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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Work Up and Treatment of Acetabular Frx



- See: Trauma Menu

- Discussion:
    - note that with acetabular fracture associated with major trauma that there will be 50% chance of at least one
           other major injury;
           - neuro and head injury (see Glasgow)
           - abdominal and chest injury (pulmonary contussion and pneumothorax);
           - genito-urinary injury
           - spine
           - spinal injury
           - pelvic fracture may occur in approx 20 % of acetabular frx;
           - frx dislocation of the hip:
                  - Surgical treatment and prognosis of acetabular fractures associated with ipsilateral femoral neck fractures. 
           - extremity injury
                  - knee injuries: PCL rupture and/or patella frx;
    - fluid management and need for transfusion are kept in mind as soon as the patient arrives in the ER;



- Radiographs:  
    - classification


- Physical Exam:
    - inspection of soft tissues:
           - including local wounds, abrasions, & closed degloving injury;
           - Morel Lavale lesion;
                  - closed degloving injury which commonly occurs over greater trochanter;
                  - subQ tissue is torn from underlying fascia creating a cavity, which places this tissue at risk for infection and/or poor healing;
           - reference:
                  - Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallée lesion.
    - palplation:
           - symphysis, pubic rami, iliac crests, sacroiliac;
           - bimanual compression & distraction of the iliac wings, & abduction & adduction of the hip should be done to detect instability;
           - manual traction can aid in the determination of vertical instability
    - GYN / urinary / rectal injuries: RUG vs. suprapubic catheter placement;
    - neurologic injury:
           - a careful detailed examination of the sciatic nerve is manditory in all cases;
           - w/ posterior injury, the sciatic nerve may be injured in 40% of patients;


- Indications for Non Operative Rx:
    - may be indicated if the superior acetabular dome is intact, based on the 3 standard roof arc measurements (which
          should be greater than 45 deg);
    - may be indicated for both column frx which are congruent and which do not have wide displacement, as determined by 3 arc measurements;
    - posterior acetabular wall should be adequate;
    - low transverse frx not involving wt bearing dome;
    - many low anterior column frx that involve only pubic portion of acetabulum can be treated by non operative means;
    - minority of low T shaped or transverse frx can be treated non-op;
    - if non surgical treatment is selected, Neufield type roller traction has the advantage of permitting active lower extremity exercises;
          - traction must be maintained from 4-8 weeks to achieve bony union;
    - in the presentation by Stover M, et al (1999), the authors were able to follow 33 patients with minimally displaced
          acetabular frx w/o surgery;
          - non displaced fractures were defined as displacement less than 1 mm, and minimally displaced frx had less than 2 mm of displacement;
          - the majority of fractures were of the transverse type;
          - 31 out of 33 fractures healed without fracture displacement;
                 - non of the 13 nondisplaced fractures displaced when patients were allowed touch down wt bearing;
          - authors advocate early touch down mobilization for minimally displaced acetabular fracture, as long as there is close radiographic follow up;
          - ref: Nonoperative treatment of fractures of the acetabulum. Stover M, et al. (15th Annual Meeting of the Orthopaedic Trauma Association);



- Surgical Treatment:
    - indications for ORIF acetabular fractures
             - articular displacement of more than 2 mm or persistent displacement following closed reduction (and traction);
             - a nonconcentric reduction after dislocation of the hip out of traction (on any radiographic view);
             - any intraarticular loose bodies associated w/ acetabular fracture
             - unstable fracture of posterior acetabular wall;
             - lack of parallelism between femoral head and acetabular roof;
             - medial femoral head subluxation;
             - instability out of traction after closed reduction;
    - total hip replacement
    - contraindications to surgery
             - acute fixation in polytrauma is avoided unless an ipsilateral hip fracture is present;
             - open fractures;
             - severe injuries to adjacent skin (Morel Lavale lesion);
             - bladder rupture
             - fever
             - osteoporosis


- Pre Op Planning:
    - timing:
          - ideal time to perform surgery is between 2 and 10 days after injury;
          - delay of 2-3 days is desirable to help decrease local intraop bleeding;
          - beyong 10 days, frx fragments are not as easily manipulated;
          - after 3 weeks delay callus can complicate frx reduction;
    - associated injuries:
          - pts must be afebrile and off ATB for > 48 hrs prior to surgery;
          - prior to surgical intervention, all other injuries are stabilized;
    - physical exam:
          - inspection of soft tissues:
          - GYN / urinary / rectal injuries:
          - neurologic injury: it is essential that all neurologic deficits are documented prior to surgery;
    - vascular injuries: (see vascular injuries in pelvic frx)
          - injury to the superior gluteal artery may lead to flap necrosis in patients undergoing iliofemoral (or other extensile exposures);
          - acetabular fractures which are displaced into the sciatic notch should undergo preoperative angiography;
          - references:
                 The Superior Gluteal Artery in Complex Acetabular Procedures. A Cadaveric Angiographic Study.
                 Preoperative angiographic assessment of the superior gluteal artery in acetabular fractures requiring extensile surgical exposures.
    - traction:
          - pts are maintained in skeletal traction preoperatively, & reduction of the femoral head is confirmed roentgenographically;
          - usually intraoperative traction is employed either through the distal femoral pin and fracture table, or an ASIF femoral distractor;
    - deep venous thrombosis;
          - consider placement of inferior vena cava - DVT filter;
          - consider heparin or coumadin;
    - blood loss:
          - expect intra-operative blood loss of 1500-3500 cc;
          - type and cross 3-4 units of pRBC
          - consider use of a cell saver;
    - flourscopy:
          - if flouroscopy is required, avoid using Nitrous oxide anesthesia since it obscurs bony details;
          - ensure that there is no contrast material in the patients GI tract or bladder;


- Surgical Approaches:
    - Iliofemoral Approach
    - Ilioinguinal Approach
          - used for frx of anterior wall, anterior column, anterior column- posterior hemitransverse frx, and both column frx;
    - Kocher Langenbach:
          - used for fractures of posterior wall, posterior column, combined frx of the posterior wall and column, T shaped frx;
          - w/ T fractures, the Kocher Langenback is used most often, unless the frx courses from proximal-anterior to distal-posterior
                  w/ anterior displacement in which case the ilio-inguinal approach should be selected;


- Complications:
    - infection
    - sciatic nerve palsy
           - can be prevented by flexion of the knee during surgery and intraop monitoring of amount of tension applied by assistants retracting the nerve;
           - early treatment consists of AFO
           - sciatic nerve recovery may occur over a 3 yr period;
           - tendon transfers are usually not performed unitl 3 yr post op;
           - reference: Sciatic Nerve Release Following Fracture or Reconstructive Surgery of the Acetabulum
    - deep venous thrombosis
    - heterotopic ossificaiton:
           - heterotopic ossification is rare w/ non operative treatment;
           - w/ operative treatment and no prophylaxis, HO may occur in 90%, and will be especially severe in 20-50%;
                 - clinically significant HO occurs in about 7-14% of surgically treated acetabular fractures;
           - typically the maximum amount of HO appears by 3 months;
           - some controversy as to whether indomethacin actually reduces HO;
           - in the study by Matta and Siebenrock (1997), indomethacin was not effective for preventing ectopic bone formation;
           - risk factors:
                  - iliofemoral approach (HO occurs in 57%)
                  - Kocher Langenbeck approach (HO occurs in 26.3%)
                  - Ilioinguinal approach (HO occurs in 4.8%)
                  - multiple trauma, head injury, T-type fracture;

                   
           - NSAIA:
                  - indomethacin 25 mg PO tid for 3-6 months;
                  - some controversy as to whether indomethacin actually reduces HO;
                  - in the study by Matta and Siebenrock (1997), indomethacin was not effective for preventing ectopic bone formation;
                  - in the report Burd TA, et al (2001), the authors studied 166 acetabular frx patients;
                         - patients were randomized to receive either radiation (800 cGy within 72 hrs of surgery or indocin 25 PO tid;
                         - grade III or IV HO developed in 11% of indocin group and 4% in the radiation group;
                         - in 16 patients that did not receive prophylaxis, all develped HO and 6/16 (38%) developed grade III or IV HO;
           - etidronate
           - radiation therapy
           - references:
                 - Does indomethacin reduce heterotopic bone formation after operations for acetabular fractures? A prospective randomised study.
                 - Indomethacin compared with localized irradiation for the prevention of heterotopic ossification following surgical treatment of acetabular fractures.



- Post Operative Management:
    - passive motion is initiated after drain removal and crutch walking w/ 15 kg wt bearing starts as soon as pain is diminished, usually two to five days postoperatively;
    - 8 weeks after internal fixation, wt bearing is increased progressively, assuming the fracture shows evidence of healing;



     - Frx - Menu
     - Axial Skeleton:
          - C-spine
          - Spine
          - Pelvis
               - distal femoral traction for reduction;
     - Neuro:
          - document any preoperative neurological deficits;
     - Cranio-Maxillo-Facial
     - Spine
     - Cardiac
     - Pulmonary
     - GU/Renal
          - suprapubic vs. foley catheter (consider RUG)
     - Vascular
          - see Bleeding w/ Pelvic Frx;
          - selective angiography may aid in the dx of of superior gluteal artery;
                  especially if frx involves sciatic notch;
                  - if one is using the anterior or posterior approaches to acetabulum using trochanteric osteotomy, superior gluteal vessels must be intact in order to avoid muscle necrosis of medius and minimus;
     - Compartments
     - Hepatic / GI tract:
          - need for diversion w/ open fractures;
     - Coag
          - consider Greenfield filter for DVT prophylaxis;
     - Checklist:
          - Anesthesia: - request GEA if compartment syn is possible;
          - Cardiology
          - Blood (4 units)
          - X-rays and Template
          - Consent
          - ATB (High dose Vanc if pt has been in SICU)
          - Posting
          - Implant Selection;
          - Positioning
               - Table type and Flouro
               - Incision
               - Sulcatrans / Cell Saver
               - Bone Graft
          - Initial Orders: (Post Op Orders)
               - NPO p Midnight x Meds
               - IVF D5W 1/2 NS c 20 KCL at 100 ml/hr
               - 2 large bore IV;
               - Foley
             - Type & Cross 2-4 units pRBC and/or FFP
             - Meds
                  - Insulin (1/2 NPH dose) + S.S. - Accu Check in AM and on call
                  - ATB:
                  - Heparin 5000 units SQ q8 hrs;
                  - Zantac
                  - Morphine
             - PreOp Labs:
                  - Musculoskeletal Labs:
                  - EKG
                  - CXR
                  - Urinalysis
             - Buck's Traction
             - Egg Crate / Pillow and turn 20 deg q2hr;
             - Hiboclens Shower and Bactroban to nares q12 hrs until OR
             - Cleocin solution 300 mg per 100 ml NS q6hr as mouth wash;

- Physical Exam:
    - extent of soft tissue injury
    - r/o open pelvic fracture (Gyn/Rectal Injuries)
    - Neurologic Injury



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Clifford R. Wheeless, III, MD on Friday, October 11, 2013 6:32 pm