Fractures of the Posterior Wall of the Acetabulum

Michael R. Baumgaertner, MD

Abstract

Only 30% of posterior-wall acetabular fractures involve a single large frag- Etiology
ment. The majority are multifragmentary or have areas of impaction.
Unsatisfactory clinical results occur in more than 80% of patients treated non- Most fractures are the result of the
surgically. Operative management usually offers the best chance of preserving sudden deceleration of an unre-
long-term joint function, but only if an anatomically reconstructed acetabulum strained occupant during a motor
can be achieved without complication. The keys to surgical success include vehicle crash. Force is transmitted
maintaining the viability of the fracture fragments and the femoral head itself, from the floorboard to the foot or
using bone grafts and buttress plating to support elevated and comminuted from the dashboard to the flexed
fragments, and protecting the neurovascular structures at risk. Complications knee through the femur to the
can include sciatic nerve injury (incidence, 3% to 18%), heterotopic ossification femoral head. With the hip flexed
(7% to 20%), and osteonecrosis of the femoral head (5% to 8%). Despite the and in varying degrees of adduc-
relative simplicity of this acetabular fracture, unsatisfactory outcomes after sur- tion and internal rotation, as the
gical repair of the posterior wall occur in at least 18% to 32% of cases, results femoral head dislocates, it fractures
that are worse than for most of the other more complex acetabular fracture pat- the posterior wall. The specific
terns. location of the fracture can be pre-
J Am Acad Orthop Surg 1999;7:54-65 dicted from the position of the
extremity at impact. 1 Generally,
the shape of the acetabular fracture
made by the femoral head is an arc
Of all types of acetabular fractures, early open reduction and internal of varying size with a radius of cur-
the posterior-wall fracture is the fixation.2 A recent study reported vature that approximates that of
most common and the seemingly a 30% failure rate within the first the head.
easiest to treat. In LetournelÕs series year after fixation.3 Letournel1 and Because of the indirect nature of
of 940 acetabular fractures, 24% Matta4 achieved perfectly anatomic the fracturing force, it is unusual to
were isolated posterior-wall frac- reductions of posterior-wall acetab- see significant direct soft-tissue
tures, and another 26% involved a ular fractures in 94% to 100% of injury in the area of the hip, but
fracture of the posterior wall as part their cases, and they have indepen- associated injuries to the extremity
of a more complex fracture pattern.1 dently demonstrated that residual are common. Major knee ligament
The familiarity of the posterior displacements greater than only 1
approach to the hip and the simplic- mm after fixation of most types of
ity of the fracture pattern lead many acetabular fractures are associated
surgeons to treat posterior-wall with clinically significant joint Dr. Baumgaertner is Associate Professor and
Chief of the Orthopaedic Trauma Service,
fractures when they might other- deterioration when patients are Department of Orthopaedics and Rehabili-
wise refer more complicated acetab- assessed at long-term follow-up. tation, Yale University, School of Medicine,
ular fractures. The purpose of this article is to New Haven, Conn.
Despite the routine nature of pos- review the assessment and man-
terior-wall fractures, poor outcomes agement of the isolated posterior- Reprint requests: Dr. Baumgaertner, Depart-
occur frequently. In EpsteinÕs long- wall acetabular fracture, emphasiz- ment of Orthopaedics and Rehabilitation, Yale
University School of Medicine, PO Box
term follow-up of 150 posterior- ing the factors influencing outcome 208701, New Haven, CT 06520.
wall fractures, 88% of patients that the treating physician can con-
treated in a closed manner had an trol. Associated fracture patterns Copyright 1999 by the American Academy of
unsatisfactory result, but so did that involve the posterior wall will Orthopaedic Surgeons.
37% of patients who underwent not be discussed.

54 Journal of the American Academy of Orthopaedic Surgeons


(e.g., posterior cruciate) injuries,
osteochondral lesions, and foot
injuries can be missed unless the
remainder of the extremity is care-
fully assessed. The physician
should critically evaluate the status
of the sciatic nerve before and after
attempts at closed reduction. A
neurologic injury occurs in 18% to
22% of patients who sustain poste-
rior-wall fracture-dislocations. 1,5
Awareness and documentation of a
motor or sensory deficit (even a
minor one) avoids postoperative
confusion and allows appropriate
preoperative counseling.
Classification
The posterior-wall fracture is one
of the elementary fracture patterns
of the acetabular fracture classifica-
tion system proposed by Letournel
and co-workers in 1964.6 Although
slightly modified subsequently,
this system has been validated by
30 years of observation and has
gained virtually universal accep-
tance by acetabular-fracture sur-
geons. In an attempt to create a
unified classification system for all
fractures, the Orthopaedic Trauma
Association recently codified Le-
Type 1
Fig. 1 The three subgroups of posterior-wall fractures. In the first type, a fracture line creates a single posterior fragment. The second
type is a multifragment fracture. The third type (also called a marginal impaction or acetabular depression fracture) is a single-fragment
or multifragment wall fracture in which some of the articular surface medial to the primary fracture line has been impacted into the can-
cellous bone of the posterior column by the dislocating femoral head, rotating the osteochondral fragment out of its anatomic plane.
Vol 7, No 1, January/February 1999
tournelÕs classification into a for-
mat that is consistent with the AO
Comprehensive Classification of
Fractures, allowing computerized
categorizing of posterior-wall frac-
tures.7,8
In this system, there are three
basic patterns of posterior-wall
fractures (Fig. 1). The simplest pat-
tern is a fracture line that creates a
single posterior fragment. Single-
fragment posterior-wall fractures
occurred in 30% of fractures in
LetournelÕs series.1 They can occur
in the posterosuperior aspect of the
joint and involve the roof, or weight-
bearing Òdome,Ó of the joint. When
these fractures occur posteroinferi-
orly, they take in a varying amount
of ischium.
The second variant is the multi-
fragment posterior-wall fracture.
This pattern is seen in about a third
of cases and can be further classi-
fied on the basis of the number and
location of fragments.
The third type of wall fracture is
the one considered to be the most
complex and difficult to treat. In
addition to a single-fragment or
multifragment wall fracture, some
of the articular surface remaining
medial to the primary fracture line
is impacted into the cancellous
Type 2
Michael R. Baumgaertner, MD
bone of the posterior column by the
dislocating femoral head, rotating
an osteochondral fragment out of
its anatomic plane. The mecha-
nism and resulting joint incongru-
ency are similar to those seen when
the lateral femoral condyle creates
a split-depression fracture of the
tibial plateau. Termed Òmarginal
impactionÓ by Letournel 1 and
Òacetabular depression fractureÓ by
Brumback et al,9 this type is report-
ed to occur in approximately one
fourth of all posterior-wall frac-
tures.
Posterior hip fracture-dislocations
cause a spectrum of osseous in-
juries. The large, isolated single-
fragment posterior-wall fracture is
relatively uncommon; the surgeon
must expect and be prepared to
anatomically reduce and stabilize
the marked comminution and
impaction of the posterior wall that
is frequently found if the patient is
to benefit from open treatment.
Radiologic Diagnosis
The anteroposterior (AP) radio-
graph of the pelvis is an essential
diagnostic test in most blunt-trauma
evaluation protocols. Provided the
Type 3
55
Posterior-Wall Acetabular Fractures
film is of good quality, most ace-
tabular fractures can be recognized
on this view. If the hip has not
been reduced, the wall fragment is
usually seen to be displaced with
the femoral head, and the defect in
the posterior wall is readily appar-
ent (Fig. 2, A). It is impossible to
completely assess a posterior-wall
fracture on an AP radiograph, but
this view is very helpful in exclud-
ing other fracture patterns.
Of the six fundamental radio-
graphic landmarks of the acetabu-
lum described by Letournel,1,6 five
will be seen to be intact and unaf-
fected by an isolated posterior-wall
fracture. Only the posterior rim
will be disrupted, although once
the dislocation is reduced, the over-
A B
C D
56
lying femoral head may make this
finding subtle. To exclude an asso-
ciated acetabular fracture that
includes a fracture of the posterior
wall, the other landmarks (anterior
rim, iliopectineal line, ilioischial
line, tear drop, and acetabular roof)
should be confirmed to be intact.
Marginal impaction, if present, can
often be recognized on the AP radio-
graph as a curved, dense subchon-
dral line that is out of anatomic
position (Fig. 2, B). All radiographic
views, but particularly the AP view
(which has the opposite hip for
comparison), should be scrutinized
to confirm that a concentric reduc-
tion with a normal clear space
exists between the femoral head
and the remaining acetabulum and
Journal of the American Academy of Orthopaedic Surgeons
that no incarcerated fragment is
preventing complete anatomic
reduction.
The obturator oblique view,
obtained by rotating the patient 45
degrees onto the unaffected side,
displays the obturator ring as near-
ly circular and uncovers the poste-
rior aspect of the acetabulum from
the anterior wall and the femoral
head. It usually shows the full
extent of the fracture fragment, the
amount of displacement, and the
defect in the acetabulum (Fig. 2, C).
Incarcerated fragments in the ante-
rior aspect of the joint are best seen
on this view. The opposite oblique
view (the iliac oblique) is obtained
by rotating the patient 45 degrees
onto the side of the fracture. The
Fig. 2 Images of a 37-year-old woman
with a left-hip fracture-dislocation. A, The
hip is dislocated with the femur adducted
and internally rotated. Note the defect in
the posterior acetabular border and the
wall fragment above the displaced femoral
head. B, After closed reduction, a wall
defect remains, and there is evidence of
marginal impaction (arrow) but the
amount of posterior-wall fracture-displace-
ment is not obvious. C, The obturator
oblique radiograph shows the wall frag-
ment clearly. D, Axial CT image demon-
strates significant marginal impaction and
an inadequately reduced wall fracture.

unbreached borders of the greater
and lesser sciatic notches confirm
that the posterior column is intact,
but the wall fracture is usually
obscured.
Computed tomography (CT) is
probably the single most valuable
tool in assessing posterior-wall
acetabular fractures, provided indi-
vidual images through the joint are
contiguous and not more than 3 to
5 mm thick (Fig. 2, D). It is always
helpful to include the contralateral
acetabulum for comparison. If
closed management is being consid-
ered, CT scanning utilizing 3-mm
overlapping sections is mandatory
to definitively exclude incarcerated
fragments and subtle joint incon-
gruity that can be missed on plain
radiographs (Fig. 3, A and B).
During dislocation, the ligamen-
tum teres frequently avulses a small
bone fragment, which appears as a
free fragment on the CT scan. As
long as it is small, low in the joint,
and restricted to the confines of the
cotyloid fossa, such a fragment is
not in itself an indication for open
management.
Computed tomography greatly
facilitates the assessment of frac-
ture comminution and residual dis-
placement. It is the ideal study for
A B
Fig. 3 Images of a 65-year-old man with a right posterior-wall fracture. A, After closed reduction, it is difficult to appreciate the extent of
the fracture on the AP radiograph. B, CT image shows an incarcerated osteochondral fragment in the joint (arrow), a comminuted rim
fragment, and a completely deficient posterior wall. C, Another, more distal CT scan shows marginal impaction.
Vol 7, No 1, January/February 1999
identifying posteromedial marginal
impaction in a fragment that is
rotated externally. However, supe-
rior impaction of the lateral aspect
of the roof, which can occur in the
plane of the axial CT section, may
be more clearly appreciated on an
AP radiograph or with CT recon-
structions. With thin sections, in-
creased bone density can be seen
where impaction into the cancellous
bed has occurred (Figs. 2, D; 3, C).
In addition, CT is frequently used
to quantify the amount of posterior
wall that remains after fracture by
allowing comparison of the frac-
tured side with the intact contralat-
eral wall.10-12
Management Options
Although Epstein2 recommended
primary open reduction for all pos-
terior-fracture dislocations, most
protocols employ urgent closed
reduction with the use of adequate
sedation and muscle relaxation.
Reduction is immediately followed
by clinical assessment of hip stabil-
ity performed by cautiously flex-
ing and slightly adducting the hip
while feeling for subluxation.
Sciatic nerve function should be re-
C
Michael R. Baumgaertner, MD
assessed and documented. Subse-
quently, the adequacy of the
reduction and the size and dis-
placement of the fragments are
assessed radiographically.9 Abso-
lute operative indications include
deteriorating sciatic nerve function
after attempted closed reduction
and the presence of an incarcerated
fragment that prevents congruent
reduction of the head to the intact
acetabulum. Inability to achieve a
closed reduction and the presence
of a femoral neck fracture are also
absolute indications for open man-
agement.
With the widespread use of CT
scanning, the amount of the poste-
rior wall that is fractured or im-
pacted (and therefore cannot support
the femoral head) can be accurately
determined before surgery. Several
authors have attempted to define
how much of the posterior wall is
needed to maintain hip stability.10-12
There is general agreement that frac-
tures involving 50% or more of the
posterior wall are unstable and de-
mand surgical repair, whereas frac-
tures involving 20% or less are gen-
erally stable and can be managed by
activity restriction with careful
observation. Vailas et al10 demon-
strated no hip subluxation at 90
57
Posterior-Wall Acetabular Fractures
degrees of flexion, 20 degrees of
internal rotation, and 20 degrees of
adduction in cadaver hemipelves
with fractures involving 25% of the
posterior wall if the posterior capsule
was intact. Of the 9 hips with a com-
plete capsulectomy, only 1 (11%)
was unstable.
There is no consensus on treat-
ment of fractures that are clinically
stable but involve 20% to 50% of the
posterior wall. For these fractures,
treatment decisions should be
based on the patientÕs clinical situa-
tion (age, activity level, expecta-
tions, other injuries) as well as the
likelihood that the surgeon can
achieve the desired surgical result
without complications. Although
the long-term effect on joint biome-
chanics of reducing the contact area
of the posterior wall has not been
adequately studied, Olson et al 13
demonstrated near doubling of the
contact force on the superior aspect
of the acetabulum after simulated
posterior-wall fracture in cadavers.
Subsequently, they showed that
even small rim fractures that would
not cause clinical instability greatly
altered joint-contact characteris-
tics.14
If the hip is stable and closed
management is elected, bed rest is
instituted until the acute pain of the
fracture-dislocation subsides. Most
authors believe that skeletal trac-
tion is not indicated. Historically, a
prolonged period of bed rest with
or without traction has been recom-
mended, but the need for this has
never been documented. 12,15 Re-
strictions against provocative
ranges of motion (Òtotal hip precau-
tionsÓ against adduction, internal
rotation, and excessive flexion)
until capsular healing occurs cer-
tainly appear appropriate, but bed
rest longer than that necessary for
comfort is not justified by any avail-
able data.16 Weight bearing should
be limited until there is evidence of
fracture healing.13,17 It is impera-
tive to monitor very closely any
58
patient who is managed nonopera-
tively with the use of only activity
restrictions. Radiographs (and
repeat CT scanning if evidence of
instability exists) should be ob-
tained 1, 3, 6, and 12 weeks after
fracture, at the minimum.
Surgical Treatment
For isolated injuries, if the hip is
reduced and nerve function is sta-
ble, emergency operation is not
warranted. Surgery should pro-
ceed as soon as the patient, the
operating suite, and the surgical
team are prepared, usually within
72 hours of injury. Maintaining the
hip in mild abduction and external
rotation should obviate the need
for preoperative skeletal traction.
If there is gross instability or if
there are bone fragments within
the joint, skeletal traction to neu-
tralize the joint reaction force is
indicated to prevent secondary
mechanical damage to the articular
cartilage.
Most of the instruments and
implants necessary to manage a
posterior-wall fracture are available
in general orthopaedic operating
rooms. Small-fragment (3.5-mm)
cortical screws of standard lengths
Journal of the American Academy of Orthopaedic Surgeons
are used with reconstruction plates
that allow contouring in all three
planes. A spiked-ball pusher to
manipulate and reduce wall frag-
ments and a T-handled universal
chuck mounted with a Schanz
screw, which can be inserted into
the greater trochanter to distract
the femoral head, are helpful acces-
sories (Fig. 4). As blood loss is
rarely less than 700 to 1,000 mL,
intraoperative red blood cell salvage
systems are usually an effective
adjunct to minimize transfusion
requirements.
Use of somatosensory evoked
potentials to monitor sciatic nerve
function intraoperatively remains
controversial. The technique is rec-
ommended by some authors to
help minimize the risk of iatrogenic
nerve insult,5,18 but others consider
it unnecessary and have reported
very low rates of neurologic com-
plications without the added
expense and surgical time associat-
ed with monitoring.19
An operating table that allows
unrestricted multiplanar and ob-
lique fluoroscopic visualization of
the pelvis is preferred over a stan-
dard operating table or a fracture
table because it greatly facilitates
intraoperative assessment of the
reduction and fixation. The C arm
Fig. 4 Instruments and
implants for treatment of
posterior-wall fractures:
from left to right, spiked-ball
pusher, T-handled universal
chuck with Schanz screw,
implant template, 3.5-mm
reconstruction plates, recon-
struction plate bending
irons, and pliers.

is positioned to be brought perpen-
dicular to the table on the side
opposite the surgeon. With combi-
nations of table tilt and C-arm cant
and rotation, AP and Judet views
can be obtained, as well as individ-
ual oblique views that show screws
end-on or in perfect profile to con-
firm exact length and position rela-
tive to the joint and pelvic cortices.
The Kocher-Langenbeck poste-
rior approach is always used for
isolated posterior-wall acetabular
fractures. The patient can be in the
lateral or prone position with the
involved extremity draped freely.
Although lateral positioning is
more familiar to most surgeons, the
prone position is preferred if there
is an extensive posterior-wall frac-
ture with gross instability or if the
fracture involves the roof of the
acetabulum, because prone posi-
tioning tends to slightly extend and
abduct the hip, thus helping to
keep the femoral head reduced. In
addition, the hip extension afford-
ed by prone positioning (along
with knee flexion) decreases the
risk of stretch injury to the sciatic
nerve.
It is important to appreciate that
the approach for repair of a posterior-
wall acetabular fracture is not the
same as a posterior approach for
total hip arthroplasty. Anatomic
planes are blurred due to muscular
hematoma from the recent trauma,
and landmarks that are normally
easily identified may be absent or
markedly distorted. The sciatic
nerve is directly at risk as it passes
through the zone of injury and
should be visually identified in
every case, as it is immediately
superficial to where implants must
be placed. Perhaps the most im-
portant difference between fracture
surgery and replacement arthro-
plasty is that the viability of the
wall fragments and the femoral
head itself must be maintained; dis-
section must proceed with this
caveat in mind.
Vol 7, No 1, January/February 1999
The skin and fascial incisions are
centered at the posterosuperior
aspect of the greater trochanter and
extend distally along the shaft and
proximally toward, but not entirely
to, the posterior superior iliac spine.
The gluteus maximus muscle is
split proximally until the first cross-
ing branches of the inferior gluteal
nerve are reached (further dissec-
tion will denervate the part of the
muscle anterosuperior to the inci-
sion). The osseous insertion of the
gluteus maximus onto the femur is
routinely released about 1 cm from
its attachment to facilitate atrau-
matic posterior retraction.
Careful posteromedial dissection
on the superficial surface of the
quadratus femoris will identify the
sciatic nerve, which is frequently in
two physically separate trunks at
this level. The lateral edge of the
nerve is then followed proximally
through the fracture zone to where
it exits the pelvis through the
greater sciatic notch, deep to the
piriformis muscle. With the nerve
identified and freed from imping-
ing bone fragments, any blood-
filled bursal tissue or avulsed mus-
culature can be safely debrided.
The interval between the inferior
gemellus and the quadratus femoris
is identified to avoid any inadver-
tent dissection into the quadratus,
which would risk injury to the
medial femoral circumflex artery
supplying the femoral head. The
tendons of the piriformis and obtu-
rator internus are identified and
carefully elevated off the joint cap-
sule before sectioning. This allows
the fractured wall fragments to
maintain their capsular attach-
ments, which are frequently their
only remaining blood supply. The
tendons are cut in midsubstance,
and the muscle ends are tagged.
Retraction on these muscles allows
exposure of the retroacetabular sur-
face posteriorly to the border of the
greater sciatic notch and the bursa
around which the obturator inter-
Michael R. Baumgaertner, MD
nus tendon exits the inner pelvis
through the lesser notch. This ten-
don can be sutured to the gluteus
fascia to create a soft-tissue sling
that retracts and protects the sciatic
nerve from the edge of a blunt-
tipped nerve retractor maintained
in the lesser notch. Nerve retractors
in the greater notch, where the
nerve is unprotected, should be
used cautiously or not at all.
If further inferior exposure is
necessary, the origin of the quadra-
tus femoris as well as the ham-
strings can be taken down off the
ischium. The pudendal nerve is
medial to the field and is not at risk.
Hip extension and knee flexion are
maintained throughout the proce-
dure, and the sciatic nerve is inter-
mittently inspected for inadvertent
compromise.
The gluteus minimus is elevated
off the capsule and ilium as neces-
sary. It is important to cautiously
elevate near the superior border of
the sciatic notch to avoid laceration
of the superior gluteal nerve, artery,
or vein, which may lie directly on
bone at this level. Anterior and
superior exposure is facilitated by
hip abduction, which relaxes the
muscle and protects the superior
gluteal nerve from traction palsy.
The field can be maintained by
placing Steinmann pins into the
superolateral ilium.
The first step in the reduction
and fixation stage is always to
inspect the joint. The wall frag-
ments are rotated back on their cap-
sular attachments, and the fracture
surfaces are debrided of clot and
callus. A Schanz screw placed into
the trochanter is usually adequate
to distract the femoral head, allow-
ing examination of both articular
surfaces, removal of incarcerated
fragments, and flushing of debris
from the joint. The size and shape
of any free cartilaginous fragments
should be noted before they are dis-
carded. Free osteochondral frag-
ments of significant size are marked
59
Posterior-Wall Acetabular Fractures

for orientation and set aside for tached to the capsule is attempted capsule and allows the fragments to
later reconstruction. If sustained only after the correction of any mar- be manipulated. A spiked-ball push-
distal retraction is desired, the ginal impaction, as this step prevents er is helpful in completing and main-
femoral distractor can be used effec- further unobstructed inspection of taining the reduction. Alternatively,
tively with one pin in the ilium and the articular surface. Slight abduc- temporary fixation can be achieved
the other in the trochanter. tion and external rotation relaxes the with small Kirschner wires directed
After joint cleansing, the femoral
head is reduced to the intact acetab-
ulum, and the quality of the joint
reduction is evaluated. An anatomic
reduction is implied if only the
edge of intact acetabular articular
surface is seen through the fracture
plane, and it is concentric and per-
fectly satisfied by the femoral head.
Marginal impaction exists if there is
any acetabular cartilage that does
not anatomically cup the reduced I
femoral head but instead is rotated
to face toward the plane of the frac-
ture. If not corrected, not only will
this aspect of the joint be incongru- W
G
ent, but the displaced articular
F
osteochondral segment will prevent
anatomic reduction of the overlying
wall fragment. Therefore, frag-
ments that are marginally impacted A B
must be recognized, elevated, and
supported with bone graft before
addressing other wall fragments.
The concentrically reduced fem-
oral head acts as a template to guide
the reduction. A narrow Cobb eleva-
tor can be used to create a plane
along the cortex of the quadrilateral
surface, deep to the depressed articu- F
lar surface and underlying cancellous
I
bone, and then to rotate the frag-
G
ments en bloc to elevate the depres- W
sion (Fig. 5). Any free osteochondral
fragments are reoriented and
reduced to the head as well. To sup-
port the reduced joint surface, a bone
graft from the greater trochanter is C D
packed into the defect that is created
Fig. 5 Technique for dealing with marginal impaction and a free osteochondral fragment.
behind the elevator. The femoral A, With the femoral head concentrically reduced to the intact acetabulum, the wall frag-
head prevents overelevation but ment with attached capsule (W) is reflected with a dental pick to reveal the marginal
allows aggressive impaction of the impaction (I) and the free osteochondral fragment (F), which is temporarily removed. B,
After harvesting of cancellous autograft (G) from the greater trochanter, an elevator is used
graft into the defect such that after to undermine and derotate the impacted fragment. The femoral head guides the reduction
the procedure, the grafted area and prevents overelevation. The autograft is impacted into the defect created by elevation.
appears more dense than the sur- C, After repositioning and support of the osteochondral free fragment with additional
graft, the wall fragment is finally repositioned. As the joint is no longer visible, the reduc-
rounding cancellous bone (Fig. 6). tion must be judged from the retroacetabular fracture line. D, The reconstructed posterior
Reduction and fixation of poste- wall is supported by a buttress plate and an appropriately directed lag screw.
rior-wall rim fragments that are at-

60 Journal of the American Academy of Orthopaedic Surgeons


Fig. 6 Postoperative CT images corresponding to Figure 3, B and C. Some devitalized
articular cartilage had to be discarded. Note densely impacted graft supporting the joint
surface but preventing complete reduction of the retroacetabular cortex. The safe corridor
of the screw and the trochanteric bone-graft donor site can also be seen.
away from the joint. The quality of
the joint reduction must frequently
be inferred from the reduction of the
retroacetabular cortical fracture lines
and the continuity of the posterior
rim.
Definitive fixation of the wall
fracture generally requires buttress
plating. Very rarely, a large single
fragment can be adequately stabi-
lized with three to five lag screws.
Goulet et al 17 demonstrated that
the combination of a buttress plate
and lag screws provided a fourfold
increase in local effective stiffness
(P<0.05) and doubling of the load
to failure (3,306 vs 1,666 N [P=0.05])
in a posterior-wall fracture model
compared with the use of two lag
screws alone. A 3.5-mm straight
reconstruction plate with seven to
nine holes was used. It can be
helpful to contour the plate on a
pelvic model preoperatively and
subsequently fine-tune the shape of
the plate in the operating room.
Leaving the plate very slightly
underbent aids in the reduction. If
the plate is fixed to the ischium
with distally directed screws and to
the lateral aspect of the ilium with
superiorly directed screws, it will
be slightly tensioned as it is seated,
compressing the wall fragments.
Vol 7, No 1, January/February 1999
Screws must be directed away
from the joint to avoid penetration,
but because of the small fragments
frequently involved, the depth of
the acetabulum, and the fact that the
joint cannot be easily visualized
after fracture reduction, violation of
the joint can occur. Suggestions for
avoiding this complication have
come from various authors, includ-
ing Bosse,20 who noted that screws
placed in any position on the acetab-
ular rim would not violate the joint
as long as they were placed in the
coronal plane perpendicular to the
long axis of the body. However, as
these planes of reference can be dif-
ficult to assess intraoperatively,
other methods of assessment should
be employed as well.
Placing Kirschner wires tangen-
tial to the articular surface under
direct vision at the proximal and dis-
tal extent of the intact acetabular rim
allows a fixed plane of reference.1
Screws placed parallel to or directed
away from these wires should avoid
the joint (Fig. 7). Letournel 1 de-
scribed, and Ebraheim et al 21
attempted to quantitate, the relation-
ship between the distance from the
acetabular rim and the angle of the
screw needed to safely avoid the
joint. In general, maintaining the
Michael R. Baumgaertner, MD
buttress plate at least 6 to 9 mm
from the acetabular rim and direct-
ing the screws parallel or posterior
to the coronal plane helps to de-
crease the incidence of penetration.
The use of specially modified
spring plates has been suggested
for the control of rim fragments
deemed critical for stability but too
small for lag-screw fixation and too
peripheral to be adequately but-
tressed. 17,22 This technique in-
volves cutting and acutely bending
the end of a one-third tubular plate
to fashion two hooks that can catch
the rim fragment. The plate is con-
toured so that its central section is
raised off the bone. When the plate
is anchored to the bone, with either
a screw or an overlying reconstruc-
tion plate, the spring plate bends
and fully engages the spikes in the
rim fragment (Fig. 8). The surgeon
who elects to use this technique
must be cognizant of the fact that
failure to position the hooks prop-
erly or postoperative displacement
or even resorption of the rim frag-
ment may expose the femoral head
to the plate itself.
Before wound closure, the hip is
taken through a range of motion to
confirm the stability of fixation.
OK OK
Unsafe
OK
Fig. 7 Placement of a Kirschner wire tan-
gential to the joint surface provides a refer-
ence for safe screw location and direction.
61
Posterior-Wall Acetabular Fractures
A B
Fig. 8 Images of a 20-year-old man with a multifragment posterior-wall fracture. A, CT
scan demonstrates marginal impaction, wall comminution, and a peripheral rim fragment
attached to the posterior capsule. B, Follow-up radiograph obtained 1 year after surgery
shows the rim fragment captured by a spring plate. The plate lies under the buttress plate
and is fixed additionally by a screw.
Additionally, the surgeon should
palpate and listen for any grating
of the joint with motion, suggest-
ing misplaced hardware. It is very
helpful to manipulate the position
of the table and the C arm so that
screws near the joint are viewed
end-on and appear as a circle on
the monitor. If the projection
shows the implant outside the joint
clear space, the screw is unques-
tionably safe (Fig. 9). Any muscle
of questionable viability should be
resected before the torn capsule
and the tendons of the short rota-
tors and gluteus maximus inser-
tion are repaired anatomically.
The fascia and dermis are then
closed in routine fashion. Hard-
copy film of the key fluoroscopic
images as well as an AP view of
the pelvis should be obtained be-
fore the patient leaves the operat-
ing room.
Postoperatively, patients com-
plete their perioperative antibiotic
regimen and continue thromboem-
62
bolism prophylaxis.23 Before dis-
charge, a complete set of pelvic
radiographs should be obtained in
the radiology suite unless the intra-
operative films are of excellent
quality. If any question remains
regarding the quality of the reduc-
Fig. 9 Intraoperative oblique fluoroscopic images obtained before buttress-plate applica-
tion suggest (left) and confirm (right) safe screw placement by showing the two lag screws
end-on and outside the joint clear space.
Journal of the American Academy of Orthopaedic Surgeons
tion or the position of the hard-
ware, a postoperative CT scan can
be obtained. Fracture healing and
the status of the joint should be
monitored radiographically with
an AP view of the pelvis 6 weeks,
12 weeks, and 6, 12, and 24 months
after surgery (Fig. 10).
Motion restrictions against ad-
duction, internal rotation, and ex-
cessive flexion are maintained for 4
to 6 weeks. Even though the fixa-
tion rarely involves the area of the
joint that resists the resultant
forces of weight bearing, touch-
down weight bearing should be
maintained for a period of at least
6 to 8 weeks. Olson et al 13 have
shown that even perfect anatomic
reduction and rigid internal fixa-
tion of a simple posterior-wall frac-
ture does not restore normal load
transfers across the joint. In an-
other study, Goulet et al17 noted a
small margin of safety between
construct strength and expected
physiologic loads.17
Strengthening exercises should
start at 6 weeks and continue for at
least 6 months. Dickinson et al24
examined patients an average of 21
months after posterior-wall acetab-
ular surgery (minimum, 6 months)
and reported a 43% reduction in

A B
Fig. 10 A, Postoperative obturator oblique view of same patient shown in Figures 3 and 6 demonstrates the reconstructed posterior wall,
the plate contour, and the diverging screw pattern. B, Intermediate follow-up AP radiograph obtained at 30 months shows well-
preserved joint space.
abductor strength in patients who
had satisfactory reductions and
who had completed a postopera-
tive physical therapy program.
They postulated that the weakness
was permanent and was related to
the amount of exposure and the
force of retraction on the superior
gluteal neurovascular bundle dur-
ing surgery.
Complications
Hematoma and infection are rare but
serious complications that are best
managed prophylactically. Their
occurrence necessitates prompt sur-
gical drainage. Like thromboem-
bolism, they are not unique to
acetabular fractures; therefore, their
diagnosis and treatment will not be
discussed further.
Iatrogenic injury to the sciatic
nerve is related not only to fracture
pattern and approach but also to
the preoperative status of the nerve
Vol 7, No 1, January/February 1999
and the experience of the surgical
team. 5 Letournel and Judet 1 re-
duced the rate of sciatic palsy from
18% in their first 126 cases in which
the Kocher-Langenbeck approach
was used to 3.3% in the subsequent
211 cases. Almost invariably, the
peroneal division is injured with or
without some tibial compromise,
and although the prognosis for
improvement is good, it is uncom-
mon to regain completely normal
muscle and sensory function. Al-
though the primary means used to
avoid nerve injury are visualization
of the nerve and positioning of the
extremity to minimize tension dur-
ing retraction, somatosensory
evoked potential monitoring has
been used to identify nerve com-
promise so that corrective actions
can be taken before irreversible
changes occur.5,18
Osteonecrosis following opera-
tive management of acetabular
fractures is generally overdiag-
nosed. When Kocher-Langenbeck
Michael R. Baumgaertner, MD
approaches have been used, rates
as high as 42% within the first
year after surgery have been
reported. 25 Rapid mechanical
destruction of the femoral head
can occur from the injury itself,
due to osteochondral impaction or
cartilage crushing, or can be the
result of inadequate reduction,
loss of reduction with recurrent
instability, or violation of the joint
by inadvertently retained bone
fragments or screws. These diag-
noses should be excluded before
considering a diagnosis of post-
traumatic osteonecrosis of the
femoral head, which does not pre-
sent until at least several months
after injury. Epstein 2 identified
osteonecrosis in 5.3% of surgically
treated posterior-wall fractures.
Letournel and Judet 1 reported a
7.5% incidence of osteonecrosis in
227 fractures that included a pos-
terior dislocation and that were
treated surgically within 21 days
of injury.
63
Posterior-Wall Acetabular Fractures
Heterotopic bone formation
occurs less frequently after a
Kocher-Langenbeck approach for
a posterior-wall acetabular frac-
ture than after an extensile ap-
proach for associated fractures.
Nevertheless, it still occurs in 20%
of patients who have not received
prophylactic therapy and is clini-
cally significant (Brooker grade III
or IV) in more than 7%.1 Male sex
and head injury are factors that
tend to increase the risk. Treat-
ment with indomethacin (25 mg
three times a day, starting on the
day of surgery and continuing for
4 to 6 weeks) has been recom-
mended as effective, safe, and
inexpensive prophylaxis against
heterotopic ossification26,27; how-
ever, a recent randomized pro-
spective study by Matta and
Siebenrock28 questions the efficacy
of this method. Low-dose periop-
erative irradiation (700 to 1,000
cGy within 48 hours of surgery) is
effective in reducing the incidence
and severity of heterotopic ossifi-
cation after acetabular fracture,29,30
but the unknown potential for late
complications from radiation dis-
courage treatment with this mo-
dality for the isolated posterior-
wall fracture in the typically
young patient.
References
1. Letournel E, Judet R; Elson RA (trans-
ed): Fractures of the Acetabulum, 2nd
ed. Berlin: Springer-Verlag, 1992.
2. Epstein HC: Posterior fracture-disloca-
tions of the hip: Long-term follow-up.
J Bone Joint Surg Am 1974;56:1103-1127.
3. Saterbak AM, Marsh JL, Brandser E,
Nepola JV, Turbett T: Outcome of sur-
gically treated posterior wall acetabu-
lar fractures. Orthop Trans 1997;21:627.
4. Matta JM: Fractures of the acetabu-
lum: Accuracy of reduction and clini-
cal results in patients managed opera-
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injury. J Bone Joint Surg Am 1996;78:
1632-1645.
5. Helfet DL, Schmeling GJ: Somato-
64
Outcome
Patients with posterior hip disloca-
tions that are associated with mini-
mal acetabular rim fractures do
well provided reduction is prompt
and atraumatic.16 There is no ques-
tion that unstable fracture-disloca-
tions that receive delayed treatment
have dismal clinical outcomes, with
failure rates approaching 90%.1,2,16
It is in the light of these extremes
that the results of acute stabilization
should be viewed. In the study of
Pantazopoulos et al,31 more than
90% of patients who had under-
gone anatomic reduction of a poste-
rior-wall fracture had a very good
clinical result 2 to 15 years (average,
7 years) postoperatively, compared
with only 50% of patients whose
reductions had 1 to 3 mm of resid-
ual displacement.
In LetournelÕs series,1 19 (16%)
of 119 perfectly reduced posterior-
wall fractures were found to have
developed significant osteoarthro-
sis at follow-up, which was as long
as 25 years. The rate of posttrau-
matic arthrosis after a perfectly
reduced posterior-wall fracture
was higher than the 10% rate for
all types of acetabular fractures
that had an anatomic reduction,
but was much lower than the 38%
sensory evoked potential monitoring
in the surgical treatment of acute, dis-
placed acetabular fractures: Results of
a prospective study. Clin Orthop 1994;
301:213-220.
6. Judet R, Judet J, Letournel E: Fractures
of the acetabulum: Classification and
surgical approaches for open reduc-
tionÑPreliminary report. J Bone Joint
Surg Am 1964;46:1615-1646.
7. Orthopaedic Trauma Association
Committee for Coding and Classifi-
cation: Fracture and dislocation com-
pendium. J Orthop Trauma 1996;10
(suppl 1):73.
8. MŸller ME, Nazarian S, Koch P,
Schatzker J: The Comprehensive Classifi-
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rate of arthrosis for posterior-wall
fractures that were not reduced
anatomically. Overall, Letournel
reported an 18% rate of unsatisfac-
tory outcome for posterior-wall
fractures.
Femoral head impaction, carti-
lage necrosis, and posterior-wall
resorption can lead to arthrosis
even after anatomic reconstruction
of the acetabulum. Despite achiev-
ing perfect reductions in all 22
posterior-wall fractures treated,
Matta had a 32% clinical failure
rate in this group, higher than that
for any other fracture pattern in his
series of 262 fractures.4
Summary
Patients who sustain an unstable
posterior-wall acetabular fracture
have a guarded prognosis. An
anatomic reduction is achievable in
the great majority of cases and is a
prerequisite to long-term hip sur-
vival. Although not even a perfect
surgical reconstruction of a joint will
guarantee long-term function, that
goal must be the mind-set of sur-
geons who choose to treat this injury,
because the results of imperfect or
unstable reductions are clearly infe-
rior and usually unsatisfactory.
cation of Fractures of Long Bones. New
York: Springer-Verlag, 1996.
9. Brumback RJ, Holt ES, McBride MS,
Poka A, Bathon GH, Burgess AR:
Acetabular depression fracture accom-
panying posterior fracture dislocation
of the hip. J Orthop Trauma 1990;4:42-48.
10. Vailas JC, Hurwitz S, Wiesel SW:
Posterior acetabular fracture-disloca-
tions: Fragment size, joint capsule, and
stability. J Trauma 1989;29:1494-1496.
11. Keith JE Jr, Brashear HR Jr, Guilford
WB: Stability of posterior fracture-dis-
locations of the hip: Quantitative as-
sessment using computed tomography.
J Bone Joint Surg Am 1988;70:711-714.
12. Calkins MS, Zych G, Latta L, Borja FJ,

Mnaymneh W: Computed tomogra-
phy evaluation of stability in posterior
fracture dislocation of the hip. Clin
Orthop 1988;227:152-163.
13. Olson SA, Bay BK, Chapman MW,
Sharkey NA: Biomechanical conse-
quences of fracture and repair of the
posterior wall of the acetabulum. J
Bone Joint Surg Am 1995;77:1184-1192.
14. Olson SA, Bay BK, Pollak AN, Sharkey
NA, Lee T: The effect of variable size
posterior wall acetabular fractures on
contact characteristics of the hip joint.
J Orthop Trauma 1996;10:395-402.
15. Rowe CR, Lowell JD: Prognosis of
fractures of the acetabulum. J Bone
Joint Surg Am 1961;43:30-59.
16. Aho AJ, Isberg UK, Katevuo VK: Ace-
tabular posterior wall fracture: 38
cases followed for 5 years. Acta Orthop
Scand 1986;57:101-105.
17. Goulet JA, Rouleau JP, Mason DJ, Gold-
stein SA: Comminuted fractures of the
posterior wall of the acetabulum: A biome-
chanical evaluation of fixation methods.
J Bone Joint Surg Am 1994;76:1457-1463.
18. Baumgaertner MR, Wegner D, Booke
J: SSEP monitoring during pelvic and
acetabular fracture surgery. J Orthop
Trauma 1994;8:127-133.
Vol 7, No 1, January/February 1999
19. Middlebrooks ES, Sims SH, Kellam JF,
Bosse MJ: Incidence of sciatic nerve
injury in operatively treated acetabu-
lar fractures without somatosensory
evoked potential monitoring. J Orthop
Trauma 1997;11:327-329.
20. Bosse MJ: Posterior acetabular wall
fractures: A technique for screw place-
ment. J Orthop Trauma 1991;5:167-172.
21. Ebraheim NA, Waldrop J, Yeasting
RA, Jackson WT: Danger zone of the
acetabulum. J Orthop Trauma 1992;6:
146-151.
22. Mast J, Jakob R, Ganz R: Planning and
Reduction Technique in Fracture Surgery.
Berlin: Springer-Verlag, 1989, p 254.
23. Fishmann AJ, Greeno RA, Brooks LR,
Matta JM: Prevention of deep vein
thrombosis and pulmonary embolism
in acetabular and pelvic fracture
surgery. Clin Orthop 1994;305:133-137.
24. Dickinson WH, Duwelius PJ, Colville
MR: Muscle strength testing following
surgery for acetabular fractures. J
Orthop Trauma 1993;7:39-46.
25. Daum WJ, Scarborough MT, Gordon
JW Jr, Uchida T: Heterotopic ossifica-
tion and other perioperative complica-
tions of acetabular fractures. J Orthop
Trauma 1992;6:427-432.
Michael R. Baumgaertner, MD
26. McLaren AC: Prophylaxis with indo-
methacin for heterotopic bone: After
open reduction of fractures of the
acetabulum. J Bone Joint Surg Am
1990;72:245-247.
27. Moed BR, Maxey JW: The effect of
indomethacin on heterotopic ossifica-
tion following acetabular fracture
surgery. J Orthop Trauma 1993;7:33-38.
28. Matta JM, Siebenrock KA: Does
indomethacin reduce heterotopic bone
formation after operations for acetabu-
lar fractures? A prospective random-
ized study. J Bone Joint Surg Br 1997;
79:959-963.
29. Moed BR, Letournel E: Low-dose irra-
diation and indomethacin prevent het-
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fracture surgery. J Bone Joint Surg Br
1994;76:895-900.
30. Bosse MJ, Poka A, Reinert CM, Ell-
wanger F, Slawson R, McDevitt ER:
Heterotopic ossification as a complica-
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65