Name: Fractures of the Acetabulum for Orthopaedic Exams
Uploaded: 2024-06-01T00:00:00.0000000
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Description: Fractures of the Acetabulum for Orthopaedic Exams

Name: Fractures of the Acetabulum for Orthopaedic Exams

Description: Fractures of the Acetabulum for Orthopaedic Exams

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Upload Date: 2024-06-01T00:00:00.0000000

Transcript: Language: EN.
Segment:0 .
Uh, we are happy to introduce Wally de la Hal, who is our mentor today, who is going to talk about acetabular fracture. This is a difficult topic to understand your own and reading it from the book because it takes a lot of three dimensional thinking in a complex structure, which is the pelvis and the acetabulum.
Before we get into the talk, may I remind everyone of the etiquette of this meeting? Please keep your mics muted until you are allowed to talk. Please I'm Ed. Please check our website for the forthcoming webinars. We have renewed the weapon we have, you know, whole puts, put a new face to the website so that you can register directly from the website for the coming webinars.
In addition, you can check our book, which is very good preparation for the exam. And Mr. Allen has is a lecturer at Cairo University. He has come to the UK in 2017, passing his FRCS exam, and since then he has done several fellowships in arthroplasty, pelvic and acetabular fracture, and now he is doing one fellowship in yet sorry young adult hip surgery in Birmingham.
Without further ado, I will leave you to with Mr. ulnar claw now. Sorry, I forgot to mention this lecture will be interactive. We need you. We need volunteers of you to answer the questions during the lecture. These will be interpretation of the X-ray mostly, and they are not designed to grill you or to test you. It is just to help everyone understand the concept better.
If you are interested in being in volunteering for that. Please just raise the hand and I would pick that up. Please, everyone, take your hand down because raising your hand means you want to volunteer for the interactive part of the lecture. If you want to contribute to the Viva session at the end, I would like you to chat directly to anyone in the chat function with the word Viva. So if you want a Viva chat to anyone with Viva, if you want the interactive part of the lecture, raise your hand.
OK, thank you. Now I've got so far three people. And without further ado, leave you with Mr. an-nahar. Thank you, FRC mentor group, for giving me this opportunity to present this lecture. So I think fractures of the acetabulum is one of the topics a lot of us worry about when we are revising our trauma for the GMFCS exam.
I think mainly that because it involves a lot of 3D sort of thinking. And just as Abdullah mentioned, just trying to make sense of it without having experienced and could be a bit tricky. What we'll try to do today is we will quickly touch on the mechanism of injury and clinical assessment. I won't spend a lot of time in the theoretical bit because most of us can read that on our own, and most of us already know about that.
What I'll try mostly to focus on is the radiological assessment and maybe the classification for the vyver part of the fix. We for the first year, we don't need to know a lot of details, but we just need to know the basics and that's what we'll try to cover. Surgical approaches, it could be quite complex and decision making could be quite complex. Again, we're not going to go through them in a complex way. We'll just highlight the principles just so that in a way you could feel comfortable and you could demonstrate that you have the basic knowledge for these types of injuries.
We'll quickly touch on the outcomes and complications. So mechanism of injury, I think we all know these are high energy injuries, 80% of them being road traffic injuries and 10% fall from height. And the reason why we have this very wide variety of fracture configuration is that the fracture depends. The fracture configuration depends on where the head of the femur was and how the force came onto the head of the femur.
So you can see that from this diagram, you can have hundreds of possibilities depending on where the head was and how the force was subjected onto the head. But we are seeing low energy trauma in elderly, and these are very different types of fractures from the high energy ones. We're not going to discuss them today, but just so we know that, yes, they do follow the same general guidelines as the young low energy fractures, but they are a different population and a different fracture pattern.
They tend to involve the anterior column more. There tends to be a lot of combination and articular impaction in these fractures, and we have different management goals when we are trying to treat these fractures. So you will see later on that with the young high energy trauma. We aim for anatomical reduction. We aim for like any articular fracture, any range of motion.
And so on. With these, we treat them more like an elderly, inactive female patient where we want functional restoration. We want to get them up. We want MDT input on their co-morbidities and so on. So if we are confronted in Aviva with an elderly 80-year-old fracture, just put that in mind that this is another totally different mindset from the one we're be discussing for the rest of the lecture clinical assessment like any high energy trauma.
We you need to mention that you will make sure that you go through the Atlas guidelines. You have to point out that these fractures have high incidence of associated injuries, and this is usually dealt with in the major trauma center. They usually are in the usually go through a trauma CT scan, getting the city of the head, chest, pelvis and so on. Like any other high energy injury, a particular sort of clinical assessment scenario which is popular in the vyver for acetabular fractures is the dislocated hip, and maybe it's more of a classic scenario than a common scenario.
It's usually you're presented with this X-ray with a dislocated hip where you go through the ADLs associated injuries and so on. And then you point out your concern about this dislocated hip, this being a surgical emergency and that you need to point out that I need to reduce this. So why do you need to use this on sort of an emergency basis? Well, I'm worried about the sciatic nerve being compromised.
I'm worried about the blood supply to the femoral head and leaving it in a dislocated position might lead to even later on. I'm concerned about the articular cartilage compromised, with the head being out of the socket and possibly rubbing against the bone, and so on. Where do you reduce this? Do you reduce this in the emergency department or do you take him to theatres?
You definitely should be taking him to theaters. You should. Generally, anesthetized muscles should be relaxed and how to reduce this, your resistance should be stabilizing the pelvis, you should be putting traction on the femur and a sort of a flexed position. Before doing so, you need to obtain appropriate consent. You need to document the neuromuscular status.
After doing so, you need to again document the neurovascular status, the sciatic nerve, and you need to comment on the stability. And then, you know, another sort of classic question after that is what if you can't reduce it in the middle of the NIPE if you're in the? Would you open this or would you abandon? I think this, you could answer it in different ways. I would say is that I would abandon because I don't have the capabilities or the expertise to deal with this in the middle of the NIPE.
In the. I would phone the major trauma center or the specialized center, which deal with this and I would follow their advice. I would suspect that they would ask us to put some sort of skeletal traction on and then transfer them to their unit. They might choose to do it in the middle of the NIPE. They might choose to do it the next morning because. Attempting to do so if it's not irreducible, I could be doing damage to the femoral head and so on.
If I persist on trying to use it. Then we go to the radiological assessment, and this is where it gets a bit tricky. And this is where we want to spend some time. So historically speaking and probably in the 40s and 50s, when. When the orthopedic surgeons were presented with these fractures, they didn't really understand what was going on and and I'm speaking to some of the very senior surgeons there thought back then was that the head somehow broke through the floor of the acetabulum and just landed into the pelvis.
And that's why the treatment back then was just to put them in traction and get that head back. And that's basically what people understood about it then came to pioneers really today in the journal, and they transformed the way people think about this. So they propose this column theory and they said, well, the acetabulum is an anterior column and it's the posterior column. They form a triangle together, and these columns are basically supporting the acetabulum.
So you've got the anterior column, which is in white here, which is the front of the ilium, the front of the acetabulum and the superior pubic ramus. You've got the posterior column, which is red, and this is the greater static notch, the lesser sciatic notch and the skin. And these two columns are what hold the acetabulum together. Between these columns, you've got the anterior wall, you've got the posterior wall and you've got the medial world floor in between.
And then they wanted to make sense of the X-rays. So they came up with this very, you know, brilliant yet very simple idea where they got some led markers and they put it on a cadaver or on a bone, and they put it on the anterior column. They put it on the posterior column and on the walls of the asylum, and they took an X-ray. And this X is from their original book. I think it was published in 1962.
I don't really remember the exact date, but this is the picture they took so that they could start making sense of these fractures and and then they came up with the lines they later no lines, which is again a sort of classic Viva scenario where you're presented with this X-rays and given the pendant, you're asked to draw these lines. So what they came up with was the epicondyle line. So the epicondyle line represents the anterior column of the slap.
I came up with an hélio. Line that represents the posterior column. If we go back to the. So it starts from the superior pubic ramus heading upwards all the way to the PSI joint. Look at the SCL line that starts from the top of the inferior pubic ramus going up to the PSI joint. So when you're drawing them, just start from the superior requirements or the inferior peel-back, then you're heading up.
Then there's the teardrop, which I think a lot of us might be familiar of from hip replacements because we use it as a landmark, and this represents the medial wall or the floor or the acetabulum. Then we've got the roof or the dome, and then we've got the anterior wall and the posterior wall. And because we know that the acetabulum is activated, the anterior wall lies more medial than the posterior wall Mr Wall.
You can start by tracing it from the back, from the lower border of the inferior payment's going upwards. The anterior wall, you can start drawing it from the lower border of the pubic of the superior pubic ramus, then going upwards. OK so again, this maybe was good and understanding what these fractures were, but they wanted some more sort of 3D representation, so they came up with these.
The juday views are basically oblique views where, as you can see, the patient lies in an oblique matter. 30 to 45 degrees and the beam goes perpendicular. So they came up with these views and this the one in front of you, is called the obturator oblique view obturator because you can see the obturator foramen right in front of you and the obturator frame and you see the aisle you picked in your line right in front of you, and that represents the anterior column of the acetabulum.
And then if you look backwards, you can see this line. This line is the posterior wall line and that represents the posterior wall. So the obturator oblique view, which you can see the Oh or the operative Raymond right in front of you. That's the anterior column epicondyle line and the margin of the posterior wall. If you go to the other side, that's the iliac oblique where you see the ilium right in front of you.
You can see this, which is the Lucasville line that represents the posterior column of the acetabulum and the anterior wall. So they're sort of opposite to one another. So the iliac oblique where you see the ilium right in front of you, that's where you see the clearest kill line. That's the posterior column and the anterior wall of the acetabulum. So this then led to the literal not classification, which a lot of us have problems sort of making sense of.
So there are two main categories we've got the elementary fractures and the associated fractures. Elementary means that we're dealing with one fracture line or one fracture. Associated means that is a combination of fractures. We'll try to simply go through them one by one. The posterior wall fracture may be a lot of us are familiar with is where the posterior wall gets broken off the acetabulum.
What would we expect to see on an x-ray? Well the posterior wall line, which we just drew would be disrupted, and some of them are associated with dislocation of the hip. Now these views, we talked about the obliterated views and the oblique view. If you remember, it was the obturator view which show that the anterior column and the posterior wall. So even though this fracture was reduced, you can still see the posterior wall fragment quite clearly on the obturator view.
But on the iliat view, the one after it, you can't see it clearly because it actually shows you the posterior column, not the posterior wall. So what about. What about the CT scanner? So if we look at the CT scan, if you look at the. Hip without the fracture, the one on the left. If you look these corners here, these are the columns and then the wall, we've got the anterior wall, posterior wall and the floor.
So if there is a break in the corner, that's a colon fracture is there's a break in the margins. That's a wall fracture. And you can see here that you've got to break in the margin here. So that's the exterior wall fracture and that white arrow is pointing to what we call marginal impact. So normally, the articular cartilage here would be facing the head.
But because this has been impacted by the head on its way out of the joint, it is now facing towards. The back of the acetabulum, rather than facing towards the joint. So this is marginal impact and this, we will talk about later on is one of the predictors of poor outcome.
So we've got a posterior column fracture, which, as the name might suggest, it's a fracture of the posterior column and on an X-ray is the skill line that will be disrupted. And you can see here on this iliac oblique view that you've got the disruption in the skill line. What about the ct? Remember we said this the corner that's going to be fractured on the CT scan and the CT scan here also shows you a dent in the head.
This is some impaction of the head or some femoral head damage. Again, another marker of poor prognosis. And this is the column fracture, the column fracture. Then we've got the anterior column fracture again, as the name might suggest. And where would we see it? We would see it on the obturator. Oblique view against the structure in the Iliad picked me a line.
And on the CT scan, it's the anterior margin that oh, sorry, yeah, the anterior corner of the anterior column that is going to show the fracture line. Then we've got this transverse fracture and the transverse fracture is basically one fracture line going from the front to the back of the acetabulum. That's why it's an elementary fracture, because it's one fracture line.
That fracture breaks the anterior wall. The anterior column. The medial wall. The posterior column. And the posterior wall. So it goes through the whole of the acetabulum. But it is one fracture line. So that might be some confusion. Maybe a, you know, something that could be mentioned in the MCU if this an elementary or is this a associated that is an elementary because it is one fracture line and it could be further divided according to its location, but that's not something at first sort of level.
If you look at the X ray, you're going to find the disruption in all of the lines. We drew the epicondyle, the IL axilo, the anterior wall, the posterior wall, but it remains one fracture line, cutting the limb into two, 1 topic and one lower bit. On the CT scan, what would you expect to see? Well, it's not in the column, it's not in the wall, but it is one fracture line passing through all of them from front to back.
So we would expect a line going from front to back here. Of course, you know, a fracture is never a straight line, it's always an irregular line. So when you actually look at the ct, you will see something like this one line going from front to back. That's a transverse fracture of the acetabulum. So then we come to the Associated fractures, which is where it gets a bit complex.
So it's basically combining these fractures together. We've got a transverse posterior wall, so we already know that transverse fracture is it's one going from front to back. So it is the same, but we add to it a posterior wall. So if you look at the lines, you will find all the lines disrupted. But on the obturator oblique view where you can see the obturator frame.
And you can see a disruption of the picture in your line because we know the anterior column is broken and you can see this here, which is the posterior wall fragment broken off. What about the t fracture, a PT fracture is another variant of the transverse, so again, one fracture line from front to back. But there is a fracture propagating downwards.
That fracture propagating downwards goes all the way down to the pubic bone, and thus it separates that transverse into a front between a posterior bit. So it's a t fracture, so you would expect on the X-ray for it to look like a transverse fracture, one fracture line going from front to back. But there is an additional fracture here in the pubic bone.
So by definition, again, another point maybe for the mk is what is the definition of a PT fracture? Well, it's a time for fracture, plus a fracture in the pubic bone. So that is your main fractured line, and that's the pubic fracture. Of course, this pubic fracture is propagating from up all the way down to the bottom, but you won't see that propagation on the X-ray.
You will be able to see it on a CT scan. So on a CT scan, it will have fracture going from front to back and one transverse downwards to the pubic bone. What about the procedure, war, procedure and procedure? Well, again, a procedure called and fracture, which we can see on the élue skill line being disrupted, plus a posterior wall fracture. We could see on the outer edge of being separated.
And you can see here how the head is dislocated or. So on a CT scan, if you sort of might have already noticed by now that on a CT scan, you've got your transverse fracture going from front to back, you've got your colon fractures going from medial to lateral. It come to the big guy here, which is the both colon fracture, both colon fractures, as the name might suggest, you've got a fracture of the anterior column and the posterior core.
But it's not only that the main hallmark of the colon fracture is that the dome or the acetabulum is no longer connected to an intact part of the ilium or no longer connected to the ideal skeleton. Again, this is another sort of MCU question. So by definition, both call and fracture is the fracture of both columns of the acid pattern, where the dome or the acetabulum is floating or is no longer connected to the rest of the axial skeleton.
And if you look at this x-ray, it might look confusing. But if you take it one step at a time, you'll notice that the pictorial line is disrupted. You'll notice that the kill line is disrupted, so we have both columns here broken off. And if you look at what's going on the ilium, you can see fractures basically everywhere here in the alien. And if you trace these fractures, you'll notice that the acetabulum or the dome is no longer connected to the rest of the axial skeleton.
So by definition, again, this is the skull and fracture. To complicate things a bit more, there's the anterior column posterior hemi transverse. From my point of view of what I've experienced from the farke's sort of scenario, I wouldn't really worry about this fracture. It's sort of the both columns little sister. If you could say the main difference really between this fracture.
And the skull and fracture is you can see that part of the dome is still connected with the rest of the axial skeleton. So it's multiple skull and fracture. It will be very difficult to differentiate in an exam scenario, whether this is a both column or whether this is an anterior column transverse without having a CT three dimension. So I wouldn't really worry about this fracture.
And particularly its treatment principles are more or less the same as both colon fracture. So if we can get all of this information just by looking at X rays, then why do we do CT scans then? And that is another possible virus or question why? Why, why bother? If you given me the whole, the whole classification just from the X ray?
Well, you can find loose bodies on the CT scan ignoring these loose bodies, you would not have a congruent and you would get early arthritis. You would miss out on articular impaction, which you have to deal with and have to reduce during your surgery again would impact your reduction and your outcome you would miss on femoral head damage. There might not be a lot you can do about femoral head damage during surgery, but it is a poor predictor of prognosis.
Maybe if you've got femoral head damage in a more elderly patient, you might consider a hip replacement straight away. And it helps, of course, in surgical planning, particularly the 3D CT scans. Now what I want to do now is I want to take this a bit from being a boring lecture to you trying to make sense of this. Now I know that if any of you are presented with these X-rays in the exam, they won't rush to the classification.
They would say this is an acetabular fracture, this is a high energy injury. I would treat him. According to atlas, we associated injuries, trauma CT can mention your concerns and so on, and so and so, but you then might be probed into commenting on this fracture. And I just want someone who would volunteer just with me. We'll try to go step by step.
I'll be guiding you so I'm not grilling you anything. What what line is, do you think are sort of disrupted here? And what do you think this type of fracture is? You are not expected to know everything from a plane next, right? But you are expected to look smart in the exam if you ask this question. So if doula or someone would help me serve anyone, if they would raise their hand.
So Mohammad Ansari has volunteered for this and he's unmuted. OK, Mohammed, are you with me? Yeah, I'm here. OK, Mohammadi, what do you think? What do you think about the ilium AM line here? And you epicondyle is disrupted here. You have killed and you also disrupted. Yeah so by definition, both columns are broken.
OK yes, that's correct. So both call them are fractured. So what? What, what? What fractures have both columns involved in them? Our cost structure. Yeah and if I say there is no pubic bone fracture, so I can say that this is not the fracture. And then the dome is attached to the oleic bone.
So it is not both column fracture, it looks like a fracture to me. OK, also fracture. Sorry, can you say again? It looks like transverse fracture to me? Yes, perfect. That's very well done. I mean, what? What what Muhammad did was very smart.
So he looked at the kill line disrupted. Ilia epicondyle line disrupted. So he thought of an algorithm in his mind, which we'll talk about later. It isn't clear there is a very there might be here, a very small pubic bone fracture here. Yeah so so this is a t, but let's look at the X-ray again, and let's look at these lines. So we've got picture in your line disrupted.
We've got the kill line disrupted, we've got the anterior wall disrupted and we've got the procedure world disrupted. We've got everything disrupted and we have one fracture line going from back to front. So if you've got the anterior column and the posterior column, both of them disrupted, you basically have four possibilities, which is what Muhammad just pointed out.
It could be a both column fractures, but the dome is still attached to the axial skeleton, so it's not a bone skull fracture. It could be a transverse fracture, which is one fracture line going through all of the acetabulum from front to back, which looks like it is the case. But before committing to saying this is a transverse fracture. Look at the pubic bone.
If that's fracture, then it is a t. This X-ray in particular. Here might not be that clear. It showed more on the CT scan, but yes, this is a t. No one's going to blame you in the exam if you don't see it and you say this is a transverse fracture. All you have is a plain X-ray and look at the amount of information you have given the examiner by now. And I think that's what you need to for the FRC as.
Yes, it could be an anterior composition transverse. It's not in this case, but I would put these as the last of my differentials for the first year. If you look at the CT scan, it's looking more like a transverse from front to back, but when you really concentrate, there is a small fracture line there and that's why it's a PT fracture.
But these, whether this is a T or this is transverse, we're talking at a very high level of sophistication and very high level of of, you can say, academic purposes. So I think that's the perfect answer. Thank you. I'm OK. If someone would like to have a go on, this one is Al go now. And I am going to mute him. You go.
I will go ahead. Can you hear me? Yes, reed, I'm good. So do you want to start with you? What do you think about the epicondyle line here? The Victoria line is disrupted as well as the elevated coal mine. Yes however, it is minimal disruption in minimal, very minimal place.
I agree. So you've got picked in the airline disrupted so so the way you would talk about it, you picked an airline donating a fracture in the anterior column. I've got the key line detecting a fracture in the posterior column. So what are you thinking now that you've got two columns disrupted?
So either both column or a T or a transverse microfracture or an entire column posterior transverse? Yeah if we look to the obturator from, we will find it is intact all through. So we exclude the t fracture. And if we look to the Dome of the establishment, is it still connected to the axial skeleton, so we exclude both and fracture. If we look to the continuation of the inferior part of the few people claim us, we will find that there was still a hole.
Is intact, so I suspect it is transverse transversal fracture. Yes, and I agree with your assessment. You've got the earlier picture the airline disrupted. You've got the kill line disrupted, you've got the posterior world disrupted, anterior wall disrupted. You've got basically one fracture line going from top to bottom, though, is still attached to the exoskeleton.
No fracture in the pubic bone. And I think this is a transverse fracture. If you look at the oblique views here again, this is the iliac oblique view where you see the issue is kill line and you can see that it is disrupted posterior column and you see the epicondyle line here on the op. The view again disrupted and as Muhammad lady said, it's minimal disruption.
You won't be going into all of these details in the Fox. This is probably where Muhammad stop. This is where you will be getting scoring a seven or eight in the exam, and that's as far as you can go. They can then suggest what sort of treatment you might suggest for the patient. Um, OK.
Third case, if anyone else wants to have a go, we have a Nishant and I will free him in a second. You go. Yes OK, listen, hi, can you hear me? So in this structure, the idea seems to be. And so look at your lines, so you've got your picture in your line, your ill, you ask your line, do you have any worries about these lines?
No so are you in line? Looks intact? Yeah you see a line again seems to be intact. OK what about the walls? So the Anfield wall, I can't see very clearly, but it seems to be disrupted and austere. Will definitely is disrupted. Definitely disrupted. OK what about the main sort of striking feature on the X ray?
And it looks like an idyllic view, and I think the joint is not congruent, so it is definitely subluxation. Exactly, exactly. So this then will take us back to. So so that's another point, and thank you for pointing that out. Yes, it's very wise to mention this, but don't always try to point out the obvious before you get into the detail.
So the obvious here is, is you've got the dislocation. So to point that out, and then if you want to look smart and say that this is an isolated posterior wall fracture because the rest of the lines seem to be intact, then do so. And then this will probably then lead to your sort of emergency management, which we sort of mentioned so that you need to reduce this, how you're going to reduce it, whether it's going to be in A&E. We said we're going to do it in the theater setting under with muscle relaxation.
We're going to document the neurovascular stages before and after. We're going to comment on the stability and we're going to put the patient interaction ideally skeletal traction after the reduction. OK, thank you. This was an easy one, do you want to do one? The next case also.
And Allen Nishant to do the next case. Well, I'll just go through this, so this is again, so this is the one we were just having a look at. You can see on the obturator view how obvious that posterior wall fracture is. And you can then see on the CT scan, you can see the combination, you can see that the marginal impaction or the articular impaction.
So just by looking at this, you would say that definitely a poor prognosis here. OK what a to go through this. So on this view, the tactical line the idea is to align is both a disruptive so and positive column, both fracture, then the central dislocation. So this on the posterior wall, the entry of all.
Both are disrupted, so central fracture dislocation involving both the columns. Yep what do you think, I mean, now that you have I mean, you mentioned the obvious, which is very good, you've got central dislocation and and you've got all of the lines disrupted. And what about the pubic bone? So the yes, the inferior peel-back RMI is fractured.
And the dome is still attached to the axilo skeleton. So this t-shaped structure? Exactly so that's perfect. So this is a t-shaped fracture with central dislocation. And of course, there are concerns here is about that dislocation, about associated sort of pelvic injuries and about the articular cartilage being exposed and being in contact direct contact with the edge of the bone.
You want to take this to theaters, you want to put a pin on it. You want to reduce this as your emergency management. That's perfect. Thank you. So again, the ilyushin new Pixel line was disrupted. Elu line was disrupted by a wall and to your wall all was disrupted. We had one fracture line going from top to bottom.
But before committing to saying it's a transverse, we have to look at the pubic bone and that gave it away as being a t fracture. Looking at the oblique views, you would then appreciate that on the up to rate, review. If you remember, the update review is where you will see the anterior column in the New line that's disrupted. We see the posterior wall, which is also fractured.
Then on the iliac oblique, you see the posterior column, which is fractured and you see the anterior wall. At the CT scan, OK, who's next? It's Joe. No, I will mute him now. OK hi, Joe.
Hello you hear me now. Yes, I can. OK so what are your thoughts? And just radiological assessment. We're not going to go through the classic answer yet. OK, so this. So the initial line, this is disrupted, the EU official line is disrupted as well. The but so that the pubic remains the curator forum.
I can see that the inferior pubic, the inferior people carrying this might be fractured. I'm not sure, but it seems that it's not congruent. oh, sorry. I would try to do that doom is not connected to the iliac bone. So I think that supposed skull fracture. And you know, this is probably the most complex fracture that you can get to the exam in 20 seconds or so.
You manage to identify that this was, yeah, because it's much easier than you might think. You've got a line disrupted in your line, disrupted. The dome is not disrupted, so it's both called Allen fracture. And then if you look at the obliques, you won't get the objects in the exam. I doubt, really, but you've got this is an idyllic view showing the yeah, the view showing the individual line disruption.
So the posterior column is disrupted and the anterior wall disrupted. Allen and this is the opportunity review showing the alien alone disrupted to recall them disrupted and the posterior and the posterior wall disrupted as well. There's a sign here. I don't know if you've heard of a sign. Exactly so what is the sign?
So because the acetabulum is no longer connected to the axilo skeleton, when you get this oblique view or lateral view. The acetabulum or the ilium remains intact and you can see that the rest of the acetabulum has moved in. Exactly so then you see the spirit of the Iliad. And that's another key question there. This is the first sign. OK OK, thank you.
Thank you, John. Thank you. Yeah so if you look at the CT scan, you can see that you can see that what Joe is doing, it's just not attached anymore to the axilo skeleton throughout all of the images, it's disrupted there. And yeah, basically, you know, one of the things you know, we used to say, when is this a both going fracture?
There's a fracture everywhere in the columns and the walls, everything's broken. So you can see here on the CT three d, how the alien here is no longer attached to the rest of the pelvis. OK, who's next? Next is ATF. But if you go.
So, yes, can you hear me? Yes so this is an APD bill from the pelvis, which shows a disruption in the medial epicondyle line, which is the rentier called fracture. I think the line is intact. Perfect yeah, there's a fracture in the pubis. Yeah, and. The dome seems to be intact as well. I can't see any fractures.
I agree. The entire column, the entire story, the entire wall of the empty and the posterior wall. I think there's a fracture in the entire world, but not the posterior. Yeah, I mean, I agree there are these fracture lines which you and that's, you know, that's how trauma is. Nothing is classic, but but you went through them perfect you.
You manage to see that illness kill line, which a lot might think is disrupted, but it's actually there. If you follow the right line, it's going up, up, up there and it's actually intact. And what is broken is the epicondyle line. It's the anterior column here that's broken the posterior wall. Yes, there is some combination, but overall it and from the CT scan, which we will be able to get more information from, it turned out to be intact and the dome was intact, as you mentioned.
And then here on the look at and to get more of that the posterior column, this is an iliac view. And can you see the posterior column here? Yeah, Yeah. So see your column is there and it is intact, as you said. And then if you go to the theater review. Now you can have a better look at that posterior wall and what do you think about that procedure will there? Still looks to be, in fact, I can't see any future exactly the anterior column.
We know it's broken ilia epicondyle line, but the wall looks intact. So basically, you know, the main what's the main fracture that sort of survived the three piece? So it's a posterior column fracture. I mean, you mean a Yeah, exactly. It's an anterior column fracture. Oh, thank you. That was very good.
Look, this is the last one, I think, OK, seven. School next. Hello yeah, that's hi, yes, good. So do you want to start? Yes this is after pelvis, which I think there is a disruption of the line, but the initial line is intact.
OK this is a very tricky one. I agree. So let's trace the picked in the line. So that's that there. That's the picture in your line. There, there, there. There it is broken. What about the earlier SQL if we start from the top of the inferior chromosome following?
Where does that leave, all right? Yeah, yeah, it's intact. There so so if usually the kill line would not with be attached back here, so actually it's broken, but from the top, it's quite deceiving because it looks like as if it's actually attached to this bone here, but it shouldn't be attached to the front of the sacrum. It's actually this place.
So so that's the area picked in the air and that's the alias kill and the broken on the top. It is quite deceiving. I agree. But it is. It is broken. That should be that should be all the way back attached to the ilium there. OK Yeah.
But again, this is only an X ray, and you can only get that much information, but what do you think? OK, so both columns are fractured. What do you think about the Dome now? Matt, I think the dome dome is attached to the axilo or to the alien, and it is a poor quality X ray, but if there is something happening there, but again, you can't just see because of the X ray, but there is, there is something.
There and and there, so there is a suspicion that this is disrupted from the axilo. I know it's not the perfect X-ray. And I think what you need to do in the exam is you demonstrate that, you know, you have that ability to comment on the lines, you have the differentials in your head and it's only a CT scan that will confirm whether this fragment, we see here is a fracture in the ilium or not, which which here.
So this is the posterior column you can see on the iliac view. Is it clear now how that is disrupted? Yes Yes. Yeah, so that should be reduced all the way back here to the acetabulum, but it's disrupted and it's actually quite displaced. So this is the iliac view showing the kill line disrupted and the anterior wall, and this is the. Up to rate review, Yes.
Yeah, and that's the epicondyle line disrupted, and if you remember, we mentioned this sign. Yes, Yes. So it is both columns fracture with the domed displaced. So it is a two column structure. Yes, exactly. Thank you. Thanks a lot. Thank you.
So I think, you know, as you can see, this is the CT scan and you can see here how it is separated from the rest of the skeleton and you are not going to be expected to be able to classify just by looking at a quick X-ray in the exam. But you just have to be able, if probe to demonstrate that, you know, the principles of the fracture, the principles of the classification.
What's the difference between this, the anterior both call and fracture and a transverse fracture? It might sound quite difficult if you're trying to just learn it by heart. Oh, and anterior column is defined as so and so. But once you get the understanding of it, it it actually makes a lot of sense, really. And I think that's why I enjoy the kind of subject fractures anyways.
So these are the fractures. Next, we need to know how to treat them. Well, I mean, I'm not going to go through any indications of treatment. And so on and indications of surgical management. These are articular fractures and in young, active, healthy individuals, you would aim for anatomic reduction. Yes, you know, I'm displaced. Fractures will be treated intraoperatively with non weight bearing and early range of motion.
And so on. So but let's cut straight to the point and what approaches are we going to do we have with this table? And this is another sort of tricky bit, another reason why people don't enjoy acetabular fractures that much. We've got a lot of approaches. So we can divide them into sort of categories. You've got the anterior approaches, which include the earlier inguinal and the pelvic.
The intra pelvic is known by a lot as the modified stopper or the stop approach in pelvic terms, or they prefer the term intra pelvic approach rather than the stopper. We've got the posterior approaches, which is mainly the pick. You can add to it that you can flip to get more exposure. You've got combined approaches, so fractures that need to be tackled in front and back.
You could combine the earlier inguinal with the copper line or the pelvic with the kokilaben pick and so on. You've got external style approaches like the extended femoral not commonly used, mainly for sort of neglected old fractures and so on. And not really one of the question points in the first exam.
How do we choose the approach well? There's a lot of details that can go into this, but generally speaking, a fractures you treat with anterior approaches, posterior fractures, the treatment approaches and then there are some exceptions and so on. So what are the anterior fractures? The anterior column fracture is treated with an amateur approach, whether it's the pelvic or the new inguinal both colon fractures, it's mainly anterior.
If you remember, the ilium was disrupted from the rest of the dome was disrupted from the rest of the acetabulum. So your main goal and where you will start treatment would be restoring the continuity of the acetabulum. So that you have to go to the front. You have to go anteriorly for that anterior hemi transverse fracture, which is sort of the. Has a lot of characteristics in common with both call and fracture again treated with an anterior approach.
You've got the posterior approach for the posterior wall, for a posterior column and a transverse posterior wall because it has a posterior role in it. What about the transverse if you just have a transverse? If you remember, we said the transverse is actually one fracture line passing from front to back, so we're actually treating one fracture. And most surgeons would then start posterior and fix and reduce and fix it through a posterior approach.
But every fracture has its character, and if they feel that the displacement is more anterior than posterior, they might choose to go anterior. So they're there. The general consensus is posterior unless the fracture dictates otherwise. A t is a transverse fracture again split into two. So you remember you have the one fracture line from front to back and you have the fracture line going down to the pubic bone.
So you now have two fractures. Usually you see where the displacement is it front or back? And you start with the more displaced column? Posterior approach for the acetabulum, so we all the concrete and brick approach for a total hip replacement. And here are the common question in the efforts.
Yes, is how is that different? So if you are treating a procedural fracture, how is what changes are you going to do in your approach to? To that of a total hip replacement, the main difference between the total hip replacement and the steel wall fracture is that in the posterior wall microfracture or in an acetabular fracture, we are still concerned about the blood supply.
So we don't want to compromise the blood supply. So the differences are all related to that fact. So the piriformis and the conjoined tendon of the rotator instead of cutting it flush with the bone, usually with a total hip replacement, you'd want to cut it straight on the bone so you can reattach it to the bone. You can't do that with a acetabular fracture. You want to leave at least a centimeter of tissue near the insertion y because you want to preserve the ascending branch of the medial circumflex vessel, which passes in that region.
So you want to stay away from it because you want to preserve the blood supply for the same reason you want to preserve the quadrature femoral muscle, which a lot of us just cut in the hip replacement, the glute max. However, most surgeons would cut the glute max because they get better exposure, and there is no worry about any blood supply coming from the good max. So that's the main difference that could be sort of a vyver question or an mq one.
OK, then we synthetic flip and believe it or not, I mean, I was asked in my first year about the clip, which I was happy to be asked about Eric slap because, you know, that's my main sort of area of interest. But I was surprised that I was asked about it in the exam. But it's basically it's a osteotomy of the country, and I'm not going to go into the details. It could be a biplanar it could be a trip later or tenotomy. The idea is that with the posterior wall you could with a posterior approach, with the cockpit language, you would get more exposure of some of the anterior wall and the anterior column without having to do a separate anterior incision.
One of. And this is part of the surgical dislocation of the hip. So the next step after that is to divide the capsule into that shape manner and to dislocate the hip, safe surgical dislocation of the hip. One of the approaches you will need to revise for your basic science or before you or either other could be added pathology or could be trauma via.
A approaches, so we've got two main anterior approaches to inguinal, and the pelvic won't be able to go through the details again today, but the idea of the ilioinguinal is that it is Windows. You have first window, you have a second window and you have a third window. The first window is the window you usually do like for a bone graft. The second window is between the vessels and the Elisabeth's muscle, and then the third window is medial to the vessels between it and between the conjoined tendon.
And maybe the main problem with this exposure was that you see the fracture in windows, you don't see it all in one go. It's a bit of a complex approach you have to dissect on the vessel. You have to dissect on this dramatic then and and it's considered to be probably one of the challenging approaches in trauma surgery. And thus a lot of people have now shifted to the anterior intra pelvic approach or the modified stop approach, which is a fancy incision.
You go between the two rectum muscles and you don't sit on the extraperitoneal on the inner surface of the pelvis. Are there differences between in terms of which approach do I choose between the anterior pelvic and the earlier inguinal? Technically speaking, yes, there are certain fractures which may be amenable to one approach over the other, but it usually comes down to surgeon preferences.
We've got surgeons who are mainly inguinal surgeons, which will treat any fractures with a New England approach, and we've got surgeons which will do intra pelvic approaches for all of their fractures. I've met surgeons in sort of these pelvic courses where they haven't done a new inguinal for 15 or 20 years, so it's a surgical choice rather than a. Any particular indication of 1 over the other? Outcomes and these may be, you know, ask more in the MCU setting, but we mentioned a lot of these outcomes while going through the lecture today.
The main prediction of outcome in pelvic novel and pelvic but in acetabular fracture is the quality of reduction. And if any of you are familiar with the work by matter where he classified the reduction based on the post operative radiographs into anatomical reduction, where you reduced within 1 millimeter of anatomical position to imperfect, which is 1, 2, 3 millimeters of displacement and poor, which is less than, sorry, more than 3 millimeters of displacement.
And they demonstrated that. The outcome depends mainly on the reduction, of course, there are other factors we mentioned the fracture type and this might be a bit surprising, but a lot would think that a fracture like the both and fracture would have a worse prognosis. That actually is the both call and fracture has a better prognosis than a lot of the other acetabular fractures, particularly more than the posterior wall fracture, the both colon fracture because the whole acetabulum shifts together.
So it has this concept called secondary gravity. If you remember, we said that the acetabulum is floating its floating, but it's sort of floating together. That's the idea of secondary gravity that happens in these both column fractures, where the posterior wall fracture, as simple as it might sound, is associated with hip dislocation. So that's even associated with marginal infection with combination.
So cerebral fracture would have much worse outcomes than both current fracture. And I think I remember I got also that in my MS q exam asking about which fracture has the worst prognosis. Fracture pattern goes without saying the more common utilities, the more articular impaction there is, then the worse the fracture is articular impaction. You find it in the posterior wall fractures and in the dome, so the dome itself could also be impacted.
You could appreciate that on a CT scan rather than an X-ray. Patient age also plays a role, and we talked about these geriatric acetabular fractures are a totally different group of fractures and not to be confused with them. It won't really matter if what. What matters is MDT input is the patient fit for surgery. Can we get him up and moving? Shall we think of fixation with this patient?
Tolerate fixation and protected weight bearing for a while or non weight bearing for a while? Or with this patient need to go straight for a hip replacement. So we can get them up and moving as quickly as possible. The latest surgery more than three weeks is considered also to be one of the poor outcomes. We're fortunate here in the UK that's not a common thing, but in other where, other, where other places it is a common problem.
Complications, I mean, number one is arthritis in numbers could vary between 20% and some studies saying 40% again depends on the quality of reduction. Even more common with posterior wall fractures and dislocations sciatic nerve injury. But and here is another sort of a bit where they ask about the different anatomical variations of the or you could ask them the vivo.
If you talk about the complications, what are the different anatomical variations of this articular vtm? And this is a very important point because there I have witnessed driver scenarios about acetabular fractures being shifted all the way from that to a VTE scenario. Most major trauma centers would have a VTE protocol for dealing with these fractures.
Where I did my fellowship in Bristol, they used to do preoperative duplex screenings for these patients. They used to do post-operative duplex scanning for five days or before discharge. And they used to put them on enoxaparin for 28 days. Different hospitals have different protocols. Different major trauma centers have different protocols. It's important that you're aware of this.
It is a problem with pelvic and establish fractures. It's a major cause of morbidity and mortality in these fractures. You should be aware of the protocol in case you are in case. The vyver then shifts from being a acetabular fracture towards being a sort of five h o, and it's as we would expect, it's more common with the extent soil approaches and the posterior approach.
So surprisingly, it's not common with the inguinal or the pelvic, but it is common with the posterior approach. Again, this is another sort of vyver thing about the evidence of using anti-inflammatories, the evidence of using radiation to as a prophylaxis on this show. And I think some centers here in the UK and I think as far as I am aware that don't want to name the center 100% sure they do for posterior approaches, they do give routine low dose radiation to the patients to for prophylaxis against each other.
OK, I think I've covered the things I want to cover and I hope that I made this a bit more easier. And thank you. Thank you very much, will it? It was thorough yet interesting and exciting, and I think everyone enjoyed listening to you. I certainly did. I'll leave you to have a cup of a glass of water while we prepare the questions.
While we talk about that, guys, if you are interested in the Viva, I'm not sure we have enough time to ask many of you. But if you do, please mention that to us. You know about the upcoming Viva course is I think we might still have one or two places left. If you are interested, please let us know and we will try and book your place. In fact, you go to the Link N you book yourself.
Thirdly for the lecture, you know that this will be on YouTube as soon as we can, we will put it on YouTube for you guys. I think it deserves a second and maybe a third listen while looking at different X-rays to try and work it out for yourself. And kudos to all those who volunteered for the interactive part. I think you've probably secured to learning than anyone who was just sitting there and listening.
Fine so. Market Minute we will be talking about the questions. For that, we will come to other members who will be joining us for the Viva. We've got Saab and avid who will be doing some of the questions for that. Stratus has asked is there a possibility that you could go through a choice of surgical approaches? Briefly, you've mentioned that and when it comes down to surgical management, it next is, kasunod said about central dislocation.
Will we apply lateral skeletal traction as primary measure or just linear traction? No, I think I think I mean, originally, when this was the main method of management, I mean, speaking to some of my senior colleagues when they were treating these non operatively, they did use lateral traction. But that's not what we do now. We just this is a temporary measure that you do it for 2848 hours until the patient is stabilized.
So just skeletal traction, the standard above the knee and you put to wait until you feel that the head is no longer in contact with the edge of the bone until you refer for defensive management. So let's take that step by step, because this could be a juicy question for the exam. OK if that is the case, then any surgeon should know how to apply it. Can you take us through it in more detail?
So how much? Where do you put the pins? How much weight do you put? How long do you leave that for? And is there any special thing to put for the pain itself? Like, I care. So, so number one, this is, of course, done ideally in theaters. It is done under a jar.
In extreme cases, you could argue it could be done locally, but for examined for, for the right answer. This is done under j. This is done under fluoroscopic guidance. The traction pin is put at the distal femur above the femoral controls and this is another bit and you need to check its insertion with the fluoroscopy. The main problem with these pins is that if you put them too close to the joint, you can cause a fracture in the distal femur.
If you put them on the condyle, you will be disrupting the knee joint. Remember the attachments of the knee capsule, so the knee capsule goes around the combo. So if you go into the condoles, you're potentially. Compromising the knee joint itself, so you want to go on the distal femur, that's and then another sort of question is do you go from medial to lateral or do you go from lateral to medial?
Well, because we're worried about the vessels immediately. So you do your small incision immediately. You you put in an instrument and go through the muscles. You go from medial to lateral because if you're worried about something immediately, you don't go blindly through it and then you, you start with as low as you can. You put two kilos to begin with. You could put three.
You keep on adding them until you feel that you have dislodged the head of the femur from the edges of the bone and monitor the patient afterwards. And yeah, and that's it. OK just a follow on question. ATF was asking what if the dislocation doesn't reduce with skeletal traction? So the central dislocation you don't want to reduce it, you might not be able to get it out of the pelvis.
You want to impact it from the bone. You just don't want that articular cartilage to be in contact with rough edges in the fracture. So you don't compromise the cartilage, but you might not be able to bring it back to where it normally was. Excellent. Thank you very much. That was very clear.
Omar is asking, if possible, some explanation of that. So protectable. Just traject all fractures and the significance of identifying them. Yeah so something that we need to know about for the exam. No, I don't think you need. These are the variants of the transverse fractures. And yes, the higher you you go, the more challenging it could be and the different approaches you can use.
That's very technical. And that's not definitely not. Let's let's leave it there then, and let's confuse. I mean, it's a big topic. One was asking, can you elaborate on the secondary congruence and roof arc angles? So you mentioned something about the secondary congruence. Would you like to talk about the angle sort of arc angles so the roof angles?
Again, it's not in the scope of the effort, it's angles. It's basically measuring the displacement of the roof on the three views the AP and the iliac and oblique and therefore sort of outcome purposes to look at the different fractures and the different outcomes. It's beyond definitely the scope of the exam. The secondary congruence? Yes, it's not, might not be asked directly in the exam, but that is the reason why both column fractures might have better prognosis than other fractures is because although the fracture is displaced as a whole, yet it is congruent, so it is a secondary congruent.
The joint is disrupted, but as they hold the head with the fracture becomes congruent on its own away from the rest of the axial skeleton. Yeah, as in the articular surface itself is separated from everything, but it is intact to itself. Yes, exactly. OK, now some Sarma was asking about the acetabular angle and how to measure it.
I think the best thing forward for that is to see how it is done on a picture rather than someone talking about it, because it's difficult demonstrate. I mean, we've done it and done it on studies, but these are it's because now we don't use plain x-rays to look at outcomes. We use CT scans, so it's becoming a very academic thing. It was described by matter in the early 90s.
It's a very specialized thing when you're comparing outcomes between different fractures. I have not heard of anyone being asked about it, either in the MCU or in the vyver. And I highly doubt this is even relevant now to modern debate up there that Ahmed was asking in which type of fracture? You may have secondary congruence. You've mentioned that and very, and was asking what sort of indications for percutaneous colon screws?
Yeah, so. So again, you know, surgical details, they could go on forever. But if you remember, like when we mentioned the transverse and the t, we said with you, you could start with a t fracture, you start with the one column, which is more displaced. So let's say in a t fracture, the anterior column is more displaced.
You fix it with open surgery and then you might fix the posterior column, percutaneous the. And that goes with any fracture you could do about colon fracture, where you reduce the anterior column and affix it to the plate, and then you could do the posterior column. You remember that fracture we had when I think it goes where the WHO said the fracture is minimally displaced, a fracture like that.
You could argue someone could try percutaneous knee fixing it again, you know, a bit too advanced, I think, for the fix. I don't think we'll go into how you will fix it and what's your choice of implant? Would you do it percutaneous? That's it's just beyond the scope of the effort. Yes thank you very much. Sorry not something consulting. Absolutely absolutely.
Guys your basis? Well, make sure that there are no holes in the things that will fail you. I'm not saying these questions shouldn't be asked. I'm glad you are asking them. It shows that you are interested and you've learnt a lot from this topic. But the idea is to try and make sure that all the bases is covered across the curriculum before you go to the next level.
I'm saying this for people who are shocked by these questions, they feel, Oh god, is this important or I don't know these. I'm going to fail. No cover the base as well. And then talk about these if you have time. First question is from Mohammed says with the availability of the city, do we need the due date views as well?
And I think this is the biggest debate we have between pelvic surgeons and DG hatches all over the country. I believe wherever I go, this is the question we send the patient to the pelvic team and they always insist on having a do views. And the argument locally is, guys, you are going to have a seat. We provided you with a three dimensional CT.
Why do you still want a juday? I think I think, yeah, I mean, it's not a question that would be awesome, but just for your knowledge. The reason is when you are reducing the fracture during the surgery, you don't use a CT scan during the surgery. Do you use your AP and oblique views? So if you have your preoperative on screen with your juday views and you want to see if you've actually managed to reduce that fracture, you want to see where that fracture is, you're going to compare it with the juday views.
You're not going to be comparing it to the CT. It's the same concept when you're an orthopedic registrar and the radiologist tells you you have a city of the tibial plateau fracture. Why do you need an x-ray? You know, it's the same concept. Well, I have a ct, which gives me all the details, but I still want an X-ray because when I operate, that will be my reference.
Not the city. Absolutely And I'm going to throw away a little controversy for you. What's your take on primary AF capacity in established practice? Yes so so that's very good. And that's I mean, I did want to try to fit this in the lecture, but then I felt it was a bit too much. But with the increase of the geriatric acetabular fractures, there is a huge role now for it, and there's talk about what we call a fix and replace, whereas you stabilize the columns without aiming for anatomic reduction.
So it's a much less morbid surgery and then eight-year-old or so ever, and you just want to get him up and moving you. You put a plate on the anterior column just to get some stability. And then you put the total hip replacement in and you put the fix it. Whereas if you put Luzon all over the socket and you allow early mobilization, the study from St George's, they compared doing them acutely during these total hip replacements acutely versus trying to fix it and then coming back in six months or so and doing the replacement.
Then they found that it was double the infection rate if you did it in a two stage procedure. So if you think that the patient is not going to do well with just a fixation, it is much less morbidity to do an acute total hip replacement rather than a delayed tooth replacement. So is there a study at the moment going on there? Yeah yes, there is. There was a randomized that unfortunately I had left Bristol by then, but it's part of them.
They're doing a multicenter studies between acute hip replacement versus fixation in the geriatric population. I'm not aware of the details. There is also talk about using the cone implant. So instead of even having to think about fixing the cones, just putting the cone into the ilium, and that was a study on that in the BMJ last year, I think from Northern Ireland and it just they had very good outcomes again, very quick sort of procedure to get the patients up and moving again.
It's a totally different category of patient and don't get caught off in the vyver at all. I haven't heard of anyone yet being questioned about the geriatric acetabular fracture in avivah, but with the numbers increasing, that might be a topic in the virus, asked major trauma centers. I think this is probably a valid question, as they may not expect you to know the answer, but to know that that's an option for the geriatric population.
I agree. Excellent well, this was an excellent talk. Excellent questions from the audience. Very informative. I really enjoyed that and I will be stopping the recording now.

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