Displaced Acetabular Fractures: Indications for

Operative and Nonoperative Management

Paul Tornetta III, MD

Abstract

Displaced acetabular fractures are a challenging problem. In contradistinction atic nerve is damaged in as many
to most conditions in which surgery is based on specific operative indications, as 20% of acetabular fractures
displaced acetabular fractures should be considered an operative problem unless affecting the posterior wall or col-
specific criteria for nonoperative management are met. These include a congru- umn, 1-3 the motor and sensory
ent hip joint on the anteroposterior and oblique (Judet) radiographs, an intact function of the extremity must be
weight-bearing surface (as defined by roof arc and subchondral arc measure- carefully documented. In particu-
ments on computed tomographic scans), and a stable joint. The final decision lar, because the peroneal division is
about the treatment method must also consider the patient’s functional most at risk, foot dorsiflexion and
demands, expectations, and physical condition and the physician’s experience eversion must be tested.
and institutional support for dealing with this type of injury. Displaced both- Closed soft-tissue injuries may
column fractures with secondary congruence may have better results than other occur about the hip region, especial-
displaced fractures. In older patients, nonoperative management may be effec- ly over the trochanter. A closed
tively utilized. Understanding the current criteria for effective use of nonopera- degloving injury is referred to as a
tive treatment will help the surgeon make these difficult decisions. “Morel-Lavallee lesion.” The sero-
J Am Acad Orthop Surg 2001;9:18-28 sanguineous fluid collections that
develop in these cavities are culture-
positive in as many as 31% of cases.4
If this injury pattern is discovered,
Displaced acetabular fractures are experience. As with all surgical pro- irrigation and debridement of these
among the most complex injuries cedures, the potential benefits of areas should be performed, and
that the orthopaedic surgeon has to surgery must be weighed against internal fixation should be delayed
manage. This is in part because their risks. until the area is clean.4
they are uncommon; a surgeon may Plain-radiographic assessment
encounter only one or two such inju- of a patient with an acetabular in-
ries per year. In cases of polytrauma, Evaluation jury begins with the five standard
associated musculoskeletal, neuro-
logic, and soft-tissue injuries may After the emergent resuscitation of
complicate evaluation and treat- the trauma patient who potentially
ment. The anatomic complexity of has an acetabular fracture, the ortho- Dr. Tornetta is Associate Professor and Vice
the acetabulum and pelvis, along paedic surgeon is generally con- Chairman, Department of Orthopaedic Sur-
gery, Boston University School of Medicine,
with the difficulty of accurately sulted. Initial assessment includes Boston, Mass; and Director of Orthopaedic
defining and classifying the fracture a careful physical examination and Trauma, Department of Orthopaedics, Boston
pattern, makes treatment decisions review of relevant radiographs. A Medical Center.
even more challenging. physical examination focusing on
The decision between surgical the acetabular injury should in- Reprint requests: Dr. Tornetta, Department of
and nonsurgical management is clude a well-documented, complete Orthopaedics, Boston Medical Center, Dowling
2 North, 818 Harrison Avenue, Boston, MA
often not a black-and-white issue. neurologic assessment of the pelvis 02118.
Many factors must be considered, and lower extremity, evaluation of
including the fracture pattern, indi- the soft tissues in the trochanteric Copyright 2001 by the American Academy of
vidual patient factors, institutional and gluteal regions, and the resting Orthopaedic Surgeons.
facilities and support, and surgeon position of the leg. Because the sci-

18 Journal of the American Academy of Orthopaedic Surgeons


views of the pelvis: anteroposte-
rior (AP), iliac oblique, obturator
oblique, inlet, and outlet. These
views will delineate associated
pelvic fractures, femoral head in-
jury, and hip dislocations. The
standard AP radiograph is usually
sufficient for recognition and clas-
sification of an acetabular fracture.
However, the 45-degree oblique
(Judet) views are needed to fully
characterize the fracture and to
determine whether there is sublux-
ation of the hip joint, which may
not be visible on the AP view. The
obturator oblique view is taken
with the affected side of the patient
rotated 45 degrees forward. This
allows clear visualization of the
anterior column in the region of the
hip, the posterior wall, and any
posterior subluxation of the hip.
The iliac oblique view is taken with
the unaffected side of the patient
rolled 45 degrees forward. This
view profiles the posterior column
from the notch to the ischium and
the anterior wall, which is curvilin-
ear and shallower than the posterior
wall. The inlet and outlet pelvic
radiographs may depict pelvic in-
juries that would affect the man-
agement of the acetabular fracture.
Occasionally, anterior sacroiliac
joint widening is present with
transverse and both-column ace-
tabular fractures, which may be
difficult to appreciate on the stan-
dard AP view.
A computed tomographic (CT)
study with 1.5- or 2-mm sections
through the affected area of the
acetabulum allows more precise def-
inition of the fracture than is possi-
ble with plain radiography. Two-
dimensional and three-dimensional
reconstructions of the fracture often
help in understanding the rotational
deformities of the displaced frac-
tures but are not necessary for deci-
sion making or operative planning.
In fact, volume-averaging, along
with the reconstructive technique,
may mask fractures that are not
Vol 9, No 1, January/February 2001
markedly displaced. The informa-
tion commonly available from the
standard radiographic series allows
classification of the fracture and
definition of many associated vari-
ables affecting outcome.
The classification of acetabular
fractures was standardized by
Letournel.5 He described five ele-
mental and five complex (associated)
fracture patterns (Fig. 1). The frac-
ture pattern has relevance to treat-
ment alternatives and prognosis.
Determinants of Outcome
Clinical outcome after treatment of
an acetabular fracture is related to
many factors. Some of these fac-
tors, such as comorbidities and
bone quality, are present before
injury. Others, such as the fracture
pattern, injury to the cartilage sur-
face of the acetabulum or the fe-
moral head, vascularity of the head,
and neurologic impairment, are
determined at the time of injury.
Still others, such as the accuracy of
final reduction of the roof of the
acetabulum and the stability of the
hip, are established at the time of
treatment. In addition, surgical
complications may have a profound
effect on outcome.
Fracture Location
More than 30 years ago, Rowe
and Lowell6 recognized the prog-
nostic importance of displaced frac-
tures affecting the roof of the ace-
tabulum. As the art of acetabular
fixation became more advanced
and fracture classification became
standardized, the guidelines for
assessment and determination of
which fractures may benefit from
surgery were developed.
Matta began this process with the
description of roof arc measurements
that describe the location of the
main-column fracture lines in rela-
tion to the roof of the acetabulum.7
These measurements are relevant
Paul Tornetta III, MD
only if there is no subluxation of the
hip. Three roof arc measurements
are made, one each from the AP,
obturator oblique, and iliac oblique
radiographs of the acetabulum. Each
arc is generated by measuring the
angle between a vertical line from
the center of the nonsubluxated
femoral head and a line from the
center of the head to the point where
the fracture enters the joint. If the
fracture does not enter the joint on
one of the views, the angle cannot be
measured, and the joint in that view
is considered intact. With larger
arcs, the fracture is farther away
from the roof of the acetabulum. For
example, in the case of a transverse
fracture, a roof arc of 10 degrees
measured on the AP radiograph
places the fracture almost directly
above the femoral head; a 90-degree
arc indicates that the fracture is low
and does not affect the roof. Dis-
placed fractures that affect the roof,
or weight-bearing surface, of the
acetabulum, do not have outcomes
comparable to those that do not
affect this area. However, the precise
area of the acetabulum that must
remain intact to allow a good func-
tional result with nonoperative treat-
ment of a displaced acetabular frac-
ture remains unknown.
The use of roof arc measurements
as a means to decide between opera-
tive and nonoperative management
has evolved since their original
description. The minimum roof arc
that is required to consider nonoper-
ative management has varied be-
tween 20 degrees and 45 degrees,
but the value currently considered
most appropriate is 45 degrees.
In subsequent work, Olson and
Matta8 described the CT correlate of
having 45-degree roof arc measure-
ments on all three views of the
acetabulum. This is called the CT
subchondral arc and is defined as
the subchondral ring of the acetabu-
lum 10 mm inferior to the subchon-
dral bone of the roof. By mathemat-
ical derivation, it was determined
19
Displaced Acetabular Fractures

A B C D E

F G H I J

Figure 1 The Letournel classification of acetabular fractures. A, Posterior-wall fracture. B, Posterior-column fracture. C, Anterior-wall
fracture. D, Anterior-column fracture. E, Transverse fracture. F, Associated posterior-column and posterior-wall fractures. G, Associated
transverse and posterior-wall fractures. H, T-shaped fracture. I, Associated anterior-column and posterior hemitransverse fractures.
J, Both-column fracture. (Adapted with permission from Matta J: Surgical treatment of acetabulum fractures, in Browner B, Jupiter J,
Levine A, Trafton P [eds]: Skeletal Trauma. Philadelphia: WB Saunders, 1992, pp 899-922.)

that if the fracture of the acetabulum
does not break this ring, then the
roof arcs must be greater than 45
degrees as measured on the three
standard views (Fig. 2). Olson and
Matta reported that early onset of
radiographic evidence of arthritis
and poor clinical results correlate
with (1) displacement present at the
time of union within the weight-
bearing dome, (2) any roof arc mea-
surement less than 45 degrees, or (3)
a broken CT subchondral arc of the
acetabulum. The subchondral CT
arc should be used only in conjunc-
tion with the standard radiographic
views, as fractures in the plane of
the CT scan may be missed if CT is
the only modality utilized.
Hip Stability
In addition to the location of the
fracture, the stability of the hip joint
affects outcome. A fracture pattern
that results in subluxation of the hip
joint increases the stress on the artic-
ular cartilage in the area adjacent
to the fracture.9 Radiographically,
subluxation manifests itself as an
incongruity between the head and
the roof, which is described as a lack
of parallelism.5 Good or excellent
clinical results are obtained after
treatment of fewer than 50% of frac-
tures in which the head is not con-
gruent with the roof after surgery,
and more than 60% of these hips
will develop arthritis.5 Subluxation
is most often manifested by a lack of
congruence of the femoral head
with the roof, but it can also take the
form of dynamic instability. In par-
ticular, certain posterior wall frac-
tures may allow dynamic hip sub-
luxation, leading to femoral-head
wear and joint degeneration.
Posterior-wall fractures cannot
be assessed by using roof arc mea-
surements, as they are outside the
planes of measurement. Radiographic
assessment is best performed with
CT, which demonstrates not only
the portion of the posterior wall
affected but also the degree of mar-
ginal impaction that is associated
with the injury10,11 (Fig. 3). Several
authors have sought to describe the
amount of the posterior wall that is
necessary to maintain hip stability,
and a number of measurement tech-
niques have been employed, in-
cluding the use of radians and lin-
ear measurements.12-14 The easiest
method for measuring the amount
of posterior wall affected is to di-
vide the length of the intact articu-
lar surface on the affected side by
that of the normal side on a CT sec-
tion obtained at the same level to

20 Journal of the American Academy of Orthopaedic Surgeons


determine a ratio. Areas of mar-
ginal impaction are considered to
be displaced. These measurements
are not necessary if any subluxa-
tion is visible on the CT scan, as
clinical instability has then already
been demonstrated. As a general
rule, dynamic clinical instability
exists in fractures affecting more
than 40% of the posterior wall,
while those affecting less than 20%
of the wall are stable. 12-14 How-
ever, instability has been reported
when as little as 15% of the wall is
affected.15
In those patients with fractures
affecting less than 40% of the poste-
rior wall, including marginal im-
paction, 15,16 a fluoroscopic stress
view of the hip can be obtained.
With the patient supine on the table
and under general or regional anes-
thesia, the hip is viewed fluoro-
scopically while it is brought into
flexion. The relationship of the
head to the roof is observed. Any
widening of the joint space indi-
cates instability in the AP view. If
the hip is stable in flexion, a posteri-
orly directed stress is applied that is
2 cm
45°
Figure 2 Having roof arc measurements
of 45 degrees on all three views of the
acetabulum is equal to having an intact CT
subchondral ring located 10 mm below the
subchondral bone of the acetabular roof.
(Adapted with permission from Olson SA,
Matta JM: The computerized tomography
subchondral arc: A new method of assess-
ing acetabular articular continuity after
fracture [a preliminary report]. J Orthop
Trauma 1993;7:402-413.)
Vol 9, No 1, January/February 2001
of sufficient force to rock the pelvis.
Again, the relationship of the head
to the roof is analyzed. The stress
view may be saved on the screen
and compared with the normal side
if there is any question about insta-
bility. This is repeated in the obtu-
rator oblique projection. Even if the
hip is stable, fractures that affect
only 33% of the wall have been
shown to increase the contact stress
in the roof of the acetabulum,
which may lead to posttraumatic
arthritis in the long term.9
Other Factors
The clinical outcome of patients
with acetabular fractures is affected
by many factors other than the frac-
ture pattern and hip stability. These
include neurologic injury, cartilage
injury, and osteonecrosis. Regard-
less of the treatment method, any of
these factors may result in a poor
clinical outcome. Neurologic injury
as a consequence of the accident may
be permanent, especially if there is a
complete injury. 17 Sciatic nerve
palsies most commonly result in a
foot-drop. Although the peroneal
division is most frequently injured, a
dense (complete) palsy may occur.
Direct cartilage injury may affect
either the acetabulum or the fe-
moral head. At this time, there is
no effective treatment for cartilage
lesions. The degree of cartilage in-
jury may affect the clinical outcome
even if there is an anatomic reduc-
tion. 5,18-25 Matta 21 demonstrated
that cartilage injury to the femoral
head visible on gross visual inspec-
tion is a risk factor for arthritis even
with an excellent reduction.
Osteonecrosis of the femoral
head may occur after hip disloca-
tion or fracture-dislocation. Al-
though immediate reduction of the
hip may decrease the rate of osteo-
necrosis, the patient is at risk for as
long as 5 years after injury.16 Dam-
age to the blood supply of the fem-
oral head may also occur during
surgery, increasing the risk of osteo-
Paul Tornetta III, MD
Figure 3 CT section of a nondisplaced
transverse and posterior-wall fracture
demonstrates that the femoral head is sub-
luxated and clarifies the area of impaction
(arrows). No articular surface of the poste-
rior wall remains intact.
necrosis. The degree of femoral
head involvement is quite variable,
and the effect on patient outcome
correlates with the size of the avas-
cular segment and its location. Os-
teonecrosis may also affect acetabu-
lar fragments, particularly small
posterior wall fragments without
soft-tissue attachments.5 This may
lead to loss of stability, followed by
femoral-head wear and joint degen-
eration.
Surgical Treatment
Surgical management of acetabular
fractures is technically demanding
and has many potential complica-
tions. The goal of surgery is to ac-
curately restore the anatomic con-
figuration of the joint surface, as
well as congruence and stability of
the hip joint, while avoiding com-
plications. The results after surgery
correlate most closely with the
quality of the reduction.7,21,23,26 At
an average of 6 years after injury,
the clinical results in patients with
fractures reduced to less than 1 mm
of displacement are superior to
21
Displaced Acetabular Fractures
those in patients with 1 to 3 mm of
displacement.21 A review of a num-
ber of series showed that even in
the most experienced hands, reduc-
tions to within 1 mm of the normal
anatomic relationship are obtained
in only 55% to 75% of cases.5,7,11,20-27
In the same series, reductions with
less than 3 mm of fracture displace-
ment and a congruent hip joint were
obtained in nearly 90% of cases. It
should be noted, however, that there
has been no study that evaluated the
precision or accuracy of these preop-
erative and postoperative measure-
ments made on plain films.
Factors Affecting Surgical
Reduction
Many factors affect the quality of
a surgical reduction, with the experi-
ence of the surgeon being one of the
most important. This is a difficult
factor to examine because the excel-
lent results reported in the large
series of operatively treated acetabu-
lar fractures come from surgeons
with significant experience. One re-
port, however, describes the results
in 49 patients treated by nine sur-
geons over a 10-year period.28 At an
average of 38 months, poor radio-
graphic results were present in 40%
of the hips, and poor clinical results
in 38%. In the largest reported
series, Letournel described his learn-
ing curve by 4-year intervals. For
acute fractures, the rate of imperfect
reductions fell from 32% to only 10%
as his experience increased.5
The timing of surgery also has a
bearing on the surgeon’s ability to
obtain an accurate reduction. The
mobility of the fracture decreases
with time from injury. Brueton29
reported that the average time to
surgery for fractures with an ac-
ceptable reduction was 11 days,
whereas for unacceptable reduc-
tions the time to surgery was 17
days. 10 Likewise, Letournel re-
ported an anatomic reduction rate
of only 52% in fractures that were
operated on more than 21 days from
22
the time of injury, despite the fact
that almost half of the fractures
were the posterior-wall type.5 Fur-
thermore, he reported that 40% of
fractures seen more than 4 months
after injury were not reconstructible.
The ability to achieve an anatomic
reduction is also affected by the
fracture pattern. The more complex
the pattern, the more difficult it is
to reduce the fracture. The degree
of comminution and the classifica-
tion affect the surgeon’s ability to
reduce a given fracture. In a series
of 262 patients, Matta 21 reported
that 96% of elemental fractures
were anatomically reduced, com-
pared with only 64% of complex
types. In Letournel’s series, ana-
tomic reductions were obtained in
94% of posterior-wall fractures but
only 61% of both-column fractures.5
The worst outcomes, as judged
by accuracy of reduction, are seen
in those patients who require a re-
vision after the initial surgical pro-
cedure resulted in a malreduction.
In one series of 64 patients, only
29% of fractures seen after 3 months
could be anatomically reduced, and
significant chondral injury of the
femoral head was present in 44%.23
Risks
Potential complications must be
carefully considered when contem-
plating surgical treatment. It must
also be borne in mind that the risks
of surgery vary inversely with the
level of experience of the surgeon.28
Injury to the sciatic nerve occurs
most commonly when fractures
are fixed through a posterior ap-
proach.1-3,28 The peroneal division
is most at risk. Careful attention to
intraoperative sensory and motor
pathway monitoring may provide
an early warning that the nerve is
under tension, and thereby de-
crease the incidence of permanent
iatrogenic injury.1,2 However, sev-
eral experienced surgeons have re-
ported iatrogenic nerve injuries in
only 2% of cases without the use of
Journal of the American Academy of Orthopaedic Surgeons
monitoring3; this rate is as low as
the reported rates when nerve mon-
itoring is used. Thus, monitoring
may be useful for less experienced
surgeons, but may not be as neces-
sary for more experienced surgeons.
Range of motion of the hip may
be diminished postoperatively if
heterotopic ossification develops.
The occurrence of heterotopic ossifi-
cation has been reported in as many
as 80% of patients with acetabular
fractures fixed through a posterior
approach. 28,30 Factors that have
been associated with the formation
of heterotopic ossification include
male gender, the use of an extensile
approach or trochanteric osteotomy,
or the presence of extensive cartilage
injury, T-shaped fracture, or con-
comitant abdominal, chest, or head
injury.31,32 In most cases, the devel-
opment of heterotopic ossification
does not markedly restrict hip mo-
tion. Indomethacin and low-dose
radiation therapy have both been
shown to be effective in reducing the
incidence of clinically important het-
erotopic ossification.30-33 Most sur-
geons now use some form of pro-
phylaxis when performing internal
fixation through a posterior or exten-
sile approach. Despite this, clinically
significant heterotopic ossification
may develop in as many as 5% of pa-
tients; some may require additional
surgery to regain hip motion.28,31
Infection after acetabular surgery
has been reported to occur in 2% to
5% of patients.5,7,11,22,25,26,28,34 How-
ever, Kaempffe et al28 reported an
infection rate of 12% in a multisur-
geon series in which each surgeon
performed only a few cases. The
presence of soft-tissue injury, such
as a Morel-Lavallee lesion, increases
the risk of infection.4,5 Infection may
be intra-articular or extra-articular,
depending on the approach used.
Extra-articular infections occur after
indirect reduction of the joint, most
commonly after an ilioinguinal
approach. Intra-articular infections
may destroy the articular surface of

the joint and make salvage difficult,
whereas extra-articular infections
usually allow preservation of the
joint.
The complications of infection,
heterotopic ossification, and neuro-
logic injury are emphasized because
of their potentially catastrophic effect
on outcome. The most common com-
plication after surgical treatment of
acetabular fractures, however, is ar-
thritis. Arthritis is a radiographic
diagnosis and is present in 15% to
45% of acetabular fractures followed
for more than 5 years.5 Matta21 re-
ported that with anatomic reduc-
tions, arthritis developed in only
16% of patients, as opposed to 45%
in those not reduced anatomically.
Likewise, Letournel reported a 10%
rate after perfect reductions and 36%
after imperfect reductions.5 The diag-
nosis of arthritis was made 10 years
or less after surgery in 80% of pa-
tients who had imperfect reductions,
but more than 10 years after surgery
in 50% of those who had a perfect
reduction. Of note, Letournel ques-
tioned the inclusion of arthritis as a
complication of surgery in those
with late presentation.
Outcome
The outcome after surgical treat-
ment of an acetabular fracture corre-
lates with the quality of the reduc-
tion and the occurrence or avoidance
of complications. In several large
series of acetabular fractures, the
overall clinical results (based on a
modified D’Abinge score) were good
or excellent in 75% to 85% of patients
with a good reduction.5,21,22,26,27,34 If
there was residual displacement of 3
mm, this dropped to 50% to 68%.
The overall clinical results in several
recent series are given in Table 1.
Decision Making
Fracture Pattern
Many factors must be taken into
consideration when deciding whether
Vol 9, No 1, January/February 2001
to treat an acetabular fracture oper-
atively or nonoperatively. Individ-
ual patient factors, institutional
circumstances, and the fracture pat-
tern should be considered (Fig. 4).
Regardless of the treatment chosen,
part of the plan must be early mo-
bilization of the patient to avoid
the risks of prolonged recumbency.
To justify surgery, the result after
surgery must be better than the
expected natural history of a non-
operatively treated fracture. Un-
like other fractures for which crite-
ria are applied to determine whether
surgery is indicated, displaced ace-
tabular fractures should be consid-
ered an operative problem unless
specific criteria for nonoperative
management are met. Patients with
fractures that meet criteria for non-
operative management can be mobi-
lized early with the expectation that
the outcome will be satisfactory.8,15
Olson and Matta8 reported the
use of a CT subchondral arc in com-
bination with other criteria in de-
ciding which acetabular fractures
may be treated without surgery.
Their criteria include an intact 10-
mm CT subchondral arc, intact 45-
degree roof arc measurements on
plain radiographs, at least 50% of
the articular surface of the posterior
wall intact on all CT sections, and a
femoral head congruent with the
acetabular roof on the AP, obtura-
Table 1
Results in Recent Series of Acetabular Fractures Treated Operatively
No. of
Author(s) (year) Fractures
Matta21 (1996) 262
Mayo22 (1994) 163
Ruesch et al24 (1994) 53
Alonso et al34 (1994)* 59
Cole et al27 (1994)† 55
Wright et al25 (1994) 87
* Only extended approaches used.
† Only modified Stoppa approach used.
Paul Tornetta III, MD
tor oblique, and iliac oblique views.
In a study of patients with dis-
placed acetabular fractures treated
without surgery,8 9 (82%) of 11 frac-
tures meeting these criteria had a
good or excellent result at 1 year,
compared with only 5 (42%) of 12
fractures not meeting these criteria.
The results in the patients who met
these criteria and were treated non-
operatively were equal to those in
patients treated operatively over
the same time period. The authors
concluded that there is no advan-
tage to operative management in
this patient population.
The use of fluoroscopic stress
views has been recommended to
augment these criteria.15 In a series
of 41 patients who met the Olson-
Matta criteria, 3 had fluoroscopically
demonstrable hip instability. Two
had posterior-wall fractures affect-
ing 15% and 35% of the posterior
wall, and 1 had a transverse fracture
(Fig. 5). The remaining patients who
had fractures that met the criteria for
nonoperative management and who
had fluoroscopically demonstrated
stable hips were treated nonsurgically
with early mobilization (20-lb toe-
touch for 10 to 12 weeks). Good or
excellent results were obtained in 32
(91%) of 35 patients followed up for
an average of 2.7 years (Fig. 6). On
the basis of these studies, if criteria
for nonoperative treatment are met
Acceptable Good or Excellent
Reductions, % Clinical Results, %
90 76
81 75
81 81
100 71
89 89
85 45
23
Displaced Acetabular Fractures

Displaced acetabular fracture (except both-column fracture)

Is femoral head congruent with acetabular roof on AP and Judet views?

Yes No
Consider patient factors:
• Age >60?
• Serious comorbidities?
Evaluate radiologic factors: Evaluate whether • Increased surgical risk?
• Intact 45° roof arc? fracture pattern can • Preexisting hip arthritis?
• 10-mm CT subchondral be improved with ORIF • Very low-demand patient?
ring intact? • Demented patient?
• >50% of posterior wall • Patient refuses transfusion?
intact on all CT sections? Yes

No

Yes No
Yes No
Consider nonoperative
treatment, with THA as salvage
Stable hip on if painful arthritis develops Consider institutional factors:
fluoroscopic stress • Surgeon experienced?
view under anesthesia? • Institution capable of
managing injury?

Yes No
Yes No

Nonoperative
management ORIF Transfer patient

Displaced both-column acetabular fracture

Secondary congruence present?

Yes No

Consider patient factors:

• Age >50?
Consider institutional factors:
• Serious comorbidities?
• Surgeon experienced?
• Increased surgical risk?
• Institution capable of managing injury?
• Preexisting hip arthritis?
• Very low-demand patient?
• Demented patient?
• Patient refuses transfusion?

Yes No
Yes No

ORIF Transfer patient

Nonoperative management

Figure 4 Top, Algorithm for treatment of displaced acetabular fractures (except both-column fractures). Bottom, Algorithm for treat-
ment of displaced both-column acetabular fractures. ORIF = open reduction and internal fixation; THA = total hip arthroplasty.

24 Journal of the American Academy of Orthopaedic Surgeons

 Paul Tornetta III, MD

A B C

Figure 5 A, AP radiograph of a 19-year-old woman with a posterior hip dislocation, a

transverse acetabular fracture, and a symphyseal dislocation. After reduction of the
dislocation, Judet views (B and C) and a CT scan confirmed that the patient had intact
45-degree roof arcs, no posterior wall fracture, an intact subchondral ring, and a con-
gruent relationship of the head to the roof on all three views. Although the patient met
the criteria for nonoperative management, the hip was stressed in the operating room
and found to be unstable. D, The femoral head lost congruence with the roof and
became congruent with the ischiopubic segment in abduction. ORIF of the acetabulum
and the symphysis was performed to maintain hip stability.

and the hip is stable, nonoperative
management permits early mobi-
lization without an increased risk of
early arthritis while avoiding the
risks of surgery.
This same principle may be ap-
plied to one component of an ace-
tabular fracture. If one fragment of
a complex fracture (usually in a
low-column or small posterior-wall
fracture) meets the criteria for non-
operative management, then open
reduction and internal fixation
(ORIF) of the rest of the acetabu-
lum may be all that is required.
This is especially likely if a second
approach would be needed, such
as for a T-shaped fracture in which
only one column can be accurately
reduced through a nonextensile
approach (Fig. 7). Nonoperative
management of such fractures
avoids the morbidity associated
with operative management due to
use of a second approach or an ex-
tensile approach. The CT arc is
most often useful in determining
which component of the fracture
affects the roof. However, after fix-
ation of a portion of a complex ace-
tabular fracture, the same criteria
for nonoperative management pre-
viously described must be met re-
garding the remaining displaced
portion.
Notably, Olson and Matta8 ex-
cluded both-column fractures in
their analysis of nonoperative frac-
ture management. This pattern de-
serves special mention, as the
results of nonoperative manage-
ment for displaced both-column
fractures are better than those for
other displaced fractures affecting
the roof. In both-column fractures,
the entire articular surface is sepa-
rated from the intact ilium. The
columns rotate away from each
other, allowing the head to medial-
ize, but they may maintain a con-
gruent relationship with the head.
This is referred to as “secondary
congruence.”
Letournel reported very good or
excellent results in 11 (85%) of 13
patients with both-column fractures
treated nonoperatively an average
of 4.3 years after injury if secondary
congruence was present. 5 How-
ever, the long-term follow-up of
these injuries is not known. One
recent biomechanical study demon-
strated statistically significant in-
creases in the contact pressures in
the roof of the acetabulum in the
presence of perfect secondary con-
gruence.35
Patient Factors
Patient factors, such as age, bone
quality, comorbidities, preinjury
function, type of employment, and
personal expectations, all have a
bearing on treatment. For young
patients, there is no good alterna-

Vol 9, No 1, January/February 2001 25

Displaced Acetabular Fractures

tive to ORIF of displaced fractures

and no long-term salvage solution
if clinically significant arthritis
develops. However, in older pa-
tients, salvage is possible with a
87° 60°
hip arthroplasty; thus, nonopera-
tive management may be consid-
ered a more viable option for older
patients.
Clinical results after surgery are
better in younger patients than in
A B
older patients. Older patients are
more likely to have poor bone stock
and suffer a loss of reduction if
treated operatively.5-21 Other factors
that may predispose to complica-
70° tions, such as diabetes and obesity,
must be evaluated. Preexisting
symptomatic arthritis is a relative
contraindication to internal fixation,
as the long-term result will likely be
poor and hip arthroplasty may even-
C D
tually be necessary.
Figure 6 An 18-year-old motorcyclist sustained a right femur fracture, a symphysis dis- The patient’s activity level may
location with bilateral ramus fractures, an anterior left sacroiliac joint injury, and a dis- also influence the decision. A house-
placed T-shaped left acetabular fracture. The roof arc measurements are drawn for clarity. hold ambulator does not have the
The anterior column is not significantly displaced (B), but the posterior column is dis-
placed 1.5 cm (C). The roof arc measurements are more than 45 degrees on the AP (A) and same requirements as a vigorous
Judet (B and C) views. The 10-mm subchondral ring was intact and the head was congru- community ambulator and may not
ent with the roof in all views. Because the hip was stable on the fluoroscopic stress views, choose the same management. The
the acetabular fracture was treated nonoperatively. The symphysis and rami were
reduced and fixed. Although the sacroiliac joint would not normally require fixation, it patient in Figure 8 is a 72-year-old
was fixed because the iliac wing fragment remained mobile after nonoperative manage- obese woman who is a household
ment of the acetabular fracture. D, Four years after surgery, the hip was rated excellent ambulator with insulin-dependent
clinically and showed no signs of arthritis.
diabetes mellitus. She suffered a
both-column fracture in a fall.
Given her lifestyle, physical de-
mands, and fracture pattern, she
chose nonoperative management
and had a very good result at 4
years. Figure 9 depicts a similar
fracture pattern in an active, well-
developed 70-year-old man with-
out identifiable comorbidities. He
chose operative management and
had an excellent result at 5 years.
Thus, management must be tai-
A B C lored to the patient as well as to the
fracture pattern.
Figure 7 A, AP view of a 42-year-old woman who sustained a T-type fracture in a motor
vehicle accident. The femoral head is subluxated medially and follows the posterior col-
umn. B, CT section obtained 15 mm below subchondral bone reveals the anterior-column Institutional Factors
fracture (arrow) entering the joint (but outside the weight-bearing surface of the acetabu- Just as each patient is different,
lum). C, After the posterior-column fracture was reduced anatomically and fixed, all three so, too, is each surgeon and institu-
views showed that the head was congruent with the roof and stable (AP view is shown).
Thus, the anterior component of the fracture met the criteria for nonoperative management tion. Specialized equipment is used
and was not reduced or fixed. by surgeons who frequently treat
acetabular fractures. This includes

26 Journal of the American Academy of Orthopaedic Surgeons

 Paul Tornetta III, MD

special traction tables, reduction

clamps, oscillating drills, and nerve
monitoring apparatus. The pres-
ence of qualified assistants is also
an important factor. Special anes-
thetic techniques, such as hyper-
volemic hypotension and the use of
a cell saver, may decrease the need
for transfusion. Many institutions
are not equipped to properly sup-
port acetabular surgery. Thus, the
individual surgeon must assess, in
A B addition to his or her own experi-
ence in dealing with these injuries,
Figure 8 A, A 72-year-old diabetic woman who was a household ambulator sustained a the institutional support available
both-column fracture after a fall. The relationship of the head to the displaced roof in all
three views indicated reasonable secondary congruence. The patient opted for nonopera- when making the decision to operate
tive management, which included immediate mobilization with a walker and wheelchair. or to transfer the patient to a center
B, Four years after her injury, she had no hip pain, and there was radiographic evidence of that specializes in the care of these
preservation of the joint space.
patients.

Summary

Acetabular fractures are complex

injuries and should be viewed as an
operative problem unless the crite-
ria for nonoperative management
are met. If the nonoperative criteria
are not met, the ultimate decision as
to whether to operate depends on
many factors, including the pa-
tient’s expectations. The individual
surgeon must evaluate his or her
own experience and the institu-
tional support available in deciding
A B
whether to operate on or transfer a
Figure 9 A 70-year-old man who had been an active community ambulator and enjoyed patient who would benefit from
walking daily sustained an acetabular fracture after a fall. A, Judet views demonstrate a operative management. Regardless
both-column fracture with imperfect secondary congruence on the iliac oblique view. After of the treatment chosen, manage-
discussion of the risks and benefits of operative and nonoperative management, the patient
chose ORIF. The immediately postoperative AP and Judet views demonstrated anatomic ment should include early mobili-
reduction of the acetabulum. B, After 5 years, the patient had minimal pain with weather zation to avoid the complications of
changes and no radiographic signs of arthritis and still enjoyed walking several miles daily. recumbency.

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