Acetabulum Set 5 p 81

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FRACTURE OF ACETABULUM ã The acetabulum can be described as an incomplete hemispherical socket with an inverted horseshoe-shaped articular surface surrounding the nonarticular cotyloid fossa. This articular socket is composed of and supported by two columns of bone, described by Letournel and Judet as an inverted Y. The anterior column is composed of the bone of the iliac crest, the iliac spines, the anterior half of the acetabulum, and the pubis. The posterior column is the ischium, the ischial
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  FRACTURE OF ACETABULUM ã  The acetabulum can be described as an incomplete hemispherical socket withan inverted horseshoe-shaped articular surface surrounding the nonarticular cotyloid fossa . ã  This articular socket is composed of and supported by two columns of bone ,described by Letournel and Judet as an inverted Y. ã  The anterior column is composed of the bone of the iliac crest, the iliacspines, the anterior half of the acetabulum, and the pubis. ã  The posterior column is the ischium, the ischial spine, the posterior half of the acetabulum, and the dense bone forming the sciatic notch. ã  The column concept is used in classification of these fractures and is centralto the discussion of fracture patterns, operative approaches, and internal fixation. ã  The dome, or roof, of the acetabulum is the weight bearing portion of thearticular surface that supports the femoral head ã Anatomical restoration of the dome with concentric reduction of thefemoral head beneath this dome is the goal of both operative and nonoperativetreatment. ã  The quadrilateral surface is the flat plate of bone forming the lateral borderof the true pelvic cavity and thus lying adjacent to the medial wall of theacetabulum.   ã  The iliopectineal eminence is the prominence in the anterior column that liesdirectly over the femoral head. ã Both the quadrilateral surface and the iliopectineal eminence are thin andadjacent to the femoral head, limiting the types of fixation that can be usedin these regions  Two-column concept of Letournel used in classification of acetabular fractures ã  The neurovascular structures passing through the pelvis are at risk  during thesrcinal injury and subsequent treatment, and the various surgical approaches aredesigned around these structures. ã  The sciatic nerve exiting the greater sciatic notch inferior to the piriformismuscle frequently is injured with posterior fracture-dislocations of the hip and fractures with posterior displacement ã  The functioning of both the tibial and common peroneal components of thesciatic nerve must be carefully documented in the emergency department andafter subsequent interventions  ã  The superior gluteal artery and nerve exit the greater sciatic notch at itsmost superior aspect and can be tethered to the bone at this level by variablefascial attachments. ã Fractures that enter the superior portion of the greater sciatic notch can beassociated with significant hemorrhage, possibly requiring angiography with embolization of the superior gluteal artery . ã Knowledge of the intrapelvic relationships of the lumbosacral trunk, common andexternal iliac vessels, and inferior epigastric vessels as well as of the obturatorartery and nerve becomes crucial as retractors, reduction forceps, drills, andscrews are used. ã One particularly noteworthy anatomical relationship is the occasional largeanastomosis between the external iliac artery or inferior epigastric arteryand the obturator artery known as the corona mortis   ã Failure to ligate this vascular connection during the ilioinguinal approach can lead to significant hemorrhage that is difficult to control as the external iliacvessels are mobilized. RADIOGRAPHIC EVALUATION   ã  The acetabulum is evaluated radiographically with an AP pelvic view as well aswith the 45-degree oblique views of the pelvis described by Judet andLetournel, commonly called  Judet views.   ã In the iliac oblique view , the radiographic beam is roughly perpendicular tothe iliac wing . ã In obturator oblique view , radiographic beam is roughly perpendicular to theobturator foramen. ã Inclusion of the opposite hip in the radiographic field on the anteroposteriorand Judet views is essential for evaluation of symmetrical contours that may  have slight individual variations and to determine the width of the normalarticular cartilage in each view. ã  The medial clear space between the femoral head and the radiographicteardrop in the injured and uninjured hips should be compared on theanteroposterior view as an indication of  femoral head subluxation. ã Fractures that traverse the anterior column   disrupt the iliopectineal line ,whereas fractures that traverse the posterior column disrupt the ilioischialline . Landmarks of standard anteroposterior radiograph of hip. 1. Iliopectineal line beginning at greater sciatic notch of ilium and extending downto pubic tubercle . 2. Ilioischial line formed by posterior four fifths of quadrilateral surface of ilium. 3. Radiographic teardrop composed laterally of most inferior and anterior portionof acetabulum and medially of anterior flat part of quadrilateral surface of iliacbone . 4. Roof of  acetabulum.   5. Edge of  anterior lip of    acetabulum. 6. Edge of   posterior lip of acetabulum.
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