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SYMPOSIUM Table of Contents   
Year : 2002  |  Volume : 36  |  Issue : 1  |  Page : 29-30
Post-operative management of acetabular fractures


Department of Orthopaedics, LTM Medical College and Hospital, Mumbai, India

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How to cite this article:
Thacker M. Post-operative management of acetabular fractures. Indian J Orthop 2002;36:29-30

How to cite this URL:
Thacker M. Post-operative management of acetabular fractures. Indian J Orthop [serial online] 2002 [cited 2019 Dec 8];36:29-30. Available from: http://www.ijoonline.com/text.asp?2002/36/1/29/35922
The goals of post-operative management [1],[2],[3],[4],[5] are:

  1. Maximize the functional status of the patient, so as to facilitate early return to function.
  2. Early detection and appropriate management of complications. [6]
Post-operative management includes

General measures:

  1. Fluid and electrolyte balance: Being a major surgery, it is important to adequately replace fluid volume and keep a watch on the electrolyte balance. Blood should be given to maintain the hemoglobin level above 8-9gm%.
  2. Pain relief: The best way of providing pain relief is by means of continuous epidural infusion of opiates. This allows early mobilization on CPM
  3. Antibiotics: We recommend broad spectrum i.v. antibiotics for a period of seventy-two hours post operatively in uncomplicated cases.
  4. Prophylaxis against DVT and Heterotopic Ossification: [7],[8] We use indomethacin, 25 mg thrice daily, for six weeks, for the prevention of heterotopic ossification. We do not use anticoagulation, except in high-risk individuals. Use of elastic stockings (or elastocrepe bandages) and active ankle mobilization is recommended.
  5. Nutrition: These patients have sustained severe trauma and tend to go into severe negative nitrogen balance. They often may have associated abdominal injuries that preclude enteric feeding. These patients must be put on parenteral hyperalimentation, so as to ensure the best nutritional status.
  6. Catheter care: Care must be taken in order to prevent this from becoming a source of sepsis
  7. and attempts must be made in order to remove the catheter as soon as possible.
  8. Bowel care: These patients may also be constipated and may require a high fluid intake, high
  9. fiber diet and stool softeners. An enema may be justified if these measures are unsuccessful.


Local measures:

  • Immobilization: Patients with simple fractures, such as a posterior lip fracture, need not be put on traction, but should be confined to bed on the first post-operative day. Patients with more complex injuries may have to be put on gentle (2-3 kg) traction till pain subsides, usually in about 10-14 days.
  • A longer period of immobilization may be indicated if the fixation is not deemed stable at the time of surgery. A longer period of immobilization may also be indicated in extensile approaches, and in these patients the rehabilitation, especially abductor strengthening, may also have to proceed at a slower pace.
  • Drains: The posterior drains are removed at 48 hours. The retropubic drain should stay in longer, for 72-96 hours. The drains may be removed earlier if they drain less than 10 cc/day.
  • Scrotal elevation may be required for some patients in whom there has been excessive handling of the spermatic cord, as this may lead to significant scrotal edema.
  • Exercises: CPM, static quadriceps exercises and ankle dorsiflexion exercises are started within 24 hours after the surgery. Upper limb exercises are required as most of the patient would need ambulatory support.
  • Suture removal is usually done at 10-12 days.


X-rays:

An A.P. view in the operating room before closure is done to ensure quality of reduction and position of implants. AP and Judet views are done after drain removal. At each follow up every month they are repeated till the fracture heals. [9]

Mobilization Protocol [1],[2],[3],[4],[5] :

Day 1: static quadriceps exercises are started.

Day 2 or 3: CPM is started, limiting the range to about 60 degrees for the first three days, to avoid tension on the wound.

Day 3 to 7: Dynamic quadriceps exercises. Once the pain has subsided the patient may start gait training on a walker or axillary crutches. Toe touch weight bearing is permitted. The patient is encouraged to ambulate with a step through gait and a heel to toe motion.

Active flexion, extension and abduction exercises while standing are encouraged. Physical therapy is directed towards regaining muscle strength at the hip, especially in the abductors, as this has been seen to correlate well with the final functional outcome. Active abduction and passive adduction are avoided for 4 weeks in patients treated with an extended iliofemoral approach.

Limitation of weight bearing is continued for 8-12 weeks post-operatively.

12 weeks: Full weight bearing ambulation is permitted only after the fracture unites, usually by about 12 weeks, gradually discarding walking aids as tolerated.

Return to sporting activity is advisable after about a year, in the absence of any other complications.

 
   References Top

1.Heeg M, Oostvogel HJM, Klasen HJ. Conservative treatment of acetabular fractures: the role of weight bearing dome and anatomic reduction in the ultimate results. J Trauma 1987; 27: 555-559.  Back to cited text no. 1    
2.Letournel E, Judet R. Fractures of the Acetabulum. Elson RA ed. New York; Springer- Verlag. 1993.  Back to cited text no. 2    
3.Matta JM, Olson SA. Factors related to hip muscle weakness following fixation of acetabular fractures. Orthopaedics 2000; 23(3): 231-235.  Back to cited text no. 3    
4.Tile M. Fractures of pelvis and acetabulum. Baltimore; Williams & Wilkins.1984  Back to cited text no. 4    
5.Tile M, Schatzker J. Rationale of operative fracture care. Berlin, Heidelberg, New York; Springer Verlag.1987.  Back to cited text no. 5    
6.Helfet DL, Schmeling GJ. Fractures of the pelvis and acetabulum. Tile M ed. 2n d ed. Baltimore; Williams & Wilkins. 1995: 451-467.  Back to cited text no. 6    
7.Bosse MJ, Poka A, Reinert CM, Slawson R, McDevitt ER. Heterotopic ossification as a complication of acetabular fractures. J Bone Joint Surg[Am] 1988; 70-A:1231.  Back to cited text no. 7    
8.Haas ML, Kennedy AS, Copeland CC, Ames JW, Scarboro M, Slawson RG. Utility of radiation in the prevention of heterotopic ossification following repair of traumatic acetabular fracture. Int J Radiat Oncol Biol Phys 1999; 145 (2):461-466.  Back to cited text no. 8    
9.Torrenta P. Nonoperative management of acetabular fractures. The use of dynamic stress views. J Bone Joint Surg [Br] [1999; 81-B: 67-70.  Back to cited text no. 9    

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Correspondence Address:
M Thacker
Department of Orthopaedics, LTM Medical College and Hospital, Sion, Mumbai 400 022
India
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Source of Support: None, Conflict of Interest: None


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