Download - Fracturas Acetabulares
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