2Tipicamente ocurren de gente joven, son secundarias a traumas de alta energia. Hay màs de 50 %de probabilidades de tener lesiones asociadas: fx de columna, trauma abdominal y toràcico, lesiones genito uninarias, fx de extremidades, lesiones de los ligamentos de las rodillas,luxaciones, trauma craneoencefalico.El tratamiento quirùrgico es frecuente para restaurar la anstomìa articular.
3Anatomía Está formado por el hueso innominado. La unión de 3 huesos: ilium, ischium, and pubis joined by the tri-radiate cartilageEl acetábulo está dividido en 2 columnas: anterior y posteriorLas 2 columnas se describen tiene la forma de unaY invertida, o la letra Griega lambda (l).Columna anterior: ant border of the iliac wing, the entire pelvic brim, the ant wall, and the superior pubic ramusColumna posterior: the ischial portion of bone ( lesser and greater sciatic notches), post wall, and the ischial tunerocity
6Radiología Five (5) Pelvic XRs Proyección anteroposterior (AP) Oblicuas Bilateral 45 grados, o proyecciones de Judet de la pelvis.Inlet y OutletTomografía computarizada, TAC, provee información adicional de la configuracion delas fracturas.
7Pelvis XR: Inlet: Pt supino con XR paralelo al plano del sacro. AP de pelvis con inclinación grados caudalmente.Outlet:Pt en supine con XR perpendicular al plane del sacroAP de pelvis con inclinación grados cefálico.
8Judet hip XR Iliac oblique: Pt is supine with involved side of pelvis rotated anteriorly 45 deg, beam directed vertically toward affected hipshows iliopectineal line, AC and PW Obturator oblique:Pt is supine with uninvolved side of pelvis rotated ant. 45 degrees, beam directed vertically toward the affected hipshows ilioischial line, PC and AW
27Nonoperative txNondisplaced fx, <5mm, or articular step-off of <2mmOperative contraindications: local or systemic infection, severe osteoporosisOperative relative contraindications: advanced age, associated medical conditions (ESRD on dialysis, ESLD, Seizure Disorder, uncontrolled DM, CHF, Neurological Disorder), associated soft tissue and visceral injuries, or a multiply injured pt not stable for a big acetabular sxDisplaced fx: large portion of acetabulum remains intact with a congruous femoral head, or secondary congruence with a both-column fx
28PW: if less than 50% of the width of the articular cartilage is displaced (ST), some authors say less than 25%Many low AW fxA minority of low T-shaped fxInfratectal transverse fxIn assesing the intact portion of acetabulum, it is useful to obtain roof arc measurementsMatta first described these angles in 1986Stable fx=all roof arc angles >45 degreesCT subchondral arc technique of Olsen: no involvement of the upper 10mm of the acetabulum by CT corresponds to an intact 45 degrees roof arc on all 3 plain XRs
29Roof Arc AnglesA vertical line is drawn from roof of acetabulum to geometric center of the femoral head, and second line is drawn from fracture to the geometric center1. Medial Roof Arc (AP pelvis)2. Anterior Roof Arc (Obturator oblique)3. Posterior Roof Arc (Iliac oblique)
31Operative txAny displaced fx, > 5mm, or articular step-off of >2mmAllows early ambulation and decreases chance of post-traumatic arthritisUsually undertaken 2-3 days after injury, when initial fx and intrapelvic vessel bleeding has subsidedIdeally performed before 10 days, so fx fragments remain mobileThree weeks after injury, a bony callus has formed, making reduction more difficult (typically not done)
32Surgical approachesKocher-Langenbeck: best access to posterior column (prone)Ilioinguinal: best access to anterior column and inner aspect of innominate bone (supine)Extended iliofemoral: best simultaneous access to the two columns (lateral)Combined approaches performed concurrently or successively is less desirableExtended iliofemoral approach has the highest incidence of ectopic bone formation (HO) and longest postoperative recovery
35Ilioinguinal approach Anterior column fracturesAnterior wall fracturesSome anterior column-posterior hemitransverse fracturesMay also be used for both column fractures with large single posterior fragment, with reduction being achieved indirectly through reduction of the quadrilateral plateFractures with associated superior ramus and symphysis pubis fractures
37Extended Iliofemoral approach T-shaped fracturesTransverse fractures with extended posterior wallT-shaped fractures with wide separations of the vertical stem of the "T" or those with associated pubic symphysis dislocationsCertain associated both column fracturesAssociated fracture patterns or transverse fractures which are operated greater than 21 days following injury
39Other approaches Stoppa approach (supine): Cole and Bolhofner Allows access to the medial wall of the acetabulum, quadrilateral surface, and sacroiliac jointTriradiate approach (prone):Alternate exposure to the external aspect of the innominate bone, with almost same exposure as iliofemoral but visualization of the posterior part of the ilium is not as good
40Postoperative careIf the fx has been reduced accurately, 90% of normal ROM will be obtained without difficulty by the ptPt is placed on bedrest initially, allowing ambulation when symptoms allowIliofemoral approach= 5 days of absolute bedrest, to allow for edema to subside and initial wound healingPROM of the hip can be instituted by PT or by a CPMGait training can usually begun on POD#215kg WB is allowed
41The pt is encouraged to ambulate with a step-through gait and a heel-toe walking motion, using crutches or walkerPt is instructed on active flexion, abduction, and extension exercises to be performed at the hip while standingAP Pelvis XR should be obtained after gait training and before discharge to confirm that loss of reduction has not occurredIliofemoral approach: active abduction and passive adduction are not allowed for the first 3 weeksLimited weight bearing is continued for 8 weeks, then WBAT with external support is begunPT is directed at regaining muscle strength at the hip, particularly the abductorsNote: NWB for 12 weeks is typically performed at LSU
42ComplicationsOperative wound infection: decreased with the liberal use of drains, and intraoperative hemostasisIatrogenic nerve palsy: Peroneal branch of Sciatic N (Kocher-Langenbeck), Sciatic N (Iliofemoral), Femoral N (Ilioingiunal)Periarticular ectopic bone formation: greatest with lateral exposure of the innominate bone, highest with iliofemoral approach, followed by Kocher-Langenbeck, and almost nonexistent with ilioingiunal or Stoppa approachesIndomethacin 25mg POTID or a localized single-dose of XRT significantly decreases risk (both equally effective- Burd et.al JBJS 2001)Thromboembolic complications (DVT, PE): Coumadin started 48 hours postop and cont for 6 wks, or LMW Heparin started POD#1 and cont for 3 wks
43Morel-Lavale lesionA closed degloving injury over the greater trochanterResults from the blunt trauma that caused the fxThe subcutaneous tissue is torn away from the underlying fascia, and a significant cavity resultsCavity contains hematoma and liquified fatThese areas must be drained and debrided before or during surgery to decrease the chance of infectionAdvisable to leave this area open through the surgical incision or a separate incisionDressing changes and wound packing are sometimes needed for a prolonged period of timePrimary excision of the necrotic fat and closure over a drain has not been routinely successful