词条 | Acetabular fracture | ||||||||||||||||||||||||||||||||||||
释义 |
| name = Acetabular fracture | synonyms = | image = AcetabularfracX.png | alt = | caption = Acetabular fracture as seen on plain X-ray | pronounce = | synonym = | field = | symptoms = | complications = | onset = | duration = | types = | causes = | risks = | diagnosis = | differential = | prevention = | treatment = | medication = | prognosis = | frequency = | deaths = }}Fractures of the acetabulum occur when the head of the femur is driven into the pelvis. This injury is caused by a blow to either the side or front of the knee and often occurs as a dashboard injury accompanied by a fracture of the femur.[1] The acetabulum is a cavity situated on the outer surface of the hip bone, also called the coxal bone or innominate bone. It is made up of three bones, the ilium, ischium, and pubis. Together, the acetabulum and head of the femur form the hip joint. Fractures of the acetabulum in young individuals usually result from a high energy injury like vehicular accident or feet first fall. In older individuals or those with osteoporosis, a trivial fall may result in acetabular fracture. In 1964, French surgeons Robertt Judet, Jean Judet, and Emile Letournel first described the mechanism, classification, and treatment of acetabular fracture. They classified these fractures into elementary (simple two part) and associated (complex three or more part) fractures.[2] AnatomyTo understand the fracture pattern of a fractured acetabulum, it is essential to have minimum three x-ray views, though use of CT scan with 3-D reconstruction of images has made understanding of these fractures easier.
Patterns of fractureTile's classification of acetabular fracture:
Judet-Letournel classification
Gallery{{Gallery|title = Acetabular fracture |align = center |File:Acetabular Fracture CT.png|Axial CT image (viewed on bone windows) of a complex comminuted left acetabular fracture involving both anterior and posterior columns. |File:AcetabFracSagMark.png|Fracture of the acetabulum }} Elementary fractures{{Gallery|title=Posterior wall fracture |align=center |File:Acet - Post wall 01.jpg|Posterior wall fracture as seen on 3-D CT scan |File:Acet - Post wall 02.jpg|Posterior wall fracture fixed with screws and plate |File:Acet - Post wall 03.jpg|Function after fixation }}{{Gallery |title = Anterior wall fracture |align = center | File:Acet Ant wall Cooper 1.jpg|Anterior wall fracture | File:Acet Ant wall CT.jpg|As seen on 3D CT image | File:Acet Ant.wall post op.jpg|Fixation with screws and plate }}{{Gallery |title = Anterior column fracture |align = center | File:Acet High Ant Column 01.jpg|High anterior column fracture 3 D CT scan picture | File:Acet High Ant Column 02.jpg|High anterior column fracture after fixation with screws and plates }}{{Gallery |title = Transverse fracture | align = center | File:Acet Transverse 01.jpg|Transverse fracture showing upper iliac fragment, lower ischial and pubic fragment | File:Acet Transverse 02.jpg|Transverse fracture fixed with screws and plate }} Associated fractures{{Gallery|title=T-shaped fracture (associated with Posterior wall fracture) |align = center | File:Acet tshape02.jpg|T shape fracture shown on bone model | File:Acet tshape AP.jpg|X-ray of T shape fracture }}{{Gallery |title = Posterior column with posterior wall (associated with Posterior column fracture) |align = center | File:Acet Post Lip column 01.jpg|Posterior column and wall fracture as seen on 3D CT | File:Acet Post Lip column 02.jpg|Posterior column and wall fixed using screws and plates }}{{Gallery |title = combined both column fractures (associated with Transverse fracture) |align = center | File:Acet Both column 01.jpg|Both column fracture showing floating weight bearing dome | File:Acet Both column 02.jpg|Both column fracture after fixation with screws and plates | File:Acet Both column 03.jpg|Function after fixation both column fracture }} Diagnosis and treatmentDiagnosisIdeal x-ray visualization of an elementary fracture will depend on the fracture type:
In all cases, CT scan can assist in identifying impacted bone pieces, which may be found within the joint, and MRI may be done to identify the extent of potential injury to the sciatic nerve. Associated injuries and complicationsThe broken bone pieces or the dislocated head of the femur may injure the sciatic nerve, causing paralysis of the foot; the patient may or may not recover sensation in the foot, depending on the extent of injury to the nerve. The posterior wall fragment may be one large piece, or multiple pieces, and may be associated with impaction of the bone. Sciatic nerve injury and stoppage of blood supply to femoral head at the time of accident or during surgery to treat may occur. Deep vein thrombosis and pulmonary embolism are other complications that may occur in any type of injury to the acetabulum. TreatmentIf the femur head is dislocated, it should be reduced as soon as possible, to prevent damage to its blood supply. This is preferably done under anaesthesia, following which, leg is kept pulled by applying traction to prevent joint from dislocating. The final management depends on the size of the fragment(s), stability and congruence of the joint. In some cases traction for six to eight weeks may be the only treatment required; however, surgical fixation using screw(s) and plate(s) may be required if the injury is more complex. The latter treatment will be called for if bone fragments do not fall into place, or if they are found in the joint, or if the joint itself is unstable. Post-surgery treatment and prognosisDepending on the stability achieved via initial treatment, the patient may be allowed to stand and walk with help of support within about six to eight weeks. Full function may return in about three months. Principles of managementAt the site of injury: After stabilizing an injured person and resuscitation, quick examination is done to check injury to vital organs. If one suspects injury to the hip, it is imperative to immobilse the limb using some kind of support to prevent movements of the injured limb to prevent further damage A trained paramedic may be able to diagnose hip dislocation by noticing the position of the injured limb. It is essential to document status of nerves and vessels before starting any treatment to protect oneself from litigation On arrival at the hospital, trained trauma surgeon will assess the patient and prescribe necessary tests including x-rays as described earlier. Non-surgical management consists of reducing the dislocated joint by maneuver under anaesthesia and applying traction to the limb to maintain position of joint and fractured bones. If non surgical management is preferred it may require six weeks to 3 months for recovery. Surgical managementThe surgical management requires high degree of training and well equipped centre. It should be carried out by experienced surgical team to get best results. The principles laid down for management are;
Innominate bone is a flat bone with many curves. In most part the bone is thick enough and has broad surfaces that are amenable to primary fixation using lag screw(s) and to neutralize forces across the bone one needs to add plate(s) on the surface of the fractured fragments for it to heal without deformity. Before surgery, patient needs tests to check fitness for surgery Anaesthesia : the surgery may be performed either under regional anaesthesia or general anaesthesia Surgical approaches. Following are the common approaches;
Implants : normally lag screws and reconstruction plates are preferred implants Post operative management: would involve initial period or bed rest, followed by mobilsation by trained therapist Total time to recover may be up to 3 months References
1. ^Solomon, APLEY'S TRAUMA AND ORTHOPAEDICS, EIGHT EDITION, 2. ^{{Cite web|url=http://www.orthoconsult.com/classify-acetabular-fractures/|title=How to Classify Acetabular Fractures|last=OrthoConsult|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}} 3. ^{{Cite news|url=http://www.orthoconsult.com/classify-acetabular-fractures/|title=How to Classify Acetabular Fractures {{!}} OrthoConsult|date=2017-05-28|work=OrthoConsult|access-date=2017-05-28|language=en-US}} External links{{Medical resources| DiseasesDB = | ICD10 = {{ICD10|S32.4}} | ICD9 = {{ICD9|xxx}} | ICDO = | OMIM = | MedlinePlus = | MeSH = | GeneReviewsNBK = | GeneReviewsName = | Orphanet = }} 1 : Bone fractures |
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