Indications For Nonoperative Management
Nonoperative management of acetabular fractures may be considered for non-displaced fractures or minimally displaced fractures (< 2 mm displacement), fractures that do not involve the weight-bearing dome of the acetabulum as determined on CT or by roof-arc angles, and in cases of secondary congruence (31). The hip must remain
congruently reduced without evidence of subluxation on radiographs and CT scans obtained with the patient out of traction. For displaced fractures, an adequate weight-bearing dome is rarely present (5%), and the presence of secondary congruence is a more common indication for nonoperative treatment (31).
The stability of nondisplaced fractures and fractures below the weight-bearing dome has been questioned. Though controversial, some reports indicate a possible role for stress radiographs obtained in the operating suite to determine fracture stability. Surgery is recommended for fractures not involving the weight-bearing dome or non-displaced fractures that demonstrate fracture instability or joint subluxation under fluoroscopic examination (50-53).
Controversy continues to exist surrounding the appropriate management of the posterior wall acetabular fracture with or without associated hip dislocation. Nonoperative treatment can be considered for a concentrically reduced joint in the absence of marginal articular impaction or incarcerated articular fragments. Proponents of nonoperative therapy mantain that the hip remains stable through a full range of motion when the degree of articular involvement is less than a third of the joint surface based on CT evaluation (51,52,54). Proponents of operative intervention suggest that even small fractures of the posterior wall involving less than a third of the joint surface will alter joint contact forces leading to early arthrosis and advocate anatomic reduction of all wall segments (3,55,56). There is general agreement that operative intervention should be undertaken in cases of instability, incarcerated fragments, marginal impaction, and large articular surface involvement (56,57).
Elderly patients with severe osteopenia or patients suffering from metabolic bone disease with inadequate bone stock for internal fixation should be considered for initial nonoperative therapy (30). Advanced age alone is not an indication for nonoperative management. Several articles suggest that acetabular fractures in the elderly demonstrate good functional outcomes following open reduction and internal fixation (2,3,56,57). Reduction and fixation of acetabular fractures through nonextensile exposures, particularly posterior wall fractures, result in an easier total joint reconstruction at a delayed time point if one is required at all.
The decision to treat a patient nonoperatively generally requires that the patient undergo a period of bed rest and, occasionally, use of skeletal traction. Skeletal traction is not used to reduce the fracture but to allow gentle motion with the joint mildly distracted, particularly in cases of displaced fractures with secondary congruence (30). In some cases, early mobilization with crutches or transfers to a wheel chair may be warranted (58). In either case, close radiographic follow up is required. If the fracture displaces or secondary congruence is lost, surgical intervention should be considered. Surgical intervention should occur within 21 days of injury, since reconstruction and results are compromised with further delay (2).
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