Everything need to know about acetabulum fractures. History, classification, ATLS protocol, investigations and management.

1. Acetabular fractures
By Dr Arshad Shaikh
Credits
Dr Anand

2. Introduction
• Contemporary icon of pelvic
and acetabular surgery .
• Ubiquitous standard of care
of acetabular fractures for
the past 25 years.
• Complete transformation of
our understanding and
treatment of fractures of the
acetabulum
• Two textbooks are the
“Bibles” of acetabular
surgery

3. Acetabular fractures
Before Letournel
• Conflicting recommendations
on Rx.
• No classification
• No consensus on
conservative or operative
• Only AP view Pelvis obtained
• Invariably poor results –
JOINT INSTABILITY/ AVN.
After Letournel
• First systematic classification
• Phenominal concepts
• AP, 45 deg oblique views ; CT
• Concept of accurate reduction
• Surgical approaches and
management protocols
• Standard plate and screw
fixation
• Aim is congruent and stable
hip.

5. Principles of acetabular fracture Rx
• Thorough understanding of 3-D anatomy of
innominate bone
• Diagnosis, Classification and operative repair
• Stable congruent hip esp. weight bearing
dome.
• Surgery is complex and done by experienced
surgeon.
• Anatomic reduction ( < 2mm ) is key to
functional outcome.

6. Mechanism of injury
• Impact of femoral head with the acetabular
surface
• Force is via GT or Axis of femur
• Fracture pattern decided by position of hip at
the time of impact
• Also force of impact and bone quality

7. Mechanism of injury

8. Mechanism of injury

9. Assessment – ATLS protocol
History
• Mechanism of injury
• Ask for position of hip
• Ask of axial loading or
direct injury
• Low energy trauma
• Underlying illness
Examination
• Open wounds
• Morel- Lavallee lesions
• Shortening
• Attitude of limb
• Neurological examination
• Document sciatic nerve
palsy

10. Associated injuries
• Extremity ( 35%)
• Head ( 19 %)
• Chest ( 18 %)
• Nerve palsy ( 13 % )
• Abdominal ( 8 % )
• Genitourinary ( 6 % )
• Spine (4 %)
• Pelvic injury
• Fracture neck of femur
• Fracture shaft of femur
• Bladder injuries
• Morel Lavalle lesions
• Knee ligament injuries

11. Anatomy & Osteology
• hemisphere recess
• quadrilateral surface
• transverse acetabular
ligament
• Dome of acetabulum
• iliopectineal eminence
• sciatic nerve relation

12. Anatomy & Osteology

13. Two column concept
•

15. Radiology of acetabular fractures

16. Radiology of acetabular fractures
Superior weight bearing
surface

17. Radiology of acetabular fractures
Iliac oblique viewObdurator oblique view

18. Radiology of acetabular fractures
Iliac oblique view Obdurator oblique view

20. Roof arc measurement

21. Roof arc measurement

22. Dynamic stress view
Dynamic hip instability

23. CT Scan- 2D/3D
• Extent & location
• intra- articular free
fragment / head
fragment
• orientation of # lines
• rotation of fragments
• status of posterior
pelvic ring
• Marginal Impaction
Don’t decide hip joint instability based on CT Scan.
PELVIC PLASTIC MODEL

24. Classification – Letournel

25. Management options-NON-SURGICAL
 Stable nondisplaced & minimally displaced
 Selected displaced fractures where intact
acetabulum maintains stability & congruity –
Low anterior column, Low transverse , low T-
shaped
 Both column fractures with secondary
congruence
 Wall fractures not compromising hip stability
 Local wound issues/ Medically unfit/ Elderly

26. Stable fracture
• Acetabular fracture < 2 mm of displacement
in dome
• Roof arc measurement greater than 45
degree on three views
• Recently , Medial roof arc > 45 degree
Anterior roof arc > 25 degree
Posterior roof arc > 70 degree
• Axial CT – superior 10 mm acetabulum
articular surface

27. Don’t apply roof arc here
Posterior wall # -
• Assess hip stability here.( Whether+/-
dislocation )
• > 50 % post. Wall is unstable
• < 50 % wall - Dynamic stress fluoroscopy
• If in doubt – assume hip is unstable
Both column #
• Secondary congruence

28. Secondary congruence

29. Secondary congruence

30. Go for non operative here
• Polytrauma with sick condition
• Severe head injury
• Open wound in the planned incision site
• Morel – Lavale lesions
• Suprapubic catheter – No ilioinguinal
approach. Wait till track seals.
• Elderly with osteoporotic bone
Gull sign – poor prognosis

31. Non operative protocol
• Bed rest
• Mobilise as soon as symptoms allow
• Begin with partial weight bearing
• Assess displacement weekly for first 4 weeks
• By 6 to 12 weeks patient returns to full weight
bearing
• Joint mobilisation throughout
• Prolonged traction only for patients who needs
surgery but contraindicated due to other reasons

32. Fix if
• Displaced # in dome.
• Posterior wall # > 50 % displacement
• Positive fluoroscopy stress test
• Both column fractures with loss of parallelism
• Incarcerated fragments in the acetabulum
after closed reduction.
Ideal time – 5 to 7 days

33. Orthopedic trauma association

34. Approaches
Anterior
• Ilioinguinal
• Iliofemoral
• Extended Iliofemoral
• Modifications of Ilioinguinal
• Modifications of iliofemoral
Posterior
• Kocher- Langenbeck
• Modifications
• Trochantric flip osteotomy
• Modified Gibson
• Modified Stoppa Intrapelvic

35. Anterior Ilioinguinal
• Anterior wall, anterior column, anterior
column + posterior hemitransverse, transverse
with major displacement in anterior region
• Careful of corona mortis
• Lowest rate of heterotrophic ossification
• Risk of damage to lat.cut.N, femoral.N,
external iliac vessels and inguinal canal

36. Ilioinguinal approach

37. Ilioinguinal approach

38. Ilioinguinal approach

39. Ilioinguinal approach

40. Ilioinguinal approach

41. Ilioinguinal approach

42. Ilioinguinal approach

43. Ilioinguinal approach

44. Ilioinguinal approach

45. Ilioinguinal approach

46. Iliofemoral approach

47. Kocher- Langenbeck approach
• Posterior wall, column, t type, transverse
• Access to sciatic notches, hip capsule
• Damage to sciatic.N, gluteal vessels and
intermediate risk of heterotrophic ossification
• Lateral/ Prone
• Prone + traction
• Knee flexion

48. Kocher- Langenbeck approach

49. Kocher- Langenbeck approach

50. Kocher- Langenbeck approach

51. Kocher- Langenbeck approach

52. Kocher- Langenbeck approach

53. Kocher- Langenbeck approach

54. Kocher- Langenbeck approach

55. Kocher- Langenbeck approach

56. Kocher- Langenbeck approach

57. Modified Stoppa’s approach

58. Extended Iliofemoral approach

59. Trochantric flip osteotomy

60. Modified Gibson’s approach

61. Choice of approach

62. Indications for emergency fixation
• Recurrent dislocation following reduction
despite traction
• Irreducible hip dislocation
• Progressive sciatic nerve palsy
• Associated vascular injury
• Open fractures
• Ipsilateral neck fractures

63. Posterior wall fractures
• 25 % of all acetabular fractures
• Kocher – Langenbeck approach
• Limit periosteal elevation to fracture site, don’t
release any fragment from capsule
• Distract head and remove osteochondral
fragments. May need hip subluxation
• Large fragment removal needs Modified Gibson’s
approach and troch flip osteotomy ( lateral)
• Bone grafting
• Two level reconstruction

76. Extended posterior wall

90. Posterior column
• 3 – 5 %
• Reduced by using Schanz screw into ischium
• Reduction clamps used
• Interfragmentary screws + butress plate.

91. Transverse #
• 5 – 19 %
• medial and superior displacement of head
• Transtectal, juxtatectal and infratectal
• Reduction – Schanz screws, sciatic notch
clamp, clamp between two screws
• Anterior column screws can be placed only at
acertain angle
• ilioinguinal approach

92. Transverse #

93. Transverse #

95. Transverse #

103. Anterior Wall and column
• 1 – 2 %
• quadrangular clamp
• screws and plate

109. Anterior column #
Very low
low
intermediate high

110. Anterior column/wall + Posterior
hemitransverse
• 7%
• Gull Wing sign – poor prognosis
• Reduce anterior column through ilioinguinal
approach
• Confirm posterior column reduction by
palpating quadrilateral surface
• screws + butress plate

111. Anterior column/wall + Posterior
hemitransverse
• 7%
• Gull Wing sign – poor prognosis
• Reduce anterior column through ilioinguinal
approach
• Confirm posterior column reduction by
palpating quaadrilateral surface
• screws + butress plate

112. T - shaped
• 7 %
• Kocher Langenbeck with prone
• Sequential anterior ilioinguinal approach
• Simultaneous access
• Reduction difficult without screws passing
through stem of T
• If associated posterior wall , low rate of
excellent reductions

113. Both columns
• 23%. Most common. Spur sign
• No portion of cartilage remains attached to
pelvic bone
• Secondary congruence
• Spur sign
• Surgical malreduction - Secondary congruence
• Anterior and posterior approach

114. Spur sign

115. Anterior column

116. Anterior column

117. Anterior column

118. Anterior column

119. Anterior column

120. Anterior column

121. Anterior column

122. Anterior column

123. Anterior column

124. Anterior column

125. Anterior column

126. Anterior column

127. Anterior column

128. Anterior column

129. Both column

130. Both column

131. Both column

132. Both column

133. Both column

134. Both column

135. Both column

141. Perioperative care
• Thromboembolism prophylaxis
• Active mobilisation by 6 – 12 weeks
• Indomethacin to prevent heterotropic
ossification X 4 – 6 weeks
• PWBW – 10 to 12 weeks

142. Complications
• Infection
• Iatrogenic nerve injuries
• Intra articular hardware
• Venous thromboembolism
• Heterotopic ossification
• Post traumatic arthosis and Osteonecrosis

143. Heterotopic ossification

144. Results
•

145. THR in acetabular #
• Elderly patient
• Post traumatic
• Patients with poor prognosis
• Cementless cup in fractured acetabulum is a
concern

146. Associated injuries
• Acetabulum + Posterior hip dislocation
• Acetabulum + Pelvic ring
• Acetabulum + Femoral head
• Acetabulum + Femoral neck in young
• Acetabulum + Shaft femur/ IT