acetabulum fracture

1. Acetabular fracture

2. Anatomy
•A deep cup like structure
•Lies in lateral aspect of hip bone and
forms hip joint with head of femur.
•It is directed downward and forward.
The margin is deficient in anteroinferior
aspect called acetabular notch.
•Floor of acetabulum is partly articular
and partly non articular.
•The articular area is shaped like a horse
shoe.
•The acetabulum is contributed2/5th by
ilium,2/5th by ischium and 1/5th pubis.

4. Incomplete hemispherical socket with an
◦ inverted horse-shoe shaped articular surface
◦ non articulating cotyloid fossa.
The articular surface is supported by
two columns of bone (described by
Letournel and Judet) as an inverted ‘Y’
These are in turn linked to the sacrum
by the sciatic buttress.
Anatomy

5. Anatomy
The anterior column:
iliac crest,
the iliac spines,
the anterior half of the acetabulum, and
the pubis
The posterior column
ischium,
the ischial spine,
the posterior half of the acetabulum,
and
the dense bone forming the sciatic
notch.

6. The dome, or roof, of the acetabulum is
the weight bearing portion of the
articular surface that supports the
femoral head
Anatomical restoration of the dome is
the goal of both operative and
nonoperative treatment.

7. Anatomy
The quadrilateral surface is the flat plate of bone
forming the lateral border of the true pelvic cavity
and thus lying adjacent to the medial wall of the
acetabulum.
The iliopectineal eminence is the prominence in
the anterior column that lies directly over the
femoral head.
Both the quadrilateral surface and the
iliopectineal eminence are thin and adjacent to
the femoral head, limiting the types of fixation
that can be used in these regions.

8. Anatomy
The sciatic nerve
The superior gluteal Artery and Nerve
Corona mortis

9. Mechanism of injury
High energy trauma secondary to RTA or fall from height.
The fracture pattern depends on
Position of femoral head at the time of injury ,
Magnitude of force and
 Age of patient.

10. Neutral position of hip--Transverse fracture.
Externally rotated and Abducted hip —Anterior Column injury
Internally rotated and Adducted hip ---Posterior Column injury.
With the direct trauma, as the degree of flexion increase, the
posterior wall is fractured more inferior in position

11. Fracture location Position of femoral head
Posterior column # Internal rotation
Anterior column # External rotation
Superior dome# Adduction
Inferior aspect of the dome fracture Abduction

12. Clinical Evaluation
Trauma evaluation: with attention to ABCD, depending on the mechanism of
injury.
Neurovascular assessment:
Position of limb
Limb length discrepency
Bowel and Bladder status
Presence of associated ipsilateral injuries must be ruled out
Soft tissue injuries (e.g., abrasions, contusions, subcutaneous hemorrhage)
may provide insight into the mechanism of injury.

13. Clinical evaluation
in most cases, the patient with a fracture of the acetabulum has sustained high-
energy trauma
The pattern of the acetabular fracture depends on the position of the hip at the time
of impact, as well as the location and magnitude of the applied force
Contusion to the knee is a red flag, indicating possible hip injury.
If awake and alert, the patient may complain of knee pain, being the first indication
of an injury to the knee (patellar fractures, chondral injuries, and ligamentous
injuries).
complete examination of the musculoskeletal system is required, especially
evaluation of the peripheral nerves.
Local closed degloving soft tissue injuries about the hip (the Morel–Lavallé lesion)

14. Sciatic nerve injury is common in fractures with a posterior hip dislocation
and fracture displacement of the posterior wall or column.
It is often incomplete, most often involving the peroneal division
Isolated sensory deficits and weakness or total loss of movement of
individual muscles can occur.
Shortening of the entire limb should be present if the hip is dislocated.

15. Radiological evaluation
Pelvic Xray
AP view
 2 Judet views (iliac & obturator oblique views)
CT scan

16. Landmarks of Standard Anteroposterior
Radiograph
1 Iliopectineal line
2 Ilioischial line
3 Radiographic teardrop
4 Roof of acetabulum.
5 Edge of anterior lip of acetabulum.
6 Edge of posterior lip of acetabulum

18. Judet View Of The Hip

19. The obturator oblique view
Anterior column #
Posterior wall #

20. The Iliac Oblique View
Posterior column #
Anterior wall #

21. Landmarks on standard view
Anteroposterior pelvis
Illiopectineal line Anterior column
Illioischial line Posterior column
Posterior lip Posterior column or wall
Anterior lip Anterior column or wall
Roof Superior articular surface
Tear drop Relationship of the column

22. Obturator oblique
Pelvic brim Anterior column
Posterior rim Posterior column or wall
Obturator ring Column involvement
Roof Superior articular surface

23. Iliac oblique
Greater and lesser sciatic notch Posterior column
Quadrilateral surface of ischium Posterior column
Anterior lip Anterior column or wall
Iliac wing Anterior column
Roof Superior articular surface

24. CT Scan
1. Computed tomography with axial cuts must be taken with thin (3-mm)
intervals
2. Gives a true mental three-dimensional picture through axial cuts.
3. CT scans can give the same information about the acetabular dome as the
roof arc measurements on the anteroposterior and oblique radiographs.
4. Axial CT scans showing the superior 10 mm of the acetabular roof to be
intact corresponded to radiographic roof arc measurements of 45
degrees.

25. CT scan Orientation
Orientation of fracture lines through acetabulum as seen on
CT scan
A, Anterior column fracture B, Posterior wall fracture

26. Classification:
Accurate classification of acetabular fractures is important for
determining the proper surgical treatment.
Although radiographic examination provides essential information for
acetabular classification, CT, including multiplanar reconstruction, is
helpful in the visualization of complex fractures.

27. Classification
1. Judet and Letournel
2. Tile’s classification
3. AO classification

28. Judet and letournel classification
1. Elementary fractures
2. Associated fractures
The elementary fracture patterns are those fractures that separate
all or part of a single column of the acetabulum
The associated patterns are either a combination of elementary
patterns or elementary plus an additional fracture component

29. Elementary fractures
1. Poserior wall
2. Posterior column
3. Anterior wall
4. Anterior column
5. Transverse

30. Anterior wall and anterior column

31. Posterior wall and posterior column

32. Transverse

33. Associated fractures
1. T shaped
2. Posterior column and posterior wall
3. Transverse and posterior wall
4. Anterior and posterior hemitranverse
5. Both column

37. TILE’S CLASSIFICATION
A) Anterior wall or column fracture
B) Posterior wall or column fracture
C) Transverse fracture
D) T-Type fracture involving both column
E) Both column fracture resulting floating
acetabulum.

38. AO Classification Of Acetabular Fractures
Type A: fracture involves only one of two
columns of acetabulum;
type A1: posterior wall fracture and
variations;
type A2: posterior column fracture and
variations;
type A3: anterior wall and anterior column
fracture.
Type B: transverse fractures with portion of
roof remains attached to intact ilium;
type B1: transverse fracture and transverse
plus posterior wall fracture;
type B2: T-shaped fracture and variations;
type B3: anterior wall or column plus
posterior hemitransverse fracture.

39. Type C: fractures of anterior and posterior
columns, no portion of roof remains
attached to intact ilium;
type C1: anterior column fracture extending
to iliac crest;
type C2: anterior column fracture extending
to anterior border of ilium;
type C3: fractures enter sacroiliac joint.

40. Posterior Wall Fracture
Most common
An isolated posterior wall fracture does not have
a complete transverse acetabular component.
Therefore, the iliopectineal line is not disrupted,
which excludes classification of the transverse
with posterior wall fracture.
 However, disruption of the ilioischial line may or
may not be present as an extension of the
comminuted posterior wall component.
 Oblique (Judet) radiographs and CT are helpful
in showing the isolated posterior wall fracture.

42. Posterior Column Fracture
The fracture begins at the posterior border of the innominate
bone near the apex of the greater sciatic notch.
It descends across the articular surface, quadrilateral surface,
ischiopubic notch (roof of the obturator canal), and finally
across the inferior ramus.
Posterior wall and posterior column fractures can be
distinguished easily.
In a posterior column fracture, the ilioischial line is interrupted.
In a posterior wall fracture, only the retroacetabular surface is
disrupted.

44. Anterior wall and anterior column fractures
 Anterior wall and anterior column
fractures can be distinguished by
the additional break in the
ischiopubic segment of the pelvis
present in the anterior column
fracture.

47. Transverse fracture
This fracture runs transversly through
the acetabulum involving both ant.
And post. Column separating iliac
portion above and pubic and ischial
portion below.
A vertical split in to obturator
foramen co-exist resulting in a T
fracture.
The various subgroups of the transverse
fracture.
Infratectal Type (A)
Juxtatectal Type (B),and
TranstectalType(C).

48. The Gull sign represents
impaction of the acetabular roof and
is a poor prognostic sign,
Present difficulties in maintaining the
reduction of the fragment.
Displacement of the fragment may
allow subluxation of the femoral
head and an incongruous hip joint.

49. Transverse # of any type
+
Vertical # through the ischiopubic
fragment
The vertical component is best seen
on the obturator oblique view.
T-Shaped fracture

50. T-Shaped fracture
The T-shaped fracture is similar to a both-column fracture in that it
disrupts the obturator ring.
Another similarity is disruption of both the iliopectineal and ilioischial
lines.
However, the superior extension of the fracture does not involve the iliac
wing, which allows differentiation from the both-column fracture.

51. Transverse and posterior wall fracture
Transverse fracture
+
Comminuted posterior wall fracture
(usually displaced)
The iliopectineal and ilioischial lines are disrupted.
The obturator oblique view best demonstrates
the position of the transverse component as well
as the posterior wall element.

52. Both columns are separated from each
other and from the axial skeleton, resulting
in a ‘floating’ acetabulum
This is the most complex type of acetabular
fracture.
Both-column fracture
No portion of acetabulum remains connected
to the rest of pelvis

54. The spur sign, shown on the
obturator oblique view, is
pathognomonic of a both-column
fracture

55. Management
Non Operative
Operative
The quality of acetabular fracture reduction is the single most important
factor in the long-term outcome of these patients, and such surgery should
be undertaken only by surgeons with sufficient experience

56. Management
Initial treatment – follow ATLS protocols
Operative treatment of acetabular fractures are usually not performed as an emergency
except with
an irreducible dislocation of hip ,
an open fracture,
vascular compromise and
worsening neurological deficit.
Normally, a closed reduction  Skeletal traction
As a general rule, acetabular fractures are articular fractures, so they have to
be treated under the principles of anatomical reduction, stable internal
fixation, and early mobilization.

57. Non operative treatment
Indications :
Stable non displaced fractures
Stable and congruous minimally displaced fractures
Selected displaced fractures
Intact acetabulum maintains stability and congruity
Low anterior column fractures
Low transverse fractures

58. Low T shaped fractures
Both column fractures with secondary congruence
Wall fracture not compromising hip stability
Infirm patients unable to withstand surgery
Severe osteoporosis precluding fracture fixation

59. Superior dome or the roof
Superior third of the weight bearing area of the acetabulum
Axial CT sections of the superior 10 mm of the acetabular articular
surface are equivalent to the weight bearing dome region
Displacement of more than 2mm of the superior dome is
indication for operative treatment

60. Measurement of roof arc
All three radiographs
◦ Medial roof arc: AP view
◦ Anterior roof arc: obturator oblique
◦ Posterior roof arc: Iliac onlique
Roof arc is the angle between a vertical line through the center of
the femoral head and another line from center of femoral head to
the fracture location at the articular surface

62. Recommendation
Greater than 45 degrees in all three radiographs : non operative treatment
Recent criteria:(Vrahas, Widding and Thomas)
Medial roof arc: >45 degree
Anterior roof arc: >25 degree non operative treatment
Posterior roof arc: > 70 degree

63. Prerequisites for non operative treatment of acetabular
fractures include both intact roof arc measurements and
congruence of femoral head to the intact acetabulum on
AP and Judet radiographs obtained out of traction

64. Bed rest with joint immobilization : for symptomatic relief in acute phase
Mobilization of the patient and hip joint should follow as soon as
symptoms allow
Begin with touch down partial weight bearing of the affected extremity
AP and oblique radiographs every week for 4 weeks- to confirm
maintenance of satisfactory position
By 6-12 weeks gradually progress to full weight bearing
Prolonged traction treatment should be considered only for those
patients with operative indications related to fracture displacement but
having contraindications to surgical intervention

65.  A localized area of subcutaneous fat necrosis over the lateral aspect of the hip caused by the
same trauma that causes the acetabular fracture.
 The size and extent of this lesion are variable, and operating through it has been associated with
a higher rate of postoperative infection. up to to be 12%.
 Requiring postoperative wound débridement, packing, and healing by secondary intention.
 Alternatively a bypass approch can be used.
 The presence of a significant Morel-Lavallée lesion can be suspected by hypermobility of the skin
and subcutaneous tissue in the affected area from the shear-type separation of the subcutaneous
tissue from the underlying fascia lata.
Morel-Lavallée lesion

66. Morel-Lavallée lesion
Higher rate of postoperative infection up to 12%.

67.  If there is associated bladder injury a suprapubic catheter has to be avoided
 Better to discuss with the urologist with possible primary repair of the
bladder rupture and Foley catheter drainage.
 Delaying surgery through the ilioinguinal approach may be performed after
the bladder rupture has sealed

68. Indications for Operative Treatment
Displaced acetabular fractures (>2 to 3 mm).
Inability to maintain a congruent joint out of traction.
Large posterior wall fragment.
Removal of an interposed intraarticular loose fragment.

69. A fracture-dislocation that is irreducible by closed methods
Both column fracture that do not retain the ball and socket
congruence
Documented posterior instability under stress examination
Less than 45 degrees for any of the roof arc OR fracture within
superior 10 mm of the weight bearing dome in axial CT scan

70. Timing of Surgery
Most authors advocate waiting 2 or 3 days after injury before performing acetabular
surgery to allow the patient to be adequately stabilized and to allow pelvic bleeding to
subside.
Ideally, operative reduction and internal fixation of acetabular fractures should be
performed within 5 to 7 days of injury.

71. Anatomical reduction becomes more difficult after that time because
◦ hematoma organization,
◦ soft-tissue contracture, and
◦ subsequent early callus formation hinder the process of fracture reduction,
After a delay of more than 2 to 3 weeks, an extensile exposure may be
necessary to obtain adequate reduction.

72. ORIF
Implants choice:
Reconstruction plates ( curved or straight)
Cortical screws
Schanz screw
Lag screws
Locking plates

73. 1. Medical Contraindications to Surgery
2. Local Soft-Tissue Problems, such as Infection, Wounds, and Soft-Tissue
Lesions from Blunt Trauma
3. An open wound in the anticipated surgical Approach
4. Systemic infection.
Contraindication for surgery

74. Surgical Approaches To Acetabulum
GENERAL APPROACH
Kocher-Langenbeck approach
Ilioinguinal approach
EXTENDED APPROACH
 Extended iliofemoral approach.
Triradiate extended approach.

75. Kocher langenbeck approach

78. Kocher-Langenbeck Approach
The Kocher-Langenbeck approach is a nonextensile approach to the
posterior acetabular column.
It allows direct visualization of the dorsocranial part of the acetabulum either
through the fracture gap or after capsulotomy.
Indications
ORIF of fractures of the posterior wall/ column
Transverse juxta- and infratectal fractures
Combined fracture types in which the posterior column or wall needs to be
reduced under direct vision

79. Ilioinguinal Approach
The ilioinguinal approach was developed by Emile Letournel based on
cadaveric dissections to provide anterior access for fractures of the
acetabulum.
It provides exposure of the inner aspect of the innominate bone from the
sacroiliac joint to the pubic symphysis.

80. Illioinguinal approach

82. The exposure is complete. The lateral window exposes the internal iliac fossa
to the sacroiliac joint and pelvic brim
The middle window exposes the pelvic brim to the pectineal eminence, the
quadrilateral surface and the anterior wall
The medial window seen here has been created by transecting the rectus
abdominis tendon. The spermatic cord is retracted laterally and the space of
Retzius, superior ramus and symphysis pubis are visualized

83. Extended Iliofemoral

84. Extended Ileofemoral Approach
Indications
Transtectal associated transverse + posterior wall fractures, or T-shaped fractures,
particularly with posterior wall comminution
Transverse fractures with significant posterior wall involvement
T-shaped fractures with widely displaced vertical limbs or pubic symphysis dislocation
Both-column fractures with posterior wall or posterior column comminution, sacroiliac joint
involvement, or very high posterior column involvement
When ORIF of associated or transverse fractures is delayed by three or more weeks
Contraindications
The extended iliofemoral approach should not be used in aged or obese patients, nor in
patients who are not committed to a long recovery process.

85. Extended Ileofemoral Approach
Advantages
The extended iliofemoral approach allows simultaneous visualization of both
posterior and anterior columns. With this exposure, reduction and fixation are
usually straightforward.
Disadvantages
Technically this approach is demanding, and has the highest complication rate.
Heterotopic bone formation is common. (Prophylaxis should be planned).
Abductor muscle weakness with prolonged rehabilitation must be expected

86. Triradiate approach

87. Fracture Type Approach
Elementary
Posterior wall Kocher-Langenbeck
Posterior column Kocher-Langenbeck
Anterior wall Ilioinguinal
Anterior column Ilioinguinal
Transverse
Infratectal/juxtatectal Kocher-Langenbeck
Transtectal Extended Iliofemoral or Kocher Langenbeck
CHOICE OF APPROACHES

88. Associated fracture types
Posterior column + wall Kocher-Langenbeck
Anterior + posterior Hemitransverse Ilioinguinal
Transverse + posterior wall
Infratectal/juxtatectal Kocher-Langenbeck
Transtectal Extended Iliofemoral or Kocher-Langenbeck
T-Shaped
Infratectal/juxtatectal Kocher-Langenbeck or combined
Transtectal Extended Iliofemoral or combined
Associated both column Ilioinguinal
Associated fracture types

89. Outcome and complications
Mortality rates after acetabular fractures range from 0% to 2.5%.
Posttraumatic arthritis:
◦ After perfect reduction ,the rate of posttraumatic arthritis is 10.2%; and after
imperfect reduction it is 35.7%.
Both-column and transverse with posterior wall fractures will have worse results because of
imperfect reduction.
Posterior wall fractures, although reduced nearly perfectly in 98%, resulted in
posttraumatic arthritis in 17%
Posttraumatic arthritis despite anatomical reductions on plain radiographs to is due to the
lack of sensitivity of plain radiographs to detect small incongruencies in the reduction.
Borrelli et al found CT to be more sensitive in showing postoperative gaps and step-offs
They recommended that postoperative CT be considered for assessment of operative
reduction.

90.  Letournel's reported rate of osteonecrosis as 7.5% after fractures
associated with posterior dislocation.
 radiographically apparent within 2 years of injury in most patients.
 Osteonecrosis of the posterior wall can be caused by the injury or by
excessive fracture site exposure because the only vascular supply of
these fragments is the injured posterior capsule of the hip.
Osteonecrosis

91. Infections
 Ranges 1% to 5%
 Risk factors –
presence of a suprapubic catheter in ilioinguinal approaches
and
the Morel-Lavallée lesion in Kocher-Langenbeck and extensile
approaches.
 Obesity has been shown to increase the rate of multiple
complications including infection. Patients with a body mass
index of more than 40 had a five times increased risk of
infection with acetabular surgery

92. Sciatic nerve injury
 Initial injury cause sciatic nerve palsy in approximately 10% to 15% of patients
 As a result of surgery occurs in 2% to 6% of patients and is more often associated
with posterior fracture patterns treated through the Kocher-Langenbeck and
extensile exposures.
 the peroneal component of the sciatic nerve was more often involved than the
tibial component and that the tibial component had a greater chance of
recovery; complete peroneal palsies had the worst prognosis.
 Functional recovery has been shown in approximately 65% of patients, and
function may improve up to 3 years after injury

93. Heterotopic ossification
Extensile approaches, --14% to 50% of patients when no prophylaxis is used;
The Kocher-Langenbeck approach -25% of patients
Rare after the ilioinguinal approach unless the external Surface of the ilium is
stripped.
The effectiveness and choice of prophylactic measures to prevent heterotopic
ossification remain controversial.
Prophylactic measures:
Indomethacin to be effective in decreasing significant heterotopic ossification after
acetabular fracture surgery.
low-dose irradiation was found to be effective in many studies

94. Thromboembolic complications
Risk of pulmonary embolism ranges from 2% to 6%.
Incidence of Deep vein thrombosis in 8% to 61%.
Venous Doppler ultrasound examination may underestimate the presence of
significant clots !
Magnetic resonance venography (MRV) is more sensitive than venography in
detecting clots within the intrapelvic veins and contralateral extremity.

95. •Inferior vena cava filter placement in high-risk groups, including
patients older than 60 years, patients with contraindications to
anticoagulation, and patients in whom morbid obesity, malignant
disease, or a history of prior deep vein thrombosis is a factor.
•Use of subcutaneous heparin as well as intermittent compression boots
while patients are awaiting surgery.
•A preoperative screening duplex Doppler scan in any patient in whom
the injury is more than 4 days old.
PREVENTION

96. Total Hip Arthroplasty as Treatment for Acetabular Fracture
Some acetabular fractures with extremely poor prognoses ARE TREATED
WITH primary total hip arthroplasty,
Example
A comminuted, incongruous, both-column fracture
An unreduced posterior fracture-dislocation of the hip with severe marginal
impaction and femoral head erosion 4 weeks after injury.
Total hip arthroplasty performed for posttraumatic arthritis after
acetabular fracture was found to require longer operative times with
greater blood loss and transfusion requirement compared with total
hip arthroplasty performed for degenerative arthritis

97. Fixation of low anterior column
fracture with contoured plate
along pelvic brim. Note
associated femoral shaft
fracture fixed with locked
intramedullary nail.

98. Posterior column and
posterior wall acetabular
fracture fixed with two
plates. First reconstructs
posterior column, and
second reconstruction
plate (supplemental
spring plate) fixes
posterior wall fragments.

99. Posterior wall fracture fixed with
contoured 3.5-mm pelvic
reconstruction plate.