■ Case Report

An Occult Acetabular Fracture Preceding a

Femoral Neck Fracture
NIKOLAOS LASANIANOS, MD; NIKOLAOS KANAKARIS, MD, PHD; PETER V. GIANNOUDIS, MD, EEC(ORTHO)

abstract
Full article available online at OrthoSuperSite.com/view.asp?rID=00000

This article describes the case of a 69-year-old patient with an occult acetabular fracture
complicated by an ipsilateral femoral neck fracture occurring within 2 months. The ac-
etabular fracture remained undiagnosed at examination due to insufficient clinical and
radiographic data interpretation. The patient was assured of early mobilization which led
to a fall and subsequent hip fracture. We focus on the potential reasons for the nondiag- A
nosis of the acetabular fracture in the first place. Acetabular fractures in the elderly may
occur after low-energy injuries. The lack of history of violent injury may mislead the clini-
cian from the proper diagnosis. Moreover, the authors want to point out the significance
of specialized radiographic control, such as obturator/iliac oblique views and computed
tomography, in vague cases of posttraumatic pelvic or hip pain. Plain anteroposterior (AP)
pelvis radiographs alone may prove an insufficient tool, especially in the eyes of relevantly
inexperienced personnel of the A & E departments. As is characteristic, a retrospective
review of the AP pelvis radiograph obtained after the first fall in our case revealed the un-
displaced fracture of the anterior column that was missed initially. Combined fractures of
the hip and the acetabulum are rarely described in the literature and are usually addressed B
by total hip arthroplasty (THA) alone. Similar fracture patterns that develop in 2 stages (2
Figure: AP radiograph of the occult undisplaced
injuries), as the 1 presented herein, are even more rare. The uniqueness of this combined acetabular fracture after the initial fall (A). AP ra-
fracture required a unique surgical treatment. The senior surgeon (P.V.G.) decided to ad- diograph of the minimally displaced acetabular
dress the acetabular fracture separately to graft the anterior column fracture and facilitate fracture and the subcapital fracture of the neck of
femur after the second fall (B).
union, as it was already 8 weeks old and the second fall had generated a further gap be-
tween the fragments. Stable fixation was felt appropriate prior to the THA. Thus, a double
surgical approach was used. Six weeks postoperatively, the patient was able to perform
full weight-bearing mobilization without an antalgic gait pattern. At 6-month follow-up,
radiographs showed the metalwork to be in place with no displacement, and the fracture
had progressed to union.

Drs Lasanianos, Kanakaris, and Giannoudis are from the Academic Unit of Trauma and Orthopae-
dic, University of Leeds, Leeds General Infirmary, Leeds, United Kingdom.
Drs Lasanianos, Kanakaris, and Giannoudis FINANCIAL DISCLOSURE.
Correspondence should be addressed to: Peter V. Giannoudis, MD, EEC(Ortho), Department of
Trauma and Orthopaedics, School of Medicine, University of Leeds, Room 194, A Floor, Clarendon
Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK.

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 ■ Case Report

F
ractures of the acetabulum com-
bined with fractures of the femoral
neck are rare.1,2 Such injury pat-
terns usually involve a central acetabular
fracture with a fracture of the ipsilateral
neck of femur and some kind of pelvic-
column disruption.3-6 In other cases, an-
terior or posterior dislocation of the hip
may be associated with a femoral neck
or head fracture.7-10 We report herein the
case of a 69-year-old man who sustained
a “2-stage” hip injury, having initially
sustained an occult acetabulum fracture
which resulted in a femoral neck fracture
within 2 months.
CASE REPORT
A 69-year-old previously ambulant man
with no history of bone pathology fell on his
left hip 2 months before being referred to our
department. The initial examination took place
elsewhere 3 days after the fall, because the pa-
tient was reluctant to visit a hospital although
being restricted to bed rest following the injury.
Radiographs were taken at that time (Figure
1A), but no obvious pathology was detected.
The patient was diagnosed with a soft tissue
injury and advised to mobilize as pain allowed.
After several physiotherapy sessions, the pa-
tient managed to achieve painful full weight
bearing on the affected site with the use of a
frame. Approximately 2 months after the first
fall during an effort to walk independently, the
patient sustained a new fall. On physical exami-
nation, the left hip was intolerable of any move-
ment, shortened, and externally rotated. Radio-
graphic examination (Figure 1B) confirmed the
clinical suspicion of an intracapsular femoral
neck fracture. Moreover, a minimally displaced
fracture of the left acetabulum was shown on
the new radiograph (Figure 1B). A computed
tomography (CT) scan revealed a nonunited
anterior column fracture (Figure 2). A double
surgical approach was used to fully address the
2 fractures. An ilioinguinal approach was first
used to stabilize the anterior column by open
reduction and internal fixation (ORIF), and a
lateral approach was used for the total hip ar-
throplasty that followed during the same ses-
sion. The floor of the acetabulum was grafted
with autologous graft taken from the femoral
head. Postoperatively, the patient tolerated par-
tial weight bearing. Six weeks postoperatively,
he was able to perform full weight-bearing
mobilization with no limp. Radiographs at 6-
month follow-up revealed all the metalwork to
be in place without any displacement, and the
fracture had progressed to union (Figure 3). No
incidence of postoperative dislocation or other
complications were recorded. On a scale of

1A 1B
Figure 1: AP radiograph of the occult undisplaced acetabular fracture after the initial fall (A). AP radiograph of the minimally displaced acetabular fracture and
the subcapital fracture of the neck of femur after the second fall (B).

2A 2B 2C
Figure 2: CT scan views of the combined fracture pattern showing the gap on the anterior column fracture.

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Figure 3: AP radiograph of the pelvis 6 months postoperatively (A). Obturator oblique view of the pelvis 6 months postoperatively (B). Iliac oblique view of the
pelvis 6 months postoperatively (C).
100, the patient classified his general state of
health as a score of 81. He had a pain-free full
range of motion on his operated hip and was
mobilizing with full weight bearing freely. His
Harris hip score was 76 points.
DISCUSSION
Acetabular fractures in the elderly are
less common than femoral neck or pelvic
ring fractures; they may result from low-
energy injuries such as a fall and may be
missed in such elderly patients.11-13 In our
case, retrospective review of the pelvic AP
radiograph obtained after the first fall re-
vealed an undisplaced fracture of the ante-
rior column that was undiagnosed initially.
However, undisplaced fractures may not
be always apparent in standard pelvic AP
or lateral radiographs. In cases of clinical
suspicion of acetabular fractures in elder-
ly patients, even if plain radiographs are
reassuring, radiographic control should
be assiduous. Oblique (iliac and obtura-
tor) views, CT, MRI, and bone scan are
the most appropriate means to verify the
presence of a fracture.11,13 In the case
presented, the initial radiographic exami-
nation was restricted to a plain AP view.
For an experienced doctor, this could be
sufficient for proper diagnosis; however,
for inexperienced medical staff, more de-
tailed radiology may be required.
Failure to detect and appropriately
treat an acetabular fracture may result
in significant complications, such as the
femoral neck fracture seen in this case.
Early mobilization was associated with
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ORTHO0809Lasanianos.indd 3
3A
increased pain, a restricted range of mo-
tion, and walking capacity, which led to
the subsequent fall. Early active rehabili-
tation should be applied only if a frac-
ture has been definitively excluded. The
reluctance of the patient to undergo such
a quick mobilization was mistaken as a
manifestation of psychological fear and
was underestimated. Painful loading to
the injured acetabulum did not allow the
undiagnosed, undisplaced fracture to heal;
therefore, when increased weight bearing
was encouraged, the regional pain was
intolerable and the new fracture occurred
with the second fall.
This type of rare injury with combined
acetabular and femoral neck fractures is
scarcely found in the English literature.
Fractures of the femoral neck can be ac-
companied by either central acetabular
dislocations (intrapelvic hip disloca-
tions),5,14,15 anterior traumatic hip dislo-
cations,7,8,16,17 or posterior traumatic hip
dislocations.18-20 Fractures on the proxi-
mal femur site, apart from the neck, may
also (or exclusively) involve the head as
well.9,16,21 Besides adult cases, it should
be noted that similar injury patterns have
also been reported in children.22-24 Our
case has the unique characteristic that the
2 fractures did not occur simultaneously,
and they are related etiologically. Mann
and Rebollo6 reported a femoral neck
fracture complicating a missed acetabular
fracture within an interval of 5 weeks. A
transcervical fracture was reported in that
case, compared to a subcapital fracture in
OCCULT ACETABULAR FRACTURE | LASANIANOS ET AL
3B 3C
ours. Moreover, the treatment in Mann’s
case concerned hip arthroplasty using au-
tograft to support the acetabular compo-
nent, whereas our patient received separate
ORIF and auto-grafting for the acetabular
fracture before the hip arthroplasty was
performed. Both operations took place
in 1 stage. The decision to address the
acetabular fracture separately was made
to graft the anterior column fracture and
facilitate union as it was already 8 weeks
old and the second fall had increased the
gap between the fragments. Therefore, a
stable fixation was appropriate prior to
THA. Autograft harvested from the femo-
ral head was used to feel the gap prior to
the insertion of the acetabular component.
Fixation of the femoral neck fracture with
cannulated screws was excluded due to
the high risk of nonunion and mobiliza-
tion restrictions, as well as the risk of fur-
ther surgery. Cemented THA was selected
instead of an uncemented THA due to the
underlying anterior column fracture and to
not compromise early rehabilitation pro-
tocol. Hemiarthroplasty was ruled out as
the definite method of treatment because
the previously untreated acetabular frac-
ture could have led to early posttraumatic
hip osteoarthritis and subsequent further
surgery.
Falls in elderly patients may some-
times result in a vague clinical state. Low-
energy injuries creating pain around the
hip area should not disorient the doctor
from making the right diagnosis. If plain
radiographs are inconclusive, more radio-
3
7/14/2009 8:26:13 AM
 ■ Case Report
graphic investigations are suggested to
facilitate the diagnosis. Whenever treating
such rare cases, fixation of the acetabular
fracture should be considered prior to the
THA. Each patient should be assessed and
treated on an individual basis according to
the fracture personality and the peculiarity
of the case.
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