Acetabular Fracture Senario

Question 1

MOI

Answer 1

1. Direct impact to GT
   
   1. Hip position
      
      1. Neutral
         
         1. transverse #
      2. Adducted
         
         1. high transverse
      3. Abducted
         
         1. low transverse
      4. ER
         
         1. Anterior Column
      5. IR
         
         1. Posterior Column
2. Indirect Trauma
   
   1. Dashboard to flexed knee
      
      1. Posterior wall

As hip flexion increases the fracture line moves more inferior

Question 2

Non-operative Rx

Indications

Answer 2

1. displacement < 2 mm in the dome with
   
   1. maintained femoral head congruency out of traction
   2. no intraarticular fragments
2. Non-ambulatory patient
3. Elderly patient with comminuted fracture
4. Severe osteoporosis
5. Local/systemic infection
6. Displaced fracture with a large portion of the dome intact (> 10mm, > 45° roof-arc angles)
7. Secondary congruence
8. Non-displaced/minimally displaced fractures
9. Posterior wall fracture without instability

Question 3

Operative Rx

Indications

Answer 3

1. Open fracture
2. Intraarticular fragment in joint
3. Significant marginal impaction
4. Non-congruent joint
5. Displacement of > 1mm of acetabular dome
6. Involvement of 10 mm of subchondral arc on CT or roof arc angles less than 45 on plain films
7. PW fractures causing instability
   
   1. >40%
   2. 20-40 grey zone – fluoro stress view
      
      1. Stress view done in OR under GA or regional.
         
         1. Hip flexed to 90 degrees and joint checked under fluoro.
         2. If concentric enough posterior force applied to rock the pelvis.
         3. If stable repeat in obturator oblique view and compare to contralateral healthy side.

< 20% tx is non-op if hip is concentric

Question 4

Relative contraindications for OR

Answer 4

1. Advanced age
2. Medical comorbidities
3. Osteoporosis
4. Morbid obesity
5. Associated soft tissue/visceral injuries
6. Contaminated wound
7. Delay in treatment > 4 weeks
8. DVT with contraindication to IVC filter

Question 5

Negative prognostic factors for outcome of acetabular fractures

Answer 5

1. Femoral head injury
2. Marginal impaction
3. Fracture-dislocation
4. Delay in treatment > 3 weeks
5. Residual displacement > 2 mm
6. Surgery by an inexperienced individual

Question 6

Risks

Answer 6

1. immediate
   
   1. nerve injury (LFCN, sciatic), hemorrhage (superior gluteal artery if # into greater sciatic notch), bleeding, infection, transfusion
2. late
   
   1. post-traumatic arthritis, chondrolysis, limited ROM, HO, instability

Question 7

HO

Risk factors

Answer 7

1. Kocher or extended iliofemoral (#1)
2. head trauma
3. men
4. trochanteric osteotomy
5. extensive cartilage damage
6. T-shaped fracture