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CASE CORNER

Case Response: Case Response:

Michael Dienst Victor Ilizaliturri
Munich, GERMANY
Mexico City, MEXICO

The diagnosis for this case is very evident. The
Imaging indicates a posterior rim fracture with minimal
displacement likely after posterior subluxation of the patient presented a traumatic posterior subluxation of
right hip joint. The rim fragment is continuous with the right hip that resulted in a posterior wall fracture.

the superior rim but shows an increasing gapping As much as the diagnosis is clear, the treatment
of the fracture further posterior and medial. Integrity
strategy is controversial.
of the Teres Lig., the acetabular labum and the In a more conservative treatment strategy, the patient
articular cartilage cannot be sufficiently assessed
can be advised to use crutches for protected weight
on the presented MR imaging. The head and neck bearing and a brace to allow limited range of motion,
areas show mild bone edema without touching the
a CT-Scan can then be repeated at 3 to 4 weeks and
weightbearing surface of the femoral head, thus a the situation re-assessed then.
significant direct bruise of the cartilage areas are less
likely. On the lateral radiograph, there is mild loss of One must take into consideration that the patient is
very symptomatic with pain in every range of motion.
offset more at the neck than at the head. The alpha
angle is around 45° thus in the normal range. The The imaging of the hip shows a posterior wall fracture
with minimal displacement.
distal loss of offset is usual an indicator of Pincer-FAI
and retroversion, which however is not present on the Because the patient is young and active in sports,
and has pain and minimal displacement, I believe
pelvis ap radiograph and CT scans.
that the fracture should be fixed immediately with
With respect to the minimal displacement and arthroscopic assistance using cannulated screws.

posteromedial location of the facture and missing Loose bodies should be removed arthroscopically
previous complaints, conservative treatment would from the fracture line and labral repair performed (most
be an option. If that was preferred by the patient,
of these lesions will be associated with some type of
weight bearing should be limited to about 20kg labra injury). Most of these cases are also associated
for 6 weeks and subsequently increased by 10 kg
with chondral damage and this is usually treated by
weeks coming back to full weight bearing at 10–12 removal of unstable cartilage and microfracture if
weeks. In ordert to prevent stretching of the posterior
needed.
capsule and further displacement of the posterior Fluid extravasation may be a concern to some
fragment, flexion should be limited to 90° for the first
surgeons because of the acetabular fracture. In
6 weeks. Continuous passive motion therapy should this particular case, the fracture is of the posterior
be recommended to at least 6 weeks to prevent
wall and there is no fracture that communicates the
adhesions.
joint with the intra-pelvic space, therefore I believe
Because of the young age of the patient, some
the procedure can be performed with the standard
fracture displacement, the loss of neck offset with the monitoring of the abdomen throughout the operation.
risk of further damage by impingement sports and the
With early intervention the patient will benefit because
high risk of non imaged further intraarticular damage, he will return to normal and sport activity sooner, the
I would recommend immediate arthroscopy. The risk
of fluid extravasation at 2–3 weeks would be small, possibility of third body wear produced by fragments
coming from the fracture line is reduced which may
and connections to the retroperitoneum unlikely
because of the fracture location. Further waiting result in better prognosis for the joint. Also early
arthroscopic assessment of the joint will be important
would reduce the option to arthroscopically reduce to understand the amount of intraarticular damage.
the fracture. During arthroscopy, further potential
damage to the Teres Lig., articular cartilage and In the other hand a more conservative strategy

particularly the anterior labrum (traction injury by like mentioned earlier may also be a valid choice,
capsule or direct impinging injury during subluxation) however it would not be my course of action.

need to be evaluated and treated. If the fracture
gaps proves relevant, the perilabral bony surface of

the posterior rim needs to be exposed, the fracture
reduced and compressed with one to two screws.
At the end of the procedure, the offset of the femoral

neck should be increased. Postoperative treatment
would be similar to that of conservative treatment.

ISAKOS NEWSLETTER 2013: Volume II 25