Upload
orthoprince
View
1.079
Download
12
Embed Size (px)
Citation preview
Acetabular supports:2 Columns (Inverted “Y”) & Sciatic buttress
Judet & Letournel
Judet & LetournelAnalysed inominate bone anatomy.Plane of Ilium & Obturator foramen ~ 90o
450 to frontal planeX rays at 45 oblique views.
Anatomy of acetabulum:Incomplete
hemispherical socket
Horse shoe shaped articular facet
Non articular condyloid fossa
Anatomy:Anterior Column -
longerPosterior Column -
shorterSciatic notch
Dome or roof – weight bearing
portion
Goal of treatmentAnatomic restoration
of domeConcentric reduction
of femoral head within dome
Neurovascular structuresExternal iliac A.
Sciatic N.Superir gluteal A. & N.Greater sciatic notch
Mechanism of Injury:Transmitted Force
Femur
Femoral head
Pelvis and acetabulum
Fracture patternDependent upon:
Position of hipDirection & magnitude of ImpactOsteoporotic bonesOther injury patterns.
DIAGS
Hip flexed –Posterior wall # DislocationInternal rotation & adduction – Dislocate
without fracture.Neutral hip - # posterior wallAbducted position – Transverse # with
posterior wall
Magnitude of force / displacement – degree of comminutionDegree of articular impaction
Strength of the bone.
Clinical Evaluation:ABCDLife threatening injuriesHEMODYNAMIC STABILITY
Superior gluteal A. or V.Selective angeographyHead, chest, abdomen
57% have other associated injuries.Secondary survey – knee, patella, ligaments.
Morel Lavalle lesionSkinSubcutaneous degloving, hematoma.Fluid wave, fluctuentCircumscribed area of anaesthesia /
EchymosisCultureSignificance in surgical treatment.
Neurological injuries30% partial injuries to sciatic N.More commonly peroneal division.Superior gluteal N.Impossible to assess abductor strength in
acute fractures.
Dislocation may be missed on examinationX rays neededDislocation – Urgently reduced
Osteonecrosis femoral head.Wearing of head against intra articular
fragmentsUrgent skeletal traction.
Associated injuries:Posterior pelvic ring disruption –
reduction and fixation prior to acetabular # treatment.
Recreate a stable posterior pelvis to reduce the acetabulum to.
Contralateral rami #sIntraop traction not used
Concurrent symphysis dislocations.
Radiographic evaluation:Pelvis AP viewJudet views – 45 degree oblique
Aid in classificationIdentify # displacements.
OUT OF TRACTIONPainful – premedication.
Pelvic inlet / Outlet views – useful but not mandatory
Pelvis AP viewX ray view
Information regarding
1Iliopectineal line
Anterior column
2 Ilioischial line
Posterior column
3 Tear drop
Relationship of columns
4 Roof (Sourcil)
Superior articular surface
5 Anterior Lip
Anterior column or wall
6 Posterior lip
Posterior column or wall
Iliac ObliqueX ray view Information regarding
1 Greater & Lesser sciatic notch
Posterior column (Posterior border of innominate bone)
Quadrilateral surface of ischium
Posterior column (Posterior border of innominate bone)
2 Anterior lip Anterior column or wall.
Iliac wing Anterior column
Roof Superior articular surface
Obturator obliqueX ray view Information
regarding
1Iliopectineal line / Pelvic brim
Anterior column
2Posterior rim or lip
Posterior column or wall
Obturator ring
Column involvement
Roof Superior articular surface
C. T. ScanRotational
displacementsIntra articular
fragmentsMarginal articular
impactionAssociated femoral
head injuriesSize of posterior wall
fragment.3-D RECON
Relationship of multiple sites of injury
Dry bone model or Line drawing:Fracture patternDrawing the fracture lines from X ray
landmarksShould be drawn always before surgery.Fracture pattern truly appreciated.
Fracture Classification:Judet and Letournel ClassificationOrthopaedic Trauma Association
Classification
Fracture Classification of Letournel and Judet A ELIMENTARY FRACTURES
1 Posterior wall 30%
2 Posterior column 3-5%
3 Anterior wall 1-2%
4 Anterior column 3-5%
5 Transverse 5-19%
B ASSOCIATED FRACTURES
1 Posterior column + wall 3-4%
2 Anterior + posterior Hemitransverse 7%
3 Transverse + posterior wall 20%
4 T – shaped 7%
5 Associated both column ABC 23%
Treatment options:Non surgical treatmentOperative treatment
Non-operative treatmentUnlike most articular #s having specific
operative indications acetabular #s are generally considered requiring operative
treatmentUnless certain non-operative criteria are met.Other factors – fracture displacement and
location, stability of hip & patient related factors.
Criteria for Non-operative Management (Four)Roof arcs >45 degrees.No fracture involvement in cranial 10 mm of
joint on CT (CT subchondral arc).No femoral head subluxation on three x-rays,
taken out of traction.For posterior wall fractures: less than 40% of
width of wall on CT .
Criteria by Olson & Matta
Roof arch measurements:Way to quantify the intact weight bearing
articular surface (WBD).In AP, Obturator and Iliac views.Correlates with 10mm of acetabular WBD on
CTNot applicable in
ABCPosterior wall
Other factorsABC
No intact acetabulum left to measurePerfect secondary congruence
Posterior wall>50% width all unstable hips<25% width all stable
Displacement <2mm – non-operative treatment regardless of location.In WBD – careful X ray follow up.Stress views may be needed (Tornetta
modified criteria of Olson & Matta).
Patient related factorsAgePreinjury activity levelFunctional demandsMedical comorbidities
Old patientsPlanned arthroplasty once arthritis develops.
Operative Treatment:Earlier the better once decided to operate.After 3 wks – results not good.Not an emergency except
Irreducible hip dislocationProgressing neurological deficitsOpen #sVascular injuries
SurgeryORIF - treatment of choiceGOAL
Anatomic reduction of articular surfaceAvoiding complicationsRestoring congruent jointStable hipMaximize the potential for long term survival
of hip.
Accuracy of reductionCorrelates with clinical outcome.<1mm Excellent results1-3mm good/fair.>3mm poor results.
Closed reduction and percutaneous fixation – proposed for elderly patients &Simple fractures with minimal displacements.No long term results available yet.
Methods of Non Operative care:Skeletal traction
Mainly historical importance in displaced, unstable #s.
Acute situation.Polytraumatized sick patientSupracondylar femur traction (Never
trochanteric – infection).Early ambulation, Limited and progressive
weight bearing
Early ambulation, Limited and progressive weight bearingMobilization with protected wt bearing – 10-
30Lb TDWBIf bilateral – transferred in bed to chair
manner.Early CPMWeight bearing at min 8 weeksCertain of stability if any doubt – Dynamic
stress views.Serial X-rays – late subluxation or loss of
position of articular fragments.
Surgical indications:Loss of congruence (Subluxation) of hip on
any view (AP or Judet x-rays) Displacement of >2 mm within the superior
articular surface (weightbearing dome) Retained intraarticular fragments, Greater than 25% of the width of the
posterior wall on CT or demonstrable instability.
Lack of secondary congruence for an associated both column fracture.
Other factors favoring operative intervention:Sciatic N lesion developing
following closed reduction orwhile in traction.
Associated fracture of femurTraction not possible
Ipsilateral knee disruptionPatellar fracture or posterior ligamentous
injuries.
Indications for Emergency ORIFIrreducible dislocation, usually by
Large fragments of bone within the jointSoft tissue interposition.Head buttonholed through capsule.
Unstable hip following reductionIncreasing neurologic deficit
Before reduction–Urgent closed reductionAfter reduction-Urgent Open reduction.
Associated Vascular injury – mc anterior column fractures.
Open fractures.
ContraindicationsIn Patient
Very osteoporoticSevere associated injuries
In FractureVery comminuted inoperable fracture
In Surgical teamNot experienced in such surgeriesNo expert help available.
Role of THRShould not be used for fractures best treated
by ORIFOlder pateints, with poor bone or extensive
comminution with probable poor results.
Surgical approaches:FRACTURE TYPE APPROACHELIMENTARY FRACTURES
1 Posterior wall Kocher-Langenbeck2 Posterior column Kocher-Langenbeck3 Anterior wall Ilioinguinal4 Anterior column Ilioinguinal5 TransverseInfratectal/JuxtatectalTranstectal
Kocher-LangenbeckExtended iliofemoral or Kocher-Langenbeck
Surgical Approaches:ASSOCIATED FRACTURES
1 Posterior column + wall Kocher-Langenbeck2 Anterior + posterior Hemitransverse
Ilioinguinal
3 Transverse + posterior wallInfratectal/JuxtatectalTranstectal
Kocher-LangenbeckExtended iliofemoral or Kocher-Langenbeck
4 T – shaped Infratectal/JuxtatectalTranstectal
Kocher-Langenbeck or combinedExtended iliofemoral or combined
5 Associated both column ABC Ilioinguinal.
Complications:Post traumatic arthrosisHeterotrophic OssificationVenous thromboembolism - 61%Neurologic injury
Sciatic – 30% of acetabular #s 2 -3% iatrogenic after surgery.
LFCN (m.c. N. injury after surgery)Infection 1-10% after surgery.