There are various types of fractures occurring in various joints of the body. Among all the fractures occurring primarily in young adults because of high velocity trauma, are the acetabular fractures or the fractures of acetabulum. These fractures can actually be serious at times and be associated with various other life threatening injuries. This article discusses acetabular fracture, its classification, diagnosis, treatments and the outcomes along with rehabilitation and physical therapies for the condition.
What is an Acetabular Fracture?
Acetabulum is the part of the pelvis that meets the upper end of the thigh bone or the femoral head, so as to form the hip joint. Thus, the hip joint comprises of the femoral head and the acetabulum; and the acetabulum is more than just the socket for the femoral head or the upper end of the thigh bone. Acetabulum forms from 3 ossification centers known as the Ilium, Ischium and the Pubis. All these 3 segments meet at the tri-radiate cartilage or a Y-shaped synchondrosis centered on the acetabulum.
Acetabular fractures or pelvis fractures are among the most serious injuries that require being treated by the orthopedic surgeons. These are caused due to traumatic incidents like motor vehicle accident, severe fall etc. Such fractures of the acetabulum requires immediate and precise treatments which may include non-surgical as well as the surgical treatments. Acetabular fractures are common in elderly people even with a lower impact fall with fragile bones because of osteoporosis. Acetabular fractures can lead to various other severe injuries or conditions.
When we use the term broken hip, it basically refers to the acetabular fracture and in such types of fractures the femoral head is mostly driven via the acetabulum because of the impact of the physical trauma that lead to the damage. Now, if the femoral head ends up outside the acetabulum then the condition is known as a dislocation of the hip joint. So, some people may have the acetabular fracture along with hip dislocation. It can rightly be said that an acetabular fracture is difficult to treat. However there are surgical and non-surgical methods to treat acetabular fractures and rehabilitation with important physical therapies help in improving the symptoms of acetabular fractures. Let us know about acetabular fracture, its classification, diagnosis, treatments and the outcomes along with rehabilitation and physical therapies
Classification of Acetabular Fracture
The most accepted classification for acetabular fractures; is the one described by Judges and colleagues. This type of classification in based on the orientation of the fractures and the structures involved in the fracture. In such type of classification of acetabular fracture; 10 patterns of the fracture are defined and these 10 patterns are divided in to 5 elementary patterns and 5 associated patterns.
Elementary Patterns of Acetabular Fractures: These patterns include anterior wall fractures, posterior wall fracture, anterior column fracture, posterior column fracture and transverse fractures.
Associated Patterns of Acetabular Fractures: These patterns include both column-fractures, posterior column fractures with posterior wall fractures, transverse fractures with posterior wall fractures, T-shaped fractures, and anterior column fractures with posterior hemitransverse fractures.
For a simple understanding, these 10 patterns can also be grouped in to 3 categories including the wall fractures, column fractures and the transverse fractures of acetabular fractures. Some fractures can be classified in more than one category.
- Anterior wall
- Posterior wall
- Posterior column with posterior wall (Also a column fracture)
- Transverse with posterior wall (Also a transverse fracture)
- Anterior column
- Posterior column
- Posterior column with posterior wall (Also a wall fracture)
- Anterior column with posterior hemitransverse (Also a transverse fracture)
- Transverse with posterior wall (Also a wall fracture)
- Anterior column with posterior hemo transverse (Also a column fracture)
Diagnosis of Acetabular Fracture
Diagnosis of acetabular fracture can be made after performing diagnosis tests or procedures before the treatment for acetabular fracture; which include the following:
- Blood tests
- EKG or an electrocardiogram for testing electrical activity of the heart
- A chest X-ray for ensuring that the lungs have not been injured because of the fracture and have no fluid in them or no infection is in the lungs.’
- CT scans, Conventional radiographs, or MRI or Magnetic Resonance Imaging.
- MRV or Magnetic resonance venogram which assesses the veins of the patients. Many people with acetabular fracture or pelvis fracture develop blood clots in the veins of the pelvis, thighs or the lower legs. This can lead to other complications. An MRV helps in detecting if there is a clot in the vein and then treatment can be possible to remove the clot or develop any further complications.
Apart from all these tests and diagnosis procedures, the doctors/nurses check the pulses, the feeling in the injured limb etc. in the patient.
Treatments of Acetabular Fracture
It is unfortunate that patients with acetabular fractures almost experience serious injury always to the surrounding soft tissues like the muscles and the skin; and the neurovascular structures like the nerves, arteries and the veins.
The treatment of acetabular fracture aims to get back the patients to their pre-injury functional level to the best extent possible and returning comfortably to their daily activities. For achieving this, the surgeons or the doctors go for proper alignment of the bones while healing is vital. It is mostly like patients with acetabular fractures usually have a displacement and require alignment to put bones back in to their place. So, physicians try to align these bones while treating the fractures.
Here are some of the ways of treatment for acetabular fractures.
Non-Surgical Treatments of :
Non-surgical treatments of acetabular fractures are usually performed in patients who have a stable acetabular or pelvis fracture or where there is no dislocation or displacement. Some cases may require a closed reduction or realignment without an open surgical procedure and are done under anesthesia with or without external fixation. Some patients who cannot tolerate surgery like those with severe medical problems, severe osteoporosis or serious infections; etc. are also likely to be treated by non-surgical means.
Surgery/ Surgical Treatments of Acetabular Fracture:
Surgery is mostly necessary to treat the acetabular fractures. Some cases may need one or more surgical procedures as a treatment of acetabular fractures. Mostly surgery patients with acetabular fractures are given small preoperative doses of an anticoagulant or heparin that helps in preventing clotting. It is also necessary to continue taking an anticoagulant after surgery until the physician has ruled out any other danger or complex issues of clotting.
Below are few of the surgical treatments for acetabular fracture.
Ex-Fix or External Fixation Technique: This is an external fixation technique, where the surgeon performs an open or closed reduction and the bones are then held in their proper place by using an external fixator or an external frame. This is performed by threading pins in to the bone on either side of the fracture of the acetabulum. Then after these pins are connected to rods outside the skin, which form a frame. Usually such a treatment is done for acetabular fracture or pelvis fracture; however depending on the severity of the fracture, there may be other treatments too.
ORIF or Open Reduction with Internal Fixation Technique: Usually those patients who along with the acetabular fracture also have displacement of joint often require an ORIF or open reduction with internal fixation in the surgical treatments. In this case the surgeon realigns or reduces the bones in a precise manner so as to prevent the development of post injury related issues, especially arthritis. Here the bones are rigidly fixed with plates and screws so as to prevent future displacement and allow for recovery and rehabilitation to start at a quick time.
Post-operative Care for Acetabular Fracture
There are some specific things to know for managing the pain and any other complications that may arise because of the injury, after the surgery for acetabular fractures. Let us check them below.
- Initially, soon after the surgery pain medications will be given via injections.
- Some patients may also be able to use a pump that would control the amount of pain medication given. This is PCA or patient controlled analgesia.
- Anticoagulants may also be given for thinning of blood to avoid formation of blood clots
- Patients are encouraged to get out of the bed as fast as they can to avoid complications that may be associated with the injury and healing.
- Physical therapy exercises will be explained and one must follow them on a strict basis.
- It may take about 6 to 18 months to recover completely from the surgery or the acetabular fracture after treatment.
Complications in Acetabular Fracture Surgery
There may be some complications involved with the treatment in acetabular fracture. Below are some of them.
- Pneumonia or an infection of the lungs is a common complication in patients who are on the bed for long.
- Deep vein thrombosis and pulmonary embolism are some of the complications of acetabular fracture surgery. There may be formation of blood clots in the veins of the acetabulum, pelvis or the lower legs and also may travel to the lungs.
- Being in one position after surgery for a long time can cause skin problems
- Due to inactivity there may be muscle complications.
- Infection at the injury site is another common complication
- Constipation can be a result of long time inactivity.
There may be a complication known as heterotropic ossification, which is a condition where the body mistakenly forms bone in a place where there is usually muscle. A prompt treatment is essential in treating acetabular fractures via surgery so as to prevent this new bone from interfering with the joint movements.
Patients may experience avascular necrosis of the head of the femur, where there may have disrupted blood flow to the head of the femur or the ball of the hip joint. This can further result in death and collapse of the bone tissue and hip joint arthritis, an important complication of acetabular fracture surgery.
In case of acetabular fractures where the articular cartilage lining of the joint is affected in an injury to the pelvis; there may be damage to the head of the femur. It is important to keep the joint surfaces from rubbing together and to avoid the risk of future development of arthritis. A prompt treatment is essential to preserve the smooth lining of cartilage and avoid complication.
Apart from all these complications; there are chances that people suffering from a traumatic injury may also experience psychological distress over changes in their appearance and physical functioning.
Recovery Time for Acetabular Fracture
Usually most patients show about 80% of recovery in a period of 6 months after the surgery. However complete recovery may take one to one and a half year. The extent of post-surgery recovery sometimes may depend on other associated injuries with the trauma, the severity of the acetabular fracture, the location of the fracture, and the age and other general condition of the patient. Recovery time in acetabular fractures depend a lot on the rehabilitation and physical therapy exercises after the surgery
Rehabilitation for Acetabular Fracture
Physical therapy exercises and rehabilitation after acetabular fracture for phase one after surgery. Soon after surgery, especially the hip ORIF, there are some physical therapies or exercises to be done in various phases that are known as rehabilitation exercises. Phase one exercises may begin the day after the surgery so as to prevent the muscles from tightening up. These exercises are performed lying down or in a sitting position.
- Ankle pumps are performed by bending the foot down and up repeatedly. This increase blood flow in the leg and helps in reducing the risk of developing a blood clot in the lower leg due to reduced mobility.
- Strengthening exercises are performed for the ankle and the knee on the affected/injured side or the leg.
- Various motion exercises are performed for the hip joint so as to keep it from becoming excessively inflexible.
- Physical therapy exercise for phase two after surgery: Here in phase two, rehabilitation exercises focus on increasing weight bearing via the injured leg. This usually begins after two weeks of the surgery.
- Standing exercises may be performed by using parallel bars which allows to support some weight with hands.
- Weight shifting exercises involve slowly increasing the amount of pressure on the injured leg in forward, backward and also in side-to-side direction.
- Physical therapy exercises for phase three after surgery: Such rehabilitation exercises in physical therapy begin after 6 weeks of surgery. By this time the patient begins to place full weight on the injured leg which underwent the surgery.
- Balance exercises are performed to prepare for walking without a walker and also on uneven ground.
- Strengthening exercises are continued that help in climbing stairs and other related activities.
- Some specific endurance exercises like stationary biking, recumbent stepper and pool activities are incorporated into the physical therapy exercising plan at the third phase after surgery and this continues as a part of your long-term fitness plan.
Acetabular fractures or pelvic fractures need proper evaluation and treatment. Hence get immediate medical opinion for any such trauma causing acetabular fracture. The most appropriate treatment will be chosen based on the severity of the condition and rehabilitation or physical therapy plan can be chalked out to ensure proper healing and recovery.