Fractures of the Acetabulum

Wall Fractures.- 5.4.2 Horizontal Extension of Fracture Line.- 5.4.3 Massive Posterior Wall Fractures.- 5.4.4 Posterior Wall and Incomplete Transverse Fractures.- 5.5 CT Study of Posterior Wall Fractures.- 6 Fractures of the Posterior Column.- 6.1 Typical Posterior Column Fractures.- 6.1.1 Morphology.- 6.1.2 Radiology.- 6.2 Extended Posterior Column Fractures.- 6.2.1 Morphology.- 6.2.2 Radiology.- 6.3 Atypical Posterior Column Fractures.- 6.3.1 Other Associated Pelvic Ring Fractures.- 6.3.2 Epiphyseal Injury.- 6.4 Transitional Posterior Column Fractures.- 6.4.1 Partial Superior Fractures.- 6.4.2 Partial Inferior Fractures.- 6.5 CT Study of Posterior Column Fractures.- 7 Anterior Wall Fractures.- 7.1 Morphology.- 7.2 Radiology.- 7.2.1 Antero-posterior View.- 7.2.2 Obturator-oblique View.- 7.2.3 Iliac-oblique View.- 7.3 Atypical Examples.- 7.4 CT Study of Anterior Wall Fractures.- 8 Fractures of the Anterior Column.- 8.1 Morphology.- 8.1.1 Very Low Fractures.- 8.1.2 Low Fractures.- 8.1.3 Intermediate Fractures.- 8.1.4 High Fractures.- 8.1.5 Atypical Examples.- 8.2 Radiology.- 8.2.1 Very Low Fractures.- 8.2.2 Low Fractures.- 8.2.3 Intermediate Fractures.- 8.2.4 High Fractures.- 8.2.5 Atypical Examples.- 8.3 CT Study of Anterior Column Fractures.- 9 Pure Transverse Fractures.- 9.1 Morphology.- 9.1.1 Orientation of Fracture.- 9.1.2 Displacement in Transverse Fractures.- 9.2 Radiology.- 9.2.1 Antero-posterior View.- 9.2.2 Obturator-oblique View.- 9.2.3 Iliac-oblique View.- 9.3 Atypical Cases.- 9.4 CT Scan Study of Transverse Fractures.- 10 T-shaped Fractures.- 10.1 Morphology.- 10.1.1 Transverse Component.- 10.1.2 Stem Component.- 10.1.3 Displacement.- 10.2 Radiology.- 10.2.1 Transverse Component.- 10.2.2 Stem Component.- 10.3 Atypical Examples.- 10.3.1 Additional Vertical Fracture of Obturator Ring.- 10.3.2 Additional Fracture Line in Cotyloid Fossa.- 10.3.3 Association of a Posterior Column and an Anterior Hemitransverse Fracture.- 10.4 CT Study of T-Shaped Fractures.- 11 Associated Posterior Column and Posterior Wall Fractures.- 11.1 Morphology.- 11.1.1 Posterior Wall Component.- 11.1.2 Posterior Column Component.- 11.2 Radiology.- 11.2.1 Antero-posterior View.- 11.2.2 Obturator-oblique View.- 11.2.3 Iliac-oblique View.- 11.3 Atypical Examples.- 11.4 Comment.- 11.5 CT Study of Associated Posterior Column and Posterior Wall Fractures.- 12 Associated Transverse and Posterior Wall Fractures.- 12.1 Cases with Posterior Dislocation.- 12.1.1 Morphology.- 12.1.2 Radiology.- 12.1.3 Atypical Examples.- 12.2 Cases with Central Dislocation.- 12.2.1 Morphology.- 12.2.2 Radiology.- 12.3 Comment.- 12.4 Very Large Postero-superior Fragment Extending to the Iliac Crest.- 12.5 CT Study of Associated Transverse and Posterior Wall Fractures.- 13 Associated and Posterior Hemitransverse Fractures.- 13.1 Morphology.- 13.1.1 Anterior Fractures with Associated Complete Posterior Hemitransverse Fracture.- 13.1.2 Anterior Fractures with Associated Incomplete Posterior Hemitransverse Fractures.- 13.1.3 Important Remarks.- 13.2 Radiology.- 13.2.1 Anterior Fracture.- 13.2.2 Posterior Column Fracture.- 13.2.3 A Special Feature of this Group.- 13.3 Atypical Examples.- 13.4 Radiological Differential Diagnosis.- 13.5 CT Study of Associated Anterior and Posterior Hemitransverse Fractures.- 14 Associated Both-Column Fractures.- 14.1 Morphology.- 14.1.1 Posterior Column Components.- 14.1.2 Additional Posterior Components.- 14.1.3 Anterior Column Component.- 14.1.4 Result of Both-Column Fracture.- 14.1.5 Displacement of the Fragments and the Femoral Head ..- 14.1.6 Atypical Examples.- 14.1.7 The Key to Reconstruction.- 14.2 Radiology.- 14.2.1 Antero-posterior View.- 14.2.2 Obturator-oblique View.- 14.2.3 Iliac-oblique View.- 14.3 Summary.- 14.4 Atypical Examples.- 14.5 Differential Radiological Diagnosis.- 14.6 CT Study of Associated Both-Column Fractures.- 15 Transitional and Extra-articular Forms.- 15.1 Transitional Forms.- 15.2 Extra-articular Forms.- 16 Associated Injuries.- 16.1 Injury of the Femoral Head.- 16.1.1 Macroscopic Injury.- 16.1.2 Vascular Injury.- 16.1.3 Molecular Injury.- 16.2 Capsular Injury.- 16.3 Vascular Injury.- 16.3.1 Acetabular Wall.- 16.3.2 Pelvic Vessels.- 16.3.3 Retro-peritoneal Haematoma.- 16.4 Other Pelvic Injuries.- 16.5 Associated Hip Injuries.- 16.6 Other Skeletal Injuries.- 16.7 Urinary Tract Injuries.- 16.8 Other Visceral Injuries.- 16.9 Associated Skull Trauma.- 16.10 Sciatic Nerve Injuries.- 17 Distribution of the Clinical Series.- 17.1 Distribution According to Age.- 17.2 Distribution According to Sex.- 17.3 Distribution According to Time After Injury.- 18 Clinical Presentation.- 18.1 Clinical Findings.- 18.1.1 Posterior Dislocation.- 18.1.2 Central Dislocation.- 18.2 Early Complications.- 18.2.1 Traumatic Shock.- 18.2.2 Retro-peritoneal Haematoma.- 18.2.3 Pre-operative Sciatic Nerve Injury.- 18.2.4 Morel-Lavallé Lesion.- 18.2.5 Intra-articular Incarceration of Bone Fragments.- 18.2.6 Other Types of Palsies.- 18.3 Special Cases.- 18.3.1 Children.- 18.3.2 Elderly Patients.- 18.3.3 Pathological Fractures.- 19 General Principles of Management of Acetabular Fractures.- 19.1 Conservative Treatment.- 19.1.1 Indications.- 19.1.2 Methods.- 19.1.3 Results.- 19.2 Justification for Operative Treatment.- 19.3 Indications for Operative Treatment.- 19.4 Timing of Surgery.- 20 Surgical Approaches to the Acetabulum.- 20.1 Classical Approaches.- 20.2 Kocher-Langenbeck Approach.- 20.2.1 Technique.- 20.2.2 Application.- 20.2.3 Closure.- 20.2.4 Dangers.- 20.2.5 Complications.- 20.3 Ilio-femoral Approach.- 20.3.1 Technique.- 20.3.2 Application.- 20.3.3 Closure.- 20.3.4 Dangers.- 20.3.5 Complications.- 20.4 Ilio-inguinal Approach.- 20.4.1 Technique.- 20.4.2 Application.- 20.4.3 Closure.- 20.4.4 Dangers.- 20.4.5 Complications.- 20.5 Combined Anterior and Posterior Approaches.- 20.6 Extended Ilio-femoral Approach.- 20.6.1 Technique.- 20.6.2 Application.- 20.6.3 Closure.- 20.6.4 Dangers.- 20.6.5 Complications.- 20.7 Post-operative Care.- 20.8 Summary of the Use of Different Surgical Approaches.- 20.9 Addendum: The Kocher-Langenbeck Extended to a Triradiate Approach.- 21 Operative Treatment of Displaced Fractures Within Three Weeks of Injury.- 21.1 Pre-operative Care.- 21.2 Choice of Surgical Approach.- 21.2.1 Kocher-Langenbeck Approach.- 21.2.2 Ilio-femoral Approach.- 21.2.3 Ilio-inguinal Approach.- 21.2.4 Fracture Types for Which There Is a Choice of Approach.- 21.3 Operative Details.- 21.3.1 Where and How to Insert Screws.- 21.3.2 Special Instruments.- 21.3.3 Implants for Osteosynthesis.- 21.3.4 Method of Internal Fixation.- 21.3.5 Reduction of Dislocation.- 21.3.6 Reduction of Fracture.- 21.4 Post-opertive Care.- 21.4.1 Local Care.- 21.4.2 Physiotherapy.- 21.4.3 Medical Treatment. JEAN-PIERRE MOULINIE.- 22 Operative Treatment of Specific Types of Fracture.- 22.1 Posterior Wall Fractures.- 22.1.1 Postero-superior Fractures.- 22.1.2 Postero-inferior Fractures.- 22.1.3 Special Features.- 22.2 Posterior Column Fractures.- 22.2.1 Special Features.- 22.3 Anterior Wall Fractures.- 22.4 Anterior Column Fractures.- 22.4.1 Middle and Low Fractures.- 22.4.2 High Fractures.- 22.4.3 Special Features.- 22.4.4 Insertion of Screws Along the Pelvic Brim.- 22.5 Pure Transverse Fractures.- 22.5.1 Pure Juxta-tectal or Infra-tectal Transverse Fractures.- 22.5.2 Pure Trans-tectal Transverse Fractures.- 22.5.3 Special Features.- 22.6 Associated Posterior Column and Posterior Wall Fractures.- 22.7 Associated Transverse and Posterior Wall Fractures.- 22.7.1 Kocher-Langenbeck Approach.- 22.7.2 Extended Ilio-femoral Approach.- 22.7.3 Special Features.- 22.8 T-shaped Fractures.- 22.8.1 Special Features.- 22.9 Associated Anterior and Hemitransverse Posterior Fractures.- 22.10 Both-Column Fractures.- 22.10.1 Approach.- 22.10.2 Reduction and Fixation Through Posterior Approach.- 22.10.3 Reduction and Fixation Through Ilio-inguinal Approach.- 22.10.4 Reduction Necessitating Both Approaches.- 22.10.5 Reduction and Fixation Through Extended Ilio-femoral Approach.- 22.10.6 A Particular Both-Column Fracture.- 22.11 Special Examples.- 22.11.1 Incarcerated Intra-articular Fragments.- 22.11.2 Bilateral Acetabular Fractures.- 22.11.3 Fractures of Paralysed Hips.- 23 Anatomical Results of Operation Within Three Weeks After Injury.- 23.1 Analysis of the Immediate Radiological Results.- 23.2 Analysis of Imperfect Radiological Reductions.- 23.3 The Learning Curve.- Appendix: CLAUDE MARTIMBEAU'S Method of Assessing Displacement in Acetabular Fractures.- 24 Early Complications of Operative Treatment Within Three Weeks of Injury.- 24.1 Death.- 24.2 Infection.- 24.2.1 Analysis of Post-operative Infections.- 24.2.2 Cause of Infection.- 24.2.3 Prophylaxis.- 24.2.4 Treatment.- 24.3 Nerve Damage.- 24.3.1 Sciatic Nerve Damage.- 24.3.2 Other Nerve Damage.- 24.4 Secondary Displacement of Fracture Site.- 24.5 Thrombo-embolism.- 24.6 Wound Complications.- 24.7 Miscellaneous Complications.- 25 Late Complications of Operative Treatment Within Three Weeks of Injury.- 25.1 Pseudarthrosis.- 25.2 Cartilage Necrosis.- 25.3 Avascular Bone Necrosis.- 25.3.1 Aetiology.- 25.3.2 Time of Presentation.- 25.3.3 Clinical and Radiological Course.- 25.3.4 Clinical and Radiological Results.- 25.3.5 Conclusion.- 25.4 Post-traumatic Osteoarthritis.- 25.4.1 Osteophytes.- 25.4.2 Osteoarthritis.- 25.5 Post-operative Ectopic Ossification.- 25.5.1 Clinical and Radiological Presentation.- 25.5.2 Aetiology.- 25.5.3 Treatment.- 25.5.4 Prevention.- 25.5.5 Results of Surgical Excision of Ectopic Bone.- 25.5.6 Ectopic Ossification and Cranio-cerebral Trauma.- 25.5.7 Ectopic Ossification and Type of Fracture.- 26 Clinical and Radiological Results of Operation Within Three Weeks of Injury.- 26.1 Clinical Results.- 26.1.1 Type of Fracture.- 26.1.2 Age of Patient.- 26.2 Radiological Results.- 26.3 Late Overall Clinical Results and Quality of Reduction.- 26.3.1 Perfect Reductions.- 26.3.2 Imperfect Reductions.- 26.3.3 Conclusions.- 26.4 Summary of Results.- 26.4.1 Early Results.- 26.4.2 Late Results.- 26.5 Conclusions.- 26.6 Comment.- 27 Reassessment of Patients Treated Operatively Within Three Weeks of Injury.- 27.1 Evolution in Patients Operated on Before 1966.- 27.2 Evolution in Patients Operated on 1966-1971.- 27.3 Evolution in Patients Operated on 1971 -1978.- 27.4 Assessment of Patients Operated on 1978-1990.- 27.5 Longitudinal Assessment of All Excellent or Very Good Results.- 28 Operative Treatment Between Three Weeks and Four Months After Injury.- 28.1 Condition of Fracture Healing.- 28.2 Surgical Approach.- 28.3 Surgical Technique.- 28.3.1 Cases with Visible Fracture Lines.- 28.3.2 Mal-union.- 28.3.3 Non-union/Mal-union.- 28.3.4 Neglected Posterior Dislocations of the Femoral Head...- 28.3.5 Incarcerated Fragments.- 28.3.6 Review of Surgical Techniques.- 28.4 Intra-operative Complications.- 28.5 Early Post-operative Complications.- 28.6 Late Post-operative Complications.- 28.7 Results.- 28.8 Conclusion.- 29 Operative Treatment More Than Four Months After Injury.- 29.1 General Considerations and Condition of Fracture Healing.- 29.2 Preconditions for Surgery.- 29.3 Time of Operation After Injury.- 29.4 Choice of Surgical Approach.- 29.5 Surgical Techniques Employed.- 29.5.1 Cases in Which Reconstruction Was Impossible.- 29.5.2 Cases in Which Reconstruction Was Possible.- 29.6 Overview of the 123 Cases Treated More Than Four Months After Injury.- 29.6.1 Reconstruction Impossible (49 Cases).- 29.6.2 Repositioning of Posteriorly Dislocated Femoral Head (11 Cases).- 29.6.3 Missed Incarcerated Fragment (16 Cases).- 29.6.4 Mal-unions, Non-unions, Mal-union/Non-unions.- 29.7 Conclusion.- 30 Exercises in Radiographic Diagnosis.