LL:ACETABULAR FRACTURES AND DISLOCATIONS Flashcards
ACETABULAR FRACTURES AND DISLOCATIONS
Anterior Dislocation PATHOPHYSIOLOGY
• Cause: Forced abduction and external rotation of
the hip
• Deformity: Extension, abduction and ER
• X-ray: femoral head appears to be inferior to the
acetabulum
ACETABULAR FRACTURES AND DISLOCATIONS
Anterior Dislocation COMPLICATIONS
Femoral vein compression, with the risk of thrombosis and embolism
Femoral artery compression
Femoral nerve compression
Risk of avascular necrosis of the femoral head
Long term-risk of osteoarthritis of the hip
ACETABULAR FRACTURES AND DISLOCATIONS
Anterior Dislocation TREATMENT
This injury requires urgent reduction under general anaesthetic. It is done by
applying strong traction, combined with internal rotation and adduction.
The patient is put on light traction for 3-6/52 and then mobilised NWB for a
further 3/52.
ACETABULAR FRACTURES AND DISLOCATIONS
CONTRA-INDICATIONS AND PRECAUTIONS OF ANTERIOR DISLOCATION
• Avoid excessive abduction, extension and external rotation, especially in
combination.
• NWB for 3/52 after the traction has been removed.
• Maintain neutral position of hip when doing bed exercises.
• Modify bedpan use to avoid hip extension.
• General contra-indications for traction
ACETABULAR FRACTURES AND DISLOCATIONS
POSTERIOR DISLOCATION PATHOPHYSIOLOGY
Cause: MVA (hip + knee flexed and the knee hits the dashboard) • Associated with acetabular fractures • Deformity: Flexion, IR and adduction appears shortened • X-ray: femoral head appears to be superior to the acetabulum
ACETABULAR FRACTURES AND DISLOCATIONS
COMPLICATIONS OF POSTERIOR DISLOCATIONS
Sciatic nerve injury
Associated fractured patella, ruptured PCL or fractured femur
Avascular necrosis of the femoral head
Fracture of the posterior wall of the acetabulum
Damage to the femoral head
Long-term risk of osteoarthritis of the hip
ACETABULAR FRACTURES AND DISLOCATIONS
TREATMENT OF POSTERIOR DISLOCATIONS
• This injury requires urgent reduction
under general anaesthetic
• Stable after reduction= light traction for
3-6/52, then mobilised according to pain
limits.
• Unstable after reduction= light traction
for 6/52 with an abduction wedge, then
mobilised NWB for 3/52.
ACETABULAR FRACTURES AND DISLOCATIONS
Contraindications and Precautions of posterior dislocations
• Avoid combined position of hip flexion and adduction.
• No hip flexion greater than 70°-90° for up to 6/52.
• No straight leg raise.
• If patient has an abduction wedge, do not remove it without
consulting the surgeon.
CENTRAL FRACTURE-DISLOCATION OF THE HIP PATHOPHYSIOLOGY
Cause
This injury may occur in a MVA if the hip is flexed and abducted or if the patient
receives a blow from the side. It can also occur during a fall from a height.
Deformity
The femoral head is driven through the medial wall of the acetabulum into the
patient’s pelvic cavity.
COMPLICATIONS OF CENTRAL FRACTURE-DISLOCATION OF THE HIP
Vascular damage with major internal bleeding and shock
Post-traumatic osteoarthritis
TREATMENT OF CENTRAL FRACTURE-DISLOCATION OF THE HIP
Conservative treatment
Only used if the acetabulum is minimally displaced or if it is too comminuted for
ORIF.
The patient is put on longitudinal skeletal traction for 6-8/52. Lateral skeletal
traction may be added to the longitudinal traction if necessary.
The patient is then mobilised TWB/NWB for a further 6/52 (preferably TWB).
CONTRA-INDICATIONS AND PRECAUTIONS OF CENTRAL FRACTURE-DISLOCATION OF THE HIP
- Avoid excessive abduction
- No straight leg raise
- General contra-indications for traction
Operative treatment
There are various approaches to the open reduction and internal fixation and the
choice depends on the nature of the fracture. Plates and screws are used to hold
the fragments of the acetabulum together.
The patient may still be kept on traction for a further 3-4/52 post surgery.
• NWB
• Keep hip in 15 of hip abduction
ANTERIOR ACETABULAR FRACTURE
This fracture involves only the anterior column of the acetabulum, the weightbearing dome is not involved.
Cause
The mechanism may be similar to that of an anterior dislocation.
Treatment
The patient is managed with skeletal traction for 6-8/52.
CONTRA-INDICATIONS AND PRECAUTIONS
• No hip extension
• No straight leg raise
POSTERIOR ACETABULAR FRACTURE
This fracture involves the posterior column of the acetabulum, the weightbearing dome is not involved.
It is often associated with a posterior dislocation of the hip.
Treatment
Conservative treatment
Conservative treatment is only used if there is minimal displacement of 2-3
fragments or conversely, if the acetabulum is completely shattered.
The patient will be put on skeletal traction for 6-8/52. The patient is then
mobilised NWB for a further 6/52.
Operative treatment
Plating is considered if there are 3-5 major fragments, or if the reduction cannot
be maintained by traction. There should be no loose fragments of bone left in the
joint.
The patient may be put on skin traction for 2-3/52 post surgery and then
mobilised NWB for a further 6-8/52.
CONTRA-INDICATIONS AND PRECAUTIONS (for conservative and operative
treatment)
• No hip flexion greater than 45 for the first 3/52 and only up to 70 by 6/52.
• No straight leg raise
TRANSVERSE ACETABULAR FRACTURE
The iliac portion of the acetabulum may or may not be separated from the pubic
and ischial portions.
Reduction is usually successful if treated on traction for 6-8/52.
The protocol is similar to that of central fracture-dislocations.
