This document discusses the classification and surgical approaches for acetabular fractures. It begins by outlining the pioneers in the field and the goal of anatomical reduction and stable fixation. It then describes the column concept and Letournel classification system involving simple and combined fracture patterns. Various surgical approaches are outlined including the Kocher-Langenbeck, ilioinguinal, and extensile approaches. Post-operative complications are also summarized.

1. Acetabular Fracture :
Classification & Surgical
Approaches

2. The Pioneers
 Robert Judet
 Emile Letournel
 Marvin Tile
Anatomical reduction and stable
internal fixation

3. Column Concept
 Two columns converging to
form a cavity

4. The Acetabular Cavity
 Two walls – anterior and posterior
 Roof
 Floor

5. Plain Radiograph

6. Judet’s Iliac Oblique View

7. Judet’s Iliac Oblique View

8. Judet’s Obturator Oblique
View

9. Judet’s Obturator Oblique View

10. CT Scan
 Size of fragment
 Degree of displacement
 Amount of articular surface
 Site of origin of fragment
 Marginal impaction

11. CT Scan
 Position of
femoral head-
dislocation,
subluxation,
perfect reduction
 Incarcerated
fragment

12. 3 D CT SCAN

13. Letournel Classification
Most acetabular fractures fit into one of
ten types
 Five simple fracture patterns
 Five associated fracture patterns

14. Simple Fractures
 Posterior wall fracture
 Posterior column fracture
 Anterior wall fracture
 Anterior column fracture
 Transverse fracture

15. Posterior wall Fracture
 Includes posterior
articular surface and retro
acetabular surface

16. Posterior Column Fracture
 Extends from
PSIS to ischio
pubic ramus
 Involves
posterior articular
surface and ilio
ischial line

17. Anterior Wall Fracture
 Uncommon
 Separation of anterior part of
articular surface along with a
large part of middle third of
anterior column
 Anterior hip dislocation can
be associated

18. Anterior Column Fracture
 Extends from
symphysis pubis to
iliac crest
 Most commonly
fracture line exits
below AIIS
 Often comminution
into the quadrilateral
plate

19. Transverse Fracture
 Across anterior and posterior columns
 Superior segment – ilium, acetabular roof
 Inferior segment – ischiopubic segment
 May be associated with central dislocation

20. Combined Fracture Types
 Posterior column and posterior wall
fracture
 Transverse and posterior wall fracture
 T-shaped fracture
 Anterior column or wall and posterior
hemi transverse fracture
 Complete both-column fracture

21. Associated Posterior Wall and
Posterior Column Fracture
 Posterior column
fracture is usually
undisplaced or
minimally displaced
 Primary fracture –
posterior wall

22. Associated Posterior Wall And
Posterior Column Fracture
 Anterior Column
intact
 Posterior dislocation
 Displaced posterior
wall
 Ilio ischial line
disrupted

23. Associated Transverse and
Posterior Wall Fracture
 Commonly posterior
dislocation
 Sometimes central
dislocation
 Highest incidence of pre op
sciatic palsy and AVN of
femoral head

24. T Shaped Fractures
 Transverse and
vertical components
 Acetabular cavity is
split into at least 3
fragments

25. T Shaped Fractures

26. Both Column Fractures
 All segments of
fractured acetabulum
are detached from the
ilium

27. AO Classification
 Type A – Fractues of a single wall or
column
 Type B –Fractures involve both columns
 Type C –Both column fractures with
articular fragments seperated from ilium

28. AO Classification

29. AO Classification

30. AO Classification

31. Injury Pattern Affecting
Prognosis
 High or low energy trauma
 Involvement of acetabular dome
 Comminution and displacement
 Joint dislocation
 Damage to femoral head
 Both-column fractures and transverse with
posterior wall fractures have worst results ,
primarily because of imperfect reduction

32. Indications For Conservative
Management
 Non displaced or displaced
<3mm
 Displaced fracture in
unimportant part of
acetabulum – low anterior
column, low transverse
 Secondary congruence in
both column fractures

33. Indications for operative
treatment
 Fracture Displaced >3mm
 Irreducible fracture dislocation
 Intra articular fragment
interfering with joint movement
 Instability of the joint
 To prepare the joint for hip
replacement

34. Contraindications to surgery
 Severe osteoporosis
 Very old patients
 Severe associated injuries
 Poor local skin condition
 Limited experience of the surgeon

35. Timing Of Surgery
 Urgent closed reduction of dislocation
 Stabilise the patient before ORIF
 Ideally within 7 days
 Poor results after 3 weeks

36. Kocher Langenbeck Approach
 Posterior wall fracture
 Injuries with associated
posterior wall fracture
 Posterior column fracture

37. Kocher Langenbeck Approach
 Transverse fracture
where major
displacement is
posterior
 T shaped fracture
with major
displacement
posterior

38. Kocher Langenbeck Approach

39. Ilioinguinal Approach
 Anterior wall
fracture
 Anterior column
fracture
 Fractures
associated with
anterior wall and
column fractures

40. Ilioinguinal Approach

41. Ilio inguinal Approach
 Incise along anterior two thirds of iliac
crest, extending to the pubic symphysis
 Elevate abdominal muscles from iliac
crest
 Open inguinal canal

42. Ilioinguinal Approach
 Detach deep abdominal
muscles from inguinal
ligament and pubis
 Open iliopsoas sheath
 Incise iliopectineal fascia
 Lateral retraction of
iliopsoas and medial
retraction of iliac vessels

43. Dangers Of Ilio Inguinal
Approach
 Lat cut nerve of thigh,
femoral nerve
 Corona mortis
 Internal iliac vein, femoral
vein
 Lymphatics
 Abdominal wall
weakness

44. EXTENSILE APPROACHES
 Used in complex fracture patterns
 Triradiate Extensile Approach
 Carnesile Extensile approach
 Extensile Ileofemoral approach

45. Triradiate Approach
 Described by Mears & Rubash
 Reduction & repair of Complex
Acetabular fractures
Avoids ischemic necrosis Of Hip
Abductors

46. Triradiate Approach

47. Carnesile approach

48. Carnesile approach

49. Complications Of Acetabular
Surgery
 Imperfect reduction, inadequate fixation
 Avascular necrosis
 Infection
 Nerve injury
 Heterotopic ossification
 Thromboembolism
Learning Curve Of The Surgeon Parallels The
Suffering Curve Of The Patient

50. Thank YouThank You
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