Tuesday, October 4, 2011

Anterior Column

A 54 years old male fell approximately four feet from a ladder onto the ground. He complained of left hip pain and was unable to stand. On presentation to the emergency department, he was awake and alert, and only complained of severe left hip pain.

He was hemodynamically stable and his physical examination confirmed left hip pain with any attempted passive movement. There was no obvious limb deformity or abnormal other findings. The injured lower extremity’s neurological and vascular examinations were within normal limits, yet the muscle power evaluation was limited due to pain.

Pelvic radiographs and a computed tomography scan demonstrated a displaced left anterior column acetabular fracture. The axial CT images demonstrated the details including the dome involvement. Three-dimensional surface rendered images further defined the osseus anatomy of the fracture.

The fracture line extended from the posterior aspect of the iliac crest, through the iliac fossa, along the pelvic brim, and divided both the acetabular dome and anterior acetabular wall regions in half. Skeletal traction was used to protect the femoral head and acetabular fracture surfaces, relax muscle spasm, provide comfort, and alert the ancillary staff to the injury before surgery.

One day after injury, the patient underwent open reduction and internal fixation of the fracture using an ilioinguinal surgical exposure. The fracture surfaces were cleansed and then the fragments manipulated and clamped. The clamp was applied onto the pelvic brim and quadrilateral surface using the Stoppa interval of the ilioinguinal exposure.

A malleable plate and interfragmentary lag screws were used to definitively stabilize the fracture. The plate was secured initially onto the stable iliac bone and located just lateral to the sacroiliac joint. Then lag screws were inserted through the plate and between the tables of the iliac crest bone.

The antegrade medullary superior pubic ramus lag screw was inserted percutaneously safely within the osseus fixation pathway using fluoroscopic biplanar imaging. On the postoperative anteroposterior pelvic image, the surgical staples indicate the ilioinguinal skin incision.

On the first postoperative day, the patient began his rehabilitation program with passive range of hip motion and isometric muscle strengthening exercises. He used crutches to protect and unload the hip repair during ambulation for 6 weeks after surgery. During weeks 7-12, a routine conditioning and strengthening program was used along with progressive weight bearing.

At his follow up evaluation 3 months after surgery, he had no complaints nor limp, his hip range of motion was symmetrical with his uninjured side, and his hip and lower extremity strength had returned to normal. He returned to his regular job four months after surgery as a laborer.

Authored By: M.L. Chip Routt, Jr., M.D.

No comments:

Post a Comment