• Rheumatology and orthopedics
  • Clinicals

Acetabular Fractures

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  • Rheumatology and orthopedics
  • 2020-07-27

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An acetabular fracture is a break in the socket portion of the "ball-and-socket" hip joint.

Mechanism of injury Of acetabular fractures

These are fractures that occur when the head of the femur is driven into the pelvis as a result of;

  • A blow on the side (as in a fall from a height)
  • A blow on the front of the knee, usually in a dashboard injury when the femur also may be fractured

Clinical Presentation of Acetabular fractures

There may be bruising and abrasions on the thigh or buttock
Degloving of skin in the area
Morel-Lavallé lesion
Posterior column fracture is usually associated with posterior dislocation of the hip and may injure the sciatic nerve

Investigations

The investigations performed include;

At least 4 x-ray views should be obtained in every case;

  • Anterior Posterior view
  • Pelvic Inlet view
  • Two 45° oblique views i.e. Iliac and Obturator oblique views

Management

The management of acetabular fractures can be divided into;

Emergency management, conservative management, and operative management

Emergency management;

Under emergency management you aim to;

Counteract shock and
Reduce a dislocation

Apply traction to the distal femur and during the next three to four days the patient's general condition is brought under control

Conservative Management;

Indications for conservative management are;

  1. Acetabular fractures with minimal displacement (in the weight-bearing zone, <3mm)
  2. Displaced fractures that do not involve the superomedial weight-bearing segment (roof) of the acetabulum or only <20% is lost- usually distal anterior column & distal transverse fractures
  3. A both-column fracture that retains the ball & socket congruence of the hip by virtue of the fracture line lying in the coronal plane and displacement being limited by an intact labrum
  4. Fractures in elderly patients, where closed reduction seems feasible
  5. A patient's with 'medical' contraindications to operative treatment (including local sepsis)

Matta and Merritt criteria

The following criteria (Matta & Merritt) should be met if conservative management is expected to succeed;

1. When traction is released, the hip should remain congruent.
2. The weight-bearing portion of the acetabular roof should be intact.
3. Associated fractures of the posterior wall should be excluded by a CT scan.

Closed reduction & Longitudinal traction, if necessary supplemented by lateral traction, is maintained for 6-8 weeks;

This will unload the articular cartilage allowing it to heal and will help prevent further displacement of the fracture.
During this period, hip movement and exercises are encouraged. The patient is then allowed up, using crutches for a further 6 weeks

Operative Management

In operative management, there are instances where surgery can be delayed for some days and others when its emergent

Indications for operative management include;

surgery can be deferred for 4-5 days in;

  • Unstable hips
  • Fractures resulting in significant distortion of the ball & socket congruence
  • Associated fractures of the femoral head &/or retained bone fragments in the joint

Immediate operations

If stable closed reduction cannot be achieved
If the joint redislocates

Open Reduction Internal Fixation (ORIF) with lag screws or special buttressing plates which can be shaped in the operating theatre.

Post-op hip movements are started as soon as possible and the patient is allowed up, partial weight-bearing with crutches, after 7 days.

Exercises are continued for 3-6 months; it may take a year or longer for full function to return.
Deep vein thrombosis prophylaxis

Complications

The complications that may arise as a result of acetabular fractures include;

  • Iliofemoral venous thrombosis
  • Sciatic nerve injury - Recovery is complete in 50%, partial in 40% & No recovery in 10%
  • Myositis ossificans - In cases where it is anticipated, prophylactic indomethacin is used
  • Avascular necrosis of the femoral head
  • Loss of joint movement & 2° osteoarthritis
References

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Ogera Dan

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