Thursday, March 1, 2012

Posterior Wall Acetabular Fracture-Dislocation

A 67 years old factory worker was injured in a high-speed automobile accident while carpooling to work. He complained of left hip pain when medics evaluated him at the accident scene, and they noted deformity of the injured lower extremity. In the emergency room, the injured hip was flexed, adducted, and internally rotated. He had diminished strength of the hip area muscles due to pain but his peripheral neurological examination was otherwise normal. There was a contusion at the anterior ipsilateral knee region, but no effusion. His patella was nontender.

Pelvic plain radiographs and a computed tomography scan identified a displaced posterior wall acetabular fracture-dislocation.  The displaced posterior wall fracture fragment involved a significant portion of the acetabular dome region. The femoral neck was not fractured.

He was sedated with intravenous medications only after consenting to closed or open reduction as needed. The manipulative closed reduction was atraumatic and successful. Skeletal traction was applied to maintain the reduction, and radiographs confirmed the reduction of the femoral head 
beneath the intact acetabular dome without obvious articular debris.

Two days after injury, he underwent open reduction and internal fixation of the posterior wall acetabular fracture using a Kocher-Langenbeck surgical exposure. The superior gluteal neurovascular bundle and sciatic nerve were visualized, mobilized, and protected throughout the operation.

The fracture surfaces were cleansed of hematoma, reduced, and temporarily held in place with K-wires.  The reduction was definitively stabilized using a contoured and balanced malleable reconstruction plate along with interfragmentary screws.

Intraoperative fluoroscopy confirmed the reduction accuracy and extra-articular screw locations. The hip joint was stressed under direct visualization to assure fracture stability. The traumatic capsular injury plus the tenotomies of the piriformis and obturator internus muscles were repaired. The necrotic caudal portion of the gluteus minimus musculature was debrided.

He began his rehabilitation on the first day after surgery with unrestricted passive range of motion, isometric exercises, and partial weight bearing. Six weeks after surgery he started resistance exercises and progressive weight bearing. At his three months postoperative clinic visit, he was full weight bearing, denied complaints, and had symmetrical hip range of motion. Oblique pelvic radiographs demonstrated a symmetrical and normal hip joint space, no implant changes, and no evidence of ectopic bone formation. He reported a slight limp at the end of each day due to some residual weakness. His hip power returned to normal over the next month and he returned to his previous job.


Authored By: M.L. Chip Routt, Jr.,M.D