Internal fixation of acetabular fractures

Curing disease: Indication An unstable acetabular fracture will lead to traumatic hip arthritis, so the dome and posterior column (foot) must be reconstructed to achieve anatomic reduction and stable fixation of the weight-bearing part, and to prevent re-dislocation, improve or restore function. Therefore, it is often suitable for surgical repair and internal fixation. Surgery should be performed as soon as possible after recovery and proper preparation. If the dislocation is before or after the merger, the emergency should be rectified first, and the bone traction should maintain the position and stability, and then further reduce the fracture and internal fixation. The choice of internal fixation depends on the specific conditions of the fracture, the common acetabular and lip fractures, the back or posterior acetabular ankle (column), abdominal or anterior acetabular (column) fractures and transverse fractures are applied to the plate; each part of the joint fracture is required Reset internal fixation. Contraindications The acetabular posterior lip fracture, the flap is too small to be internal fixation. Preoperative preparation 1. There is no need for emergency surgery for acetabular fractures without dislocation. If there is no compound injury, it is usually 3 to 5 days after the injury. At this time, the injury surface of the pelvis has stopped bleeding, which is suitable for surgery. 2. There may be more bleeding during surgery, and blood should be prepared. Prepare all types of internal fixtures and instruments that may be needed. Surgical procedure Incision and approach (1) posterior incision: for acetabular posterior lip fracture, posterior column (foot) fracture, transverse fracture, T-shaped fracture and apical fracture of the humerus leading edge. Generally, the prone position is taken, and the knee flexion is 45°, so that the sciatic nerve is not easily damaged, and the femoral condyle is pulled by the needle bone. The Langenbeck-Kocher incision was used, centered on the upper part of the femur, up to 2/3 of the posterior iliac crest and the trochanter, and the lateral extension of the thigh was 10 cm (Fig. 3.5.1.1.1-5, 3.5). .1.1.1-6). In order to obtain more extensive exposure, the root of the inferior tidal artery can be turned over, cut at the piriform muscle stop point, and turned upside down to reveal the sciatic nerve and the large ischial notch, the inferior gluteal nerve and the arteriovenous vein. Cut off the small external rotation muscles and invert them inward, and cut the lower bursa, which reveals the small ischial notch and the upper edge of the ischial tuberosity. The biceps femoris does not need to be cut off routinely (Fig. 3.5.1.1.1-7). (2) Judet-Letournel can reveal the pubic symphysis and pubic symphysis, the middle of the pubic symphysis and its deep bone surface, and can extend to the quadrilateral surface of the large ischial notch. The side of the lumbosacral muscle, the concavity and the face of the ankle can be accessed from the front of the humerus. Therefore, it is suitable for the anterior column (foot) fracture of the acetabulum, including the anterior column of the pubic pubis (foot) and the internal fixation of all the suprapubic branches. Generally, the supine position is taken, and the incision starts from the 1/3 point of the iliac crest, and the anterior superior iliac spine is moved forward to the pubic symphysis. The anterior wall muscle of the iliac crest is cut along the iliac crest, and the iliac crest muscle is peeled off from the inner surface of the iliac crest, reaching the edge of the true pelvis. Gauze stuffing to stop bleeding. The extra-abdominal oblique tendon and the subcutaneous loop were cut parallel to the upper 2 cm of the inguinal ligament, the inguinal canal was opened, and the spermatic cord was separated and protected. The upper edge of the inguinal ligament was sharply cut to reveal the iliopsoas muscle sheath, and the femoral nerve was properly protected. The lateral femoral cutaneous nerve was protected when the anterior superior iliac spine was opened and the lower abdominis muscle was attached to the lower edge of the transverse abdominis muscle. The diaphragm is then peeled off along the edge of the true pelvis until it is fully revealed. The iliac crest and the transverse abdominis aponeurosis are separated from the medial side of the abdomen, which enters the posterior pubic space. If necessary, the rectus abdominis can also be cut 1 cm from the upper edge of the pubis (Fig. 3.5.1.1.1-9, 3.5.1.1.1-10). (3) Lateral approach: suitable for transverse fractures across the acetabular apex, with transverse acetabular anterior column (foot) or some anterior and posterior column (foot) fracture. Generally, the lateral position is taken, and a pelvis bracket is placed between the two thighs to facilitate up-and-down adjustment, and longitudinal traction of the lower limb is combined to maintain the femoral head in the correct position. The skin incision is in the shape of "?", starting from the posterior superior iliac spine, and descending along the anterior superior iliac spine, descending along the anterior border of the lateral femoral muscle and ending in the middle of the femoral. The gluteal muscle and tensor fascia lata were exfoliated from the inferior temporal margin of the iliac crest, and entered in the anterior iliac spine of the anterior iliac sacral muscle. Avoid damage to the lateral femoral cutaneous nerve and cut the tendon bundle along the direction of the incision. Continue to peel the gluteal muscle along the tibia and flip it down to reveal the joint capsule and peel off the leading edge of the large trochanter. Cut the gluteus maximus near the big trochanter. The formed tissue flap including the three gluteal muscles and the tensor fascia lata and its neurovascular vessels is lifted backwards, that is, a layer of external rotator muscles covered by the posterior joint. Cut the piriformis and obturator muscles, which extend into the posterior column (foot) of the entire hip to the top of the ischial tuberosity, but no more than the pubic bone. It is also possible to peel off the inner surface of the concave surface and reach the plane of the shame line. (4) The combined anterior and posterior incisions were adapted to both hips (posts) and T-shaped fractures. Take the lateral position and make the incision before and after, which can widely reveal the anterior and posterior anterior. 2. Reconstruction and internal fixation From a biomechanical point of view, the most important thing in acetabular fractures is to reconstruct the dome and the posterior column of the acetabulum. Therefore, treatment must begin with these two parts. (1) The fracture of the labrum, especially the posterior lip fracture, will affect the stability of the joint and the natural distribution of negative gravity, so it is suitable for early recovery. When the simple joint capsule is avulsed and the fracture piece is large, it can be cut open and directly restored by the technique, and the soft tissue attached to the bone surface is destroyed as little as possible, and fixed by one or more lag screws. Note that the nail tip cannot penetrate into the file. (2) The acetabular posterior column (foot) fracture often has avulsion of the joint capsule. Each invading the acetabulum, the fracture fragments can enter the joint. Requires a perfect reduction and removal of free bone fragments from the joints. It can be directly restored by hand or maintained by the rongeur, and then fixed with a lag screw or a dynamic compression plate. The steel plate is generally 6 to 7 holes, and the plastic shape is intended to be attached to the bone surface, from the upper pole of the ischial tuberosity to the posterior or posterior plane of the humerus. If the dome of the iliac crest is still intact, after the femoral head is rectified, the bone is fixed by a circular needle to maintain the position, and then the fracture is treated. (3) The acetabular anterior column and transverse fractures are fixed with steel plates, and the dynamic compression plate is better than the general steel plate. Combined fractures should be carefully analyzed, and each part requires rectification and firm internal fixation.

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