01Approach to the Critical Patient/attcp61

Immediate priorities

›Polytrauma resuscitation framework

›ATLS primary survey

›Airway with cervical spine protection

›Breathing and oxygenation

›Circulation with hemorrhage control

›High-energy mechanism assumption

›Treat as multisystem trauma until excluded

›Acetabular fracture rarely isolated in young patients

›If hemodynamically unstable, activate massive transfusion protocol

›Suspect pelvic or retroperitoneal hemorrhage

›Concurrent intra-abdominal injury screen

›Pelvic hemorrhage threats

›Shock physiology

›SBP < 90 mmHg

›Heart rate > 120 beats/min

›Pelvic ring instability

›Apply pelvic binder at level of greater trochanters

›Avoid repeated manual pelvic spring testing

›If ongoing instability despite binder, angioembolization or pelvic packing

›Superior gluteal artery source common

›Interventional radiology and trauma surgery activation

›Limb-threatening branch points

›Hip dislocation with acetabular fracture

›Posterior dislocation shortened internally rotated adducted limb

›Closed reduction within 6 hours to reduce avascular necrosis risk

›Vascular compromise

›Absent distal pulses

02History/hx51

Mechanism and presentation

›Mechanism of injury

›Dashboard injury

›Knee-to-dashboard force in motor vehicle collision

›Classic for posterior wall and posterior column

›Fall from height

›Axial load through femoral head

›Transverse or both-column patterns

›Low-energy fall in elderly

›Osteoporotic insufficiency pattern

›Anterior column predominance

›Direction of force at impact

›Flexed adducted hip

›Posterior wall fracture

›Posterior dislocation risk

›Extended abducted hip

›Anterior column fracture

›Anterior dislocation risk

Symptom characterization

›Pain features

›Deep groin hip or buttock pain

›Inability to bear weight

›Pain with any attempted hip motion

›Timing

›Acute onset with trauma

›Delayed presentation in elderly insufficiency fracture

›Associated symptoms

›Sciatic nerve distribution

03Physical Exam/exam45

Vitals and general

›Hemodynamic snapshot

›Tachycardia

›Hemorrhage marker

›Pain or anxiety contributor

›Hypotension

›Pelvic or retroperitoneal bleeding

›SBP < 90 mmHg

›Limb appearance

›Posterior dislocation posture

›Shortened internally rotated adducted

›Orthopedic emergency

›Anterior dislocation posture

›Externally rotated abducted

›Less common pattern

Focused hip and neurovascular exam

›Palpation and motion

›Tenderness localization

›Groin and greater trochanter

›Buttock

›Range of motion

›Severely limited and painful

›Do not perform frog-leg maneuver

›Log roll test

›Pain with gentle internal rotation

›Pain with gentle external rotation

›Neurovascular assessment

›Sciatic nerve peroneal division

04Differential Diagnosis/ddx34

Hip and pelvic fracture differentials

›Bony injuries

›Femoral neck fracture

›ICD-10 S72.0

›Shortened externally rotated limb on AP pelvis

›Femoral head fracture Pipkin

›ICD-10 S72.05

›Associated with posterior hip dislocation

›Pelvic ring fracture

›ICD-10 S32.8

›Pubic rami and sacral fractures on CT

›Acetabular fracture

›ICD-10 S32.4

›Intra-articular displacement on Judet views

›Joint and soft tissue

›Hip dislocation without fracture

›Pure dislocation

›Post-reduction CT to exclude occult fracture

›Greater trochanteric fracture

›Lateral hip pain

›Isolated radiographic finding

Atraumatic and mimics

›Pathologic and insufficiency

›Pathologic fracture

›Metastatic breast prostate lung renal thyroid

›Lytic lesion on imaging

›Insufficiency fracture

›Osteoporotic elderly

05Laboratory Tests/lt28

Hematologic and transfusion

›Blood count and crossmatch

›Complete blood count

›Baseline hemoglobin

›Serial monitoring for hemorrhage

›Type and screen and crossmatch

›Prepare for surgical blood loss

›Massive transfusion anticipation

›Coagulation studies

›PT INR and PTT

›Especially if anticoagulated

›Transfusion threshold

›Hemoglobin < 80 g/l in asymptomatic patient

›Symptomatic anemia lowers threshold to treat

›Balanced product ratio in active bleeding

Metabolic and perfusion

›Organ function panel

›Basic or comprehensive metabolic panel

›Renal function for contrast and drug dosing

›Electrolyte baseline

›Lactate

›Tissue hypoperfusion marker

›Trend with resuscitation

›Targeted screening

›Urinalysis

›Hematuria screen for urologic injury

›Prompts retrograde urethrogram if blood at meatus

›Preoperative cardiac markers in elderly

06Diagnostic Tests/dt73

Scoring Systems

›Judet and Letournel classification

›Elementary fracture types

›Anterior wall and posterior wall

›Anterior column and posterior column

›Transverse

›Associated fracture types

›Transverse plus posterior wall

›T-shaped

›Both-column

›Anterior column plus posterior hemitransverse

›Posterior column plus posterior wall

›Roof arc and articular continuity criteria

›Matta roof arc measurements

›Medial roof arc >= 45 degrees

›Anterior roof arc >= 25 degrees

›Posterior roof arc >= 70 degrees

›CT subchondral arc

›Intact superior 10 mm of acetabulum supports nonoperative care

›Assesses articular surface continuity

›Displacement threshold

›Step-off >= 2 mm predicts poor outcome

›Obturator oblique view best for step-off

›Examination under anesthesia

›Dynamic fluoroscopic stress

›Benchmark for posterior wall stability

›Stable fractures do well nonoperatively

›Stability determination

07Disposition/dispo31

Admission and level of care

›Universal admission

›All acetabular fractures admitted

›Pain control and traction

›VTE prophylaxis and orthopedic management

›ICU or trauma service

›Polytrauma or hemodynamic instability

›Associated significant injuries

›Specialist consultation triggers

›Sciatic nerve palsy

›Neurology or neurosurgery input

›Document deficit serially

›Hematuria or vascular compromise

›Urology for urologic injury

›Vascular surgery for ischemia

›Geriatric co-management

›Perioperative optimization

›Bone health and fall prevention

Transfer and follow-up

›Transfer criteria

›No local acetabular surgery expertise

›Transfer to Level I trauma center

›Stabilize and arrange traction before transfer

›Time-sensitive issues

›Reduce dislocation before transfer when possible

›Communicate neurovascular status

›Outpatient orthopedic follow-up plan

›Follow-up timing

08Treatment/t80

Initial stabilization

›Emergency department measures

›Resuscitation

›ATLS protocol and balanced transfusion

›Pelvic binder if concurrent ring instability

›Closed reduction of dislocation

›Ideally within 6 hours of injury

›Reduces avascular necrosis risk

›Skeletal traction

›Distal femoral pin for subluxation

›Temporizes while awaiting surgery

›Analgesia

›Fascia iliaca compartment block

›Regional analgesia for hip and groin pain

›Opioid-sparing benefit

›IV opioids

›Morphine 0.05 to 0.1 mg/kg IV titrated

›Hydromorphone 0.0125 to 0.02 mg/kg IV alternative

›Acetaminophen

›1 g IV or PO every 6 hours

›Avoid preoperative NSAIDs given bleeding risk

VTE prophylaxis

›Chemoprophylaxis options

›Low-molecular-weight heparin

›Enoxaparin 30 mg subcutaneous twice daily

›Standard regimen after pelvic and acetabular fracture

›Aspirin

›Aspirin 81 mg twice daily

›PREVENT CLOT trial noninferior to LMWH for death after fracture

›Timing

›Initiate within 24 to 48 hours of injury

›Continue 4 to 6 weeks postoperatively

›Mechanical and monitoring

›Sequential compression devices

›Bridge when chemoprophylaxis delayed by bleeding

›Adjunct after surgery

›Surveillance

›Symptom-directed venous duplex

›Western Trauma Association algorithm guidance

Definitive management

›Nonoperative management indications

›Congruent and stable joint

›Congruent hip on AP and Judet views

›Stable hip on examination under anesthesia

›Intact weight-bearing dome

›Roof arc angles within criteria

›Intact superior 10 mm on CT subchondral arc

›Protected weight-bearing protocol

›Toe-touch or non-weight-bearing 6 to 12 weeks

›Serial radiographs to confirm maintained reduction

›Operative management

›Open reduction internal fixation

›Default for displaced fractures in fit patients

›Ideally within 3 to 10 days of injury

›Surgical approaches

›Kocher-Langenbeck posterior

›Ilioinguinal or anterior intrapelvic Stoppa

›Combined approach for complex patterns

›Arthroplasty pathways

›Acute total hip arthroplasty for poor bone quality or femoral head damage

›Percutaneous fixation for minimally displaced elderly fractures

›Delayed total hip arthroplasty for post-traumatic arthritis

Postoperative and adjuncts

›Heterotopic ossification prophylaxis

›Indomethacin

›25 mg three times daily for 6 weeks

›Avoid if NSAID contraindicated

›Radiation prophylaxis

›Single-dose 700 cGy postoperatively

›Alternative when NSAIDs not tolerated

›Perioperative antibiotics

›Cefazolin

›2 g IV within 1 to 2 hours before incision

›Continue 24 hours postoperatively

›Anti-staphylococcal coverage

›Weight-based redosing intraoperatively

›Vancomycin if MRSA risk

›Early rehabilitation

›Mobilization

›Out of bed within 24 hours postoperatively

›Physical therapy for gait training

›Recovery expectation

›76 to 89% good-to-excellent functional outcomes

›Post-traumatic arthritis in roughly 17%

09Special Populations/sp30

Pregnancy

›Pregnant trauma considerations

›Imaging approach

›AP pelvis radiograph with abdominal shielding

›CT pelvis when maternal benefit outweighs fetal risk

›Resuscitation priorities

›Maternal stabilization improves fetal outcome

›Left lateral tilt to relieve aortocaval compression

›Medication and monitoring

›LMWH preferred for VTE prophylaxis

›Fetal monitoring when viable gestation

Geriatric

›Older adult features

›Fracture pattern

›Anterior column-based predominance

›Insufficiency fracture with low-energy fall

›Treatment modifications

›Percutaneous fixation when cannot mobilize from pain

›Acute total hip arthroplasty for poor bone quality

›Comprehensive care

›Cardiac risk stratification before surgery

›Osteoporosis treatment and fall prevention

Pediatrics

›Pediatric differences

›Triradiate cartilage involvement

›Physeal injury can cause growth arrest

›Acetabular dysplasia risk with later growth

›Mechanism and evaluation

10Background/b34

Epidemiology

›Incidence and distribution

›Bimodal age distribution

›Young patients with high-energy trauma roughly 66%

›Elderly with low-energy osteoporotic falls

›Common fracture types

›Posterior wall most common overall

›Anterior column rising in elderly

›Complication burden

›Post-traumatic osteoarthritis 16.9% at roughly 44 months

›Sciatic nerve injury up to 20% and AVN 11% with dislocation

Pathophysiology

›Mechanism of injury

›Force transmission through femoral head

›Femoral head acts as hammer against acetabulum

›Hip position determines fracture pattern

›Column and wall anatomy

›Anterior and posterior columns form inverted Y

›Weight-bearing dome critical for outcome

›Insufficiency mechanism

›Osteoporotic bone fails under normal load

›Quadrilateral plate medialization in elderly

Therapeutic Considerations

›Outcome determinants

›Anatomic reduction

›Step-off >= 2 mm predicts poor outcome

›Restoration of congruent joint surface

›Native hip survival

11Patient Discharge Instructions/pdi16

copy discharge instructions

›Acetabular fracture aftercare

›Follow weight-bearing restriction exactly as instructed

›Keep follow-up orthopedic appointments for repeat x-rays

›Take blood thinner or aspirin as prescribed to prevent clots

›Take pain medicine as directed and avoid driving while on opioids

›Warning signs to return to the ER

›New or worsening numbness or weakness in the leg or foot

›Increasing pain swelling or inability to bear weight as expected

›Calf swelling chest pain or shortness of breath

›Fever wound drainage or spreading redness

›Difficulty passing urine or blood in the urine

›Recovery and prevention

›Attend physical therapy for hip strengthening and gait training

›Eat calcium and protein-rich foods and stay hydrated

›Bone density testing and fall prevention if over 60

›Avoid alcohol and sedatives that increase fall risk

12References/r11

Guidelines and key sources

›Guideline and society sources

›ACR Appropriateness Criteria Acute Hip Pain 2024 update

›Western Trauma Association VTE critical decisions algorithm

›AAOS reviews on acetabular and posterior wall fracture management

›Landmark trials and evidence

›PREVENT CLOT trial aspirin versus LMWH for fracture thromboprophylaxis

›Matta roof arc and Olson CT subchondral arc articular continuity studies

›Letournel classification and 3D CT classification accuracy data

›Coding standards

›ICD-10 S32.4 fracture of acetabulum

›SNOMED CT acetabular fracture disorder concept

Evidence & Review

Evidence & Review