Your Fractured Acetabulum

A guide for patients about the injury and

post operative recovery

Trauma and Orthopaedics Department

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Contents

Introduction 3
Why are you at St George’s Hospital 3
Acetabulum fractures 3
Surgery for acetabulum fractures 4
Are there any risks or complications? 4
After your acetabular surgery 6
What should I expect after my operation? 7
Being transferred or discharged 8
Medication 8
Follow up appointments 9
Prognosis 9
Post traumatic stress 9
Physiotherapy 10
Getting up 12
Occupational therapy 13
How you and your family can 15
Nutrition and recovery 15
Further information 16

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Introduction
This information is for patients and their families, about having an
operation to repair a fractured (broken) acetabulum (socket of the hip
joint) at St George’s Hospital. It explains
• what the operation involves
• risks and side effects
• what you need to do after the operation.

Why are you at St George’s Hospital?

You have been admitted to St George’s Hospital with a broken hip
socket, although you may have other injuries as well. The acetabulum is
a cup-shaped hollow in the pelvis into which the head of the femur (thigh
bone) fits to form a ball and socket joint - your hip joint.

St George’s hospital is the largest specialist centre for fractures of the

acetabulum in the UK with several patients being referred from other
hospitals each week. Over many years this has led to the development
of very specialised expertise and knowledge.

Acetabulum Fractures
Acetabular fractures are uncommon, and generally occur from:
• road traffic accidents
• falls
• sporting injuries (less common).

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There are many ways the acetabulum can break. Imagine breaking a
soup bowl – sometimes it may break into only two pieces, whereas other
times it will completely shatter.

Not all fractures require an operation, and sometimes treatment will

involve not walking on the fracture (for example, using crutches) and
careful monitoring with x-rays. Occasionally the decision whether to
operate or not cannot be made using x-rays or scans (CT scan), and we
may need to assess the stability of your fracture using x-rays in the
operating theatre.

Surgery for Acetabulum Fractures

If you require surgery, this can be done in several ways. The exact
surgical plan will be discussed with you before you are asked to consent
(agree) to surgery. In general, most acetabular fractures are operated on
either through the buttock (bottom) muscles, or through the groin area
(between the legs). Surgery generally involves putting the pieces back
where they came from and holding them there with plates and screws.

Your operation should take between one and two hours. The operation
can take longer if your operation is complicated. Most of these
operations require a general anaesthetic. Whilst you are asleep you will
be unaware of what is happening during the operation. Please ask the
nurses for the booklet called You and your anaesthetic.

Depending on how complicated your surgery is, you may spend some
time in intensive care or the high dependency unit after your operation.
You may also just spend a few hours in the recovery unit while you
recover from the anaesthetic before being moved to the ward.

Are there any risks or complications?

There are a number of complications that can occur after acetabular
fractures, usually related to the injury but occasionally to surgery. It is
important that you tell us if you become aware of any of these, because
early treatment can be more effective.

1. Arthritis
The biggest long term complication of a broken acetabulum is the
development of arthritis. The main reason we operate on these fractures
is that we know from past experience that if we leave the fractures in a
poor position, although they will often heal, arthritis may follow within five

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years. Statistically, even if fracture surgery is successful, up to one in five
people go on to require a hip replacement within five years. This is
mainly because of the amount of damage done to the joint surfaces at
the time of injury. This means that even if the pieces are put back
together perfectly, the cartilage (soft tissue) on the joint surface is
damaged beyond repair. In some cases the bone is crushed and simply
doesn’t fit back together properly, or the bone loses its blood supply and
dies over the next two years. However, even in these complex cases,
many patients will avoid hip arthritis for many years after successful
surgery and it is therefore generally the best option.

2. Sciatic Nerve Injury

The most common early complication of this fracture is nerve damage,
most often to the sciatic nerve. This is a big nerve that passes down the
back of your thigh and branches into the lower leg. Symptoms can vary
and include numbness or pain in the foot, calf or thigh, weakness of the
foot and ankle, or complete inability to move the leg.
Other nerves can also be damaged, leading to similar symptoms in other
parts of the leg. Nerve injuries can take many months and sometimes
years to recover, having no recovery at all is very unusual. If the sciatic
nerve is injured by the fracture then it will usually be looked at during
surgery, and more information can be obtained regarding the likelihood
of recovery.

3. Infection
Infection is another possible complication, against which many measures
are taken including antibiotics at the time of surgery. Infection usually
presents with:
• pain
• redness
• discharge (oozing) from the wound
• occasionally a feeling of being generally unwell.
If you think your wound is infected after you have left hospital you
should contact your GP. If they want to admit you to hospital it is best if
you are re-admitted to St George’s hospital.

4. Difficulty passing urine

This means you need a urinary catheter (a tube to drain the urine from
your bladder) for a few days after surgery, until you are able to use a
bedpan or toilet.

5. Chest infection
This might mean that you need a course of antibiotics.

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6. Other anaesthetic complications
These can occur during or after any big operation. This includes
problems with your bowel and heart. They are usually caused by the
stress of surgery making an already existing condition, which may or
may not be known about, worse. The anaesthetist will see you before
your operation and can explain these risks in more detail.

Possible Complications
• Pain
• Bleeding which can happen during or after the operation. A
blood transfusion is sometimes needed.
• Blood clots in your legs. These can travel to the lungs and
cause a pulmonary embolism (a clot in your lungs). You will be
given blood thinning tablets to help with this – there is more
information on this on page 8.

To minimise risks, it is important that you follow all instructions in this

booklet as well as those given to you by your doctor, nurse and therapy
team.

After your acetabular surgery

After surgery, you will not be allowed to put any weight through the
broken side for 12 weeks (three months) – you will be given crutches or
a frame to help with this. This is to protect the fracture from moving until
it heals – the metal plates can hold bone against some forces but not
against the weight of walking. If the fracture moves and heals in a
different position then the outcome will most likely be worse in the long
term. This can lead to:
• long term pain
• the development of early arthritis
• a permanent limp.

Other things that you can do to help your fracture heal well include:
• eating a good diet
• following the advice of your physiotherapist
• not smoking.

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What should I expect after my operation?
On the day of your operation
• You will need to rest until the effects of the anaesthetic have
passed. You may not be able to feel or move your leg for several
hours with some types of anaesthetic.
• When you awake you may feel some pain or discomfort, the
nursing staff can give you something to ease this.
• You will have an oxygen mask on; this will usually be taken away a
day or so after your operation.
• You may also feel slightly nauseous (sick), and the nursing staff
can give you something to ease this.
• The nursing staff will check your pulse, blood pressure and
temperature frequently during the first 24 hours after your
operation.
• You will notice that you have a drip in your arm; this gives you
fluids until you feel well enough to eat and drink properly.
• You will also have a urinary catheter, which drains urine from your
bladder until you are able to use a bed-pan or toilet.
• After your operation you may also have a blood transfusion to
replace some of the blood lost during the operation.
• You will have a large dressing covering your wound and you may
also have a drain in your wound. The drain removes excess fluid
from around the operation site.
• While in bed you should take frequent deep breaths to help keep
your chest free of infection.
• Doing regular ankle and foot-pumping exercise will help keeping
the blood moving around your body.
• During your hospital stay you will wear elastic stockings to help
your circulation. These can be removed for you to wash your legs,
and should be laundered regularly.
• While in bed, and also if sitting for long periods of time, it is
important that you change your position regularly. This will help
prevent you developing any pressure sores, especially on your
bottom and heels. The nursing staff can advise you about this.

On the first day after your operation

• You will be sitting on the edge of the bed or into a chair with the
help of your nurse or physiotherapist.
• Your drip may be removed, your wound may be re-dressed and if
present the wound drain may be removed.
• Your urinary catheter will remain until you have become more
mobile around the ward and able to use the commode.

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 • Your physiotherapist will instruct you on your exercise programme.
Please refer to the physiotherapy section of this booklet, on page 10.
• You will be seen by an occupational therapist (OT) who will discuss
or practise strategies with you for managing activities of daily living
(the tasks you need to do on a day to day basis).
• The OT will give most patients a form for measuring the height of
furniture at home, this is to check that you will be able to get on
and off these pieces of furniture and so they can arrange
equipment for you if necessary.
• The ward encourages patients to wear their own clothes and shoes
brought in from home as soon as possible to help you feel normal.

Within the first five days after your operation

• You should be mobile with either a frame or crutches. You will not
be allowed to put any weight through your leg for the first three
months (see page 12 for more information).
• You will be able to sit out of bed for longer periods, including all
meals.
• You will be able to dress yourself in your own clothes with help
from your care team.
• You will be able to shower or wash with help from your nurses.

Please note the above is only a guide and in some circumstances

progress may be slightly quicker or slower than the plan above. At this
time the team will also be looking into your discharge and planning for
your return home with you.

Being transferred or discharged

In some cases you will be transferred to your local hospital and this will
be done with hospital transport. If you are discharged home from St
George’s Hospital you must arrange for a friend or relative with transport
to collect you.

Medication
After your operation, in hospital you will be started on warfarin tablets to
thin your blood. This is because after acetabular fractures you are much
more likely than normal to suffer deep vein thromboses (DVTs). These
are blood clots - usually in the calf veins. We put all acetabular fracture
patients on this tablet for a fixed time of three months, unless there are
other complications. Being on warfarin requires a blood test every week

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or two weeks, which should be organised for you before you are
discharged. After three months this tablet can be stopped.

Follow up appointments
After discharge from hospital, you will usually be reviewed in the fracture
clinic at 6 weeks, 12 weeks, 6 months and 12 months after your injury. At
each visit you will be seen by a doctor, and x-rays will be taken. We will
also ask you to fill out forms at each visit which will help us to document
how well you are doing over time. The information from these forms is
anonymous but highly useful to us, and over time will enable us to
improve the service we provide. It is important that you as a patient
understand that you have a significant part to play in the recovery from
your injury, but also that you can help to improve the service so that
future patients may benefit.
The risk of problems from acetabular fractures, and especially
developing arthritis, goes on for many years, and for this reason we
follow-up patients indefinitely. Therefore, after your clinic visit at one
year, we will also arrange to see you at two years, five years, ten years
and beyond.

Prognosis
After most acetabular fractures, three months later you will be allowed to
walk without crutches (although this is best started with the help of a
physiotherapist) and start to return to a normal life. How quickly people
get back to normal is very variable, and depends on many factors
including:
• your age
• the type of fracture
• how it was fixed
• other injuries
• other medical problems.
It is important to remember however that you will keep improving for at
least 12 to 18 months after your fracture, and sometimes even up to two
years. If you have any specific questions about starting other activities
(such as driving and sport) then bring this up at one of your clinic visits.

Post Traumatic Stress

As these injuries are often a result of a serious accident, post traumatic
stress can occur. If you would like more information there is a booklet
available on your ward (Post-traumatic stress disorder: the treatment of

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PTSD in adults and children). The sister in charge can also refer you to
our chaplaincy service for further support.

Physiotherapy
Before your operation
• You may be seen pre operatively by the physiotherapist who will test
the power (strength)and sensation (feeling) in both of your legs.
• The physiotherapist may listen to your chest and teach you how to
clear any phlegm if necessary.
• The physiotherapist will teach you the following exercises which you
can start immediately and should continue to do soon as you are
able, after the surgery.

Exercises
1. Foot pumps

Move you feet briskly up and down.

Repeat 10 to15 times every hour.

2. Static quads (thigh squeezes)

Tighten your thigh
muscles by pushing
the back of your knee
into the bed (in other
words straightening
your knee as much as
possible)
Hold for a count of
five, and then relax
Repeat 10 times every
hour.

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3. Heel slides
Slide your heel towards your
bottom, so your hip and knee
bend.
Then straighten your leg.
Your physiotherapist may help
you move your injured leg at first,
until you can manage the
exercise on your own.
Repeat 10 times, three times a
day.

After your operation

• Continue the previous exercises you were shown before the
operation.
• The physiotherapist will help you move your hip joint:
o up and down (flexion and extension)
o out to the side and back (abduction and adduction)
o turn it in and out (internal and external rotation).
• The physiotherapist will show you some additional exercises and
advise you when to start them. The following exercise should be done
at least four times a day, as you are able. Start with 10 to 15
repetitions for each exercise. You can increase the number of
repetitions as your condition improves.

4. Leg position
When you are lying down,
your leg naturally turns
outwards. For this exercise,
turn your whole leg inwards
so that you foot is facing your
other leg.
Hold this position for five
seconds, and then relax.
Repeat five times

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5. Hip abduction (leg out to side)

Slide your leg out to the side, keeping your

knee straight. Then return your leg back to
the middle. Your physiotherapist may help
you move the injured leg at first, until you
can manage the exercise on your own.
Repeat 10 times, three times a day.

6. Inner range quads (leg lifts)

Place a rolled towel under

your knee on the operated
leg. Tighten your thigh
muscles and straighten the
knee, lifting your heel off the
bed.
Hold your leg straight for a
count of five seconds, and
then lower it gently.
Repeat 10 times

Getting up
When the surgeon has seen the x-rays taken after your operation you
may be able to start getting up with the physiotherapist, depending on
any other injuries you may have.

• You may feel dizzy or light headed the first few times you get up as
your body adjusts to an upright position after a period of bed rest.
• You will use a frame at first but progress onto elbow crutches. You will
not be allowed to put full body weight on the operated leg for three
months (non-weight bearing or touch weight bearing) but your
physiotherapist will discuss this with you.

Once you have progressed from your frame to getting around with
crutches on your own, you will be taught how to climb stairs.

Almost from your first day with us, we will be talking to you and your
family or carer about arrangements for your care when you go home.

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This is so that any necessary plans can be made before you are
discharged home. When you are safely managing the above things on
your own and there are no other nursing or medical problems, your
discharge or transfer date will be discussed.

You may be given additional exercises or advice. Please use the

space below to make any notes.
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Precautions
You must not roll towards or lie on your operated side for long
periods of time for the next three months.
Any additional precautions can be written below
__________________________________________________________
____________________________________________________
__________________________________________________________
____________________________________________________

Occupational Therapy

What is occupational therapy?

Occupational therapy (OT) staff help people of all ages who have
physical, mental or social problems as a result of accident, illness or
ageing, to do the things they want to do. These could be daily activities
that many of us take for granted, from grocery shopping or brushing your
teeth, to more complex activities such as caring for children, succeeding
in studies or work, or maintaining a healthy social life.
After an acetabular fracture an occupational therapist plays an important
role in helping with all daily activities and this will include planning for
your discharge and taking into account any of your needs relating to your
home environment.

What things will the OT assess and recommend?

Your OT will ask you to give information about your home, which may
include measuring the heights of some of your furniture at home so you

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can practice standing from or getting onto hospital equipment (such as
beds and chairs) of similar heights before leaving hospital. Providing
these details about your home environment will assist with
recommending a discharge plan for you. If necessary, the OT will
arrange for your home to be assessed by a member of the OT team in
Social Services.
Apart from the home environment your OT will talk with you about how
you were completing your day-to-day tasks before coming into hospital,
including work and leisure activities. They will then look at what you are
able to do now, usually focusing on the things that are most important for
returning home from hospital. This might include getting into the bath or
shower, or preparing a drink or meal. Your OT will then work with you to
help you to return to your previous abilities if you are able. This may
include practice of these tasks or provision of equipment.

Sometimes equipment may be recommended to increase your

independence or make activities easier. Some examples are
summarised below:
• Bathing – a bath board for over the bath or a perching stool for a
strip wash.
• Small aids – a reacher to pick items up off the floor, long handled
shoe horn to assist with putting on your shoes and socks.
• Toileting – a raised seat to make the toilet seat higher or a frame to
give you arms to push up from or a commode if required.
• Seating –special blocks to sit under your armchair to raise it or a
high backed chair.
• Bedroom – special blocks to raise your bed or a lever on the side
of the bed to help you from lying to sitting.
• Wheelchair – if you require a wheelchair for mobility the OT will
also consider equipment to assist you to get on and off the
wheelchair.

The OT will assist you to find somewhere in your local area to provide
this equipment. Unfortunately, more often than not, due to the short term
need for this equipment there will be some cost to you.

Keeping this in mind the OT can keep practicing with you to ensure that
you only need to consider the equipment that is essential for discharge.
Further practice with this equipment may be required once you return
home and this can be arranged by your care team with your local
rehabilitation service.

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How you and your family can help?
Simple things like bringing in your own clothing early in your admission to
allow for a return to your usual day-to-day tasks can be very helpful.
Getting up from bed and dressing in your own clothes can often make a
huge difference in your rehabilitation.

Providing accurate information about the layout and the heights of the
furniture at home would assist the OT to assess the suitability of your
home environment for discharge. Digital photos can also assist with this
process and the OT may discuss this with your family. Your family or
friends may need to be available to allow access to local services to
assess your home when delivery of equipment is required.

Nutrition during recovery

During your recovery it is important for you to maintain a healthy diet.
Bone fractures can put a lot of stress on the body which means the body
needs extra nutrition to help the healing process.
The most important nutrients in healing bones are

1. Protein for growth and repair of cells and tissues: meat, poultry, fish,
eggs, legumes (peas, beans, lentils, dahl), cheese, milk and yoghurt.
2. Carbohydrates and fats for energy: breads, breakfast cereals, pasta,
potatoes and rice.
3. Vitamins and minerals to help the body repair itself. These are found
in all foods but you may require supplements to provide your specific
needs.

Try to ensure a protein and carbohydrate food is included in each of your

meals. A balanced diet is one with plenty of variety so include fruit and
vegetables too.
Your appetite can be affected during your recovery and you may not feel
hungry. This can be caused by:
• medications
• pain
• nausea
• decreased mobility
• disrupted bowel motions (diarrhoea or constipation).

If you feel that your appetite is poor and/or you have recently lost weight
please speak with your nurse as you may require a referral to the ward

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Dietician. Supplement drinks are available that will provide important
nutrition.

If you have any special dietary requirements, allergies or intolerances

please notify your nurse who can help arrange the correct diet for you.

Further information
The ward contact details are below if you have any questions.

St George’s Healthcare NHS Trust

St George’s Hospital
Blackshaw Road
London
SW17 0QT

Website: www.stgeorges.nhs.uk

Telephone: 020 8672 1255 (hospital switchboard)

• Gunning ward extension: 3219 / 3218
• Holdsworth ward extension: 3388 / 3216

Produced July 2011, to be reviewed July 2014

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