Cadmore media player playing video Acetabular Fractures for Postgraduate Orthopaedic Exams
Video Player
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the video. Pressing escape will close all displays and pressing it again will jump to the end of the player.
You can press A to open the Keyboard Shortcut Dialog which also provides an audio description of the player and all of its features.
Language
1x
Play Speed
Adjust Volume
Transcript
Search
Result Count
of
Click to jump to result
Search
Re-center
Segments
Result Count
of
Click to jump to result
Search
Name:
Acetabular Fractures for Postgraduate Orthopaedic Exams
Description:
Acetabular Fractures for Postgraduate Orthopaedic Exams
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/8b290dda-27ae-4924-9d72-83f7fc7d64d2/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H35M12S
Embed URL:
https://stream.cadmore.media/player/8b290dda-27ae-4924-9d72-83f7fc7d64d2
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/8b290dda-27ae-4924-9d72-83f7fc7d64d2/Acetabular Fractures for Postgraduate Orthopaedic Exams.mp4?sv=2019-02-02&sr=c&sig=0UPFKZIdjGHfIRFow9nfxuFvLlmwa%2FQfnUORBfWtVqk%3D&st=2024-11-21T17%3A41%3A06Z&se=2024-11-21T19%3A46%3A06Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
Use today, Mrs. Homa Arshad, to present a talk about acetabular fractures for the FRCS, and this will be in the combined session between the FRCS mentor group and ORUK.
Mrs. Arshad is a consultant of the pelvis in the lower limb provision arthroplasty, as well as surgeon and the clinical lead at the Royal London Hospital. We will start with the lecture, followed by any questions you want to ask. Please do by writing in the chat box and I will ask Mrs. Arshad at the end. Also, we will have these questions answered off just after the lecture.
After that, we will go for the MSCI poll and the answer to that is anonymous. So please participate in the Q&A after that will have a very interesting vyver practice, which will be not recorded. Then the closure to further things that I want to recommend is the concise, orthopedic notes, which is a very important provision notes for the FRC.
It helped me personally for the exam and the UK basic science books. Without further ado, I will please Mrs. Arshad. Can you start sharing your screen and present us the very interesting topic of acetabular as. Hi, good evening, everybody, and thank you very much for attending this webinar. I'm going to talk about acetabular fractures today with a focus on the exam and.
If you can put your questions, I tend to ask questions as we go along, but you can put more questions than answers if you like, into the chat. And we're going to have a discussion at the end. So why can't I make this work ok? So these are basically the things that I want you to get to grips with that we're going to help you with the exam to remember that when you go into the exam, you're going to be assessed as if you are a day one consultant.
And so you must be able to describe the initial management. The classification worldwide that's most widely used is the due date maternelle classification for acetabular fractures. We're going to talk briefly about approaches and then when you're discussing any clinical case to talk about prognosis is really helpful. And so imagine that you're presented with this case in the vyver.
And obviously, this is a high energy injury, and it's quite unsettling to be shown something dramatic, but they will expect you to be safe and to understand the simple aspects. And so the really important distinction is between pelvic and acetabular fractures, which are often lumped together because they're in the same part of the body. They're the same surgeons who deal with them.
But in the exam, they will expect you to distinguish between the two. So this, as you can see, if you look at the sacroiliac joints, the widening and injury of the right circle joint as compared to the left side, which looks normal and the obvious dislocated hip with the acetabular fracture. This fits into the injury pattern of a combined pelvic and acetabular fracture, which occurs in 15% of cases.
And so that is unusual. And the other features they have in common are that these patients sometimes need resuscitation. So in terms of that pelvic trauma, when it's high energy injury, these patients are frequently more frequently in need of resuscitation. And you can recognize it by the fact that there is a disruption to the synthesis. There's usually ramus fractures and disruption of the sacroiliac joints, whereas with acetabular fracture you are if your eye is drawn to the socket of the ball and socket joint of the hip and that's disrupted.
The dome is injured. The Eternals lines, which we're going to talk about or disrupted that is an acetabular fracture. And so there are some things in common but very important to make this really basic distinction between the two. And one useful way to think about it is if you're dealing with pelvic trauma and pelvic fractures, then you're aggressive.
Trauma surgeon side has to come out and you're going to use that because resuscitation of the patient is key and initial management is some case is going to save a life, whereas with acetabular fractures, the challenge is more around the anatomical reconstruction of that fracture. And so your Einstein side is more important because the challenge lies in the planning and surgery.
And so when we talk about acetabular fractures, the common principle is what the tunnel's classification is based on, and the acetabulum is considered to be represented by an anterior column and a posterior column. Imagine you are in the exam now, and we're going to talk about initial management of an acetabular fracture. You are a day one consultant at a major trauma center and in the emergency department.
In the resuscitation room, you are naturally going to be three rows back. You're not part of the normal assessing team, but you will be asked for your opinion. And so a patient who presents with a dislocated hip. What is our approach to the initial management of that patient? The first question you'll be asked in the exam is what is your approach to this patient?
And so what I would suggest is not to ask questions about it, so it's natural to think, gosh, I don't know the age of the patient, I don't know the sex of the patient, I don't know the mechanism of injury, but ask them questions will just irritate the examiners. So talk about what you can see. You can see the hip is dislocated, and the first thing to say is to recognize this is a surgical emergency.
This is a surgical emergency requiring urgent reduction of the dislocated hip. And I will start by assessing this patient, according to principles. What are you going to do next? What is the so we've got some miscues at the end to talk about that and to test your learning. But I would suggest that the most important thing at this point is once you have assessed the patient by 80 principles to examine the neurological status and the vascular status of the limb.
And then there is a need for urgent reduction and a question over where we carry that out patient is best served by urgent reduction without delay. And so that means usually in the emergency department with appropriate sedation and personnel. And as well as assessing the neurological and vascular status, what else do you need to know about this patient? So you also need to know.
You need to carry out an assessment of the limb because an attempt to close reduction, for example, in this situation would be very disappointing. And so assess the neurological status, assess the vascular status because that informs what happens immediately and what happens next and the implications of any deficit you have after a reduction maneuver and assess the whole limb and be able to describe the maneuver.
So the maneuver is a 2 person technique using counteraction, appropriate sedation, flexing the hip and knee to 90 degrees and applying traction. And this slide describes maneuvers with increasing personnel and increasingly more complicated maneuvers, which I do not recommend, so we attempt it once in the emergency department with sedation and personnel. And if that doesn't work, then we transfer the patient to theater.
Now there's a question about what if the patient has an associated acetabular fracture? So if we look at the initial X-ray of this patient? Uh, we think if we assess the whole limb that the rest of the limb is intact, but probably the most important fracture to exclude, as were. The most important fracture to exclude is a fracture of the femoral neck. And I would suggest that this imaging gives you some degree of confidence, there is no fracture of the femoral neck.
And so you can safely perform a reduction maneuver, but if in doubt, then you want to carry out a CT scan. And if you suspect an associated acetabular fracture, it's good practice to carry out a CT scan to understand what you're dealing with. And then carry out an attempt at closed reduction. So this is a different type of dislocation, the majority of dislocations occur with dashboard injuries and are opposed to dislocation.
This is an anti-hero dislocation and with a posterior of dislocation. The limb is shortened internally, rotated with an anti-air dislocation. The limb is externally rotated, and the maneuver is quite different. So the leg will be in a completely different attitude. And the maneuver you need to do to relocate this is also different.
You apply traction, but also you need to apply direct pressure to the femoral head to push it back in place. Unfortunately, the anterior wall of the acetabulum is far shallower than the posterior wall. And so this is usually straightforward. So to summarize, native hip dislocation, it's a surgical emergency. If you don't think there are any fractures, then the most important initial maneuver is to assess the neurological status of the vascular status of the limb and carry out an urgent reduction with the CT scan if you are concerned about the femoral neck.
Uh, the. As long as the neck is intact. Associated fractures around the acetabulum, the initial management is the same. But if you try and it won't come back closed and it won't come, you don't have it won't come back closed even in the operating theater or there's a delay, then you need to make sure you have the right people there or the patient is in the right environment for an open reduction, which could be with a hip surgeon familiar with the posterior approach who understands how to explore the sciatic nerve and urgent immediate transfer if necessary.
So moving on to acetabular anatomy, the column concept is key. And so the anterior column you can see here in green is far larger, with the posterior column being a much more limited structure. And we're going to talk about how they're represented on X-rays and how to differentiate them on CT scans as well. So these lines, all of these lines call these lines are really useful for defining the acetabular anatomy.
They're known as returnables lines, and they represent each important anatomical part of the acetabulum. So starting with the idea peritoneal line, this represents the anterior column and you can see the anterior column here in green a very extensive structure, including most of the ileum, the anterior superior and inferior iliac spines, and the pubic symphysis and the.
If you were to look down onto a bony pelvis, you don't see a line. The line is an overlapping condensation of cortical bone that you see on a plain X-ray. So it's important to recognize that. The only issue line represents the posterior column again, starting from the medial border of the isham, going up the ileum and around to the sacroiliac joint and the posterior column is a much more limited structure.
You can see here the ischium, and the. Issue spine, the greatest society for him and the Society for women, the radiographic teardrop. Is remember, you're not this is not a structure that you see looking down onto the bony acetabulum. This is a image, a representation you see on an X-ray. AP radiograph. And this represents the medial wall of the acetabulum.
The radiographic roof represents the dome and then the anterior rim and posterior rim represent the margins of the acetabulum, the anterior, and there can be quite difficult to see. So one tip is the anterior rim. If you follow the inferior margin of the superior pubic ramus to the edge of the acetabulum, you can pick up the anterior in that way and the posterior rim. If you follow the lateral border of the ischium upwards you, that picks up a line that runs into the posterior rim, representing the border of the posterior wall of the acetabulum.
And so these lines lateral lines are really useful when it comes to defining what the fracture is and fracture classification and the system. The tunnel system describes five elementary and 5 associated patterns based on two columns and two walls. And it can be. When I was a trainee, I find it quite difficult to get my head around this, but actually these the classification can be quite nicely described by dividing it into groups.
So if we think of posterior fracture dislocations, the elementary fractures are post-approval posterior column the associated fractures or transverse posterior wall posterior column posterior wall. And note here that there is one of these associated fracture patterns, more than one fracture line that does not cross both columns, so one of the pitfalls of answering questions on acetabular fractures is to see something that looks complex and say as the sort of reflex, this is the both column fracture, and it isn't always it could be posterior column posterior wall.
Pay attention to your toenails lines and you won't get caught out. Elementary, a injuries, a war, which is actually quite rare. So an A war, if you see that on a CT scan or you see a report saying that or you think you're seeing that, it's more often actually the root of ramus, which is right at the border of the acetabulum and represents a pelvic ring fracture anterior wall by itself is unusual.
And so it's actually often a root of ramus and a pelvic ring fracture, or rarely associated with an anterior dislocation. Anterior column again, is unusual. Much more commonly, fracture and anterior column fracture has a poster element to it. And the associated type is anterior column posterior hemi transverse, which is one of the very one of the most common fractures of both columns. And then we have transverse a shapes, so the transverse fracture is an elementary type fracture, single fracture line crossing both columns, whereas the associated is a t-shaped fracture with a single fracture line across from both cones and a second fracture passing inferior.
So I must remember these images come from my colleague Julian Cooper in Birmingham, so thank you for those he's keen for them to be used for teaching purposes associated. Both column fractures have particular features that you can pick up really easily and impress examiners with. The fracture is a complete articular fracture, so the part of the island, which is most posterior, is separated.
So if you look at the weather, fracture lines are here. The acetabulum itself has no connection with the sacroiliac joint and the axial skeleton. It is completely separated by fracture lines. And as a result of that, the whole of the acetabulum tends to be displaced immediately, and it occupies a position in the pelvis where it looks often like an acetabulum. You have this secondary congruence where the fracture fragments come to lie in a position around the femoral head.
We call that secondary congruence, and so we'll talk about the features of associated both column fractures because it's really pretty straightforward. So this is an axial CT scan of an associated birth column fracture, and you can see here there's quite an extensive anterior column fracture. This is the constant fragment Follow it down. And as you follow it down, you can see that it's separate from the rest of the acetabulum.
The rest of the acetabulum is medium sized, and there's no connection between the fracture fragments and that constant fragment that we saw higher up. So that is an associated both column fracture. And if we look at the coronal part of the CT scan, we can see that and often in the exam, they'll show you one or two images, but it will have the salient features on it. So we can see that the fact the fragments of the dome and the acetabulum are quite medial relative to the groups relative to the constant fragment.
So this is the same scan. Here's the constant fragment posterior column and you can see here posterior column. There's the fracture line and you can see the whole of the acetabulum as medium size relative to the relative to the constant fragment and the posterior column and the x, the co-pilot joint and the rest of the skeleton where it compared to where it should be.
It's medial ized, and it's got this secondary congruence with fracture fragments just lying around the femoral head. And so. Another useful feature to look out for. Who is this shop spike of alia in X-ray and AP X-ray or an oblique X ray? You see that sharp spike of alien sticking out, and we call that the spur sign.
And it occurs because the whole of the acetabulum media list relative to the relative to the constant fragment leaving the alien behind. So features are associated both column fracture, secondary congruence, memorialization and the first sign. OK so what about prognosis, so you can see that this looks like a a, you know, acetabular fracture becomes a spectrum.
Some can be completely displaced, visible only on a CT scan, some can be very displaced. And so and there are different fracture patterns, so they vary in terms of prognosis. And so what do we know which of the fractures that are going to be most problematic? And when we talk about prognosis, we're talking about, we're not talking about death of a patient. We're talking about death of the hip as in the hip, ending up in a total hip replacement.
So in terms of that, what do we know about who which patients are likely to end up needing a hip replacement because this informs how we advise them and how we follow them up and an understanding of what needs to happen next. And so this is a historical study, for matter. They've been several stents, including a recent one from Sweden looking at prognostic factors, but we see the same thing in every study. There are the same factors that lead to a poor prognosis and with long term follow it, we can tell which are the hips that are likely to survive and which are the ones that don't.
And posterior wall. So is posterior wall a simple? It's a simple fracture. Surely that could be a good one to have posterior wall used to have a name for herself as being an easy fracture to fix? Because if you were a hip surgeon familiar with the post-injury approach in the days before the trauma network, you could probably expose it, put it back and fix it.
But even in the hands of experts, posterior wall carries a poor prognosis. And the reason is the associated complications from surgery, including sciatic nerve injury. Calcification and the need for hip replacement because of secondary osteoarthritis. And so post-raw wall carries a poor prognosis. Initial displacement, so very dangerous. And then there are many features here that are a feature of fragility fracture the acetabulum, but can occur at any age.
So the most the clearest poor prognostic indicator for a patient ending in a hip replacement is age. The older you are, the more fragile your bone tends to be, and the more difficult it will be for that hip joint to recover from a catastrophic injury. Even with an attempt to anatomical reduction. And so the other features that can happen at any age but are really a feature of osteoporotic fractures or fragility fractures or femoral head damage, marginal infection incongruence and difficulty achieving an anatomical reduction.
There's also something here about the extended auli'I femoral approach, which we'll talk about briefly later. So what's this? Do people have people seen this before? Is there? People have the experience with noting this on the perhaps on the CT scan? So you see it when it's very obvious on a plane X ray, but actually a CT is needed to see this when it's more subtle.
And this is the single sign. So the Siegle sign represents serious, significant down impaction, which is basically crushing of cancellous bone as the femoral head is driven up into the acetabulum. It's a feature of acetabular of acetabular fractures, fragility fractures of the acetabulum, but it can occur in any age, and it's a poor prognostic sign reflecting a need often for total hip replacement surgery rather than fixation alone.
And so. Marginal impact. So this is the CT image, and you can see the image on the right shows huge incongruously, at the lower end of the screen, you can see follow the socket around the femoral head and suddenly you can see the shape of the socket, but it's being pushed back towards the medial wall by this impaction.
And so in a young patient, what we do is elevate that infection, put a bone graft often from the greater cancer into it, and try to restore the congruence congruence of the hip joint. This is a surgical image, so you can see there the subchondral bone of the acetabulum has been pushed back to a seriously non anatomical position and left like that this hip will have a poor prognosis. So hip replacement surgery fractures is not straightforward, often to take the displaced acetabular fracture and end up with a stable hip replacement requires to some extent.
Often some reduction of the fracture and there are different strategies. So to summarize that reduction of the fracture and total hip replacement surgery, or use of a cage type implant, which bypasses the fracture, those are the two main strategies. And this is you can see the amount of metal that's been put in here. There's an anterior column plate, a medial plate, two posterior column plates, a modular acetabular component of the hip replacement, allowing maximal bony contact and adjustment of the direction of the bearing surface for maximal fixation of maximal stability.
So these are cases that are associated with a higher complication profile. OK approaches are basically anterior and posterior, and I would say really learn your approaches for the exam because they are a gift. And if you have an opportunity to talk about them, you can just run through the steps. And as long as you are confident and accurate with describe them, that will be very satisfactory to the examiners.
And so the anterior approaches here on the left as a fan Pfannenstiel incision and on the right and midline incision, which is sometimes used in the damage control situation when pelvic packing is done. And so you occasionally find yourself in a situation where you want to do an anterior approach and the patients already had a midline laparotomy and you want these the same scar, same incision. So you can the modify, stop or approach is excellent for visualization of the whole of the anterior column and the medial wall of the acetabulum, allowing you to access even the posterior column.
So you can see here you can get all the way back to the greater sciatic foramen, not to see it face on. Obviously, you're looking in from the front, but you can place retractors there. You can put reduction instruments there. You can use all sorts of indirect reduction techniques. And so this is a very versatile approach for dealing with probably the majority of fractures, which are not posterior column or posterior wall.
And you can see that it's quite a. If you're not, it's an approach that requires care because you're passing in a window between some major vessels, so the vessels are passing to one side. No one here represents what? That's the theory of the gastric artery. 3 is the branch of the internal iliac. And two is the corona Mortis.
So the ilut inguinal approach will allow you to come in from a very different trajectory on the anterior column of the acetabulum, whereas the modified soccer approach brings you in quite immediately and you'll encounter the corona Mortis most of the time. And with exposing the whole of the anterior column and the whole of the medial column, it's extremely versatile.
So so this represents the olive inguinal approach. And the modified stock approach has been described in the past as using the medial window of the world approach. The skin incision is sort of similar, but actually you come in on and your exposure is completely different. The maximal utility of the annual approach is to see the part of the anterior column, which is directly over the hip joint.
So if you want to, if you want to expose that, it's unusual to need to expose that in particular. But but you you should definitely be able to describe the England approach in detail because it is a gift. If you're given it in the exam, you can score many points by just describing it accurately. OK, so this is a deep section of a posterior approach.
The posterior approach is basically the cock Lundbeck approach, which is the approach. Same approach you used in a hip replacement, except a much more extensive skin is often needed up to the posterior superior iliac spine or towards that area. Because patients having this type of surgery are frequently young, muscular patients with huge muscles and often also the anatomy is quite distorted.
The sciatic nerve is not necessarily where you expect it to be. And so a larger approach unless you are doing spics and replace surgery for an acetabular fracture. If you want to see the important structures and particularly to try and preserve the muscularis of the hip, a larger exposure is often necessary. And the release with this red line here, you can see the release is through the short external rotation of the hip, preserving the medial slap complex femoral vessel, which runs in the quadriceps femoris.
And so so those are the principles of the cockell approach, and there are variants of it. But this is basically the workhorse for posterior approaches. So other helpful approaches. Variants of approach include the Gibson, which rather than going through directly through the center of gluteus maximus and dividing it into two takes an end of a more anterior so separating going in the facial interval between gluteus maximus and tensor fascia.
So that's quite a nice approach. The GANs truck and Terry osteotomy and surgical dislocation we use for a posterior approach where you want to perhaps fix the posterior column of wall, but you also have a very large dome fragment and you want to see inside the acetabulum. It's also described as being useful for seeing the anterior margin of the acetabulum, but actually you can often get to that just by use of retractors.
The Adelaide is a very extensive posterior approach and practice is a useful anterior approach, but I wouldn't learn any of these approaches in detail for the exam. I would focus on the most important. You will not be expected to know any of these folks on the most important aspects, which we've talked about, including the initial approach, initial management classification and simple anterior posterior approaches.
And these are approaches which were more commonly used historically or rarely used these days do mention them, don't go there. Extended olive femoral approach and try a regional approach. Both have problems particularly bearing in mind that the ultimate need for some of these patients is a total hip replacement. The extended early femoral approach is associated with very high infection rate.
The because you basically stroll the soft tissues off the ileum front and back. The tri radiate approach crosses every approach that you might use to do a hip replacement. And so it's a bit of a nightmare faced with that in that situation. And so if you start talking about these approaches, they're difficult to describe and you'll start digging a hole for yourself from the exam.
Stay away from them would be my advice. And so these are examples of fixation on top of the screen anterior approach, but on the screen posterior approach. And you can see with the anterior approach at the top, you can put a very long anterior column plate and a medial plate directly onto the medial wall of the acetabulum to buttress the fracture anatomically. And you can do all of this through an anterior approach, even though you'll see the posterior limb of the medial plate lies along the posterior column and through fixation.
Used a number of plates to try and get those small plates of spring plates, which are very useful for very small and marginal fractures of the posterior wall. And these are column screws, so we can pass percutaneous column screws. We use column screws. The image on the left of the screen is but screw a retrograde posterior column screw used as an adjunct for a posterior column fracture with a posterior wall plate.
And the image on the right of the screen for an undisclosed acetabular fracture. The indications are very limited, so polytrauma patients who are unable to mobilize due to pain are probably the two most important indications for putting these. These are to integrate anterior column and posterior column screws occasionally useful technique probably most often used if one column is displaced and the other needs an open approach.
And rather than having to do two approaches, you could do one approach and then pass a percutaneous screw to supplement your fixation. So to summarize, acetabular fractures X-ray and CTE are complementary to each other, the lines of the acetabulum will help you with diagnosing the problem and planning what you need to do. Marginal infection is often quite subtle and can often only be seen on a CT scan, and so a CT scan is also useful to see loose fragments.
And we've talked about the predictors of non anatomical predictors of a poor outcome, resulting in total hip replacement with age being the strongest predictor.
Segment:0 .
Use today, Mrs. Homa Arshad, to present a talk about acetabular fractures for the FRCS, and this will be in the combined session between the FRCS mentor group and ORUK.
Mrs. Arshad is a consultant of the pelvis in the lower limb provision arthroplasty, as well as surgeon and the clinical lead at the Royal London Hospital. We will start with the lecture, followed by any questions you want to ask. Please do by writing in the chat box and I will ask Mrs. Arshad at the end. Also, we will have these questions answered off just after the lecture.
After that, we will go for the MSCI poll and the answer to that is anonymous. So please participate in the Q&A after that will have a very interesting vyver practice, which will be not recorded. Then the closure to further things that I want to recommend is the concise, orthopedic notes, which is a very important provision notes for the FRC.
It helped me personally for the exam and the UK basic science books. Without further ado, I will please Mrs. Arshad. Can you start sharing your screen and present us the very interesting topic of acetabular as. Hi, good evening, everybody, and thank you very much for attending this webinar. I'm going to talk about acetabular fractures today with a focus on the exam and.
If you can put your questions, I tend to ask questions as we go along, but you can put more questions than answers if you like, into the chat. And we're going to have a discussion at the end. So why can't I make this work ok? So these are basically the things that I want you to get to grips with that we're going to help you with the exam to remember that when you go into the exam, you're going to be assessed as if you are a day one consultant.
And so you must be able to describe the initial management. The classification worldwide that's most widely used is the due date maternelle classification for acetabular fractures. We're going to talk briefly about approaches and then when you're discussing any clinical case to talk about prognosis is really helpful. And so imagine that you're presented with this case in the vyver.
And obviously, this is a high energy injury, and it's quite unsettling to be shown something dramatic, but they will expect you to be safe and to understand the simple aspects. And so the really important distinction is between pelvic and acetabular fractures, which are often lumped together because they're in the same part of the body. They're the same surgeons who deal with them.
But in the exam, they will expect you to distinguish between the two. So this, as you can see, if you look at the sacroiliac joints, the widening and injury of the right circle joint as compared to the left side, which looks normal and the obvious dislocated hip with the acetabular fracture. This fits into the injury pattern of a combined pelvic and acetabular fracture, which occurs in 15% of cases.
And so that is unusual. And the other features they have in common are that these patients sometimes need resuscitation. So in terms of that pelvic trauma, when it's high energy injury, these patients are frequently more frequently in need of resuscitation. And you can recognize it by the fact that there is a disruption to the synthesis. There's usually ramus fractures and disruption of the sacroiliac joints, whereas with acetabular fracture you are if your eye is drawn to the socket of the ball and socket joint of the hip and that's disrupted.
The dome is injured. The Eternals lines, which we're going to talk about or disrupted that is an acetabular fracture. And so there are some things in common but very important to make this really basic distinction between the two. And one useful way to think about it is if you're dealing with pelvic trauma and pelvic fractures, then you're aggressive.
Trauma surgeon side has to come out and you're going to use that because resuscitation of the patient is key and initial management is some case is going to save a life, whereas with acetabular fractures, the challenge is more around the anatomical reconstruction of that fracture. And so your Einstein side is more important because the challenge lies in the planning and surgery.
And so when we talk about acetabular fractures, the common principle is what the tunnel's classification is based on, and the acetabulum is considered to be represented by an anterior column and a posterior column. Imagine you are in the exam now, and we're going to talk about initial management of an acetabular fracture. You are a day one consultant at a major trauma center and in the emergency department.
In the resuscitation room, you are naturally going to be three rows back. You're not part of the normal assessing team, but you will be asked for your opinion. And so a patient who presents with a dislocated hip. What is our approach to the initial management of that patient? The first question you'll be asked in the exam is what is your approach to this patient?
And so what I would suggest is not to ask questions about it, so it's natural to think, gosh, I don't know the age of the patient, I don't know the sex of the patient, I don't know the mechanism of injury, but ask them questions will just irritate the examiners. So talk about what you can see. You can see the hip is dislocated, and the first thing to say is to recognize this is a surgical emergency.
This is a surgical emergency requiring urgent reduction of the dislocated hip. And I will start by assessing this patient, according to principles. What are you going to do next? What is the so we've got some miscues at the end to talk about that and to test your learning. But I would suggest that the most important thing at this point is once you have assessed the patient by 80 principles to examine the neurological status and the vascular status of the limb.
And then there is a need for urgent reduction and a question over where we carry that out patient is best served by urgent reduction without delay. And so that means usually in the emergency department with appropriate sedation and personnel. And as well as assessing the neurological and vascular status, what else do you need to know about this patient? So you also need to know.
You need to carry out an assessment of the limb because an attempt to close reduction, for example, in this situation would be very disappointing. And so assess the neurological status, assess the vascular status because that informs what happens immediately and what happens next and the implications of any deficit you have after a reduction maneuver and assess the whole limb and be able to describe the maneuver.
So the maneuver is a 2 person technique using counteraction, appropriate sedation, flexing the hip and knee to 90 degrees and applying traction. And this slide describes maneuvers with increasing personnel and increasingly more complicated maneuvers, which I do not recommend, so we attempt it once in the emergency department with sedation and personnel. And if that doesn't work, then we transfer the patient to theater.
Now there's a question about what if the patient has an associated acetabular fracture? So if we look at the initial X-ray of this patient? Uh, we think if we assess the whole limb that the rest of the limb is intact, but probably the most important fracture to exclude, as were. The most important fracture to exclude is a fracture of the femoral neck. And I would suggest that this imaging gives you some degree of confidence, there is no fracture of the femoral neck.
And so you can safely perform a reduction maneuver, but if in doubt, then you want to carry out a CT scan. And if you suspect an associated acetabular fracture, it's good practice to carry out a CT scan to understand what you're dealing with. And then carry out an attempt at closed reduction. So this is a different type of dislocation, the majority of dislocations occur with dashboard injuries and are opposed to dislocation.
This is an anti-hero dislocation and with a posterior of dislocation. The limb is shortened internally, rotated with an anti-air dislocation. The limb is externally rotated, and the maneuver is quite different. So the leg will be in a completely different attitude. And the maneuver you need to do to relocate this is also different.
You apply traction, but also you need to apply direct pressure to the femoral head to push it back in place. Unfortunately, the anterior wall of the acetabulum is far shallower than the posterior wall. And so this is usually straightforward. So to summarize, native hip dislocation, it's a surgical emergency. If you don't think there are any fractures, then the most important initial maneuver is to assess the neurological status of the vascular status of the limb and carry out an urgent reduction with the CT scan if you are concerned about the femoral neck.
Uh, the. As long as the neck is intact. Associated fractures around the acetabulum, the initial management is the same. But if you try and it won't come back closed and it won't come, you don't have it won't come back closed even in the operating theater or there's a delay, then you need to make sure you have the right people there or the patient is in the right environment for an open reduction, which could be with a hip surgeon familiar with the posterior approach who understands how to explore the sciatic nerve and urgent immediate transfer if necessary.
So moving on to acetabular anatomy, the column concept is key. And so the anterior column you can see here in green is far larger, with the posterior column being a much more limited structure. And we're going to talk about how they're represented on X-rays and how to differentiate them on CT scans as well. So these lines, all of these lines call these lines are really useful for defining the acetabular anatomy.
They're known as returnables lines, and they represent each important anatomical part of the acetabulum. So starting with the idea peritoneal line, this represents the anterior column and you can see the anterior column here in green a very extensive structure, including most of the ileum, the anterior superior and inferior iliac spines, and the pubic symphysis and the.
If you were to look down onto a bony pelvis, you don't see a line. The line is an overlapping condensation of cortical bone that you see on a plain X-ray. So it's important to recognize that. The only issue line represents the posterior column again, starting from the medial border of the isham, going up the ileum and around to the sacroiliac joint and the posterior column is a much more limited structure.
You can see here the ischium, and the. Issue spine, the greatest society for him and the Society for women, the radiographic teardrop. Is remember, you're not this is not a structure that you see looking down onto the bony acetabulum. This is a image, a representation you see on an X-ray. AP radiograph. And this represents the medial wall of the acetabulum.
The radiographic roof represents the dome and then the anterior rim and posterior rim represent the margins of the acetabulum, the anterior, and there can be quite difficult to see. So one tip is the anterior rim. If you follow the inferior margin of the superior pubic ramus to the edge of the acetabulum, you can pick up the anterior in that way and the posterior rim. If you follow the lateral border of the ischium upwards you, that picks up a line that runs into the posterior rim, representing the border of the posterior wall of the acetabulum.
And so these lines lateral lines are really useful when it comes to defining what the fracture is and fracture classification and the system. The tunnel system describes five elementary and 5 associated patterns based on two columns and two walls. And it can be. When I was a trainee, I find it quite difficult to get my head around this, but actually these the classification can be quite nicely described by dividing it into groups.
So if we think of posterior fracture dislocations, the elementary fractures are post-approval posterior column the associated fractures or transverse posterior wall posterior column posterior wall. And note here that there is one of these associated fracture patterns, more than one fracture line that does not cross both columns, so one of the pitfalls of answering questions on acetabular fractures is to see something that looks complex and say as the sort of reflex, this is the both column fracture, and it isn't always it could be posterior column posterior wall.
Pay attention to your toenails lines and you won't get caught out. Elementary, a injuries, a war, which is actually quite rare. So an A war, if you see that on a CT scan or you see a report saying that or you think you're seeing that, it's more often actually the root of ramus, which is right at the border of the acetabulum and represents a pelvic ring fracture anterior wall by itself is unusual.
And so it's actually often a root of ramus and a pelvic ring fracture, or rarely associated with an anterior dislocation. Anterior column again, is unusual. Much more commonly, fracture and anterior column fracture has a poster element to it. And the associated type is anterior column posterior hemi transverse, which is one of the very one of the most common fractures of both columns. And then we have transverse a shapes, so the transverse fracture is an elementary type fracture, single fracture line crossing both columns, whereas the associated is a t-shaped fracture with a single fracture line across from both cones and a second fracture passing inferior.
So I must remember these images come from my colleague Julian Cooper in Birmingham, so thank you for those he's keen for them to be used for teaching purposes associated. Both column fractures have particular features that you can pick up really easily and impress examiners with. The fracture is a complete articular fracture, so the part of the island, which is most posterior, is separated.
So if you look at the weather, fracture lines are here. The acetabulum itself has no connection with the sacroiliac joint and the axial skeleton. It is completely separated by fracture lines. And as a result of that, the whole of the acetabulum tends to be displaced immediately, and it occupies a position in the pelvis where it looks often like an acetabulum. You have this secondary congruence where the fracture fragments come to lie in a position around the femoral head.
We call that secondary congruence, and so we'll talk about the features of associated both column fractures because it's really pretty straightforward. So this is an axial CT scan of an associated birth column fracture, and you can see here there's quite an extensive anterior column fracture. This is the constant fragment Follow it down. And as you follow it down, you can see that it's separate from the rest of the acetabulum.
The rest of the acetabulum is medium sized, and there's no connection between the fracture fragments and that constant fragment that we saw higher up. So that is an associated both column fracture. And if we look at the coronal part of the CT scan, we can see that and often in the exam, they'll show you one or two images, but it will have the salient features on it. So we can see that the fact the fragments of the dome and the acetabulum are quite medial relative to the groups relative to the constant fragment.
So this is the same scan. Here's the constant fragment posterior column and you can see here posterior column. There's the fracture line and you can see the whole of the acetabulum as medium size relative to the relative to the constant fragment and the posterior column and the x, the co-pilot joint and the rest of the skeleton where it compared to where it should be.
It's medial ized, and it's got this secondary congruence with fracture fragments just lying around the femoral head. And so. Another useful feature to look out for. Who is this shop spike of alia in X-ray and AP X-ray or an oblique X ray? You see that sharp spike of alien sticking out, and we call that the spur sign.
And it occurs because the whole of the acetabulum media list relative to the relative to the constant fragment leaving the alien behind. So features are associated both column fracture, secondary congruence, memorialization and the first sign. OK so what about prognosis, so you can see that this looks like a a, you know, acetabular fracture becomes a spectrum.
Some can be completely displaced, visible only on a CT scan, some can be very displaced. And so and there are different fracture patterns, so they vary in terms of prognosis. And so what do we know which of the fractures that are going to be most problematic? And when we talk about prognosis, we're talking about, we're not talking about death of a patient. We're talking about death of the hip as in the hip, ending up in a total hip replacement.
So in terms of that, what do we know about who which patients are likely to end up needing a hip replacement because this informs how we advise them and how we follow them up and an understanding of what needs to happen next. And so this is a historical study, for matter. They've been several stents, including a recent one from Sweden looking at prognostic factors, but we see the same thing in every study. There are the same factors that lead to a poor prognosis and with long term follow it, we can tell which are the hips that are likely to survive and which are the ones that don't.
And posterior wall. So is posterior wall a simple? It's a simple fracture. Surely that could be a good one to have posterior wall used to have a name for herself as being an easy fracture to fix? Because if you were a hip surgeon familiar with the post-injury approach in the days before the trauma network, you could probably expose it, put it back and fix it.
But even in the hands of experts, posterior wall carries a poor prognosis. And the reason is the associated complications from surgery, including sciatic nerve injury. Calcification and the need for hip replacement because of secondary osteoarthritis. And so post-raw wall carries a poor prognosis. Initial displacement, so very dangerous. And then there are many features here that are a feature of fragility fracture the acetabulum, but can occur at any age.
So the most the clearest poor prognostic indicator for a patient ending in a hip replacement is age. The older you are, the more fragile your bone tends to be, and the more difficult it will be for that hip joint to recover from a catastrophic injury. Even with an attempt to anatomical reduction. And so the other features that can happen at any age but are really a feature of osteoporotic fractures or fragility fractures or femoral head damage, marginal infection incongruence and difficulty achieving an anatomical reduction.
There's also something here about the extended auli'I femoral approach, which we'll talk about briefly later. So what's this? Do people have people seen this before? Is there? People have the experience with noting this on the perhaps on the CT scan? So you see it when it's very obvious on a plane X ray, but actually a CT is needed to see this when it's more subtle.
And this is the single sign. So the Siegle sign represents serious, significant down impaction, which is basically crushing of cancellous bone as the femoral head is driven up into the acetabulum. It's a feature of acetabular of acetabular fractures, fragility fractures of the acetabulum, but it can occur in any age, and it's a poor prognostic sign reflecting a need often for total hip replacement surgery rather than fixation alone.
And so. Marginal impact. So this is the CT image, and you can see the image on the right shows huge incongruously, at the lower end of the screen, you can see follow the socket around the femoral head and suddenly you can see the shape of the socket, but it's being pushed back towards the medial wall by this impaction.
And so in a young patient, what we do is elevate that infection, put a bone graft often from the greater cancer into it, and try to restore the congruence congruence of the hip joint. This is a surgical image, so you can see there the subchondral bone of the acetabulum has been pushed back to a seriously non anatomical position and left like that this hip will have a poor prognosis. So hip replacement surgery fractures is not straightforward, often to take the displaced acetabular fracture and end up with a stable hip replacement requires to some extent.
Often some reduction of the fracture and there are different strategies. So to summarize that reduction of the fracture and total hip replacement surgery, or use of a cage type implant, which bypasses the fracture, those are the two main strategies. And this is you can see the amount of metal that's been put in here. There's an anterior column plate, a medial plate, two posterior column plates, a modular acetabular component of the hip replacement, allowing maximal bony contact and adjustment of the direction of the bearing surface for maximal fixation of maximal stability.
So these are cases that are associated with a higher complication profile. OK approaches are basically anterior and posterior, and I would say really learn your approaches for the exam because they are a gift. And if you have an opportunity to talk about them, you can just run through the steps. And as long as you are confident and accurate with describe them, that will be very satisfactory to the examiners.
And so the anterior approaches here on the left as a fan Pfannenstiel incision and on the right and midline incision, which is sometimes used in the damage control situation when pelvic packing is done. And so you occasionally find yourself in a situation where you want to do an anterior approach and the patients already had a midline laparotomy and you want these the same scar, same incision. So you can the modify, stop or approach is excellent for visualization of the whole of the anterior column and the medial wall of the acetabulum, allowing you to access even the posterior column.
So you can see here you can get all the way back to the greater sciatic foramen, not to see it face on. Obviously, you're looking in from the front, but you can place retractors there. You can put reduction instruments there. You can use all sorts of indirect reduction techniques. And so this is a very versatile approach for dealing with probably the majority of fractures, which are not posterior column or posterior wall.
And you can see that it's quite a. If you're not, it's an approach that requires care because you're passing in a window between some major vessels, so the vessels are passing to one side. No one here represents what? That's the theory of the gastric artery. 3 is the branch of the internal iliac. And two is the corona Mortis.
So the ilut inguinal approach will allow you to come in from a very different trajectory on the anterior column of the acetabulum, whereas the modified soccer approach brings you in quite immediately and you'll encounter the corona Mortis most of the time. And with exposing the whole of the anterior column and the whole of the medial column, it's extremely versatile.
So so this represents the olive inguinal approach. And the modified stock approach has been described in the past as using the medial window of the world approach. The skin incision is sort of similar, but actually you come in on and your exposure is completely different. The maximal utility of the annual approach is to see the part of the anterior column, which is directly over the hip joint.
So if you want to, if you want to expose that, it's unusual to need to expose that in particular. But but you you should definitely be able to describe the England approach in detail because it is a gift. If you're given it in the exam, you can score many points by just describing it accurately. OK, so this is a deep section of a posterior approach.
The posterior approach is basically the cock Lundbeck approach, which is the approach. Same approach you used in a hip replacement, except a much more extensive skin is often needed up to the posterior superior iliac spine or towards that area. Because patients having this type of surgery are frequently young, muscular patients with huge muscles and often also the anatomy is quite distorted.
The sciatic nerve is not necessarily where you expect it to be. And so a larger approach unless you are doing spics and replace surgery for an acetabular fracture. If you want to see the important structures and particularly to try and preserve the muscularis of the hip, a larger exposure is often necessary. And the release with this red line here, you can see the release is through the short external rotation of the hip, preserving the medial slap complex femoral vessel, which runs in the quadriceps femoris.
And so so those are the principles of the cockell approach, and there are variants of it. But this is basically the workhorse for posterior approaches. So other helpful approaches. Variants of approach include the Gibson, which rather than going through directly through the center of gluteus maximus and dividing it into two takes an end of a more anterior so separating going in the facial interval between gluteus maximus and tensor fascia.
So that's quite a nice approach. The GANs truck and Terry osteotomy and surgical dislocation we use for a posterior approach where you want to perhaps fix the posterior column of wall, but you also have a very large dome fragment and you want to see inside the acetabulum. It's also described as being useful for seeing the anterior margin of the acetabulum, but actually you can often get to that just by use of retractors.
The Adelaide is a very extensive posterior approach and practice is a useful anterior approach, but I wouldn't learn any of these approaches in detail for the exam. I would focus on the most important. You will not be expected to know any of these folks on the most important aspects, which we've talked about, including the initial approach, initial management classification and simple anterior posterior approaches.
And these are approaches which were more commonly used historically or rarely used these days do mention them, don't go there. Extended olive femoral approach and try a regional approach. Both have problems particularly bearing in mind that the ultimate need for some of these patients is a total hip replacement. The extended early femoral approach is associated with very high infection rate.
The because you basically stroll the soft tissues off the ileum front and back. The tri radiate approach crosses every approach that you might use to do a hip replacement. And so it's a bit of a nightmare faced with that in that situation. And so if you start talking about these approaches, they're difficult to describe and you'll start digging a hole for yourself from the exam.
Stay away from them would be my advice. And so these are examples of fixation on top of the screen anterior approach, but on the screen posterior approach. And you can see with the anterior approach at the top, you can put a very long anterior column plate and a medial plate directly onto the medial wall of the acetabulum to buttress the fracture anatomically. And you can do all of this through an anterior approach, even though you'll see the posterior limb of the medial plate lies along the posterior column and through fixation.
Used a number of plates to try and get those small plates of spring plates, which are very useful for very small and marginal fractures of the posterior wall. And these are column screws, so we can pass percutaneous column screws. We use column screws. The image on the left of the screen is but screw a retrograde posterior column screw used as an adjunct for a posterior column fracture with a posterior wall plate.
And the image on the right of the screen for an undisclosed acetabular fracture. The indications are very limited, so polytrauma patients who are unable to mobilize due to pain are probably the two most important indications for putting these. These are to integrate anterior column and posterior column screws occasionally useful technique probably most often used if one column is displaced and the other needs an open approach.
And rather than having to do two approaches, you could do one approach and then pass a percutaneous screw to supplement your fixation. So to summarize, acetabular fractures X-ray and CTE are complementary to each other, the lines of the acetabulum will help you with diagnosing the problem and planning what you need to do. Marginal infection is often quite subtle and can often only be seen on a CT scan, and so a CT scan is also useful to see loose fragments.
And we've talked about the predictors of non anatomical predictors of a poor outcome, resulting in total hip replacement with age being the strongest predictor.
Form Title Download
Transcript
Form Title Bookmark
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Share
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Accessibility and Keyboard Shortcuts
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html video player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the video player are generally tabs, one of which shows a scrolling transcript of the video and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the video is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the video by opening up an explore dialog which contains tabs for a visual navigation of the video using thumbnails, an about tab which contains rich metadata about the media, a segments tab which contains further information about the video, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
I: Info Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus / Exits Player
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Embed Size
-
You Size - Responsive
-
We Size - Responsive
-
Picture Overlay Popup
-
400 x 225
-
512 x 288
-
400 x 700
-
768 x 1024
-
1024 x 512
-
1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Exit Clip Mode
You have requested to see a portion of the video outside of the clip.
Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode