import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' ## Indications - **Displaced anterior column fractures** with >2mm articular step-off through weight-bearing dome - **Pelvic brim displacement >5mm** compromising hip stability - **Anterior column + posterior hemitransverse** fracture patterns - **Both-column fractures** requiring anterior approach for reduction - **T-type fractures** with significant anterior component displacement - **Associated hip dislocation** not reducible by closed means - **Incarcerated intra-articular fragments** from femoral head impaction **Examiner Question**: "How do you determine if the weight-bearing dome is involved?" **Model Answer**: "I use **Matta's roof arc measurements**. On AP and both oblique views, I draw a vertical line through the femoral head center, then measure the angle from this line to where the fracture exits the articular surface. If ANY of the three roof arc angles is **less than 45°**, the weight-bearing dome is involved and surgery is indicated. Additionally, on CT, I look at cuts through the dome - the superior 10mm of acetabulum carries 90% of load." - **Measuring roof arcs incorrectly** - must be from vertical line through head center - **Missing dome impaction on plain films** - CT essential to see marginal impaction - **Underestimating posterior wall** - if >40% involved, add posterior approach - **Ignoring quadrilateral plate** - medial displacement predicts instability - Low anterior column fractures extending to pubic ramus - Anterior wall fractures with >25% involvement - Quadrilateral plate displacement with medial head protrusion - Failed closed reduction of associated hip dislocation - Acetabular fracture with ipsilateral pelvic ring injury requiring ORIF **Examiner Question**: "When would you use a modified Stoppa approach instead of ilioinguinal?" **Model Answer**: "I would consider **modified Stoppa** for: (1) **Low anterior column fractures** extending below the pectineal eminence; (2) **Quadrilateral plate comminution** requiring direct visualization and buttress plating; (3) **Bilateral anterior injuries** - single midline incision; (4) **Elderly patients with medial head protrusion**. The Stoppa provides better visualization of the quadrilateral plate and pelvic brim from below, with less soft tissue dissection than ilioinguinal. However, ilioinguinal is better for high anterior column injuries and when iliac wing access is needed." - **Using ilioinguinal for low fractures** - Stoppa gives better quadrilateral access - **Single approach for both-column** - may need combined anterior + posterior - **Ignoring posterior wall size** - if >40%, add Kocher-Langenbeck - **Not considering patient factors** - previous surgery, obesity affect approach choice **Absolute:** - Active pelvic sepsis or soft tissue infection - Severe medical comorbidities precluding major surgery - Moribund patient with limited life expectancy - Severe osteoporosis precluding internal fixation **Relative:** - Delayed presentation >21 days (consider THA) - Severe femoral head damage (Pipkin III/IV - consider THA) - Pre-existing severe hip osteoarthritis - Low anterior column below teardrop (consider Stoppa) - Morbid obesity (technical difficulty) - Previous ipsilateral inguinal surgery (scar tissue) **Examiner Question**: "A 78-year-old presents with anterior column fracture 25 days after injury. How do you manage?" **Model Answer**: "At 25 days, the fracture is past the optimal window (3-7 days) and approaching the 21-day threshold where ORIF becomes significantly more difficult due to callus formation. Options: (1) **If good bone quality and mobile fragments on CT** - attempt ORIF but counsel about increased difficulty and possible conversion; (2) **If significant callus/healing or poor bone** - primary THA is often preferable; (3) **Consider patient factors** - age 78 makes THA reasonable as definitive treatment. I would discuss with the patient that delayed ORIF has higher complication rates and may still require THA conversion." - **Morel-Lavallée lesion** - degloving injury, high infection risk, may need staged approach - **Femoral head damage on CT** - Pipkin III/IV suggests primary THA may be better option - **Delay >21 days** - callus makes reduction extremely difficult, consider THA - **Active infection** - absolute contraindication, staged treatment required ## Pre-operative Planning ### Clinical Assessment - Mechanism: high-energy (MVA, fall from height) vs low-energy (elderly) - Time since injury (optimal surgery 3-7 days) - Associated injuries: urological, vascular, neurological - Comorbidities: anticoagulation, diabetes, smoking, immunosuppression - Functional baseline and expectations - **Neurovascular**: femoral, sciatic nerve function documented - **Skin**: Morel-Lavallée lesion (degloving), abrasions, open wounds - **Associated injuries**: chest, spine, long bone fractures - **Ipsilateral limb**: leg length, rotation, stability - **Urological**: blood at meatus, high-riding prostate, perineal bruising ### Imaging Review **Matta Roof Arc Measurements**: Draw vertical/horizontal lines through femoral head center on AP and obliques. Measure angle from fracture to weight-bearing dome. If ALL three arcs >45°, non-operative management may be considered. ### Templating and Planning - **Fracture classification**: Judet-Letournel (elementary vs associated) - **Approach selection**: Ilioinguinal for anterior column, Kocher-Langenbeck for posterior - **Plate selection**: 3.5mm reconstruction plates, pre-contoured pelvic brim plates - **Screw lengths**: Template from CT (typically 30-50mm pelvic brim, 20-35mm quadrilateral) - **Blood products**: Type and screen, have 2-4 units PRBC available ### Consent Discussion **Expected Outcomes:** - Anatomic reduction (<2mm): 85-90% good/excellent clinical outcome - Non-anatomic reduction: 50% poor outcome - 20-30% eventual THA conversion at 10-15 years despite good reduction **Specific Risks to Discuss:** | Complication | Incidence | Key Points | |--------------|-----------|------------| | LFCN injury | 70% | Usually temporary numbness anterolateral thigh | | Femoral nerve | 1-3% | Usually neuropraxia, recovers 6-12 months | | Vascular injury | <1% | External iliac - catastrophic if occurs | | Corona mortis bleed | 5-10% | Ligate prophylactically | | DVT/PE | 5-10% | Extended prophylaxis required | | Infection | 2-3% superficial, <1% deep | Higher with Morel-Lavallée | | Heterotopic ossification | 20-50% | Prophylaxis reduces to 5-10% | | Post-traumatic arthritis | 20-30% | Despite anatomic reduction | | Nonunion | ~5% | Higher with comminution | ## Equipment ### Implants - 3.5mm pelvic reconstruction plates (multiple lengths: 6-14 hole) - Pre-contoured pelvic brim plates (if available) - 3.5mm cortical screws (lengths 20-60mm) - 3.5mm cancellous screws (for lag technique) - 4.5mm cortical screws (for iliac wing if needed) - Spring plates for comminution - 2.0mm K-wires for provisional fixation ### Instruments - Pelvic reduction set (Farabeuf clamps, Jungbluth clamps, ball spike pushers) - Cobb elevators (essential for subperiosteal dissection) - Small Hohmann retractors - Self-retaining retractors (Charnley, Balfour) - Reduction forceps (pointed, serrated) - Plate bending press and irons - Long drill bits and depth gauge ### Adjuncts - Cell saver (blood loss 500-1500mL expected) - C-arm fluoroscopy (must achieve AP, obturator oblique, iliac oblique) - Radiolucent table - Vessel loops (for nerve/vessel protection) - Bone wax, Surgicel, topical haemostatics - Large-bore suction drains (19Fr) ## Anaesthesia and Positioning ### Anaesthesia - **Preferred**: General anaesthesia with arterial line - **Considerations**: - Hypotensive anaesthesia (MAP 60-65) reduces blood loss - TXA 1g IV at induction, repeat 1g at 3 hours - Cell saver if anticipated blood loss >1L - Avoid spinal/epidural (need to assess lower limb neurology post-op) ### Patient Positioning - Supine on radiolucent table - Small bump (folded towel) under ipsilateral buttock - internally rotates hemipelvis - Both arms tucked or one arm board (ensure brachial plexus protected) - Foley catheter (decompresses bladder, protects in medial window) - All pressure points padded - C-arm positioned on contralateral side for swing access - Ensure AP, obturator oblique (45° affected side down), iliac oblique (45° affected side up) achievable ### Skin Preparation - 2% chlorhexidine in alcohol - Prep: umbilicus to mid-thigh, midline to posterior axillary line - Include genitalia in prep (if extension to medial window needed) ### WHO Checklist / Time Out - [ ] Correct patient, correct side (mark with permanent marker) - [ ] Consent confirmed with specific risks - [ ] Antibiotics given (cefazolin 2g IV within 60 min of incision) - [ ] VTE prophylaxis plan documented - [ ] Blood available (type and screen, 2-4 units) - [ ] Equipment checked (reduction instruments, plates, fluoroscopy) - [ ] Team briefing: anticipated blood loss, potential complications ## Surface Anatomy and Landmarks ### Key Landmarks - **ASIS (Anterior Superior Iliac Spine)**: Start point of incision, LFCN exits 10-20mm medial - **Pubic Symphysis**: End point of incision, medial window limit - **Inguinal Ligament**: Runs from ASIS to pubic tubercle - stay 2cm superior - **Pubic Tubercle**: Palpable 2cm lateral to symphysis, spermatic cord passes superficial - **Iliac Crest**: Lateral window extends along inner table ### Incision - **Type**: Oblique curvilinear (bikini line modification) - **Start**: ASIS - **Course**: Curves medially along Langer's lines, 2cm above inguinal ligament - **End**: Pubic symphysis (can extend 2-3cm across midline if needed) - **Length**: 12-15cm (adjust for body habitus and fracture extent) ## Surgical Approach ### Internervous Plane - **Lateral Window**: No true internervous plane - iliacus elevated subperiosteally - **Middle Window**: Between iliopsoas (femoral nerve) and external iliac vessels - **Medial Window**: Subperiosteal on superior pubic ramus ### Superficial Dissection **Step 1: Skin and Subcutaneous** 1. Incise skin along marked bikini line 2. Divide subcutaneous tissue and Scarpa's fascia 3. Identify and protect superficial epigastric vessels (ligate if crossing) 4. Expose external oblique aponeurosis **Step 2: External Oblique and LFCN** 1. Incise external oblique aponeurosis 2cm above inguinal ligament 2. **CRITICAL**: Identify lateral femoral cutaneous nerve (LFCN) - exits 10-20mm medial to ASIS, crosses iliacus 3. Protect LFCN with vessel loop - most commonly injured nerve (70%) 4. If LFCN in way, may need to sacrifice (counsel patient: anterolateral thigh numbness) The LFCN is the most commonly injured structure (70% temporary neuropraxia). Look for it early under the external oblique fascia, 1-2cm medial to ASIS, running obliquely over iliacus. Protect with vessel loop or sacrifice with informed consent. ### Deep Dissection - Three Windows **LATERAL WINDOW (Iliac Wing)** 1. Subperiosteal elevation of iliacus from inner table using Cobb elevator 2. Expose from ASIS posteriorly toward SI joint as needed 3. Pack with laparotomy sponge to maintain exposure 4. This gives access to iliac wing and superior anterior column **MIDDLE WINDOW (Pelvic Brim)** 1. Identify iliopsoas muscle (lateral) and external iliac vessels (medial) 2. Create interval between these structures 3. Ligate lateral femoral circumflex vessels crossing this window 4. **CRITICAL**: Identify and ligate CORONA MORTIS if present (30% incidence) - Aberrant obturator vessel connecting external iliac to obturator system - Crosses 15-25mm from pubic symphysis - Ligate prophylactically with clips or ties 5. Subperiosteal elevation along pelvic brim to quadrilateral plate 6. External iliac vessels: NEVER retract laterally (causes kinking) - only gentle medial retraction **Corona Mortis**: Present in ~30% of patients. An aberrant connection between external iliac/inferior epigastric and obturator vessels. If avulsed during subperiosteal dissection, causes significant bleeding that is difficult to control. Always actively look for it 2-3cm from symphysis and ligate before avulsion. **MEDIAL WINDOW (Superior Pubic Ramus)** 1. Detach rectus abdominis from pubic symphysis (tag for repair) 2. Identify spermatic cord (male) or round ligament (female) 3. Retract cord/ligament medially with Penrose drain 4. Subperiosteal elevation along superior pubic ramus 5. Stay on bone to protect bladder (10-20mm medial) 6. Expose Cooper's ligament (pectineal line) to pubic tubercle 7. Access to anterior column inferior extension and quadrilateral plate ## Operative Technique ### Step 1: Fracture Assessment 1. Debride fracture haematoma from all three windows 2. Assess fracture pattern under direct vision 3. Confirm CT findings - marginal impaction, loose bodies 4. Obtain fluoroscopy: AP, obturator oblique, iliac oblique 5. Plan reduction sequence based on fracture pattern **Key Principle**: Restore pelvic brim continuity FIRST (middle window) as reference for remaining reduction **Examiner Question**: "What fluoroscopy views do you obtain for acetabular fracture ORIF and what does each show?" **Model Answer**: "I obtain **three views**: (1) **AP pelvis** - shows both columns, teardrop integrity, overall alignment; (2) **Obturator oblique (45° affected side DOWN)** - shows anterior column profile and posterior wall en face - best view for posterior wall reduction; (3) **Iliac oblique (45° affected side UP)** - shows posterior column profile and anterior wall en face. Each view shows one column in profile and the opposite wall en face. I must achieve all three to assess complete reduction." - **Not obtaining all 3 views** - miss malreduction in one column - **Missing marginal impaction** - often not visible, correlate with CT - **Ignoring loose bodies** - must remove from joint to prevent chondrolysis - **Rushing to reduce** - proper assessment saves time and prevents re-do ### Step 2: Fracture Reduction - Use Farabeuf or Jungbluth clamps - Ball spike pusher through stab incision for percutaneous joysticks - Pointed reduction forceps for fragment manipulation - Sequence: brim first, then superior (lateral window), then inferior (medial window) **Examiner Question**: "What is your reduction sequence for anterior column fractures?" **Model Answer**: "I follow the principle of **restoring the pelvic brim first** as the reference for remaining reduction. Sequence: (1) Debride haematoma from all windows; (2) Identify fracture pattern and key fragments; (3) **Reduce pelvic brim in middle window** using Farabeuf clamps - this is the 'keystone'; (4) Reduce superior fragments through lateral window; (5) Reduce inferior fragments through medial window. I verify with fluoroscopy (AP, obturator oblique, iliac oblique) before definitive fixation." - **Aggressive clamp placement** - can fracture osteoporotic bone - **Overtightening Farabeuf** - causes fragment comminution - **Not verifying with fluoro** - may accept hidden malreduction - **Wrong sequence** - reducing ends before brim loses reference - Cannot use lag screws - use buttress plating - Reduce largest fragments first - Accept minor gaps if articular surface aligned - Consider bone graft for significant defects **Examiner Question**: "How do you manage comminution in acetabular fractures?" **Model Answer**: "With comminution, I follow these principles: (1) **Avoid lag screws** - will collapse fragments; (2) Use **buttress/neutralization plates** instead; (3) **Reduce largest fragments first** and work toward smaller ones; (4) **Accept minor gaps** in cortical bone if articular surface is congruent; (5) **Bone graft significant defects** using iliac crest; (6) Consider **spring plates** for small marginal fragments. The goal is restoring articular congruity, not anatomic cortical reduction." - **Lag screws through comminution** - collapses fragments, loses reduction - **Striving for anatomic cortical reduction** - impossible with comminution - **Not grafting defects** - leads to late collapse - **Ignoring elderly bone quality** - augmented fixation may be needed - Elevate impacted dome fragments - Support with bone graft (from iliac crest) - Buttress with plate/screws **Examiner Question**: "How do you address marginal impaction in acetabular fractures?" **Model Answer**: "Marginal impaction is often missed on plain X-rays - **CT is essential**. Management: (1) Identify impaction location (usually superomedial dome); (2) Create a **cortical window** or access through fracture line; (3) **Elevate impacted articular fragments** using curved curette or bone tamp; (4) **Support with bone graft** (cancellous from iliac crest or femoral head); (5) **Buttress with plate** to prevent re-collapse. If not addressed, impaction leads to early arthritis despite apparent anatomic reduction." - **Missing impaction on plain films** - always get CT - **Elevating without graft support** - fragments will re-collapse - **Inadequate buttress** - need plate to maintain elevation - **Damaging articular cartilage** - use smooth instruments, indirect elevation **Reduction Verification:** - Direct vision: palpate articular surface through windows - Fluoroscopy: AP (both columns), obturator oblique (anterior column/posterior wall), iliac oblique (posterior column/anterior wall) - **Goal**: <2mm articular step-off Anatomic reduction (<2mm articular displacement) is critical for outcome. Matta's data: Anatomic reduction = 85-90% good/excellent outcome. Non-anatomic = 50% poor outcome. Do not accept malreduction. ### Step 3: Provisional Fixation 1. Use 2.0mm K-wires perpendicular to fracture line 2. Alternative: 2.7mm Schanz pins for larger fragments 3. Leave tails long for easy removal 4. Confirm no joint penetration with fluoroscopy (all 3 views) 5. Check stability of reduction before plating **Examiner Question**: "How do you confirm your K-wires are not intra-articular?" **Model Answer**: "I confirm with **all three fluoroscopy views** (AP, obturator oblique, iliac oblique). The key is that a K-wire may appear extra-articular on one view but penetrate joint on another. I look for: (1) Wire tip relationship to the teardrop on AP; (2) Wire relationship to the posterior wall on obturator oblique; (3) Wire relationship to the anterior wall on iliac oblique. If any doubt, I remove and reposition. An intra-articular wire causes **chondrolysis and rapid arthritis**." - **Intra-articular K-wire** - causes chondrolysis, check ALL 3 views - **Wire migration** - use smooth wires, leave tails long for removal - **Over-drilling** - can breach joint, use depth stop if available - **Wire through comminution** - won't hold, use larger fragment ### Step 4: Definitive Plate Fixation **Anterior Column Plate (Pelvic Brim):** 1. Contour 3.5mm reconstruction plate to pelvic brim (inner table) 2. Plate runs from iliac wing, across brim, to superior pubic ramus 3. Position: on bone, medial to iliopectineal eminence 4. Screw placement: - Iliac wing: bicortical 4.5mm or 3.5mm (30-50mm) - Pelvic brim: unicortical 3.5mm directed posteriorly (20-35mm) - Superior ramus: unicortical 3.5mm directed posteriorly 5. **CRITICAL**: Medially-directed screws risk external iliac vessels - direct posteriorly 6. Lag screws through plate for large non-comminuted fragments 7. Minimum 6 cortices each side of fracture **Safe Screw Trajectory**: Screws along pelvic brim should be directed POSTERIORLY toward posterior column, NOT medially. Medially-directed screws risk external iliac vessels (10-20mm medial) and obturator vessels. Posterior direction is safe for 30-50mm screws. - **Medially-directed screws** - risk external iliac vessels, ALWAYS direct posteriorly - **Insufficient cortices** - need minimum 6 cortices each side of fracture - **Over-contouring plate** - weakens plate, may break - **Intra-articular screw** - check all 3 fluoro views before final tightening ### Step 5: Quadrilateral Plate Support (If Needed) - **Indication**: Medial wall comminution or displacement, elderly with osteoporosis - Contour 3.5mm plate from superior ramus along quadrilateral plate - Position INFRAPECTINEAL (below pectineal line) - Screws directed posteriorly 30-40° into posterior column - Acts as buttress preventing femoral head medialization **Examiner Question**: "When do you add a quadrilateral plate and how do you position it?" **Model Answer**: "I add quadrilateral plate buttress for: (1) **Medial wall comminution**; (2) **Elderly osteoporotic bone**; (3) **Central head protrusion**. Positioning: Place the plate **INFRAPECTINEAL** (below the pectineal line) along the quadrilateral surface. Screws are directed **posteriorly 30-40°** into the posterior column - this avoids the hip joint. The plate acts as a buttress preventing the femoral head from medializing. Pre-contoured quadrilateral plates are now available and simplify this step." - **Suprapectineal placement** - screws risk joint penetration - **Medially-directed screws** - risk obturator vessels and bladder - **Inadequate buttress** - head will medialize with weight-bearing - **Not recognizing need** - comminuted medial wall WILL fail without buttress ### Step 6: Final Fluoroscopy 1. Remove all provisional K-wires 2. Obtain definitive AP, obturator oblique, iliac oblique views 3. **Verify**: - Anatomic reduction all columns - No intra-articular screws (critical - causes chondrolysis) - Adequate screw purchase - Joint congruency restored 4. Document images in operative record **Examiner Question**: "What are you looking for on your final fluoroscopy images?" **Model Answer**: "On final fluoroscopy, I systematically verify: (1) **Reduction quality** - <2mm step-off in weight-bearing dome on all views; (2) **No intra-articular hardware** - check each screw on all 3 views, a screw may look extra-articular on one view but penetrate joint on another; (3) **Screw purchase** - bicortical where possible, not protruding posteriorly; (4) **Joint congruency** - concentric femoral head, no subluxation; (5) **Overall alignment** - pelvic brim restored, no gapping. I save images for the operative record." - **Only checking one view** - intra-articular screw may be hidden on single view - **Accepting step-off** - >2mm predicts poor outcome, revise now not later - **Not documenting images** - medicolegal protection, save all views - **Missing loose bodies** - cause chondrolysis, must remove before closure ## Closure ### Haemostasis - Systematic check of all three windows - Bone wax for iliac wing bleeding points - Cautery for soft tissue bleeders - Topical haemostatics (Surgicel, Floseal) for ooze - Irrigation with 3L normal saline minimum ### Drain Placement - Large-bore drain (19Fr) in lateral and/or middle window - Route away from vessels and nerves - Secure to skin, connect to suction - Remove when output <30mL/8hrs (typically 48-72 hours) ### Layered Closure 1. **Deep**: Repair rectus abdominis to pubic periosteum (0 Vicryl) 2. **Middle**: Approximate external oblique over inguinal ligament (0 Vicryl) 3. **Scarpa's fascia**: 2-0 Vicryl (reduces dead space, hernia risk) 4. **Dermis**: 3-0 Vicryl or Monocryl 5. **Skin**: Subcuticular 4-0 Monocryl or staples ### Dressing - Waterproof adhesive dressing - Abdominal binder for comfort - Mark drain exit sites ## Intra-operative Complications **External Iliac Vessel Injury** - Recognition: Sudden profuse bleeding, hypotension - Prevention: Stay on bone, retract vessels gently medially, identify corona mortis - Management: 1. Direct pressure immediately 2. Call vascular surgery 3. Proximal and distal control 4. Primary repair or interposition graft 5. Fasciotomies if prolonged ischaemia **Corona Mortis Bleeding** - Recognition: Sudden arterial bleeding from medial window - Prevention: Actively identify and ligate BEFORE avulsion - Management: Direct pressure, clip or suture ligation **Examiner Question**: "You encounter sudden profuse bleeding from the middle window. What do you do?" **Model Answer**: "I immediately apply **direct pressure** with a laparotomy pack and call for help. I suspect external iliac vessel injury. Steps: (1) Maintain pressure while team activates massive transfusion protocol; (2) **Call vascular surgery** immediately; (3) Extend incision if needed for proximal control; (4) Once vascular surgeon arrives, obtain **proximal and distal control** with vessel loops or clamps; (5) Identify injury - primary repair if clean laceration, interposition graft if complex; (6) Check distal pulses post-repair; (7) **Fasciotomies** if ischaemia time >4-6 hours." - **NEVER retract vessels laterally** - causes kinking and injury - **Pack and hold** - don't blindly clamp, will worsen injury - **Call early** - vascular surgery takes time to arrive - **Know proximal control** - common iliac above inguinal ligament **LFCN Injury (Most Common)** - Recognition: Post-op anterolateral thigh numbness - Prevention: Identify early, protect with vessel loop - Management: Usually neuropraxia, recovers 3-6 months. Counsel patient. **Femoral Nerve Injury** - Recognition: Weak hip flexion/knee extension post-op - Prevention: Iliopsoas protects if subperiosteal dissection maintained - Management: Document, NCS/EMG at 6 weeks, physiotherapy, usually recovers **Examiner Question**: "The patient has quadriceps weakness post-operatively. What is your assessment?" **Model Answer**: "I would assess for **femoral nerve injury**. Examination: (1) Test hip flexion (iliopsoas - femoral L2-3); (2) Test knee extension (quadriceps - femoral L2-4); (3) Test knee jerk (L3-4); (4) Sensory testing anterior thigh and medial leg (saphenous). If femoral neuropathy confirmed, I would: (1) **Document findings**; (2) Order **NCS/EMG at 6 weeks** to assess severity; (3) Intensive physiotherapy to prevent contracture; (4) Knee brace for safety. Prognosis: most are neuropraxia from retraction, recover over 6-12 months. If no recovery by 6 months, consider exploration." - **LFCN** - look for it FIRST, 1-2cm medial to ASIS under external oblique - **Femoral nerve** - protected by iliopsoas IF you stay subperiosteal - **Document pre-op neurology** - must have baseline for comparison - **Avoid prolonged retraction** - release retractors every 30 minutes **Recognition**: Urine in wound, haematuria, catheter malfunction **Prevention**: - Foley catheter to decompress - Stay subperiosteal on superior ramus - Bladder 10-20mm medial to dissection **Management**: - Intraoperative: Primary repair in two layers, prolonged catheter drainage - Urology consultation **Examiner Question**: "You see clear fluid in the wound during medial window dissection. What do you do?" **Model Answer**: "I suspect **bladder injury**. Immediate steps: (1) Stop dissection and irrigate; (2) Confirm bladder injury - instill methylene blue or saline via Foley and observe for leak; (3) Identify extent of injury; (4) **Primary repair in two layers** - inner layer 3-0 vicryl continuous, outer layer 3-0 vicryl interrupted; (5) Test repair - fill bladder and check for leak; (6) **Prolonged catheter drainage** 10-14 days; (7) Obtain **urology consultation**; (8) Cystogram before catheter removal. Document injury and repair in operative note." - **Always insert Foley** - decompresses bladder, makes it smaller target - **Stay on bone** - subperiosteal dissection keeps you away from bladder - **Bladder 10-20mm medial** - respect this boundary - **Previous pelvic surgery** - bladder may be adherent, extra caution ## Post-operative Care ### Immediate (Recovery - Day 0) - Neurovascular check documented (femoral and sciatic nerve function) - Post-operative X-rays (AP pelvis, Judet views) - VTE prophylaxis: LMWH (enoxaparin 40mg SC) starting 12 hours post-op - Pain management: PCA, then oral analgesia - Drain output monitoring ### Day 1-3 - Mobilise with physiotherapy: toe-touch weight bearing - Continue VTE prophylaxis - **HO Prophylaxis** (start Day 1): - Indomethacin 75mg PO daily × 6 weeks (preferred), OR - Single-dose radiation 700 cGy within 72 hours (if NSAID contraindicated) - Remove drains when output <30mL/8hrs (typically 48-72h) - Wound check before discharge ### Discharge Criteria - Pain controlled on oral analgesia - Mobilising safely with frame/crutches - Wound clean and dry - Understands weight-bearing restrictions - VTE prophylaxis plan (LMWH or DOAC × 4-6 weeks) - HO prophylaxis plan - Follow-up arranged ### Weight-bearing Protocol | Fracture Pattern | Weight-bearing | Duration | |------------------|---------------|----------| | Simple anterior column | Toe-touch | 6-8 weeks | | Anterior + PHT | Toe-touch | 8-10 weeks | | Both column | Toe-touch | 10-12 weeks | | With comminution | Toe-touch | 12 weeks | ### Follow-up Schedule - **2 weeks**: Wound check, suture/staple removal - **6 weeks**: Clinical review, X-rays, consider advancing weight-bearing - **12 weeks**: Clinical review, X-rays, usually progress to full weight-bearing - **6 months**: X-rays, assess for AVN, HO, arthritis - **1 year**: X-rays, functional outcome assessment - **Ongoing**: Annual or as symptoms dictate - **AVN**: MRI at 6-12 months if groin pain (10-20% incidence) - **Post-traumatic arthritis**: Progressive joint space narrowing (20-30%) - **HO**: Brooker classification on X-rays - **Hardware symptoms**: May require removal after union (12-18 months) ## Viva Scenarios ## Key Exam Points ### Must-Know Facts for Viva 1. **Classification**: Draw all 10 Judet-Letournel patterns - 5 elementary (anterior wall, anterior column, posterior wall, posterior column, transverse) + 5 associated (T-type, posterior column + wall, transverse + posterior wall, anterior column + PHT, both column) 2. **Surgical Indications**: Roof arc <45°, dome impaction, posterior wall >40%, displaced through weight-bearing dome >2mm, brim >5mm 3. **Three Windows**: - Lateral: ASIS to SI joint, LFCN at risk - Middle: Between iliopsoas and external iliac vessels, corona mortis - Medial: Superior pubic ramus, bladder at risk 4. **Danger Structures with Distances**: - LFCN: 10-20mm medial to ASIS (70% injury rate) - External iliac: 10-20mm medial to pelvic brim - Corona mortis: 15-25mm from symphysis (30% present) - Bladder: 10-20mm medial to superior ramus 5. **Outcomes Data**: - Matta: anatomic reduction = 85-90% good outcome - Non-anatomic = 50% good outcome - 20-30% THA conversion at 10-15 years despite good reduction ## References 1. **Matta JM**. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. *J Bone Joint Surg Am*. 1996;78(11):1632-45. 2. **Letournel E, Judet R**. Fractures of the Acetabulum. 2nd ed. Springer-Verlag; 1993. 3. **Giannoudis PV, et al**. Operative treatment of displaced fractures of the acetabulum: a meta-analysis. *J Bone Joint Surg Br*. 2005;87(1):2-9. 4. **Tile M, et al**. Fractures of the Pelvis and Acetabulum: Principles and Methods of Management. 4th ed. Thieme; 2015. 5. **Tornetta P 3rd, Matta JM**. Outcome of operatively treated unstable posterior pelvic ring disruptions. *Clin Orthop Relat Res*. 1996;(329):186-93. 6. **Karunakar MA, et al**. Iatrogenic nerve palsy after acetabular surgery. *J Orthop Trauma*. 2003;17(2 Suppl):S19-25. [LFCN injury data] 7. **Okcu G, Erkan S**. The corona mortis: a systematic review. *Surg Radiol Anat*. 2004;26(6):475-81.

Acetabular Fracture ORIF - Anterior Column

Acetabular Fracture ORIF - Anterior Column