Presentor

Don Tharnpraisarn, MD.

 Disrupt ?

Diagnosis ?
 Disrupt ?

Diagnosis ?
Associated Injury

• Arterial injury

: Superior gluteal a.
Need Emergency embolization

1
Corona mortis

• Vascular anastomosis betw

een External iliac a. or Infe
rior epigastric a. with the o
bturator a.
• 6 cm. from symphysis
2
Associated Injury

• Nerve injury
: Sciatic n. (30%)
Peroneal division
more common

3
 Morel-Lavalle lesion

• Separation of the subcutaneous tissue fr

om the underlying deep fascia
• MRI and ultrasonography: recommende
d to confirm the diagnosis 4
 Radiographic Evaluation

1) Plain film
Pelvis AP Iliac oblique Obturator oblique

+ +
2) CT scan

5
 Pelvis AP
1.Iliopectineal line

2. Ilioischial line

3. Tear drop line

4. Acetabular roof

5. Anterior rim

6. Posterior rim
Iliopectineal line = Anterior column
Ilioischial line = Posterior column

8
Acetabular roof = Wt. Bearing dome

9
 Tear drop

Cotyloid fossa

Obturator canal
10
Anterior wall

12
Posterior wall = More vertical

13
Obturator oblique view

Anterior column

Posterior wall

Obturator foramen

14
Iliac oblique view

Posterior column
Anterior wall Iliac crest 15
Spur sign

= Both column fracture

Acetabulum completely
disconnected from the axial
skeleton

Spur sign
( Obturator oblique view )
16
Gull wing sign

= Articular dome impaction

Poor prognostic factor

Gull wing sign

17
 Roof Arc Measurement
(Describe by Matta et al)
> 45⁰ in all view  Conservative Tx.

Vertical
line

Fracture
line

Medial Anterior Posterior 19

 Roof Arc Measurement
(Modified by Varahas)
x !
n f
lum
co
o th
d B
an
al l
r w
r io
s te
Po
in
s e
t u
No
Medial > 45⁰ Anterior > 25⁰ Posterior > 70⁰
 Conservative Tx. 20
 Letournel and Judet classification

Elementary fractures

Most common
(25%)
Post. Ant. wall Ant. Transverse
Post. wall
column column
21
Associated fractures

Poorest outcome 3rd common 2nd common

(20%) (23%)
Posterior
Transverse Anterior plus
T-type Column Both
plus Posterior
plus Column
Posterior Hemitransverse
Posterior
Wall 22
Wall
• Posterior wall fracture management
• Morel-Lavallée & N/V complication management
• Special consideration: Pt. & associated fracture
 Goal of Treatment
• Restore hip joint stability
• Congruity of weight bearing portion

Special considerations
1)Post wall fracture 6)Multiple trauma patient
2)Soft tissue concern 7)Obese patient
3)Open fracture 8)Geriatric patient
4)Artery injury 9)Associated pelvic fx.
5)Nerve injury 10)Associated long bone fx.
11)Associated hip dislocation
25
 Post wall fracture
Moed et al.
> 50 % =“Unstable” Sx.
Fragment size
< 50 % EUA
( Dynamic stress fluoroscopic
Examination under GA )

Joint sublux. Joint congruent

Sx. Conservative
AP Obturator oblique
Fragment size(%) = ( Y-X ) x 100
Y
Jeffrey M. ReaganBerton R. Moed 27
Fragment size

“ unstable ”  Sx. 
28
 Poor prognosis factors
• Extensive wall comminution
• Marginal impaction
• Injury to the femoral head articular surface
• Osteonecrosis of the femoral head
• Delay in time to reduction of an associated disl
ocation of the femoral Head
• Older age of the patient

29
Nomogram predicting the early need for THA

Suggest THA in high risk pt. Tannast et al.30

Post-op 2 Yr.  OA  THA 31
 Soft tissue concerns
Morel-Lavallée lesions Many management options
• Debridement & Open packing
 Delayed wound closure & ORIF
Rockwood 8th
Hak et al(1997)

• Percutaneous Debridement
 Delayed wound closure & ORIF
Tseng and Tornetta(2006)

• Debridement + ORIF immediately

Campbell 12 th

Carlson et al(2007)

• Debridement + ORIF & Negative pressure

 Delayed wound closure Yuan J, et al(2014)
 Open acetabular fracture

• Similar to other intra-articular fractures

débridement
Reduction & fixation
wound closure

34
Arterial Injury

• Superior gluteal a. injury

Q: May cause Abductor m.

necrosis ???
, especially in extensile
approach ???
A: No
extended iliofemoral
approach can be used safely
Matta JM , J Bone Joint Surg(2005)
J Orthop Trauma(2000)
35
Multiple traumatize patient
“ Acetabular fractures usually not the cause
of acute traumatic hemodynamic instability ”
Not emergency condition except…

> Greater sciatiac notch fx.

Bleeding superior gluteal a.

Need emergency embolization

36
Delayed Acetabular ORIF > 2wk. Need extensile approach
 Obese patient

• BMI > 30 kg/m2

Risk
Increase Blood loss, Op-time,
Infection rate, HO formation

Management
• weight-based antibiotic dose
• Adequate O2 & nutrient supplement
• negative pressure therapy via wound vacuum system
38
 Geriatric patient

• Age > 60-65 Yr.

Primary goal:
preserve life & early mobilization

Secondary goal:
restore native hip
Management options
• Conservative treatment
• ORIF
• THA : severe articular impaction & femoral head injury
39
 Geriatric patient
femoral head impaction Marginal impaction

56-year-old woman, Fall

Outcome
• Mortality rate 8.1-19.1% (in 1-5 Yr.)
• 23.1% Convert to THA after ORIF
40
 Associated Hip Dislocations

• 85% of patients have posterior wall fracture

• Urgent Close reduction within 12 hr. (Moed et al, 2002)
41
 Associated Long Bone Fractures
Example case
# Ipsilateral transverse acetabular & femoral shaft fx.

Management ?
Step suggested
AOEF femur 
ORIF acetabulum 
Retrograde IM nail

42
 Associated Pelvic Fractures
• Most common type associated: APC
• 2nd common: LC + Transverse type

• Initial management: Pelvic Ex-fix + skeletal traction

• Definitive management: as standard

43
 Summary

• Remember 6 film parameters & 10 types classification

I/C for Surgery

1) Displaced > 2 mm. in Wt. bearing dome (Roof-arch Â)
2) Posterior wall fx. > 50% or Unstable in EUA
3) Joint incongruity eg. Incongruent Both column fx.
• Morel-Lavallée lesions  Debridement
• Consider THA in Old + Marginal impacted fx.
• Superior gluteal a. injury  Emergency embolization
 References

• ICL 2017 Chapter 1

• CAMPBELL’S 13th & RW 8th EDITION
• Slide ติวสอบบอร์ด
 Disrupt ?
Rt: Disrupted Iliopectineal
+Ilioischial line+Inf. Pubic
rami
Lt.: Disrupted post. Wall
Intact column
 • Pubic symphysis widening
• Crescent sign Rt.

Post column spike

Diagnosis
Lt: Post. wall fx.

Rt: T-type fx.

+Associated LC II
(crescent frx.) & VS
Nomogram predicting the early need for THA

2 0%
Ri sk

THA risk in 2 yr. = 20% Tannast et al.

Thank you for your kind attention