Acetabular fractures

Dr. Roshan D.
 Introduction
■ Generally caused by high energy trauma
■ Such high energy injuries usually have a
high incidence of major associated injuries
■ The fracture or fracture dislocation
produced depends on the
magnitude and the direction
of the injuring force as well
as on the strength of the bone.
 Acetabulum - Anatomy
■ Incomplete hemispherical
socket with an
♦ inverted horse-shoe
shaped articular surface
♦ non articulating cotyloid
fossa.
■ The articular surface is
composed of and
supported by two
columns of bone
(described by Letournel
and Judet) as an
inverted ‘Y’
 Acetabulum – Anatomy
‘The Column Concept’
■ Used in the classification of the fractures
■ The anterior column
♦ Iliac crest, iliac spines, the anterior half of the
acetabulum and the pubis.
■ The posterior column
♦ Ischium, ischial spine, posterior half of the
acetabulum and the dense bone forming the sciatic
notch
■ The shorter posterior column ends at its
intersection with the anterior column at the top of
the sciatic notch
 Acetabulum - Anatomy
■ The dome or roof is the weight bearing
portion of the articular surface that
supports the femoral head
■ The quadrilateral surface is the flat plate of
bone forming the lateral border of the
pelvic cavity
■ The iliopectineal eminence is the
prominence in the anterior column that lies
directly over the femoral head.
 Acetabulum – Anatomy
Neurovascular structures
■ The sciatic nerve
■ The superior gluteal Artery and Nerve
■ Corona mortis
 Classification
(Letournel and Judet)
■ Simple fractures
♦ fractures of the posterior wall, posterior
column, anterior wall, anterior column and
transverse fractures.
■ Associated fractures
♦ T-shaped fractures, fractures of the posterior
column and posterior wall, transverse +
posterior wall fracture, anterior fracture +
hemitransverse posterior fracture and both
column fracture.
 Classification
Comprehensive Classification after Letournel
■ TYPE A - PARTIAL ARTICULAR ONE
COLUMN FRACTURE
♦ A1—Posterior wall
♦ A2—Posterior column
♦ A3—Anterior wall and/or anterior column
 Classification
Comprehensive Classification after Letournel
■ TYPE B PARTIAL ARTICULAR
TRANSVERSE ORIENTED FRACTURE -
Transverse types with portion of the roof
attached to intact ilium
♦ B1—Transverse + posterior wall
♦ B2—T types
♦ B3—Anterior with posterior hemitransverse
 Classification
Comprehensive Classification after Letournel
■ TYPE C COMPLETE ARTICULAR, BOTH
COLUMN FRACTURE - both columns are
fractured and all articular segments,
including the roof, are detached from the
remaining segment of the intact ilium, “the
floating acetabulum.”
♦ C1—Both column—anterior column fracture extends
to the iliac crest (high variety)
♦ C2—Both column—anterior column fracture extends
to the anterior border of the ilium (low variety)
♦ C3—Both column—anterior fracture enters the
sacroiliac joint
 Classification
Comprehensive Classification after Letournel
■ Qualifiers: Additional information can be documented
concerning the condition of the articular surfaces to
further define the prognosis of the injury. The information
should be, as additional qualifiers, identified by Greek
letters.
♦ a1) Femoral head subluxation, anterior
♦ a2) Femoral head subluxation, medial
♦ a3) Femoral head sublucation, posterior
♦ b1) Femoral head dislocation, anterior
♦ b2) Femoral head dislocation, medial
♦ b3) Femoral head dislocation, posterior
♦ g1) Acetabluar surface, chondral lesion
♦ g2) Acetabular surface, impacted
♦ d1) Femoral head, chondral lesion
♦ d2) Femoral head, impacted
♦ d3) Femoral head, osteochondral fracture
♦ e1) Intra-articular fragment requiring surgical removal
♦ f1) Nondisplaced fracture of the acetabulum
Classification
 Acetabular anatomy

Anterior column fracture Anterior column with an

anterior wall fracture
 Acetabular anatomy

Anterior wall fracture Associated anterior wall and

transverse fractures
 Acetabular anatomy

Classic posterior wall Posterior column fracture

fracture
 Acetabular anatomy

Posterior wall with posterior Posterior wall fracture with a

column fracture transverse fracture
 Acetabular anatomy

Superior dome fracture Transverse fracture

 Acetabular anatomy

T-type fracture Anterior wall fracture with

dislocation
 Signs and symptoms
■ Apart from local examination
♦ Look out for associated life threatening
injuries (intra-abdominal injuries)
♦ A, B, C first before the rest
♦ Older patients
◘ Arrhythmia, transient ischemic attacks  may have led to the
fall
♦ SDH can occur when older patients fall.
 Radiographic Evaluation
■ Requires
♦ A CT scan
♦ 3 plain radiographic views
◘ Antero-posterior view of the hip
◘ 45° iliac oblique view
◘ 45° obturator oblique view

Judet view  45° oblique view

 Plain Radiographs
1 - AP View
■ Start evaluation with this view
■ Iliopectineal line – represents the anterior column; Ilioischial line
– represents the posterior column; Posterior lip – represents the
posterior wall; Anterior lip – represents the anterior wall; Dome;
Tear-drop
 Plain Radiographs
2 - The obturator oblique view
■ Anterior column
fracture
displacements
■ Posterior wall
fragments and their
displacement
 Plain Radiographs
3 - The iliac oblique view
■ Posterior border of
the posterior column
and
■ Continuity of the true
posterior column can
be determined.
 CT Scan
■ 3 mm interval axial cuts
■ Include the entire pelvis
to avoid missing a
portion of the fracture
■ Compare with opposite
hip

 Watch for
Anterior and posterior wall fragments, marginal
impaction, retained bone fragments in the joint,
comminution, presence or absence of a
dislocations and any sacroiliac joint pathology.
 Management
■ Initial treatment – follow ATLS protocols
■ Operative treatment of acetabular
fractures are usually not performed as an
emergency
■ Normally, a closed reduction  Skeletal
traction
■ Even a rare true central dislocation is
treated that way
 Operative Surgical anatomy
■ Posterior wall fragments
♦ vary in the size and degree of comminution
♦ Well appreciated in a CT scan.
♦ Unrecognized fracture lines maybe detected
at surgery
♦ So the posterior wall fracture should never be
fixed with lag screw alone.
♦ The posterior wall fragment receives its blood
supply from the capsule  avoid detaching
the capsule from its blood supply.
 Operative Surgical anatomy
■ Posterior Column fractures
♦ Can occur anywhere along the posterior
column from the ischial spine to the sciatic
notch.
♦ Typically, the column fragment rotates.
♦ It is necessary to derotate the fragment and
check the reduction.
 Operative Surgical anatomy
■ Anterior Column fractures
♦ Occur at various levels along the anterior
column.
♦ Although the pubic ramus is part of the
anterior column, ramus fracture usually
indicates the presence of a pelvic fracture
rather than an acetabular fracture.
 Operative Surgical anatomy
■ Transverse fractures
♦ Run across the acetabulum.
♦ The fractures that cross the region of the fovea are
called infratectal.
♦ The fractures that cross just above the fovea are
juxtatectal
♦ fractures crossing higher are transtectal.
■ T-type fractures
♦ Transverse fracture with a fracture line seperating the
anterior column from the posterior column
 Operative Surgical anatomy
■ Anterior and posterior hemi-transverse
fractures
♦ This is an anterior column fracture with and
additional fracture line that runs transversely
across the posterior column.
♦ Here, the displacement is usually anterior and
the posterior column not significantly
disturbed.
♦ Thus reducing the anterior column usually
reduces the posterior column.
 Operative Surgical anatomy
■ Both column fractures
♦ Entire acetabulum is separated from the axial
skeleton.
♦ Sometimes, it is called as a floating acetabulum.
♦ Since the entire acetabulum is separated from the
ilium, the actual joint can appear congruent.
♦ This radiographic appearance is called the
secondary congruence.
♦ Spur sign
 Spur sign
■ Pathognomonic of
both column fratures.
see in obturator
oblique view
 Surgical Approaches
■ Iliofemoral
■ Ilioinguinal
■ Kocher Langenbeck
■ Triradiate transtrochanteric
■ Extended iliofemoral
■ Combined anterior and posterior approach
 Indications for non-operative
treatment
■ Non displaced and minimally displaced fratures.
■ Fractures that traverse the wt bearing dome, but
with less than 2 mm displacement – managed
by non wt bearing and or skeletal traction for 8
weeks.
■ Secondary congruence in displaced both column
fractures.
■ Closed treatment gives good results.
 Indications for non-operative
treatment
■ Fractures with significant displacement but, in which the
region of the joint involved is judged to be unimportant
prognostically.
■ This can be determined by the roof arc measurement
described by Matta and Olson as 45 degrees for each
roof arc, medial, anterior and posterior.
■ Another roof arc measurement as proposed by Vrahas,
Widding and Thomas is 25 degree fro the anterior roof
arc, 45 degree of the medial roof arc and 70 degree for
the posterior roof arc.
■ Most authors agree that displaced fractures through the
weight bearing dome should be treated with ORIF,
regardless of how they ‘line up’ in traction.
 Medical contraindications to
surgery
■ Multisystem injury
■ An open wound in the anticipated surgical
field  The Morel – Lavallée lesion
■ Presence of a suprapubic catheter is a
contraindication for ilioinguinal approach.
■ Elderly patients with osteoporotic bone –
where ORIF may not be feasible.
Indications for operative treatment
■ In fracture incongruity due to
♦ Posterior column or wall injuries
♦ Displaced fractures of the superior dome
♦ Retained bony fragments
■ In the limb
♦ Sciatic nerve injury
♦ Fracture of the ipsilateral femur
♦ Injury to the ipsilateral knee
■ In the patient – polytraumatised patient
 Treatment of specific fracture
patterns
■ Posterior wall fractures
♦ Posterior Langenbeck approach with the patient
positioned either prone or lateral using lag screw and
a reconstruction plate placed from the ischium over
the retro acetabular surface onto the lateral ileum. (If
the fracture extends superiorly into the dome, a
trochanteric osteotomy may be performed to allow
additional exposure)
♦ To avoid AVN of the posterior wall, the posterior wall
fragments must not be detached from the posterior
capsule. The knee must be kept flexed throughout the
procedure to avoid injury to the sciatic nerve.
 Treatment of specific fracture
patterns
■ Posterior column fracture
♦ Though uncommon if significantly displaced, requires
ORIF (Kocher Langenbeck approach).
♦ Typical fixation is with a lag screw combined with a
contoured reconstruction plate along the posterior
column.
♦ Rotational deformity must be corrected by placing a
Shanz screw in the ischium to control rotation while
the fracture is reduced with a reduction clamp
 Treatment of specific fracture
patterns
■ Anterior wall and anterior column fracture
♦ Isolated anterior wall fractures are uncommon.
♦ Sometimes, they are associated with anterior hip
dislocation.
♦ Fractures requiring surgery are fixed with a buttress
plate applied through an ilioinguinal or iliofemoral
approach.
♦ Anterior column fractures are approach similarly with
fixation by a contoured plate along with a pelvic brim.
 Treatment of specific fracture
patterns
■ Transverse fractures
♦ Transtectal fractures have the worst prognosis and
accurate reduction is essential.
♦ Juxtatectal fractures also usually require reduction.
♦ Typical reduction is through a posterior approach
using a Farabeuf clamp to reduce the fractures while
rotation is controlled by a Shanz screw in the ischium.
♦ Posterior fixation typically is with a buttress plate
along the posterior column and anterior fixation using
a 3.5 mm lag screw placed into the anterior column
from a position above the acetabulum.
 Treatment of specific fracture
patterns
■ Posterior Column fracture with associated
posterior wall fracture
♦ A Kocher-Langenbeck approach is used with or with
out a trochanteric osteotomy.
♦ The column fracture is reduced first.
♦ A short reconstruction plate is placed posteriorly
along the posterior edge of the column. A separate
plate is used for the wall fragment.
♦ T screws through the plate secure rotational reduction
on the posterior column fragment.
 Treatment of specific fracture
patterns
■ Transverse fracture with associated
posterior wall fracture
♦ The common fracture can be difficult to
reduce.
♦ The posterior wall component requires a
posterior exposure, but reduction of the
anterior part of the transverse fracture can be
difficult through a Kocher-Langenbeck
approach and extensile or combined
approach is frequently necessary.
 Treatment of specific fracture
patterns
■ T-type and anterior column-posterior Hemi-
transverse fracture
♦ They are treated through an ilioinguinal approach with
a contoured plate placed along the pelvic brim and lag
screws extending into the posterior column.
♦ For a T-type fracture with severe posterior
displacement but minimal anterior displacement,
posterior approach alone may be sufficient with
placement of anterior column lag screw.
♦ If both the anterior and posterior components of the
fracture are significantly displaced, an extensive or
combined approach are required.
 Treatment of specific fracture
patterns
■ Both column fractures
♦ These have varying degrees of comminution and can
be extremely complex and difficult to treat.
♦ Many both column fractures can be treated through
an anterior ilioinguinal approach.
♦ But a posterior or extensile exposure is required for
involvement of the sacroiliac joint, significant posterior
wall fracture, or intraarticular comminution.
♦ Reduction is begun from the most proximal portion of
the fracture and proceed towards the joint.
Implants for acetabular fractures
 Post-operative care
■ Closed suction drain
■ Antibiotic for 48 – 72 hours
■ Passive motion of the hip on the 2nd or 3rd day.
■ Touch down ambulation & crutches on 2nd to
4th day.
■ The minimal weight bearing status is continued
for 8 weeks in patients with simple fractures and
12 weeks in most others.
■ Rehabilitation of the abductor muscle group is
needed.
 Complications
■ General
♦ Thromboembolic disease
♦ Infection
■ Specific
 Specific Complications
■ Sciatic nerve injury
♦ Thirty percentage of acetabular fractures have
associated sciatic nerve injury.
♦ In 2 – 6 % of patients, it occurs as a result of surgery
and is more often associated with posterior fracture
pattern treated through a Kocher-Langenbeck and
extensile exposures.
♦ The peroneal component of sciatic nerve is more
often involved than the tibial component.
♦ Complete peroneal palsies have the worst prognosis.
Tibial component has greater chances of recovery.
 Specific Complications
■ Other nerves
♦ Femoral nerve injury – though rare, care to be taken
during the anterior ilioinguinal approach.
♦ Superior Gluteal nerve injury is vulnerable in the
greater sciatic notch, resulting in abductor paralysis.
♦ Pudendal nerve injury
♦ Injury to the lateral femoral cutaneous nerve
causes sensory loss in the lateral aspect of the thigh.
 Specific Complications
■ Post-traumatic arthritis
■ Heterotopic ossification
■ Chondrolysis
■ AVN
Thank You