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SYMPOSIUM Table of Contents   
Year : 2002  |  Volume : 36  |  Issue : 1  |  Page : 13-16
Principles of management of acetabular fractures


LTM Medical College & Hospital, Mumbai, India

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How to cite this article:
Thakkar C J, Magu N K. Principles of management of acetabular fractures. Indian J Orthop 2002;36:13-6

How to cite this URL:
Thakkar C J, Magu N K. Principles of management of acetabular fractures. Indian J Orthop [serial online] 2002 [cited 2019 Oct 19];36:13-6. Available from: http://www.ijoonline.com/text.asp?2002/36/1/13/35916
Non-operative Treatment

Indications: [1],[2],[3]

  • Displacement less than 2 mm
  • Severe comminution: Poor bone quality
  • Medical contraindications
  • Late presentation
  • Local infection
  • Non-availability of adequate surgical facilities
  • Adequate intact weight bearing dome with congruent head


Methodology of non-operative treatment: Longitudinal skeletal traction is applied through the supracondylar area of the femur or upper tibia. Lateral traction through a schanz screw in the subtrochanteric region. Avoid trans-trochanteric screw for lateral traction as it increases the chances of inflammation / infection of the trochanteric bursa, making the patient unfit for surgery at a later date if decided. Assess the reduction by proper X-rays [Figure 1]. Maintain traction for six to eight weeks. While in traction it is important to continue isometric exercises.

Surgical management

Aims of surgery: [2],[3],[4],[5],[6]

  • Socket restoration
  • Socket stabilisation
  • Congruent reduction
  • Early mobilisation
  • Delayed weight bearing
Timing of surgery: Reduction of the dislocated head is carried out as an emergency procedure by closed manipulation. Immediate surgery may be considered for neuro-vascular injury or irreducible dislocation. Open reduction and internal fixation is performed between 5th and 15th post injury day. By the 5 th day most of the patients are haemodynamically stable and can be thoroughly investigated. After 15 days the surgery becomes difficult due to organization of the haematoma, early callus and contraction of pelvic ligaments. [2],[5]

Preoperative planning: Planning includes detailed analysis of various injuries. Common associated injuries are to the sacro-iliac joint, knee ligaments, rib cage, head of femur. [4],[6] Look for pelvic visceral injuries. Complex bi-column fractures may require about 3 to 4 units of blood. In absence of 3DCT scans, it is essential to make line drawings from the X-rays and mark a scheme of fracture pattern on the innominate bone model and carry the same to the operation theatre for better three dimensional orientation [Figure 2]. Prophylactic intravenous antibiotics are given 2 hours before surgery and repeated 8 hourly following the first dose for a period of 3 to 5 days.

Position and approach: Judet and Letournel [4] suggest operative treatment of these fractures on modified fracture table either in prone or supine position depending on the approach. We prefer to treat these fractures surgically, in floppy lateral position, without the use of fracture table. Depending on the more displaced column, we use either posterior Kocher-Langenbeck approach or anterior ilio-inguinal approach. Since last 3 years, as we have gained more experience, we prefer the anterior ilio-inguinal approach and only if we are able to manage both the columns that we take an additional posterior approach. We prefer to tackle the fractures in single stage.

Surgical instruments and implants: Steinmann pin for retraction, Schanz screw mounted on a T-handle, Lion's bone holding forceps, good pair of Deaver's abdominal retractors, various sizes of punches, 1cm wide straight and curved osteotomes, long and sturdy pointed bone holding forceps, 1.5mm and 2mm, 150mm long K-wires, long 2mm, 2.5mm, 3.2mm and 4.5mm drill points, long 3.5mm, 4.00mm, 4.5mm and 6.5mm cortical and cancellous screws, with washer, long malleable reconstruction plates are the preferred instruments and implants. We have not yet found the use of special bone holding forceps. We rarely, if ever, need a distractor.

Tricks and tips: The following tricks and tips may be useful during the trying part of the surgery:

  • A schanz screw in the iliac crest and one in the femoral neck connected with a multi directional distractor will allow adequate distraction of the joint and may also help in achieving reduction by the principle of ligamentotaxis. [6]
  • A 5 mm schanz screw with a T handle inserted in the ischial tuberosity will allow manipulation of the lower part of the posterior column helping to get rotational control over it. [6]
  • Holes may be drilled into the outer cortex of pelvic bone [Figure 3] to get purchase for the pointed reduction forceps. [6]
  • Distracted anterior column fractures align very well, without any force, if the patient is temporarily turned to lateral position.
  • Temporary fixation of fragments with K wires will reduce the number of floating fragments.
  • Impacted intra-articular pieces can be elevated with 5mm of cancellous bone bed and reduced around the femoral head, and the gap thus created should be grafted with cortico­ cancellous bone either from the iliac crest if the gap is sizeable, or from the greater trochanter if the gap is small.
  • Interfragmentary screw fixation is the mainstay of the fixation. This should be neutralized with malleable reconstruction plate [Figure 4].
  • Work within the fracture.


 
   References Top

1.Matta JM, Anderson LM, Epstein HC, Hendricks P. Fractures of acetabulum: a retrospective analysis. Clin Orthop 1986; 205:230.  Back to cited text no. 1    
2.Rowe CR, Lowell JD. Prognosis of fractures of acetabulum. J Bone Joint Surg [Am] 1961; 43­A: 30 - - 59.  Back to cited text no. 2    
3.Tile M. Fractures of pelvis and acetabulum. Baltimore; Williams & Wilkins. 1984  Back to cited text no. 3    
4.Letournel E. Acetabular fractures, classification and management. Clin Orthop 1980; 151: 81-106.  Back to cited text no. 4    
5.Pennal GF, Davidson J, Garside H, Lewis J. Results of treatment of acetabular fractures. Clin Orthop 1980; 151: 115 - 123.  Back to cited text no. 5    
6.Tile M, Schatzker J. Rationale of operative fracture care. Berlin, Heidelberg, New York; Springer -Verlag. 1987.  Back to cited text no. 6    

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Correspondence Address:
C J Thakkar
Lokmanya Tilak Memorial Medical College & Hospital, Sion, Mumbai 400 022.
India
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Source of Support: None, Conflict of Interest: None


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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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