Acetabulum Fracture
Dr Sijan Bhattachan
3rd year resident
Orthopaedics & Trauma Surgery, NAMS

Introduction
• Treatment of acetabular fractures is a complex area
of orthopaedics that is being continually refined.
• Caused by high energy trauma and associated
injuries are frequent.
• Management of entire patient should follow
accepted ATLS protocol.

Anatomy
• Acetabulum; Incomplete hemispherical socket with
an inverted horseshoe shaped articular surface
surrounding the nonarticular cotyloid fossa.
• Articular socket supported by two columns of bone,
described by Letournel and Judet as an inverted Y.

Columns

Dome

Quadrilateral Plate

• Sciatic nerve & Superior gluteal vessels

Corona Mortis

Mechanism of injury
• Impact of femoral head with acetabular articular
surface

Radiographic evaluation
• AP view
• Judet views (45 degrees oblique views)
-Iliac oblique view
-Obturator oblique view

Roof Arc
• Matta et al developed a system for roughly
quantifying the acetabular dome after fracture, which
they called the ‘Roof arc” measurement.

• Determines if the remaining intact acetabulum is sufficient to
maintain a stable and congruous relationship with femoral head.
• If any of the roof arc measurements in a displaced fracture are
less than 45 degrees, operative treatment should be considered

• CT scan is invaluable in the treatment of acetabular
fractures.

Classification
• Letournel & Judet;

Posterior Wall Fracture
• 25% of all acetabular fractures

Posterior Column Fracture

Both column Fracture
• 23% of all acetabular fractures
• Acetabulum completely disconnected from axial skeleton.
• Central dislocation of femoral head

• Spur Sign; External cortex of most caudal portion of
intact ilium.

• Secondary congruence

Treatment Protocol
• Radiographs allow proper fracture classification
• Fracture location and displacement determine need
for surgery
• Fracture Pattern determines Approach.

Non Operative ; Indications
• Nondisplaced and minimally displaced fractures (<2 mm)
• Fractures with significant displacement but in which the region of the joint
involved is judged to be unimportant prognostically (roof arc).
• Secondary congruence in displaced both column fractures
• Medical contraindications to surgery
• Local soft tissue problems, such as infection, wounds and soft tissue lesions
• Elderly patients with osteoporotic bone in whom open reduction may not be
feasible

Non Operative Treatment Techniques;
• Bed Rest with joint mobilisation.
• When there is adequate fracture healing , usually by
6-12 weeks , gradually progress to full weight
bearing..
• Prolonged traction treatment for those patients with
operative indications related to fracture displacement
but having contraindications to surgical intervention.

Indications for operative treatment
Fracture characteristics:
• With 2 mm or more of displacement in the dome of acetabulum as
defined by any roof arc measurements of less than 45 degrees
• any subluxation of the femoral head from a displaced acetabular
fracture noted on any of the three standard radiographic views
• Posterior wall fractures with more than 50% involvement of the
articular surface of the posterior wall.
• Incarcerated fragments in the acetabulum after closed reduction of
hip dislocation

• Urgent surgical interventions
-Irreducible hip dislocation
-Open fracture
-Vascular compromise
-Worsening neurologic deficit
• No delay beyond 15 days for elementary fractures and 10 days
for associated types

Surgical Approach
• Anterior
-Ilioinguinal
-Modified Stoppa
• Posterior (Kocher-Langenbeck approach)
• Extensile approaches
-Extended iliofemoral
-Triradiate approach
-T approach
• Combined Anterior & Posterior Approach

Selection of Surgical approach
• Fracture type
• Elapsed time from injury to operative intervention
• Magnitude and location of maximal fracture
displacement

Fracture Reduction & Fixation;
• First reduce and stabilise the
displaced columns , if present and
then reduce any wall fracture.
• After definitive fixation of the
reduced fragments, the entire
construct is stabilised with
buttress plates.

Percutaneous Treatment
• Mini open exposure through lateral window of ilioinguinal
incision.
Indications;
• To prevent potential further fracture displacement.
• Displaced fractures in elderly.
• Simple fractures with minimal displacement
• As an adjunct to standard ORIF techniques
• Severe injuries that prevent formal ORIF

Kocher-Langenbeck
Approach
• Indications;

Dissection

Complications;
• Infection
• Sciatic nerve palsy
• Heterotopic ossification

Special considerations
• Transecting the piriformis & obturator internus tendons
1.5 cm from GT.
• Quadratus femoris & obturator externus intact.
• Sciatic nerve directly visualised & protected; Recognize
anatomical variations.

• Sciatic nerve & Piriformis;

Ilioinguinal Approach
• Developed by Letournel after extensive cadaveric anatomical
study.
• Indications;

Access

Dissection

• Iliopectineal fascia separates Lacuna musculorum and
Lacuna vasorum.

• 3 windows;

Complications;
• Infection
• Femoral nerve palsy
• Injury to Lateral femoral cutaneous nerve
• Vascular injury

Modified Stoppa Approach
• Exposes internal surface of the anterior column and
the quadrilateral surface.
• It can be used for many fractures previously treated
through ilioinguinal approach.

Dissection

• Use of Stoppa Approach with the Lateral window of
the ilioinguinal approach has been promoted as a
way of avoiding the dissection of the middle window
of the ilioinguinal approach and thus exposure of
femoral vessels and nerve.

Complications
• Overall mortality rates (0 - 2.5%)
• Post traumatic arthritis & osteonecrosis of femoral head
• Infections
• Sciatic nerve palsy (10-15% ;2-6%)
• Heterotopic ossification
• Thromboembolic complications
• Intra articular hardware

THR
• In older patients with extremely poor prognoses.
• Indications include intraarticular comminution,
full thickness abrasive loss of articular cartilage,
impaction of femoral head, impaction of dome,
associated femoral neck fracture and
preexistent arthritis.
• Fractures can be fixed with percutaneous
screws, plates or cables and fixation augmented
with multiple screw fixation of the ingrowth cup.

• 45 yr/M ; Left Acetabulum Fracture

• Modified Stoppa with lateral window of Ilioinguinal
Approach

References
• Campbell’s operative orthopaedics, 13th edition.
• Rockwood & Green’s Fractures in Adults, 8th
edition.
• OTA lecture series III (Acetabulum Fracture).