofnerBolhofner Allows access to the medial wall of the Allows access to the medial wall of the

acetabulum, quadrilateral surface, and acetabulum, quadrilateral surface, and sacroiliac jointsacroiliac joint

Triradiate approachTriradiate approach (prone): (prone): Alternate exposure to the external aspect Alternate exposure to the external aspect

of the innominate bone, with almost of the innominate bone, with almost same exposure as iliofemoral but same exposure as iliofemoral but visualization of the posterior part of the visualization of the posterior part of the ilium is not as goodilium is not as good

Postoperative carePostoperative care If the fx has been reduced accurately, 90% of If the fx has been reduced accurately, 90% of

normal ROM will be obtained without difficulty by normal ROM will be obtained without difficulty by the ptthe pt

Pt is placed on bedrest initially, allowing Pt is placed on bedrest initially, allowing ambulation when symptoms allowambulation when symptoms allow

Iliofemoral approachIliofemoral approach= 5 days of absolute bedrest, = 5 days of absolute bedrest, to allow for edema to subside and initial wound to allow for edema to subside and initial wound healinghealing

PROM of the hip can be instituted by PT or by a PROM of the hip can be instituted by PT or by a CPMCPM

Gait training can usually begun on POD#2Gait training can usually begun on POD#2 15kg WB is allowed15kg WB is allowed

The pt is encouraged to ambulate with a step-The pt is encouraged to ambulate with a step-through gait and a heel-toe walking motion, through gait and a heel-toe walking motion, using crutches or walkerusing crutches or walker

Pt is instructed on active flexion, abduction, Pt is instructed on active flexion, abduction, and extension exercises to be performed at the and extension exercises to be performed at the hip while standinghip while standing

AP Pelvis XR should be obtained after gait AP Pelvis XR should be obtained after gait training and before discharge to confirm that training and before discharge to confirm that loss of reduction has not occurredloss of reduction has not occurred

Iliofemoral approachIliofemoral approach: active abduction and : active abduction and passive adduction are not allowed for the first 3 passive adduction are not allowed for the first 3 weeksweeks

Limited weight bearing is continued for 8 Limited weight bearing is continued for 8 weeks, then WBAT with external support is weeks, then WBAT with external support is begunbegun

PT is directed at regaining muscle strength at PT is directed at regaining muscle strength at the hip, particularly the abductorsthe hip, particularly the abductors

NoteNote: NWB for 12 weeks is typically performed : NWB for 12 weeks is typically performed at LSUat LSU

ComplicationsComplications Operative wound infectionOperative wound infection: decreased with the : decreased with the

liberal use of drains, and intraoperative hemostasisliberal use of drains, and intraoperative hemostasis Iatrogenic nerve palsyIatrogenic nerve palsy: Peroneal branch of Sciatic : Peroneal branch of Sciatic

N (Kocher-Langenbeck), Sciatic N (Iliofemoral), N (Kocher-Langenbeck), Sciatic N (Iliofemoral), Femoral N (Ilioingiunal)Femoral N (Ilioingiunal)

Periarticular ectopic bone formationPeriarticular ectopic bone formation: greatest : greatest with lateral exposure of the innominate bone, with lateral exposure of the innominate bone, highest with iliofemoral approach, followed by highest with iliofemoral approach, followed by Kocher-Langenbeck, and almost nonexistent with Kocher-Langenbeck, and almost nonexistent with ilioingiunal or Stoppa approachesilioingiunal or Stoppa approaches

Indomethacin 25mg POTID or a localized single-dose Indomethacin 25mg POTID or a localized single-dose of XRT significantly decreases risk (both equally of XRT significantly decreases risk (both equally effective- Burd et.al JBJS 2001)effective- Burd et.al JBJS 2001)

Thromboembolic complicationsThromboembolic complications (DVT, PE): (DVT, PE): Coumadin started 48 hours postop and cont for 6 Coumadin started 48 hours postop and cont for 6 wks, or LMW Heparin started POD#1 and cont for 3 wks, or LMW Heparin started POD#1 and cont for 3 wkswks

Morel-Lavale lesionMorel-Lavale lesion A closed degloving injury over the greater A closed degloving injury over the greater

trochantertrochanter Results from the blunt trauma that caused the fxResults from the blunt trauma that caused the fx The subcutaneous tissue is torn away from the The subcutaneous tissue is torn away from the

underlying fascia, and a significant cavity resultsunderlying fascia, and a significant cavity results Cavity contains hematoma and liquified fatCavity contains hematoma and liquified fat These areas must be drained and debrided before or These areas must be drained and debrided before or

during surgery to decrease the chance of infectionduring surgery to decrease the chance of infection Advisable to leave this area open through the Advisable to leave this area open through the

surgical incision or a separate incisionsurgical incision or a separate incision Dressing changes and wound packing are sometimes Dressing changes and wound packing are sometimes

needed for a prolonged period of timeneeded for a prolonged period of time Primary excision of the necrotic fat and closure over Primary excision of the necrotic fat and closure over

a drain has not been routinely successfula drain has not been routinely successful