[ORT-L] Neglected acetabular fracture


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[ORT-L] Neglected acetabular fracture

alex at orto
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Mar 21, 2007, 11:27 PM

Post #1 of 4 (2089 views)
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[ORT-L] Neglected acetabular fracture	Can't Post

Dear all,

A male 23 y.o. injured 6 weeks ago - mine trauma, impacted by a
carriage. Isolated injury of the acetabulum. At the initial hosptial
was on bed traction some weeks. After discharge visited anotheê
orthopaedic surgeon who referred him to our unit. To date looks like a
malunion. Images attached.
The question is about what to do now - either leave it as is or
perform open reduction? If the latter what approach, reduction
manoeuvres and fixation would you advice? Thx in advance!

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

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mlroutt at u
New User

Mar 24, 2007, 8:46 AM

Post #2 of 4 (2080 views)
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Re: [ORT-L] Neglected acetabular fracture [In reply to]	Can't Post

The joint is non-concentric as the head appears to be either "following the
caudal segment", or the dome component is displaced from the tethered
head...or so it seems...and he's young...so, many fracture surgeons would
recommend reduction and fixation.

So we must decide preoperatively which part is the displaced segment?

It's difficult to know from these few selected images which component of the
injury (was before and now) should be deemed the "soon to be mobile"
segment. It's my best guess that it is the caudal portion and there exists a
healing fracture line somewhere thru the posterior column...one image
suggests it. If true, its early healing/union should be disrupted, and the
resultant fragment mobility then allows accurate reduction.

Such work is not always possible using a single exposure...it's not
unreasonable to first access the healed zone and osteotomize it using one
direct exposure, then turning the patient if necessary to use another
opposite exposure to further mobilize the fracture, reduce, clamp, and fix
it.

On the other hand, some surgeons advocate an extended iliofemoral exposure
for these scenarios. For a variety of reasons, I've never been much of a
fan.

In summary, reduction and fixation would be good. If you have an excellent
3D brain, a quality OR fluoroscopy unit, and are slick with an osteotome and
clamps thru the ilioinguinal exposure then you've made your best choice.
Remember that the symphysis is the caudal segment's "hinge" and may need
destabilizing as well if it's affecting the reduction adversely.

If you have other images which cause you to decide to destabilize the
posterior column fracture component using a direct or EIF exposure, then you
have better info than we can see.

Or you can just leave it...he has good dome coverage and it may be a durable
hip for some time...maybe.

Chip

> Dear all,
>
> A male 23 y.o. injured 6 weeks ago - mine trauma, impacted by a
> carriage. Isolated injury of the acetabulum. At the initial hosptial
> was on bed traction some weeks. After discharge visited anotheê
> orthopaedic surgeon who referred him to our unit. To date looks like a
> malunion. Images attached.
> The question is about what to do now - either leave it as is or
> perform open reduction? If the latter what approach, reduction
> manoeuvres and fixation would you advice? Thx in advance!

M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
325 Ninth Avenue
Box 359798
Seattle, WA 98104-2499
phone 206-731-3658
FAX 206-731-3227
--

---
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fbwilson at earthlink
New User

Mar 24, 2007, 11:52 AM

Post #3 of 4 (2080 views)
Shortcut

RE: [ORT-L] Neglected acetabular fracture [In reply to]	Can't Post

Chip, et. al.,

While not claiming to have the best 3D brain around, it appears to me from
the limited images available, that the caudal segment is stable from the
symphysis to the SI joint on the fracture side. I would love to see the rest
of the transverse CT images to see where the fracture line actually exits
posteriorly on both the inner and outer tables of the ilium. In my hands,
assuming that the femoral head has followed the cephalad (dome) fragment, I
would use an ilioinguinal approach and take down the fracture line from
anterior to posterior, distracting with a lamina spreader, if necessary, to
clean out and inspect the joint. I would then reduce the cephalad fragment
to the caudal fragment using jungbluth or farabeuf clamp and screws and then
apply a plate and screws. If the fracture exits posteriorly would you then
favor an additional posterior approach to clean out and reduce from that
side?

My concept is that what I am after is restoring the anterior portion of the
acetabular ring to the superior dome portion to re-establish the containment
of the femoral head in an intact "horseshoe". Is this accurate?

Best regards,

Fred
Frederic B. Wilson, M.D.
Assistant Professor
Trauma and Adult Reconstruction
Department of Orthopaedic Surgery
Louisiana State University Health Sciences Center
2020 Gravier St., #728
New Orleans, Louisiana, 70112
Voice: 504-568-4680
Fax: 504-568-4466
Cell: 504-994-4555
e-mail: fbwilson@earthlink.net

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of Chip Routt
Sent: Saturday, March 24, 2007 10:47 AM
To: ORT-L@www2.aaos.org
Subject: Re: [ORT-L] Neglected acetabular fracture

The joint is non-concentric as the head appears to be either "following the
caudal segment", or the dome component is displaced from the tethered
head...or so it seems...and he's young...so, many fracture surgeons would
recommend reduction and fixation.

So we must decide preoperatively which part is the displaced segment?

It's difficult to know from these few selected images which component of the
injury (was before and now) should be deemed the "soon to be mobile"
segment. It's my best guess that it is the caudal portion and there exists a
healing fracture line somewhere thru the posterior column...one image
suggests it. If true, its early healing/union should be disrupted, and the
resultant fragment mobility then allows accurate reduction.

Such work is not always possible using a single exposure...it's not
unreasonable to first access the healed zone and osteotomize it using one
direct exposure, then turning the patient if necessary to use another
opposite exposure to further mobilize the fracture, reduce, clamp, and fix
it.

On the other hand, some surgeons advocate an extended iliofemoral exposure
for these scenarios. For a variety of reasons, I've never been much of a
fan.

In summary, reduction and fixation would be good. If you have an excellent
3D brain, a quality OR fluoroscopy unit, and are slick with an osteotome and
clamps thru the ilioinguinal exposure then you've made your best choice.
Remember that the symphysis is the caudal segment's "hinge" and may need
destabilizing as well if it's affecting the reduction adversely.

If you have other images which cause you to decide to destabilize the
posterior column fracture component using a direct or EIF exposure, then you
have better info than we can see.

Or you can just leave it...he has good dome coverage and it may be a durable
hip for some time...maybe.

Chip

> Dear all,
>
> A male 23 y.o. injured 6 weeks ago - mine trauma, impacted by a
> carriage. Isolated injury of the acetabulum. At the initial hosptial
> was on bed traction some weeks. After discharge visited anotheË
> orthopaedic surgeon who referred him to our unit. To date looks like a
> malunion. Images attached.
> The question is about what to do now - either leave it as is or
> perform open reduction? If the latter what approach, reduction
> manoeuvres and fixation would you advice? Thx in advance!

M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
325 Ninth Avenue
Box 359798
Seattle, WA 98104-2499
phone 206-731-3658
FAX 206-731-3227
--

---
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mlroutt at u
New User

Mar 24, 2007, 12:17 PM

Post #4 of 4 (2080 views)
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Re: [ORT-L] Neglected acetabular fracture [In reply to]	Can't Post

Who knows? The images are insufficient to detail a reasonable plan.

Chip

> Chip, et. al.,
>
> While not claiming to have the best 3D brain around, it appears to me from
> the limited images available, that the caudal segment is stable from the
> symphysis to the SI joint on the fracture side. I would love to see the rest
> of the transverse CT images to see where the fracture line actually exits
> posteriorly on both the inner and outer tables of the ilium. In my hands,
> assuming that the femoral head has followed the cephalad (dome) fragment, I
> would use an ilioinguinal approach and take down the fracture line from
> anterior to posterior, distracting with a lamina spreader, if necessary, to
> clean out and inspect the joint. I would then reduce the cephalad fragment
> to the caudal fragment using jungbluth or farabeuf clamp and screws and then
> apply a plate and screws. If the fracture exits posteriorly would you then
> favor an additional posterior approach to clean out and reduce from that
> side?
>
> My concept is that what I am after is restoring the anterior portion of the
> acetabular ring to the superior dome portion to re-establish the containment
> of the femoral head in an intact "horseshoe". Is this accurate?
>
> Best regards,
>
> Fred
> Frederic B. Wilson, M.D.
> Assistant Professor
> Trauma and Adult Reconstruction
> Department of Orthopaedic Surgery
> Louisiana State University Health Sciences Center
> 2020 Gravier St., #728
> New Orleans, Louisiana, 70112
> Voice: 504-568-4680
> Fax: 504-568-4466
> Cell: 504-994-4555
> e-mail: fbwilson@earthlink.net
>
>
> -----Original Message-----
> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
> Of Chip Routt
> Sent: Saturday, March 24, 2007 10:47 AM
> To: ORT-L@www2.aaos.org
> Subject: Re: [ORT-L] Neglected acetabular fracture
>
> The joint is non-concentric as the head appears to be either "following the
> caudal segment", or the dome component is displaced from the tethered
> head...or so it seems...and he's young...so, many fracture surgeons would
> recommend reduction and fixation.
>
> So we must decide preoperatively which part is the displaced segment?
>
> It's difficult to know from these few selected images which component of the
> injury (was before and now) should be deemed the "soon to be mobile"
> segment. It's my best guess that it is the caudal portion and there exists a
> healing fracture line somewhere thru the posterior column...one image
> suggests it. If true, its early healing/union should be disrupted, and the
> resultant fragment mobility then allows accurate reduction.
>
> Such work is not always possible using a single exposure...it's not
> unreasonable to first access the healed zone and osteotomize it using one
> direct exposure, then turning the patient if necessary to use another
> opposite exposure to further mobilize the fracture, reduce, clamp, and fix
> it.
>
> On the other hand, some surgeons advocate an extended iliofemoral exposure
> for these scenarios. For a variety of reasons, I've never been much of a
> fan.
>
> In summary, reduction and fixation would be good. If you have an excellent
> 3D brain, a quality OR fluoroscopy unit, and are slick with an osteotome and
> clamps thru the ilioinguinal exposure then you've made your best choice.
> Remember that the symphysis is the caudal segment's "hinge" and may need
> destabilizing as well if it's affecting the reduction adversely.
>
> If you have other images which cause you to decide to destabilize the
> posterior column fracture component using a direct or EIF exposure, then you
> have better info than we can see.
>
> Or you can just leave it...he has good dome coverage and it may be a durable
> hip for some time...maybe.
>
> Chip
>
>
>
>
>
>
>
>
>> Dear all,
>>
>> A male 23 y.o. injured 6 weeks ago - mine trauma, impacted by a
>> carriage. Isolated injury of the acetabulum. At the initial hosptial
>> was on bed traction some weeks. After discharge visited anotheê
>> orthopaedic surgeon who referred him to our unit. To date looks like a
>> malunion. Images attached.
>> The question is about what to do now - either leave it as is or
>> perform open reduction? If the latter what approach, reduction
>> manoeuvres and fixation would you advice? Thx in advance!
>
> M.L. Chip Routt, Jr.,M.D.
> Professor-Orthopedic Surgery
> Harborview Medical Center
> 325 Ninth Avenue
> Box 359798
> Seattle, WA 98104-2499
> phone 206-731-3658
> FAX 206-731-3227

M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
325 Ninth Avenue
Box 359798
Seattle, WA 98104-2499
phone 206-731-3658
FAX 206-731-3227
--

---
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