E. Letournel R.

Judet

Fractures of the
Acetabulum
Translated and Edited by R. A. Eison

With 289 Figures in 980 Separate Illustrations

Springer-Verlag Berlin Heidelberg GmbH 1981

EMILE LETOURNEL

Professeur agrege d'Orthopedie et de Traumatologie

Chirurgien des Höpitaux de Paris
Chef du Service d'Orthopedie et de Traumatologie
Centre Medico-Chirurgical de la Porte de Choisy
15, Avenue de la Porte de Choisy, F-75634 Paris Cedex 13

ROBERT JUOETt

Professeur honoraire d'Orthopedie et de Traumatologie

a la Faculte de Medecine de Paris
Chirurgien honoraire des Höpitaux de Paris
6, Square Jouvenet, F-Paris 16

Translator and Editor

REGINALO A. ELsoN

The Northern General Hospital,

GB-Sheffield 5

Title of the original French edition:

Les Fractures du Cotyle. © Masson et Ci" Paris, 1974

ISBN 978-3-662-02327-3 ISBN 978-3-662-02325-9 (eBook)

DOI 10.1007/978-3-662-02325-9

Library of Congress Cataloging in Publication Data

lUDET, ROllERT. Fractures of the acetabulum
Translation of Les Fractures du Cotyle
Bibliography: p. Includes index
I. Acetabulum (Anatomy) - Fractures. 2. Hip joint - Surgcry. I. LETOURNEL, EMILE, joint author. II. ELSON,
REGINALD. III. Title. [DNLM: I. Acetabulum - Injuries. 2. Fractures.
WE 750 J91f] RD549.l8213 617'.158 80-28998

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© by Springer-Verlag Berlin Heidelberg 1981
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2124/3130-543210
Preface to the English Edition

It has been a pleasure to comply with requests to publish this book in

English. During the intervening years, there has been little to add to our
views as to the best management of acetabular fractures, but an additional
chapter has been incorporated comprising recent findings in our patients
and slight changes in emphasis on the indications for operations.
Additionally, having recognised that one of the greatest difficulties in this
method of treatment lies in the pre-operative assessment of the standard
radiographs, we have prepared a short series of radiographs which the reader
may find advantageous for study.
We are grateful to Mr. Reginald Eison who has translated and revised
the French edition. Considerable alteration of the text and the general presen-
tation was necessary in order to make the material palatable in English.
Our thanks are due to our new publishers, Springer-Verlag, for their keen
interest and skill.

E. LETOURNEL
R. JUDET
Preface to the French Edition

It is a long time since we first attempted surgical treatment of fractures

of the acetabulum accompanied by displacement, with the aim of restoring
perfect articulation. Such treatment demands an exact reconstitution of the
anatomy of the acetabulum and pelvic bone.
This volume comprises an account of our efforts to assess the place of
open reduction and internal fixation of displaced fractures of the acetabulum.
The principal aim is simple: the perfect restoration of the articular surface
and the associated bony architecture.
Our first surgical attempts were made before 1950, but it was only after
1956, due to intense dissatisfaction at the poor results obtained by conserva-
tive means, that we decided to operate routinelyon all of these displaced
fractures. This decision was implemented very strictly until the end of 1970;
now we desire to report the fruits of the fourteen years of the study.
In 1956 the treatment of choice for fractures of the acetabulum, from
a surgical point of view, remained very questionable. Current opinion had
been summarised in areport by Cauchoix and Truchet to the Societe Fran-
~aise d'Orthopedie (1951) following which the situation remained static in
France as weil as other countries. A full study of the literature has confirmed
this state of affairs. Certain groups of fractures had been individualised
and these merited keeping: for example, fractures of the posterior wall,
transverse fractures, associated transverse and posterior fractures and T-
shaped fractures. The majority of cases remained in a group simple to define,
but of no great practical value, confused together as "Ies enfoncements
du cotyle" (" stove-in" acetabulum). The dislocation which accompanied
most of these fractures had captured the attention of the authors, and treat-
ment was largely devoted to this aspect of the injury. Conservative manage-
ment was universally advised whenever even an approximate reduction of
the dislocation could be achieved. A few tentative surgical interventions
had been performed, documented by Cauchoix and Truchet (1951), but they
remained the exception. In most of the uncommon reports of operative
treatment, the acetabulum had been approached by the posterior route al-
though the anterior approach had been used occasionally, following the
Smith-Petersen incision or as advised by Levine (1943). These reports were
sporadic and related to few clinical cases.
In order to approach fractures of the acetabulum safely and with maximum
ease, it is necessary to understand the pathological anatomy, otherwise errors
are inevitable. We have reviewed in detail all our cases operated or treated
conservatively and have revised the radiological study of the innominate
bone. The comparison of sets of radiographs and the discoveries at operation
together with study of anatomical specimens have led us to propose a new
classification into which all known forms of fracture have now been placed.
VIII Preface to the French Edition

Discrete groups are artificial, for all varieties of the fractures and dislocations
fit into a continuous spectrum; at the same time, if it is recognised that
there are transitional forms between each, discrete types must be described
in order to provide a classification, the basis of understanding.
The positive wish to complete the spectrum has caused us to look specifi-
caIly for missing members, and in most instances these have been found
and incorporated without difficulty in the schematic groups which we have
chosen.
Surgical approach to fractures of the acetabulum was not weIl developed.
For the posterior aspect, the Kocher-Langenbeck group of incisions were
appropriate but from the front the classical approaches were not very useful.
As a consequence we have developed anterior and antero-lateral approaches
which, when chosen wisely, permit a wide exposure of the front of the
pelvic bone - the ilio-inguinal and extended ilio-femoral approaches. A fuIl
anatomico-pathological and radiological study is an essential preparation
for any surgeon embarking on open operative treatment; it enables a judicious
choice of surgical approach to be made.
We shall include very little concerning conservative management. ROWE
and RIEUNAU (1971) have given complete accounts and it is to these authors
that the reader should refer for opinion on conservative treatment.
In support of the methods we advocate, some account of the results of
this active approach to treatment pursued from 1956 to 1971 will be given.
While we believe a lot of the work to be original, we have tried throughout
to recognise the names of those who have preceded us and who have intro-
duced terms and concepts of value. We apologise for any omissions.
The chapters describing the incidence of complications and the results
of surgical management have been condensed. In accordance with the advice
of our editor we have attempted to keep the book within acceptable dimen-
sions and have reduced the length of a few chapters especially with regard
to the treatment of old lesions.
In spite of personal efforts this book would not have been possible without
many coIlaborators to aIl of whom we are immensely grateful, especially
to lEAN BOCQUENTIN and FRANK GEMELIN who have defined the radiological
study of the normal acetabu1um; DANIELE VACHER who helped us in the
foIlow-up and computer analysis of the patients; and MICHELE ROSEC and
DANIELE DUMONT who performed valuable and essential secretarial help.
The analysis was made possible by the management of Le Centre M6dico-
chirurgical de la Porte de Choisy whom we acknowledge with pleasure.

E. LETOURNEL
R. lUDET
Editor's Preface

It is a privilege to have been entrusted with the preparation of the English

edition of this book. I have been aware of the authors' work for some
years and personal observation has inspired enormous respect for their experi-
ence and expertise in this field. Undoubtedly, the information they present
forms a unique collection.
As a practising orthopaedic surgeon, I feel bound to warn colleagues
not to approach the subject lightly. Even now, having translated every sen-
tence, I find aspects here and there difficult to comprehend. The authors
have lived with the work for years and this shows abundantly in their ability
to interpret radiographs and to operate. It is necessary to learn some new
terminology, not difficult in itself but requiring effort nevertheless; thereafter,
having grasped the c1assification and basis underlying the spectrum of frac-
tures, their interpretation from radiographs is more straightforward. Even
here, the average orthopaedic surgeon will be surprised how much effort
is necessary to appreciate the fractures in three dimensions. The operations
are logical but always of considerable magnitude. Undoubtedly, the anterior
approaches should be practised on a ca da ver. The numbers of fractured
acetabula likely to be encountered by one surgeon is going to be small
and practical experience hard to acquire. If open operation is to be encour-
aged, it is yet another procedure which should be centralised; after resuscita-
tion and treatment of other injuries, operation on the acetabulum is not
urgent (apart from reduction of a posterior dislocation); after a week, the
majority of patients can be transported. The authors themselves warn against
operating unless the necessary background study has been performed. Chapter
2 may be read to advantage after study of radiology and the c1assification
in Chapter 3.
A superficial appraisal of post-operative radiographs gives the impression
that the surgeon has scattered metal irresponsibly. In fact, when exposed
at operation, the application of the plates and screws is so obviously correct;
one of the most remarkable features is the immediate solidity obtained when
all goes to plan, even in the most complex fractures.
In the translation, I have tried to render the French presentation into
a style acceptable to English readers and yet preserve some of the original
flavour. Much of the French text is in the first person and sounds foreign
to us; nevertheless, while putting into the third person passive the authors'
recommended instructions and teaching, I have left in the first person their
discussion when this related to what they did in treating their patients or
when they debate on opinion.
It is remarkable how many terms cannot be translated directly. For exam-
pIe, the French caU the root of the superior pubic ramus, le corps (body)
x Editor's Preface

du pubis, while aur body of the pubis becomes fa farne quadrilatere (the
quadrilateral plate) du pubis.
I wish to thank VALERIE BARCLA y and ANN J OHN who typed the manuscript.
Finally, there are a number of features on the innominate bone of which
nomenclature may cause problems. A glossary of these is appended in the
ho pe that the defined meaning will aid the reader who decides to pursue
a study of the subject.

REGINALD A. ELSON
Contents

Glossary ...... . XXI

1 Surgical Anatomy
1.1 Columns of the Acetabulum
1.2 Posterior Column 1
1.3 Anterior Column . . . . . 2
1.3.1 Iliac Segment . . . . 2
1.3.2 Acetabu1ar Segment 3
1.3.3 Pubic Segment . . . 3
1.4 Structure of the Innominate Bone in Relation to Load-Bearing 4
1.5 Vascular Supp1y 4
1.5.1 Interna1 Surface 5
1.5.2 Externa1 Surface 5
1.5.3 Acetabu1um 6

2 Mechanics of Acetabular Fractures 7

2.1 Force Applied to Greater Trochanter in the Axis of the
Femoral Neck. . . . . . . . . . . . . 8
2.1.1 Neutral Abduction-Adduction . . . . . . . . . . . 8
2.1.2 Abduction and Adduction . . . . . . . . . . . . . 9
2.2 Force Applied to the Flexed Knee in the Axis of the Femoral Shaft 9
2.2.1 Hip Joint Flexed 90° . . . . . . . . . 10
2.2.2 Different Degrees of Hip Flexion 10
2.3 Force Applied to Foot with Knee Extended 10
2.3.1 Hip Flexed . . . . . . . . . . . . . 10
2.3.2 Hip Extended . . . . . . . . . . . 10
2.4 Force Applied to Lumbo-sacral Region 11
2.5 Comment . . . . . . . . . . . . . . . . . 11
2.6 Clinica1 Correlation . . . . . . . . . . . 11
2.6.1 Blow on Knee or Dashboard Injuries 11
2.6.2 Blow on Greater Trochanter 12
2.6.3 Blow Under Foot . . . . . 12
2.6.4 Blow on Sacro-iliac Region 12

3 Radiology of the Acetabulum . . . 13

3.1 Antero-posterior Radiograph of Pe1vis 15
3.2 Antero-posterior Radiograph of Acetabulum 15
XII Contents

3.2.1 Anterior Border of Acetabulum 15

3.2.2 Posterior Border of Acetabulum 15
3.2.3 Roof ... . 15
3.2.4 Teardrop .. . 15
3.2.5 Ilio-ischial Line 18
3.2.6 Pelvic Brim . . . 19
3.2.7 Other Radiological Features 19
3.3 Obturator-oblique Radiograph .. 22
3.3.1 Pelvic Brim . . . . . . . . . . 24
3.3.2 Posterior Border of Acetabulum 24
3.3.3 Obturator Foramen .. 24
3.3.4 Iliac Wing . . . . . . . . . . . . 24
3.3.5 Posterior Border of Ilium . . . . 25
3.3.6 Junction of Anterior and Posterior Columns 25
3.4 Iliac-oblique Radiograph 25
3.4.1 Posterior Border of Ilium 25
3.4.2 Outer Limit of Acetabulum 25
3.4.3 Iliac Wing . . . . . . . . . 25
3.4.4 Posterior Border of Acetabulum 25
3.4.5 Other Radiological Features 27
3.5 Other Techniques . . . . 27
3.5.1 Tomography .. . 27
3.5.2 Stereo-radiography 27

4 Diagnosis and Classification . 29

4.1 Radiology . . . . . . . . . . 29
4.2 Classification . . . . . . . . 30
4.2.1 Elementary Fractures 32
4.2.2 Associated Fractures 32
5 Posterior Wall Fractures 33
5.1 Typical Posterior Wall Fractures 35
5.1.1 Morphology . . . . 36
5.1.2 Radiology ... . 36
5.2 Postero-superior Fractures 37
5.2.1 Morphology . . . . 40
5.2.2 Radiology . . . . . 40
5.3 Postero-inferior Fractures 42
5.3.1 Morphology .. . 42
5.3.2 Radiology . . . . 43
5.4 Special Forms of Posterior Wall Fractures 43
5.4.1 Extended Posterior Wall Fractures .. 43
5.4.2 Massive Posterior Wall Fractures 43
5.4.3 Horizontal Extension of Fracture Line 43

6 Fractures of the Posterior Column .. 49

6.1 Typical Posterior Column Fractures 49
6.1.1 Morphology 49
6.1.2 Radiology 50
Contents XIII

6.2 Extended Posterior Colurnn Fractures 53

6.2.1 Morphology . . . . . . . . .. 53
6.2.2 Radiology . . . . . . . . . . . 54
6.3 Atypical Posterior Colurnn Fractures 54
6.3.1 EpiphysealInjury . . . . . . . 54
6.3.2 Other Associated Pelvic Ring Fractures 54
6.3.3 Paget's Disease . . . . . . . . . . . . 58
6.4 Transitional Posterior Colurnn Fractures 58
6.4.1 Morphology 58
6.4.2 Radiology 58

7 Anterior Wall Fractures 61

7.1 Morphology . . . . . 61
7.2 Radiology . . . . . . . 61
7.2.1 Antero-posterior View 62
7.2.2 Iliac-oblique View .. 64
7.2.3 Obturator-oblique View 64
7.3 Atypical Exarnples . . . . . . 64

8 Fractures of the Anterior Column 69

8.1 Morphology . . . . . . . 69
8.1.1 Very Low Fractures .. 69
8.1.2 Low Fractures . . . . . 69
8.1.3 Interrnediate Fractures 70
8.1.4 High Fractures .. 70
8.1.5 Atypical Exarnples . 71
8.2 Radiology . . . . . . . . . 71
8.2.1 Very Low Fractures 71
8.2.2 Low Fractures . . . 72
8.2.3 Interrnediate Fractures 72
8.2.4 High Fractures .. 73
8.2.5 Atypical Example 74

9 Pure Transverse Fractures 87

9.1 Morphology . . . . . . 87
9.1.1 Orientation of Fracture 87
9.1.2 Displacernent in Transverse Fractures 87
9.2 Radiology . . . . . . . . . . 90
9.2.1 Antero-posterior View . 90
9.2.2 Iliac-oblique View . . . 91
9.2.3 Obturator-oblique View 91
9.3 Atypical Cases .. 91

10 T-shaped Fractures 101

10.1 Morphology . . . 101
10.1.1 Transverse Cornponent 101
10.1.2 Stern Cornponent 102
10.1.3 Displacement . . . . . 102
XIV Contents

10.2 Radiology 102

10.2.1 Transverse Component 103
10.2.2 Stem Component · 103
10.3 Atypical Examples 104
10.3.1 Additional Vertical Fracture of Obturator Ring 104
10.3.2 Additional Fracture Line in Cotyloid Fossa 106
10.3.3 Association with an Anterior Hemitransverse Fracture 106

11 Associated Posterior Column and Posterior Wall Fractures · 117

11.1 Morphology . . . . . . . . . . . . . . · 117
11.1.1 Posterior Wall Component .. 117
11.1.2 Posterior Column Component 117
11.2 Radiology . . . . . . . . . . . 118
11.2.1 Antero-posterior View · 118
11.2.2 Obturator-oblique View 118
11.2.3 Iliac-oblique View · 118
11.3 Atypical Examples 118
11.4 Comment . . . . . 119

12 Associated Transverse and Posterior Wall Fractures 123

12.1 Posterior Dislocation 123
12.1.1 Morphology . 123
12.1.2 Radiology 124
12.1.3 Atypical Examples · 125
12.2 Central Dislocation 126
12.2.1 Morphology 126
12.2.2 Radiology 126
12.3 Comment 130

13 Associated Anterior and Posterior Hemitransverse Fractures 137

13.1 Morphology . . . . . . . . . . . . 137
13.1.1 Anterior Fracture . . . . . · 137
13.1.2 Posterior Column Fracture 138
13.2 Radiology . . . . . . . . . . . · 138
13.2.1 Antero-posterior View · 139
13.2.2 Iliac-oblique View . . . · 140
13.2.3 Obturator-oblique View 140
13.3 Atypical Examples 141
13.4 Radiological Differential Diagnosis 141

14 Associated Both-Column Fractures 151

14.1 Morphology . . . . . . . . . . . . 151
14.1.1 Posterior Column Components 152
14.1.2 Additional Posterior Components · 153
14.1.3 Anterior Column Component 154
14.1.4 Result of Both-Column Fracture · 155
Contents xv
14.1.5 Displacement of the Fragments and the Femoral Head 156
14.1.6 Atypica1 Examp1es . . . . . 156
14.1.7 The Key to Reconstruction 156
14.2 Radio10gy . . . . . . . . . . . 158
14.2.1 Antero-posterior View 158
14.2.2 Obturator-oblique View 160
14.2.3 Iliac-obJique View 161
14.3 Summary . . . . . . . . . . . . 162
14.4 AtypicaJ Examp1es . . . . . . 162
14.5 Differential Radio10gical Diagnosis 163

15 Transitional and Extra-articular Forms · 199

15.1 Transitiona1 Forms . .200
15.2 Extra-articu1ar Forms · 202

16 Associated Injuries .. · 205

16.1 Injury of the Femoral Head · 205
16.1.1 Macroscopic Injury · 205
16.1.2 VascuJar lnjury · 205
16.1.3 Mo1ecu1ar Injury · 205
16.2 Capsu1ar Injury .. . · 205
16.3 Vascular Injury . . . . .206
16.3.1 Femoral Head . .206
16.3.2 Acetabular Wall · 206
16.3.3 Pe1vic Vessels .206
16.3.4 Retro-peritoneaJ Haematoma · 206
16.4 Other Pelvic Injuries . . . . . . . . · 207
16.5 Urinary Tract Injury . . . . . . . . · 208
16.6 Other Ske1eta1 and Viscera1 Injuries · 208
16.7 Sciatic Nerve Injury . . . . . . . · 208

17 Distribution of the Clinica1 Series .209

17.1 Distribution According to Age . · 209
17.2 Distribution According to Sex . · 209
17.3 Distribution According to Time After Injury · 209

18 Clinical Presentation · 211

18.1 C1inica1 Findings · 211
18.1.1 Posterior Dis10cation · 211
18.1.2 Central Dis1ocation · 211
18.2 Early Comp1ications · 211
18.2.1 Traumatic Shock · 211
18.2.2 Retro-peritonea1 Haematoma · 212
18.2.3 Pre-operative Sciatic Nerve Injury · 212
18.2.4 More1-Lavalle Lesion . . . . . . . · 215
18.2.5 Intra-articu1ar Incarceration of Bone Fragments · 215
XVI Contents

18.3 Special Cases .217

18.3.1 Children · 217
18.3.2 Elderly Patients · 217
18.3.3 Pathological Fractures · 218

19 General Principles of Surgical Management · 221

19.1 Conservative Treatment · 221

19.1.l Indications . . . . · 221
19.1.2 Methods of Conservative Treatment .222
19.1.3 Results of Conservative Treatment .222
19.2 Problem of Surgica1 Access .. .222
19.2.1 C1assica1 Approaches . .224
19.3 Kocher-Langenbeck Approach .225
19.3.1 Technique .225
19.3.2 App1ication .229
19.3.3 Closure .. .230
19.3.4 Dangers · 230
19.3.5 Complications · 230
19.4 Ilio-femoral Approach · 232
19.4.1 Technique · 232
19.4.2 Application · 232
19.4.3 Closure .. · 233
19.4.4 Dangers · 233
19.4.5 Complications · 233
19.5 Ilio-inguinal Approach · 233
19.5.1 Technique · 233
19.5.2 Application · 237
19.5.3 Closure .. · 238
19.5.4 Dangers · 238
19.5.5 Complications · 238
19.6 Combined Anterior and Posterior Approaches .240
19.7 Extended Ilio-femoral Approach .240
19.7.1 Technique .240
19.7.2 Application · 243
19.7.3 Closure .. .244
19.7.4 Dangers and Complications .244
19.8 Summary of Use of Different Surgical Approaches .244

20 Early Treatment of Displaced Fractures .245

20.1 lustification for Operative Treatment · 245

20.2 Indications . . . . . . . . . . . .246
20.3 Pre-operative Care . . . . . . . . . . .246
20.4 Choice of Surgical Approach .247
20.4.1 Kocher-Langenbeck Approach · 247
20.4.2 Ilio-femora1 Approach .247
20.4.3 Ilio-inguina1 Approach . . . . .247
Contents XVII

20.5 Fracture Types with Uncertain Choice of Approach .247

20.5.1 Transverse Fractures .247
20.5.2 T-shaped Fractures .. .248
20.5.3 Both-Column Fractures .248
20.6 Operative Details . . . . . . . .248
20.6.1 Principles of Osteosynthesis .248
20.6.2 Special Instruments . . . . . .249
20.6.3 Implants for Osteosynthesis · 250
20.6.4 Method of Internal Fixation · 251
20.6.5 Reduction of Dislocation · 252
20.6.6 Reduction of Fracture · 253
20.7 Post-operative Care . . . . . . . · 253

21 Treatment of Specific Types of Fracture · 255

21.1 Posterior Wall Fractures . . . . . . · 255
21.1.1 Postero-superior Fractures · 256
21.1.2 Postero-inferior Fractures .256
21.1.3 Special Features · 256
21.2 Posterior Column Fractures · 256
21.2.1 Special Features · 257
21.3 Anterior Wall Fractures .. · 257
21.4 Anterior Column Fractures · 257
21.4.1 Middle and Low Fractures · 257
21.4.2 High Fractures .. · 258
21.4.3 Special Features · 258
21.5 Pure Transverse Fractures · 258
21.5.1 Special Features · 259
21.6 Associated Posterior Column and Posterior Wall Fractures · 259
21.7 Associated Transverse and Posterior Wall Fractures · 259
21.7.1 Special Features .260
21.8 T-shaped Fractures . . . . . . . . . . . . . . . . . . . .260
21.8.1 Special Features . . . . . . . . . . . . . . . . .260
21.9 Associated Anterior and Hemitransverse Posterior Fractures · 261
2l.10 Both-Column Fractures . . . . . . . . . . . . . . . . . . . . . .262
2l.10.1 Approach . . . . . . . . . . . . . . . . . . . . . . . . . .262
2l.l0.2 Reduction and Fixation Through Posterior Approach .263
21.l0.3 Reduction and Fixation Through Ilio-inguinal Approach .264
2l.10.4 Reduction Necessitating Both Approaches .266
2l.10.5 A Particular Both-Column Fracture . · 267
2l.11 Special Examples . . . . . . . . . . . . . . . . · 267
21.11.1 Incarcerated Intra-articular Fragments · 267
21.11.2 Bilateral Acetabular Fractures · 267
21.11.3 Fractures of Paralysed Hips . . . . · 267

22 Early Complications of Operative Treatment · 311

22.1 Death 311
22.2 Infection . . . . . . . . . . . . . . . . . . . 311
XVIII Contents

22.2.1 Analysis of Post-operative Infections · 311

22.2.2 Cause of Infection · 312
22.2.3 Prophylaxis · 312
22.2.4 Treatment · 313
22.3 Nerve Damage · 313
22.3.1 Imm"t:~diate Post-operative Sciatic Palsy · 313
22.3.2 Prognosis . . . . . . . . . . . . . . · 314
22.3.3 Delayed Sciatic Palsy . . . . . . . · 315
22.4 Secondary Displacement of Fracture Site · 315
22.5 Thrombo-embolism . . . . . . . . . . . . · 315

23 Late Complications of Operative Treatment · 317

23.1 Pseudarthrosis . . . . . . · 317
23.2 Cartilage Necrosis . . . . · 317
23.3 Avascular Bone Necrosis · 317
23.3.1 Etiology . . . . . · 318
23.3.2 Time of Presentation · 319
23.3.3 Clinical and Radiological Course · 319
23.3.4 Clinical Results · 319
23.4 Post-traumatic Osteoarthrosis .320
23.4.1 Osteophytes . . . . . . · 320
23.4.2 Osteoarthrosis . . . . . · 320
23.4.3 Analysis of Clinical Progress · 320
23.4.4 Treatment . . . . . . . . . . · 321
23.5 Para-articular Ectopic Bone Formation · 321
23.5.1 Clinical Results · 321
23.5.2 Etiology · 321

24 Anatomical Results of Operation Within Three Weeks of Injury . 323

24.1 Reduction of Femoral Head . . . . . . . . . . 323
24.2 Acetabular Reconstruction . . . . . . . . . . . 323
24.3 Reduction After Various Types of Fracture . 326

25 Clinical Results of Operation Within Three Weeks of Injury . 327

25.1 Assessment of Results · 327
25.1.1 Type of Fracture .327
25.1.2 Quality of Reduction .327
25.1.3 Age of Patient . . . . · 329
25.2 Radiological Results · 329
25.3 Late Clinical Results and Quality of Reduction · 330
25.3.1 Perfeet Reduction . · 330
25.3.2 Imperfect Reduction · 330
25.4 Summary of Results · 334
25.4.1 Early Results · 334
25.4.2 Late Results · 335
25.5 Conclusions 335
25.6 Comment · 335
Contents XIX

26 Surgieal Management More Than Three Weeks After Injury . 337

26.1 Aim of Surgery . . . . . . . 337
26.2 Prerequisites for Operation . 337
26.3 Specific Fracture Types . . . 337
26.3.1 Posterior Wall Fractures . 337
26.3.2 Posterior Co1umn Fractures . 338
26.3.3 Anterior Fractures . . . 338
26.3.4 Transverse Fractures . 338
26.3.5 T-shaped Fractures . . 338
26.3.6 Associated Anterior and Hemitransverse Fractures . 338
26.3.7 Associated Transverse and Posterior Co1umn Fractures . 339
26.3.8 Both-Co1umn Fractures . 339
26.3.9 Incarceration 339
26.4 Summary . . . . . . . . . . . . . 340

27 Reassessment of Patients Treated Before 1971 . 381

27.1 Recent Follow-up of Patients .381
27.1.1 Clinical Condition Very Good . . . . .381
27.1.2 Clinical Condition Good . . . . . . . . 381
27.1.3 Clinical Condition Intermediate or Poor . 381
27.2 Indications for Operative Treatment · 381
27.2.1 Total Incongruence . · 382
27.2.2 Partial Incongruence · 382
27.2.3 Apparent Congruence · 382
27.3 Operative Treatment 1971-1978 · 382
27.4 Conclusion . . . . . . . . . . . . · 383

28 Exercises in Radiographie Diagnosis · 385

Bibliography . · 423

Subject Index .427

Glossary

Acetabular notehes both anterior and posterior lips of acetablIlar margin present with
weil defined indentations in their mid-parts
Aeetabulo-obturator radiologicallandmark described in SeeL 3.2.1
line
An terior pillar thiekened area of iliae wing which supports gluteus medius tubercle
Anterior tubercle of tubcrcle located on margin of obturator foramen atjunetion of inferior
obturator foramen pubie ramus and ischial ramus
Gluteal surfaee extern al iliac fossa
Gluteus medius tubercle tubercle of iliae erest
Innominate bone used throughout text for os innominatum or pelvie bone
Interspinous noteh area of anterior border of innominate bone between anterior superior
and anterior inferior iliae spines
Ischio-pubic notch reeess atjunction ofbody ofisehium with root ofsuperior pubic
ramus
Marginal impaetion (Freneh: fraeture mixte) -the impaction and incarceration into the
underlying eaneellous bone of sm all osteochondral fragments from
the shattered margin ofthe acetabulum (further explanation on
page 35)
Obturator ring convenient description of the whole bone structure enclosing
the obturator foramen
Osteosynthcsis widely used and eonvenient term which embodies reduetion and
fixation offraeturcs
Pelvic brim refers to brim of true pelvis: an anatomically eomplex formation which
eould be variously called ilio-pectineal, innominate or (posteriorly)
areuate lines
Posterior tubercle of tubercle located on margin of obturator foramen at junction of body
obturator foramen of isehium and pubic ramus
Psoas gutter ilio-peetineal surface of innominate bone in wh ich the psoas lies at
its departure from the pelvis
Root of superior that part ofthe superior pubic ramus whieh contributes to the
pubie ramus acetabulum (in Freneh: body of the pubis)
Sciatic buttress eondensation of trabecular bone which related to the angle of the
greater sciatic foramen and formed by system described in Sect. 1.4
Sub-eotyloid groove groove under overhanging lip of postero-inferior aspect of inferior
horn of articular surface
Teardrop commonly used radiological feature which the French call (more
accurately ) a " U"
1 Surgical Anatomy

Rouviere (1940) has given us a particularly clear 1.1 Columns of the Acetabulum
description of the acetabulum wh ich we have in
no way altered. The fractures with which we are
At first sight the acetabulum appears to be con-
concerned comprise signiticant areas of the walls
tained within an arch. The limbs of the arch are
of the acetabulum together with the bony segments
posterior (or ilio-ischial), and anterior (or ilio-pu-
wh ich support them. In addition, the acetabulcu
bic). For a better understanding ofthe pathological
margin can be injured and fragmented but the
anatomy of the fractures, we must alter somewhat
pieces may be too small to warrant osteosynthesis.
this basic concept of the architecture. It is bett er
to regard the acetabulum as being contained within
It is common to distinguish between the anterior
the open arms of an inverted Y formed by a poste-
wall, posterior wall, and the superior wall or roof
rior column, the ilio-ischial component, and an
of the acetabulum, but for reasons which will be-
anterior column which is much longer and extends
come clear, we shall distinguish the postero-supe-
from the anterior end of the superior iliac crest
rior segment (which forms the bridge between the
to the pubic symphysis; the upper end of the poste-
roof and the posterior wall), and the postero-infe-
rior column is attached to the posterior aspect
rior segment (wh ich comprises the lower part of
of the anterior column, a little above its mid-Ievel
the posterior wall together with the posterior horn
(Fig. 1).
of the acetabular articular surface).

For the purposes of surgery, a clear understand-

ing of the underlying bone supporting the acetabu-
lum is more important than any descriptive anat-
omy of the socket itself: it is by a perfect recon-
struction of the foundation that an adequate osteo-
synthesis of the surface will be achieved. It is
equally important to learn the relationships of cer-
tain key anatomical landmarks, for the correct re-
alignment ofthese will restore the innominate bone
and enable us to fix the parts effectively. The in-
nominate bone is a complex and irregular struc-
tu re ; although it is difficult to learn, we cannot
over-emphasise the necessity for detailed anatomi-
cal clarity. For example, until relatively recently,
the integrity of the concavity of the iliac wing was
not regarded as particularly important to restore ;
this is not so. We now appreciate how important
is the seemingly small detail that in a patient Iying
recumbent, the anterior superior iliac spine should
lie perpendicularly above the posterior nutrient
foramen of the iliac wing.
1.2 Posterior Column
We have called this the ilio-ischial column in order
to indicate its components: above, iliac, and below,
ischia!. It is thick, the surfaces are easily recog-
nised, and it offers solid material for internal fixa-
tion. It is triangular in section, and presents inter-
nal, posterior and antero-Iateral surfaces.
(a) The internal surface comprises the quadri-
lateral area on the inner aspect of the body of
the ischium. This is continuous at the middle part
of its posterior margin with the inner surface of
the spine of the ischium, being orientated here
obliquely internally and posteriorly.
(b) The posterior surface comprises (from above
downwards) an area forming part of the posterior
2 Surgical Anatomy

A B c

Fig. I A-D. Columns of the acetabulum (dried bone). A Lateral aspect, B obturator-oblique
view, C iliac-obliquc view, 0 scheme of endopclvic aspecl. White, Anterior column; Red,
Posterior column; BllIc. Tie beam uniting inferior cnds of the columns (ischio-pubic ramus)

wall of the acetabulum, the subcotyloid groove 1.3 Anterior Column

in which runs the tendon of obturator externus,
and the ischial tuberosity. Note that the spine of
This, the ilio-pubic column, extends from the ante-
the ischium is situated at a slightly higher level
rior end of the iliac crest to the pubic symphysis.
than the inferior margin of the posterior horn of
In general form it is concave both anteriorly and
the acetabular articular surface.
medially, its arc being bridged by the inguinal liga-
(e) The antero-lateral surlace includes above, the ment. One can distinguish from above to below
posterior part of the acetabular surface. This is three segments: iliac, acetabular, and pubic.
bounded by the projecting inferior horn which
forms the edge of the sub-eotyloid groove for the
obturator externus tendon. Below, the antero- 1.3.1 Iliac Segment
lateral surface is formed by the body of the is-
chium. This forms the anterior part of the iliac wing and
presents two surfaces.
The posterior border of the ilio-ischial column
is formed above by the ilium, and below by the (a) The pelvic surface is coneave from above
greater and lesser sciatic foramina separated by to below and extends as far as the ilio-peetineal
the spine of the isehium. line.
Anterior COlll11111
(b) The externa! SlIr!l/('(' is markedly roughened
and forms a large anterior part of the gluteal sur-
face ofthe ilium inc\uding the anterior pillar which
extends upwards to the gluteus medius tuberc\e.
Its anterior border is marked by the ,mterior
superior and anterior inferior iliac spines separated
by the interspinous notch. The inferior portion
of the anterior inferior iliac spine is immediately
adjacent to the acetabular margin.
1.3.2 Acetabular Segment
This is triangular prismatic in shape and presents
three surfaces.
(a) The postcyo-!atera! surläce supports the ante-
rior articular segment of the acetabulum and the
front part ofthe cotyloid fossa. Note that the ante-
rior horn is loeated about I cm above the level
of the upper border of the obturator foramen.
(b) The interna! surlace is generally eoncave and
is formed by the anterior part of the quadrilateral
surface. It extends as far forward as the obturator
canal and is limited superiorly and anteriorly by
the ilio-pectineal line.
(c) The antero-superior sur/ace prescnts from
above downwards, the gutter of the ilio-psoas ten-
don just below the anterior inferior iliac spine,
and the ilio-pectineal eminence. At the level of
the acetabulum the bone of this surface forms the
anterior lamella of the anterior wall of the acetabu-
Ium. It is limited internally by the ilio-peetineal
line which is alway s interrupted in fraetures of
the anterior wall of the aeetabulum. It may be
useful to remember that the inferior limit of the
ilio-pectineal eminence is situated at a lower level
than the anterior horn of the acetabulum (Fig. 2).
1.3.3 Pubic Segment
This is the superior pubic ra mus and constitutes
the slenderest piece of the column as weil as its
most forward and medial part. It also is triangular
in section and presents three surfaces.
(a) The antero-superior surjace affords insertion
for the peetineus musc\e. It is distinctly spiral in
configuration and in order to apply a plate for
internal fixation, it is always neeessary to twist
this to fit the shape of the segment. The area is
3
Anterior inferior
iliac spine Outline of anterior wall
of acetabulum
I
,
I
I
I
1
I
\
\
I
/
t
\
\
\.- ..... _--,.,"'~
Fig. 2. Landmarks 01" thc middlc segment 01" thc antcrior colllmll
bounded posteriorly by the attaehment of the pee-
tineal part of the inguinal ligament and forms here
part of the anatomical brim of the true pelvis;
this terminates at the pubie spine.
(b) The interna! surll/ce is generally coneave pos-
teriorly and above, it faees almost medially. Fol-
lowing its curve, it comes to be continuous with
thc pelvic surface of the body of the pubis which
looks postero-superiorly.
(c) The inferior sur/ace forms the bony roof of
the obturator foramen and faces mainly inferiorly
and increasingly anteriorly as it approaches the
body of the pubis.
The antcrior column is eomplicated and the
main guide when assessing its continuity is the
ilio-pectineal line which constitutes an unbroken
arc and whieh appears to reinforce the antero-
superior part of the acetabulum; as stated already,
fractures of this line always indicate a fraeture
of the anterior column.
Both anterior and posterior columns unite a lit-
tle above the level of the mid-point of thc anterior
column and form an angle of approximately 60°.
Within this angle is located the acetabulum itself.
The summit of the angle is filled with a fillet of
compact bone which constitutes the roof of the
acetabulum and forms the keystone of the arch.
The anatomica! roof corresponds to a segment of
articular surface which subtends to an angle of
45° to 60° and is located between the anterior infe-
rior iliae spine and the ilio-isehial notch of the
acetabular margin (not always c\early visible) pos-
4 Surgical Anatomy
tcriorly. Medially. the anatomical roof does not
rcach thc edge of thc cotyloid fossa; on the con-
trary. it is joincd to the superior border of thc
cotyloid fossa by a distinct plate of compact bone
which is often easily visible in a coronal section
of the area.
Joincd together in the manner described. thc
two columns are linked with the auricul,n surface
of thc sacro-iliac joint by the sciatic buttress de-
scribcd by ROUVIE:RE (1940).
1.4 Structure of the Innominate Bone
in Relation to Load-Bearing
The shape and internal structure of the innominate
bone is related to thc forces which must be
transferred from thc head of the femur to the verte-
bral column.
Rouvn':RE (1940) describes how these forces pass
firstly through thick condensed areas of bone
which arise tangentially from the auricular surface
of the ilium (i.e. its articular surface at the sacro-
iliac joint) and pass adjacent to the upper part
of thc greatcr sciatic noteh. He calls the particular
condcnsation of bone in this region the sciatic hut-
tress (Fig. 3).
From this point two systems of bony trabeculae
arise: the first is relevant to thc erect post ure and
comprises elements related to the postero-superior
part of the acetabulum and which continue thence
into the anterior column; and the second is of
functional significance during sitting. in wh ich the
bony thickenings pass alm ost vertically as far as
Fig. 3. Internal structure of thc innominate bone
(CAMPA:->ACCI. 1967). Trabeculac of thc anterior
column: J sacro-acetabular. 4 sacro-pubic.
5 ilio-acetabular. Trabeculac of the postcrior
column: 2 sacro-acetahular. 3 sacro-ischial.
Thcrc is overlap bctween these groups
thc ischial tuberosity (LATARGET. ROUVIERE.
DELMAs. 1940) and involve essentially the posterior
column.
CAMPANACCI (1967). discussing fractures of the
pclvis, prcscnted a bcautiful analysis of our under-
standing of the architecture of the innominate
bone. It confirmcd thc above account and cor-
responded exactly with our radiological studies of
the various laminae and thickenings of the bone.
He distinguished three fundamental trabecular sys-
tems within the bone structure: sacro-acetabular,
sacro-pubic, and sacro-ischial. We can relate the
trabecular architecture in a logical fashion to the
anterior and posterior columns (Fig. 3).
The posterior column contains the lower or is-
chial members of thc sacro-acetabular group of
thickenings, together with the sacro-ischial com-
ponents. The anterior column corresponds to the
remaining upper members of the sacro-acetabular
group and the sacro-pubic components, which join
another system in the ilium- the ilio-acetabular
group.
The massive thickening of bone trabeculae in
the region of the sciatic buttress explains why this
region is only exceptionally involved in fractUfes
of the acetabulum; fractures involving either col-
umn are confined below this particularly strong
area.
1.5 Vascular Supply
The blood supply is rich. largely on account of
the broad arcas of muscular attachmcnt. A study
made in 1933 by J. LAPART was repeated in 1960
 VascuhH Supply
Exlernal anlerior ~tiI?"-;I-_-'<-~-I- lIio · lumbar
iliac artery artery
A B
Fig. 4A, B. Vascu!ar supply of the innominatc bone. A Interna! aspect, B external aspeet
a nd \96\ by pu pils of Professor SALMON (L. LOUIS
and M. BERGOUIN). It is from these authors that
we have extracted the following short account
(Fig.4).
l.5.1 Internal Surface
The largest nutrient foramina, one artery of which
we are most frequently obliged to divide when
using the ilio-inguinal approach to fractures of the
acetabulum, is situated in the iliac fossa I cm in
front of the auricular surface of the sacro-iliac
joint and I cm above the ilio-pectineal line. It re-
ceives a branch of the ilio-lumbar artery.
Other smaller nutrient foramina are located:
- below the ilio-pectinealline in front of the greater
sciatic noteh, and also in the roof of the obtura-
tor canal where branches of the obturator artery
supply the bone;
- on the internal surface of the ramus of the is-
chi um, supplied by the internal pudendal artery;
- above the anterior inferior iliac spine and along
the iliac crest, by branches of the circumflex
iliac artery which anastomose with branches of
the fourth lumbar artery ;
- and posteriorly, by branches of the ilio-Iumbar
artery which penetrate the rough surface behind
the auricular articular surface of the sacro-iliac
joint.
5
Artery of Ihe roof
01 Ihe acelabulum
(follows reflecled head 01
reclus lemoris)
Pubic branch
01 obluralor artery
(LouIS ami BI':R(;OUIN. ItJoO)
1.5.2 External Surface
There is one particularly large nutrient foramen
in the middle of the gluteal area of the wing of
the ilium, just in front of the anterior gluteal line.
It receives a branch of the superior glutcal artery.
Other supplies are:
- multiple nutrient vcssels around the margins of
the acetabulum wh ich form a complete vascular
circ1e, from the obturator artery, the inferior
gluteal artery and other local anastomotic
branches including the artery of the roof. a con-
stant branch of the superior gluteal artery;
- the cotyloid fossa itself wh ich is perforated by
a number of small vessels from the acetabular
branch of the obturator artery;
- the body of the pu bis wh ich is supplied by
branches of the obturator artery;
- and the region of the sciatic buttress which re-
ceives several branches of the superior gluteal
artery.
The intra-osseous distribution of the arterial
supply has also been studied by the same authors .
From the periphery of the innominate bone. small
arteries are directed towards the central areas.
They are approximately parallel and form a pali-
sade which can be observed on arteriography.
The two principal nutricnt arteries entering thc
gluteal surface of the ilium and thc surfacc of the
6 Surgical Anatomy
iliac fossa respectively are located at approximately
the same level. They divide in the spongy bone
into many vessels which anastomose and form a
star-shaped configuration.
1.5.3 Acetabu1um
Around the periphery of the acetabulum there ex-
ists a vascular palisade of radiating vessels (the
peri-acetabular circle) , while at the level of the
cotyloid fossa branches from the obturator artery
develop another star-shaped group of anasto-
moses.
We have noticed, when treating fractures of the
acetabulum involving the posterior wall, often as-
sociated with a dislocation of the head of the fe-
mur, that we do not meet branches of the peri-
acetabular circle. For practical purposes it seems
that in all fractures involving the posterior part
of the acetabulum, these arteries are tom and sub-
sequently thrombose. On the contrary, when there
is a central dislocation of the hip and the posterior
wall of the acetabulum remains intact, detachment
of the soft tissues of the area is accompanied by
considerable bleeding from these vessels.
Despite the rich blood supply with so many
anastomoses, extensive perioste al stripping of frac-
ture fragments can lead to avascular necrosis and
must be restricted to aminimum.
2 Mechanies of Acetabular Fractures

Fractures of the acetabulum occur as a result of F' F'

force acting between this part and the head of
the femur, the last link of a chain of transmission
from the greater trochanter, the knee or the foot.
Alternatively, a blow on the back of the pelvis
can have the same action.
In general, there are four points of application
for the energy necessary to produce a fracture of
the acetabulum : the greater trochanter, the knee
(when this joint is in the tlexed post ure), the foot
(the knee being extended), and the posterior aspect
of the pelvis. Before considering each of these,
certain general aspects should be understood.
The resultant force acting at any time between
the head and the acetabulum may be regarded Fig.5. Analysis of force acting on the acetabulum through
as passing through the centre of the head which the greater trochanter
is, for practical purposes, identical with that of
the cent re of curvature of the acetabulum.
It is seen in Fig. 5 that a force F applied at
a point A on the femur may be resolved into two of the bone. However, the interposition between
components: F is that component of force trans- the two articular surfaces of double compliant car-
mitted to the acetabulum and is represented by tilaginous layers considerably modifies the trans-
a projection from the point of application of force mission of the forces . Of the various theoretical
Fand passing through the centre of curvature of analyses, we favour the following:
the head. The line of this force passes through Again referring to Fig. 5, it is seen that the force
the point of impact / on the acetabulum. The other F is applied to the acetabulum at point / and is
component, f, is perpendicular to Fand has the attenuated by the compound cartilage. lt remains
effect of tending to rotate the upper shaft of the maximal at point / but becomes distributed over
femur in the direction shown. a circular zone seen shaded in section. The magni-
In all cases where a fracture has occurred, the tude of the force at each point of the circular
direction of force F must have been near to that area may be represented vectorially by the arrows
of the neck axis AC, therefore F must have ap- on either sidc of Fand these form with respect
proached it in magnitude; correspondingly, force to magnitude an elliptical area. The sum of these
f must have been negligible. imaginary forces amounts to F. The line of frac-
If the hip were a perfect ball and socket joint, ture and subsequent displacement of the fragments
the two opposing surfaces meeting exactly and be- can be related to the force pattern displayed in
ing made of homogeneous material, the forces this diagram. The position and magnitude of the
applied to the femur and transmitted by the head force pattern is determined at the moment of im-
to the acetabulum would tend to bc distributed pact by the attitude of the femur and the direction,
in some weil defined way to the whole surface magnitude and point of application of the force
8 Mechanics of Acetabular Fractures

(bl 25° extern al rotat ion

anterior column fracture \
\
\
+ (c) Maximum 50° external rotation
\ - Anterior wall fracture
\ t
I
\
(al Neutral rotation
- anterior column and "
posterior hemi-transverse fracture "
,,
,,

(d) 20° internal rotat ion

-> Transverse or \
both-column fractures \
"
--
\ \
" \ I

--
'\ \
--- ~~

(el Maximum 50° internal ro tation_ Fig. 6. Horizontal section

- Transverse and posterior through hip joint showing
wall fracture sites of application of force
as infiuenced by internal and
externa l rotation

itself. The different strain-rate sensitivities of the
tissues involved ren der an exact analysis of the
situation very difficult, but c1early the rate of appli-
cation of the force is highly significant.
2.1 Force Applied to the Greater
Trochanter in the Axis of the Femoral
Neck
The point of impact in the acetabulum is deter-
mined by the degree of abduction or rotation of
the femur. For practical purposes, flexion of the
femur plays little part.
2.1.1 Neutral Abduction-Adduction
Throughout the range of external/internal rotation
ofthe hip the site of impact lies on a line of latitude
of 30° to 40°, the axis of which is determined by
the inclination of the neck of the femur. Referring
to Fig. 6:
(a) In neutral rotation, because of the normal
anteversion of the femoral neck, a blow over the
trochanter is transmitted approximately to the co-
tyloid border of the anterior horn of the acetabular
articular surface. The diagram shows that the frac-
ture will involve the cent re of the acetabulum and
the anterior column.
(b) In external rotation, when this approaches
about 25°, the impact operates against the bony
buttress afforded by the anterior column and in-
volves this part predominantly.
(c) If the external rotation is even more extreme
at 40° to 50°, the force is exerted entirely on the
anterior wall of the acetabulum.
(d) With internal rotation of varying degrees ,
the central zone of the acetabulum is involved and
the anterior column progressively less so. At about
20° of internal rotation, the zone of impact is to
some extent shared by both columns. The lesion
produced will be variable and, depending upon
the exact description of the force, it may comprise
a simple transverse fracture of the acetabulum,
a T-shaped fracture, or in extreme cases a fracture
of both columns.
(e) In extreme internal rotation approaching 50°,
the point of impact involves the junction between
the posterior articular horn and the cotyloid fossa.
This area is supported by the posterior column
which is likely to be fractured and is always asso-
ciated with a complete or incomp1ete transverse
component.
Force Applied to the Flexed Knee in the Axis of the Femoral Shaft 9

Fj
1"''''-
:
,,
® ,
(c) 50° abduction of nec,k, ,,
,,
CD
(c) 30° abductlon of neck - ,
,
,
, , , ,//
.
I .
,
.,
I
I I
I
,
I ,
\ I
\

: 20° adduction of I
I

I
(b) 30° maximum ~rl rll ".-t,;"n l : Iowerl imb \
\
of neck or 30° Neutral abduction of '

.,
\
\, ' .... ........
abducl ion of lower li mb lowerlimb , ,
\
,,
,
\

Fig. 7. Coronal section through hip joint in 20° internal rotation

,
\ ,I
"', ... \-...~\
showing sites of application offorce as influenced by abduction- '''-:.::. . >{
adduction (d) 25° adduclion
-+ poslerior dislocation

(a) Neulral abduclion and Iraclure 01 lip

-+ posl erior dislocalion
01 poslerio r wall
Fig. 8. Horizontal section through the hip joint showing force [>
and fraclure of poslerior
acting through the knee wall

2.1.2 Abduction and Adduction
For any given degree of rotation, the main point
ofimpact in the acetabulum will be altered accord-
ing to any abduction or adduction posture at the
moment of injury.
Ifwe take as an example 20° of internal rotation,
the main line of impact corresponding to different
degrees of abduction will approximate to a coronal
section through the centre of the hip joint. Refer-
ring to Fig. 7:
(a) In neutral abduction-adduction the centre
of the area of impact occurs at the inner margin
of the roof of the acetabulum. A transverse frac-
ture at this level or, alternatively, a T-shaped frac-
ture or a both-column fracture can all result. The
force considered he re results from a blow over
the trochanter but a similar pattern would prevail
if the force were transferred along the axis of the
shaft of the femur, the hip being abducted to 60°
at the moment of impact.
(b) With significant degrees of adduction, the
impact affects increasingly the roof of the acetabu-
lum and a transverse fracture through this part
is the result.
(c) In abduction, a much more common state
of affairs, the main point of impact shifts progres-
sively inferiorly leading to transverse fractures be-
low the articular margin of the roof and becoming
progressively horizontally disposed.
In summary, it can be seen that any combination
of rotation and abduction-adduction can occur
and correspondingly, an infinite number of frac-
ture patterns can result. Nevertheless, each can
be rationalised according to the above analysis.
2.2 Force Applied to the Flexed Knee
in the Axis of the Femoral Shaft
In principle, if the hip is flexed at 90° and a blow
is sustained on the knee, provided the neck of
the femur is not fractured, the acetabulum will
break if the force is sufficient. In Fig. 8 the co m-
ponent of the fracture F' which is directed towards
the centre of rotation of the femoral head is re-
sponsible for the direction and magnitude of the
zone of impact sustained by the acetabular surface.
The degree of rotation of the femur does not play
a significant part but combinations of flexion-ex-
tension and abduction-adduction together produce
another range of possibilities.
10 Mechanics of Acetabular Fractures

2.2.1 Hip Joint Flexed 90°

(bl 115 0 Ilexion
/ ;' - Iracture 01 posterior horn
From Fig. 9a it ean be seen that the main impaet
reeeived by the aeetabulum is in the horizontal
plane eorresponding to an are, part of a great
eirc1e. Referring also to Fig. 8:
" . (cl 60 0 flexion
(a) In neutral abduetion, the posterior wall of - posterior-superior Iracl ure
the aeetabulum reeeives the impaet and a pure 01poslerior wall
fraeture of this part may result.
Fig. 9. External aspect of hip showing sites of application of
(b) In maximum abduetion approaehing 50°, it force acting through the knee with the hip flexed
is the postero-medial segment whieh is damaged
resulting in posterior eolumn fraetures often asso-
eiated with transverse fraetures.
posterior disloeation of the hip, may be assoeiated
(e) In about 15° abduetion most of the foree is with a transverse fraeture.
exerted on the posterior eolumn.
As in previous examples, the speetrum of possi-
In these situations with the hip flexed at 90°,
bilities eombining abduction-adduetion and flex-
it is the posterior eolumn whieh is overwhelmingly
ion-extension is infinite but at the same time
involved, with the possible partieipation of the
capable of definition and predietable in effect.
floor of the aeetabulum in maximum abduetion;
the anterior eolumn ean be involved only seeondar-
ily by a transverse-type fraeture line.
(d) If the femur is addueted, the main site of
impaet approaehes thc posterior margin of the ace- 2.3 Force Applied to Foot with Knee
tabulum and it is under these eireumstanees that Extended
posterior disloeation with or without fraetures of
the margin of the aeetabulum is produeed.
2.3.1 Hip Flexed
These are the cireumstances operating when, dur-
ing a frontal collision in a car, foree is transmitted
2.2.2 Different Dcgrees of Hip Flexion through the brake pedal to the foot and thenee
through the extended knee and the hip joint. If
Referring to Fig. 9: the hip is neutral or tending to lie in abduction
at the time, the postero-superior zone of the aee-
(a) With inereasing flexion (Fig. 9b). the lowest
tabulum is involved and the upper wall fracture
part ofthe posterior wall beeomes exposed to foree
is eommonly assoeiated with a transverse eom-
transmitted along the shaft of the femur. In ex-
ponent. The pattern is similar of eourse to that
treme flexion. the lowest part of the posterior wall
prevailing when the blow is reeeived on the flexed
ean be fraetured. the line extending to the upper
knee. with the hip also in flexion.
pole of the isehial tuberosity.
(b) As flexion of thc hip beeomes less than 90°
(Fig. 9c). it is the postcro-superior segment of the 2.3.2 Hip Extended
acetabulum that is increasingly prejudiced. This is
precisely the situation seen in dashboard injuries This oeeurs typieally when a subjeet falling from
when the passenger in a car having his legs erossed a height lands on his feet in a vertieal posture.
is flung forward at the moment of collision, strik- If the limb is a little abdueted. the main point
ing his knee. A disloeation with or without fraeture of impaet with respeet to the aeetabulum is on
of the aeetabular margin may be produced. Alter- the inner segment of the roof; the degree of rota-
natively. if the hip is abducted and in less than tion does not influenee the result, a trans-teetal
90° flexion, a posterior fracture, perhaps with transverse fraeture.
Clinical Correlation 11

2.4 Force Applied to Lumbo-sacral YI

Region

If in the stooping posture the hip is flexed at 90°

and a blow is received on the back, it is easy
to see that the posterior wall of the acetabulum
can be fractured. Similarly, with different degrees
of flexion precisely the same range of fractures
can be seen as applied to circumstances in which
the force is introduced along the femur. The injury
has occurred in miners stooping at the time of
a roof fall but in general it is rare; we have only
one example, a man stooping at the bottom of
a trench who was injured by a fall of stone.

2.5 Comment
From the above considerations two points should
be emphasised: Firstly, the force which pro duces
a fracture of the acetabulum will be responsible
for the degree and direction of displacement of
the fragments and also for the direction of a dislo-
cation of the head of the femur, should this occur.
Secondly, we have explained how, from a de-
scription of the force, the site of potential fracture
of the acetabulum can be deduced. It does not
matter how this force is transmitted to the acetabu-
lum, as is demonstrated in Fig. 10. In position 1
(flexion 90°, abduction 0° and internal rotation
20°) the angle of abduction with respect to the
neck of the femur is at 45°. In position 2 (flexion
90°, abduction 45°, internal rotation 0°) the angle
of abduction with respect to the shaft of the femur
approximates to 45°. It matters not whether the
force is applied to the trochanter in position 1 or
to the knee in position 2; the site of impact with
reference to the acetabulum will be similar in both
cases.
Fig. 10. Diagram showing how the same force can act on the
acetabulum through the knee when the hip is abducted or
through the greater trochanter with the hip in neutral abduction
2.6.1 Blow on Knee or Dashboard
Injuries
Posterior wall fractures of all types 42
Posterior column fractures 2
Transverse fractures 3
T-shaped fractures 1
Associated transverse and posterior
fractures 18
Somewhat uncertain with respect to our theoret-
ical analysis are the three transverse fractures and
the T -shaped fracture. These were associated re-
spectively with accidents to car occupants in two
cases, one motor cycle victim and one simple fall.

2.6 Clinical Correlation Table 1

Activity at time of accident Number

In our series of 469 fractures of the acetabulum,
we know the cause of the accident in 459 cases Car occupant 329
(Table 1). From Table 2 it is seen that it has been Motor cyc\ist 27
impossible, despite careful enquiry, to establish the Pedestrian 63
site of impact in more than 50% of the accidents Fall from a height 20
Simple fall 13
analysed. The descriptions refer to cases in which Other ca uses 7
the site of impact and mechanism of injury was Unknown 10
fairly certain, and could be related to the type
Total 469
of fracture which resulted.
12 Mechanics of Acetabular Fractures

Tablc 2

Activity at time Site of impact

of accident
Dashboard injury Blowon Blowon Blowon Not
or blow on knee trochanter foot back obvious

Car occupant 62 23 9 235

Molor cyclist 3 12 12
Pedeslrian 58 5
Fall from a height 13 2 5
Simple fall 10 2
Other causes 3" 3
Total 66 116 12 3 262

" Includes 2 crush injuries.

We feel that the configurations of the fractures
are explicable only if the blow occurred on the
knee while the hip was approximately fully
extended and being in a small degree of abduction.
We believe that this posture and the site of blow
apply in each of the accidents mentioned.
2.6.2 Blow on Greater Trochanter
Pure posterior fractures
Posterior column fractures
Transverse fractures
Anterior wall or anterior column frac-
tures
T -shaped fractures
Associated transverse and posterior
fractures
Associated posterior column and
posterior wall fractures
Associated anterior and posterior
hemitransverse fractures
Both-column fractures
It is remarkable that 91 of these 116 fractures
were both-column fractures, pure anterior frac-
tures, or mixed anterior and posterior hemitrans-
verse fractures. The only difficult examples to ex-
plain mechanically comprise the three posterior wall
fractures and the three posterior column fractures.
Even in full internal rotation, it is difficult to ex-
plain how such a posteriorly directed force could
be transmitted ; the accidents concerned involved
two car occupants, two motor cyclists and two
pedestrians. The possibility of misinterpreting the
site of impact must of course be recognised.
3 2.6.3 Blow Under Foot
3
6 Various types of posterior fracture 8
Associated transverse and posterior
20 wall fractures 3
9 Epiphyseal displacement in a posterior
column fracture
3
All of these fractures corresponded to our me-
chanical theory.
13
58
2.6.4 Blow on Sacro-iliac Region
A blow on the back and two transverse crushing
injuries resulted in the three transverse fractures.
These are explicable if the hip was in some abduc-
tion and slight flexion at the time of injury.
3 Radiology of the Acetabulum
The reader studying this ehapter is advised to have
at hand a dried innominate bone or pelvis. In order
to interpret aeeurately the radiologieal features of
a fraetured aeetabulum, it is neeessary to pursue
in a diseiplined fashion an orderly study of eaeh
standard view, then to put these together in three
dimensions, eomparing when neeessary with the
appearanee of the opposite side, and finally to
relate the findings to the radiologieal features of
the eolumns of the aeetabulum. Eaeh landmark
must be followed in turn, and serutinised for possi-
ble traversing fraeture lines; it is important to
note whether at the site of sueh a break, there
is frank displaeement or not. Treatment should
not be eommeneed until a full understanding is
aehieved and, most important, during the eonse-
quent well-planned operation the surgeon will
know what to expeet and not have to try to analyse
the fraeture during the proeedure. A systematie
and detailed study of the pre-operative radiographs
with the unashamed aid of a dried bone will enable
this goal to be aehieved. As experienee grows, more
rapid appraisal beeomes possible.
During our studies we believe that we have
assessed and tried to use most of the speeial radio-
graphs whieh have been advoeated. The orienta-
tion of the aeetabulum is sueh that the usual an-
tero-posterior and lateral radiographie views do
not give suffieient information and we have at-
tempted to find others whieh would reetify the
defieit.
The elementary faet should be reealled that a
radiologieal line is produeed by rays tangential
to a bony surfaee or erossing a border. A bone
surfaee yields the same radiologieal line provided
the angle of ineidenee of the ray remains eonstant.
Provided the slight inevitable variation in the posi-
tion of a patient at the time of radiologieal exami-
nation is within reasonable limits, the appearanee
of most surfaees will be eonstant. It is possible
to define a zone of a surfaee whieh will offer a
eonstant radiologieal outline (Fig. 16 b). Outside
the limits of this zone, the eonfiguration of the
adjaeent surfaees will offer a markedly alte red ra-
diologieal image. Nevertheless, it ean be diffieult
to find pairs of films whieh ean be aeeurately su-
perimposed, and yet on easual inspeetion, appear
similar.
We have eome to the firm eonclusion that in
order to study the masses of bone whieh limit
and enclose the aeetabulum and whieh may be
involved in fraetures thereof, four radiographie
views suffiee:
- a standard antero-posterior view of the whole
pelvis;
- a standard antero-posterior view eentred on the
affeeted hip; and
- two oblique views taken aeeurately at 45°.
It is unusual to need other teehniques like tomo-
graphy or stereo-radiography.
The antero-posterior view of the pelvis must be
taken on a large plate (36 x 43 em) and is eentred
on the pubie symphysis. The antero-posterior view
of the injured hip is eentred on the head of the
femur and must include the whole of the innomi-
nate bone.
Of all the possible oblique views, the two at
45° to the eoronal plane a're by far the best. The
obturator foramen is approximately perpendieular
to the plane of the posterior two-thirds of the iliae
wing. One or the other is seen in profile on eaeh
oblique view.
The obturator-oblique view is very similar to
that deseribed by W ALER (1955a and whieh approxi-
mated to that deseribed by TEUFEL (1930). It ap-
proaehes that used by D' AUBIGNE (1968) ealled the
postero-internal view. These authors used a beam
eoineident at 40° (and direeted superiorly at 10°
14
in the case of WALER). Oblique views have received
many names, astate which has produced confu-
sion.
One of the oblique views exposes perfectly the
entire surface of the iliac wing and projects the
inner and outer surfaces of the bony ring enclosing
the obturator foramen (the obturator ring). We
have called this the iliac-oblique view. The other
displays perfectly the outline of the obturator ring
around the obturator foramen, while showing in
section the iliac wing and superimposing the ante-
rior and posterior iliac spines; this we have called
th obturator-oblique view.
The two views are obtained by rolling the injured
patient carefully from one side to the other and
supporting hirn during exposure of the films on
suitable cushions. The transverse axis of the pelvis,
which must in each case be at 45° relative to the
X-ray table, is easy to assess.
For the iliac-oblique view, it is the uninjured
hip which is elevated, the injured part resting on
the table. The centre beam of the vertically dis-
posed tube aims at a point one finger-breadth be-
low the level of the anterior superior iliac spine
of the injured side and at the centre of a trans verse
line from the spine to the mid-line.
For the obturator-oblique view, the injured hip
is raised and the centre be am aims at a point one
finger-breadth below and medial to the antero-
su,perior iliac spine of this side.
It is essential that in each case the whole of
the iliac bone should be seen both vertically and
transversely.
Radiology of the Acetabulum
Fig. H. Antero-posterior radio graph of
pelvis showing T-shaped fracture on
the right and associated T -shaped and
posterior wall fracture on the left
In the obturator-oblique view, the perfectly ex-
posed picture superimposes accurately the anterior
and posterior iliac spines, the iliac wing is seen
in section as narrow as possible, and correspond-
ingly the outline of the obturator foramen is as
large as possible, being parallel with the plane of
the film. If the iliac wing appears widened, it is
due to the rotation of the patient being insufficient;
unless attempts are made to correct this, accurate
appraisal will be difficult.
In a correctly positioned iliac-oblique view, it
is the iliac wing which is seen widely spread out
and the bony outline of the obturator ring as thin
as possible in section, the obturator foramen being
invisible.
The two oblique views can be taken in the vast
majority of cases, even following recent injuries,
without re course to general anaesthesia. Should
the presence of other injuries make radiography
difficult, there are two possibilities: the X-ray
examination can be conducted und er general
anaesthesia, or, without moving the patient, the
tube can be tilted to 45°, the injured person resting
in neutral decubitus. Unfortunately the latter tech-
nique results in varying distortions according to
the build of the patient, this applying especially
to the iliac bone. We advise that following a study
of these distorted views, which will give some idea
of the fracture configurations, the radiographs
should be repeated at the time of operation under
anaesthesia in the approved fashion.
Antero-posterior Radiograph of Acetabulum
3.1 Antero-posterior Radiograph
of Pelvis
This must always be taken and may reveal:
- the uncommon bilateral acetabular fracture
(Fig. 11) wh ich has occurred only four times in
469 cases;
another fracture of the pe1vic ring independent
of the fractured acetabulum and passing through
perhaps the obturator ring, the iliac wing or
even the sacrum;
dislocation through one or more of the joints
of the pelvic ring.
3.2 Antero-posterior Radiograph
of Acetabulum
Because of the more laterally disposed central ray
there is some modification in this view (Fig. 12 A)
compared with the previous one. The difference
however is slight and perhaps one could dispense
with it.
Six fundamental radiological landmarks of the
acetabulum are seen in this view:
- borders of the anterior and posterior walls of
the acetabulum;
- roof;
- teardrop;
- ilio-ischial line;
- pelvic inlet (brim of the true pelvis); the in-
nominate line.
3.2.1 Anterior Border of Acetabulum
This is visible only on films of good quality. It
begins at the external border of the roof but it
is distinctly more horizontally disposed than the
posterior border and is superimposed on the
shadow of the posterior wall. Its mid-point is
marked by a change of direction at a notch of
characteristic angle, be10w which it descends fur-
ther almost parallel to the outline of the posterior
border. Finally, the line follows a curved path to
become continuous with the superior border of
the radiological obturator foramen. We call the
whole line, the acetabulo-obturator line (Figs. 13 A,
14 A and 14 B). It is seen to comprise three segments,
separated by two distinct changes of curvature:
from above downwards and medially these are the
anterior border ofthe acetabulum, the juction of the
15
superior pubic ramus with the ilium, and then the
anterior lip of the bony roof of the obturator canal
which becomes continuous with the anterior bor-
der of the obturator foramen. The inferior margin
of the anterior horn of the acetabular articular
surface is located at the mid-point of the middle
segment.
3.2.2 Posterior Border of Acetabulum
Clearly visible as an approximately straight line,
this is continuous inferiorly with the beginning of
the outline of the posterior horn of the articular
surface. Here the line forms a sharp curve convex
inferiorly wh ich terminates medially and overlies
the outline of the upper margin of the ischial tuber-
osity (Fig. 12).
3.2.3 Roof
The zone of articular surface which forms the ra-
diological outline of the roof the c1assical "dome"
occupies a segment approximately 3-4 mm broad
(Figs.14B and 14D). The exact appearance on a
radiograph depends on the alignment of the pelvis
relative to the beam. Obviously it is produced by
the ray tangential to this surface area. If the pelvis
is tilted forwards, the radiological roof will re-
present a more posterior segment than that wh ich
typical, and similarly, if the pelvis is tilted back-
wards it will show a more anterior segment.
The dense sharp margin when traced inferiorly
pursues a bayonet course which corresponds to
the cotyloid fossa and then forms the externallimb
of the radiological teardrop.
Since the outline of the roof represents such
a narrow segment of bone, this tiny portion gives
no indication of the overall integrity of the whole
roof. This must be assessed from the continuities
of the anterior and posterior borders to which it
must remain attached.
3.2.4 Teardrop
From Fig. 14 it can be seen that the outline of
the radiological teardrop is produced by a U-
shaped continuous surface of bone; the lower bor-
der is located in the ischio-pubic notch which at
the same time forms the superior border of the
obturator foramen at its highest point.
16 Radiology of the Acetabulum

Fig. 12. Antero-posterior radiograph (A) and diagram (a) show-

ing radiological landmarks : 1 posterior bord er of acetabulum,
2 anterior border of acetabulum, 3 roof, 4 teardrop, 5 ilio-ischial
line, 6 brim of tme pelvis

.,..._) /1-2--
/ rj_......
c.~ /
\ / .... "";,.-
Superior pole i :
of ischia! I
tuberosity Posterior horn "Tangent to surface projecting
of artlcular and supporting posterior horn
surface
A a

Fig. 13A, B. Source of acetabulo-obturator line. A Oudine on

antero-posterior radiograph of dried bone (lead foil has been
applied to the anterior part of the articular cartilage and the
oudine ofthe anterior horn is indicated by the arrow C), B dried
A bone showing lead marker on the acetabulo-obturator line
Antero-posterior Radiograph of Acetabulum 17

A B

~: :
Anterior inferior
iliac spine
Seclor of roof
seen on antero-
posterior
radiograph

Roof of obturator canal

D E

Fig. 14A-E. The teardrop. A Radiograph of dried bone (lead limbs of the teardrop formed by tangential incidence at sites
wire accentuates the outline of the teardrop and the acetabulo- not in the same coronal plane, D possible sources of the tear-
obtura tor line, and lead foil outlines the roof), B corresponding drop, E zone of bone responsible for the internal limb of the
dried bone. C-E Diagrams. C Horizontal section showing the teardrop

The extern al limb of the teardrop is tangential
to part of the surface of the outer aspect of the
cotyloid fossa; the curvature is regular and slightly
concave externally. It is the posterior moiety of
the cotyloid fossa surface which becomes incident
to the X-ray beam producing the image.
The internal limb of the teardrop is formed by
the outer wall of the obturator canal which merges
posteriorly with the outline of the quadrilateral
surface of the ischium. Horizontally, the internal
surface is slightly concave which contrasts with
the concave extern al surface of the cotyloid fossa
(Fig. 14C).
If the dry specimen is carefully examined it will
be seen that the zones of the surfaces responsible
for the two limbs of the teardrop do not lie in
the same coronal plane and for this reason, in
different subjects, marked variations in the relative
disposition of the two limbs can result - in some
instances they can actually cross. When the two
limbs merge a true teardrop appearance is seen.
In most instances it is however a radiologieal" U",
usually a more exact deseription than teardrop.
As stated above, the bottom of the teardrop
is the acetabular noteh whieh forms the superior
border of the obturator foramen. It has a variable
18
Fig. ISA-O. Source of ilio-ischialline. A Dried bone with main
source of the line removed from the q uadrilateral surface. R-
o Antero-posterior radiographs of dried bone. 8 I1io-ischial
line crossing the teardrop, C ilio-ischial line absent in a speci-
men prepared as in Fig. rSA, 0 ilio-ischialline reappears when
the area of cortical bone removed in Fig. 15 A is rep1aced with
lead foil
relationship with the acetabulo-obturator line and
is projected in the neighbourhood of its middle
segment. Depending on the exact location of the
central ray, the lowest part of the U passes some-
times above or sometimes below the line; this is
easily explained when it is appreciated that the
two elements are not in the same coronal plane.
The shape of the radiological U varies consider-
ably from even a slight modification of the orienta-
tion. Thus internal rotation of that side of the
pelvis results in a U produced by the anterior
moiety of the cotyloid fossa and the extern al wall
of the obturator canal. At this level the bone is
thicker and the resulting U is gene rally larger at
its base; further, its internallimb is often shorter.
3.2.5 Ilio-ischial Line
This was described by DUVERNAY-PARENT and
in our opinion has a fundamental importance
which has not been recognised sufficiently in the
past.
The line is a result of the incidence of the X-ray
beam tangent across a segment of the quadrilateral
surface of the ischium (Fig. 15). Its anterior limit
Radiology of the Acetabulum
coincides with the posterior border of the obtura-
tor foramen and its posterior part lies a finger-
breadth in front of the tip of the ischial spine;
superiorly it ends 1 cm below the top of the greater
sciatic notch but the inferior limit is always diffi-
cult to locate precisely because it is superimposed
on the external border of the obturator foramen.
The line usually begins above in common with
the arcuate line (the iliac segment of the ilio-pecti-
nealline) with which it appears to blend. Occasion-
ally however the two can be seen as separate en-
tities being separated by a clear space on the radio-
graph. Traced downwards it pursues a straight or
more usually slightly curved course and terminates
as the outer border of the obturator foramen. On
the way it is superimposed on, or crosses, the te ar-
drop. The exact relationship between these two,
ofwhich we shall see the importance later, depends
again on the orientation and individual shape of
the pelvis as weIl as its relation to the X-ray beam
(Fig. 15B).
The respective sources of the teardrop and the
ilio-ischialline are distinct entities although some-
times radiographically superimposed. The relation-
ship of these landmarks assists in the exact location
of certain fractures of the acetabulum.
Antero-posterior Radiograph of Acetabulum
R _ __
B c
3.2.6 Pelvic Brim
Radiologically, the line indicating the pelvic brim
(i.e. brim of the true pelvis) does not correspond
throughout with the arcuate line, the anatomical
boundary. Between the superior border of the
symphysis pubis and the beginning of the ilio-is-
chialline the radiological pelvic brim and the ana-
tomical pelvic brim correspond exactly; the seg-
ment constitutes about the anterior three-quarters
of the brim of the true pelvis as seen on the radio-
graph.
A little before reaching the posterior quarter,
the radiological pe1vic brim is formed by a surface
1-2 cm below the arcuate line and which corre-
sponds roughly to the lower half of the internal
face of the sciatic buttress and then to the internal
part of the roof of the greater sciatic notch which
is related to the glute al vessels (Fig. 16).
19
D
The radiological outline of the arcuate line itself
would extend to the projection of the anterior sur-
face of the second sacral vertebra.
3.2.7 Other Radiological Features
(a) The posterior border of the ilium. This is not
visible (Fig. 17 a 1) except where it constitutes the
most internal part of the superior border of the
greater sciatic notch which shows below the ar cu-
ate line (Fig. 17 a 3). The ischial spine is sometimes
visible a little above the teardrop, between the ilio-
ischialline and the pelvic brim (Fig. 17 a 2).
(b) The articular surface (Fig. 17 a 4). A c1ear
indication of the breadth of the acetabular surface
at the level of the roof is given because it corre-
sponds exactly to the lamina of compact bone
which supports it in this region. The posterior horn
20 Radiology of the Acetabulum

Fig. 16A-C. Souree of radiologie al pelvie brim. whieh differs

in its posterior part from the anatomieal pelvie brim (areuate
line). A Antero-posterior radiograph of pelvis with lead wire
applied to the anatomieal pelvie brim. B dried bone on whieh
(he zone of quadrilateral surfaee whieh is the souree of the
ilio-isehial line has been exeised and where distinet triangular
surfaees havc been covered with lead foil in order to outline Wthin this zone.
eompletely the posterior part of (he radiologieal pelvie brim. anatomical and
radiological pelvic
C Diagram. explaining B brims cmrespond Lead wire marker
exactly along pelvic brim

B
Antero-posterior Radiograph of Aeetabulum 21

Fig. 17. Antero-posterior view. A Radio-

graph of dry speeimen in whieh as many
as possible of the linear radiologieal
landmarks have been aceentuated with
lead wire. The iliae spines. the ilio-pectin-
eal eminenee and tbe articular surfaees
have been covered with thin lead sbeet.
a diagram

/
Posterior inferior
Iliac spine
(jj)
//--------
![@ ,
lIio-pectineal
Anterior superior emlnence
iliac spine
Antenor inferior
iliac spine
-_ .. -- \\~
\"
"--
l(
"
~
Acelabulo-obturator li ne
Tangent to projecting
surface supporting
a 6~ine

is outlined by the posterior border and inferiorly
by the medially directed curve with which it is
continuous. The anterior horn, narrow and slen-
der, descends to a level about a finger-breadth
above the outline of the posterior horn and stops
at the mid-point of the middle segment of the ace-
tabulo-obturator line (see above).
(e) The spine of the pubis. The line produeed
by the roof of the obturator eanal is usually visible
(Fig. 17 a 5); the surface of bone at the medial end
of this line eorresponds to the eondensation of
bone supporting the pubic spine inferiorly but the
spine itself is poorly seen, if at all. Laterally, the
roof of the obturator canal appears to be contin-
uous with the acetabulo-obturator line.
(d) The ilio-pectineal eminence. Although not vis-
ible in the antero-posterior radiograph, its site
should be known (Fig. 17).
(e) Inferior border of the ischio-pubic ramus. This
is simply and anatomically displayed (Fig. 17 a 6).
(f) Iliac wing. A thiekening, the anterior pillar,
forms the main support of the iliae wing and passes
from the roof of the aeetabulum to a point at
the junetion of the anterior and middle third of
the crest (Fig. 17 a 7). The highest part of this pil-
lar, whieh forms the gluteus medius tubercle, is
not the most external point of the convexity of
the erest seen on the antero-posterior radiograph.
The latter arises from the wing, anterior and infe-
rior to the gluteus medius tubercle.
22 Radiology of the Acetabulum

A B

\
Supra-acetabular surfac':J
(site 01 spur slgn when (
Iractured and junction 01 I
anterior and posterior \ Fig. 18A-D. Obturator-oblique view. A Standard radiograph
columns) (perhaps centered slightly too low but with tip of coccyx above
centre of head), a diagram of radiological lines to be sought,
B radiological outlines marked on dried bone with lead wire,
b dia gram, C dried bone with external landmarks of the iliac
wing outlined with lead wire (see text), D dried bone with source
\ of the inner radiological outline of the iliac wing marked with
a \ lead wire

3.3 Obturator-oblique Radiograph pelvic brim (the fundamentalline of the anterior

When taken perfect1y, this view shows the tip of
the coccyx approximately above the centre of the
cotyloid fossa (Fig. 18). The following features
should be studied:
column);
certain elements of the articular surface espe-
ciaUy the posterior border ;
- obturator foramen and surrounding ring of
bone;
- iliac wing as seen in seetion.
Ohturator-ohlique Radiograph 23

i '\
I . \
. \ '

{/ \\ ~\ Projectlon 01 Internalillac lossa

Gluteus medius tubercle "-<." " I (1 on Fig 180)
~, \\ .

Posterior superior iliac spine

"'.
'-J:.'~ \\ \ The anatomlcal pelvlc brlm
IS In dotted line when It dillers In
. \ ;~ \ \ \ position Irom radiologlcal outllne
Anterior pillar 01 ihac wing r ,,' ~''J.,. ...'
(1 on Fig. 18C)
Gluteus maximus tubercle ::-x1 \
Projection 01 extern al iliac lossa
~,. ~.\\. \.

,~
" ~--
L~D_ _ _ __
.-
Projection 01 ala 01 sacrum
Short segment 01 anatomlcal pelvic brlm
(2 on Fig, 18C)
Anterior superior ihac spine i~' Projection 01 iliac wing immediately
above pelvic brim
Exfernal surtace 01 sciatic buttress ~i'
-4::1~---Anterlor inlerior iliac spine
(3 on Fig. 18C) ,
,"",,;-.3I!k"-- External margin 01 psoas gutter
Rool 01 acetabulum
Retro-acetabular surtace - - - - t - f l /

Projection 01 anterior articular surlace

superimposed on anterior Hp
01 acetabulum ,---\

' '. /
" f - : b i : spine

7
Projectlon 01 anterior part 01 \', ,": Projection 01 wall supporting
the Ischlo publc notch " / publc spine

Projection 01 surtace wh ich supports the', "" ../

tip 01 the postenor horn 01 the ....... , ___ . _,.>- --- R.OOI 01 obturator canal
articular surtace
Postenor border 01 obturator canal
Site 01 posterior border 01 innominate bone Anterior border 01 obturator canal
which is not visible in this view
b

c o
24
3.3.1 Pelvic Brim
In the obturator-oblique view the pelvic brim does
not appear as regular in outline as in the antero-
posterior view. It is seen as a line composed of
several segments (Fig. 18 B). It corresponds to the
ilio-pectineal line from the angle of the pubis as
far laterally as a point situated a little above the
roof of the acetabulum at the level of the antero-
inferior iliac spine; this first segment is perfectly
clear and well defined. It then continues as a short
segment measuring 3-4 cm (Fig. 18 b, points B, C)
relating to the internal margin of the ilium tangen-
tial with respect to the X-ray beam, just above the
pelvic brim (Fig. 18 D ] and Sect. 3.3.4). Finally the
line changes direction to become continuous with
the outline of the incidence on the wing of the first
sacral vertebra, making an obtuse angle with the
brim. Between this terminal portion of the radio-
logical pelvic brim and the internallimit of the iliac
fossa (B, C segment on Fig. 18 b) is a further short
segment ab out 1 cm long, which breaks the smooth
curvature twice and corresponds to the anatomical
arcuate or innominate line (Fig. 18b, points C,D).
For practical purposes one must remember that
this exact description of the composition of the
radiological pelvic brim will not always apply, be-
cause of changes of orientation and projection.
In some instances, the outline may appear as a
perfectly regular curve but this will be the case
only if the rotation of the pelvis is a little below
45°.
Between the pelvic brim and the projection of
the articular surface ofthe acetabulum a somewhat
dense vertically disposed line is visible. It corre-
sponds to the psoas gutter. It is slightly curved,
being concave externally, and the point where it
rejoins the radiological pelvic brim marks the
termination ofthe projection due to the anatomical
pelvic brim (Fig. l8B, b).
3.3.2 Posterior Border of Acetabulum
This is easily visible in its entirety delineating the
outer aspect of the posterior horn and the posterior
wall of the acetabulum.
A study, in which a lead marker is applied to
the articular surface, proves that the image which
appears below the posterior horn is formed by
Radiology of the Acetabulum
the outline of the wall which supports the latter
part and forms also the upper wall of the sub-
cotyloid groove.
3.3.3 Obturator Foramen
The outline is complete and the symphyseal surface
of the opposite pubis to the side being examined
is superimposed thereon. The line we have de-
scribed previously on the antero-posterior radio-
graph, formed in its outer part by the roof of
the obturator canal and on its inner part by the
condensation of bone supporting the pubic spine,
is seen as if extending from the superior border
of the obturator foramen. The whole bony frame
of the obturator foramen (the obturator ring) is
practically undistorted in this projection.
3.3.4 Iliac Wing
There are several vertically disposed outlines, often
superimposed, being projected from various sur-
faces (Fig. 18 C, D). The outer limit (Fig. 18 b, C 1)
of the wing is produced by the beam tangential
to the pillar of bone which extends from the tuber-
cle of the iliac crest (in French: the gluteus medius
tubercle) to the roof of the acetabulum; it describes
a smooth curve concave externally. (This bony
thickening in the iliac wing we shall refer to as
the anterior pillar.) Below, it is continuous with
a second curve convex externally and formed by
the upper outer segment of the wall of the acetabu-
lum posteriorly. It terminates at a point corre-
sponding to the lower margin of the upper third
of the articular surface. The exact point will corre-
spond to the degree of pelvic tilt relative to the
X-ray beam of incidence, appearing higher or
lower correspondingly. Similarly if the degree of
rotation of the pelvis is less than 45°, the iliac
wing appears to terminate externally at the outer
border of the acetabulum, level with the roof.
Above, the outer border protrudes where it meets
the outline of the tubercle of the iliac crest.
The internal surface of the iliac fossa projects
a line apparently continuous with the arcuate line;
it is seen on a dried bone that it is produced by
the deepest part of the internal iliac fossa
(Fig. 18 D 1).
Between the concavities of these two lines, which
although approaching each other never actually
cross, there exists a third line, almost vertical,
Iliac-oblique Radiograph
which corresponds to the most concave part of
the outer (gluteal) surface of the iliac wing
(Fig. 18 C 2). The location of this line on the dried
specimen is seen to coincide alm ost exactly with
the outline of the segment of bone producing the
image of the inner limit of the iliac wing. Note
that the outer limit of the iliac wing, as seen on
this view, is produced by the pillar supporting the
gluteus medius tuberc1e of the crest (Fig. 18 b, C 1)
and lies much more anteriorly.
In summary, the shadow of section of the iliac
wing is marked by three principallines. These are:
(a) the extern al limit which corresponds to the
anterior pillar of bone supporting the iliac crest;
(b) the internallimit wh ich appears to be a pro-
longation of the pelvic brim and corresponds to
the most concave part of the iliac fossa; and
(c) an intermediate line with respect to the exter-
nal and internal limits, tangential to them or cut-
ting them, and which represents the most concave
part of the projection considered here of the gluteal
surface.
3.3.5 Posterior Border of Ilium
The outline is convex externally in its upper two-
thirds and becomes concave in its lower third. The
upper portion is produced by the hindmost part
of the iliac crest (the postero-superior iliac spine
being the most laterally projecting point) and then
by a line tangential to the thickest posterior part
of the posterior gluteal line (the gluteus maximus
tuberc1e). Below, it merges with the outline of the
iliac wing just above the roof of the acetabulum
(Fig. 12 a, 3). The size of its outline depends upon
the degree of rotation of the pelvis at the time
of radiography. It can disappear of the rotation is
insufficient.
3.3.6 Junction of Anterior and
Posterior Columns
This area, which may be disrupted in certain frac-
ture types, is seen as a line just above the roof
in this view (Fig. 18a).
Note that (1) only the upper part of the anterior
border of the acetabulum is visible because, below
its notch, the outline is superimposed on the
shadow of the anterior wall seen in section, and
(2) the anterior wall, seen largely in section, termi-
25
nates about 1 cm above the upper limit of the
obturator foramen. The verticalline which appears
to continue the outline inferiorly and reaches the
upper limit of the obturator foramen is the floor
of the cotyloid fossa (Fig. 18 b).
3.4 Iliac-oblique Radiograph
On this view (Fig. 19) the following features are
displayed:
- posterior border of the iliac bone;
- anterior border of the acetabulum;
- iliac wing.
3.4.1 Posterior Border of Ilium
This is strictly anatomical in outline and easy to
define.
3.4.2 Outer Limit of Acetabulum
An approximately straight line is produced in its
upper half by the anterior border of the acetabu-
lum, and in its lower half by rays tangential to
the superior ramus of the pubis. The anterior horn
of the articular surface of the acetabulum extends
to a level a little below the junction of these two
segments (Fig. 19a, b).
3.4.3 Iliac Wing
The complete profile of the iliac wing is displayed
together with both anterior iliac spines separated
by the interspinous notch, behind which there is
a slightly more dense area of bone extending from
the roof of the acetabulum to the crest - the ante-
rior pillar. The whole iliac crest is seen.
3.4.4 Posterior Border of Acetabulum
This appears regularly concave externally and me-
dial to the outline of the anterior border. It termi-
nates at a distinct bony projection formed by the
posterior horn of the articular surface which is
supported by a short curved section, concave in-
fero-Iaterally; the latter is the supporting wall of
the posterior horn and runs adjacent to the outline
of the pubic spine.
26 Radiology of the Acetabulum

Pelvic brim (invisible

on this view) 'y ....... -.
Anterior /
superior /
iliac spine /
Projection of posterior lip of i Projection of floor of
obturator canal Anterior Inferior
Iliac spine
,( cotyloid fossa
ProJection of Internal margin
root of superior Roof of obturator canal ;::J~\",~'r---"., of posterior wall of
pubic ramus \ / .. ' acetabulum
\ I
\ I
\
,, \
\
"
"\
, I
,{
Outline of ischio-pubic ramus Outline of pubic
a seen in section b symphysis

Fig. 19 A-D. lliac-oblique view. A Standard radiograph. a dia- and the two dense Iines relating to it and emanating from
gram of radiologieal outlines 10 be sought. B radiologieal out- the pubis. D dried bone as in C with lead wires in situ. The
lines marked with lead wire. b diagram. C Radiograph of dried more lateral lead wire is the inner branch of the teardrop
bone with lead wire marking the roof of the obturator canal
Other Techniques
c
3.4.5 Other Radiological Features
The following features should be observed:
(a) The roof of the obturator canal appears as
a line concave supero-externally and usually dis-
tinguishable as being more acutely concave than
the outline of the posterior articular horn to which
it is adjacent and roughly parallel (Fig. 19 A, C).
The line relates to two further dense lines emanat-
ing from the pubis. The upper (or inner) of these
is the internal surface of the superior pubic ramus;
the lower or external is from the anterior surface
of the superior pubic ramus - it terminates below
at the pubic spine, but is continued upwardly by
the outline of the anterior surface of the roof of
the pubis (Fig. 19 A, C).
(b) The inner limit of the acetabulum is marked
in its lower part by two lines, roughly concentric,
the upper and outer being the internal border of
the posterior wall, and the lower and inner being
the cotyloid fossa (Fig. 19B, C).
(c) The outer limit of the lower part of the whole
radiological outline is formed by the ischia 1 tuber-
osity.
27
(d) The ischio-pubic ramus appears within the
outline of the body of the ischium as a weil delin-
eated "hanging drop" (Fig. 19 B).
(e) The pelvic brim is never visible on this view.
It is useful to know that it is located about a
finger-breadth higher than the angle formed by
the greater sciatic notch (Fig. 19 B).
(f) The seetion of the roof seen on this oblique
view must be interpreted in the knowledge that.
in comparison with the antero-posterior radio-
graph. its articular section is at 45°. Anterior or
posterior tilting of the pelvis during radiography
will cause this segment to displace forwards or
backwards.
3.5 Other Techniques
3.5.1 Tomography
This has proved useful occasionally for the precise
location of incarcerated fragments of bone. In cases
seen some time after injury it has been superior
to plane radiographs in the assessment of fracture
union before considering any active operative
procedure.
3.5.2 Stereo-radiography
We have found the technique difficult and it does
not contribute to the exact understanding afforded
by good-quality simple radiographs.
4 Diagnosis and Classification
Before surgical intervention in a fractured acetabu-
lum can be accepted as a means of treatment, accu-
rate diagnosis based on radiology is essential. As
in other conditions, classification aids accurate un-
derstanding of these sometimes complex fractures.
Recognition of the existence of a fracture does
not in general present a great difficulty although
a vertical crack in the coronal plane or in the
anterior wall of the acetabulum may not be so
easy to confirm. Once a fracture is recognised its
anatomico-pathological type should be defined
with precision, together with an assessment of dis-
placement of the fracture fragments. It is on this
appraisal that the fundamental decision with re-
gard to choice of operative approach will be made.
4.1 Radiology
Radiological magnification and other dis torsions
must be taken into account. Enlargement is more
significant for the anterior structures of the pelvis
when the views are taken with the patient lying
supine. It must be remembered that the fracture
seen on the radio graph is the projection of a linear
displacement. This displacement can have any di-
rection and the imaginary line which joins two
points formerly contiguous and forming the same
anatomical structure will, in our three standard
views, have very different appearances. When a
fragment rotates on a vertical axis with respect
to the X-ray beam, its appearance in the antero-
posterior view approximates increasingly towards
that which it would normally project in one or
the other oblique view.
These simple observations need to be kept in
mind and their conscious appreciation will contrib-
ute enormously to a disciplined understanding of
the standard views recommended. A knowledge
of the classification provides the background
which facilitates understanding.
In radiographs showing the post-operative ap-
pearances, plates and screws used for internal fixa-
tion often appear very large. This is in part due
to simple radiographie magnification of the im-
plants and gives a false appearance, but addition-
ally, the area of projection of the innominate bone
on a radio graph is relatively less magnified espe-
cially in the obturator-oblique view, and these two
factors combine to enhance the false impression
that the method of osteosynthesis is disproportion-
ately gross. These facts can be proved simply by
placing a Shermann plate on a dried bone and
observing the radiographie appearance thereof.
The linear image of a structure is the result of
its presenting a surface tangential to the X-ray
beam, for example, the ilio-ischialline seen in the
antero-posterior view of the acetabulum. An im-
age so produced will appear only in that single
view: the appearance modified considerably or
completely disappears once a sufficient rotation
of the part represented has occurred. Further, a
constant and therefore a comparable appearance
is preserved only if the displacement remains paral-
lel to its original orientation and thus perpendicu-
lar to the X-ray beam. A fracture line cannot be
assumed to be undisplaced unless this is confirmed
in at least two of the views; the image of a displace-
ment may be invisible in the antero-posterior view
but considerable in an oblique view (Fig. 21 A).
Comparably, a maximum displacement on one
oblique may appear undisplaced on the other
oblique as a result of the rotation through the
90° difference between these views. On the antero-
posterior view, such a displacement will appear
moderate (Fig. 21 B).
30 Diagnosis and Classifieation

A B C
~

~
~

Antero-posterior

a ~ lIiac-oblique

b
Ob"'''tm~btq", ~
c .,50"
,

Fig. 20A-C. Comparison of main radiologieal outlines as seen a diagram. B iliac-oblique radiograph. b diagram. C obturator-
in the three standard vicws. A Antcro-posterior radiograph. oblique radiograph. c diagram

4.2 Classification CAUCHOIX and TRUCHET (1951) subscribed to this

For a long time the classical typing of fractures
of the acetabulum led to two broad categories:
- central dislocation; and
- posterior dislocation of the hip with a fracture
of the acetabulum.
basic classification. However, these authors feit
that it did not encompass all aspects and they
were obliged to recognise the existence of interme-
diary forms:
- fractures of the posterior wall of the acetabulum
associated with a central dislocation (this group
Classification 31

Table 3

Antero-posterior view Iliac-oblique view Obturator-oblique view

Landmarks Brim of true pelvis ++ Anterior border acetabulum ++ Pelvic brim ++

of anterior
column
Anterior border ± Anterior border iliac wing ++ Anterior part 01' obturator ++
and crest ring
Teardrop and rclationships + Iliac wing ++
with ilio-ischial line

Landmarks Posterior border + Quadrilateral surface of + Posterior bord er ++

01' posterior of acetabulum ischium of acctabulum
llio-ischial
column
line
Ilio-ischial line ++ Posterior border of ++ Posterior part of ++
innominate bone obturator ring

Roof Superior segment Similar Similar

++ Landmark especially weil displayed: + Landmark usually weil seen : ± Landmark may not be seen.

corresponds exactly with our fracture complex

which associates a transverse and a posterior
element with central dislocation); and
~
AI trans-acetabular fractures of the pelvis with
~; posterior dislocation (again, this necessitates an
association between basic fracture types, namely
A' AzAI a transverse element with a posterior wall frac-
A Antero-posterior ihac -obliqu e
ture).
We believe that this distinction between a central
dislocation of the hip and a posterior fracture-dis-
location is too crude and must be abandoned, if
only for one reason: a consideration of the mecha-
nisms whereby a fracture of the acetabulum is pro-
duced .
There is no doubt that these fractures result from
a force acting between the femoral head and the
lIiac-oblique
ß acetabulum itself. The force can be transmitted
from the knee or the foot or alternatively from
the pelvis onto the femoral head as a result of
a blow on the back. These forces can drive the
femoral head into any aspect of the acetabulum
producing a central or a posterior dislocation at
any level and c\early, the number of fractures and
dislocations which can be produced is infinite.
Many of these are much more complicated than
, the crude classification would suggest but can be
", ,, analysed on basic mechanical principles.
To say that an injury ofthe acetabulum is simply
iOSo/,
__ ~~~~ ___ J_ ~ a central dislocation and to leave it at that is totally
Ä.B' inadequate if a serious attempt to red uce the frac-
Antero-poste rlor lliac-obllque

Fig. 21 A-C. Diagrams of fracture-dislocation. A No displace- one oblique view may not be apparent on the other. C Displace-
ment is seen on the ante ro-posterior view but marked displa ce- ment along an axis 45 ° to the horizontal may be apparent
ment on the iliac-oblique view . ß Marked displacement on on the antero-posterior view but absent on one oblique view
32 Diagnosis and Classification

ture accurately is envisaged. Almost without excep- information on which this book is based is derived
tion, American, English and German authors have from 469 of the early cases of the series, of which
used this crude distinction and we cannot accept 415 underwent operative treatment. We propose
their arguments. the division of these fractures into two large groups
CREYSSEL and SCHNEPP (1961) have tried to cate- (elementary fractures and associated fractures),
gorise fractures using the above broad division, each of which will be broken down in the manner
and distinguishing principal and accessory fracture shown.
lines. We do not agree with this approach for it
seems that all fracture lines traversing the acetabu-
lum are of similar significance; while certain frac- 4.2.1 Elementary Fractures
ture complexes are commoner because of the
modes of injury responsible, until now, no one These comprise fractures in which apart or all
has proved that any particular zone of the acetabu- of a recognisable element of the acetabular ar-
lum is more prone to injury for local mechanical chitecture has been detached. We include with
reasons. Further, their classification used the term these, by virtue of its purity, the trans verse frac-
" trans-acetabular" to describe trans verse fractures ture. There are five elementary forms:
alone. We reject this concept, for by definition, - fractures of the posterior wall of the acetabu-
all fractures traversing the acetabulum must be lum;
trans-acetabular. - fractures of the posterior column;
Since 1960 our own classification of fractures - fractures of the an terior wall of the acetabulum;
of the acetabulum has undergone progressively a - fractures of the anterior column;
number of modifications. We readily recognise a - trans verse fractures.
number of fractures already described elsewhere
and include these in our classification based on
what we regard as the fundamental grouping of 4.2.2 Associated Fractures
lesions of the two columns which support the ace-
tabulum, not taking into account the direction of These include at least two of the elementary forms
dis placement ofthe femoral head. The latter aspect above. There are five principal associations:
is important, of course, but not from the point - T -shaped fractures;
of view of c1assifying the fractures. In effect, we - fractures of the posterior column and posterior
shall demonstrate a single family of fractures each wall;
of which can be described individually yet forming - transverse and posterior fractures (with a dislo-
together a continuous spectrum of possibilities. cation of the femoral head either posteriorly or
At the date of publication of the English edition centrally) ;
of this book, we have treated 632 fractures of the - fractures of the anterior column or anterior wall
acctabulum of which 568 have been operated associated with a hemitransverse fracture pos-
upon. We remain of the belief that open rcduction teriorly;
and internal fixation is the method of choice. The - both-column fractures.
5 Posterior Wall Fractures

Table 4

Fractures of posterior wall 126 26.8%

Posterior lip 3 0.6°/.,

Typical - one fragment 46 9.8%
Typical - multifragment 36 11.9%
Postero-superior 15 3.2%
Postero-inferior 6 1. 3 'Yo
(With secondary comminution of all types 20 4.3%)

Fractures of the posterior wall of the acetabulum

involve separation of a segment of the posterior
articular surface; the fracture line leaves un-
disturbed the major portion of the posterior col-
umn. A posterior dislocation can be associated.
Strict1y, these are partial fractures of the poste-
rior column and one could include them under
this heading. However, they have been recognised
as a particular entity for a long time and concern
a clearly defined anatomical area. Their clinical Fig. 22 A, B. Diagrams of posterior fracture. A Pure fracture-
presentation, especially with a dislocation, is so dislocation. B fracture-dislocation with marginal impaction (see
text)
typical that it is reasonable to describe them in
a special group.
transition al forms alm ost amounting to
These fractures fall into the following distinct
complete fractures of the posterior column de-
sub-groups:
taching in one or several fragments the posterior
- typical fractures of the posterior wall confined
wall, and a portion of the posterior cortex ad-
totally below the roof;
jacent to the acetabulum including the anterior
- postero-superior fractures in which part of the
border of the greater sciatic notch and a segment
adjacent roof be comes separated;
of variable size of the quadrilateral surface of
- postero-inferior fractures in which the detached
the ischium - massive posterior wall fractures;
fragment includes the inferior horn of the articu-
- transitional forms in which there are associated
lar surface, the sub-cotyloid groove and often
incomplete transv~rse fractures (to be discussed
the superior portion of the ischium.
later in the group of associated fractures).
These three main types may result in detachment
of one or more fragments. Less commonly the In all varieties of posterior wall fractures. whenever
following are seen: a segment of the posterior wall becomes separated.
- extended fractures which may detach in several allowing a posterior dislocation to occur. the
fragments a segment extending from the roof detached fragment may remain attached by its cap-
to the superior portion of the ischial tuberosity; sule to the femur or the capsule may rupture
34 Posterior Wall Fractures

Fig. BA, B. Posterior wall fracture. A Scheme of pure

posterior wall fracture , B possible attachments of pos-
terior wall fragment (see text)

A B

/
_·-· ....1
/' . ..."..._,i)
/ " I
Fig. 24A-D. Posteri o r wall fracture. A Antero-posterior radio- i ) .
graph. B antero-po sterior radiograph after rcduction , b dia- ; '-.\
gram , C iliac-oblique radiograph, c di agram . D obturato r-ob-
lique radiograph, d diagram. Note incarcerated fragment on
\
\
Band D, and irregular area on infero-internal aspect of femoral
head on A and D caused by damagc at the moment of di sloca-
\
tion b \
Typical Posterior Wall Fracturcs 35

(Fig. 22). The significance of the capsular injury
is that it facilitates the escape of the femoral head.
In contrast, when the capsule remains intact, the
head dislocates after fragmenting the edge of the
fracture margin, the osteochondral segments be-
coming incarcerated and impacted into the ad-
jacent bone. We have distinguished these two
mechanisms and call the results simple fracture-
dislocations (by far the commoner and accounting
for 106 cases - 84%), and fracture-dislocations
with marginal impaction (less common and ac-
counting for 20 cases of the 126 - 16%). lt is im-
portant to recognise the impacted fragments due
to marginal impaction perhaps radiologically but
failing this, during operation, for only by freeing
these and restoring them to proper alignment can
the complete articular surface be reconstituted. Af-
ter effective support with cancellous bone, redis-
placement of these fragments of articular surface
need not occur.
5.1 Typical Posterior Wall Fractures
Incidence: 105 out of 126 cases, of which 17 exhib-
ited marginal impaction.

c o

/
(
/".-\-._ .,
i ' .
i !
;'
i. ! '~ '-I
.li
i
\ I
\I (. i.
. \l \
I " \
! ) \
c see Fig. 19a d
36
5.1.1 Morpho1ogy
There is a detachment of a single or broken frag-
ment involving a segment of the posterior articular
surface but not involving the posterior horn or
the roof (Fig. 23).
The detached fragment or fragments vary in size,
in site, and in the amount of articular surface
involved. Thus all possibilities may occur, from
a mere abrasion of the posterior lip of the ace tabu-
lum detaching fragments only 2-3 mm in breadth
and therefore impossible to reposition, to gross
fragments comprising the whole posterior wall.
These fractures result more usually in the detach-
ment of one large fragment.
Referring to Fig. 23 B, the possibilities with re-
gard to the soft tissue attachment include total
loss of capsular and muscular attachment (Bi), re-
tention of capsular attachment (Bii) wh ich may
lead to marginal impaction (see above), retention
of retro-acetabular soft tissue attachment (Biii),
or impaction of fragments which have lost soft-
tissue attachment following marginal impaction
(Biv). Loss of soft-tissue attachment leads to avas-
cularity; during operative intervention while the
vascular supply is rich, it must not be abused by
careless management of the soft-tissue pedicles.
When the posterior wall segment is shattered,
polyhedral and sometimes small fragments bearing
only cortical bone of the retro-acetabular surface
may be encountered; they are of value in providing
mechanical stability. Fragments bearing articular
cartilage must, in contrast, be pieced together accu-
rately.
5.1.2 Radio1ogy
This is straightforward but a detailed description
offers a useful introduction into the understanding
of the more complicated fractures which are en-
countered later.
(a) Antero-posterior vieH'. Before reduction of
the dislocation the detached bone of the posterior
wall looks like a cap adjacent to the femoral head
(Fig. 24 A). The reduction of the dislocation, usu-
ally performed as a matter of urgency, may well
be stable and then the problem is to recognise the
nature and magnitude of the posterior fragment.
From this view alone it is not possible to assess
its size or its displaced position.
Posterior Wall Fractures
Five of the six fundamental radiological lines
are not disturbed, viz. the roof, the pelvic brim,
the ilio-ischial line, the teardrop, and the anterior
border of the acetabulum. Only the posterior bor-
der is interrupted, its extremities being uni ted by
an abnormal notch created by the loss of the
detached fragment. The notch is variable in size
and can be obscured by the intact anterior wall.
(b) Wac-oblique vieH'. This confirms (Fig.24C)
that the posterior border of the innominate bone,
the anterior border of the acetabulum, and the
iliac wing are all intact. The detached posterior
wall fragment is superimposed on the iliac wing
and often difficult to see.
(c) Obturator-oblique vieH'. Most information
with regard to the posterior wall fracture is here
(Fig. 24D). The innominate line and the obturator
ring are intact. The following three features should
be sought:
- The head of the femur may be fully reduced
or there may be a persistent sub luxation not
apparent on the antero-posterior view.
- The notch created by the fracture and which
interrupts the posterior border of the acetabu-
lum creates a deep defect in the posterior wall.
- The exact size of the detached fragment is
displayed because in this view it is exposed (be-
ing unsuperimposed), and its largest section is
perpendicular to the X-ray beam.
The comparison between an antero-posterior
view and an obturator-oblique view in which the
true magnitude of a detached fragment is seen, is
shown strikingly in Fig. 25. The obturator-oblique
view also shows the dis placement of the posterior
fragment and Fig. 26 illustrates how deceptive the
antero-posterior view can be in suggesting that an
adequate reduction has been achieved.
It remains to attempt an exact evaluation of
the nature of the detached fragment. Most exam-
pies comprise a large single piece of bone similar
to that just described. Simple comminution of the
detached bone is usually visible and easily detected.
Marginal impaction may be more difficult to detect
but in the light of its presence in 17% of our
posterior wall fractures, this should be sought care-
fully. In a few instances, impacted fragments of
articular surface have been found at operation
and even retrospectively, these cannot be detected
on the radiographs. In general however, the evi-
den ce is available:
Postero-superior Fractures 37

A
- Sometimes reduction of the femoral head is
incomplete, so that it stilI lies slightly posterior.
and it is seen to be related to a dense line of
variable length which is perfectly concentric with
its surface and separated from it by a cIear space.
The cIear space is created by the radiolucent
articular cartilage Iying on a detached fragment
.............. - -..... , I

/
/
/
~-+/
\

\
/ which has become impacted. Its bony margins
are not visible (Fig. 30).
I \
I \ ~ Alternatively, accompanying aperfeet redue-
I \
I \ tion, segments of varying length whieh ereate
\
\ a den se eurved line and whieh should be eoneen-
\\ trie with the femoral head are seen to be dis-
\
\ plaeed. In Fig. 27 the displaeed line is visible
\\ above the roof of the aeetabulum, and in Fig. 28
a
\
\
two impaeted fragments are seen, additional to
the main detaehed posterior wall fragment, these
being driven posteriorly into the eaneellous bone
of the posterior eolumn and appearing superim-
posed on the femOi'al head.

Fig.25A, B. Detached fragment. A Antero-posterior radio- 5.2 Postero-superior Fractures

graph on wh ich the fragment detached from the posterior wall
appears small but with care the large defect in the posterior
wall can be perceived. a diagram. B obturator-oblique radio- Ineidenee: 15 out of 126 fraetures. of whieh three
graph on wh ich the detached fragment is seen to be large exhibited marginal impaetion.
38 Posterior Wall Fractures

" ,
"/"-,'---',"
I \
I \
\
I
I
I
r
I
\
\
\
\
\
\
\
a

Fig. 26. A, B. Dctached posterior wall fragment. A Antero-pos-

terior vicw. on which fragment appears a little displaced, a dia-
gram, B obturator-oblique view. on which the fragment is seen
markedly displaced

Fig.27. Posterior wall fracture with marginal impaction. In

this antero-posterior view the fragment is adjacent to the roof
outline after reduction of the dislocation
 Fig. 28A-C. Posterior wall fraeture with marginal impaction.
A Antcro-posterior view. a diagram. B iliae-oblique view. C
obturator-oblique vicw

Detached fragment .
/
/'- .-'-',.)..i
i '--i
i. \.\ ,-
I . i
{ /
\ i
\ f
\
\ i
j
a /
A i

Fig. 29. Scheme of postcro-

B C superior fracture
40
5.2.1 Morphology
The detached fragment comprises the postero-
superior sector of the acetabulum (Fig. 29). The
lower part of the posterior wall always remains
in place, and sometimes even the whole. Varying
amounts of the roof are included in the detached
fragment, this being the characteristic feature of
postero-superior fractures. Also, the detached frag-
ment takes part of the lower outer surface of the
i!ium . The cavity created by the fracture as seen
from the outer aspect can vary in size and position.
The detached fragment may be in one piece (six
cases), in two or more pieces (six cases), or include
marginal impaction (three cases).
5.2.2 Radiology
Oistinct differences are seen in comparison with
the previous typical posterior wall fracture .
(a) Antero-posterior view. The i!io-ischial !ine,
the teardrop, the pelvic brim !ine and the anterior
border of the acetabulum are intact (Fig. 31 A).
It is the roof of the acetabulum which is seen
to be involved, but the detached fragment appears
as before like a cap over the femoral head. The
Posterior Wall Fractures
Fig. 30. Postero-superior fracture with marginal impaction. The
roof has been almost totally detached in several fragments.
i
\
',.
I" , - . ~ .">..,
i
I
i
amount of the roof contained by the fragment
varies according to how far forward the fracture
line reaches; usually part of the roof remains vis-
ible towards the medial side of the acetabulum.
Only the upper part of the posterior border of
the acetabulum is seen to be involved.
In some cases, the !ine of the roof of the acetabu-
lum remains in its proper pi ace but appears very
thin, continuing the curve of the most internal
portion of the roof which has its normal density
(Fig. 31 A). This effect is the result of a fracture
line which extends very far anteriorly and leaves
in place only the most forward portion of the roof.
The typical radiological appearance of an uninjured
roof is brought about by the X-ray beam passing
tangentially through an arc of significant length
thereof, as described in Fig. 140.
An extreme example, wh ich we have seen on
only one occasion, is that in wh ich the roof is
totally detached, this amounting to a pure superior
fracture completely above the boundary of the
posterior border and posterior wall (Fig. 32). It
can be seen from the diagram that the detached
roof takes with it the anterior part of the iliac
wing but the pelvic brim remains intact. We be!ieve
that this rare fracture must be included with the
postero-superior group because, in contradistinc-
tion to typical fractures of the anterior column,
Postero-superior Fractures 41

Fig. 31 A-C. Postero-superior fracture. A antero-postcrior ra-

diograph, a diagram (note the thin outline of the roof), B ob-
turator-oblique view, C iliac-oblique view

Outline of roof +.....,,,~

still visble
but faint (
.,..-:::::..~.j
I 'j
i '
i
'\
a
\
A

B C
42 Posterior Wall Fractures

Fig. 32 A, B. Pure superior fraeture taking the antcrior part

of the iliac wing, AScheme. B antero-posterior radiograph ,
b diagram

so much of the roof is detached. It is reasonable B

to regard this interesting example as a transition
between postero-superior fractures and fractures
of the anterior column.
A postero-superior fracture can also entail mar-
ginal impaction (Fig. 30).
(b) Oblique ViCH'S. These confirm the injury to
the roof but do not supply any further notable
detail. It is always on the obturator-oblique view
that the size of the detached fragment can be
assessed (Fig. 31 B) .
.....
'\
.~ .-.' '.
i ~ \.
.(
I )
5.3 Postero-inferior Fractures
i
I
Incidence: 6 out of 126 fractures (three single frag- \
ment, three multifragment).
b
These fractures are rare and their anatomical
red uction sometimes offers considerable difficulty
because of their low situation on the edge of the
acetabulum. We isolated them as a special group
in 1962. in the innominate bone separates a fragment which
includes the sub-cotyloid groove, the upper part
of the ischial tuberosity, and the ischial spine.
5.3.1 Morphology Tracing the surface marking of the fracture
(Fig. 33 A), this passes along the shallow groove
With respect to the articular surface, the detached under the posterior horn of the articular surface
fragment includes the lower part of the posterior descending towards but not reaching the obturator
wall and the posterior horn. As a result of the foramen near its postero-superior tubercle. It then
construction of the bone in this region , the split curves to reach the ischial tuberosity at a variable
Special Forms of Posterior Wall Fractures
level and returns on the inner aspect of the bone
to reach the greater sciatic notch. Finally it crosses
the retro-acetabular surface to reach the posterior
lip of the acetabulum.
In a single case. we have observed an isolated
detachment of the posterior horn of the acetabu-
lum articular surface taking with it a portion of
the upward-sloping surface of the sub-cotyloid
groove.
5.3.2 Radiology
(a) Antero-posterior view. In typical cases the
posteriorly dislocated femoral head is ac-
companied by a large fragment of bone wh ich re-
mains congruent with its infero-medial aspect and
carries a portion of the articular surface. The frag-
ment includes the subacetabular groove and the
upper pole of the ischial tuberosity. the latter being
recognised by their typical configurations
(Fig. 33 B). The ilio-ischial line. the teardrop and
the pelvic brim are intact as in all posterior frac-
tures. but conspicuous within the outline of the
true pelvis are seen the ischial spine together with
a segment of the anterior border of the greater
sciatic notch, wh ich are parts of the detached frag-
ment. Sometimes the fracture line can be seen pas-
sing under the ischial spine where it cuts the poste-
rior border of the ischium (Fig. 33 B).
(b) Iliac-oblique view. The points are displayed
at which the fracture line crosses the posterior bor-
der of the innominate bone. that iso at the levels
of the greater sciatic notch above and the ischial
tuberosity below.
(c) Obturator-oblique vieH'. The fracture of the
ischial tuberosity is confirmed and also the fact
that the obturator ring, while damaged. remains
in continuity.
Two atypical forms should be noted. Firstly,
an isolated fracture of the posterior horn which
can be recognised only on oblique views. Secondly,
and in only one case, we have observed in addition
to a typical postero-inferior fracture, a transversely
disposed fracture line without displacement which
produced a sm all deformity. rather like a green-
stick fracture, of the border of the pelvic brim
(Fig. 34 B). This can be regarded as a transition al
form of fracture.
43
5.4 Special Forms of Posterior Wall
Fractures
5.4.1 Extended Posterior Wall Fractures
In this variant, the detached fragment with articu-
lar surface has been in several pieces ; it included
the most posterior part of the roof, the posterior
wall, and a segment from the upper pole of the
ischial tuberosity. This has been seen in four in-
stances and in each the anterior border of the
greater sciatic notch was not disturbed or was
merely cracked (Fig.35).
5.4.2 Massive Posterior Wall Fractures
In two remarkable cases there was an enormous
posterior fragment comprising in one piece the
posterior wall, the whole retro-acetabular surface,
the angle and the anterior border of the greater
sciatic notch, the ischial spine itself, and in one
case the superior pole of the ischium. These large
fragments amount to a significant part of the
posterior column and could be considered amongst
this latter group of fractures. namely partial supe-
rior fractures of the posterior column. We have
preferred to include them amongst special fractures
of the posterior wall in order not to disturb the
homogeneity of fractures of the posterior column.
Further. the most massive posterior wall fracture
which we have seen (Fig. 37) spared the greater
part of the ilio-ischial line. except perhaps in a
very small degree in its uppermost part. and its
relationship with the teardrop was not disturbed.
in contrast with wh at is seen in true posterior co 1-
umn fractures. These massive posterior wall frac-
tures are transition al with respect to posterior col-
umn [ractures.
5.4.3 Horizontal Extension
of Fracture Line
The fracture extends horizontally and takes from
the anterior border of the greater sciatic notch
a bone fragment which accompanies the main
detached piece of posterior wall. Sometimes the
fragment from the greater sciatic notch margin
becomes isolated (Fig. 36).
44 Posterior Wall Fracturcs

8 C

Fig.33A-C. Postero-inferior fraeture. A Seheme. 8 antero-

posterior radiograph. C iliac-oblique radiograph
Special Forms of Posterior Wall Fractures 45

/
/
i
\
"\ \
\
b
c

Fig. 34A-C. Extended postero-inferior fracturc with tran sve rse AScheme. B antcro-posterior radiograph. b diagram. C i1iac-
ele me nt crossing and kinking the out li ne of the pelvic brim. oblique view
46 Posterior Wall Fractures

/
'- ', I 'i

ij 'iC'"
1.,\
\ \
\.
\.
\
"i
)
a \ ['
Fig.35A-C. Extended posterior fraeture. A Antero-posterior
radiograph. a diagram. B iliae-oblique radiograph, C obtura-
tor-oblique radiograph C

Fig.36A- C. Ex tended po sterior fraetllre taking the anterior a diagram , B iliae-oblique radiograph, C obturator-oblique ra- C>
border of the seiatic noteh. A Antero-posterior radiograph, diograph, c diagram
Special Forms of Posterior Wall Fracturcs 47

I
.'-. _ . -1. ~\

) i
I
j
I
j
Fragment whlch
corresponds to site of
break In outllne of
greater sciatic

) --"" '-
.",.,. "- .

Fig.36A-C c C
48 Posterior Wall Fractures

'\

Fig. 37 A, B. Ycry extended posterior fracture. AScheme. B an-

tero-posterior radio graph. b diagram b
6 Fractures of the Posterior Column
Table 5
Fractures of posterior column 21 4.5°;',
Typical 13 2.8 %
Extended (detaching teardrop) 5 I. 1'Yc,
Superior 0.2 %
Epiphyseal separation 2 O.4'Yo
lt was in 1959 that we identified, from the amor-
phous general diagnosis of central dislocations of
the hip, the fractures of the posterior column; this
was the earliest development of the column classifi-
cation which we now favour. Other writers had
recognised that there were some with special fea-
tures. Thus KNIGHT and SMITH (1958) likened the
left acetabulum, seen from the outer aspect, to
a clock and described fracture lines disposed verti-
cally and from two to six o'clock. These included
fractures of the posterior column but they did not
emphasise their individual character nor describe
their radiological characteristics. T ANTON (1916)
reported an experimental fracture of the ischium ,
performed by WALTHER (1891) which corresponds
to a pure fracture of the posterior column.
6.1 Typical Posterior Column Fractures
6.1 .1 Morpho1ogy
The whole posterior column is detached in one
fragment (Fig. 38).
On the outer surface of the innominate bone
the fracture line begins near the summit of the
angle of the greater sciatic notch tangential to the
curved dense trabeculae present here. lt descends
obliquely downwards and outwards across the
retro-acetabular surface reaching and splitting the
Fig. 38. Scheme of typical posterior column fracture
lip of the acetabulum behind the roof sec tor. From
this point, the Jine crosses the articular surface
at the junction of the roof with the posterior wall
segments and then crosses the cotyloid fossa in
its most posterior part so that the components
forming the teardrop are not disturbed. The oppo-
site side of the obturator ring is fractured at a
variable point along the ischio-pubic ramus, most
usually in its middle part ; we have one example
in which the ischio-pubic ramus was not fractured.
As seen from the inner aspect, the fracture line
leaves the angle of the greater sciatic notch and
descends across the quadrilateral surface at first
obJiquely downwards and forwards, and then verti-
cally. It follows a path separate from the innomi-
nate line which is nct transgressed and reaches
the obturator foramen behind the ischio-pubic
notch. The separated fragment of the posterior
column is limited by the posterior border of the
innominate bone.
In addition to the main fracture line, in the up-
per part there may be some comminution and sepa-
50 Fractures of the Posterior Column

ration of tiny bone fragments; except in one case

these small additional pieces have not involved
the articular surface.
In typical fractures the thick part of the roof
is left intact, but occasionally there is some impac-
tion of one or two fragments from the inner thin
margin of the roof which seem to have been dis-
placed by the head during its postero-medial dis-
placement.
The posterior column in these fractures is driven
inwards and posteriorly. In most cases the head
follows it and remains congruent with the posterior
wall and the posterior horn of the articular surface;
17 examples of the 21 posterior column fractures
could be regarded as centrally dislocated. Of oper-
ative importance is that the posterior capsule is
normally intact.

6.1.2 Radiology
(a) Antero-posterior view (Figs. 39 and 40 A). The
femoral head appears displaced inwards and often
encroaches upon the outline of the pelvic inlet.
It gives the clear notion of having driven medially
A before it the massive bony fragment, which carries
the posterior horn of the articular surface, and
on which one sees more or less clearly the ilio-
ischialline. The posterior fragment is limited above
by a fracture line crossing the posterior wall, some-
times very clear. On other occasions the fracture
line indicated only by an interruption of the poste-
.'\ ___ Posterior border rior border of the acetabulum, and the superior
_.
. - ........."-
of acetabulum
........

\.
limit of the fragment cannot be detected precisely .
Below, the position of the fracture in the ischio-
pubic ramus is variable. Usually, at the innermost
\
"' " j limit of the displaced fragment, the outline of the
\ / ischial spine can be seen.

I
\ i Alongside these abnormal appearances the fol-
i I lowing features should be noted :
a \ ! - The roof of the acetabulum maintains its normal
density. It is intact and in its proper position.
- The integrity of the innominate line from the
sacro-iliac joint to the pubis is fundamental in
establishing that the anterior column is intact.
- The anterior border of the acetabulum is intact
and its outline with the characteristic notch is
abnormally clear due to the inward dis placement
of the posterior column which it normally over-
shadows.
Fig.39. Typical fracture of the posterior column. A Antero-
postcrior radio graph. a diagram. The other standard radio- - The teardrop is intact and it maintains its nor-
graphs are not available for this early case (1956) mal relationship with the innominate line. In
Typical Posterior Columl1 Fractures 51

A B

Postellor border
\lio-isch ia! hne
- ',
of acetabulum
Antenof borde!
\ of acetabulum
\
\ --t\
\ \
/ l
i )
I I
i I
a I b \

Fig. 40 A, B. Fracture of the posterior column. A Antero-poste-

rior radiograph, a diagram, B iliac-oblique radiograph, b dia-
gram
52 Fractures of the Posterior Column

A B

;"
.
/4.~ \
- '\
\
\
~.-" i

Fracture 01 the
Ischlo-pubic notch

Fig. 41 A-C. Posterior column fracture with posterior displace-

ment of column and femoral head. A Antero-posterior radio-
graph. B obturator-oblique radiograph. b diagram. C iliac-ob-
c lique radio graph
Extended Posterior Column Fractures
eontrast the ilio-isehial line is displaeed inwards
with respeet to the teardrop.
All the radiologieal landmarks of the anterior
eolumn are seen to be undisturbed. Like the rooL
the anterior eolumn is eompletely spared in the
typieal posterior eolumn fraeture.
In summary. one reeognises the typieal posterior
eolumn fraeture on the antero-posterior view. from
the massive fragment whieh ineludes the ilio-isehial
line pushed inwards by the head. the integrity of
the innominate line and its normal relationship
to the teardrop. while the ilio-isehial line is dis-
plaeed inwards with respeet to both these strue-
tures.
In the majority ofinstanees (17 out of 21 eases).
the displacement of the disloeated femoral head
is predominantly inwards. i.e. the appearanee is
one of eentral disloeation. In four eases the femoral
head lay slightly displaeed with respeet to the iliae
wing and aeetabular outline. in an outward and
upward direetion; in these examples it was always
adjaeent to the posterior horn of the artieular sur-
face of the aeetabulum (Fig. 41). (The oblique ob-
turator view eonfirmed that the displacement was
essentially posterior). We do not speak of posterior
subluxation, for the posterior eapsule is not rup-
tured.
The antero-posterior view mayaiso show:
~ one or several tiny fragments detaehed from the
upper part ofthe fraeture line sometimes bearing
a fragment of the artieular surfaee;
possible impaction of the inner thin part of the
roof;
the site of fraeture often visible at the upper
part of the posterior eolumn. This is brought
about by the inward displacement of the eolumn
whieh subtraets from the density of this part
of the innominate bone and eauses it to appear
mueh more transparent in an area more or less
triangular. situated just outside the innominate
line (Fig. 39);
the outline of the eotyloid fossa whieh some-
times appears duplieated beeause its two seg-
ments, from the anterior and posterior eolumns
respeetively, are only slightly displaeed or tilted
with respeet to eaeh other.
(b) Iliac-oblique vieH'. There are two important
features (Figs. 40B and 41 Cl: Firstly, the internal
and superior boundaries of the displaeed fragment
are delineated clearly. Internally, it is limited by
the posterior border of the pelvie bone extending
to a variable point along the greater seiatie noteh;
53
frequently. the fragment ineludes the angle of the
greater seiatie noteh but oeeasionally the angle is
not detaehed with it. In the latter instanee the
angle remains in its proper plaee and the upper
part of the fraeture line. instead of being direeted
obliquely upwards and inwards. beeomes more
horizontally disposed in its inner part and cuts
the anterior border of the greater sciatic notch
at a variable level.
Seeondly. the iliae-oblique view demonstrates
that the anterior border of the aeetabulum. of
whieh the outline is fairly clear. is intact.
Note that the roof is intaet. only its internal
part oeeasionally exhibiting impaction. and that
the iliac wing. the iliae erest and the anterior bor-
der of the ilium are uninjured.
(e) Ohturator-ohliquc vieH'. Oceasional posterior
displacement of the head is demonstrated
(Fig. 41 B). Above all. this view eonfirms with great
clarity the integrity of the innominate line and
of the anterior column.
The exaet position of the fraeture of the isehio-
pubie ramus ean be seen clearly as also the level
of the break in the posterior bord er of the aeetabu-
lum. Most frequently the latter is high but exeep-
tionally it is low. the direetion of the fraeture line
in the back of the aeetabulum then being very
oblique; we have seen this in only one ease. The
roof is eonfirmed as being intact.
6.2 Extended Posterior Column
Fractures
In five of our 21 posterior eolumn fraetures the
appearanee is modified beeause the teardrop re-
mains attached to the posterior eolumn. being dis-
plaeed with it and with the ilio-isehial line
(Fig. 42).
6.2.1 Morphology
These fraetures approach the limit of the posterior
eolumn group and an enormous fragment of bone
is detaehed. Viewed from the outer side the frae-
ture line always includes the angle of the greater
seiatie notch; in one example it aetually included
the whole superior border of the noteh. It deseends
towards the aeetabulum sometimes as in the typieal
form but tends to pass higher on the artieular
54
Fig. 42. Schcme of extended fracture of the posterior column
surface and detach the posterior part of the roof
with the posterior column. The essential modifica-
tion of the fracture line which creates this sub-
group occurs at the level of the cotyloid fossa:
instead of dividing the area vertically in its more
posterior part, the fracture line descends in the
anterior part.
On the medial surface of the innominate bone,
the fracture line is situated very far forward, and
it skirts the pelvic brim (to which it is almost tan-
gential) and then descends to the obturator fora-
men in such a manner that the posterior part of
the external wall of the obturator canal is taken
with the posterior column fragment.
Thus all of the elements wh ich form the ra-
diological teardrop are detached wirh the posterior
column and the remaining innominate bone is very
thin at the level of the innominate line. The ischio-
pubic ramus is broken at a variable site.
6.2.2 Radiology
(a) Antero-posterior view. It is a little difficult
to recognise the fracture in this view (Fig. 43 A)
because one sees both the teardrop and the ilio-
ischialline on the fragment wh ich has been driven
inwards by the femoral head; they may preserve
their normal relationship or exhibit slight separa-
tion. In contrast, the loss of the relationship of
the teardrop with the innominate line is very mani-
fest. The pelvic brim seems to be intact, for its
curve is regular; however, it has lost radiological
density in its middle part and this can make its
integrity difficult to confirm. The roof is always
Fractures of the Posterior Column
a little impacted in its inner part. In some very
extreme examples of this group, the column takes
with it the hind part of the roof and this segment,
having lost its normal relationship with the seg-
ment remaining on the anterior column, forms
with it an image like a gull in f1ight (Fig. 44 A, a).
(This appearance may be seen in the oblique views
as weil.) The rupture of the posterior border of
the acetabulum is often very high. The ischio-pubic
ramus is broken, as before, at a variable site.
The oblique views are indispensable in diagnos-
ing this fracture.
(b) Iliac-oblique view. This confirms (Fig. 43 B)
the extended character of the upper limits of the
fracture which sometimes inc1udes the superior
border of the greater sciatic notch.
(c) Obturator-oblique vieH'. This confirms
(Fig. 43 C) the integrity of the innominate line and
the anterior border of the acetabulum, thus dem-
onstrating the preservation of the anterior col-
umn. The thinning in the region of the pelvic brim
visible on the antero-posterior view completely dis-
appears on the obturator-oblique because rela-
tively, the displaced posterior fragment now lies
behind the root of the superior pubic ramus and
the overall thickness of bone traversed by the X-
ray beam is restored (Fig. 21 C). The view is espe-
cially valuable in displaying the sloping upper seg-
ment of the pelvic brim (Fig. 44C).
6.3 Atypical Posterior Column Fractures
6.3.1 Epiphyseal Injury
We have seen two examples of an epiphyseal frac-
ture-separation of the posterior column, one in
a boy of 14 years (Fig. 45) and the other in a girl
of 10 years.
6.3.2 Other Associated Pelvic Ring
Fractures
In two patients, there has been an anterior, vertical
fracture of the innominate bone on the same side
(one case) or both sides (one case). The fracture
of the superior pubic ramus (Fig. 44) is particularly
difficult to explain but it should be observed that
this lesion was totally extra-articular and did not
constitute an element of the fractured acetabulum
itself.
Atypical Postcrior Column Fractures 55

a Fig. 43A-C. Extended fraeture of the posterior column. A An-

tcro-posterior radiograph. a diagram. B iliac-ohlique radio-
graph. C obturator-oblique radiograph. c diagram. Thc tear-
drop is dctaehed with thc posterior eolumn. Thc middle segment
of the pclvic brim is thinncd. and almost appears to bc broken.
but it is shown in C to bc intaet (this view best demonstratcs
this land mark)

/
?"<., ......-
I

c c
56 Fraetures of thc Posterior Column

!(._ ......... . . .."'"

\. '- \
I
I \.
. \
I i
i i
i C
i
a
i
i

Fig. 44A-C. Extended fracture of the posterior column. A An-

tcro-postcrior radiograph. a diagram. B obturator oblique ra-
diograph. C iliac-oblique radiograph, c diagram. In this case
there is an associated fraeture of the superior pubic ramus
which eould causc difficulty in interpretation: with the fraeture
of the inferior ramus, an essential componcnt of the posterior
column fracturc, it rcscmbles a vertieal fraeture through the
obturator ring
 Atypical Postcrior Column Fractures 57

Fig.45A-C. Epiphyseal separation of the posterior column.

A Antero-poslerior radiograph of pelvis, B obturator-oblique
radio graph, C iliac-oblique radio graph C
58
A
6.3.3 Paget's Disease
We have operated on a pseudarthrosis of the is-
chium (Fig. 46) which was associated with no dis-
placement of the femoral head. This fracture fol-
lowed a direct blow to the ischium which was
clearly the site of Paget's disease. The fracture line
crossing the ischium in its upper part was of the
same character as those separating the posterior
column and cutting the greater sciatic notch in
its middle part; it displaced the posterior part of
the articular surface together with the lower frag-
ment. CAMPANACCI (1967) has reported three simi-
lar ca ses but these were not treated operatively.
6.4 Transitional Posterior Column
Fractures
We have seen one high partial fracture of the poste-
rior column, transitional with respect to posterior
Fracturcs 01' the Posterior Column
Fig. 46A, B. Pseudarthrosis 01' ischium at the base 01' the poste-
rior column. A Iliac-obliquc radiograph, B tomograph
wall fractures and therefore meriting special de-
scription.
6.4.1 Morpho1ogy
The fracture line detaches the upper part of the
posterior column taking the angle of the greater
sciatic notch, and descends across the hind part
of the quadrilateral surface so as to detach a large
fragment ofthe ischial body not involving the tuber-
osity but including the ischial spine (Fig. 47 A).
6.4.2 Radiology
(a) Antero-posterior view. A reduplication of the
ilio-ischial line is created by the vertical fracture
line crossing and displacing the quadrilateral sur-
face; the coronal plane of the fracture is well poste-
rior. The reduplication of the outline of the roof,
of which the posterior segment has accompanied
the displaced fragment and has hinged inwards,
Transitional Posterior Column Fracturcs 59

Reduplication of
ilio-ischial line

' ,.~ . ,
} \
.. \
i
/
b i
\.
B

Fig. 47 A-C. Partial superior fraeture of the posterior eolumn b dia gram. C iliac-oblique radiograph (taken after post-trau-
(transitional form). A Seheme, B Antero-posterior radio graph. matie osteoarthrosis had been established)

ereates with the undisturbed segment an image like
a gulJ in fligh t (F ig. 47 B). Below, the inferior angle
of the detaehed fragment appears in the supero-
extern al quadrant of the obturator foramen.
(b) Oblique views. We have only the iliae-oblique
view, this having been taken when an osteoar-
throsis of the hip had already developed, perhaps
superimposed on an osteoneerosis. Degenerative
ehanges oeeurred in spite of insignifieant displaee-
ment of the original fraeture.
This ease is an example of a transition between
the fraetures of the posterior eolumn and the
extended fraeture of the posterior wall whieh takes
with it the anterior border of the greater seiatie
noteh but does not disturb the ilio-isehial line or
the obturator foramen.
7 Anterior Wall Fractures
These are the counterparts of the posterior wall
fracture and to our knowledge had not been de-
scribed as an entity until we separated them in
1968. They are uncommon (Table 6) but their exis-
tence is significant in that they complete the range
of fractures which can occur, disposed like a fan
around the boundaries of the acetabulum.
Table 6
Fractures of anterior wall 10 2.1 %
Fractures of the anterior wall of the acetabulum
result in aseparation of the anterior part of the
articular surface together with a large part of the
middle third of the anterior column.
7.1 Morphology
Seen from the Guter side (Fig. 48), the fracture line
begins at the anterior border of the acetabulum
a little below the anterior inferior iliac spine. It
crosses the articular surface detaching the anterior
wall with a small variable amount of the anterior
part of the roof of the acetabulum. It then descends
across the cotyloid fossa to reach the ischio-pubic
notch a little behind the anterior horn of the articu-
lar surface. Traversing the obturator foramen the
fracture line cuts the superior pubic ramus oblique-
ly forwards and inwards.
On the internal surface the fracture line, leaving
the anterior border of the acetabulum, is directed
backwards and inwards reaching the innominate
line 3-4 cm in front of the sacro-iliac joint. It
crosses the innominate line and then descends
nearly vertically to reach the upper border of the
obturator foramen.
The detached fragment is seen to be trapezoidal,
involving much of the upper surface of the superior
pubic ramus. The Ion ger parallel side is from the
pelvic brim and the lesser is the anterior border
of the acetabulum. The detached fragment does
not include the medial part of the superior pubic
ramus, the pubic angle, or the anterior inferior
iliac spine.
Sometimes the typical form described is modi-
fied: (1) The detached fragment may be split along
a line which, with respect to the longitudinal axis
of the superior face of the fragment, may be di-
rected transversely or longitudinally. (2) In five
examples of the ten, there was a bony plate of
varying size associated with the typical detached
fragment and separated from the lowest part of
the cotyloid fossa and the quadrilateral surface.
It was limited anteriorly by the principal fracture
line below the pelvic brim, and above and below
by splits running horizontally and more or less
parallel across the quadrilateral surface. The seg-
ment, which comprises the floor of the cotyloid
fossa and part of the quadrilateral surface, was
seen to be deflected and driven in by the femoral
head. The posterior column was not disturbed.
The segment in all cases maintained an osseous
hinge situated posteriorly at a variable distance
from the anterior border of the greater sciatic
notch. It did not bear any articular surface.
7.2 Radiology
The integrity of the ilio-ischial line and the poste-
rior border of the acetabulum seen on the antero-
posterior view, together with the intact posterior
border of the innominate bone as seen on the iliac-
oblique view, confirm that the posterior co lu mn
is intact.
62 Anterior Wall Fractures

Fig. 48. Scheme of anterior wall fraeture

The fracture involves part of the anterior co 1-

umn, hut never the whole.

7.2.1 Antero-posterior View

The anterior inferior iliac spine and the angle of

the pubis are spared (Figs.49A, 50A and 51A). A
The only radiological landmarks broken are:
- the anterior border of the acetabulum, gene rally
in its upper third;
- the innominate line in its middle part, the
detached segment forming the larger parallel
side of the separated trapezoid so characteristic
of the fragment; and
the superior pubic ramus which is crossed ap-
proximately horizontally by a fracture line.
The teardrop is sometimes invisible (as in two
of our examples) but in most cases it is displaced
\
inwards with respect to the ilio-ischial line and \. .'- ' ' - ' ,
is tilted together with the fragment of the pubic 'Y- ../ \
ramus to which it nearly always remains related; \ \
) \
sometimes, however, it forms an isolated fragment I .
I
or remains attached to the accessory plate-like I
/
/
fracture formation involving the quadrilateral sur- /
face, described above. I
The fragment of the anterior wall may be split a i
transversely (Fig. 51 A), as in two of our cases,
or longitudinally. A longitudinal split, if it is recog-
nisable radiographically, appears as a duplication
of the fragment or of the pelvic brim (Fig. 52 A); Fig. 49A-C. Antcrior wall fraeture. A Antero-posterior radio-
sometimes it is only discovered at operation. graph. a diagram. B iliac-oblique radiograph, b diagram. C ob-
turator-oblique radiograph. c diagram. The detached fragment
The roof is always involved to some extent. Its has rotated about the fraeture of the superior pubic ramus
thin internal part is detached and, in one case and the internal segment of the roof is impaeted into the subja-
out of two, a more significant fragment involving cent spongy bone
Radiology 63

B c

-t-.,
'- \
i.)
!
I
\
b \ c
64
the inner third or half of the roof adheres to the
fragment and is displaced by the femoral head.
In all our cases, on the antero-posterior view, the
outer segment of the roof was not disturbed and
remained in place. In one case, we encountered
an impacted segment of the roof due to marginal
impaction as described in the posterior wall group
(Figs. 49 A and C). The region of the detached
anterior wall is often clearly visible as a radiolucent
area situated just inside the internal limit of the
undamaged roof (Fig. 50). If not evident on this
view, it may be visible on the iliac-oblique
(Fig. 52 C).
The nature of the dis placement of the fragment
can be estimated from the following features:
- it may be displaced inwards in one piece by
the head, creating a discontinuity in the innomi-
nate line at the level of the superior pubic ramus
(Fig. 50A);
- or it may be tilted by the femoral head, an angu-
lation appearing at the level of the superior pu-
bic ramus. The pectineal part of the inguinal
ligament acts as a stabilising hinge at this point
if it is not ruptured (Figs. 49 A and 51 A).
The femoral head is dislocated anteriorly and
is externally rotated. Inwardly it overlaps the
ilio-ischial line.
7.2.2 Iliac-oblique View
This confirms the integrity of the posterior border
of the innominate bone and displays very c1early
(in six cases out of ten) the commonly present
elevated bone plate on the inner aspect of the pelvis
which is seen in section (Figs. 51 C and 52C). It
establishes the point of rupture of the anterior
wall of the acetabulum and confirms the integrity
of the anterior inferior iliac spine together with
the anterior border of the ilium above the acetabu-
lum (Figs. 49B and 51 C).
7.2.3 Obturator-oblique View
The fracture of the anterior wall is unmistakable.
The view also confirms the integrity of the poste-
rior border of the acetabulum and shows the site
of fracture of the obturator ring to be at the level
Anterior Wall Fractures
of the ischio-pubic notch and the roof of the obtu-
rator canal (Fig. 49C). Above all it displays per-
fectly the trapezoidal shape of the detached ante-
rior wall fragment; this is seen to be driven inwards
by the femoral head. The extent of the articular
surface which it bears can also be assessed.
The amount of the roof detached with the frag-
ment is delineated and may appear as the inner
segment relating to the anterior wall and continu-
ing to lie adjacent and symmetrically with the fem-
oral head. Alternatively the inner segment of the
roof may be detached, tilted, and can be impacted
into the spongy bone of the anterior column
(Fig.49C).
The obturator-oblique view is essential for as-
sessing fractures of the anterior wall.
7.3 Atypical Examples
Unusual radiological appearances may be created
by the following features:
- fracture lines, which run longitudinally, due to
splitting of the detached fragment and which
are only apparent near the innominate line and
may be confused with it (Fig. 52);
the elevated bone plate from the quadrilateral
surface, which on the antero-posterior view may
appear as a reduplication of the main fragment;
it becomes precisely delineated on the iliac-
oblique view;
associated fractures of the ischio-pubic ramus
(three cases) without displacement in two cases
(Fig. 51) and displaced in one case (Fig. 52), so a
displaced segment of the anterior column lies
between the fracture of the anterior wall and
the fracture of the ischio-pubic ramus. The con-
figuration forms an association between a frac-
ture of the anterior wall and a fracture of the
anterior column, this relationship being similar
to that between a posterior wall fracture and
a posterior column fracture described m
Chap.6.
We confine these three cases to the group of
anterior wall fractures, partly in order to keep the
c1assification as simple as possible, and partly be-
cause of the dominant anterior wall element.
 Atypieal Examples 65

Fig. SOA-C. Anterior wall fraeture. A Antero-posterior radio-

graph. a diagram. B obturator-oblique radiograph. C iliae-
oblique radio graph (taken six months after injury) C
A

/ - )

/ / ~ .l.
I </ \.\
! I. \
\ \\ .
\ .(
. ! )
\ I j
\ r'
i (
i
a

ted fragments
Impac&_~
,- " Quadrilateral
\
\
surface of
I the ischium
I
I
.Il
-'

C
c Fig.51A-C
 Atypieal Examplcs 67

Fig. 52A-C. Assoeiated fraeture of antcrior eolumn and anteri-

! '~r- ' -" / or wall. A Antero-posterior radiograph , a diagram. B obturator-
I .
. I. oblique radiograph, C iliae-oblique radiograph, c diagram.

,
I
f "- The fraeture line detaching the anterior fragment runs longitu-
dinally adjaee nt to the pelvic brim. causing an appearance of
reduplicalion on the radiographs. A fraeture lifting a plale
\
of bone from the quadrilateral surfaee is limited anteriorly
\ by the main fraelure line. Therc is also a fraeture of lhe isehio-
a \ pubie ra mus

<l Fig, 5\ A-C. Anterior wall fraeture. A Antero-posterior radio- shown c1early in C. The anterior fragme nt is in two parts.
graph, a diagram, B obturator-oblique radiograph, C i1iae-ob- both applied to the head. The teardrop is not visible. There
Iique radio graph, c diagram. The extension of the fraeture lift- is an undisplaeed fraeture of the inferior pubic ramus
ing a plate from the quadrilateral surfaee of the isehium is
68 Anterior Wall Fractures

Elevated cortex
01 quadrilaleral surface
limiled anleriorly
by break in pelvic brim

c
Fig.52C
8 Fractures of the Anterior Column
Table 7
Fractures of anterior column 22 4.7'%
Very low (anterior horn articular surface) 6 1.3%
Low (psoas gutter) 3 0.6'10
Middle (anterior interspinous noteh) 6 \.3%
High (iliac crest) 5 1.\ %
Incomplcte 2 0.4%
In fractures of the anterior column of the acetabu-
lum (lUDET and LETOURNEL 1960) a single segment
of variable size is separatcd by a fracture line ex-
tending from the middle of the ischio-pubic ramus
below, to any point above as far backward as the
mid-point of the iliac crest. This description has
contributed to the basis of our fundamental
concept of the architecture of the acetabulum (see
Chap. land Fig. 2).
8.1 Morphology
As depicted in Fig. 53 these fractures fall broadly
into four categories depending upon the level at
which the upper end of the fracture line cuts the
border of the innominate bone: very low, low,
intermediate and high (Table 6).
8.l.1 Very Low F ractures
The displaced fragment comprises the lowest part
of the anterior wall and articular surface of the
acetabulum (Fig. 53 A). Seen from the outer aspect
of the pelvis, the fracture line cuts the anterior
wall horizontally, then descends vertically through
the cotyloid fossa and finally divides the ischio-
pubic ramus in the same line, or towards the pubic
angle or even at both points. From the inner as-
pect, the superior surface of the pubis is crossed
horizontally and the innominate line is cut in its
middle part; from this point the fracture line de-
scends vertically across the anterior part of the
quadrilateral surface.
Very low fractures lcave undisturbed a large part
of the articular surface, which explains why in five
instances out ofsix the femoral head reduced spon-
taneously and was stable. Only in one case did
a dislocation remain (Fig. 54).
8.1.2 Low Fractures
The upper limit of the fracture line reaches the
psoas gutter (Fig. 53 B).
From the outer aspect the fracture line begins
just below the anterior inferior iliac spine, crossing
the lip of the acetabulum and the articular surface,
and detaching a fragment of the anterior wall
which includes some part of the roof. It then be-
comes more vertical, traversing the cotyloid fossa
to reach the ischio-pubic noteh. Inferiorly, the is-
chio-pubic ramus is fractured.
From the inner side the fracture line begins be-
low the anterior inferior iliac spine and cuts the
posterior third of the innominate line obliquely
posteriorly and inferiorly: it then descends to meet
the superior border of the obturator foramen by
separating the anterior part of the quadrilateral
surface.
Next to the main fragment we have seen in one
case a supplementary detached segment including
part of the innominate line hehim! the point de-
scribed above. This has been associated with a
bone plate from the quadrilateral surface driven
in by the head and similar to that which has been
described in Chap. 7.
70
In all cases the femoral head has been subluxated
anteriorly and has remained congruent with the
displaced anterior fragment. The main fragment
has been split at the level of the anterior wall
in two out of three instances.
8.1.3 Intermediate Fractures
The displaced sector is bounded by a fracture line
which passes above from between the anterior
superior and inferior iliac spines and below
through the ischio-pubic ramus (Fig. 53 C).
From the exterior aspect, beginning between the
anterior iliac spines, the fracture line curves down-
wards so as to inc1ude a large part of the superior
segment of the acetabulum. It descends further
crossing the cotyloid fossa and passes through the
ischio-pubic notch; finally, it cuts the ischio-pubic
ramus usually well towards the body of the pubis.
From the inside, the fracture line, which may
be somewhat concave postero-superiorly or more
sharply angulated, mects the innominate line and
cuts it a few centimetrcs in front of the sacro-iliac
joint. It then descends across the quadrilateral sur-
face diverging from the pelvic brim and reaches
the superior border of the obturator foramen.
Often, in addition to this main fragment being
driven forwards and inwards, a supplementary
fragment was detached as a result of damage to
the hind part of the innominate line, or a bone
plate from the quadrilateral surface, and hinged
posteriorly, was seen in half of our examples.
Atypical ex am pIes are seen:
- The anterior column may be split through or
below the anterior wall (Fig. 58).
- The ischio-pubic ramus has been broken in one
instance in its middle part.
- The fracture line passing through the iliac wing
may stop a few millimetres short of the anterior
edge of the bone, the fracturing energy having
been expended and insufficient to break the
dense trabeculae which strengthen the region of
the bone between the iliac spines.
The head of the femur always follows the dis-
placed fragment and remains subluxated ante-
riorly.
8.1.4 High Fractures
These fractures result in separation of a massive
segment of the anterior column wh ich comprises
Fractures of the Anterior Column
the anterior wall of the articular surface, nearly
all of the roof, and the front part of the iliac
wing (Fig. 53 D). The important feature which they
have in common is the separation of the anterior
part of the wing, while in the lower part, the frac-
ture line is variable in position. The photo graph
of the dried bone (Fig.61) is a good example.
From the outer side, the fracture leaves the iliac
crest at a variable point in front (two cases) of
the anterior pillar of the iliac wing, or behind it
and sometimes very posteriorly disposed. From
the crest, the line pursues a somewhat jagged
course to reach the margin of the acetabulum be-
hind the roof. It traverses the articular surface
detaching nearly all of the roof and enters the
cotyloid fossa. From this level it can pursue a
variety of courses:
Becoming horizontal, it may cut the anterior
wall and border of the acetabulum (two cases,
Fig. 63). In this instance the obturator ring is
not broken and the lowest part of the anterior
wall also remains undisturbed. This fracture li ne
limits the shaded zone shown in Fig. 53 D.
- It may reach the ischio-pubic notch and beyond
this break the superior pubic ramus where, in
addition, an intermediate fragment may be
detached (Fig. 60).
- After reaching the ischio-pubic notch it may
cross the obturator foramen to break the ischio-
pubic ramus at the inferior border of the
symphysis (one case), or in the middle of the
ischio-pubic ramus (one case) or even at both
points.
From the inner side of the pelvis the fracture
line, having left the iliac crest by the same jagged
course corresponding to the outer side, reaches
somewhere towards the back portion of the brim
of the true pelvis and then descends over the qua-
drilateral surface more in its anterior part diverg-
ing from the innominate line to end in the ischio-
pubic notch. As is occasionally the case, if it re-
crosses the innominate li ne (Fig. 53 D) the obtura-
tor foramen is spared.
The massive anterior column fragment is rarely
detached in one piece and it is usual to find second-
ary splits in the bone. These have been seen at
the level of the interspinous notch (one case,
Fig. 60), at the level of the anterior wall (one case),
or at the level of the superior pubic ramus (one
case).
In addition to this main fragment or fragments
we have seen also:
Radiology
- on three occasions out of six, a bone plate hing-
ing posteriorly from the hind part of the quadri-
lateral surface (Fig. 60C) and not bearing any
articular surface;
- in one case, a high fragment detached and taking
with it a portion of the roof of the acetabulum;
- impacted fragments, which are found more fre-
quently than the radiographs would indicate.
The amount of articular surface involved varies
and the fragments become impacted in the un-
derlying cance110us bone of the column.
8.l.5 Atypical Examples
In two cases the fracture line in the iliac wing
did not quite reach the iliac crest, being arrested
1-2 cm from the edge by the strong bone which
occurs at this level.
In one case the iliac wing fracture line was very
posterior and reached the superior pole of the sa-
cro-iliac joint taking with it the superior and verti-
cal segment of the auriClIlar surface. Continuing
inferiorly, the line skirted the pelvic brim and
spared also the margin of the greater sciatic notch,
running downwards to reach the ischio-pubic
notch (Fig. 62).
Another special example is described at the end
of this chapter (Sect. 8.2.5).
Anterior column fractures detach an anterior
segment of the ilium which is variable in size and
orientation. Inspection of the outlines in Fig. 53
shows that the more inferior the site of the fracture
through the obturator ring, the lower is the iliac
wing component at its site of rupture of the ante-
rior border of the bone.
8.2 Radiology
The most significant radiological character in a11
fractures of the anterior column (as was the case
for fractures of the anterior wall of the ace tabu-
lum) is the integrity of the posterior column as
indicated in the antero-posterior view by the un-
broken posterior border of the acetabulum and
the ilio-ischial line, and in the iliac-oblique view
by the perfect outline of the posterior border of
the innominate bone.
The exception to these generalisations is the ilio-
ischial line. In 16 out of 22 cases it was intact
71
but in the others, its outline was disturbed due
to the associated minor fracture of the quadri-
lateral surface elevating a posteriorly hinged
plaque of bone.
The latter can present as:
- a simple irregularity of the ilio-ischialline creat-
ing an interruption in the normal curve (seen
in two cases presenting with elevated bone plates
from the quadrilateral surface);
a forked appearance produced by splitting of
the line in its middle part corresponding to a
small elevated bone plate (one case, Fig. 57);
rupture of the ilio-ischialline in two places with
a medial dis placement of the middle segment
with respect to the basic line (two cases).
The different varieties of anterior column frac-
tures are diagnosed by a direct radiological study
of the anterior column.
8.2.1 Very Low Fractures
(a) Antero-posterior view. The landmarks of the
posterior column and the whole of the roof are
undisturbed (Fig. 54).
The innominate line is broken in its middle part
below the level of the roof of the acetabulum and
the detached segment extends as far as the pubic
symphysis. The anterior border of the acetabulum
is fractured in its lower half below its characteristic
notch. The teardrop and the ilio-ischial line are
displaced relative to each other so that the teardrop
lies on the inside of the line (in four cases out
of six). Sometimes one can see a reduplication of
the teardrop, the outer image keeping its relation-
ship with the ilio-ischial line while the other is
displaced within it (Fig. 55). The bony ring of the
obturator foramen is broken, perhaps in the mid-
die of the ischio-pubic ramus, at the level of the
angle of the pubis, or at both of these points.
The femoral head stayed in place or spontaneously
reduced in five cases out of six. In only one case
did an anterior sub luxation persist (Fig. 54).
(b) Iliac-oblique vielt'. This confirms the integrity
of the posterior border of the innominate bone
but does not show clearly the level of the fracture
line of the anterior border of the acetabulum.
(c) Obturator-oblique view. It shows clearly the
point of fracture of the innominate line and of
the ischio-pubic ramus; the size of the detached
fragment of the anterior column is delineated. In
72
some instances it may be difficult to affirm how
much of the anterior horn of the acetabular articu-
lar surface has been involved (Fig. 56). It will be
remembered, however, that normally this part of
the acetabulum terminates inferiorly at approxi-
mately the centre of the middle segment of the
acetabulo-obturator line.
8.2.2 Low Fractures
The upper point of detachment of the anterior
column is situated a little higher than in the pre-
vious instance and encroaches on the anterior part
of the roof of the acetabulum.
(a) Antero-posterior view. The roof of the acetab-
ulum is seen to be injured, an internal portion
representing a quarter or more being detached
(Fig. 57 A); this part of the roof may stay attached
to the anterior column or may constitute aseparate
fragment which has been elevated or driven into
the subjacent cancellous bone. The latter is an
example of marginal impaction being produced by
pressure from the head of the femur as it dislocates.
Most significantly, the innominate line is frac-
tured in its posterior part at about the level of
the roof of the acetabulum, and the sector of the
pelvic brim which is displaced inwards and for-
wards extends from this point to the pubic sym-
physis.
Also, the teardrop is seen to maintain its rela-
tionship with the innominate line and is displaced
inwards with respect to the ilio-ischialline. In addi-
tion to linear displacement its attitude is further
disturbed for it appears to have pivoted. The dis-
placement of the teardrop with respect to the ilio-
ischial line occurs in the reverse direction to that
which we see in fractures of the posterior column,
a most important point.
The anterior border of the acetabulum is broken
in its superior segment. The bony outline of the
obturator foramen is broken at two points, one
at the level of the anterior half of the ischio-pubic
ramus and the other in the region of the ischio-
pubic notch but the latter point of rupture is not
always visible.
The femoral head lies in extern al rotation and
is dislocated anteriorly, being clearly displaced in-
wards of the ilio-ischial line.
The upper area of damage of the column is
sometimes visible as a tri angular clear zone at the
level of the roof, between it and the pelvic brim
Fractures of the Anterior Column
(Fig. 57 A), exactly as was observed at the zone
of detachment of the posterior column fracture
(Figs. 39 and 43 A).
(b) Iliac-oblique view. The following features are
visible:
- the fracture line through the anterior border of
the acetabulum, although its level may be diffi-
cult to define precisely;
- the uninterrupted outline of the posterior border
of the innominate bone;
- the frequent occurrence (in two-thirds of cases)
of a bone plate, seen in section, lifted from the
quadrilateral surface and driven in by the femo-
ral head;
- the integrity of the iliac wing and of the iliac
crest.
(c) Obturator-oblique view. This is the most im-
portant view showing the dis placement of the ante-
rior column by the femoral head (Fig. 57 B). The
head is seen to rest and be framed congruently
by the articular surface borne by the displaced
segment of the anterior column. The points of rup-
ture of the obturator ring can be determined and
the posterior border of the acetabulum is seen to
be intact.
The typical features of these low fractures of
the anterior column reflect point by point certain
characteristics of fractures of the posterior column
with which they have adefinite symmetry.
Atypical examples occur:
- On the antero-posterior view, the ilio-ischialline
although visible may appear bent, forked, or
bifurcated (Fig. 57 A) in its middle part. This is
the result of elevation of a bone plate from the
quadrilateral surface which is seen most clearly
on the iliac-oblique view.
- An additional fragment may be present, asso-
ciated with the innominate line posterior to the
main detached segment of bone; this is easily
recognisable because one surface is identifiable
as the typical curve of the pelvic brim.
8.2.3 Intermediate Fractures
(a) Antero-posterior view. Radiologically these are
very similar to the low fractures of the anterior
column but the detached segment is somewhat dif-
ferent in shape and the fracture line cuts the obtu-
rator ring at the level of the body of the pubis
or the highest part of the ischio-pubic ramus;
above, the fracture line crosses the iliac fossa to
Radiology
reach the notch between the anterior iliac spines
- the interspinous notch. The innominate line is
cut much more posteriorly. Sometimes, the large
anterior detached fragment is itself split across the
anterior wall of the acetabulum (Figs. 53 C and
58A).
A significant part of the roof, or sometimes the
whole roof, with the detached fragment of the ante-
rior column to which it remains attached, tilts with
it and remains approximately congruent to the dis-
placed femoral head (Fig. 58 A).
(b) Iliac-oblique vieH!. As before, these fractures
can be accompanied by elevation of a bone plate
from the inner aspect of the pelvis visible in the
iliac-oblique view (Fig. 59 B).
In two cases out of the six, the fracture line
in the iliac wing did not quite reach the notch
between the anterior iliac spines. The true trajec-
tory was only discovered at operation.
Figure 59 A shows the antero-posterior radio-
graph of an intermediate anterior column fracture,
apparently very comminuted. The corresponding
iliac-oblique view reveals however that despite con-
siderable osteoporosis, the posterior column re-
mains intact.
(c) Obturator-oblique vieH!. A fracture line above
the acetabulum (Fig. 58 D) may be visible. It re-
sembles the spur sign which will be explained later
(Chap. 14), and is of the same significance. The
fracture above the acetabulum is never as displaced
as it is in the both-column type in which the projec-
tion of the fragment above the fracture line pro-
duces the typical spur appearance (Figs. 125 and
142). Reduplication of the image of the roof com-
monly occurs (Fig. 58 B).
8.2.4 High Fractures
(a) Antero-posterior vieH!. Again, the principal
landmarks of the posterior column (the posterior
border and the ilio-ischial line) are not damaged
(Fig. 62A). The greater part or the whole of the
roof is tilted and the landmarks of the anterior
column are broken or displaced ; above these there
is a fracture line in the iliac wing which reaches the
crest. The iliac wing fracture segment can appear
doubled because the individual fracture lines
through the adjacent cortices may not be in the
same plane. If the line is fairly straight on the
extern al face, the appearance may be one of an
inverted "V" on the internal iliac fossa surface.
73
The break in the iliac crest may be situated a little
behind the anterior superior iliac spine, towards
the summit or even considerably behind this; we
have mentioned already the single case of sacro-
iliac joint involvement with detachment of the frag-
ment (Fig. 62).
The roof is detached with the anterior column,
usually in its entirety or leaving behind only its
outer part representing hardly one-quarter of the
normal roof; the displaced fragment of roof re-
mains approximately concentric with the anteriorly
dislocated femoral head.
The site of fracture of the pelvic brim is variable.
Thus the entire related bar of bone may be
detached from its extreme posterior end to the
pubic angle; a secondary fracture line may occur
at the level of the anterior wall of the acetabulum.
Alternatively, if the pelvic brim is fractured very
posteriorly, the anterior fracture line may be at
the root of the superior pubic ramus (two cases;
Fig. 60) or at the level of the anterior wall of the
acetabulum (two cases; Fig. 63), the obturator
foramen not being involved.
The teardrop is tilted and displaced inwards with
respect to the ilio-ischial line but it can constitute
an isolated fragment supplementary to the main
fragment (Fig. 60A).
The obturator ring can be broken at the level
of the ischio-pubic notch (not always visible in
this view), along the superior pubic ramus, at the
angle of the pubis, in the ischio-pubic ramus, or
at two of these sites. In some instances the ring
is not broken (two cases; Fig. 63).
(b) Iliac-oblique vieH!. As before, this (Fig. 62 C)
confirms the intact posterior border of the innomi-
nate bone. It has shown in one instance (Fig. 60 C)
a bone plate, visible in section, lifted internally
from the quadrilateral surface.
(c) Obturator-oblique view. In this view
(Figs. 60 B, 62B and 63B) the long section of the
anterior column is seen to be displaced and driven
inwards by the femoral head to which it remains
approximately congruent, the articular surface be-
ing part of the displaced fragment. The points of
rupture of the bony ring forming the obturator
foramen are clear. Nearly always in these cases
a fracture line is seen above the acetabulum in
the iliac wing.
Atypical examples of high fractures included in
our series are those in which the fracture line in
the iliac wing failed to reach the iliac crest by
a centimetre or two. In another, a split divided
74
A Very low
c Intermediate
Fig. 53 A-D. Schemes showing the four types of fracture of
thc anterior column. The hatched area in D represents the out-
line of two of our exceptional cases
the anterior part of the iliac wing from the anterior
column and passed through the notch between the
anterior iliac spines (Figs. 60 and 61).
8.2.5 Atypical Example
A special example of a fracture of the anterior
column which has been seen only once (Fig. 64)
was associated with an anterior dislocation of the
hip. This was rea\1y a low fracture of the anterior
Fractures of the Anterior Column
B Low
D High
column. The fracture cut the anterior border of
the acetabulum near the level of its notch. It then
descended across the cotyloid fossa and seeemed
to strike the densely trabeculated bone limiting
the ischio-pubic notch (wh ich was not fractured)
from where it deviated towards the ischium from
above to below skirting the bony ring of the obtu-
rator foramen. This low fracture of the anterior
column appears therefore to have inc1uded in the
detached fragment the whole of the obturator fora-
men (the integrity of which was preserved) separat-
ing it from the rest of the posterior column.
Radiology 75

I
- ·_·-i
./ ~/\
! I j
! ',\
1\/
\ i
\ \.
\ ")
i ;" a
\ ./
a /

Fig.54. Very low fracture of the anterior collimn. A Antcro- Fig. 55. Very low fracture of the anterior collimn. A Antero-
posterior radio graph, a diagram posterior radiograph . a diagram. The redllplication of the tcar-
drop indicates that the fracture line crosses the cotyloid fossa
76 Fracturcs of the Anterior Column

A -.::- ----.,1- Area 01 detachmenl

01 anlerior column
Posterior border
ofilium

_.-.,.
"

\ ...... .
('
I
. \.
(
. \.
, J. \
J
.
a

\ i
i
i i
i I
\
a
"

I
\

Fig. 56. Very low anterior column fracture. A Antero-posterior
radiograph. a diagram. We cannot prove that the horizontal
fracture line crossing the anterior column cuts the articular
surface; perhaps it passes just below it
Fig. 57 A-C. Low fracture of the anterior column A Antero-
posterior radiograph showing branching of the ilio-ischial line
and th e site of detachment of the anterior column. a diagram.
B obturator-oblique radiograp h. b diagram. C iliac-oblique ra-
diograph (post-operative) showing the undisturbed border of
the iliac bone
Radi o logy 77

C
........_(. \
\ .
I \.
I' I
i
/
/
/
b /

Fig. 578, C
78 Fraetures of the Anterior Column

A B

Anterio r limit of part

of innominate bone which
remains in p lace
Fragment of roof
--"....-:,.-;- remaining in place
. /.-....,
'-·- i.,.- \ / ,\
li . . I \
j.-;'
/
\
\
. . . ·-/1) \ .
,/ i /'- \
/ i
I i
I
, I
b f
/
a \

Fig. 58A- D. Middle fracture of the a nterior eolumn. A Antero- eation of the roof outline and the supra-acetabular fraeture
postcrior radiograph, showing teardrop on aseparated frag- line , C iliae-oblique radiograph, c diagram, 0 sc heme of the
ment, a diagram, B obturator-oblique radiograph with redupli- spur sign
Radiol ogy 79

Segment of fracture
seen in profile as spur sign

Fracture line crossing

internal iliac fossa

Figs. 59 and 60 see pages 80 and 81

Fig. 59 A-C. Middle fraeture of the anterior column. A Antero-

posterior radiograph, a diagram, B obturator-oblique radio-
graph, C iliae-oblique radiograph. c diagram. The antero-poste-
rior view appears complicated because of numerous accessory
fraeture lines resulting from osteoporosis. The oblique view
shows that the posterior eolumn is intaet

Fig. 6OA-C. High fraeture of the anterior eolumn. A Antero-

posterior radiograph. a diagram, B obturator-oblique radio-
c graph, b diagram. C iliac-oblique radiograph, c diagram. There
is an additional fraeture line extending forwards to the inter-
Fig.58C,D spinous noteh
A
B

/~,
)(- \

\\
I
\I
I I
I \
I I
/

,I
I

I
I
I
a I

Posterior border
of the pelvic bone - - ----\

Elevated
segment of ,
quadrilateral ----'~--I \
surface \
\
of ischium \
I
I
I
I
\
\
\
\
c \

Fig. 59 A- C. Caption see p. 79 c

A

Posterior border
01 pelvic bane B

0~
/
i
/
a \ ./.- .........
))
;/-'U
/
i
i
\
\
\ i
\
)
"'i
,.~

b i i

c 79
82 Fractures 01' the Anterior Column

"",,. . . . .----::r- Art ic ular

surface 01
sacro- iliac joint

-;
//':;.
i j
/ i..
( ~
\
i
i
I
a

Fig. 61 A, B. High fracture of the anterior column. A Lateral }<'ig,62A

view and B medial view of dried bone corresponding to Fig. 60
Radiology 83

B c

Fracture surlace
01 iliac wing

Greater sciatic
notch in situ

Fig.62A-D. High fracturc of the anterior column involving a diagram, B obturator-oblique radiograph only the lower
the sacro-iliac joint. A Antero-posterior radiograph with horse- parts of the sacro-iliac joint lines are visible, b diagram,
shoe-shaped outline of the sacro-iliac surface seen in profile, C iliac-oblique radiograph, D scheme
84 Fractures 01' the Anterior Column

A B

Segment 01 pelvic brim

leI! in place
(
/ i-'- '- ' /
( I /. ;
i (.I j
I I ". ._.J
i I ,1\
I I.
I I i..
i \
.1

i//,-'
a i \
'-.
\
\
\
b \.

Fig.63A-C. High fracture of the anterior column. A Antero-
posterior radiograph. a diagram, B obturator-oblique radio-
graph, b diagram, C iliac-oblique radiograph (after repair). The
fracture line spares the obturator ring, cutting the anterior
wall transversely and following the hatched area shown in
Fig. 53 D. 1t might be thought from the antero-posterior view
that the pelvic brim is intuct; this is disproved on the obturator-
oblique view. The iliac-oblique view proves the continuity of
the posterior border of the innominate bone. Contrast this
fracture with the pure superior wall fracture shown in Fig. 32
Radiology 85

c
86 Fractures of the Anterior Column

Fig. 64A-C. Atypical fracture of the anterior column. A An-

tero-posterior radio graph before reduction of the anterior dislo-
cation. There is a low fracture line cutting the anterior wall
at its notch; in the cotyloid fossa it is deflected by the strong
bone of the ischio-pubic notch but it continues and splits the
ischial body. The obturator ring is spared. B Antero-posterior
radiograph after reduction, b diagram, C iliac-oblique radio-
graph after reduction
C
9 Pure Transverse Fractures
The line of a transverse fraeture of the aeetabulum
divides the innominate bone into two segments.
The upper is essentially ilium and the lower, whieh
we shall eall isehio-pubie, may eontain some part
of the embryologie ilium. Other simple fraetures
of the aeetabulum result in separation of all or
part of a eolumn, whereas transverse fraetures cut
transversely both eolumns and divide each into two
parts. The upper and lower segments of the divided
eolumns remain intaet with respect to each other.
The reason for including this fracture type as
a member of the simple group pertains to the sim-
plicity of the fracture line. It tends to orientate
with respect to the trabecular pattern of the bone
in a radial or horizontal fashion and not, as is
commoner in the other pure forms, in a more sagit-
tal direetion. The innominate bone possesses a nar-
rowed region or isthmus which has been deseribed
as the elective site oftransverse fractures; undoubt-
edly the isthmus exists and in some instanees trans-
verse fracture lines have been seen to oecur here.
However, sinee 1958, we have observed that the
site of these transverse fractures is extremely vari-
able and eompletely independent of the apparently
narrowed zone.
9.1 Morphology
The configuration of a transverse fracture is
confirmed during surgical operation as being pr ae-
tically in one plane. The obliquity of the plane
can vary in any direction.
It is useful to regard the lip of the acetabulum
as being a circle, the circumferenee of which will
be sectioned at two points by a transverse fraeture
which resembles a chord (Fig. 65). The chord may
be orientated horizontally or obliquely and accord-
Table 8
Transverse fractures 43 9.2'Y.,
7 1.5%
Trans-tectal
Juxta-tectal 27 5.8%
Infra-tectal 8 1.7%
Incomplete 0.2%
ingly the fraeture line may be low posteriorly and
high anteriorly or low anteriorly and high poste-
riorly.
On a coronal section of the acetabulum
(Fig. 65 B) the plane of the fracture can be
prolonged in a cephalic direction across the head
of the femur where it represents the axis of one
of the great circles of the sphere. The direetion
taken will vary from those horizontally disposed
and therefore situated low in the acetabulum, to
those which are very oblique and involve the roof.
The possible eombinations of obliquity and level
in this type of fracture are infinite.
The anatomieal description of the fracture may
be eonsidered aecording to the level at which it
cuts the aeetabulum, and to the displacement of
the elements concerned.
9.1.1 Orientation of Fracture
According to the level at which fractures break
the acetabulum they may be classified as follows:
(a) Infra-tectal, cutting the inferior part of the
anterior and posterior walls of the acetabulum or
only the horns of the articular surface. The coty-
loid fossa is split horizontally (Fig. 66 A).
(b) Juxta-tectal, cutting the anterior and poste-
rior walls and passing through the highest point
of the cotyloid fossa in the region of the internal
88
o "rupture en travers de I'os des iles" (transverse
A
B was no displacement. In the others, 17 exhibited
Fig. 65 A, B. Diagrams of variations in the plane of transverse
fraetures
limit of the roof. It may be impossible to tell pre-
operatively whether the roof is involved (Fig. 66 B).
(c) Trans-tectal, passing at the level of the roof
of the acetabulum only leaving a small part of
the outer roof in si tu on the iliac wing (Fig. 66 C).
In effect, a plane section of the innominate bone
is produced which is in line with the fracture where
it cuts the articular aspect of the acetabulum. Ta-
ble 8 shows the distribution of transverse fractures
in our series, according to this description.
Seen from the retro-acetabular surface an in-
fratectal fracture is horizontally disposed and cuts
posteriorly the lesser sciatic notch or may divide
the ischial spine longitudinally. All the other frac-
ture Iines have an obliquity which becomes greater
as the fracture generally becomes higher; they cut
the anterior border of the greater sciatic notch
at a variable level. The highest forms involve the
angle ofthe greater sciatic notch (Fig. 70) and even
a segment of the superior border.
From the inside of the pelvis, from the point
of rupture of the anterior border of the acetabu-
lum, the fracture line, straight in outline, more
or less oblique backwards and inwards, reaches
the innominate line and beyond this descends on
the quadrilateral surface in order to regain the
point of rupture of the posterior border of the
iliac bone. This endo-pelvic direction varies with
each case. The point of rupture of the pelvic brim
is determined by the obliquity of the fracture sur-
face: it can approach the sacro-iliac joint in ex-
treme cases.
Pure Transverse Fraeturcs
We have preserved the name, transl'ersefracture,
in preference to others because they remind us
of the c1assical description by MALGAIGNE (1847)
fractures of the hip bone). We have avoided the
term trans-acetabular (CREYSSEL and SeHNEPP
1961) because all fractures of the acetabulum have
this characteristic.
9.1.2 Displacement in Transverse
Fractures
(a) Displacement of the ischio-pubie segment. In
eight cases (3 juxta-tectal and 5 infra-tectal) there
slight displacement and in 18 it was marked. When
present, the dispJacement may appear to be main-
tained by the position of the femoral head but
in some instances, the head returns to its proper
position under the fragment of roof Jeft on the
upper segment of iliac wing.
The attachments which the fragment maintains
with the pubic symphysis dictate the mann er in
which the ischio-pubic segment is able to move.
This appears to occur generally inwards into the
true pelvis but really the displacement of the frag-
ment is more complex than would appear at first
sight. Both theoretically and for practical reasons,
it is important to understand that the dispJacement
comprises two components:
Firstly, there is a rotation around a vertical axis
passing through the pubic symphysis (Fig. 67 A).
Displacement around this axis cannot occur with-
out some distortion of the pubic symphysis itself.
If the movement is pure, the acetabulum which
is situated posterior to the axis of the symphysis
appears displaced inwards. The posterior part of
the fracture line is always more displaced than
the anterior, i.e. there is more displacement at the
sciatic notch.
Secondly, a rotation can occur around a fairly
horizontal axis passing from the point of rupture
of the posterior border of the pelvic bone to the
pubic symphysis (Fig. 67 B).
At the point of rupture in the greater sciatic
notch there is little displacement, the symphysis
pubis is slightly distorted, and the segment of the
pelvic brim on the ischio-pubic fragment tilts in-
wards, carried by that part of the bone immediately
above the axis of rotation. It is only this part which
appears displaced in an antero-posterior radiograph.
In fact, the ischial tuberosity also tilts, but out-
Morpho!ogy
Fig. 66A-C. Sehemcs of transverse
fraetures. A Infra-teeta! type.
B juxta-teeta! type.
C trans-teeta! type
\.
\.\ -
~ '\
B
wards. The axis of rotation which always passes
through some point in the pubic symphysis can
pass, not necessarily through the point of ru pt ure
of the posterior border of the innominate bone
(that is to say, at the level of the fracture), but
through a point on the posterior border situated
below the fracture line. In this instance, the pivot-
ing of the fragment around the axis will be charac-
terised by greater tilting in its upper part than
in the preceding case. The combined displacement
of the posterior border and of the pelvic brim
is inwards while the ischial tuberosity tilts out-
wards.
It is most usual für the displacement of the is-
chio-pubic fragment to be produced by an associa-
tion of these two rotations - vertical and horizon-
tal. The pubic symphysis is the site of büth the
vertical axis and the horizontal axis, so that the
ischio-pubic fragment displaces inwards more in
its posterior part, and at the same time tilts in
89
~
--~
. ~ Axisol
. rotation X:Y
'~J
Fig. 67 A, B. Diagrams of eompo-
nents 01' disp!aeement of ischio-pub-
Seetion 01 pelvic ie fragment in transverse fractures.
brim resulting lram
maximum displacement A Rotation about vertica! axis pass-
ing through pubic symphysis. B ro-
c::. tation about axis passing from pub-
ie symphysis to baek 01' fraeture line
\
such a manner that its superior part is displaced
inwards while its inferior part is displaced out-
wards.
To these elements of displacement can be added
some elevation of the fragment wh ich can further
complicate the radiological interpretation. This
special mode of displacement of the ischio-pubic
fragment can ünly result through a distortion of
the pubic symphysis. In only three ca ses was a
separation of the pubic symphysis associated with
a transverse fracture and as soon as the stability
of the pubic symphysis is lost, the mechanism of
displacement described no longer occurs.
(b) Di~placement o( the iliac Fagment. It is the
rule that this part remains in situ, but in a few
cases it had been driven üutwards and was asso-
ciated with an anterio-inferior rupture of the sacro-
iliac joint. The femoral head was thrust between
the two fragments tending to displace the superior
outwards and the inferior inwards.
90
We have seen two disloeations of the saero-iliae
joint and it is diffieult to say whether they were
the direet eonsequenee of the displacement of the
transverse fraeture itself or whether they were see-
ondary injuries.
(e) Displacement of the femoral/wad. The femo-
ral head ean reduee spontaneously and lie under
the intaet segment of roof; this was found in
17 eases and at first sight did not appear displaeed.
When it remains displaeed (26 out of 43 eases)
it is direeted towards the inside of the pelvis as
a eentral disloeation. One eould be eritieal of the
term eentral disloeation in eonsideration of the
fact that the head is not disloeated with respeet
to the inferior fragment; however, the same argu-
ment eould be applied to a posterior disloeation
in that it remains in eontaet with a small posterior
fragment. The term eentral disloeation is useful
and is eommonly employed, remembering always
the inward displacement observed on the antero-
posterior radiograph may be small eompared with
a mueh larger anterior or posterior eomponent.
Onee we have observed a transverse ineomplete
fraeture eutting the posterior wall and the posterior
two-thirds of the quadrilateral surfaee yet not in-
volving the anterior eolumn.
9.2 Radiology
9.2.1 Antero-posterior View
Often, the antero-posterior view is in praetiee suffi-
eient for eonclusive diagnosis. All of the vertieally
disposed elements relevant to the aeetabulum (pel-
vie brim, ilio-isehial line, anterior and posterior
borders of the aeetabulum) are seen to be inter-
rupted by a transverse fraeture. The obturator ring
is not broken.
The level of rupture of the vertieal landmarks
of the eolumns varies aeeording to the orientation
of the plane of the fraeture. They are divided at
approximately the same horizontal level in infra-
teetal fraetures. Juxta-teetal and trans-teetal frae-
ture lines are progressively more oblique upwards
and medially and thc degree of obliquity ean be
gauged by eomparing the level of rupture of sueees-
sive vertieal landmarks.
If the plane of the fraeture passes through the
eotyloid fossa at a distanee from the roof whieh
it leaves intaet, clearly it is of the infra-teetal type
Pure Transverse Fractures
(Fig. 68). If it passes at the level of the limit of
the internal margin of the roof or through its most
internal part it is juxta-teetal (Fig. 69), but the
exaet position in higher examples is diffieult to
see preeisely, espeeially if thc obliquity in the sagit-
tal plane is also marked; the essential feature is
that the dense shadow of the roof of the artieular
surfaee is intact. There is separation of a portion
of the roof only in the trans-teetal type of trans-
verse fraeture (Fig. 70).
In alt types of transverse ji-actures an unfi'actured
segment of roof remains associated with the iliac
wing.fi·agment. Should part of the roof be detaehed
with the isehio-pubie segment it is seen to be eon-
tinuous with the line of the eotyloid fossa and
frames, eoneentrieally in most instances, the head
of the femur (Fig. 70).
The isehio-pubie fragment, displaeed inwards by
variable amounts, is in one piece, and the obtura-
tor ring is not broken. The lower segment of the
ilio-isehialline and the teardrop are clearly visible
and preserve their normal interrelationships. As
stated above, the extent of any displacement is
variable; it is more marked in high and oblique
transverse fraetures but can be eonsiderable in the
low forms as well (Fig. 71). The assessment of the
nature and amount of displacement occurring in
a transverse fraeture or, more exactly, of the mu-
tual displacements of the two main fragments, and
the anterior and posterior ends of the fracture line,
is important in the choiee of surgical approach
and can be quite diffieult. A correct appreciation
is founded on the following concepts:
(a) On the antero-posterior view of the pelvis
taken strietly symmetrically, if the iliac wing ap-
pears larger than that on the opposite side, this
apparent opening of the iliac fossa area indicates
a posterior and outward displacement of the upper
segment of the fracture. This is allowed by an
anterior opening of the sacro-iliae joint.
(b) The driving inwards in one piece of the is-
chio-pubic fragment due to pivoting of this frag-
ment around a vertieal axis passing through the
pubic symphysis, can be interpreted on the antero-
posterior radiograph by observing displacement of
the vertical landmarks. The displacements relative
to each other of the pelvic brim, the ilio-isehial
line and the posterior border of the ilium and ace-
tabulum inerease progressively from front to back
during rotation through a vertieal axis passing
through the pubie symphysis. Unfortunately, mag-
Atypical Cases
nifieation owing to radiologieal tcehnique renders
diffieult the interpretation of the radiologieal shift
of these landmarks.
(e) The rotation around a horizontal axis, pass-
ing also through the symphysis and whieh allows
thc upper part of the fragment to tilt inwards and
the lower part outwards, may be seen more easily.
If the posterior border of the innominate bone
appears without displacement and yet the pelvie
brim and the ilio-isehial line are displaeed, the
former more than the latter, this is due to pivoting
around a horizontal axis going from the point of
rupture of the posterior border to the pubie
symphysis.
Rarely, the pelvie brim is undisplaeed whereas
the posterior border ofthe bone and the ilio-isehial
line are displaeed; this oeeurs when the isehio-
pubie fragment has rotated around an axis extend-
ing from the point of rupture of the pelvie brim
to the pubie symphysis.
The degree of apparent eentral disloeation is
extremely variable. In 20 eases out of 43 it was
severe, the external surfaee ofthe head ofthe femur
being in eontaet with the superior fraeture surfaee
and having lost all eontaet with the intaet portion
of roof on the iliae segment. In 6 eases the head
pr.otruded mueh less into the pelvis, but the upper
Jomt spaee had lost its normal eongruenee. In
17 eases the head was perfeetly framed by the re-
maining intaet segment of the roof on the upper
iliae fragment.
9.2.2 Iliac-oblique View
This shows the outline of the fraeture on the qua-
drilateral surfaee of the isehium and the point of
rupture of the greater seiatie noteh.
The fraeture line includes the angle and somc-
times even the superior border of the greater seiatie
noteh (Fig. 69). It may cut the anterior bordcr
of the greater seiatie noteh at a variable level:
in the upper third (Fig. 68), the inferior quarter
dividing the isehial spine (Fig. 71), or by splitting
the lesser seiatie noteh. In eontrast, it is often diffi-
eult on this view to loeate preeisely the point of
rupture of the anterior border of the aeetabulum.
91
9.2.3 Obturator-oblique View
This gives the best indieation of the orientation
of the plane of the fraeture in relation to a partieu-
lar great eirele of the aeetabulum, and it gives
a good idea of the severity of any eentral disloea-
tion. It eonfirms the uninjured state of the obtura-
tor ring, one of the essential eharaeters of the pure
transverse fraeture. The level of the fraeture at
the posterior border ofthe aeetabulum is also seen.
As always, it is eomparison of the two oblique
views with the antero-posterior view whieh allows
a full assessment of the relative dis placement of
the two fragments produeed by the fraeture,
thereby providing the deeision as to whieh surgieal
approach is neeessary.
9.3 Atypical Cases
(a) Fractures without displacement (8 eases out
of 43). These are only of theoretieal interest and
their treatment is simple. Accurate diagnosis re-
quires first-class radiography (Fig. 68).
(b) Oblique fi"actures in the sagittal plane. The
plane may be oblique from below posteriorly or
above posteriorly; the landmarks of the eolumns
seen on the antero-posterior view are not cut at
the same level. The fraeture line may reaeh the
angle of the greater seiatie noteh behind and the
pelvie brim in its middle part in front. The opposite
obliquity ean be marked so that the fraeture line
cuts the inferior margin of the aeetabulum behind
and the pclvie brim above and very far back
(Fig. 71). Displacement adds to the problem of
diagnosis but the integrity of the obturator fora-
men and the study of the oblique views should
allow the fraeture eomplex to be defined.
(e) Trans-tectal trans verse fi"acture assoeiated
with an anterior vertieal fraeture of the pelvis. Fig-
ure 72 shows an anterior fraeture line whieh is
vertieal and extra-aeetabular. We have included
it here and not with the T-shaped fraetures, be-
eause a segment of the pelvie brim remains asso-
eiated with the posterior eolumn and the anterior
fraeture appears eompletely independent from the
transverse eomponent. Figure 73 gives another
example.
(d) Transverse fi"acture lvith anterior dislocation.
In a single ease, a pure transverse fraeture was
assoeiated with an anterior disloeation of the hip
(Fig. 74).
92 Pure Transverse Fracturcs

" .
)
\. ..-.\
.
,-. _.~ '\
-\v .\
.
/ j
/
I
I
a i
b

Fig. 68A, B. Infra-tectal transverse fracture. A Antero-posterior There is no displacement and the fracture line cuts the greater
radiograph. a diagram. B iliac-oblique radio graph. b diagram. sciatic notch at the junction of the middle and upper thirds
Atypical Cases 93

Posterior ~.-----<___7 - - - - \
borderl
\
\
\
i
I
;
;
a i

Fig. 69A, B. Juxta-tectal transverse fracture with pseudarthrosis

120 days after injury. A Antero-posterior radio graph. a dia-
gram, B iliac-oblique radiograph
94 Pure Transverse Fractures

Fig. 70 A-C. Trans-tectal transverse fracturc. A Antera-posteri- displacement with dislocation of the sacra-iliac junction and
or radiograph, a diagram, B obturator-oblique radiograph, a fracture of the femoral neck
b diagram, C iliac-oblique radiograph, c diagram. There is grass
Atypica l Cases 95

J-'f-
I
./ '":I.~-\ i
i ('-l .
i \ '/-
.j \?
! v
I
!
c
96 Pure Transverse Fracturcs

Fig. 71 A, B. Transverse fraetures. Low infra-teetal fracture with

fraeture line cleaving the ischial spine: A Antero-postcrior ra-
diograph, a diagram, B iliae-oblique radiograph, b diagram
Atypical Cases 97

Fig. 71 C-E. J uxta-teetal fraeture displaeed anteriorly but not

posteriorly: C Antero-poslerior radiograph showing impaction
of the supero-external border of the femoral head. c diagram.
D obturator-oblique radiograph, E iliae-oblique radiograph E
98 Pure Transverse Fracturcs

Fig. 72 A, B. Trans-tectal transverse fracture associated with

a douhle fracture of the anterior segment of thc pelvic ring.
A Antero-posterior radiograph, a diagram. B iliac-oblique ra-
diograph. The apparently free segment 01' thc pclvic brim is
attachcd to thc inferior segment of the acetahulum Fig.73A
Alypical Cases 99

i ;' " Fig. 73A-C. Juxta-Ieclaltransverse fraelure. A Antero-postcri-

i or radiograph, a diagram, B obturator-oblique radiograph eon-
firming that a segment of thc pclvic brim remains with the
\ ........-
isehio-pubie fragment, b diagram, C iliac-oblique radiograph.
c diagram. Thc ischio-pubic fragment includes the superior
border of the greatcr sciatic notch. The double fracture of
the obturator ring docs not involve the acctabulum. thercfore
a this is not a T-shaped fracture
100 Pure Transverse Fractures

/'
/
i .-'-'-.
~/ 1)
1\ \ .
\\....
h
l/
,
......-'I.

,
,.
\\. I
.
.I .
I, )
.
Fig. 74A, B. Exeeptional transverse fraeture with anterior dislo·
I ",,- eation of the hip. A Antero·posterior radio graph, a diagram,
a ;' B iliae-oblique radiograph
10 T-shaped Fractures
Table 9
T-shaped fraelures 30 6.4 'AI
Vertical 16 3.4'Yo
Anterior 7 1.5%
Posterior 7 1.5%
It is appropriate to begin the study of assoeiated
and eomplex varieties with the T -shaped fraeture.
Although the outlines are simple, the radiologieal
interpretation ean be difficult. Diagnosis must be
aeeurate beeause ofthe diffieulty of open reduetion
whieh sometimes neeessitates two surgieal ap-
proaehes.
Typieal T -shaped fraetures assoeiate a transverse
fraeture with a vertical split whieh divides the is-
ehio-pubie eomponent into two parts, and whieh
passes through the middle part of the obturator
foramen (Fig. 75).
In our earlier publieations we used to consider
these fraetures relatively rare, having had only
three examples amongst our first 75 eases. If we
hold to our definition of the typieal lesion, they
remain fairly rare: subsequently we have had only
16 eases out of the total of 469. With more expe-
rienee over the years we eneounter fraetures asso-
eiating a transverse eonfiguration with a split in
the inferior segment eutting the outline of the obtu-
rator foramen obliquely, sometimes in a forward
direetion and sometimes baekwards. Now we in-
clude under the heading T-shaped, a11 fraeture
forms whieh assoeiate a transverse fraeture of the
aeetabulum, at whatever site, with an oblique or
vertieal split traversing the obturator ring (Ta-
ble 9, Fig.76).
Previously, assoeiated fraetures of the posterior
eolumn with an anterior hemitransverse fracture
had been regarded as aseparate group. The assoei-
ation eertainly exists and it eompletes the sym-
metry of acetabuhu lesions. However, the outline of
this assoeiated fraeture eomplex is so ncar that
of a typieal T -shaped fraeture that we eannot ra-
diologiea11y differentiate them. The upper segment
of the posterior eolumn eomponent together with
thc anterior hemitransversc eomponent approxi-
mate to the eonfiguration of a transverse fraeture
from whieh arises the vcrtieal split of the isehio-
pubie eomponent, i.e. the lower segment of the
posterior eolumn eomponent (Fig. 77). The elimi-
nation of this assoeiated fraeture simplifies classifi-
eation and eauses no praetieal ineonvenienee, ei-
ther radiologiea11y or from the point of view of
surgieal treatment.
Later we sha11 deseribe assoeiated fraetures eom-
prising a fraeture of the anterior eolumn with a
posterior hemitransverse eomponent. We do not
include these with the T -shaped fraeture group be-
eause the anterior eolumn eomponents are so mueh
more eomplieated, and the posterior hemitrans-
verse fraetures are easily identified.
10.1 Morphology
This ean be deseribed aeeording to the transverse
eomponent, the vertieal eomponent, and femoral
head displaeement.
10.1.1 Transverse Component
In our 30 T -shaped fraetures, the transverse eom-
ponent was trans-teetal in 8 eases, juxta-teetal in
14 and infra-teetal in 8.
No further deseription is neeessary beeause the
transverse element is identieal to the pure trans-
verse fraeture deseribed in the previous chapter.
102 T -shaped Fractures

stern 01
Tdi rected
" A
Stern 01 T inclined anteriorly
Fig. 75. Scherne of a typical T -shaped fracture. posteriorly ~ (ant erior T-shaped !racture)
(posterior
T-sha ped
Stern 01 T vertical (vertical
Iractures)
Fig. 76. Scherne showing possible directions of the stern of the 1> T-shaped Iracture)
T in T-shaped fraeturcs

10.1.2 Stern Cornponent rior part of the quadrilateral surface so to meet

the site of rupture 01' the posterior bord er of the
(a) Vertical T-shaped .Jf"acture. This is the com- ischial tuberosity. In one case, the fracture line
monest. The split descends through the middle of cut the hindmost part 01' the bony margin of the
the cotyloid fossa to cut the ischio-pubic notch obturator foramen to which it was almost tangen-
and then traverses the obturator foramen to frac- tial (Fig. 83).
ture the ischio-pubic ramus in its middle (14 cases)
or at two points (2 cases) (Fig. 75).
10.1.3 Displacernent
(b) Anterior T-shaped.Jf"acture. In 7 cases out of
In our series 01' 30 T -shaped fractures, the trans-
32, the split is obliquely disposed downwards and
verse component was severely displaced in 24 in-
forwards. It runs adjacent to the anterior horn
stances, moderately displaced in three and undis-
of the articular surface, cuts the ischio-pubic notch
placed in three. The vertical component displace-
very anteriorly and then, on the other side of the
ment was severe in 14 cases, moderate in 11 and
obturator ring, splits the body or the angle of the
absent in 5.
pubis (Fig. 78 A).
The head ofthe femur usually appears dislocated
centrally (22 cases) or partly so (3 cases). In 2 of
(c) Posterior T-shaped.Jf"acture. In the remaining
the 7 ca ses 01' T-shaped fractures in which the
7 cases, the split of thc inferior fragment is ob-
oblique branch was disposed backwards, down-
liquely disposed posteriorly and downwards
wards, and trans-ischial, the head was apparently
(Fig. 78 B), but here its direction is variable. Most
dislocated posteriorly.
frequently it descends to the level of the ischial
Among the associated lesions we have observed
body detaching a sizeable bone fragment from the
two double fractures, (anterior and vertical) of the
ischium itself. This fracture line usually spares thc
pelvis and two fractures of the superior pubic
obturator ring (6 cases out of 7). More precisely,
ramus.
the fracture line descends in the cotyloid fossa,
following the margin of the posterior horn of the
articular surface and then passing between it and
the edgc of the obturator foramen. Dcscending
further on thc external surface of the ischium it
10.2 Radiology
finally cuts its posterior border. From the inner
sidc 01' the pelvis the fracture line is seen to bc The two components 01' this associated fracture
slightly concave posteriorly and to cross the poste- should be identified sequentially.
Radiology 103

Fig. 77 A, B. T-shaped fractures. Schcrnes showing why it is

not possible to distinguish between. A the classical T configura-
tion and B that associating a fracture of the postcrior colurnn
with an anterior hernitransverse cornponent

10.2.1 Transverse Cornponent

On the antero-posterior and oblique views all the
vertieally disposed landmarks, as weil as the more
slanting ones relating to the aeetabulum, are
broken. One segment of eaeh of these remains
attaehed to the iliae wing whieh itself is intaeL
ß
The upper segments of the vertieal landmarks on
the iliae wing are limited inferiorly by a fraeture Fig. 78A, B. T-shaped fractures. Schernes showing classification
line whieh has the regularity of the plane of the of fractures according to the direction of the stern of the T.
pure transverse fraeture. The level of rupture of A Anterior. B posterior
the landmarks va ries with the obliquity of the frae-
ture in its transverse aspeeL
is seen readily, the fraeture through the eotyloid
The roof is involved or left uninjured aeeording
fossa and that through the isehio-pubie noteh may
to whether the transverse element is trans-teetal
be mueh more diffieult to confirm : it remained
(8 eases), juxta-teetal (14 eases) or infra-teetal
invisible in five examples where there was a frae-
(8 eases). Always, there remains an intaet segment
ture of the isehio-pubie ramus aeeompanied by
of roof attaehed to the iliae wing, and one to whieh
little displacement (Fig. 79). It is diffieult to
at operation it will be possible to bring baek and
eoneeive that a transverse fraeture eould be asso-
maintain the head of the femur; this is an impor-
eiated with a fraeture of the braneh of the isehio-
tant differenee between T -shaped fraetures and
pubie ramus without there being also a fraeture
fraetures of both eolumns. Displaeement at the
in the eotyloid fossa to eomplete the vertieal seg-
transverse element is almost always signifieant
ment of the T. Praetieally then. whenever a trans-
(25 eases out of 31).
verse fraeture is seen assoeiated with a rupture
of the isehio-pubie ramus. it should be possible
to eonfirm that it is a T-shaped fraeture.
10.2.2 Stern Cornponent It is important to avoid eonfusing a T-shaped
fraeture with a transverse fraeture assoeiated with
The isehio-pubie eomponent eharaeterises a T-
an anterior fraeture of the obturator ring. outside
shaped fraeture and is not always easy to reeognise.
the aeetabulum (Fig. 73). In both instanees. the
(a) Vertical T-shaped fractures. While the rup- isehio-pubie ramus will be broken at one or two
ture of the isehio-pubie ramus in one or two plaees points. In a T -shaped fraeture there is only one
104
fracture of the pelvic brim, whereas an anterior
fracture of the obturator ring in addition to a pure
transverse fracture will present with two fractures
of the brim.
The stern fracture line is easy to confirm when
the two fragments of the column are separated
on the antero-posterior view or on an oblique view,
or when the fracture through the ischio-pubic
notch is visible on the antero-posterior view or
more easily on the obturator-oblique Vlew
(Fig. 80).
In the few cases where it was not possible to
see the fracture through the ischio-pubic notch,
especially when the obturator-oblique view was not
available (as in earlier cases of our series), we be-
lieve that we can confirm the fracture in the coty-
loid fossa by the following indirect signs:
- superimposition of inferior fragments of both
columns on the antero-posterior view (Fig. 81);
- displacement of the teardrop with respect to the
ilio-ischialline on the antero-posterior view (five
cases), explainable only by a split in the cotyloid
fossa and aseparation of the columns (Fig. 80);
- the crossing of the two columns on the iliac-
oblique view which gives an X-shaped configura-
tion.
Thus in order to establish the presence of a verti-
cal T -shaped fracture, the rupture of the ischio-
pubic branch seems to us sufficient but one should
search further for absolute proof:
- a fracture through the ischio pubic notch espe-
cially visible on the obturator-oblique view;
- the vertical fracture line passing through the
quadrilateral surface as seen on the iliac-oblique
view, although on many occasions this is so diffi-
cult to see (Fig. 80).
(b) Anterior T-shaped fractures. The fracture
through the obturator ring (Fig. 82) is sited at the
most anterior part ofthe ischio-pubic ramus or at the
angle of the pubis. In a few cases moreover, the
bony ring has been ruptured in two places. In
5 cases out of 7 we found this to be very
anterior with respect to the line dividing the coty-
loid fossa so that the teardrop was detached with
the fragment of the posterior column. The ischio-
pubic notch was apparently broken at the level
ofthe acetabulo-obturator line, in its most anterior
part.
In two cases, although the teardrop was
detached with the fragment of the anterior column,
the split between the two column fragments re-
T-shaped Fractures
mained visible in the antero-posterior view. In
these cases one could observe on this view a separa-
tion of the U and the ilio-ischial line.
In one particular transitional case, a transverse
fracture was associated with a split in the cotyloid
fossa and the ischio-pubic notch; at the same time,
the ischio-pubic ramus was not fractured.
(c) Posterior T-shaped./i"actures. In these the ver-
tical split is in general clear and does not pose
any particular problem. On the antero-posterior
view, it may be apparent that it cuts the most
posterior part of the obturator foramen margin
detaching a segment comprising the body of the
ischium which forms the posterior part of the obtu-
rator ring (Fig. 83). Most frequently, it splits the
body of the ischium and detaches an enormous
fragment ofthis bone while leaving intact the obtu-
rator foramen (Figs. 84 and 85). It is of interest
to compare the radiographic appearances shown
in Figs. 64 and 84 which are at first sight so similar.
The teardrop and the ilio-ischial line are always
disturbed with respect to each other and, in 2 ca ses
out of 7, there was an appearance of duplication
of the ilio-ischial line (Fig. 84).
The oblique views only confirm the existence
of the vertical split and the usual integrity (6 ca ses
out of7) ofthe obturator foramen. It is the obtura-
tor-oblique view which best delineates the poste-
rior fracture line.
10.3 Atypical Examples
10.3.1 Additional Vertica1 Fracture
of Obturator Ring
Sometimes, associated with the T-shaped fracture,
there is an accessory vertical fracture line through
the obturator ring. Such an additional fracture pre-
sents no therapeutic difficulty (Fig. 86). The obtu-
rator-oblique view shows the main vertical split
in the cotyloid fossa, and more anteriorly, the sec-
ondary vertically-disposed fracture of the obturator
ring which divides the superior pubic ramus and
which may "share" the foot of the stern of the
main vertical component of the T through the is-
chio-pubic ramus. In most instances, the antero-
posterior view of the pelvis reveals a fracture of
the obturator ring of the opposite innominate
bone.
Atypieal Examplcs 105

\,/.-...
( - "-
.
I
\.
_.'\ i ,
\i !
a
Y !
( I

Fig. 79 A, B. T-shaped fraeture. A Antero-posterior radio graph, pearanee. in which a fraeture of the middle of the pubie ramus
a diagram, B iliae-oblique radiograph. This is a classieal ap- is assoeiated with a single 1'raeture 01' the pelvic brim
106 T-shaped Fraetures

The fracture is recognisable as T -shaped, for

adjacent to the transverse component, there is a split
in the cotyloid fossa cJearly visible on the obtura-
tor-oblique view. The other fracture \ine, more
anterior, interrupts the outline of the obturator
foramen and cuts the innominate line helow the
transverse fracture component, isolating therefore
a segment of the pelvic brim. This segment is a
fragment from"the anterior column relating to the
T complex proper.

10.3.2 Additional Fracture Line

in Cotyloid Fossa

We recently opera ted upon a patient with an old

fracture (Fig. 87) where, in addition to a juxta-
tectal transverse fracture \ine, there was a double
vertical split almost totally isolating the cotyloid
fossa; the femoral head was dislocated posteriorly
and the acetabulum was occupied by the psoas
and the obturator muscJes, rendering the disloca-
tion irreducible. Moreover, the two main column
fragments had come together and had uni ted at A
their adjacent articular borders. The intermediate
segment carrying most of the cotyloid fossa had
displaced inwards with respect to the two preced-
ing segments and complicated the malunion fur-
ther.

10.3.3 Association with an Anterior

Hernitransverse Fracture

Figure 88 shows very convincingly a posterior col-

umn fracture associated with an anterior hemi-
transverse fracture, an example which we incJude
with the T -shaped fractures. It is also unusual be-
cause the anterior fracture line appears passing
below the tip of the anterior horn; it leaves the a
pelvic brim and crosses the root of superior ramus
ofthe pu bis, as is seen on both the antero-posterior
and obturator-oblique views. This is not an asso- Fig. 80 A-C. Vertieal T- shaped fracture.
ciated vertical anterior fracture of the pelvis for A Antero-posterior radiograph showing impacted fragment of
the pelvic brim is broken only at one single point. roof, a di agram, B obturator-oblique radiograph on wh ich the
fraclure line of the superior part of the obturator ring is visible,
We incJude it with the T-shaped fractures for there
b diagram , C iliae-obliqlle radiograph showing fraelure linc sep-
is some difficulty in distinguishing it from the case arating lhe two colllmns, c diagram. Th e stern componenl
shown in Fig. 82. Note that only the posterior wa11 of thi s fr aeture has two fracture lines in the inferior pubic
of the articular surface had been detached. ramus
At YPlcal
. Examplcs

e.~
__
.,) (0\
'\
\
I

c
108 T-shaped Fractures

/ b Antenor column
/
/
\
\
\
\
./
a I /

Fig. 81 A, B. Vertical T-shaped fracture. A Antero-posterior ra- position in A and their separation in B furnishes sufficient evi-
diograph, a diagrarn, B iliac-oblique radiograph, b diagrarn. dence of astern and therefore this is a T-shaped fracture
The separation of the colurnns is not visible, but their superirn-
Atypical Examplcs 109

._.--.,
\.
\
J \
/ i
.I i
J
I
I i
a I

Fig. 82A-C. Anterior T-shaped fracture. A Antero-posterior ra- separated fragment. The fracture line in the cotyloid fossa lies
diograph, a diagram, B obturator-oblique radiograph on which very antcriorly and the obturator ring is cut at the level of
the fracture of the ischio-pubic notch is visible, b diagram. the angle of the pubis
C iliac-oblique radiograph, c diagram. The teardrop is on a
110 T-shaped Fractures

Fig.82C

Fig. 83. Posterior T-shaped fracture. A Antero-posterior radio-

graph. a diagram. Note the separation of the teardrop from
the ilio-ischial line
Atypical Examples 111

\,.
-(
,.... - '\
\
J i
I i
J
/
, i
I

\
, i
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1
I
a
A

,-.. ,
\
i
'-....1 i
!
J
/
/
b /
B

Fig.84A-C. T-shaped fracture with trans-ischial stern, A An-
tero-posterior radiograph. a diagram. B obturator-oblique ra-
diograph with split of the ischio-pubic fragment weil exposed
through the ischium, b diagram, C iliac-oblique radiograph.
c diagram, The obturator ring is intact. The reduplication of
the ilio-ischial line proves that there is a fracture through the
the posterior part of the quadrilateral surface, The image 01'
the more internal of the ilio-ischial lines has anormal relation-
ship with the teardrop, The iliac fragment is cut inferiorly
as in a transverse fracture
112 T -sha ped Fractures

\_ .......
\
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/ '
.
. \
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c \.." .,

Fig.84C

Fig.85A, B. T-shapcd fracturc with postcrior stem splitting l>

the ischium. A Antero-posterior radio graph with pelvic brim
only a httle displaced. B obturator-oblique radiograph on which
it is cvcn less displaced. Note thc pure transverse element B
Atypieal Exa mples 113

Fig. 86A-C. T-shaped fraeture wit h assoeiated fraeture of the

super ior pubie ramus. ASeheme. B iliae-oblique radiograph.
b diagram. C ob turat or-ob li que radiograph showing the frae-
ture lin es of the isehio-pubie ramus. the superior ramus and
the iseh io-pubic noteh . c diagram

C
B

~~
./'
I
I
/~., ( ...
._ .-\
.
-
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\ .,
.
~ .I
'-..- . i
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i
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b c
114 T -sha ped F ractures

\\
\
b
B

Fig. 87 A-D. T-shaped fracture with double stern in the coty- AScheme, B antero-postcrior radiograph, b diagram, C obtura-
loid fossa scparating a segment of the quadrilateral surface. tor-oblique radiograph, D iliac-oblique radiograph, d diagram
Atypical Examplcs 115

A
D

/ .
/ Anlerior wall
i of acelabulum
/ '~ .
! I
./ 1-- '
.
I !
. ~
"
\. \
.
.
\
\ \.
\
\ \
I \
I \
d \ a \

Fig.87D

Fig. 88A-C. fracture ofthe posterior column with a hcmitrans-

verse anterior fracture. A Antero-postcrior radiograph. a dia-
gram. B obturator-oblique radiograph. b diagram. C iliac-ob-
lique radiograph. c diagram. The hemitransverse element cuts
but does not displace the anterior column. It is probably extra-
articular for although it may cut the pelvic brim. in Band
C it rcaches the fOot 01' thc superior pubic ramus
116 T-shapcd Fractures

Fig. 88 Band C
11 Associated Posterior Column and Posterior Wall Fractures

This association comprises a fracture of the poste-
rior wall of the acetabulum in one or several frag-
ments, perhaps with marginal impaction, together
with a fracture of the posterior column. The latter
is not always complete and frequently little or not
at all displaced.
The combination occurs infrequently but the
characteristics thereof are so well defined that it
seems plainly justified to individualise it.
summit of the angle (one case), or in the middle
part of the anterior border (one ca se ).
On the q uadrilateral surface the fracture line
has the characteristics of the posterior column frac-
ture and like it most commonly reaches the ischio-
pubic notch. It does not transgress the innominate

11.1 Morphology

11.1.1 Posterior Wall Component

This can be represented by any of the types that
we have already described. In our series these were
postero-superior in four cases, typical in seven
cases, and postero-inferior in one case; in six exam-
pies the displaced posterior wall fragment was in
one piece, and in six cases it was comminuted.
There was marginal impaction in six examples.
The posterior wall fragment or fragments re-
mained congruent with the femoral head when it
was dislocated but not when it had been reduced.
The posterior dislocation of the femoral head
was almost constant (11 cases out of the 12). In
one case the head had spontaneously reduced and
was found concentric with the roof and the anterior
wall, which were intact.

11.1.2 Posterior Column Component

The fracture line begins in the cavity created by
the posterior wall fracture and reaches the greater
sciatic notch (Fig. 89), most commonly (10 ca ses) Fig. 89 A, B. Schemes of associated posterior column and poste-
a little inside the angle, exceptionally below the rior wall fractures
118
li ne (Fig. 89 A). In two cases, the column separated
from the ischial tuberosity and did not disturb
the bony ring of the obturator foramen (Fig. 89 B).
The ischio-pubic ramus was broken only in one-
quarter of our cases and more usually the posterior
column fracture line split the ischio-pubic notch
but spared the ischio-pubic ramus. It is almost
as if the fracture energy exhausted itself before
being able to" achieve a rupture here. This in-
complete fracture of the posterior column suggests
that the injury is primarily a fracture of the poste-
rior wall and the other component, the detachment
of the posterior column, is secondary.
The displacement of the posterior column is
variable in magnitude: there was no displacement
in one case in three; in only four cases of the 12
was the angle of the greater sciatic notch signifi-
cantly displaced into the pelvis.
11.2 Radiology
11.2.1 Antero-posterior View
Two sets of features are striking: firstly, the un-
broken innominate line and anterior border of the
acetabulum, which confirm that the anterior col-
umn is intact; and secondly, the posterior disloca-
ti on of the femoral head which displaces, in one
or several fragments of significant size, the poste-
rior wall (Fig. 90) and the posterior superior sector
of the acetabulum or of the postero-inferior seg-
ment (Fig. 91). If it is just the central part of the
posterior wall wh ich is displaced, the roof is seen
to be intact but if it is a postero-superior segment,
part of the roof is included. A postero-inferior
fragment remains concentric with the femoral head
and includes the sub-cotyloid groove and the upper
part of the ischia I tuberosity. In one ca se out of
two, the head of the femur remained related to
some fragments due to marginal impaction
(Fig. 92).
The posterior column fracture is recognised ei-
ther by its obvious displacement inside the outline
of the pelvic brim, the posterior border with the
ischial spine and the angle of the greater sciatic
notch being clearly visible (Fig. 91), or because
the ischio-pubic ramus is brokcn at a variable
point, being sometimes associated with a fracture
of the postero-superior margin of the obturator
foramen (Fig. 90).
Associatcd Posterior Column and Posterior Wall Fracturcs
The displacement of the posterior column may
be slight, in which case the ilio-ischial line keeps
an almost normal relationship with the teardrop.
In such cases, it is rarely possible to diagnose this
posterior column fracture from the antero-poste-
rior view alone (Fig. 90).
11.2.2 Obturator-oblique View
This confirms the integrity of the innominate line
and therefore of the anterior column, and delin-
eates the size and the nature of the posterior frag-
ments. In particular, the direction of the inferior
part of the fracture line detaehing the posterior
column can be seen. This line sometimes leaves
undisturbed the ischio-pubic ramus (Fig.9l) or
may break it in its middle part (Fig. 90) unless
it splits the ischium without involving the obtura-
tor foramen. There is no fracture of the superior
border of the obturator foramen when the fracture
line splits the ischium.
11.2.3 Iliac-oblique View
This shows the amount of displacement of the
posterior column, the direction of the upper part
of the fracture line on the inner aspect of the pelvis,
and the level of rupture of the greater sciatic notch.
It confirms that the anterior border of the acetabu-
lum is intact (Figs. 91 and 92).
11.3 Atypical Examples
The posterior dislocation does not always persist.
In one case the head was in place, centred about
the undisplaced roof and the anterior wall; since
the posterior fragments remained displaced, it is
certain that the dislocation had spontaneously
reduced.
The fracture of the posterior column, if it ex-
tends very far forwards including the teardrop and
the ilio-ischialline on the displaced fragment, pro-
duces a thinning of the upper part of the pelvic
brim seen in the simple forms described earlier
in extended fractures of the posterior column.
In one unusual case there is no fracture of the
ischio-pubic ramus but the obturator ring was
broken at the level of the superior pubic ramus.
Comment 119

11.4 Comment column and posterior wall lesions are associated.

This association between a posterior column and
a posterior wall fracture mus! be differentiated
from the pure posterior column fractures . Cer-
tainly, the latter are accompanied sometimes by
detached fragments in the upper part of the frac-
ture complex, but these fragments are small and
rarely carry articular cartilage. Their removal does
not compromise the overall reconstitution of the
articular surface. The posterior column is always
significantly displaced. In contrast, when posterior
it is the fracture of the posterior wall which pre-
dominates, and the fracture of the posterior col-
umn is sometimes incomplete or often only slightly
displaced.
The special examples which associate posterior
fracture and an incomplete posterior column frac-
ture detaching a fragment from the ischium and
not involving the obturator foramen , form the
transition between certain very extended fractures
of the posterior wall and the more typical forms
of the association which we have just studied .

/
/
I.
-
/ . _.:f-.,
.I
\

i. I
\.
\
. \
\
1
i
a b

Fig. 90 A, B. Associated posterior column and posterior wall border high up but reaches only the middle pa rt of the greater
fracture. A Antero-posterior radio graph. a diagram . B iliac-ob- sciatic notch
lique radi ograph , b diagram. The fracture line cuts the posterior
120 Associated Posterior Column and Posterior Wall Fractures

b /
." \
\
i
i
{
\
\
i

Fig. 91 A-C. Associated posterior column and posterior wall

fracture with posterior dislocation. A Antero-posterior radio-
graph. a diagram. Thc postero-inferior fracture is clearly visible
and the posterior border of the iliac bone is projected on thc
inner aspect of the pelvic brim. The ischio-pubic ramus is not
fractured. B Iliac-oblique radiograph showing the isolated pos-
terior border of the iliac bone, and the posterior column dis-
placed with the ischio-pubic ramus which acts as a hinge, b dia-
gram, C obturator-oblique radiograph. Note that the oblique
radiographs were taken with thc beam at 45° to the film, result-
ing in marked distortion c
Comment 121

A
B

t7J/
/--l
f -, i /+-"
/

I i... ( !-\ \
j,1
\ \ I
.
L.
\
iI //
\
\
I \(
\ \. \
\
\ ! i
a\ b I /
/

Fig. 92A-C. Associated posterior column and posterior wall turator-oblique radiograph. c diagram. The impacted fragments
fraeture with marginal impaction. A Antero-posterior radio- are separated from the head by a translucent area in A and B
graph, a diagram, B iliac-oblique radiograph, b diagram, C ob-
122 Associatcd Posterior Column and Posterior Wall Fractures

Hg.92C
12 Associated Transverse and Posterior Wall Fractures
Table \0
Associated transverse and posterior wall 95 20.2'Yo
fractures
Posterior dislocation 78 16.6%
Central dislocation 17 3.6%
The assoemtlOn of a transverse fraeture with a
fraeture of the posterior wall is frequent. It has
been reeognised for a long time and is ae-
eompanied by disloeation of the femoral head
wh ich is more eommonly posterior (78 ca ses) but
sometimes eentral (17 eases). The meehanieal the-
ory, outlined in Chap. 2, explains and relates these
sub-eategories to the site and direetion of impact.
From a purely praetieal point of view, one eould
eombine all of these fraetures into one group be-
eause they are amenable to operative management
through the same approach and have similar ra-
diologieal eharaeteristies, apart from the direetions
of disloeation. These are sometimes identieal or
so similar that it is impossible to eonclude, from
a radiologieal study of the fraeture alone, whieh
might be the direetion of disloeation assoeiated
therewith. This notion is reinforeed by the fact
that in scveral ca ses a posterior disloeation has
been eonverted after "reduction" into a eentral
dislocation. The same fraeture ean therefore be
assoeiatcd with either type of disloeation (Ta-
ble 10).
We shall preserve a division into two sub-
groups, depending on the type of disloeation, be-
cause meehanieally they are produeed by different
modes of impact. Above all, the ineidenee of com-
plieations with assoeiated transverse and posterior
wall fraetures with posterior disloeation is striking:
it is in this variety that we find most pre-operative
seiatie paralyses (19 ca ses ) and most seeondary os-
teoneeroses of the femoral head.
12.1 Posterior Dislocation
12.1.1 Morpho1ogy
(a) Transverse component. This was eomplete in
63 out of the 78 eases of posterior disloeation, and
it embodies all the eharaeteristies of the pure trans-
verse fraeture. The line eommenees posteriorly in
the noteh ereated by the separation of the fragment
of the posterior wall. It is eq uivalent to a trans verse
fraeture in whieh a portion eorresponding to the
detaehed segment of the posterior wall is laeking
(Fig. 93 C). The fraeture line ean vary both in its
site and in its orientation as is the ca se with the
pure transverse fraetures.
The exaet site of rupture of the anterior border
eould only be loealised radiologieally in 29 ca ses
out of 63. It was situated in 12 eases at the level
of the noteh of the anterior border ; in 13 examples
it was higher and in the remaining four, lower.
The level of the rupture of the posterior border
of the pclvie bone was very variable (Fig. 930).
As is the ca se for the pure transverse fraeture,
the level of the transverse eomponent eould be
classified into infra-teetal (24 eases), juxta-teetal
(36 eases) or trans-teetal (3 eases).
In seven examples the posterior fraeture was as-
soeiated with a T -shaped fraeture; the stern of the
T was vertieal or posterior oblique.
In 15 eases the transverse fraeture was in-
eompletc. The fraeture line cuts the posterior bor-
der of the iliae bone, sometimes at the level of
the isehial spine whieh it divides longitudinally or
above this. Then it passes through the eotyloid
fossa on the external aspeet and exaetly through
the quadrilateral surfaee on the internal aspeet of
the bone, as do the pure transverse fraeture lines.
but it stops a little short of the ilio-peetineal line.
as if the fraeture energy were exhausted. Typieally.
the fraeture surfaee is plane. as is generally the
124
ca se for transverse fractures. This incomplete
trans verse fracture line can be without displace-
ment but more frequently one sees an inward shift
of its inferior lip of 2-3 mm. Incomplete forms
represent the transition between pure posterior
wall fractures and the associated transverse and
posterior fractures.
As in the pure transverse fractures the inferior
ischio-pubic fragment is displaced inwards. The
displacement predominates at the posterior part
of the fracture due to the compound rotation of
the inferior fragment around vertical and horizon-
tal axes described in Chap. 9. In 8 cases the dis-
placement was absent although the transverse com-
poncnt was complete.
(b) Posterior wall component. In the majority
of cases (68 out of 78), this resulted in separation
of an area of posterior wall wh ich was not commi-
nuted in 38, in two fragments in 11, and in several
pieces in 19 examples. In 6 cases the posterior frac-
ture was accompanied by marginal impaction. In 4
cases the fracture was of the postero-inferior variety.
Assoeiated Transverse and Posterior Wall Fraetures
1 ease ---:7:~~-"I.'l
16 cases, /'"
I
,
I,
r
8 cases'
I
1-
10 casesl_
D
Fig. 93 A-D. Associated transverse and posterior wall fraetures.
A Scheme showing infra-teetal transverse component, B seheme
showing juxta-teetal transverse eomponent, C diagram of plane
of transverse component, n distribution of sites of rupture of
the anterior border of the greater sciatie notch (55 cases)
The extent of this fracture is variable both in
relation to the articular surface and to the posterior
acetabular surface. Sometimes the whole anterior
border of the greater sciatic notch may be detachcd
in one separate fragment. The posterior fragments,
displaced posteriorly by the femoral head, are
always vcry displaced and they never reduce even
if the head has done so and is apparently stable
after reduction.
(c) Dislocation. Posterior or postero-superior
dislocations are accompanied by a large posterior
capsular rupture in practically all instances.
Rarely, in the unusual cases with marginal impac-
tion, the main detached fragment remains attached
to the damaged capsular remnant.
12.1.2 Radiology
In typical cases (56 out of the 78) the fracture
complex was easy to recognise.
(a) Antero-posterior view. The posterior disloca-
ti on is the most striking feature. The femoral head
projects behind the roof of the acetabulum which
is outlined and superimposed thereon; it is in some
degree of internal rotation and its inner pole may
appear slightly inside the line of the pelvic brim.
The femoral head is surmounted or capped by
one or more fragments of the posterior wall which
Posterior Dislocation
are visible frequently through the relatively trans-
parent iliac wing; the supplementary fragments
may appear to lie behind the neck or even below
it.
Besides the fragment of the posterior wall and
the postcrior dislocation, it is possiblc to confirm
the presence of an associated transverse fracture
because all of the vertical and the oblique land-
marks of the acetabulum (pelvic brim, ilio-ischial
line, anterior border and cotyloid fossa) are broken
while the obturator ring is spared; on the inferior
fragment, the teardrop and the inferior segment
of the ilio-ischial line maintain their normal rela-
tionship. The roof is intact, and the ischio-pubic
fragment is displaced inwards as a whole.
(b) Iliac-oblique vieH'. This confirms the integrity
of the iliac wing and of the roof. The point of
rupture and the displacement of the posterior bor-
der of the innominate bone can be located while,
with more difficulty, that of the anterior border
of the acetabulum may be seen (Figs. 94, 95 and
97).
(c) Obturator-oblique view. The posterior disloca-
tion together with the size ofthe posterior fragments
and the extent of the cavity left in the posterior
border of the acetabulum are all delineated. The
integrity of the obturator ring and the degree of
obliquity and site of the transverse fracture are
confirmcd.
(d) Overall radiological assessment. There are sev-
eral points in the radiological diagnosis which
can be summarised to advantage:
(i) Localisation of the posterior wall component.
The fracture of the posterior wall presents as a
noteh in the posterior border as seen on the antero-
posterior and obturator-oblique views, usually at
the level of the posterior border. Sometimes the
fraeture is more inferior and one or more frag-
ments earry the posterior horn of the artieular sur-
face together with the sub-eotyloid groove and the
superior segment of the isehium; these fragments
may remain or not eongruent with the femoral head
whieh is in a posterioriy subluxed position (Fig. 96).
It ean generally be reeognised on the antero-
posterior view whether thc fraeture is simple or
involves marginal impaetion (6 eases out of 61).
The volume of the one or several posterior frag-
ments is variable: sometimes they comprise the
whole of the posterior wall and all of the retro-
acetabular surfaee and include the anterior border
of the greater seiatie noteh, or they may be very
small.
125
(ii) Charaeter of the transverse component. This
is most eommonly juxta-teetal or infra-tectal
(Fig. 95), rarely trans-tectal. The obliquity of the
antero-posterior direetion of the fraeture line is
often diffieult to judge, for as a rule the point of
rupture of the anterior border of the acetabulum
is poorly visible. The fraeture of the pelvie brim
may be diffieult to loeate and it may be only at
the point of rupture of the posterior border of the
iliae bone that the trajectory ean be loeated aeeu-
rately (Figs. 93, 94 and 97).
(iii) Displacement of the ischio-pubie fragment.
This is identieal with that explained in Chap. 9 for
pure transverse fraetures, and measured from the
displacement of the same landmarks. Reeapitulat-
ing briefly, the isehio-pubie fragment pivots mutu-
ally around two axes: (I) The vertieal axis passes
through the pubie symphysis and the displacement
is therefore greater posterioriy than anterioriy;
this mode predominates most frequently (Fig.94).
(2) The horizontal axis extends from the pubie
symphysis to the point of rupture of the posterior
border of the pelvie bone; the displacement is
mostly at the pelvie brim whieh tilts inwardly while
at the posterior border there is minimal shift. The
body of the ischium rotates outwards.
Both eomponents oeeur together in the majority
of ca ses, and at operation the posterior fragment
appears driven medially and at the same time tilted
inwards in its upper part.
12.1.3 Atypical Examples
(a) Incomplete transverse FactlIre (15 eases). The
anterior bordcr of the greater seiatic noteh exhibits
a low fraeture on the antero-posterior and iliae-
oblique view but the innominate line, and therefore
the anterior eolumn, appear intaet on both the
antero-posterior and obturator-oblique Vlews
(Fig. 98).
Sometimes it is clear that the ilio-isehial line
is fraetured and the displacement indieates the di-
rection of thc fraeture li ne on the quadrilateral
surface. Displacement is usually very slight.
(b) Association oj"the posterior wall fraeture \I'ith
a T-shaped fractllre (6 eases). In addition to the
fracture of the posterior wall and the transverse
eomponent, there is a vertieal split of the isehio-
pubie fragment with a vertieal T -shaped fraeture
configuration (Fig. 99) or a T with a posteriorly
dirceted oblique braneh dividing the body of the
126
ischium and sparing the obturator foramen
(Fig. 1(0). The latter associated fracture is transi-
tional with respect to transverse fractures asso-
ciated with a postero-inferior wall fracture (dis-
cussed earlier in this chapter).
(c) Incarceration 01' a fragment 01' the posterior
wall (4 cases).
(d) High tran~uerse Jracture with fracture oJ the
iliac wing. Very unusually (2 cases) we have seen
an association between a high transverse fracture,
alm ost trans-tectal, and a fracture line extending
across the iliac wing reaching the iliac crest. The
exact configuration of the wing fracture lines was
not explored on both surfaces of the bone, one
ca se having been approached through a posterior
approach and the other through the ilio-inguinal
approach. Through the ilio-inguinal operative field
we saw the fracture line in the iliac wing meeting
the transverse fracture in the iliac fossa. Thus the
iliac fracture did not transgress the pelvic brim
(Fig. 101 A). This observation together with ra-
diological study enabled us to establish that the
iliac wing fracture spared the articular surface and
joined the transverse component at the level of
the retro-acetabular surface. The whole roof re-
mained on the separated fragment of the ilium.
A similar case was recently (1981) approached
1aterally and the configuration of the fracture lines,
as described above has been verified. Remember
that we studied earlier a pure postero-superior
fracture not involving the pelvic brim, with an iliac
fracture line extending to the crest of the ilium
(Fig. 32), and a fracture of the upper part of the
anterior column which involved a slightly larger
fragment bearing together with the roof a segment
of the pelvic brim but sparing the obturator fora-
men (Figs. 53 and 63).
The relationship between these cases serves
again to demonstrate continuity between the differ-
ent varieties of fractures of the acetabulum.
12.2 Central Dislocation
12.2.1 Morphology
A fracture identical in configuration to those de-
scribed above (Sect. 12.1) can exist with a central
dislocation of the femoral head (17 cases). There
are a few minor differences in the extreme exam-
pies of both of these groups.
(a) Transverse component. This was juxta-tectal
in 9 cases and infra-tectal in 8 cases. It was remark-
Associated Transverse and Posterior Wall Fractures
able that in four low infra-tectal examples, the
transverse fracture line was oblique, being directed
very steeply upwards and forwards; it cut the is-
chial spine (3 ca ses) or the sub-cotyloid groove
(one case), and in either instance the point of frac-
ture of the pelvic brim was relatively posterior
and therefore high.
The transverse fractures in this association were
always displaced, this being inevitable because the
ischio-pubic fragment had been driven inwards by
the femoral head. The elements of the displacement
of the inferior fragment were the same as those
described in previous cases (Fig. 67).
In four instances a vertical split of thc inferior
fragment was associated with the transverse frac-
ture 1ine, thus amounting to a T-shaped fracture
with one or two breaks in the ischio-pubic ramus.
(b) Posterior component. There were 9 fractures
of the posterior wall each comprising one or two
fragments; of these, one involved marginal impac-
tion, three were posterior extended comminuted
fractures extending from the roof to the sub-coty-
loid gutter, and four were postero-superior frac-
tures of which one was accompanied by marginal
impaction.
Thc posterior fragment tends to be 1ess displaced
than is the case for posterior dislocation simply
because the femoral head lies in a different posi-
tion.
(c) Dislocation. Most commonly this was ob-
vious and severe, but in a few cases it was not
so and in one the head had returned underneath
the roof of the acetabulum.
12.2.2 Radiology
(a) Antero-posterior view. The transverse fracture is
as always confirmed by the rupture of the verti-
cal landmarks and the oblique lines related to the
acetabulum (the pelvic brim, the ilio-ischial line,
and the anterior border of the acetabulum). The
transverse fracture line may be juxta-tectal or in-
fra-tectal, or it may be situated even lower, divid-
ing the ischial spine posteriorly and passing oblique-
ly upwards and forwards, therefore cutting the
pelvic brim in its middle part (Fig. 102). The head
appears dislocated centrally and has lost all con-
tact with the roof. The ischio-pubic fragment is
displaced around the usual axes. A postero-supe-
rior fracture is clearly visible as it involves the
external part of the roof. The typical posterior
Central Dislocation 127

Fig. 94A, B. Associated juxta-tectal transverse and posterior

wall fracture with posterior dislocation. A Antero-posterior ra- / -. ./
diograph, a diagram , B iliac-oblique radiograph, b diagram.
The marked inward displacement of the ischio-pubic fragment
/ '\I.i
is very prominent in its postcrior part (A). The fracture line i'"
detaches the angle of the greater sciatic noteh. The uneven \ /
contour of the pubic symphysis reveals the si te of rotation \ li Roof
\ \ \'
about a horizontal axis lf. ,\
i -'obturator \ \
b i / canal V
wall fracture is more difficult to see when it affects
amiddie part of the posterior wall, with one or The transverse fracture line reaches the greater
more fragments, because these cast shadows which sciatic notch posteriorly. The obturator ring is
are superimposed behind that of the femoral head most commonly intact (12 cases out of 17), but
or the femoral neck; the irregular outline of the the presence of a rupture of the ischio-pubic ramus
posterior border of the acetabulum, or of a large in one or two p1aces should lead to a search for
notch outlined at its level, should lead the observer a vertical split of the ischio-pubic fragment (see
to look carefully for the posterior fracture. Sect. 12.1.3 (b) above).
128 Associated Transverse and Posterior Wall Fractures

/~.

/
i
\
\
\
i
i
a i

/"8 '/)
I • ~/ L-
i ./~\

,
\
I ~--~ . ~
\ ( ''0..
\

\ \
c \ \
\

Fig.95A-C C
 Central Dislocation 129

Separation 01
posterior
border 01
ischium
'I
i
i
I
A a
Fig.96. Assoeiated infra-teetal and postero-inferior wall frac- The detached fragment does not remain adjacent to thc femoral
ture with posterior disloeation. A Antero-posterior radiograph. head. There is pure dislocation in the right hip. Such fractures
a diagram. The postero-inferior fraeture line is typical and docs are transitional with respeet to posterior T -shaped fractures
not involvc the obturator ring. lt cuts the lesser sciatic notch.

Fig.97. Associated low infra-teetal transverse and posterior

wall fraeture with posterior dislocation. A Antero-posterior ra-
diograph. a diagram. The transversc eomponent splits the
ischial spine

\
i ......
\ . . .~ , / \
\
i
j
i
i
I
i
A

<J Fig.95A-C. Associated infra-teetal transverse and posterior are distorted because the X-ray beam was not perpendicular
wall fraeture with posterior dislocation. A Antero-posterior ra- to the film. A fracture line passes through the inferior fragment
diograph. a diagram. B iliac-oblique radio graph. b diagram. below the transverse fracture line. through the ischial spine.
C obturator-oblique radiograph. c diagram, The oblique views separating the anterior border of the greater sciatic notch
130
/"'_. .I
/ -)j
/ I
{ \
\
\
\ \\
a I
Fig.98A, B. Associated incompletc transverse and posterior
wall fracture with posterior dislocation. A Antero-posterior ra-
diograph, a dia gram, B obturator-oblique radiograph, b dia-
(b) Iliac-oblique view. In particular, this shows
thc level of the fracture of the posterior border
of the innominate bone and sometimes the point
at which the transverse fracture line cuts the ante-
rior border of the acetabulum.
(c) Obturator-oblique view. This confirms the
central dislocation of the head, and it shows one
or more posterior fragments of which the displace-
ment is always less than in the case of a posterior
dislocation of the hip. Also, it shows clearly the
obliquity ofthe plane of the transverse component.
It confirms or proves the existence of a vertical
split of thc ischio-pubic notch above, and the is-
chio-pubic ramus below, in one or two places, in
the ca se of a T -shaped fracture.
Associatcd Transverse and Posterior Wall Fractures
~-__i
/
i
,-/
b \
gram. The transverse fracture component does not spread into
the anterior column. The posterior dislocation had been re-
duced before the radiographs were taken
12.3 Comment
The association of a transverse fracture and a frac-
ture of the posterior wall comprises two sub-
groups which are determined according to the di-
rcction of the dislocation.
When a posterior dislocation prevails, the trans-
verse component may be regarded as an extension
of the posterior lesion, sometimes incomplete
moreover. The posterior fracture remains the more
important component because it allows the head
to escape posteriorly. With a central dislocation,
the principal lesion is the transverse component
which allows the head to dislocate directly inwards
Comment 131

Roof
-~.,~~~ '.. Incarcerated
I \ - . .fragment of roof

.-:,// ,i \ '.
\. '.
\,1\,_ . . .
I. '-
(--,
j '\ ...........
,..... \ ,\ "\
\ \.
'-/'
/" , \! \ j
/ \
)
( \. "

\ '-.
i '\ iI Inferior
fragment
'-\
- . . _. ~
..- . ..,.,' \ \ of poslerior
a ./ a \ \ acetabulum Stem of T
crossing ischium

Fig. 99. Associated vcrtical T -shaped and posterior wall fraeture Fig. 100. Assoeiated trans-ischial posterior T -shaped and poste-
with posterior disloeation, A Antero-posterior radio graph, rior wall fraeture with posterior dislocation. A Antero-posterior
a diagram radiograph, a diagram. This view shows the vertical split in
the ischium. Note the incarcerated fragment of roof

and the posterior fraeture is the aeeessory lesion,
the result of the fraeture energy dissipating at the
level of the posterior wall.
The two sub-groups are related by the faet that
a posterior subluxation after reduction can be
transformed into a central dislocation, increasing
the displacement of the isehio-pubic fragment.
Without knowledge 01' the preceding events, from
the secondary central dislocation films, it is not
possible to conceive that the displaeement was ini-
tially posterior (Fig. 104). Fragments 01' posterior
wall can be carried into the joint space as a result
of the reduction, which further complicates the
appearanee (Fig. 104).
132 Associated Transverse and Posterior Wall Fractures

~,,\
\
\
i
//)
/
j
i
\
c

b
Fig.IOIA-C
Comment 133

D
(4t\
,
.
' .
'- - ".
I
'
I
. '
\,
iI
". I.
\ I
) I
i i
" I
a '\. .

/ "1-'-
,
i I
i
j
I
I
I
,/
,/
/
d

Fig. 10 I A-D. Associated transverse and superior fracture. lt
takes the roof and extends to the iliac erest, giving a false
impression of an upside-down T; the stem does not split the
rooffragment. ASeheme, B antero-posterior radio graph, b dia-
gram, C obturator-oblique radio graph, c diagram, D iliae-ob-
lique radiograph, d diagram
Fig. \02. Associated trans-teetal transverse and posterior wall
fracture with central disloeation. A Antero-posterior radio-
graph. a diagram. Posteriorly the transverse componcnt splits
the ischial spine
134 Associated Transverse and Posterior Wall Fractures

A B

a b

Fig. 103A-C. Associated juxta-tectal transverse and posterior tero-posterior radio graph, a diagram, B obturator-oblique ra-
wall (in two segments) fracture with central dislocation. A An- diograph, b diagram, C iliac-oblique radio graph, c diagram
Comment 135

'-.. ._ ."'\
\
I
/
./
.
/
/
/
c a /

Fig.l03C

Fig. 104A-C. Associated transverse and posterior wall fraeture

with posterior dislocation converted to a eentral disloeation
during attempts at reduction. Note pedunculated inearcerated
fragment. A Antero-posterior radiograph, a diagram, B obtura-
tor-oblique radiograph, b diagram, C iliac-oblique radio graph
136 Associated Transverse and Posterior Wall Fractures

'r
~
C

~"-'---
I .
/- \-
. \
I
/
/"
b
/
/
j
Fig. 104B and C
13 Associated Anterior and Posterior Hemitransverse Fractures

Table 11

Associated anterior and posterior 23 4.9%

hemitransversc fraetures

Anterior wall 9 1.9%

Anterior eolumn 14 3.0%

We identified this assoeiation in 1960, and in our

series of 469 eases it has oeeurred on 23 oeeasions
(4.9%). It eomprises an anterior fraeture of the
aeetabulum, whieh may be a fraeture of the ante-
rior wall or a fraeture of the anterior eolumn, to-
getherwith a fraeture ofthe posterior eolumn, whieh
is exaetly the same as the posterior half of a pure
transverse fraeture. Aeeordingly, we have ealled
this eomponent a hemitransverse posterior fraeture
(Table 11).

13.1 Morphology

13.1.1 Anterior Fracture

If this is a fraeture of the anterior wall of the
aeetabulum (Fig. 105) (9 ca ses) the detaehed frag-
ment has the typieal eharaeters of the pure form.
It may be displaeed in one piece or remain attaehed
to the superior pubie ramus on whieh it rotates.
Frequently however, it is split either longitudinally
or transversely. The femoral head whieh is driven
against the fragment is disloeated anteriorly. The
displacement is always marked. An assoeiated frae-
ture of the isehio-pubie ramus in its middle part
may be seen (2 eases) in whieh ease the lesion eom-
prises a tripie fraeture: the anterior wall, the ante-
rior eolumn and the posterior hemitransverse eom-
ponents. We have already diseussed this in Chap. 8
and have stated there why we eonsider for praetieal
Fig. 105 A, B. Sehemes of assoeiated fraetures. A Associated
anterior wall and posterior hemitransverse. B assoeiated middle
anterior column and posterior hemitransversc
reasons that these are like pure anterior wall
fraetures. In 2 eases out of 9 there was elevation
of the cortex from the quadrilateral surfaee whieh
was also displaeed inwards by the head.
More frequently there was a fraeture of the ante-
rior eolumn (14 eases) and this may be classified
as for the pure lesion (SeeL 8.1):
138
- low anterior eolumn fraeture, the fraeture line
eutting the psoas groove (one ca se in whieh there
was no rupture of the isehio-pubie ramus);
- intermediate anterior eolumn fraeture (4 ca ses)
(Fig. 115 B);
high eomplete anterior eolumn fraeture
(5 ca ses) ;
- high ineomplete anterior eolumn fraeture in
whieh the fraeture line did not reaeh the iliae
erest (4 eases).
As stated earlier, the displacement of the ante-
rior eolumn is always severe. In the high anterior
eolumn fraetures, there were three examples in
whieh the fraeture line extended from the iliae crest
to the angle of the pubis; in two eases the detaehed
fragments were split at the level of the anterior
wall of the aeetabulum or through the superior
pubie ramus. In one ease at least a very large
fragment, in one piece, rotated around the point
of rupture whieh was situated very far back along
the areuate line (Fig. 109). In another ease, the
iliae wing fragment included the angle of the saero-
iliae joint.
We must emphasise aga in that these anterior
lesions together with the anterior displacement of
the femoral head whieh aeeompany them are
identieal to those whieh we have seen in pure ante-
rior lesions and they are quite independent of the
posterior eolumn lesion.
13.1.2 Posterior Column Fracture
The posterior eolumn is erossed by a fraeture line
identieal with the pure transverse variety and may
oeeur at any of the levels deseribed in Chap. 9
(Fig. lOS). We found its point of rupture at the
posterior border of the aeetabulum to be in its
inferior quarter or below in 15 eases, in its middle
part in 4 eases, and in its upper part in another
4 eases; we have seen one epiphyseal separation of
the posterior eolumn in this group. The point of
rupture of the anterior border of the greater seiatie
noteh is related to the level of the fraeture line
of the posterior border of the aeetabulum; in so me
instanees it divided the isehial spine longitudinally
while in the remainder it cut the greater seiatie noteh
at any level even reaehing its superior border.
The displacement of the posterior eomponent
was less marked than in the ca se of the anterior
eolumn lesion. There were nine signifieant dis-
placements, six very slight displacements, and two
eases showed none at all.
Associated Anterior and Posterior Hemitransverse Fractures
In six instanees, the posterior fraeture line was
ineomplete and it stopped short of the dense trabee-
ulae found in the anterior border of the greater
seiatie noteh. This group forms a transition be-
tween a pure anterior eolumn fraeture and the
assoeiation with whieh this ehapter is eoneerned.
The speeimen shown in Fig. 106 is a typieal exam-
pIe of this weil defined group.
From anatomieal and radiologieal points of
view, the fraeture lines of the two eomponents
of the assoeiation appear as independent entities.
The fraeture, separating in one piece the anterior
eolumn, is eoneave antero-superiorly and is di-
reeted obliquely downwards and forwards; it
diverges gently from the brim of the true pelvis
on to the quadrilateral surfaee. The fraeture line
whieh cuts the posterior eolumn meets the anterior
eolumn eomponent at a right angle. The trans-
verse hemi-fraeture line is almost straight when
seen on the quadrilateral surfaee and cuts the
greater seiatie noteh at a variable level. The retro-
aeetabular surfaee is divided more or less obliquely
by this straight fraeture line as is the ca se in trans-
verse fraetures (Fig. 106 B).
Two fundamental points should be observed:
(1) While the posterior fraeture line detaehes the
inferior part of the posterior wall, and the fraeture
of the anterior eolumn detaehes the anterior wall
and part of the roof, a sector of the artieular sur-
face of the roof always remains on the wing of
the ilium. This differentiates these fraetures from
the both-eolumn type to be deseribed later
(Fig. 107 B). (2) The outline of the fraeture as seen
from the inner aspeet of the pelvis is eompletely
different from those of the T -shaped fraeture whieh
also leave a sector of the artieular surfaee in plaee
on the iliae eomponent (Fig. 107 C).
13.2 Radiology
It is not neeessary to deseribe in detail the anterior
lesion whieh retains the eharaeteristies of the pure
anterior eolumn fraeture or of an anterior wall
lesion (Figs. 108-111).
On the antero-posterior and obturator-oblique
views, the anatomieal type is easy to define. The
femoral head follows the anterior lesion and may
be truly anteriorly disloeated having lost eontaet
with the rest of the remaining roof, or it may
be only subluxed. Oeeasionally it is displaeed in-

Fig. I06A-C. Assoeiated anterior wall and posterior ineomplete
hemitransverse fraeture. Clinieal speeimen relating to Fig. 112.
In A the roof remains in p1aee under the wing. above the
posterior end of the transverse fraeture eomponent. In B the
fraeture line stops before the anterior border of the greater
seiatie noteh. C shows method of fixation. Sec x-rays on Fig. 112
wards and forwards and remains related to a large
segment of the artieular surfaee earried by the ante-
rior eolumn; an apparent eongruenee of the two
parts may be a diagnostie pitfall, for the head
may not seem to be disloeated at first sight and
it is easy to miss observing that there is a segment
of the roof whieh has remained in its proper plaee
on the iliae wing on the antero-posterior view
(Figs. 109 and 114); it may appear on the obtura-
tor-oblique view albeit sometimes very small.
Again, the head ean return under the remaining
part of the roof and appears quite separate from
the anterior eolumn fraeture.
A bone plate from the artieular surfaee is so me-
times displaeed inwards by the femoral head. It
will appear on the iliae-oblique view (Figs. \09 and
111) .
The main problem is to reeognise and define
the fraeture in the posterior eolumn.
B
C
13.2.1 Antero-posterior View
The posterior wall of the aeetabulum is erossed
by a fraeture line wh ich ean loeate at any level
on the posterior border of the aeetabulum. It is
almost straight, being slightly obliq ue upwards and
inwards thereby reaehing the ilio-isehialline, eross-
ing it in most eases. In the fraetures without dis-
placement (4 eases), the line fol\ows this pattern
and merely marks the posterior border and the
ilio-isehial line. Displacement, when it oeeurs, is
inwards and assoeiated with a rotation of the lower
segment of the posterior eolumn around a vertieal
axis; this is reeognisable by a step in the posterior
border of the aeetabulum and separation at the
ilio-isehial line (Fig. 108). In the rare eases when
the fraeture line is very low, it cuts the ilio-isehial
line and the teardrop, the lesion of the anterior
eolumn having avoided the zone of the teardrop
140
AI A2
B CI
and passing into the anterior part of the cotyloid
fossa.
In most instances, the ilio-ischial line was fr ac-
tured (12 cases); it was sometimes displaced
(4 cases), and occasionally apparently intact
(3 cases) (Fig. 112). The ilio-ischialline lost its rela-
tionship with the teardrop, a consequence of the
anterior fracture (17 out of 19 cases).
In two examples out of 23 the posterior fracture
line had a very oblique and curved direction on
the posterior wall and appeared to reach the inter-
nal border of the roof of the articular surface.
These cases were not treated operatively, and the
exact nature of the fracture line was not recog-
nised. One of them was a hemitransverse in-
complete fracture which spared the greater sciatic
notch (Fig. 111).
13.2.2 Iliac-oblique View
This shows best the direction of the posterior part
of the fracture line at the level of the quadrilateral
Associated Anterior and Postcrior Hernitransverse Fractures
Fig. 107 A-C. Sehern es of various asso-
ciated anterior and hernitransverse frac-
tures. AI Anterior colurnn and posteri-
or hernitransverse. A 2 anterior wall and
posterior hernitransverse, A3 endopelvic
aspeet of Aland A 2, B both-colurnn frae-
ture (to show differencc), CI T-shaped
fracture (to show differenee), C 2 endo-
pelvie aspect of CI
A3
C2
surface. Its straight character is emphasised. The
fracture line in most instances reaches the anterior
border of the greater sciatic notch at a variable
level; in extreme cases when it is low it divides
the ischial spine but when high, it terminates at
the angle of the greater sciatic notch.
A possible fracture of the iliac crest and the
fracture outline on the iliac wing, when this type
of anterior column component is present, are also
seen on this view.
13.2.3 Obturator-oblique View
The posterior fracture line skirts the posterior wall
following an obliquity which often seems more
marked than that observed on the antero-posterior
view. The point of rupture on the posterior border
of the acetabulum is weil visualised. When an
extended fracture line of the anterior column is
present, taking with it the greater part of the roof
so that on the extern al surface of the iliac wing
it reaches the posterior part of the roof, the outer
Radiological Differential Diagnosis
aspeet of the supra-aeetabular region presents with
a break marked by a slight change in eontour of
the wing but with little or no separation. This
fraeture line appears in seetion on the iliae wing
above the aeetabulum and detaehes the anterior
eolumn.
A feature that eontributes to individualise this
fraeture is the persistenee on the posterior iliae
fragment of a segment of artieular surfaee isolated
below by the transverse fraeture line, and above
by the upper part of the anterior eolumn fraeture
line.
The reeognition of the remaining artieular sur-
face on the posterior iliae segment is essential for
the eomplete diagnosis of the fraeture eomplex.
Unfortunately this ean be diffieult beeause it is
not weil situated for good radiologieal definition
in the standard views. The diagnosis is less diffieult
when the anterior lesion is a fraeture of the anterior
wall, for even when fairly extended, such a fraeture
always leaves in plaee the greater part of the roof
whieh ean be reeognised easily on the antero-poste-
rior and oblique views. There is no doubt as to
the eontinuity of the undisplaced roof segment with
the iliae wing.
Greater diffieulty oeeurs in eases of fraeture of
the anterior eolumn, for the eolumn fragment may
include a large part of the roof. Further, the poste-
rior hemitransverse fraeture may be high, so that
the artieular segment remaining in plaee may bc
very small.
The short articular segment may be invisible on
the antero-posterior view when the anterior col-
umn fraeture is high and extended (Fig. 109); fur-
thermore, it is not seen in the iliae-oblique view
for here it is perpendieular to the direetion of thc
X-ray beam. It may appear only on the obturator-
oblique view as a small seetion of roof above and
internal to the remaining part of the posterior bor-
der of the aeetabulum (Fig. 109 B). In short, this
anatomieal variety will be identified in the antero-
posterior view or the obturator-oblique view, or
perhaps both, only on reeognising the seetion of
roof in situ, even if it is very small and overshad-
owed by the surrounding bone of the iliae wing.
13.3 Atypical Examples
(a) Incomplete iliac wing component. A high an te-
rior eolumn fraeture ean present with an in-
eomplete break in the iliae wing (4 eases); the frae-
141
ture does not reaeh the erest, stopping just below
it, but the jagged outline in the wing extending
towards the crest is unmistakable on the antero-
posterior and iliae-oblique views.
(b) Incomplete hemitransl'erse component. The
hemitransverse eomponent may be ineomplete
(6 eases). The fraeture line is obvious at thc level
of the posterior wall of the aeetabulum on the
antero-posterior and obturator-oblique views. The
ilio-isehial line ean appear broken, bent or un-
involved but of most signifieanee is the interrup-
tion of the posterior border of the aeetabulum.
The iliae-oblique view shows that it is a transitional
fraeture beeause the posterior fraeture avoids the
anterior border of the greater seiatie noteh, the
fraeture energy having been exhausted before ha v-
ing ruptured the dense trabeeulae of the anterior
border of the greater seiatie noteh. In these eases,
the posterior fraeture line ean be displaeed so that
the inferior fragment of the eolumn rotates around
a point at the anterior border of the greater seiatie
noteh (Figs. 106, 111 and 112).
(e) Associated anterior wall, anterior column and
posterior hemitransverse fractures. In a few eases
we have seen a rupture of the isehio-pubie ramus
at one or two plaees together with displacement
of the anterior wall clearly visible on the antero-
posterior and obturator-oblique views; the ante-
rior wall segment was detaehed and driven in in
one piece. This amounts to the assoeiation of a
fraeture of the anterior wall with a fraeture of
the anterior eolumn, plus a hemitransverse poste-
rior fraeture. As another transitional form, it
eompletes the overall unity of these fraetures of
the aeetabulum (Fig. 113).
(d) Associated epiphyseal separation ()t' the poste-
rior column. There was one ease: a ehild who had
a high anterior eolumn fraeture detaehing the ante-
rior part of the iliae wing with the pubis, assoeiated
with an epiphyseal separation of the posterior eol-
umn along the posterior braneh of the Y-shaped
aeetabular eartilage (Fig. 114).
13.4 Radiological Differential Diagnosis
In this group of assoeiated fraetures, the differenti-
ation from T -shaped and both-eolumn fraetures
is of partieular importanee.
(a) T-Shaped Fracture. In such a fraeture
(Fig. 107), the anterior eolumn is broken at a vari-
142
A B
\
·-tr'- "\
) .>
Ir
I
I
a I
Fig. \08 A and B
able level but the plane of the upper fraeture is
identieal to that of a pure transverse fraeture ae-
eompanied by its regularity. Even T-shaped frae-
tures with the stern direeted obliquely forwards
have a different design in that they seetion the
anterior eolumn transversely; they do not result
in separation of the artieular surfaee of the anterior
wall with its trapezoidal-shaped fragment of the
eolumn (as in the anterior wall variety) or with
a segment mueh more extensive than this (in the
fraetures of the anterior eolumn).
In assoeiated anterior eolumn and posterior he-
mitransverse fraetures, whieh we have just studied,
Associated Antcrior and Posterior Hemitransverse Fractures
\
)
I
b
it is only the posterior eomponent whieh is identi-
eal to the pure trans verse type (see Fig. 107 and eom-
pa re Figs. 108A and 80A)
(b) Both-co/umn fracture. Sueh a fraeture in
whieh all the artieular surfaee is detaehed embodies
a eharaeteristie spur formation (seen on the obtu-
rator-oblique view) resulting from marked dis-
plaeement. This is very different from the slightly
displaeed fraeture line above the aeetabulum whieh
is seen in the assoeiated fraeture eomplex whieh
we have just studied. No seetor of the roof remains
in plaee in a both-eolumn fraeture.
Radiologieal Differential Diagnosis 143

c A

Elevated co rtex 01
c quad rilateral
surtace
/
......- ." ' /
./ -yt" DDLl.
II .\
1..., .
\ \
\
\
i
a i

Fig. 108A-C. Assoeiated anterior wall and posterior hemitrans-
verse fraeture. A Antero-posterior radiograph, a diagram, B ob-
turator-oblique radiograph, b diagram, C iliae-oblique radio-
graph, c diagram. Note in A and C the plate 01' bone eie va ted
from the quadrilateral surfaee
Fig. 109 A-C. Assoeiatcd anterior column and posterior hemi-
transverse fracture. A Antero-posterior radiograph, a diagram,
B obturator-oblique radiograph, b diagram, C iliae-oblique ra-
diograph. c diagram. The antcrior column is entirely detached
from the anterior superior iliac spine to the pubic spine and
has rota ted around the point 01' rupture of thc pelvic brim.
lt is associated with the hemitransverse component seen in
A as a rupture of thc postcrior border of the acetabulum and
of the ilio-isehial line. In B it cuts the middlc third of the
posterior wall of thc aectabulum and thc upper third of thc
greater sciatic noteh. Note the plate of bone lifted from the
quadrilateral surface 01' the isehium
144 Associated Anterior and Posterior Hemitransverse Fractures

/
\ /
\ I
\ )
b i / c

Fig. 109 Band C

Radiological Differential Diagnosis 145

-) ..
,_.- ."'.
"

,
.
/' ~

( \.
\
.
I
\
.)
.
I i
I i
i
i
i
a \

Fig. 110 A-C. Associated low communited anterior and postcri-

or hemitransverse fracture. A Antero-postcrior radiograph.
showing five fragments between the antero-inferior iliac spine
and the middle of the ischio-pubic ramus, a diagram. B obtura-
tor-oblique radiograph. C iliac-oblique radiograph -'-----' C
146 Associated Anterior and Posterior Hemitransversc Fracturcs

\, "\
...... ...... .
.
-'-'
L·
\
\ \
I j
I
i
{
..... '-
a
b \

Fig. 111 A, B. Associated low anterior and incomplete posterior traverses the posterior wall very obliquely upwards and in-
hemitransverse fracture. A Antero-postcrior radiograph . a dia- wards. stopping before the greater sciatic notch and not cutting
gram. B iliac-oblique radiograph. b diagram. The fracture line the ilio-ischial line

Fig. 112A-C. Associated anterior wall and posterior hemitrans- posterior border of the bone is seen in C to be intact: the [>
verse fracture. A Antero-posterior radiograph. a diagram . B ob- hemitransverse fracture line dies out in thc region of dense
turator-oblique radiograph. b diagram . C iliac-oblique radio- bone around the angle of the grcatcr sciatic noteh. See also
graph, c diagram. Thc ischio-pubic ramus is fractured. The Fig.106
Radl'(l! oglca!
' D'ff' ' D',Idgnosls
1 erentw! '

/
I
I
i
\
/)
a j

Fig. 112A-C C
148 Assoeiated Anterior and Posterior Hemitransverse Fraetures

/ .....
" V .\
- \\ \
,) \
7 I

,
/
/

J
b I

Fig. II3A-C. Associated anterior wall or column and hemi-
transverse fracture. A Antero-postcrior radiograph, a diagram,
B obturator-oblique radiograph, b diagram, C iliac-oblique ra-
diograph, c diagram. Interpretation is fairly difficult. At first
sighL A suggests a T-shape; in fact an area of detachmcnt
of the anterior column ean be seen. This is clearer in B where
a typieal anterior wall fraeture is assoeiated with a fraeture
of the isehio-pubie ramus. In C the posterior hemitransverse
eomponent is seen to be incomplete
Radiologieal Differential Diagnosis 149

Incomplete hemitransverse
Iracture line

Break in posterior border

01 acetabulum

Fig. ll3C

Fig. ll4A-C. Assoeiated extended anterior eolumn fraeture and

epiphyseal separation of the posterior eolumn. A Antero-poste-
rior radio graph. a diagram. B obturator-oblique radiograph.
b diagram. C iliae-oblique radiograph. c diagram. The antcrior
fraeture extends from thc anterior superior iliae spine to the
pubie spinc. Notc the buekling of the anterior part of the
iliae wing whieh was diffieult to reduce at operation
150 Associatcd Antcrior and Posterior Hemitransverse Fractures

B C

Epiphyseal
separation 01
posterior column

Fig. 114B and C

14 Associated Both-Column Fractures

In a thesis (LETOURNEL, 1961), the associated

both-column fracture was described, but it was
not until 1963, fo11owing the description of eleven
opera ted cases, that a furt her account was submit-
ted. RIGAULT (J 962) co11ected the first cases of
D' AUBIGNE under the name" central displacements
of the acetabulum ". This description, which al-
ludes to the method of production of the lesion,
has unfortunately the inconvenience of using yet
again a term we find imprecise: it does not give
an adequate account of the injury to the bane
framework which limits the acetabulum and which
is split in a special and typical manner.
The present study cancerns 87 cases which have
a11 been treated operatively by the anterior, the
posterior, or both approaches; the concJusions en-
able us to advance with certainty the anatomical
and radiologieal features whieh fo11ow.
We reserve the term assoeiated both-eolumn
fraeture for those whieh isolate mutua11y from eaeh
other, the two eolumns tagether with the related
segments of artieular surfaee. The only part to
remain attaehed to the saerum is a piece of the
iliae wing, varying amounts of whieh may remain.
From this latter fragment, all segments ofthe artieu-
lar surfaee have been separated (Fig. 115).

14.1 Morphology
These fraetures appear very eomplieated and they
are usua11y deseribed as "eomminuted", this term
masking an insuffieient study of the radiographs.
Their eomplexity is in fact very variable but never-
theless with experienee and operation through an
appropriate approach, we have reeently aehieved
exeellent reduetions in 41 out of 74 fraetures.
In a simple example eaeh of the eolumns sepa-
rates as one entity, the roof remaining with the
B
Fig. 115A, B. Both-column fracturcs. Schemcs showing iliac
component A extending to iliac crest, B extending to the antcri-
or border 01' the ilium
anterior eolumn. In the majority of eases the frae-
tures beeome mueh more complex beeause the
prineipal fragments are split by seeondary fraetures
whieh cut the anterior eolumn in two or three
fragments or whieh isolate a posterior segment or
a postero-superior segment of the aeetabulum as
a separate fragment. One fragment may not bear
152
any articular surface, coming from the iliac fossa
or from the brim of the pelvis. Sometimes, further
local fragmentation occurs along any one of the
multiple fracture lines crossing the pelvic bone,
furt her complicating the basic structure of the in-
Jury.
It is convenient to study separately the fragment
of each column.
14. L 1 Posterior Column Components
The posterior column is detached above by a frac-
ture which begins at a variable level on the poste-
rior border 01' the pelvic bone.
(a) Fracfure line af angle ofgreater sciafic noteh.
In about one case in two (39 out 01' 87) (Fig. 116)
the fracture line begins at about the angle 01' the
greater sciatic notch and descends on the retro-
acetabular surface obliquely downwards and for-
wards to reach the acetabular lip. The line then
cuts the articular surface and reaches the posterior
limit 01' the upper margin 01' the cotyloid fossa.
From here it skirts the upper margin 01' the coty-
loid fossa adjacent to the articular surface 01' the
roof for a short distance and then descends in
Associated Both-Column Fractures
Fig_ 116A-D_ Fracture lincs dctaching the
postcrior column. Diagrams of A distribu-
tion on rctroacctabular surfacc (66 cascs),
B possible sitcs of secondary fracture lincs.
C thc posterior fragment. D a special ex-
<lmplc. See Fig. 140 for radiographs
the anterior moiety, following the edge of the ante-
rior articular surface. Lower down it reaches the
ischio-pubic notch in its anterior part. On the op-
posite side 01' the obturator foramen the fracture
line cuts the ischio-pubic ramus at a variable posi-
tion. In 25 ca ses there was a fracture through the
body of the pubis, straight in outline but fre-
quently presenting a special appearance, concave
from above, and characteristic because we have
seen it only in both-column fractures (18 ca ses out
01' 87) (Fig. 124). In 42 instances, the ischio-pubic
ramus was fractured at one point, in 10 instances
it was fractured at two sites, and in 15, fractures
were present at both the ischio-pubic ramus and
the body ofthe pubis. In only two cases the inferior
margin 01' the obturator foramen was spared.
On the inner surface 01' the pelvis (Fig. 115) the
fracture line, from inside the angle 01' the greater
sciatic notch, is directed forwards obliquely and
downwards or horizontally, following a straight
or jagged course. Before reaching the brim 01' the
true pelvis it changes direction, becoming more
vertical before it reaches and fractures the ischio-
pubic notch. Very rarely it reaches the upper mar-
gin ofthe obturator foramen more posteriorly than
this. In a few cases the region 01' the notch IS
detached and appears as a separate fragment.
Morpholog o
Fig. 117. Seheme of an atypical both-column fraeture. The pos-
terior column includes a segment of the antcrior wall. See
Fig. 142 for radiographs
(b) Fracture fine at anterior border 0/ greater
sciatic noteh. In a little more than one case in
two (48 out of 87) (Fig. 116 A) the fracture line
detaches the posterior column from the anterior
border of the greater sciatic notch below the angle,
usually high, but sometimes at a lower point. From
there, descending obliquely downwards and for-
wards, it reaches the posterior lip of the acetabu-
lum at a variable site. lt traverses the posterior
part of the articular surface dividing it horizon-
tally, and reaches the anterior part of the cotyloid
fossa and ischio-pubic notch. From there the is-
chio-pubic fracture configuration is as before.
On the inner aspect of the pelvis, the fracture
line, apart from its point of departure from the
sciatic notch which is lower, has a trajectory simi-
lar to that described in (a) above.
(c) Exceptionaf cases. There have been several
exceptions to the descriptions in (a) and (b) above:
153
Fig. 118. Sehcmc of possiblc fraeture lincs detaching the anteri-
or column
In two examplcs the posterior column took with
it the superior border of the greater sciatic notch
and this, in one instance, was completely
detached and iso la ted.
In two other cases, the superior border of the
greater sciatic notch was separated and took
with it the lower part of the sacro-iliac articular
surface (Fig. 122).
- In five cases, there was a partiClllar mode of
detachment of the posterior column in which
this fracture li ne was spiral in configuration. It
began low on the anterior border of the greater
sciatic notch and joined the acetabulum, the spi-
ral effect existing between the outer and inner
surfaces of the pelvis (Fig. 116A).
In 62 of the total 87 cases the posterior column
was detached as one large piece including or ex-
c1uding the angle of the greater sciatic notch.
14.1.2 Additional Posterior Components
lt remains to describe the additional fracture lines
which may confuse the basic pattern:
(a) Secondary fracture 0/ the posterior column.
In 18 cases there was a fracture line which split
the posterior column (Fig. 116 B). It was most
commonly little or not displaced and was related
to the ischial spine, being adjacent to the superior
border (7 cases), at its summit and splitting it lon-
gitudinally (2 cases), or extending from a variable
point along the anterior border of the greater
sciatic notch (9 cases).
These fracture lines traverse the retro-acetabular
surface rejoining the posterior border of the ace-
tabulum and dividing the articular surface a little
154
} Fracture lines }
cunlng
anterior wall
Extra-anicular
Iracture lines
Fract ure lines
through superior pUbic ramus
Fig. 119. Scheme 01' possihlc fracture lines on the antcrior col-
umn involving the superior puhie ramus. (Thc articular surface
is shown hatched)
above the posterior horn. In a single case, the
anterior border 01' the greater sciatic notch was
detached in an isolated fragment. In one recent
case (Fig. 1160). there was a horizontal split with-
out displacement which divided the ischial spine
longitudinally and cut the posterior wall. The seg-
ment of the posterior column supra-adjacent to
this fracture line was divided by another splii. cor-
onal in plane. which followed the profile of the
anterior border of the greater sciatic notch and
therefore separated one fragment which carried
with it part 01' the cotyloid fossa. the other com-
prising a fragment 01' the posterior wall.
(b) Frac!ur(' of' pos!aior wall. In eight cases a
secondary fracture line detached a fragment 01' the
posterior wall (Fig. 116C) which carried some ar-
ticular cartilage. Leaving the main fracture above
the posterior column. this secondary fracture line
reached lower down to a variable point on the
posterior bord er 01' the articular surface. freeing
a posterior fragment and a portion 01' the articular
surface. In one case. this posterior fragment was
very extensive. extending inferiorlyon to the is-
chium.
A posterior column configuration as described
in (a) and a posterior fragment existed together
in five cases.
(c) fnm!r(,I11('n! of'pehic brim. In four cases. the
posterior column took with it a segment 01' the
pelvic brim (Fig. 117). In two 01' these we are cer-
tain that a segment 01' the anterior wall remained
attached to the fragment 01' the posterior column.
Associated Both-Column Fractllres
Fractures 01
the root
01 pubic ramus
Fig. 120. Scheme showing concept 01' displacement of fragments
Icading to apparent congrucnce
The fracture line above which separated the poste-
rior column. instead of avoiding the innominate
line. cut it and then divided the anterior wall of
the acetabulum; thus the anterior column was split
a little lower at the beginning of the obturator
canal by a fracture roughly parallel to the main
fracture. or having a bayonet-shaped configura-
tion. Thus a segment 01' the anterior wall or the
anterior wall itself remained attached to the poste-
rior column. This situation explains that in these
two cases wh ich had in other ways all the radio log-
ical appearances of both-column fractures. a per-
fect reduction was obtained by operating through
the posterior approach (Fig. 219).
In the two other cases. the innominate line was
followed by the fracture line which liberated the
posterior column. and the anterior wall was
detached as a separate fragment.
These fractures differ from the T -shaped frac-
tures associated with a vertical anterior fracture
of the same innominate bone. because no section
of roof remains attached to the iliac wing segment
(see page 113).
14.1.3 Anterior Column Component
In a11 our cases, the anterior column has been
separated by a fracture which. on the extern al sur-
face 01' the pelvis, begins at a variable point on
the retro-acetabular surface, confluent with the
fracture component which separates the posterior
column; most frequently this was towards the mid-
dIe 01' the surface but sometimes near the posterior
border. The fracture line travels across the iliac
wing perhaps reaching the iliac crest or extending
more anteriorly to the anterior border of the iliac
bone (Fig. 115).
Morphology
(a) Fraefllre /ine eXfending fo the iliac crest. This
is the commonest oecurrence. The fracture line
can be regular and curved, cutting both inner and
outer cortices approximately in the same pi ace,
but much more frequently it is zig-zag and the
configuration on opposite cortices is markedly dif-
ferent. Eventually, the two cortical fractures meet
each other again at the iliac crest splitting it vari-
ably. The most frequent site is in the anterior quar-
ter, level with or behind the anterior pillar, but
it may be at the summit of the crest or in its
posterior part, rarely in its most anterior part in
front of the pillar, or even at the antero-superior
iliac spine. Sometimes (Fig. 118), this iliac wing
component bifurcates in the middle of the iliac
fossa, reaches the crest at two points and isolates
a triangular segment of the iliac erest (13 cases).
Rarely (3 cases), the iliac fracture line just reaehes
the iliac crest without breaking it and forms there-
fore a hinge on which the anterior column tilts
(Fig. 129).
On the inner surface of the pelvis (Fig. 118) the
fracture line cuts the cortex of the iliac fossa in
a zig-zag fashion, passing forwards from the poste-
rior nutrient foramen, and reaches the arcuate line
2-3 cm in front of the angle of the sacro-iliac joint.
It then crosses the brim of the pelvis and after
a short distance, generally oblique below and for-
wards, rejoins the fraeture line whieh separates
the posterior column.
(b) Fracture !ine extending to anferior border
(15 eases out of 87). The iliac fracture line always
begins on the retro-aeetabular surface at a variable
point on the fraeture line separating the posterior
column; it then crosses the iliac wing without
reaching the crest.
The trajectory is generally curved and regular,
skirting 2-3 cm above the superior border of the
acetabulum, and reaches the interspinous notch
(Fig. 115 B). Sometimes it passes nearer the aeetab-
ulum and reaehes the anterior border below the
anterior inferior iliae spine (5 cases). Rarely, the
line starts at the back of the acetabulum passing
horizontally to split the roof of the acetabulum
and allowing a small segment of the artieular sur-
face to remain on the iliac wing; it terminates
in the psoas groove. The latter is a transitional
form with respect to fraeture of the posterior col-
umn associated with a hemitransverse anterior
fraeture whieh we included in our study of T-
shaped fractures.
On the inner surface, the fracture in the iliac
155
wing, of which the outline is zig-zag or curved,
always cuts the innominate line in front of the
saero-iliac joint and rejoins the fracture line cutting
off the posterior column.
14.1.4 Result of Both-Column Fracture
Between the fraeture li ne of the iliac wing, and
the fraeture which liberates the posterior column,
the anterior column finds itself totally detached
earrying with it the roof and the anterior wall
ofthe acetabulum. This large anterior eolumn frag-
ment was not detached in a single piece except
in two eases where the iliac wing component
reaehed the crest, and in five cases where the iliac
fraeture went to the anterior border ; most com-
monly, it is split (Fig. 119); this may oecur at the
level of the root of the superior pubic ramus, at
the level of the superior pubic ramus, (perhaps
at these two points), at the level of the iliac wing
or at the level of the acetabular roof.
When the secondary split is at the level of the
root of the superior pubic ramus (Fig. 119) it is
most eommonly perpendicular with respect to the
axis of the column; it is situated above, below
or at the level of the noteh on the anterior border
of the acetabulum and crosses the artieular surface
ofthe anterior wall. Sometimes, the split is oblique
or bayonet-shaped, and ean therefore pass extra-
artieularly lea ving the anterior wall attached to
the superior part of the anterior column. A particu-
lar aceessory fraeture line ean occur here so that
the roof of the obturator canal becomes a small
isolated fragment.
At the level of the superior pubie ramus we
find again a fraeture line whieh may be perpendicu-
lar to the axis of the pubic ramus, but which is
more often oblique; it stays little displaced and
is difficult to discover because the fragments are
maintained by the peetineal part of the inguinal
ligament whieh always remains unruptured al-
though it has in a few eases stripped off the pubic
ramus.
Rarely the anterior column is fractured infe-
riorly at two points, one at the root of the superior
pubie ramus and one more medially (two cases).
The intermediate fragments may be split by further
longitudinal fracture lines.
In four instances, at a variable point along the
iliae fracture line, there was a related horizontal
split whieh reached the anterior border of the bone
at the level of the interspinous noteh or at the
156
psoas groove (Fig. 118), isolating therefore an
anterior fragment of iliae wing. Oeeasionally this
split stopped short of the region of the anterior
border whieh was not ruptured.
In ten eases in whieh seven fraeture lines reaehed
the iliae erest and threc reaehed the anterior border
of the bone, thcre was a split situated at the level
of the roof of the acetabulum whieh isolated a
posterior superior fragment earrying a segment of
artieular eartilage (Fig. 115 B).
In eonelusion, two main groups of fraetures of
the both-eolumn type are classified aeeording to
the nature of the iliae fraeture. They are related
(1) bceause eertain fraetures extending towards the
iliae crest are assoeiated with a split direeted to-
wards the anterior border ; or (2) beeause eertain
fraetures with an iliae eomponent direeted towards
the anterior border also have an element whieh
is ineomplete but aseends towards the iliae crest
without reaehing it.
14.1.5 Displacement of the Fragments
and the Femoral Head
Thc force aeting on the trochanter whieh brings
about these fraetures aeeounts for the nature of
the internal dis placement sustained by the eol-
umns. There is also an aeeompanying rotation
around their main vertieal axes which results in
an angular displacement of their artieular surfaces
relative to the femoral head whieh is displaeed
centrally (Fig. 120). This rolling effeet maintains
in a signifieant number of eases a eertain degree
of eongruenee between the head and the various
segments of the fraetured artieular surfaee. This
apparent congruence is aeeompanied of neeessity
by separation ofthe fragments eomposing different
segments of the socket and by a narrowing of the
mouth of the aeetabulum, the segments at the lip
margin being obliged to overlap eaeh other in or-
der to maintain a eontaet with the head.
The configuration of the fraetures of both eol-
umns ean be further eomplieated by the existenee
of supplementary fragments. F or example:
- a detaehed segment of bone from the posterior
part of the pelvie brim limited by a fraeture line
separating the anterior eolumn and the angle
of the saero-iliae joint;
- fraeture eomponents in the iliae wing, separate
and triangular or polygonal, whieh only involve
Associated Both-Column Fractures
one cortex, partieularly of the posterior and infe-
rior part of the fraeture of the iliac fossa a little
in front of thc saero-iliae joint;
- comminution of the fraeture line at the level
of the pubis.
14.1.6 Atypical Examples
In two eases where the fraeture line reaehed the
anterior border of the ilium, an assoeiated break
in the anterior eolumn at the level of the root
of the superior ramus isolated a segment of the
anterior eolumn whieh itself was split by a verti-
eally disposed fraeture line separating the two cor-
tiees, the outer earrying the roof and the inner
a segment of the pelvic brim (Fig. 121).
In two examples, the sacro-iliae joint was
involved in the endopelvie aspeet of the fraeture.
Figure 122 outlines the configuration of these le-
sions. (Reeently, we have seen an example in which
the saero-iliae fragment shown in Fig. 122 re-
mained attaehed to the posterior eolumn.)
In a few eases there existed other lesions of the
pelvis, namely, separation of the pubie symphysis,
pure separations of a saero-iliae joint (5 eases),
and a fraeture of the opposite obturator ring
(4cases).
In one reeent injury (Fig. 123) we found an in-
eareeration of the posterior eolumn within the
pelvis whieh evcn retrospeetive study of the radio-
graphs did not define. We established through the
ilio-inguinal operative approach that inside the pel-
vie brim the posterior eolumn had been displaced
inwards and was rotated about 60° on its vertical
axis. Its retro-aeetabular surfaee rested against
what remained of the quadrilateral surfaee below
the brim of the pelvis. The integrity of the eapsular
attaehment and upward displacement of the poste-
rior fragment made reduction, and indeed under-
standing, of the lesion very difficult.
14.1.7 The Key to Reconstruction
Whatever the eomplexity of the fraeturc or the
number of fragments, eaeh segment of artieular
surfaee belongs to one or the other column. There
remains attaehed to the saerum apart of the iliae
wing whieh never bears artieular surfaee but is the
key to reeonstruetion.
Morphology 157

A B

C D E F

Fig. 121 A-F. Atypical both-eolumn fraeture. A. B Clinieal spee-

imen, C-F schemes showing fraeture configuration. See
Fig. 141 for radiographs
158
Fig.122. Both-column fracture involving sacro-iJiac joint.
Schemcs of two cxamplcs. in both of wh ich the fracture line
detachcs the superior bordcr of the greater sciatic notch and
thc lowcr part ofthc sacro-iJiac surfacc in onc isolated fragment.
See Figs. \36 and \37 for radiographs
14.2 Radiology
Although both-column fractures appear at first
sight very complex on radiography, the broad diag-
nosis is in fact relatively simple, even on the antero-
posterior view alone; the precise diagnosis of the
lesion necessitates study of the oblique views in
order to appreciate the displacement, to recognise
the secondary fractures, and eventually to choose
the best surgical approach.
14.2.1 Antero-posterior View
(a) CentrcJ! dislocation olfemoral head. The head
lies clearly displaced inwards, often appearing
within the pelvic brim in external rotation.
Associated Both-Column Fractures
- _ Upper segment 01
posterior column in situ
Posterior column
entrapped and rotated
60° about its axis
Fig. 123. Diagram of displacement and incarceration of posteri-
or column. See Fig. 140 for radiographs
(b) In ward displacement 01 posterior column. The
femoral head drives inwards and tilts a large bony
fragment which comprises at least the inferior part
of the ischium.
This fragment constitutes a major part of the
posterior column and it is bounded helow by a
fracture line through the ischio-pubic ramus or
by a fracture line concave from above through
the body ofthe pubis (Figs. 124B and 129B) which
we have met only in fractmes of both columns.
Above, it is bounded by a fracture line which
breaks through the posterior wall of the acetabu-
lum at a high but variable level. One does not
always see the point of rupture of the posterior
border because of tilting of the inferior segment.
Nevertheless, if the posterior border of the inferior
fragment is traced upwards, this leads to the inner
aspect of the outer roof segment, proving that there
is a high fractme of the posterior border and its
displacement. The line of the fracture of the poste-
rior wall is sometimes easily visible.
On the medial aspeer, the posterior border of
the iliac bone is recognised in its upper part by
the characteristic outline of the greater sciatic
notch which is detached, perhaps at the level of
its angle or at the level of a point along its anterior
border. Lower down, the ischial spine can be de-
fined, often within the area of the pelvic brim.
It is important to identify the spine and to avoid
confusing it with other fragments of bone wh ich
when outlined radiologically can have a remark-
ably similar appearance. (Figure 142 shows such
an example in which the middle segment of the
innominate line simulates the ischial spine. The
ischial spine is visible below and externally.)
Radiology
Certain other features of importanee ean be re-
lated to the displaeed inferior posterior eolumn
fragment:
(i) The ilio-isehialline is less clear than normally
but easily reeognisable; it is often ineomplete be-
low (beeause of the rotation of the fragment), and
in most eases it has lost its normal relationship
with the teardrop whieh seems to be displaeed in-
wards from it.
(ii) The teardrop and the eotyloid fossa belong
to this fragment. They may remain aligned with
the head of the femur (Fig. 127) but in all eases
they have lost their normal relationship with the
superior pubie ramus and the innominate line
whieh indieates aseparation and the passage of
the fraeture line in the eotyloid fossa near the ante-
rior wall of the aeetabulum. Sometimes the tear-
drop and the ilio-isehial line have maintained their
relationship fairly normally (Fig. 124).
(iii) The posterior horn of the aeetabular artieu-
lar surfaee is sometimes visible, more or less
eoneentrie with the head of the femur.
(iv) The ilio-isehial fragment has lost its normal
relationship with the segment of the brim of the
pelvis belonging to the superior pubie ramus and
whieh appears mueh more horizontal than normal.
The erossing of the superior pubie ramus and the
ilio-isehial line eonfirm their relative displaee-
ments.
(v) Sometimes two points of rupture of the
posterior bord er of the aeetabulum ean be seen
on the antero-posterior view, one situated high
and the other lower, isolating a fragment of the
posterior wall (whieh is eonfirmed on the obtura-
tor-oblique view) (Fig. 126). In other instanees, a
fraeture line aeross the ilio-isehial fragment meets
the greater seiatie noteh at a variable position;
it is generally little or not at all displaeed (Figs. 139
and 140).
(e) Arcuate fine fracture. The pelvie brim is
broken posteriorly in a eonstant pattern at a point
diffieult to loeate with preeision on the antero-
posterior view. This proves the rupture of the ante-
rior eolumn (but not neeessarily its separation
from the posterior column). In addition, it is eom-
mon for additional fraetures to oeeur at the level
of the root of the superior pubie ramus (the frae-
ture line then traversing the anterior wall of the
aeetabulum), or at the level of the superior pubie
ramus, when it is extra-artieular. These seeondary
fraetures ean be eomminuted.
159
(d) Roof" o( fhe acetahullll11. This is tilted and
displaeed as a whole, so as to look more or less
downwards and im\"{/rds. To a varying degree it
eontinues to frame the femoral head. This variable
degree of tilt is evident by eomparison with the
opposite side on the routine radiograph of the
whole pelvis.
(e) I/iac \ring ji"acfllrc. Aeeording to the ease,
this extends to the iliae crest (66 eases out of 87)
or to the anterior border of the ilium (21 eases
out of 87). The iliac crest is fraetured in a variable
position and the fraeture line is most eommonly
saw-toothed in eonfiguration rat her than eurvilin-
ear. Often, it givcs the impression of duplieation
beeause the breaks in opposite eortiees do not
align.
Fairly frequently, in the middle part of the iliae
fossa, the iliae wing fraeture line bifureatcs so as
to reaeh the iliae crest at two points and isolates
thereforc a triangular fragment of thc iliae wing
with its base superiorly disposed (Figs. 125 and
128).
In other eases the fraeture line reaches the ante-
rior border at very variable positions:
- at the level of the antero-superior iliae spine
(Fig. 131);
- at the level of the interspinous noteh (Fig. 133);
- at the level of the psoas groove just below the
antero-inferior iliae spine;
- exeeptionally, the fraeture line erosses the roof
in order to reaeh the psoas groove and allows
therefore a short segment of roof to remain on
the iliac wing eonstituting a transitional feature
(Fig. 134).
The iliae fraeture may stop before quite reaehing
the erest (Fig. 129).
(f) Ohturator ring. This is broken in its lower
part, at the level of the isehio-pubie ramus in one
or two plaees or at the body of the pubis or in
both plaees. Exeeptionally (two cases) the ring was
not brokcn.
(g) "Curved image ". (Fig. 132). In the great major-
ity of both-eolumn fraetures, the antero-posterior
radiograph ineludes a curved image whieh starts
from the lower pole of the saero-iliae joint, deserib-
ing in an outward direetion a eurved trajeetory,
dense, regular, and like the initial part of the pelvie
brim (one ean superimpose it on the first part
of the opposite pelvie brim). It may then appear
to straighten and stop, but if examined earefully
it ean be seen as a variable outline, thin and
160
sinuous, whieh eontinues outwards, perhaps eurv-
ing upwards and oblique1y, or in deseribing a spur
pointing downwards (Figs. l38 and 140) beeoming
inereasingly indistinet. The latter eorresponds to
the optieal seetion of the fraeture whieh separates
the posterior eolumn and forms the lower limit
of the iliae fragment whieh remains attaehed to
the saero-iliae joint.
The eurved image has two possible sources :
(i) It may be produeed only by a segment of
the radiologieal pelvie brim. It then has the same
density and the same eurvature possessed by the
opposite side (Figs. 131 and 141) and eorresponds to
the internal face of the seiatie buttress (see page
19). This zone is not identieal with the anatomieal
pelvie brim whieh may be detaehed without alter-
ing the eurvedimage (Fig. 132, type I). It ean ap-
pear more open than on the opposite side by virtue
of separation of the saero-iliae joint whieh may
allow outward rotation of the iliae wing; even so,
its eurvature and its density are perfeetly regular,
similar to the opposite side.
(ii) In other eases (Fig. l32, type II), eareful
examination shows that the eurved image loses
thiekness from its internal aspeet quite sharply and
beeomes more vertieal. The inferior segment repre-
sents the highest part of the ilio-isehial line
(Figs. 129 and 130) and eorresponds to the inei-
denee of the X-ray beam tangential to the upper
part of the ilio-isehial zone eontinuous with the
seiatie buttress. Its lower limit is formed by a V-
shaped fraeture, open above, whieh is the optieal
seetion of the fraeture whieh separates the posterior
eolumn from the undisturbed iliae fragment. This
seeond vertieal thin segment eorresponds therefore
to the outline of the upper part of the ilio-isehial
line after separation of the pelvie brim with the
anterior eolumns on whieh it is normally super-
imposed. Following an anatomieal reduetion, it ean
be seen to eoineide perfeetly with the ilio-isehial
line. When the seeond segment ofthe eurved image,
dense but thin, does not exist, it is beeause the
fraeture line whieh detaehes the posterior eolumn
at the level of the quadrilateral surfaee is horizontal
and situated above the ilio-isehial zone.
In summary, the centrally displaeed femoral
head driving inwards the ilio-isehial fragment, to-
gether with the tilt of the whole roof and an iliae
fraeture line, establish the injury as a both-eolumn·
fraeture of whieh the eharaeteristies will be more
aeeurately delineated on the oblique views.
Associated Both-Column Fractures
Aeeessory features whieh ma be observed on
the antero-posterior view are:
- aeeompanying lesions of the pubie symphysis
or the saero-iliae joint (Figs. l36 and l37);
- the spur sign (to be deseribed later), seen mueh
more clearly on the obturator-oblique view
(Fig. 125);
- another injury of the pelvis, in partieular a frae-
ture of the opposite pubie rami;
- a reduplieation of the pelvie brim image seen
when the fraeture line detaehing the posterior
eolumn splits the areuate line longitudinally (one
ease).
14.2.2 Obturator-oblique View
This eontributes the following information:
(a) Central dislocation of the femoral head.
(b) Separation of the roof Its outline is eontin-
uous with that of the anterior wall. These two
often remain eongruent with the femoral head.
(e) Fracture of the pelvic brim. The site is often
extremely posterior, and this is the best view to
10eate it. It is eommonly broken again, perhaps
at the level of the root of the superior pubie ramus
or more medially, the fraeture line involving or
sparing the anterior wall of the aeetabulum. These
two areas of damage ean be eomminuted. Whereas
on the antero-posterior view, as a result of the
tilting, one sometimes loses the outline of the mid-
dIe segment of the pelvie brim, he re it is always
clearly visible.
(d) Rupture of the obturator ring loeates at the
isehio-pubie noteh where the break is often clear
and eorresponds to the separation of the two eol-
umns at the isehio-pubie ramus or in the body
of the pu bis.
(e) The spur sign (Fig. 135). On the obturator-ob-
lique view the external border above the aeetabulum
is outlined, being tangential to the X-ray beam, and
eonstitutes here the outer limit of the image of
the iliae wing. The fraeture line in the iliae wing
passes through the external cortex of the supra-
aeetabular region and medial displacement of the
lower segment is manifest by the interruption of
the outer cortex. The iliae wing fraeture line slopes
upwards and medially or deseribes a V-shape, open
upwards; in either ease the eonfiguration forms
a eharaeteristie bony spur. The variable outline
Radiology
of the spur depends on the orientation, shape and
direetion of the iliae wing fraeture line. The lower
eomponent, adjaeent to the roof of the aeetabu-
lum, belongs to the antero-inferior iliae segment
and is displaeed inwards by the head. We have
seen this spur sign in 95% of eases of both-eolumn
fraetures. It will not be visible if the obliquity of
the pelvis is insuffieient, for it ean be masked by
the anteriorly displaeed segment of the iliae wing,
the posterior part of the iliae wing being hidden.
It ean be diffieult to see when the fraeture is situ-
ated low and obseured by the femoral neck.
The spur sign was laeking in two eases when
the fraeture extended to the psoas groove
(Fig. 134). It was represented in a few eases by
loeal kinking in the supra-eotyloid region with
slight lateral opening if the eentnd displacement
was present. It ean be diffieult to see in eases where
a displaeed fragment of the posterior wall beeomes
radiologieally superimposed; eareful serutiny will
however reveal the spur (Fig. 127).
The spur sign ean reduplieate, this being due
to the bifureation in a Y-shaped iliae wing fraeture
with the isolation of a triangular fragment
(Fig. 128).
In eases of iliae wing fraeture whieh extend to
the iliae erest, it is quite often possible to see two
clear dense lines forming the outer limits of the
two segments of the iliae wing separated by the
iliae fraeture line. They eonverge towards the iliae
erest, the more internal of the two reaehing the
outer aspeet of the roof of the aeetabulum. The
outer border of the more external of the two
reaehes the spur (Fig. 129).
Where an iliae wing fraeture extends to the ante-
rior border, a short segment of variable height
of the iliae wing appears on the inner aspeet of
the spur and surmounting the roof of the aeetabu-
lum.
A similar appearanee to the spur sign has been
seen in eertain pure fraetures of the anterior eol-
umn, namely those in whieh the iliae wing fraeture
line reaehed from the iliae erest to an area behind
the roof ofthe aeetabulum. It is easy to understand
that in the obturator-oblique view, the supra-aee-
tabular segment of such a fraeture line may be
visible but in general there is very little displaee-
menL The fact that all the outlines of the posterior
eolumn are intaet makes it unlikely that this may
be misinterpreted as a true spur sign.
(f) Posterior 01' postero-superiorji·agment. If pres-
ent, it is seen usually as a triangular segment lim-
161
ited on the outer aspeet by part of the posterior
border of the aeetabulum and tilted with the femo-
ral head (Figs. 127 and 131).
(g) Sacro-iliac joint. This injury oeeurs oeeasion-
ally and is revealed in the obturator-oblique radio-
graph.
(h) Fracture through the root of the superior pubic
ramus. This extends into the anterior wall of the
aeetabulum. Comminution of this eomponent ean
isolate the roof of the obturator eanal.
14.2.3 Iliac-oblique View
(a) The displacement oi the posterior colul11l1frac-
ture is usually clearly manifested. In a few ca ses
the greater seiatie noteh at first sight appears intaet
but close examination reveals an abnormal angula-
tion of its anterior border. Also seen are the rela-
tive positions of the femoral head, the eotyloid
fossa, and sometimes the posterior horn of the
aeetabular artieular surfaee, as weil as the point
of rupture of the greater seiatie noteh. A supple-
mentary fraeture of the superior or anterior border
of the greater seiatie noteh is sometimes identifi-
able (Fig. 138).
A fraeture may exist whieh splits the posterior
eolumn (Fig. 139). In rare eases, this is of spiral
configuration, situated low on the greater seiatie
noteh (Fig. 126).
(b) The Wac ji'acture fine is aeeurately delin-
eated. Its trajeetory, (eurvilinear or zig-zag on both
eortiees), the point of rupture of the fraeture line
on the iliae erest or the anterior border of the
bone, and the existenee of a possible split towards
another point of the iliae erest isolating a triangu-
lar fragment or towards the anterior border at
the level of the interspinous noteh or at the psoas
groove, are all seen.
The anterior iliae fragment is seen to bear a
fragment of the artieular surfaee of the roof of
the aeetabulum whieh is tilted with it and frames
the femoral head with varying aeeuraey.
In eases where the fraeture line in the iliae wing
reaehes the anterior border and is assoeiated with
a split of the anterior eolumn whieh cuts superiorly
the anterior wall of the aeetabulum, the roof finds
itselfisolated with a segment ofthe wing, polygonal
in shape, and whieh appears totally separated from
the rest of the anterior eolumn (Fig. 133); this im-
portant fragment ean moreover be split in the eor-
onal plane as we shall see (Fig. 141).
162
Note that the fraeture line of the quadrilateral sur-
face whieh separates the two eolumns is only rarely
visible, and that the point of rupture of the anterior
border of the aeetabulum is equally as diffieult to
delineate.
14.3 Summary
For didaetie purposes, we have deseribed the stan-
dard radiographie views separately. With expe-
rienee, the views are most rapidly and more usefully
read together, the antero-posterior and the obtura-
tor-oblique views to study the anterior eolumn,
and the antero-posterior and the iliae-oblique
views for the posterior eolumn.
The basis of both-eolumn fraetures rests on fea-
tures already deseribed but may be summarised
thus:
- eentral disloeation of the head which drives me-
diallya large fragment or the whole of the poste-
rior eolumn, confirmed on the antero-posterior
and iliac-o blique views;
- the iliae wing fraeture eonfiguration, seen on
the antero-posterior and the iliac-oblique views;
- the spur sign, seen on the obturator-oblique
Vlew.
The standard views indicate the degree of con-
gruenee between the femoral head and the various
fragments of the articular surfaee of the ace tabu-
lum. Often superfieially this seems good and may
be an apparent indieation in favour of eonservative
management. However, surgical treatment in a sig-
nificant number of ca ses has shown us that, while
the femoral head was in good contaet with the
anterior wall and indeed with the remaining roof
attached to the anterior column, there persisted
eonsiderable displacement of the artieular surfaee
earried by the posterior eolumn and at operation
we have neuer found the overall congruenee of
the aeetabulum in these fractures thoroughly satis-
faetory.
14.4 Atypical Examples
(i) In two eases, the fracture of both eolumns was
associated with a fraeture-disloeation of the sacro-
iliac joint on the same side (Fig. 122).
Associated Both-Column Fractures
From the inner aspect of the pelvis, the fraeture
line traeed from the iliac erest began in its
posterior part and reaehed the anterior border of
the sacro-iliac joint a little above the pelvic brim.
It crossed the saero-iliac artieulation and detached
its inferior portion, continuing posteriorly to the
posterior border of the bone above the postero-
inferior iliae spine. A little before reaehing the
saero-iliae joint the fraeture line bifureated and
the inferior branch, running towards the pelvie
brim, cut it 2-3 cm in front of the angle of the
sacro-iliae joint, and then descended on the quadri-
lateral surface to rejoin the fracture line which
detached the posterior eolumn and originated with
it at the angle or the upper third of the anterior
border of the greater seiatic noteh. Thus a bony
segment became isolated whieh carried the inferior
half of the artieular surfaee, the postero-inferior
iliac spine, the superior border ofthe greater seiatic
noteh, and a variable portion of its anterior border.
This free segment displaeed and rota ted consider-
ably.
The fragment and its related artieular surfaee
is reeognised in the antero-posterior view when
it is pivoted through about 90° (Fig. 137), and on
the antero-posterior view and on the iliac-oblique
view in which it is less rota ted (Fig. 136). The artic-
ular surfaee is located under a U-shaped image
of dense eonsistency a little square at the base
and broadly open above. In the antero-posterior
and iliac-oblique views, when this U-shaped image
is not apparent, a separate fragment may be seen
whieh is limited behind and below by a line which
has a eharaeteristie profile. This is produeed by
the postero-inferior spine prolonged by the supe-
rior border, the angle and apart of the anterior
border of the greater seiatie noteh (Figs. 136 and
137).
(ii) Comminution of one or more segments of
the multiple fracture lines which traverse the iliae
bone can be extensive. It is possible to be per-
suaded (e.g. the ca se in Fig. 138) that there would
be no chance of a suceessful reeonstruction but
this is not neeessarily so.
(iii) In a eertain number of fraetures of both
eolumns where the iliac fracture wing reaches the
interspinous region between the iliae spines on the
anterior border, there exists at the same time a
split in the anterior eolumn erossing the upper
anterior wall of the aceta bulum, isolating therefore
a superior segment ofthe anterior eolumn eompris-
ing the roof and a segment of the pelvie brim.
Differential Radiological Diagnosis 163

In two eases this fragment was split sagittally in umns is isolated. The upper limit of seetion of
such a way that the external part earried the roof the eolumns forms a plane transverse fraeture sur-
of the aeetabulum, and the internal part with a face. Above all, the fraeture line (be it infra-,juxta-,
part of the iliae fossa earried a segment of the or trans-teetal) leaves in place, attached to the
pelvie brim. The radiologieal sem·eh for this frae- iliae wing, an artieular segment of greater or lesser
ture that ean be the eause of eonsiderable surgieal size. The iliae wing is not involved by any of the
problems is diffieult. The outline ean be deteeted fraeture lines. There is no spur sign in the obtura-
best on the antero-posterior and iliae-oblique views tor-oblique view (Fig. 106).
(Figs. 121 and 141).
(b) Antcrior eolumn and posterior hcmitransvcrsc
(iv) In four eases a special feature was that the Faeturcs. These assoeiated fraetures are also very
detaehed posterior eolumn included a segment of different from both-eolllmn fraetures, for although
the pelvic brim. In two of these the pelvie brim an anterior part of the roof is detached with the
was split by the fraeture line wh ich detaehed the anterior eolumn, the posterior hemitransverse
posterior eolumn. fracture component cuts the posterior wall in-
In the other two eases, the posterior eolumn feriorly and the upper part of the latter remains
took with it a segment of the pelvie brim and in plaee, attaehed to the posterior part of the iliae
a segment eorresponding to the anterior wall of wing with at least the upper part of the posterior
the aeetabulum (Fig. 117). One reeognises this pe- wall (Fig. 143).
euliarity on the antero-posterior view for on the At operation, using the posterior approach, one
ilio-isehial fragment the tem·drop and the ilio-is- finds only the transverse eomponent eutting the
chi al line may have kept their relationships and posterior column; the fracture of the iliae wing
at the upper part of the fragment is seen a short only joins it at the level of the eotyloid fossa.
segment of the pelvie brim whieh keeps its usual The eonfiguration of the fracture is displayed per-
relationships with the preceding elements. In this feetly in the extended ilio-femoral approach.
ease, the roof and the polygonal segment above Finally, when the iliae wing fraeture line reaehes
it in the iliae wing form an isolated fragment very the acetabulum a little behind the roof, it appears
clearly separated from the rest of the anterior eol- on the obturator-oblique view as an inflexion above
umn (Figs. 142 and 117). These two eases approach the aeetabulum but not as a trlle spur sign as is
the limit of the classifieation of the both-eolumn the ease in the both-column group.
fraeture. One could regard them as eomprising a This association is distinguishable beeause on
pure transverse fraeture li ne plus an anterior verti- the antero-posterior or obturator-oblique view or
eal fraeture of the pelvis dividing extra-artieularly on both, an external fragment of the roof, some-
the obturator ring and a postero-superior fraeture times small, is maintained in plaee and appears
isolating a fragment earrying all the artieular sur- on the external limit of the bone between the
face situated above the transverse fraeture line. slightly displaeed wing fraeture above the aeetabu-
Thus they form the threshold transition al group lum and the point of rupture of the posterior bor-
between fraetures of both eolumns and transverse der of the aeetabulum. One should not eonfuse
fractures assoeiated with a postero-superior frae- it with an isolated posterior fragment which always
ture. tilts with the artieular surface it earried.
(e) Associated transvcrse fi"actures with fi"aetures
of the iliac wing. A vertieal split of the iliac wing
leaves from the posterior aeetabular region and
14.5 Differential Radiological Diagnosis aseends towards the iliae erest. The upper fragment
eomprises a11 the anterior part of the iliae wing,
Both-eolumn fraetures should be distinguished
and the artieular segment situated above the trans-
from the fo11owing:
verse fracture line (Fig. 101). These form the link
(a) T-shaped li·aelures. Although the bony ring and transition between both-eolumn fraetures and
of the obturator foramen is cut above and below, transverse fraetures assoeiated with posterior frae-
only an inferior segment of eaeh of the two co 1- tures.
164 Associated Both-Column Fractures

A B

"- Spur sign

"-
'\
i
(
\
\
\
\
\

a b

Fig. 124A-D. Both-eolumn fraeture. A Antero-posterior radio-
graph, a diagram, B obturator-oblique radiograph. b diagram.
C iliae-oblique radiograph, c diagram, D seheme of fraeture
configuration. Thc fraeture line in the iliac wing reaehes the
crest behind the anterior pillar. Thi.; is a rare cxamplc in which
the columns are detached in whole pieces. It was approached
from the posterior aspect and the anterior column was not
seen: nevertheless, none of numerous radiographs have shown
any fracturc through the anterior border of the acetabulum.
The spur sign is c1early visible in B
Differential Radiologieal Diagnosis 165

c
166 Associated Both-Column Fractures

Break in crest
/-~\ /
/ ~I-

I \
\ \
\
\
\
I
I
a I

Fig. 125A-C. Both-column fracture in which the iliac compo- fraeture of the superior pubic ramus, probably extra-articular,
nent bifurcates and isolates a triangular fragment. A Antero- and a corresponding one of the ischio-pubic ramus. The anteri-
poste rior radiograph. a diagram, B obturator-oblique radio- or border of the greater sciatic notch is separated as a discrete
graph, b diagram , C iliac-oblique radiograph. c diagram. The fragment C and there is a split in the pelvic brim A
Differential Radiologieal Diagnosis 167

c
Triangular segment
of iliac wing

Fragments of cortex
of internal iliac fossa

//
c /
168 Assoeiated Both-Column Fraetures

A B

Reduplication 01
iliac wing outline

"

\
\
\
\ I
\ I

/
i
b
,/
I

/
i
a i
i
Fig. 126A-C. Both·eolumn fraeture with iliae eomponent ex· lines tangential to the two parts of the iliae wing are separat-
tending to the erest. A Antero-posterior radiograph, a diagram . ed and angulated. The split in the anterior eolumn is extra-
B obturator-oblique radiograph , b diagram. C iliae-oblique ra- articular. lt will be reealled that the anterior horn of the articu-
diograph. c diagram, The fraeture line which detaehes the poste- lar surface reaehes one eentimeter below the noteh in the anteri-
rior eolumn starts at the lower part of the greater seiatie noteh or border of the acetabulum and therefore any fraeture line
and has a spiral eonfiguration. In B. there is no spur sign eutting the column below this point is extra-artieular
but the fraeture line above the aeetabulum in c1ear and the
Differential Radiologieal Diagnosis 169

c
170 Assoeiated Both-Column Fractures

Postero-superior /'GllI\.lo"CT:\\\I\
fragments
/
/ i /'.,. ..... _.
/
I , i
\ i
\ \
\ \
\
\
a \ b \.

Fig. 127 A-C. Both-eolumn fraeture with iliac eomponent ex- me nt of the aeetabulum. The fraeture line at the level of the
tending to the crest. A Antero-posterior radiograph, a diagram, root of the superior pubie ramus is extra-artieular. The greater
B obturator-oblique radiograph, b diagram, C iliae-oblique ra- seiatie notch is eut in its middle part
diograph, c diagram. Therc is an isolated postcro-superior frag-
Differential Radiologieal Diagnosi s 171

c
172 Associated Both-Column Fractures

B
Triangular segment of iliac wing

//"-':"'V'
/ J
( !
\ \
'\
j
i /--
a i i

Fig. 128A-C. Both-column fracture in which the iliac compo- extra-articular fracture line at the root of the superior pubic
nent bifurcates and isolates a large triangular wing fragment. ramus, The bifureated iliac wing fracture complex forms a dou-
A Antero-posterior radio graph, a diagram, B obturator-oblique ble spur sign in B
radiograph, b diagram, C iliac-oblique radiograph, There is an
Differential Radiological Diagnosis 173

c
174 Associated Both-Column Fractures

A B

Reduplication and
separation at iliac
wing fracture
Outlineof
segment of iliac
wing lett in place

Fig. 129 A-D. Both-column fracture with iliac component ar- tion. There is kinking of the iliac wing fracture outline in A.
res ted 2 cm from the iliac crest. A Antero-posterior radiograph. In B the splitting of the Iines tangential to the surfaces of the
a diagram , B obturator-oblique radiograph, b diagram , C iliac- fractured iliac wing is clear. The fracture of the anterior column
oblique radiograph , c diagram, D scheme of fracture configura- is extra-articular
Differential Radiologieal Diagnosis 175

c
Crest apparently intact

c
176 Associated Both-Co lumn Fractures

/'
....... - ../.

I
/-~)
. \
i '\
~ \ I
\ I
\ i
a b

Fig. 130 A-C. Both-column fracture with i1iac component ex- diograph. The posterior column is detached at the bottom of
tending to the crest. A Antero-posterior radiograph. a diagram . the greater sciatic noteh. The curved image is long. There are
B iliac-oblique radiograph , b diagram. C obturator-oblique ra- several fracture lines across the anterior wall
Differential Radiological Diagnosis 177

c
178 Assoeiated Both-Column Fraetures

Curved image

rragment 01
Poslerior wall /:;:-..-\f-~~--.J
l
i
/ .r.~.~
.1 i
I
. V
.~
i
~ . \
\
\ \
\
i \
\
a j b

Fig. 131 A-D. Both-eolumn fraeture with iliae eomponent ex-
tending to the anterior superior iliae spine. A Antero-posterior
radiograph, a diagram, B obturator-oblique radiograph, b dia-
gram, C iliae-oblique view, D seheme 01' fraeture eonfiguration.
An intra-artieular fraeture of the anterior eolumn extends to
the anterior border at the noteh. There is a charaeteristic up-
wardly eoneavc fraeture line ofthe body ofthe pubis. A segment
01' the pelvie brim is detached with the posterior column; the
posterior wall fraeture is not shown in the seheme
Differential Radiologieal Diagnosis 179

c
180 Associated Both-Column Fractures

A-E. Different types of cUNed image

RADIOLOGICAL
DRY BONE APPEARANCE
Bone surface producing posterior
quarter 01 radiological pelvic brim

.. ~iological
~ ~vicbrim

Projeclion 01
fracture line
separaling Ihe posterior
column

Type I

Anatomica l pelvic brim

Anatomical
pelvic brim

Surface producing
ilio-ischial line

BOlh-column Type 11 Fig. 132. Scheme explaining sources of curved

Iracture lines images (see text)
Differential Radiologieal Diagnosis 181

".\ Spur sign

~.

_.,
"i .......
\
i
\ j
I
....
i
"- , /
/
a b /

Fig. 133A-C. Both-eolumn fracture with iliae eomponent ex- the anterior column is intra-articular and reaches the notch
tending to the interspinous noteh. A Antcro-posterior radio- on the anterior border ofthe acetabulum. Thc posterior column
graph, a diagram, B obturator-oblique radiograph. b diagram : is detached at the level of the angle 01' the greater sciatic notch
C iliac-oblique radiograph. c diagram. One fraeture line aeross
182 Associated Both-Column Fractures

'f\- '- .
.....( \
Ir' "
)' i
f
\
' ..... , i
a '\.,
\ \

\
\
\
j
i
i
i
c

Fig.133C

Fig.134 A and D
Differential Radiologieal Diagnosis 183

B C
/

Small segment of
roof in place
iA-\ -..,
\ ... ~/'''''\ '-..,. i i
\ \i I
/ {
./ .i
/ " !
/ .\ I.
b I c
\ I

Fig. 134A-D. Both-column fracture in which the iliac compo-
nent extends to the psoas groove. A Antero-posterior radio-
graph, a diagram, B obturator-oblique radiograph, b diagram,
C lliac-oblique radio graph, c diagram, D scheme of fracture
configuration. The fracture line detaching the posterior column
starts near the angle of the sciatic notch. From here a line
crosses the roof horizontally leaving one small segment on
the iliac wing fragment, seen in A and B. This fraeture is
transitional between T-shaped and both-column [raeture
groups. We have included it in the latter because the fraeture
component which separates the anterior column sterns from
the retro-aeetabular surfaee
184 Associated Both-Column Fractures

i
Plane of section of
bone seen In
Obturator-oblique vlew

Fig. 135. Sehe me explaining the spur sign

Articular surlace

S~~::ti~;c~nt/~l/ )./.\~·"'~~J\
01 sciatic notch i
i
/,
.~\ ·t/·j\---
.

\
\
\
a i I

Fig. 136A
Differential Radiological Diagnosis 185

Anlerior bord er
01 grealer scialic notch
/):-...~.
! \.
I Break In anterlor wall-
of acetabulum
i
\
'\
b i c

Fig. 136A-C. Both-column fracture with iliac component ex-
tending to crest and with involvement of the sacro-iliac joint.
A Antero-posterior radiograph, a diagram, B obturator-oblique
radiograph, b diagram, C iliac-oblique radiograph, c diagram.
The fracture line reaches the intermediate level of the sacro-iliac
joint and separates in one fragment the lowcr part of the articu-
lar surface of the sacro-iliac joint. the superior border 01' the
greater sciatic noteh. and the upper one-third of the margin
of the noteh. This is suggested in A and confirmed in C. The
fragment is seen in B to be limited inferiorly by the profile
of the greater sciatic notch. The fracture of the anterior column
is intra-articular. See Fig. 122 for scheme
186 Associatcd Both-Co lumn Fractures

A B

,/
i
) " '\
~-\" ,
'-fspur's,gn ~

(I L
/ '-----
Greater sClallc notch\ /
/ "\ ~

I / -"'-._-/! / -....
I _-
I
1 //
\ I

'\\ ( ~
\ 1 ..---
b I

Fig. 137 A-C. Both-eolumn fraeture with iliae eomponent ex-
tending to the crest and involving the saero-iliae joint. A An-
tero-posterior radiograph , a diagram, B obturator-oblique ra-
diograph, b diagram , C iliac-oblique radiograph, c diagram.
The configuration is similar to that deseribed in Fig. 136 and
shown in the seheme in Fig. 122. The detached fragm ent has
rotated through 90° and is less weil seen on the oblique views.
In A the displaced sacro-iliac fragment is see n end-on. In C a
characteristic fragment is seen protruding into the pelvic area.
In B the margin of the greater sciatic notch is very prominent
externally due to the rotation of the fragment
Differential Radiologieal Diagnosis 187

Fragment bearing
articular surlace 01
sacro-iliac joint
~ ,

c
188 Associated Both-Column Fractures

/'
I
./-'r-)
I .
. l
I .
\ \
\
\
i
a \

Fig. 138A-C. Both-column fracture with iliac component ex- fracture lines and there is an intra-articular fracture of the
tending to the crest. It is apparently comminuted. A Antero- anterior column. The anterior border of the greater sciatic notch
postcrior radiograph, a diagram, B obturator-oblique radio- forms a separate fragment. Reconstruction is feasible and the
graph, C iliac-oblique radiograph. There are multiple cortical pro gnosis good.
Differential Radiologieal Diagnosis 189

Fig.138C

Curved image -----r'--frif".

\ '~'-""
'--L/
J'
\.
f.J \
/
/
;'
/
a
I

Fig. 139. Both-column fraeture with iliae component extending

to the crest. A Antero-posterior radiograph. a diagram. The
posterior eolumn fraeture line splits the isehial spine and there
is an extra-articular fracture near the root 01' the superior pubic
ramus
190
Fig. 140A-C. Both-column fraeture with iliac component ex-
tending to the crest. A Antero-posterior radio graph. a diagram.
B iliac-oblique radiograph. b diagram. C obturator-oblique ra-
diograph. This fraeture is distinguished by multiple Iines. Note
(I) the split of the ischial spine and another fracture li ne (2)
which divides the posterior column in the eoronal plane. This
ASSllciated Both-Column Fraetures
separates a fragment carrying the quadrilateral surface and
another carrying the retro-acetabular surface and the articular
surface. The rotation of the posterior column through 90° and
its jamming in this position led to considerable operative diffi-
culties (Fig. 230). See Fig. 1160 for seheme and Fig. 123 for
diagram
Differential Radiological Dia gnosis 191

c
192 Associated Both-Column Fracturcs

Two fragments of
upper part of
an terior column
clearly seen

Fracture line
\('- '--.
'.....
J \.
/
. \.
. / .
.I I
\/ .I i
/f I j
( i /
\. \ i
. /
. I i
a \ i b

Fig. 141 A-C. Both-column fracture with iliac component ex-
tending to the interspinous notch. A Antero-posterior radio-
graph. a diagram, B obturator-oblique radiograph, b diagram,
C iliac-oblique radiograph, c diagram. In this particular case,
the anterior column fracture at the level of the anterior wall
isolates a fragment of the column. This is in two segments
separated by a break in the coronal plane. That Iying more
medially carries part of the internal iliac fossa surface forming
the pelvic brim; the outer carries articular surface and part
of the external iliac fossa. See Fig. 121 for cJinical specimen
and scheme
Differential Radiological Diagnosis 193

. .-i._.~racture line
f
,
'- .\
\ .
.i \
\1 I
I
\
c
\
\
 194 Associated Both-Column Fractures

Anterior border .
of acetabulum I-
_"\ "7
/ -T!" "
I
/ "r
l",

\\
False appearance of
an ischia! spine which
is really here
\
a , b

Fig. 142A-C. Both-column fracture with iliac component ex-
tending to the interspinous notch. A Antero-posterior radio-
graph, a diagram, B obturator-oblique radiograph, b diagram,
C iliac-oblique radio graph, c diagram. The anterior column ap-
pears broken in three placcs: at the level of the notch of the
anterior wall, at the root of the superior pubic ramus, and
at the angle of the pubis. Everything is somewhat confused
by the fact that the posterior column fragment takes with it
a segment of the pelvic brim isolating a short fragment of the
anterior border seen in a and c. See Fig. 117 for scheme
Differential Radiological Diagnosis 195

Separated -
anterior wall ).
/ \
i
i
)
i
i
c i
196 Associated Both-Column Fractures

A B

Fig. 143A-D. Associated extended and comminuted anterior
column and posterior hemi-transverse fractures (not a both-
column fracture). A Antero-posterior radiograph, B obturator-
oblique radiograph, C iliac-obliquc radiograph, c diagram,
D scheme of fracture configuration. The hemitransverse ele-
ment splits the ischial spine. In (C) a portion of articular surface
remaining in the upper segment of the posterior column is
clearly visible. This is associated with a split, undisplaced and
directed towards the sacro-iliac joint
Differential Radiological Diagnosis 197

I'
I '-
/
I
I

I
/
/
c
15 Transitional and Extra-articular Forms

Table 12 Table 12 (eontinued)

Simple fraetures Assoeiated fraetures

Posterior wall 126 26.8% T-shaped 30 6.4%

Posterior lip 3 0.6% Vertieal 16 3.4%
Typieal - one fragment 46 9.8% Anterior 7 1.5%
Typieal - multifragment 39 8.3% Posterior 7 1.5%
Postero-superior 12 2.6%
Postero-inferior 6 l.3% Posterior eolumn and posterior wall 12 2.6%
With marginal impaetion 20 4.3%
Typieal 7 1.5%
Posterior eolumn 21 4.5% Postero-superior 4 0.9%
Postero-inferior 0.2%
Typieal 13 2.8%
Postero-superior I 0.2% Transverse and posterior 84 17.9%
Detaehing teardrop 5 1.1%
Infra-teetal and posterior 25 5.3%
Epiphyseal separation 2 0.4%
Juxta-teetal and posterior 28 6.0%
Anterior wall 10 2.1% Trans-teetal and posterior 3 0.6%
Infra-teetal and postero-superior 1 0.2%
Typieal 8 1.7% J uxta-teetal and postero-superior 6 1.3%
With isehio-pubie fraeture 2 0.4% Posterior with marginal impaetion 6 1.3%
Transverse incomplete 15 3.2%
Anterior eolumn 22 4.7%
Extending to iliae erest 5 1.1 % T -shaped and posterior 11 2.3%
Extending to interspinous noteh 6 1.3%
Extending to psoas gutter 9 1.9% Anterior eolumn and posterior 23 4.9%
Ineomplete 2 0.4% hemi transverse
Anterior wall 9 1.9%
Transverse 43 9.2% Middle segment anterior column 0.4%
2
Trans-teetal 7 1.5% Superior segment anterior column 6 1.3%
Juxta-teetal 27 5.8% Posterior hemitransverse ineomplete 5 1.1 %
Infra-teetal 8 1.7% Posterior epiphyseal separation 0.2%
Incomplete 0.2%
Both-column 87 18.6%
Total (Simple fraetures) 222 47.3%
Extending to iliae crest 66 14.1%
Extending to anterior interspinous notch 15 3.2%
Extending to psoas gutter 6 1.3%
Our study of the anatomical and radiological fea-
Total (Assoeiated fraetures) 247 52.7%
tures of fractures of the acetabulum has been
conducted over more than a decade. Personal ob- Total 469 100%
servations have led to the isolation, from a previ-
ously somewhat amorphous group, ofthe posterior
wall fracture with marginal impaction, isolated As the series grew, we were led progressively to
fractures of the anterior and posterior columns, accepting all the types of injury as members of
the associated anterior column and posterior hemi- a spectrum; the interrelationship between them
transverse fracture and the both-column fracture. is logical and based on observable mechanical fac-
200
A
tors, namely, the description and site of application
of the injury force, the anatomy of the bones
concerned, and the composite mechanical prop-
erties of these. The exact analysis in any one fr ac-
ture would be difficult to achieve, of course, but
the broad outline is not too complicated to grasp.
15.1 Transitional Forms
Between the different categories exist the trans i-
tional forms, that is to say, those presenting the
typical lesion of one group but having features
of another neighbouring group.
The transitional forms are fundamental in link-
ing together the types we have described. They
are shown schematically in the diagrams in
Figs. 144 and 145. Figure 144 shows how, in the
different varieties of fractures of the walls or of
the columns, any segment of the articular surface
can be detached. Thus the main divisions of this
surface (postero-inferior, posterior, postero-supe-
rior, antero-superior, and anterior - impossible to
define exactly anatomically) can be detached either
by fractures of the wall or by fractures of the
Transitional and Extra-articular Forms
Fig. 144 A- D. Scheme dem onstra ting manner in which any seg-
ment of the articular surface of the acetabu lum can be i o lated
by pairs of fracture lines (see lext)
columns. Figure 145 outlines the prineipal transi-
tional forms between the different eategories of
fraeture of the aeetabulum which we have dis-
tinguished and relates these to the gross aeetabular
architeeture and not just to the artieular surfaee.
Thus, referring to Fig. 145, between the poste-
rior wall (A) and the posterior eolumn (D) we
have observed a posterior fragment taking with
it the anterior border of the greater seiatie noteh
(B) as weil as a partial upper fraeture of the poste-
rior eolumn (C). Again, between the pure posterior
wall fraeture and the assoeiated trans verse and
posterior fraetures, we have several eases in whieh
a fraeture of the posterior wall with posterior dislo-
eation of the femoral head beeomes assoeiated with
the outline of a transverse fraeture, the latter fail-
ing to reach the anterior eolumn and the innomi-
nate line (E, F, G), presumably on account of
dissipation of the fraeture energy. Comparably,
between the pure anterior eolumn fracture and the
anterior eolumn fraeture associated with a poste-
rior hemitransverse element, we have two observa-
tions in whieh the posterior hemitransverse ele-
ment is ineomplete and eeases anterior to the dense
trabeeulae at the anterior border of the greater
seiatie noteh (H, I, J).
Transitional Forms 201

Fig. 145 A- J. Scheme of interrelationship be tween transit ional

fo rms of fracture (see text)

1-1
J

" ~
~

Bridging the both-eolumn fraetures in whieh the
iliae eomponent is direeted towards the erest of
the ilium or those with the iliae fraeture line going
to the anterior border, we find two transitional
forms. There are those in whieh there exists at
the beginning of the fraeture line, rising towards
the erest, a seeond split wh ich joins the interspi-
nous noteh; similarly, when the fraeture in the
iliae wing reaehes the anterior border there may
arise from this main fracture line at the level of
the internal iliac fossa a split whieh aseends to-
wards the erest, sometimes stopping just before
reaehing it.
Between the T-shaped fraetures with a poste-
riorly direeted trans-isehial stern and transverse
fraetures assoeiated with a postero-inferior wall
fraeture detaehing the upper pole of the ischial
tuberosity, we have seen numerous transition al
types . In these, the stern fraeture line beeomes
more and more oblique with respeet to the ischium.
ranging from being a tangent to the posterior rnar-
gin of the obturator foramen. to one detaehing
only the upper pole of the isehial tuberosity.
Nevertheless euer)' example will approxirnate to
one of the basic types deseribed; herein lies the
diagnostic value of orderly understanding and c\as-
sifieation.
202
Fig. 146A, B. Vertical anterior fraeture of the obturator ring.
A Ant ero-posterior radiograph, a diagram , B obturator-oblique
radiograph, b diagram. Despite the appearance in A, it was
eonfirmed at operation that the fraeture complex was entirely
Note that two links of the chain are lacking
which would complete the symmetry between le-
sions of the two columns. These are: (1) associated
fractures of the posterior column with an anterior
hemi-transverse element. These we have classed
for the reasons described earlier, with T -shaped
fractures; and (2) the associated fractures of the
anterior wall and anterior column which we have
grouped with fractures of the anterior wall.
It has been unnecessary to group these sepa-
rately but their existence cannot be disputed and
the fan of lesions around the acetabulum is thus
perfeet.
Transitional and Extra-articular Forms
extra-articular. Close inspection of A shows the teardrop to
be in normal relation to the ilio-ischial line, and the anterior
border describes its normal inflexions without interruption. In
B the anterior wall is intact
15.2 Extra-articular Forms
It remains to consider the types of fracture which
at first sight appear to involve the acetabulum but
on close scrutiny do not involve the articular sur-
face itself. They cannot be dismissed as ordinary
fractures of the pelvic ring for they are intimately
concerned with the mechanical architecture of the
acetabulum. Good-quality radiography is impor-
tant if articular damage is to be excluded with
certainty (Figs. 146, 147 and 148).
Extra-articular Forms 203

B C

Fig. 147. A Antero-posterior radiograph, a diagram. B ob- the acetabulum a11 the landmarks of the aeetabular region are
turator-oblique radiograph. C iliac-oblique radiograph. The intact. The relationship of teardrop to the ilio-ischial line ap-
fracture eomplex is entirely extra-artieular. Between the vertieal pears distorted because the eentral fragment bcaring the ace ta-
anterior fraeture and the unusual horizontal fraeture above bulum is rotated
204 Transitional and Extra-articular Forms

Fig. 148. A Antero-posterior radiograph, B obturator-oblique part and rejoins the greatcr sciatic notch after traversing the
radiograph, C iliac-oblique radio graph. A vertical fracture line quadrilateral area. The other component is the disjunction of
crosses the iliac fossa cutting the pelvic brim in its middle the pubic symphysis. The acetabulum is not fractured
16 Associated Injuries
16.1 Injury of the Femoral Head
It is not surpnsmg that there is a considerable
incidence of damage to the femoral head in view
of the magnitude of the force necessary to produce
a fracture of the acetabulum and the fact that
it is the femoral head which transmits this force.
At operation, we have had the opportunity of in-
specting the articular surface and have noted the
occurrence of femoral head lesions, recognising
that only part of the head has been accessible to
view. The lesions can be considered under three
headings: macroscopic, vascular, and microscopic
or molecular; these can be associated.
16.1.1 Macroscopic Injury
This may be detected from examination of the
pre-operative radiographs. There can be a partial
subsidence of the femoral head in its infero-medial
or supero-lateral quadrant (11 cases). A partial
fracture of the femoral head may exist detaching
the infero-lateral segment which remains in the
acetabulum while the head is posteriorly dislocated
(6 cases).
Often, however, the lesion is not seen ra-
diographically and it is only at operation that it
is discovered. There may be superficial abrasions
of the acetabular cartilage or more extensive de-
struction of the surface layers of varying area; the
depth of injury may extend to the subchondral
bone and was significant in seven of our cases.
In cases of posterior subluxation, the round liga-
ment is always detached. It may detach a small
cartilaginous plaque which one should not omit
to excise.
16.1.2 Vascular Injury
We have not performed contrast radiography of
the vessc\s of the femoral head and we suspect
that injury is a less frequent occurrence than that
seen after pure dislocations of the hip. There is
a smaller incidence of avascular necrosis and it
is possib\c to perform a late reduction of a disloca-
ti on associated with a posterior fracture without
this likelihood.
16.1.3 Molecular Injury
STEWART and MILFORD (1954) believe that the di-
reet shock and the recoil suffered by the femoral
head could prod uce intercellular disorganisation
sufficient to bring about cellular death of the bone.
It is interesting to note that in nine of the cases
cited by this author and in two of ours which
were followed by avascular necrosis there was only
a horizontal transverse fracture, slightly displaced
and probably without significant capsular damage.
16.2 Capsular Injury
Capsular te ars must occur in all cases of posterior
dislocation of the head and are frequent in central
dislocations. In the case of posterior dislocation,
the capsular rent may present with particular fea-
tures:
(a) In a pure fracture-separation it may happen
that the one or several posterior fragments are
separated and driven by the femoral head into
the substance of the posterior glute al muscles. The
capsule is tom along the acetabular posterior mar-
206
gin, at least along the length of the fragment. Thc
posterior fragment ean remain in eontinuity with
a shred of eapsule as has oeeurred in some inear-
cerated examples.
(b) There may be marginal impaetion, the frae-
ture fragments remaining attaehed to the eapsule
whieh is tom at the .. upper and lower limits of
the fragments. The head passes aeross the posterior
wall without ereating further eapsular damage of
partieular importanee.
(e) In eentral disloeations, the eapsular lesions
are variable and diffieult to systematise. In one
ease of transverse fraeture we noted the total dc-
taehment of the eapsule at the level of thc isehio-
pubie fragment wh ich perhaps explained the failure
of an attempted closed reduetion. In the majority
of eases, the eapsular attaehment to the eolumns
is preserved.
16.3 Vascular Injury
16.3.1 Femoral Head
Vaseular injury of the femoral head has been dis-
eussed above (Seet. 16.1.2).
16.3.2 Acetabular Wall
During surgieal approach to the retro-aeetabular
area, in eases of transverse or both-eolumn frae-
tures with eentral disloeation of the hip, we often
eneounter vaseular bundles of varying size pressed
against the bone to whieh they adhere; they nou-
rish the posterior wall. In eontrast, during the
posterior approach for fraetures of the aeetabulum
aeeompanying a posterior disloeation, whether or
not these are redueed, we do not see these vessels,
a fact whieh seems to prove that their tearing or
their thrombosis oeeurred earlier at the time of
trauma. Such vaseular lesions of the aeetabulum,
aggravated subsequently by periosteal injury dur-
ing the reduetion, may explain a eertain number
of post-operative neeroses of the posterior wall.
Similar arguments apply to anterior wall injuries.
The ineidenee of proven osteoneerosis is very low
but nevertheless there is every indieation that eare
should be taken to avoid further periosteal dam-
age.
Associa ted I nj uries
16.3.3 Pelvic Vesscls
The only vessel damage we have seen with any
signifieant regularity is to the gluteal arteries : they
may be torn or stretehed by the displacement of
the posterior eolumn. When the fraeture detaehes
the angle of the greater seiatie noteh, it menaees
the superior gluteal vessels. In five instanees we
have found the gluteal vessels trapped in the upper
part of the fraeture of the posterior eolumn at
the angle of the greater seiatie noteh. On several
oeeasions the liberation of the gluteal bundle
produeed a severe haemorrhage beeause after hav-
ing been damaged at the time of the injury, their
entrapment had seeured a temporary haemostasis.
H aemostasis of the gluteal vessels is always diffi-
eult and requires several ligatures espeeially for
the assoeiated veins. The gluteal nerves may be
damaged and some eases ofweakness or post-oper-
ative paralysis of the gluteus medius have been
due to the nerve being ligated.
Despite oeeasional vigorous haemorrhage, we
have not had to resort to opening the abdomen
or to enlarge the greater seiatie noteh as had been
classieally advised. The posterior approach ean be
enlarged beyond the eonfines of the greater seiatie
noteh by division of the saero-spinous ligament
whieh faeilitates greater aeeess to the inside of the
pelvis. This measure has always allowed us to se-
eure adequate haemostasis of the superior gluteal
vessels.
We have not eneountered any other more signifi-
cant vaseular injury in more than 500 surgieal in-
terventions for aeetabular fraetures.
16.3.4 Retro-peritoneal Haematoma
As stated above, we have never found a serious
injury of a major intrapelvie vessel. The extensive
museular tearing together with the fraeture lines
through wide areas of spongy bone appear suffi-
eient to explain the large haematomata whieh are
always found at operation; sometimes these extend
superiorly as far as the perinephrie region. They
elevate extensively the parietal peritoneum of the
iliae fossa and abdominal wall. The volume of
haematoma is diffieult to measure but it may be
eonsiderable, requiring replaeement of a large
blood volume. Although a eonstant finding, the
elinieal eonsequenee is highly variable; on several
oeeasions, it has led to an exploration of the abdo-
men beeause of suspeeted viseeral damage.
Other Pehic Injuries 207

16.4 Other Pelvic Injuries

Apart from the bilateral aeetabular fraetures, other

lesions of the pelvie ring are eommon, espeeially
vertieal fraetures aeross the obturator foramen.
Vertieal anterior fraetures appear to us to be me-
ehanieally independent of the fraeture of the aee-
tabulum. They ean be situated perhaps at the side
of the fraeture of the aeetabulum, perhaps at the
side of the opposite aeetabulum, and perhaps on
both sides at one time. They have been assoeiated
with 15 eases: one posterior eolumn fraeture, six
trans verse fraetures, six transverse with posterior
fraetures, two anterior with transverse fraetures,
and four both-column fraetures.
Lesions of the pubie symphysis and saero-iliae
joints are variable. In our se ries of operated eases
there have been:
- eight separations at the pubie symphysis of signi-
fieanee wh ich were repaired either at the same
operation or later. These were assoeiated with
three trans verse fraetures, four transverse with
posterior fraetures, and one anterior plus hemi-
transverse posterior fraeture; A
eight saero-iliae lesions of signifieanee. These
were most often fraeture-separations of the sa-
ero-iliae joint whieh necessitated a special ap-
proach or were treated through the same opera-
tive route as the aeetabulum (Fig. 149). Frae-
ture-separations were more frequent than pure
disloeations. They were assoeiated with one
anterior eolumn fraeture, one anterior plus
posterior hemitransverse fraeture, and six both-
eolumn fraetures;
- a simultaneous disloeation of the pubie
symphysis and of the saero-iliae joint which was
assoeiated with a transverse fraeture. B

We have not estimated the frequeney of in-

eomplete saero-iliae disloeations aceompanying, in
partieular, both-eolumn fraetures. We have en-
eountered on a few oeeasions at operation an ante-
rior instability of the saero-iliae joint with
eomplete tearing of the anterior ligament. The gap-
ing of the anterior aspeet of the sacro-iliac joint
was hardly visible on the radiograph, but did not
es cape attention at the time of the anterior ilio-
inguinal operative approach and perhaps is most
easily dealt with by this route if judged neeessary.
The frequency of symphyseallesions is alm ost
eertainly higher than the number reeorded here
would indieate. The reason is that, espeeially in
Fig. 149 A, B. Both-eolumn fraeture with an iliac eomponent
extending to the anterior border and accompanicd by a separa-
tion of the sacro-iliac joint. A Antero·postcrior radiograph.
B scheme. The wholc auricular surfaee is detached and only
the postero-supcrior segment 01' thc wing remains attaehed to
the sacrum. The fracture detaching the auricular area is quite
separate from the both-column complex. It is unique in our
expcriencc in this latter respect: usually the sacro-iliac injury
eomponent is part of the both-column fracture if present. It
was a poliomyclitic-hip
208
earlier cases, we did not record or look for them
specifically. Only the more significant ones, and
those treated, have been reported.
16.5 Urinary Tract Injury
These are related to the associated fracture of the
anterior pelvis and not directly to a fracture of
the acetabulum. We have only encountered one
rupture of the bladder and two ruptures of the
urethra associated with lesions of the anterior arch
of the pelvis which were independent of the frac-
ture of the acetabulum. The urinary injuries had
been repaired before the operation for the fracture
of the acetabulum which concerned uso Every case
is individual and there are instances when the uri-
nary and osseous injuries should be repaired at
the same operation. F or example, if there is a rup-
ture of the bladder, this must be treated urgently
and if the condition of the patient is good enough,
the acetabulum can be dealt with at the same time.
Repair of the membranous urethra is often delayed
for about 5 days; this is also a suitable time for
operation on the acetabulum.
Associated Injuries
16.6 Other Skeletal and Visceral Injuries
A fracture of the acetabulum is always associated
with major trauma, commonly with multiple in-
juries to limbs, abdomen, thorax, spine or head.
In our series, 117 cases were accompanied by other
fractures, 3 cases had abdominal visceral damage
and 30 cases had severe or significant cranial
trauma.
Fractures of the femur on the same side as the
acetabular fracture in general take first place in
treatment. Also, they are responsible for the frac-
ture of the acetabulum or a dislocation being
missed in no small number of cases. We have seen
two femoral neck fractures on the same side, seven
fractures of the femoral shaft on the same side,
and three fractures of the head and of the neck
of the ipsilateral femur. The latter were produced
during attempts to reduce the dislocated femoral
head conservatively.
Besides bilateral fractures we have observed
three pure dislocations of the opposite hip.
16.7 Sciatic Nerve Injury
These will be studied later in Sect.18.2.3.
17 Distribution of the Clinical Series

17.1 Distribution According to Age 17.3 Distribution According to Time

The ages of our 469 patients ranged from 12 to
85 years, two-thirds of the patients being within
20 to 60 years old. Four patients were more than
80 years old and each of these had an anterior
column lesion.
Table 13 shows the distribution according to age
of the various types of acetabular fracture. It is
seen that there is no particular age-type relation-
ship except possibly the for anterior fractures In
the eldest patients.
17.2 Distribution According to Sex
Males preponderate greatly. Of the 469 cases, 319
(68%) were males and 150 (32%) were females
(Table 14).
Tablc 13
After Injury
Patients with fractures of the acetabulum did not
all reach us early and therefore the following will
be considered in discussing the indications for sur-
gical management.
- 334 recent lesions arrived between 0 and 21 days
after the acciden t;
67 fractures arrived late, between 21 and
120 days;
- in 19 cases there was established malunion, the
injury having occurred more than 4 months pre-
viously;
- there were 3 pseudoarthroses;
- there were 28 posterior fractures with persistent
dislocation;
- there were 3 necroses of the femoral head;

Type of fracture Age of patient (years) Total

10-19 20-29 30-39 40-49 50-59 60-69 70-79 >80

Posterior wall 28 36 24 34 15 3 141

Posterior co lu mn 3 4 3 7 2 2 21
Anterior column 2 2 5 5 4 2 22
Anterior wall 2 2 2 2 10
Transverse 3 14 12 7 6 43
T-shaped 3 13 4 10 31
Transverse and posterior 2 15 21 16 17 8 79
wall
Posterior column and 3 6 2 12
posterior wall
Anterior and posterior 2 2 4 6 3 3 3 23
hemitransverse
Both-column 3 27 17 10 17 8 5 87
Total 16 95 113 87 96 43 15 4 469
210 Distribution of the Clinieal Series

Table 14 10 malunions had post-traumatic osteoarthrosis;

3 mal unions had necrosis of the femoral head;
Type of fraeture Sex of patient Total there were 2 pseudarthroses of the acetabulum
Male Female
with osteonecrosis.
Table 15 reports the age and condition of the
Posterior wa1l 109 32 141
lesion at the time of our first examination as a
Posterior eolumn 18 3 21 function of the type of the fracture.
Anterior eolumn 11 11 22
Anterior wa1l 6 4 10
Transverse 25 18 43
T-shaped 19 12 31
Transverse and posterior 61 18 79
wa1l
Posterior eolumn and 11 12
posterior wa1l
Anterior and posterior 19 4 23
hemitransverse
Both-eolumn 40 47 87
Total 319 150 469

Table 15

Type of Post-injury Condition of fraeture when first seen Total

fraeture
0-3 3-17 Mal- Pseud- Posterior Osteo- Malunion Pseud- Malunion
weeks weeks Uillon arthrosis sub- neerosis and arthrosis and
luxation osteo- and neerosis
arthrosis neerosis

Posterior wa1l 80 10 6 24 2 2 126

Posterior 10 7 21
eolumn
Anterior eolumn 19 2 22
Anterior wa1l 8 10
Transverse 23 11 3 2 4 43
T-shaped 19 6 4 30
Transverse and 67 18 3 4 95
posterior wa1l
Posterior eolumn and 11 12
posterior wa1l
Anterior and posterior 22 23
hemitransverse
Both-eolumn 76 9 2 87
Total 335 66 19 3 28 3 10 2 3 469
18 Clinical Presentation
Clinical findings relating to the fracture of the ace-
tabulum itself offer little further of note other than
what is evident on the radiographs. A few points
may be dealt with summarily.
In order not to miss a fracture of the acetabulum
which may be the single injury or a component
of multiple trauma, it is necessary always to have
radiographs of all hips involved in trauma or
suspected of so having been. Ensure that radio-
graphy of the pelvis and of the hips is performed
in all cases of multiple trauma especially if there
is a fracture of the femur on the same side. Visceral
injury of any type deflects attention from the hips.
18.1 Clinical Findings
These are dominated by the direction of the dis-
placement of the femoral head.
18.1.1 Posterior Dislocation
The classical signs are often lacking, for the dislo-
cation may be atypical and the limb does not adopt
the typical attitude of flexion-adduction; con-
versely, on occasions we have thought to have
found, in view of flexion-adduction and slight in-
ternal rotation, a pure posterior dislocation
whereas the radio graph displayed an associated
transverse and posterior fracture with posterior
dislocation of the hip.
18.1.2 Central Dislocation
The deformity of the lower limb is highly variable
and not particularly helpful. Loss of active move-
ment is total and the shortening is not marked.
We agree with others that a significant sign may
be sinking-in of the greater trochanter, which ex-
ternal rotation alone cannot explain. We have
found no value in palpation and internal examina-
ti on of the pelvis, an observation made by COTTA-
LORDA (1922). It may be useful to assess the relative
positions of the iliac spine for central dislocation
will often be accompanied, especially in both-col-
umn fractures, with eversion of the iliac wing; the
anterior superior iliac spine on the traumatised
side is therefore displaced laterally in comparison
with the opposite side and lies a little inferior.
18.2 Early Complications
Immediate clinical examination is necessary for
base lines against which to monitor the patient
for hypovolaemic shock, retro-peritoneal haema-
toma, intra-abdominal visceral complication and
sciatic nerve paresis. Careful examination should
be made for bruising which may indicate the site
of action of the fracturing force and can form
a characteristic collection of clear fluid over the
trochanter, as described originally by MOREL-
LAVALLE (1891).
18.2.1 Traumatic Shock
Intensive treatment may be necessary. The cause
of shock relates to the severity of the trauma and
to haemorrhage from the fracture site and often
from other visceralIesions. The respective part
played by the various elements producing the
shock may be difficult to apportion.
212
18.2.2 Retro-peritoneal Haematoma
This always occurs to some degree due to the loose
tissue in which it can extend easily. It results in
a haemorrhagic syndrome of variable systemic ef-
feet and on local examination in a puffiness or
even a spasm of the parietal muscles of the lumbar
region and sometimes of the anterior abdominal
wall, which should be assessed at frequent intervals
during the first few hours. On occasions a laparo-
tomy has been necessary on account of a possible
intra-abdominal lesion requiring haemostasis.
During the following days the retro-peritoneal
hamatoma may be responsible for paralytic ileus
or sub-acute obstruction and which has in some
cases necessitated naso-gastric aspiration. It may
be the cause of a fever of otherwise unknown origin
which delays operative intervention for the fracture
of the acetabulum.
Retro-peritoneal haematoma, present in all frac-
tures of the pelvis or the acetabulum, but of which
the extent is variable, is responsible for numerous
laparotomies without positive findings or in which
only a little blood is found. Knowledge of this
clinical feature and the frequency of the haema-
toma justifies strict and repeated observation, but
in general should avoid unnecessary abdominal
exploration.
18.2.3 Pre-operative Sciatic Nerve Injury
These are of considerable frequency and presented
in 57 cases out of 469, that is 12.1 %. Their medico-
legal importance must not be forgotten and their
discovery before any operative intervention or
treatment should be recorded. In 16 cases of post-
operative paralysis of the sciatic nerve (11 recent
operations and 5 late cases) the nerve had not
been examined properly pre-operatively; undoubt-
edly a proportion of these were due to the original
injury.
Sciatic palsy is not always obvious. Naturally,
the injured person tries to move his leg as little
as possible and often has not noted his weakness.
It therefore is necessary to assess in turn all the
muscles of the leg, sometimes with firmness, in
the case of a reluctant patient with head injury
or local pain, by stressing to hirn the value of
this examination with which he must cooperate
in an effort to show voluntary movement. Pain
can almost completely obliterate voluntary move-
Clinical Presentation
ment but with patience and perseverance one can
always arrive at a valid appraisal.
The extent of the sciatic damage is variable and
comprised in our series:
- total sciatic paralysis (7 cases);
- extern al popliteal component paralysis,
com plete or partial (24 cases);
- internal popliteal component alone (1 case);
patchy and involving both popliteal territories
(17 cases);
- ill-localised and not clear (5 cases);
- and hypersensitivity in sciatic skin distribution
(only 3 cases).
Sciatic nerve involvement is most likely with a
posterior dislocation of the head (27 out of 36 cases
opera ted upon shortly after injury), occurs some-
times with a central dislocation (8 cases out of 36)
and even in one case where there was no disloca-
tion at the time of the initial radiograph. Table 16
shows, in the 302 cases operated upon shortly after
the injury, the type of paralysis pre-operatively
with respect to the type of dislocation. Table 17
indicates the paralyses associated with the various
types of injury; it is clear that lesions of the posteri-
or column are the predominant cause.
Out of 469 cases of fractures of the acetabulum
there were 304 with lesions involving predominant-
ly the posterior column and among the latter there
were 53 sciatic nerve injuries (17.4%). It is striking
that markedly displaced transverse, T-shaped and
both-column fractures are not accompanied by
such a high incidence, no doubt due to the predomi-
nantly medial direction of the femoral head dis-
placement. Note however that in the 23 examples
of anterior and posterior hemitransverse fractures
there were three sciatic nerve injuries (12 %) despite
the fact that the dislocation was markedly anterior.
At operation, various macroscopic lesions of the
sciatic nerve have been demonstrated, namely:
- partial division of the nerve in its outer aspect
in one case;
- penetration of the nerve by a sharp bone frag-
ment which lacerated it irregularly and led to
a patchy distribution paralysis (1 case);
- stretching of the nerve across a bony bridge
formed by a posterior fragment: the nerve exhib-
ited a flattened, thinned appearance over 1-3 cm
(4 cases) and this caused a total sciatic paralysis
in one case, an extern al popliteal paralysis in
two cases, and an irregularly distributed paral-
YSIS 111 one case;
- the inclusion of almost the whole nerve in the
fracture line of a transverse lesion. The dis pi ace-
Early Complications 213

Table 16

Direction of Extent of seiatie nerve lesion Total

disloeation
Complete Lateral Mixed Poorly Sensory
sciatie popliteal lesion defined only
palsy palsy

Posterior 3 14 5 3 2 27
Central 2 4 I 8
None

Table 17

Extent of seiatie Type of fraeture Total

nerve lesion
Posterior Posterior Transverse Posterior Transverse T-shaped Both- Anterior
wall eolumn and wall and eolumn and
posterior posterior posterior
wall eolumn hemi-
transverse

Complete seiatie palsy I 2 3

Lateral popliteal palsy 6 9 17
Medial popliteal palsy
Mixed lesion 2 9
Poorly defined 2 4
Sensory only I 3

Total 10 16 2 2 3 36

Total fraetures 75 9 63 11 14 17 74 19 302

treated by operation

Table 18

Extent of Neurologieal outcome Functional recovery

sciatic nerve
lesion Com- Signifi- Par- Sensory No Poorly Normal Minor Rcsid- Sig- Ortho- Poorly
plete cant tial residua recov- defined deficit ual but nificant paedic defined
recov- reeov- recov- ery normal deficit appliance
ery ery ery activity

Complete
sciatic palsy
External 4 8 3 8 2 5 2
popliteal palsy
Medial
popliteal palsy
Mixed lesion I 3 3 I 3 2
Poorly defined I I 2 2
Sensory only 2 I 3

Total 8 13 7 4 2 2 14 7 7 4 3
214 Clinical Presentation

Fig. \51. Primary incarccration. A Antero-posterior radio-

graph. Two attempts at cIoscd reduction failcd. The fragment
always lay in thc outlinc 01' acetabulum

Fig. \50. Undisplaced transverse fracture complicated by a

complctc sciatic palsy. A i\ntero-postcrior radiograph. Thc
sciatic nerve was fOllnd to be trapped in thc fracture

Fig. 152. Sccondary incarceration after redllction 01' a posterior

dislocation with a posterior wall fractllre. A Antero-posterior
radio graph
Earl)' Complications 215

ment was not apparent on the radiographs 4 achieved motor recovery but were left with
(Fig. 150). Evidently, the nerve trunk had been pure sensory residual defects;
trapped in the fracture line which had displaced 2 cases did not recover at a\1: and
momentarily at the time of the trauma. The 3 cases have been lost to fol\ow-up.
sciatic paralysis was total (1 case);
With regard to function, at the time of the last
- a large haematoma extending into the sheath
consultation:
of the nerve and associated with an extern al
- 14 had normal function:
popliteal paralysis (I case).
7 eases had resid ua but led practically normal
In several operative interventions, we have seen lives:
the sciatic nerve inc1uded in the fracture line which - 7 patients were slightly disabled:
detached the posterior column and with it the angle 4 cases maintain a significant disability :
of the greater sciatic notch, but without the nerve - I patient is permanently disabled, having to use
suffering any apparent damage from this interposi- an orthosis.
tion.
In 28 out of 36 SClatlC paralyses explored at
early operations, the nerve had throughout its vis-
18.2.4 Morel-Lavelle Lesion
ible length a eompletely normal appearance. We
do not know the cause of paralysis in such cases.
The trochanteric region must always be examined
Different authors have debated the problem and
since on many occasions we have seen evidence
a11 hypothesise a stretching of the nerve by the
of a blow with loeal loss of sensation, abrasion,
femoral head or by fragments which were pushed
bruises, and haematoma formation. lt is often later
backwards in front of this at the time of the injury.
during the next days that a soft fluctuant area
However, the neurologieallesion does not locate
develops and there is a serious risk of infection.
necessarily to such a level of damage and DECOULX
If this is allowed to occur, the safety of early oper-
(1961) in particular has drawn attention to the
ation is reduced because it is in the operation zone.
possibility of stretching of the lumbar plexus. The
Aspiration or decompression should be performe?
roots at the uppermost level, and therefore the
urgently as so on as the condition is apparent. TYPl-
longest and the most vertical, are the most vuln~r­
ca\1y, the fluid responsible is clear and pale ye11ow-
able in this respect. Lumbar roots four and flve
ish.
eontribute to the external popliteal component
which is most often affected.
We reported (lUDET and LETOURNEL 1966) con- 18.2.5 Intra-articular Incarceration
firmation of this lumber plexus lesion. Evidence
based on certain of the electromyographic studies
of Bone Fragments
performed more than three months after the
We have inc1uded this as an early complication
trauma have revealed indisputable injury to the
although strictly it is a possible feature of any
nerves innervating quadriceps musc1es. This injury
fracture of the acetabulum. The index of suspicion
associating both the sciatic and the femoral nerve
should always be high for the late complications
can result only from appropriate root damage.
from having failed to recognise the lesion are se-
Electromyographic examination of 11 of the 36
rious. The diagnosis is essentially radiological.
cases of pre-operative paralysis showed that three
lncarceration of bone fragments has been recog-
exhibited undoubted abnormality of quadriceps in-
nised as an early complication and described for
nervation while eight were electromyographica\1y
a long time. CAUCHOIX and TRUCHET (1951), URIST
normal.
(1948) and D'AuBIGNE (1968) have each reported
Out of the 36 pre-operative paralyses in
a number of cases. Like these authors we have
302 cases operated upon early with respect to the
always insisted that it constitutes an absolute indi-
time of injury, we have observed after treatment
cation for surgical intervention.
and release of any sciatic entrapment or compres-
Old missed examples of incarceration have not
sion, the fo11owing results (Table 18):
to our knowledge been described. They form part
- 8 gained complete recovery; of our consideration of lesions seen late
- 13 gained significan tly good recoveries; (Chap. 26), and we have reported these elsewhere
- 7 had partial recoveries, motor and sensory; (lUDET and LETOURNEL 1971). VACHER (1966)
216
collected our first nine cases which occurred
among 305 early fractures. Out of 469 cases of
fractured acetabula we have recorded 13 cases of
incarceration, recognised early (4.3%), as well as
seven examples seen late, which had been missed.
We consider here the ones recognised early.
(a) Sourcc. According to the type of fracture,
we have seen: '.
- 1I examples after fracture of the posterior wall
of which one exhibited marginal impaction :
one case that occurred after a T-shaped fracture
associated with a posterior wall fracture:
one case seen after a transverse fracture asso-
ciated with a posterior wall fracture.
In 1I instances there was a single incarcerated
fragment but in two cases there were two pieces
and in one case there were three fragments.
CAUCHOIX and TRUCHET (1951) considered that
fragments came from the cotyloid fossa, but in
all of our examples they were from the posterior
wall of the acetabulum as demonstrated by radio-
graphy and at surgery. Radiographs showed a cor-
responding defect in the posterior border of the
acetabulum or from the outer part of the roof
and these were, of course, proved at the time of
exploration of the joint. During anterior explora-
tory operations of lesions seen late, it was
confirmed that the roof and the anterior wall of
the acetabulum were intact.
(b) M cchanism. There are two possibilities:
(i) Primary incarceration. One or several frag-
ments, perhaps pedunculated, enter the articular
space at the moment of injury, probably at the
same time as dislocation. The head meets and traps
them during attempts at reduction. If the fragment
is sm all and free it may lodge in the cotyloid fossa
being pumped into the anterior part thereof. If
the fragment is very large it will be impossible
to reduce the head (Fig. 151). Smaller fragments
may allow reduction but some displacement will
persist showing as incongruence.
(ii) Secondary incarceration. This is a conse-
quence of the reduction itself. The fragment, main-
taining a posterior soft-tissue pedicle, is drawn into
the joint during the process of reduction and lodges
between the head and the roof. The proof that
this incarceration occurs at the same time as the
reduction is seen on radiography: on the views
taken with the head dislocated, the little fragment,
wh ich will soon be incarcerated, is perfectly visible
Clinieal Prcscntation
in a different positIOn and lies extra-articularly
(Fig. 153). The volume of the fragments, being
smalI, does not impede reduction but an incon-
gruence persists, with downward displacement of
the head. The reduction is stable.
(c) Sizc and attachmcnt. Both of these features
are variable. In one case of primary incarceration,
the fragment was enormous (Fig. 151). It
embodied the outer half of the articular surface
of the posterior wall together with a large segment
of the posterior acetabular surface. As a rule, the
fragments are of sm all volume which may be free
and correspond to a sm all sector of the articular
surface, 1-2 cm 2 in area, with irregular contours,
and associated with a bed of cancellous bone of
varying thickness. They may comprise a segment
of the posterior border of the acetabulum, 1-2 cm
long and about 0,5 cm wide, bearing a narrow
brim of articular cartilage 3-5 mm wide.
The capsular connections of the fragment deter-
mine to some extent what will happen to them.
It is essential to distinguish free fragments, de-
prived of a11 connection, wh ich can, if they are
of sma11 volume, be chased into the joint, and
lodge in the cotyloid fossa genera11y in its antero-
inferior part. One finds these a long way from
their origin. Pedunculated fragments which remain
attached to a fragment of the posterior capsule
maintain a blood supply. For this reason,
neglected, they can actua11y grow in size. The at-
tachment limits the distance that these fragments
can penetrate the joint. This rarely exceeds 1-2 cm
from the articular margin, and we have always
retrieved them from between the head and the roof.
In a few instances, the pendunculated fragment
is associated with one or two free fragments; it
is always necessary to check this possibility when
removing the one which appears obvious.
(d) Diagnosis. This incarcerated fragment is rec-
ognised early in two different circumstances.
Firstly, a dislocation may be irreducible due to
a large radiographically obvious fragment
(Fig. 151). Secondly, and more commonly, the in-
carceration is only recognised on the control films
taken after reduction of a posterior dislocation,
even if the hip appears stable and has an appar-
ently good range of movement. The antero-poste-
rior radiograph is usually adequate to display the
fragment but it is essential to examine the oblique
views. On the antero-posterior view, the head,
reduced into its cavity, is related to a sm all frag-
ment interposed between it and the roof, and often
18.3 Special Cases
A
carrying a sector of articular surface Iying adjacent
to that of the roof. The superior joint space is
significantly widened and the head is eccentric in-
feriorly. The fragment may be seen extruded to-
wards the extern al border of the roof partly in
the cotyloid fossa (Figs. 152 and 153). The oblique
views confirm the site of the fragments.
18.3 Special Cases
18.3.1 Children
We have had the opportunity to study three cases
with an associated epiphyseal dis placement in the
region of the Y -shaped cartilage. In one case there
was aseparation of the posterior column (Fig. 45),
in another aseparation of the posterior column
associated with a fracture of the anterior column
(Fig. 114), and the third case comprised a complete
separation of the elements of the Y cartilage
(Fig. 154).
The poor prognosis is a strong indication for
reduction and fixation surgically. In order to avoid
217
Fig. 153A, B. Incarccration following reduction of postcrior
dislocation of the hip associated with a T-shaped fraeture and
postcrior wall fracture. A Antero-posterior radiograph berore
rcduction showing little fragment outside thc acctabulum. B an-
tero-posterior radiograph after reduction
an epiphysiodesis, any plate or screw crossing the
epiphyseal cartilage should be removed later.
The radiographic diagnosis of the fracture is
helped by comparative views of the opposite hip.
18.3.2 Elderly Patients
We have operated on 55 recent fractures of the
acetabulum in patients more than 60 years old (Ta-
ble 13). We have found all types of fracture but
undoubtedly there is a higher incidence of anterior
column and both-column fractures. Probably, it
relates to the most frequent cause, namely, pedes-
trians being knocked down by a vehicle and receiv-
ing a direct blow in the trochanteric region.
Treatment was alm ost always surgical and it was
only in relatively rare cases where the radiograph
showed a severe degree of osteoporosis, that we
found the fracture so comminuted and so difficult
to fix solidly (the screws could not gain asolid
hold) that we were not able to get an exact reduc-
tion. As will be seen later, the late results of these
freshly operated fractures were pleasing.
218 Clinical Presentation

Fig. 154A-C. Epiphyseal separation of Y -shaped cartilage.

A Antero-posterior radiograph, B obturator-oblique radio-
graph, C iliac-oblique radiograph
c

18.3.3 Patho1ogical Fractures of trying to treat a painful pseudarthrosis by a

total hip arthroplasty (Fig. 155).
We had one case of interest wh ich was a patholog- Paget's disease and the problems of fixation
ical pure low transverse fracture. A chondrosar- presented by osteoporosis in the elderly are men-
coma was proved histologically during the course tioned elsewhere.
Special Cases 219

Fig. 155 A, B. Pathologieal juxta-teetal transverse fracture

(ehondrosarcoma). A Antero-posterior radiograph . B iliac-ob-
Iique radiograph
A
19 General Principles of Surgical Management
COTTALORDA (1922) stated that "while modern in-
dustrial life gives us the means to inflict serious
fractures of the acetabulum, despite sporadic at-
tempts, the results of treatment have stayed as
they were at the time of Ambroise Pare."
By 1955, methods of treatment had without
doubt changed, but really, the results remained
roughly those which prevailed 30 years previously.
There was, we felt, a tendency to overestimate the
quality of results by conservative management and
for this reason we decided to manage all fractures
of the acetabulum with displacement by open re-
duction. Thus from 1955 to 1970 our attitude did
not change and our indications remained simple
and absolute. The improvement in functional re-
sult which we observed as a consequence of this
active approach, and the steady increase in surgical
management both in other French hospitals and
abroad, seemed to confirm that we had chosen
the best approach.
It was necessary to study new methods of surgi-
cal access and to adapt and improve those which
had been tried earlier. It became obvious that poor
surgical reductions were in most instances due to
failure to recognise the nature of the lesion pre-
operatively and therefore to choose a correct surgi-
cal approach. The results of inadequate open reduc-
tion are comparable to those of conservative man-
agement with the added risk of infections and all
other forms of post-operative complication; conse-
quently, unless operative management can be
shown to achieve a better result, the risks make
it unacceptable. It must of course be recognised
that many complications such as embolic phe-
nomena occur also with conservative management.
After our last report we found a reasonably good
functional result in the few cases of both-column
fractures upon which we had not been able to
operate. Thus, since 1970, for this type of fracture
alone, if seen late, we prefer to continue conserva-
tive treatment in view of the less certain result
of attempted surgery. This exception to surgical
management is supported by the satisfactory re-
sults of conservative management published by
other authors, especially MAZAS and D'AuBIGNE
(1969). We emphasise the fact that cases of both-
column fractures seen late constitute for us the
only restriction to surgical management. Also, we
have been impressed by the good quality of reduc-
tions obtained by the Decoulx team (1977) in both-
column fractures, by their "forced reduction ", as
the authors describe the procedure.
19.1 Conservative Treatment
19.1.1 Indications
Conservative treatment is indicated for the follow-
ing conditions:
(a) Fractures without displacement
(b) Medical contra-indications. There have been
a number of patients for whom we have regretted
not having having taken the risk of an early reduc-
tion, instead of those imposed by the later prob-
lems of total hip replacement for the post-trau-
matic osteoarthrosis which developed. At the same
time, it is obvious that for reasons of age or infir-
mity, there will be patients for whom the risks
of operative treatment would be too great.
(c) Both-column Jractures seen laIe. Certain as-
sociated fractures of both columns, seen later than
3~4 weeks after injury, in which the fracture heal-
ing was too advanced, make osteosynthesis too
difficult and uncertain.
(d) Pre-existing oSleoarthrosis. Old lesions and
others in which there was a pre-existing osteoarth-
222 General Principles of Surgical Management

rosis preclude operation, although even here, eare Table 19

should be taken to ensure that a reasonable aeetab- ---------------------
Statc of acetabltlar injury Number
ulum is available for future total hip replaeement.
managed conservativcly
(e) Locul in/cc/ions. In a few eases we have been
foreed to avoid operation in patients seen early Rcccnt injuries ( < 3 wecks) 31 (outof334)
Old injuries (3 17 wecks) 15
but who had already been treated eonservatively Malunion 3 (out of 19)
and devcloped eOTDplieations, notably from pin- Femoral hcad osteonecrosis I (out of 3)
track infeetions used for skeletal fixation to the Malunion with ostcoarthrosis 4 (out of 10)
lower end of femur, neck of the femur, or the Total 54 (out of 469)
pelvis.
Table 19 deseribes the eondition of the 54 pa-
tients in whom we abstained from surgieal manage-
18 of these the results were exeellent. Only two
ment.
were eomplieated, these being posterior fraetures
with posterior disloeations whieh probably had
redueed spontaneously. One resulted in a superior-
19.1.2 Methods of Conservative pole avaseular neerosis of the femoral head and
the other developed a post-traumatie osteoarthro-
Treatment
sis whieh was treated later by MeMurray osteo-
tomy.
These include bed rest with eareful progressive pas-
Nine eases were not opera ted upon despite being
sive mobilisation of the injured hip, followed by
displaeed; one bilateral injury was operated upon
walking with erutehes at about 6 weeks. Weight-
elsewhere. Three transverse fraetures were not
bearing is possible at a bout 10 weeks beeause the
operated upon in 1954 and 1957 but eertainly
eonsolidation of fraetures of the pelvis is usually
would have been a few years later. Of these,
rapid. Manipulative reduetion of a posterior dislo-
two developed post-traumatie osteoarthroses, and
eation of the head reeognised on radiography is,
one pseudarthrosis of the aeetabulum still painful
of course, urgent whether or not it is assoeiated
after 10 years; the patient nevertheless refuses any
with a fraeture ofthe aeetabulum. The only eontra-
further treatment. One assoeiated transverse and
indieation to manipulative reduetion is the exis-
posterior fraeture seen in 1951 has developed a
tenee of a partial fraeture of the head of the femur;
severe post-traumatie osteoarthrosis. One dis-
the serious possibility exists of eonverting this to
plaeed posterior eolumn fraeture has aehieved an
a eomplete subeapital fraeture of the femoral neck.
exeellent result despite pre-existing rheumatoid
Commonly, the disloeation onee redueed is stable
arthritis and having a signifieant protrusio aeetab-
and is maintained easily by means of gentle exter-
ulae. One woman of 83 years with an anterior eol-
nal rotation of the hip. When it is impossible to
umn fraeture with a hemitransverse eomponent
reduee, or if it is unstable, rat her than attempt
had severe osteoarthritis after nine months.
traetion we would always prefer to operate. Delay
Two both-eolumn fraetures exhibiting appar-
in the reduetion of the posterior disloeation preju-
ent eongruenee not opera ted upon early have elini-
diees the eireulation of the head of the femur and
eally good results, having lost only external rota-
perhaps the seiatie nerve. Longitudinal traetion
tion; radiographieally however, these hips are far
through a pin in the tibia, after reduetion of the
from normal (Fig. 156).
posterior disloeation, is not neeessary if the head
is stable; if it is unstable, traetion will not keep
it in plaee.
19.2 Problem of Surgical Access

19.1.3 Results of Conservative Treatment During the 15 years of operative management of

aeetabular fraetures, we have pursued a dream of
Conservative management was employed in finding a method of approach whieh would permit
31 reeent eases. Twenty were without displace- us to eope with all problems of reduetion, whatever
ment, most fraeture types being represented. In type of fraeture was involved. This approach
Problem 01' Surgical Access 223

B
A

Fig. 156A-C. Both-column fraeture treated conservatively on

account of loeal infection. One year later the radiographs iJlus-
trate the eoneept of apparent eongruenee. A Antero-posterior
radiograph, B obturator-oblique radiograph , C iliae-oblique
radiograph C
224
would have to enable us to reach at the same
time, and with the same degree of ease, both col-
umns of the acetabulum and also to allow access
to the inside of the pelvis. The latter is indispens-
able in the control of some fracture fragments and
sometimes in order to explore nerves and vessels
included in the fracture li ne or lacerated thereby.
Despite attempts and anatomical research we
are still some way from this goal and remain
forced to choose electively the approach for one
or the other column. Further, it is only by means
of the finger-tip or an instrument that we can reach
the column opposite to the approach we havc
chosen. On occasion, we must deal with each col-
umn by two separate approaches cither during thc
same operation or separated by an interval of
8-15 days.
19.2.1 Classical Approaches
We believe that we have used, at one time or an-
other, the majority of approaches to the hip de-
scribed in the literature with varying success. As
originally describcd, they have been abandoned
or modified:
(a) Posterior approaches. Langenbeck approach
(1874): With the subject in the lateral position,
and the thigh flexed at 45° so that the longitudinal
axis of the femur is directed towards the posterior
superior illiac spine, the approach is basically
through the gluteus maximus in line with its fibres.
The incision extends from the posterior superior
iliac spine to the greater trochanter; it is deepened
through the aponeurosis of the gluteus maximus
and the muscle is split throughout its length start-
ing over the trochanter where the sub-gluteal space
is more easily found. This approach is adequate
for the posterior part of the joint but gives only
a very narrow field and is limited distally. Even
with the subject prone, the overall access is poor.
Kocher approach (1907): With the subject in the
lateral position, KOCHER recommended a two-
limbed incision of which the summit is at the supe-
rior angle of the greater trochanter, the inferior
or vertical branch descends along the outer aspect
of the thigh and the superior branch is directed
towards a point three finger-breadths in front of
the posterior superior iliac spine. Below the angle,
the deep fascia is divided in the same line, and
General Principles of Surgical Management
above, along the antero-superior border of the fas-
cia covering the gluteus maximus. The incision is
through aponeurotic tissue throughout.
GmsoN (1950) with much honesty described the
Kocher approach using the lateral position. The
description was widely accepted and in France at
least, the name of GmsoN remains attached to this
approach, KOCHER being almost totally forgotten.
The Kocher approach yields good access infe-
riorly, but above, one is impeded by the gluteus
maximus, especially in the region of the neurovas-
cular bundle of the muscle where it emerges from
the greater sciatic notch, or if it is desired to gain
access to the whole of the greater sciatic notch.
It can be detached from the bone, but even this
does not give the access which might be expected.
JUDET and LAGRANGE (1958) have combined
these two classical incisions thereby gaining the
advantages offered by each. Since 1960, we have
called this combination the Kocher-Langenbeck
approach.
(b) Anterior approaches. Smith-Petersen ap-
proach: We commenced our attempts to operate
upon the anterior aspect of the acetabulum using
the second modification of this author's classical
description. Unfortunately, even when the gluteal
muscles have been stripped from the iliac crest
and from the external surface of the iliac bone,
the sheet muscles of the abdomen detached from
the crest, and the iliacus separated as far as the
pelvic brim, the only parts accessible are the ante-
rior segment of the iliac wing and crest, the roof
of the acetabulum, the anterior border of the upper
part of the ilium, the internal iliac fossa as far
as the sacro-iliac joint and the posterior one-third
of the innominate line. The extern al iliac vessels
preclude an exploration of whole pelvic brim, and
access to the quadrilateral surface of the ischium
is impossible. These restrictions confine the ap-
proach to treating a few simple transverse fractures
or a high pure anterior column fracture.
LEVINE (1953) described a method using the
same cutaneous incision as the Smith-Petersen ap-
proach but including only the separation of the
internal iliac fossa muscles. This was even more
inconvenient than the classical Smith-Petersen ap-
proach and did not even allow access to the roof
or the outer aspect of the wing of the ilium.
Modification of the vertical component of the
Smith-Petersen approach has offered more ade-
quate access to the anterior column. This is the
ilio-femoral approach which we shall study later.
Kocher-Langenbeck Approach
(c) Lateral approach. Ollier approach (1892): Of
all approaches to the hip this is the most deceptive
with regard to the acetabulum and is full of unreal-
ised promises. It is performed with the subject
in the lateral position. A curved incision is made
of which the summit is 5 cm below the greater
trochanter and the ends are directed respectively
towards the anterior and posterior superior iliac
spines. The posterior branch traverses the gluteus
maximus as in the Langenbeck incision whereas
the anterior follows the interval between the tensor
and the gluteus medius, care being taken with re-
spect to the nerve to the tensor fascia lata. Deeper,
the greater trochanter can be detached and lifted
together with the glute al muscles, or the tendons
of these can be cut from the bone, their origins
being subsequently stripped from the iliac bone.
This approach gives access only to the outer
face of the iliac bone and to the posterior wall
of the acetabulum but not to the ischium, to the
roof if one strips the muscles and perhaps to the
upper part of the anterior column. It provides no
access to the inner aspect of the pelvis, a serious
dis advantage. At first sight it offered the possibility
of operating on both columns simultaneously but
in fact the access to both remains very limited.
As a result of practical experience we use the
Kocher-Langenbeck incision as our only posterior
approach.
Of the anterior operations the Wo-femoral ap-
proach developed from the second Smith-Petersen
modification is now rarely indicated; it has been
replaced by our Wo-inguinal approach.
Lateral exposure with access to the posterior
column and part of the anterior column has been
achieved by our extended ilio-femoral approach.
19.3 Kocher-Langenbeck Approach
The operation is performed with the subject lying
prone on an orthopaedic table. The advantages
of skeletal traction as originally contrived were
marred by the effect of tension on the sciatic nerve,
which could not be safely retracted. Post-operative
paralysis (see page 313) was alarmingly frequent:
23 ca ses out of our first 125 operations (18%). All
of .these could not however be attributed to trac-
tion for authors using the lateral decubitus position
without traction, the incidence was similar. Even
225
without taking into account this serious complica-
tion the presence of the nerve under tension is
a source of anxiety to the surgeon and constitutes
an obstacle to reduction and fixation.
19.3.1 Technique
Since 1965 (in 88 out of 213 operations for recent
injuries) we have always used the Kocher-Lang-
enbeck approach with the subject prone on the
orthopaedic table; traction is exerted by means
of a skeletal traction through the condyles of the
femur (Fig. 157). The Steinmann pin with a stirrup
allows traction with the knee flexed at about 45°,
the leg being maintained in this appropriate posi-
tion by means of a suitable prop. Flexion of the
knee relaxes the sciatic nerve significantly. It is
essential to identify the nerve as so on as the gluteus
maximus is split for it is so mobile as a result
of this posture that it risks being missed in the
fat and can be injured by a retractor ; it is never
like the violin string which it resembles in oper-
ations with the knee extended. Traction on the
flexed knee has reduced the 18% incidence of
sciatic palsy to 6.8%. Nevertheless, there is no
pi ace for complacency because there were six
sciatic palsies out of 88 operations, despite trans-
condylar traction with the knee flexed.
Sciatic nerve damage sometimes results from ob-
vious causes but in other instances, it has occurred
despite every care; we believe that the majority
are due to injury from levers and retractors, even
from those specially designed for the purpose. The
part most at risk is the outer aspect of the nerve
(corresponding to the external popliteal com-
ponent), pressure being applied unconsciously
from the bone levers adapted for exposing the
posterior column. The surgeon must be constantly
vigilant with respect to both his own activities and
those of his assistants, particularly the one on the
opposite of the table who can unwillingly exert
traction or pressure on the nerve intermittently
throughout the procedure.
The angle of the incision is located over the
superior border of the greater trochanter
(Fig. 158). The superior branch (the Langenbeck
component) is directed towards the postero-supe-
rior iliac spine, its length varying with the amount
of access to the posterior column required but
usually it extends to within 6~8 cm of the spine.
Sometimes it is necessary to extend it as far as
226 General Principles of Surgical Management

B
Fig. 157 A, B. Kocher-Langenbeck approach. A Patient in
pro ne position with transcondylar femoral traction and knec
flexcd, B detail
Kocher-Langenbeck Approach
Fig. 158. Kocher-Langenbcck approach. Sec text
the spine recognising, however, the risks of par-
alysing the upper part of the gluteus maximus.
This extension is not necessary unless a particularly
difficult fracture is encountered or haemostasis of
the superior gluteal vessels proves necessary.
The inferior branch descends 15-20 cm vertically
on the outer face of the thigh passing equidistant
between the anterior and posterior borders of the
greater trochanter.
The superficial fascia is divided in line with the
skin incision and the gluteal fascia opened in the
region of the greater trochanter. The fascia lata
is divided vertically and thc aponeurotic incision
continued upwards using scissors or by blunt sec-
tion, splitting the fibres of the gluteus maximus ;
this process separates the upper third which re-
ceives its blood supply from the superior gluteal
artery from the lower two-thirds supplied by the
inferior gluteal vessels.
The innervation of the gluteus maximus is from
only the inferior gluteal nerve. and if the splitting
227
Fig. 159. Kocher-Langcnbeck approach
of the muscle is pursued too medially, the large
nerve trunks destined to innervate the superior
third of the musc\e are met at the medial part
of the gluteal incision. These must be protected
as much as possible. If it is essential to extend
the incision as far as the postero-superior iliac
spine the nerve filaments will certainly be cut and
some permanent weakness of the gluteus maximus
ensue.
The sub-gluteal bursa is opened and divided at
the level of the trochanter and the margins of the
gluteus maximus are retracted; this exposes the
plane of the deep layer of musc\es, and inferiorly_
the femoral insertion of the gluteus maximus
(Fig. 159). The plane must be developed from the
level of the lower part of the inter-trochanteric
crest where it gives rise to the quadratus femoris.
Following the posterior face of this musc\e me-
dially, the external aspect of the sciatic nerve can
be located safe1y. The nerve is followed towards
the greater sciatic notch and should be explored
228 General Principles of Surgical Management

A
Fig. 160 A-D. Kocher-Langenbeck approach

throughout its course, especially if apre-operative

sciatic palsy has been detected; it should be freed
from haematoma and bone fragments. Frequently,
we divide the femoral insertion of the gluteus max-
imus at the level of the femur, ligating at the same
time a branch of the posterior circumflex femoral
vessel which is divided where it lies just behind
the tendon. This has the advantage of liberating
more of the gluteus maximus and allows it to be
held back more easily, reducing the chance of dam-
age to the sciatic nerve from retractors, and expos-
ing more of the ischial tu berosity.
In cases where the piriformis and the obturator
internus are intact they should be divided through
their tendons of insertion, the proximal ends of
which are attached to long sutures (Fig. 160 B)
which are passed through the medial edge of the
cut gluteus maximus, so retracting the sciatic nerve
and providing protection throughout the rest of
the operation. Ifthese muscles have been lacerated,
D
their medial ends should be sought and marked
with sutures in the same way. In ca ses where it
is necessary to gain access to the ischial tuberosity,
it is preferable to strip the origin of the quadratus
femoris from the bone rather than to divide this
muscle in order to avoid unnecessary damage to
the posterior circumflex artery.
The posterior capsule or the site of the posterior
dislocation is reached after dividing the extern al
rotators. By simple retraction or stripping of the
capsule, the retro-acetabular surface of the poste-
Kocher-Langenbeck Approach
rior column is exposed (Fig. 160). The retro-ace-
tabular surface is cleaned of soft tissue progres-
sively and, in the case of a posterior wall fracture,
the stripping process is pursued from the margins
of the fracture. Eventually the anterior border of
the greater sciatic notch and the ischial spine co me
into view. Remember that whereas below, muscles
cushion the sciatic nerve, above, the nerve rests
directly against the bony edge of the greater sciatic
notch. By lifting the obturator internus, the un-
derlying bursa is opened in its extra-pelvic part
(Fig. 160 C and 0). This affords access to the lesser
sciatic notch and beyond this to the inner wall
of the pelvis. Inspection of the deep aspect of the
obturator internus reveals the discrete tendons of
origin ofthe obturator internus converging to form
the main tendon. This muscle protects us from
the internal pudendal neurovascular bundle wh ich
is never seen.
Next, the sub-cotyloid gutter is identified; it is
necessary to expose the body of the ischium of
which the superior border covered with dense fi-
brous tissue may be difficult to strip using scissors.
It is essential to keep right against the bone because
the sciatic nerve is somewhat tethered making re-
traction difficult; it is a site of risk for the nerve.
This completes the approach. Uncommonly, the
stripping of the posterior acetabular surface causes
bleeding from large periosteal vessels. ASteinmann
pin driven into the upper part of the ischial tuber-
osity outside the sciatic nerve acts as an effective
retractor of the gluteus muscles.
19.3.2 Application
Access is available to the whole of the posterior
column, i.e. to the greater and lesser sciatic
notches, to the ischial spine, to all the retro-acetab-
ular surface, to the sub-cotyloid groove, and to
the posterior part of the ischio-pubic ramus which
can be osteotomised by this route in the treatment
of a malunion of an acetabular fracture.
The sciatic nerve is conveniently retracted in two
ways: traction on the divided obturator internus
by means of the stay-suture, or alternatively using
a special retractor (Fig. 161) which we have de-
signed by modifying a Leriche retractor; this has
a convex surface which rests against the nerve and
at its end bears aspike which can be inserted
into one or other of the sciatic notches. We cannot
over-stress that throughout the operation the
sciatic nerve should be observed; it can at any
229
moment insinuate itself under the retractor du ring
manipulations especially by the assistant. A damp
swab should protect it from the bare metal, the
flat surface of the extremity of the instrument being
kept parallel to the direction ofthe nerve. I ts extrem-
ity must remain at all times in contact with bone.
Through the greater sciatic notch there is digital
access to the quadrilateral surface which must be
examined and cleaned in order to reduce and con-
trol a transverse fracture line. U sing an instrument
or by means of a finger it is easy to reach the
obturator canal and explore the posterior part of
the pelvic brim. The anterior part of the pelvic
brim can only be palpated with the tip ofthe finger.
Endopelvic access can be improved by dividing
the sacro-spinous ligament or, as proposed by
VIRENQUE (1956), by dividing the ischial spine itself
at its base. One or other of these procedures frees
further the sciatic nerve which can be held back
into the pe1vis to advantage.
In summary, the surgeon achieves perfect access
to the posterior column and some control of the
internal aspect of the quadrilateral surface and pel-
vic brim by instrument or the finger.
If grasping the posterior column proves to be
difficult, it may be helpful to insert a traction screw
or pin into the ischial tuberosity. This facilitates
manipulation of the column as a wh oIe.
The extern al surface of the iliac wing (6 ca ses)
can be stripped of perioste um as far forwards as
the anterior border. Then a Lambotte hook can
be slid in anteriorly to gain purchase on the ante-
rior column. We prefer to avoid this periosteal
stripping of the muscle origins as we consider it
as responsible for some ca ses of periarticular ca\cifi-
cation and for significant damage to the gluteal
muscles themselves and to their neurovascular
supplies. If it is necessary to reach the anterior
column in the superior acetabular region (but not
sufficiently to warrant an anterior incision) we
would now prefer to divide the tendinous insertion
of the gluteal muscles into the greater trochanter,
and not to strip their insertions. In fact, if the
choice of approach has been correct this is rarely
necessary and the only stripping required is in
the posterior part of the wing in order to apply
a plate. In the vast majority of cases the gluteus
medius is left completely undisturbed.
In one ca se where the prone position was contra-
indicated by reason of a flail chest injury, and
in another instance in which there was a double
anterior fracture of the pelvis associated with a
fracture of the acetabulum, the prone position on
230
A
B
Fig. 161 A, B. Kocher-Langenbeck approach. A Special sciatic
nerve retractor, B retractor in operative position. See also
Fig.174D
the orthopaedic table was not possible ; we used
the Kocher-Langenbeck incision but with the pa-
tient Iying on the opposite side as has been re-
commended by other authors. This hip was practi-
ca\1y fully extended but the knee was kept flexed
at about 60° in order to relax the sciatic nerve.
We feIt much less at ease, perhaps from habit,
but the reduction obtained was satisfactory .
19.3.3 Closure
The c\osure of the Kocher-Langenbeck incision
is easy and simple. It is important to reconstitute
a muscular bed under the sciatic nerve in order
to protect it from a plate or screws. The stay-
sutures placed on the obturator internus and the
piriformis facilitate identification and suturing of
these to the fibrous remnants remaining attached
to the posterior border of the trochanter. Having
repaired these tendons, the neighbouring muscular
be\1ies should also be approximated so as to pro-
General Principles of Surgical Management
vide a complete curtain protecting the nerve. One
or two suction drains are inserted (one draining
the gluteal region and the other the pelvis by one
of the sciatic notches).
19.3.4 Dangers
(a) Sciatie nerve. It is not without justification that
we labour the dangers of damage to the sciatic
nerve. The main trunk in the operative field can be
damaged by a retractor or by some other instru-
ment. In one case, when we used skeletal traction
with the knee flexed, it was lacerated with scissors
during the incision mainly because it was so loose.
It is from this experience that we recommend the
particular care of the nerve especially often split-
ting the gluteus maximus. It should be identified
straight away.
The sciatic nerve mayaiso be damaged by
stretching at the level of its plexus of origin as
a result of strong traction. In this ca se the appear-
ance of the nerve is normal and post-operative
electromyography of the femoral nerve and of the
sciatic nerve musc\e distributions may show the
plexus as being the source (see Sect. 22.3.1).
(b) Superior gluteal nerve and gluteal vessels.
These are greatly at risk during freeing of the sharp
point of the posterior column fracture at the angle
of the greater sciatic notch. Haemostasis can be
difficult and especia\1y the veins necessitate multi-
ple ligatures. In order to do this, it may be neces-
sary to split the gluteus maximus as far as the
postero-superior iliac spine. It would be profitable
in these cases to isolate and preserve the superior
gluteal nerve, since after these efforts at haemo-
stasis we have observed on several occasions a post-
operative weakness of the gluteus medius due to
coagulation or ligatures. Unfortunately, this isola-
tion of the superior gluteal nerve is difficult and
often impossible. Severe bleeding from the gluteal
vessels occurs in about 5% of operations.
19.3.5 Complications
Apart from lesions of the sciatic nerve, the follow-
ing have been observed:
(a) Osteophyteformation. Ectopic bone is formed
fairly frequently (42 cases out of 213). In 22 cases,
it was superior, not very extensive, and did not
cause symptoms. Limitation of movement was un-
Kocher-Langenbeck Approach
Fig. 162. llio-femoral approach. See text
eommon. Even more extensive developments
(whieh oeeurred in 15 eases) were praetiea11y with-
out any clinieal eonsequenee. Of three very large
osteophytes limiting movements, two were
removed surgiea11y. Their origin is diffieult to ex-
plain, but they are always situated in the superior
operative area, that part whieh has been disturbed
by stripping of thc gluteal muscles.
(b) Haematoma formation. We now drain a11
posterior operation wounds although earlier this
was not the ease. As a result, post-operative hae-
matoma neeessitating evacuation is rare.
(e) In[ection. Out of 213 Kocher-Langenbeck
approaches for recent fractures we have had ni ne
deep infections (4.2%). Five of these were second-
ary infections of a haematoma, three infections
were associated with a post-operative sciatic palsy,
and one was a late infection.
(d) Post-operative gluteal weakness. For a long
time, the occurrence of clinica11y detectable weak-
ness was not recognised either by ourselves or to
our knowledge in other re ports. It appears to be
231
Fig. 163. Ilio-femoral approach
more significant than appreciated previously. In
the ease of gluteus maximus, the cause is section
of nerve fibres coming from the inferior gluteal
nerve and crossing the medial part of the muscle
perpendicular to the incision, while for the gluteus
medius and gluteus minimus, it is damage of the
superior gluteal nerve as a result of efforts at hae-
mo stasis, or of stretching or crushing of the supe-
rior gluteal neurovascular bundle by retractors.
The incidence of these lesions was not measured
in the earlier cases of our series; routine scrutiny
has been relatively recent. We have observed signif-
ieant post-operative gluteal weakness of both types
in 18 patients.
Invo1vement of the gluteus maximus results in
an asymmetrical appearancc due to atrophy of the
buttock above the incision but without any appre-
ciable functionalloss. Awareness of the possibility
has made the condition seem relatively frequent
perhaps. Very occasionally there has been a serious
atrophy of the buttock above the incision with
a clinically detectable functional defieiency.
In a few cases severe damage to the superior
gluteal nerve led to paralysis of both the gluteus
232
I
. tion medially .
,: "
i
! inferior iliac spine is elevated but it is not necessary
Fig. 164. Ilio-femoral approach
medius and gluteus minimus. In some ca ses it was
permanent and caused significant limp which could
not be controlled even after intensive physiother-
apy in order to try to develop what remained of
the muscles. These severe cases occurred where the
gluteal component of the incision had been ex-
tended medially and there was also a weakness of
the upper part of the gluteus maximus.
19.4 Ilio-femoral Approach
19.4.1 Technique
As stated earlier, this approach is similar to that
of SMITH-PETERSEN (J 917) but differs sufficiently to
warrant furt her description.
It is performed with the subject supine on either
an orthopaedic or an ordinary operating table. The
incision (Fig. 162) follows the iliac crest as far for-
ward as the anterior superior iliac spine and then
descends along the outer line of the sartorius mus-
cle for about 15 cm. It is distinctly more oblique
General Princip\es of Surgical Management
than the Smith-Petersen incision. The external face
of the iliac wing is not stripped but the iliac crest
is freed from the anterior abdominal muscJes and
the internal iliac fossa exposed by eJevating the
iliacus muscJe (Fig. 163). At the level of the an te-
rior superior iliac spine, the inguinal ligament is
detached together with the sartorius which is freed
along its external border taking ca re to preserve
the nerve supply. One is obliged to divide the exter-
nal branch of the lateral cutaneous nerve of the
thigh. Flexion of the thigh facilitates the separation
of the lateral border and of the deep face of the
ilio-psoas muscle, the tendon ofwhich can be easily
divided at the level of the inguinal ligament so
alJowing easier retraction of the muscular portion
of the muscle and greater access to the anterior
column. Remember that section of the psoas ten-
don exposes the femoral nerve to the risk of dam-
age and the surgeons must therefore be vigilant
and protect the nerve from tension during retrac-
The beginning of the tendon of the straight head
of the rectus femoris at the level of the antero-
to divide it. In the region of the interspinous notch
at the anterior border of the iliac wing, the external
face of the iliac wing is stripped, thereby enabling
the jaws of a Farabeuf bone-holding forcep to
be applied, which will allow asolid purchase on
the upper part of the anterior column. An artery
is always found at this level and haemostasis is
necessary.
19.4.2 Application
This method of approach (Fig. 164) offers good
access to the iliac crest, the upper part of the ante-
rior column, and the root of the superior pubic
ramus. It is practically impossible to reach below
the ilio-pectineal eminen ce evcn after dividing the
psoas ; certainly no access is possible beyond the
eminence to the superior pubic ramus. Across the
iliac fossa one can reach the sacro-iliac joint, the
brim of the pelvis in its posterior part, and gain
limited access to the internal wall of the true pelvis
with the finger or an instrument as far as on the
quadrilateral surface of the ischium in its posterior
part. There is easy access to the most internal part
of the capsule of the hip and section of the ilio-
femoral ligament at the level of the acetabulum
may enable a perfect reduction of the anterior co 1-
umn.
Ilio-inguinal Approach 233

19.4.3 Closure
This is routine and anatomical. The psoas tendon
can be repaired if the ends are not too retracted.

19.4.4 Dangers
(a) Femoral nerve. Even with the hip flexed, the
femoral nerve is always in danger but was never
actually damaged in our series of operations. The
femoral vessels are easily retracted and have never
been injured.
(b) Lateral cutaneous nerve of the thigh. This is
always an obstacle to the anterior incisions and
in the ilio-femoral approach the lateral branch
always has to be sacrificed; the femoral branches
which follow the lateral border of the sartorius
muscle can be spared and retracted inwards with
the sartorius and the ilio-psoas.

19.4.5 Complications
After eleven operations using the ilio-femoral ap-
proach, the following complications occurred:
- two complete paralyses or marked weakness of
the ilio-psoas, but no example of quadriceps
paralysis ;
a few haematoma formations in the iliac fossa
requiring drainage;
necrosis of the skin at the angle of the in cis ion ;
it was less frequent than in the case of the Smith-
Petersen incision in which the angle is more
acute, and it constitutes a secondary infection
menace in case of haematoma formation;
no infections, even in complicated cases.
19.5 Ilio-inguinal Approach
LETOURNEL (1960) described an original anterior
approach developed in cadaveric studies. The ilio-
inguinal approach, which we have used largely
since 1965, developed from this. It embodies the
particular feature of completely opening the
inguinal canal of which asound anatomical repair
is much more effective than would perhaps be
expected.
Fig. 165. Contra-indication to traction on the orthopaedic table.
A Antero-posterior radiograph. Bccause of an anterior fracture
on the opposite side, pressure from the pelvic prop or post
dcforms the ischio-pubic fragment position; correct reduction
of this fracture could not be obtained
19.5.l Technique
The patient is operated upon in the supine position
on an orthopaedic table in the case of an isolated
fracture of the acetabulum; this permits easy trac-
tion, abduction and adduction during the pro ce-
dure. If there are associated fractures of the ante-
rior segment of the pelvic ring, bilateral or on
the side opposite to that of the acetabular fracture,
it may be better to use an ordinary table; traction
risks further displacement of the anterior part of
the pelvis or causes it to collapse and render correc-
tion of the fractured acetabulum impossible
(Fig. 165). The orthopaedic table can be used,
however, in order to benefit from the traction,
but it is necessary to stabilise the opposite thigh
and to dispense with the pelvic post.
The frequent need to extract the femoral head
from the pelvis, and to maintain its reduction dur-
ing the acetabular reconstruction, led us to devise
 . _---- --
---_ .. _---- ~

.~
....J
, 1
.J

-~- - D

E
F

H ), '·b

Fig. 166A-L. Ilio-inguinal approach. See text

L
236
a method of lateral traction. External traction by
means of slings round the inner aspect of the thighs
has not proved successful; disproportionate force
is necessary and most of this is expended on the
thigh musculature. There is no doubt that when
necessary, it is best to insert a suitable screw into
the greater trochanter and head (Fig. 166 A) and
to use this as a trochanteric traction device. This
must be put in through a short local incision over
the trochanteric region. The screw is inserted at
the upper limit of the vastus lateralis in the tro-
chanteric region and from there into the neck. Rib-
bon gauze is packed into the wound. If a Morel-
Lavalle lesion is encountered, this should be ex-
cised and after rem oval a local suction drain
should be used. Traction can be applied by an
assistant or preferably by means of a specially de-
signed bracket attached to the table.
The cutaneous incision (Fig. 166 B) follows the
iliac crest in its anterior two-thirds; it must extend
posteriorly beyond the summit of the convexity
of the crest in order to facilitate retraction of the
anterior abdominal muscles. From the anterior
superior iliac spine the incision is directed, lightly
concave from above and medially, as far as the
mid-line which it should reach about a finger-
breadth above the symphysis pubis. This internal
part of the incision is deliberately a little high be-
cause, although the inguinal canal has to be
opened, we try to pass above the pubic hair in
order to minimize the risks of infection.
The sheet muscles of the abdomen are stripped
from the iliac rest in one layer, and then elevated
in continuity with the iliacus muscle, thereby ex-
posing the iliac fossa as far back as the sacro-iliac
joint and the pelvic brim; the fracture line in the
iliac wing can be freed with a rugine and the field
temporarily packed with gauze. It is almost always
necessary to achieve haemostasis, using bone wax,
in the nutrient foramen of the posterior and infe-
rior part of the internal iliac fossa located 1-2 cm
from the sacro-iliac joint and the pelvic brim.
The aponeurosis of the externaioblique (Fig.
166C) is incised from the anterior superior iliac
spine as far as the median line, care being taken
to ensure that the cut is above the superficial ring of
the inguinal canal which should be left intact. In
its outer part, this incision should be performed
cautiously in order to safeguard the lateral
cutaneous nerve of the thigh throughout the oper-
ation. The situation of the nerve is very variable;
it may be just adjacent to the anterior superior
iliac spine, or as much as 2 cm inward from it.
General Principles of Surgical Management
The inferior lip of the aponeurosis of the exter-
nal oblique is elevated and retracted inferiorly so
exposing the conjoint tendon and the origin of
the muscular portion of the internaioblique and
transversalis abdominis from the outer half of the
inguinal ligament. This origin consists of short fine
tendinous fibres which have the same direction
as the muscular fibres and which appear to be
attached to the inguinal ligament itself. The con-
joint tendon is separated from the inguinal liga-
ment and its origin detached, using a bistoury,
cutting not the muscle but the fibrous tendinous
zone of origin, and leaving with the conjoint ten-
don a linear tendinous fringe 2-3 mm wide. This
detail is fundamental for the ease of repair of the
inguinal canal.
Careful incision through the fibrous zone allows
direct access to the psoas sheath which adheres
at this level to the inguinal ligament. If the incision
of the conjoint tendon is made too high, the extra-
peritoneal space is entered unnecessarily. Incision
at the correct level leads directly into the psoas
sheath.
It is now necessary to mobilise the ilio-psoas
muscle wh ich is enclosed in the iliac fascia safe-
guarding the femoral nerve which is not disturbed
on its muscle bed (iliacus). Having opened the
sheath transversely, with a finger, the medial limit
can be located (the ilio-pectineal fascia) (Fig.
166 D). U sing the finger as a guide, the medial
surface of the ilio-pectineal fascia is freed of tissue
containing lymphatics adjacent to the femoral
sheath. The fascia is divided down to the ilio-pec-
tineal eminence. From here, the attachment of the
iliac fascia to the bone is progressively divided
along the brim of the true pelvis thereby offering
access to the true pelvis and the quadrilateral sur-
face of the ischium (Fig. 166 E).
The ilio-psoas muscle, the femoral nerve lying
thereon, and the lateral cutaneous nerve which is
freed over several centimetres by sectioning the
aponeurotic fibres which tether it superiorly, are
gathered in a broad sling of corrugated rubber
(Fig. 166F).
In the inner part of the field, a second sling
is placed around the spermatic cord in the male
or the round ligament in the female. This isolation
of the cord, or the round ligament, is often
performed at the time of opening the extern al
oblique before the separation of the conjoint ten-
don. The cord is displaced and in the inner part
of the incision, the transversalis fascia is exposed
together with the internal fibrous part of the con-
Ilio-inguinal Approach
joint tendon which form the posterior wall of the
inguinal canal. The fascia and the fibrollS part
of the conjoint tendon are incised a few millimetres
from its lower insertion, so opening the retro-pubic
space which is always the site of considerable hae-
matoma formation; this is evacuated and then
packed with gauze (Fig. 166F).
If it is necessary reach as far as the symphysis pu-
bis or even further, the rectus abdominis is divided
1-2 cm from its insertion (Fig. 1660 and H). This
may be necessary only in its outer part but the
whole of the breadth of the muscle can be mobi-
lised. One can go beyond the mid-line either by
dividing the tendon of the opposite rectus abdom-
inus, or by stripping the superior border of the
opposite pubis and then retracting the muscle, pre-
serving its continuity.
There remains nothing further than to mobilise
the extern al iliac vessels of which the extern al face
has been exposed when dividing the ilio-pectineal
fascia; the anterior aspect is freed by dividing the
transversalis fascia, a procedure to be performed
with care. The vessels must be isolated with the
finger (Fig. 1660) so as to conserve around them
to a maximum the cellular tissue containing the
accompanying deep lymphatics and which a too
rigid dissection will risk dividing. The vessels are
encircled by a third sling after having checked that
the possible retro-pubic anastomosis between the
extern al iliac and obturator arteries is not going
to be torn. The structures passing under the
inguinal ligament having been thus isolated in their
respective slings are mobile transversely and it is
between them that the pelvic bone can be reached
(Fig. 166 H).
19.5.2 Application
The ilio-inguinal approach, performed in its en-
tirety, offers extensive access to the internal face
of the iliac bone and the pelvic cavity.
(a) Retracting the ilio-psoas inwards (Fig. 166 I)
gives access to:
- the whole of the iliac crest, for one can prolong
the cutaneous incision or the detachment of the
anterior abdominal muscles as far posteriorly
as necessary;
- the whole of the internal iliac fossa as far as
the sacro-iliac joint. If a procedure internal to
the iliac fossa is necessary Steinmann pins driven
into most remote part of the fossa maintain
237
retraction of the soft parts and avoid the in-
cessant skidding of deep retractors so difficult
to hold in place. A malleable strip applied to
these two Steinmann pins forms a stable and
highly efficient retractor system;
- the sacro-iliac joint and further medially if neces-
sary, by stripping the superior surface of the
ala of the sacrum. It can prove necessary to
apply a plate here if the sacro-iliac join t is widely
displaced, or if a portion of the articular surface
is connected to a fragment of the anterior col-
umn:
- the posterior half of the pelvic brim;
the anterior aspect of thc innominate bone as
far as the ilio-pectineal eminen ce. At the inter-
spinous notch, by incising the aponeurotic tissue
and dividing vessels which are always found
here, limited stripping of the muscles is possible
so as to expose the front part of the extern al
iliac surface. It is then easy to insert the jaws
of a Farabeuf bone forcep and gain solid control
of this part of the anterior column.
(b) Between the psoas retracted outwards and the
vessels retracted inwards (Fig. 166J) there is access
to:
- the anterior border of the bone from the ilio-
pectineal eminence as far as the middle of the
superior pubic ramllS;
- the middle part of the pelvic brim;
- the whole quadrilateral surface (digital or instru-
mental access), the greater sciatic notch of which
the oudine can be palpated, to the ischial spine,
and thus to the posterior column fractures
which may frequently be reduced and fixed by
this route.
(c) Between the vessels retracted outwards and
the spermatic cord retracted inH'ards there is access
to:
- the whole of the superior pubic ramllS from
which the pectineal muscle can be stripped as
necessary;
- the pectineal part of the inguinal ligament;
- the deep surface of the obturator canal and the
obturator neurovascular bundle.
(d) Retracting the spermatic cord laterally
(Fig. 166 F) and according to the degree of mo bili-
sation of the rectus abdominis gives access to:
- the angle of the pubis, and the internal surface
of the body of the pubis;
- the symphysis pubis;
- the superior pubic ramus of the opposite side.
238
Fig. 167. Osteosynthesis performed through the ilio-inguinal
approach. Transverse fracture associated with aseparation of
the pubic symphysis and a vertical fracture of the left pubic
ramus. A Antero-posterior radiograph showing osteosynthesis
A symphyseal separation can be reduced and
fixed easily by the ilio-inguinal route at the same
time as the fracture of the acetabulum (Fig. 167).
In summary, by the ilio-inguinal route there is
access to the whole internal face of the iliac wing,
to the whole of the anterior column and to the
pubic symphysis. There is also the less effective but
nevertheless very valuable possibility of reaching
the posterior column, and one can easily assess
the shape of the greater sciatic notch.
19.5.3 C10sure
The repair must be conducted with great care. The
slings are cut and removed one by one and it
is verified that the pulsation of the femoral artery
is normal. The parietal muscles of the abdomen
are re-inserted to the gluteal fascia by interrupted
sutures. Their re-attachment may be difficult for
the muscles retract; complete relaxation with mus-
cle paralysis is valuable at this stage. A suction
drain IS placed in the internal iliac fossa
(Fig. 166 K).
The re pair of the inguinal canal is conducted
in the following stages: the posterior wall is recon-
stituted by re-inserting the internaioblique, the
transversalis and with these the superior lip of the
divided fascia iliaca to the inguinal ligament in
a single layer as far medially as the femoral vessels
(Fig. 166L). Medial to the vessels, the rectus ab-
General Principles of Surgical Management
dominis and the conjoint tendon are repaired. The
fascia transversalis is sutured as far laterally as
possible, this suture of the fascia being continued
in front of the external iliac vessels.
After replacing the spermatic cord, the aponeu-
rosis ofthe externaioblique is sutured. The superfi-
cial inguinal ring was not disturbed and conse-
quently the inguinal canal is safely restored; the
superficial and deep inguinal rings remain dis-
placed relative to each other. A suction drain is
placed in the retro-pubic space before closure. The
skin and superficial fascia are closed over a third
suction drain.
19.5.4 Dangers
(a) Lateral cutaneous nerve oi the thigh. This may
remain apparently intact but can have been
stretched during the procedure. In order to avoid
the lesion, it is necessary to have liberated the
nerve sufficiently superiorly and always to be vigi-
lant with regard to retractors.
(b) Retro-pubic anastomosis. The communica-
tion between the extern al iliac artery and the obtu-
rator or deep inferior epigastric arteries can tear
or be cut at the time of freeing the posterior aspect
of the vessels. It should be avoided by specifically
looking for the anastomosis, separating it and co-
agulating or dividing it between ligatures. Fairly
frequently the anastomosis is not found or it may
not exist; it may have been lacerated by the frac-
ture and haemostasis already achieved. If cut, the
veins can retract into the obturator canal and be
very difficult to control; in practice, this ineident
is unusual and the anastomosis is easy to locate
and to control.
(e) Internal iliac vein. Onee this was injured by
a retractor. Suture was possible and there were
no complieations.
19.5.5 Complications
Certainly, complications oecurred, espeeially at the
beginning of our use of this approach.
(a) Lymphatic damage. In three of the early
procedures, we dissected too near the vessels and
in effeet divided the lymphatie ehannels passing
at the inner part of the femoral ring. We believe
that lymphangitis, oedematous swelling at the up-
I1io-inguinal Approach
per part of the thigh with redness and warmth
which were limited above by the incision, were
due to lymphatic obstruction. These phenomena
subsided in 8-10 days but not without causing us
considerable anxiety.
(b) Cutaneous necrosis. This has been rare, occur-
ring in only two cases in the region of the antero-
superior iliac spine, limited to 1 cm on both sides
of the incision. There were no consequences other
than scarring.
(c) Haematoma. This may occur at four sites:
in the retro-pubic space, in the internal iliac fossa,
in the inguinal canal, or subcutaneously. Haema-
toma in the retro-pubic space has not always had
to be aspirated but sometimes drains have had
to be left in pI ace more than eight days due to
continued loss. Haematomata in the iliac fossa are
the most dangerous especially because of their fre-
quency, and they are difficult to detect: palpation
of the internal iliac fossa is always painful in the
first post-operative days. Fluctuation is extremely
difficult to elicit. The frequency of these haemato-
mata persuades us to prolong suction drainage and
to have several drains disposed throughout the
area. In obese patients haematomata of subcuta-
neous tissue or of the inguinal canal have been
seen. They can also be difficult to locate in spite
of their superficial siting.
(d) Infection. Secondary infections have unfortu-
nately been fairly frequent with this incision and
it is probably the major hazard of the ilio-inguinal
approach. They alm ost always occur during the
later stages of healing, developing from haemato-
mata of the iliac fossa or subcutaneous tissue
wh ich have not been detected. The causes of the
infection are various: in two cases they were asso-
ciated with secondary infection of a Morel-Lavalle
lesion neglected or unperceived and located at the
zone of impact over the greater trochanter. In an-
other instance there was a sloughing ulcer of the
buÜock. In our other cases no evident cause was
found.
lt is perhaps relevant that the ilio-inguinal in ci-
si on passes through the upper part of the pubic
hair region and the frequency of subcutaneous in-
fections after hernia operations is thought to be
significant for this reason. We try to reduce the
danger by a meticulous preparation of the skin
and whenever possible by making the incision
above the hairy zone. This relationship between
infection and the passage of the incision through
239
the hair is impossible to prove and we think that
infection of the superficial haematomata, or of the
iliac fossa may have a lymphatic origin; inevitably,
the ilio-inguinal approach is accompanied by divi-
sion of lymphatics draining the lower limb and
any superficiallesion distal to the level of drainage
including the buttock, the perineum, and the exter-
nal genitalia could result in contamination of hae-
matoma in the area of the wound.
All operations on fractures of the acetabulum
by the ilio-inguinal approach should be covered
by prophylactic antibiotics. At the time of writing
(1979), out of the last 74 ilio-inguinal operations
performed with systemic antibiotic prophylaxis, we
had one deep infection (1.35%) whereas in the
first 22 operations, without antibiotic cover, there
were 7 infections (31.8%).
Infections were treated by early excision of all
necrotic material. The majority of them have not
left any residual problems, even those in which
the plates used for the osteosynthesis were not
removed at the time of excision. We shall discuss
this topic further in Chap. 22.
(e) Nerve injurie,I'. Sensory deficit in the territory
of the lateral cutaneous nerve of the thigh has
included paraesthesiae or anaesthesia of variable
severity; it has been the result of traction wh ich
has been sometimes difficult to avoid. There were
three ex am pIes of complete anaesthesia and 15 of
reduced or altered sensation. We have not seen
any lesion of the femoral nerve as assessed from
quadriceps function c1inically. Permanent loss of
ilio-psoas function occurred in a single case. A
few tran si tory weaknesses recovered, aided by
physiotherapy.
(f) Abdominal wall weakness. We have had one
complication with hernia formation requiring
operative treatment, but earlier there had been an
infection of the retro-pubic space which had neces-
sitated extensive drainage. In the majority of other
cases the anterior abdominal wall regained its nor-
mal strength. In six cases we detected some asym-
metry on coughing and in one other case, hernia
formation which has not required treatment.
(g) Vascular damage. Apart from damage to the
retro-pubic anastomosis and to the femoral vein,
neither of which had any serious post-operative
effects, we must report one other major vascular
injury. This occurred in an elderly woman who
had a both-column fracture, and during the oper-
ation wh ich necessitated prolonged traction on the
240
vascular slings, the arterial pulse had not been
checked nor was it checked after removal of the
slings. Within the first 24 h, arterial obstruction
of both the external iliac and internal iliac vessels
became apparent. Arteriography confirmed that
there was a secondary extensive thrombosis reach-
ing proximally to the bifurcation of the aorta. De-
spite arterial disobl!"teration the impaired circula-
tion in the limb, in the buttock particularly, did
not improve and the patient died after 3 days. This
complication was the result of using the ilio-
inguinal approach and of careless use of the slings
around the vessels. It is important to check repeat-
edly the circulation in the artery and in the event
of vascular impairment, immediate disobliteration
is advised.
19.6 Combined Anterior and Posterior
Approaches
Fractures of the acetabulum may have to be
treated through combined approaches. Now we
use the combination of the Kocher-Langenbeck
and the ilio-inguinal, but until 1965 we combined
the ilio-femoral and the Kocher-Langenbeck ap-
proaches.
The two procedures can be performed at the
same operation or staged within an interval of
8-10 days. When conducted together, there is inev-
itably considerable loss of blood and devascular-
isation of the innominate bone. Blood replace-
ment must be adequate throughout the operation,
and especially if haemorrhage has been severe dur-
ing the first approach, a pause for adequate re-
suscitation should be made before changing the
position of the patient.
Whenever safety is in doubt, we perform the
double approach as a staged procedure, but this
carries a serious disad van tage: one can never be
sure that the patient will be fit for the second
stage after the lapse of 10 days.
Out of 302 recent lesions of the acetabulum we
have used combined approaches on 15 occasions.
Seven ofthese were conducted during the same oper-
ation and eight were delayed. There was one late
infection among the 15 operations.
The mobility of the hips after combined ap-
proaches has been graded for comparison by the
d' Aubigne classification: In seven cases the two
approaches were performed at the same operation.
General Principles of Surgical Management
One patient was lost to follow-up, and there were
three hips in grade 6, two in grade 5, and one in
grade 3. In eight cases the two approaches were
performed as staged operations. There were four
hips in grade 6, two in grade 4, one in grade 2
and one hip (with complete ankylosis in deformed
position) in grade O.
19.7 Extended Ilio-femoral Approach
Motivated by the need for an approach permitting
the simultaneous exposure ofboth columns, we have
developed progressively a posterior enlargement
of the ilio-femoral procedure. It is very extensive
and is the best we can advise at this time for
selected cases requiring such simultaneous expo-
sure of the columns, predominantly from their
outer aspects.
19.7.1 Technique
The patient is placed in the lateral posItIon on
the orthopaedic table (Figs. 168 and 169). A pelvic
support on a column which can be raised or
lowered during the operation, is positioned hori-
zontally between the thighs. This can, when re-
quired, exert press ure on the inner aspect of the
upper thigh and at the appropriate moment, can
be used effectively to disimpact the femoral head
from the pelvis and aid the reduction and fixation
of the fracture by maintaining the femoral head
in the desired position.
The incision is in the form of an inverted J
(Fig. 170) beginning at the posterior superior iliac
spine. It follows the iliac crest as far as the anterior
superior iliac spine and from there descends
straight towards the outer border of the patella
half-way down the thigh.
The gluteal fascia is incised (Fig. 171) adjacent
to the sloping external aspect of the iliac crest
and the gluteal muscles are detached progressively
from the iliac wing. Towards the anterior superior
iliac spine this includes the tensor fascia lata of
which the anterior border is followed. The dissec-
tion remains in the fibrous sheath of the muscle
in order to avoid as much as possible dividing
the branches of the lateral cutaneous nerve of the
thigh. Below, the fascia lata is split down to the
lower end of the incision. Numerous small vessels
from the superficial circumflex iliac are divided
Extended Ilio-femoral Approach 241

Fig.168

Fig. 169

Fig. 168. Extended ilio-femoral approach. Front view of patient Fig. 169. Extended ilio-femoral approach. Back view of patient
in the lateral position on the orthopaedic table in the lateral position on the orthopaedic table
242 General Principles of Surgical Management

Fig. 170. Extended ilio-femoral approach. See text

and coagulated below the anterior superior iliac

spine and it is necessary to ensure that the nutrient
foramen found in the anterior part of the outer
aspect of the iliac wing is plugged with wax
(Fig. 171 A and B).
The articular capsule of the hip is exposed on
its superior and anterior surfaces by separating
muscle and fat progressively from medially to
laterally until the anterior face of the greater tro-
chanter is reached. Here, the tendon of the gluteus
minimus is divided and subsequently that of the
gluteus medius on the external face of the greater
trochanter. The exact site of division of these ten-
dons is such that short, clearly delineated distal
stumps remains; this will be used in the repair
at the end of the operation. It is helpful to mark
the respective tendon stumps with recognisable su-
tures so as to facilitate more rapid and accurate
repair.
The result of this wide dissection is that a mas- B
sive flap of tissue comprising the gluteus minimus Fig. 171A, B. Extended ilio-femoral approach
Extended Ilio-femoral Approach 243

A B
and medius, the tensor fascia lata, together with
their neurovascular bundles, is lifted from the
outer ilium. The flap is retracted postcriorly to
expose the posterior surface of the hip covered
by thc short external rotators. The piriformis and
obturator internus are severed and marked with su-
tures in the same manner as for the posterior ap-
proach. The proximal ends are retracted poste-
riorly and the layer of musc\e, predominantly obtu-
rator internus, protects the sciatic nerve. By open-
ing the synovial bursa under the obturator in-
ternus, access is gained through the lesser sciatic
notch to the interior of the true pelvis. The whole
of the posterior column down to the tuberosity
of the ischium is exposed (Fig. l72A).
Whenever it is necessary to inspect the interior
of the joint, either to verify the quality of reduc-
tion, or to look for debris, a roughly circumferen-
ti al capsulotomy is performed.

19.7.2 Application

The extended ilio-femoral approach exposes vir-

c tually the whole of the extern al surface of the in-
nominate bone. More exactly the exposure in-
Fig. 172A-C. Extended ilio-femoral approach cludes:
244 General Principles of Surgical Management

- the wh oie extern al aspect of the ilium; ilio-femoral approach on only seven occasions and
- the posterior column as far inferiorly as the is- it was somewhat premature to define its indications
chial tuberosity; and hazards. Since that time, with increasing confi-
- the anterior column as far medially as the ilio- dence we have used it on 30 occasions. There have
pectineal eminence. Even a little more can be been few complications. In particular, the possibil-
encompassed, because division of the tendons ity of ectopic bone formation which caused us anx-
of both heads of the rectus femoris muscle ex- iety folJowing such wide stripping of muscle from
poses the inferior part of the ilio-pectineal emi- the iliac wing has not presented any problem. The
nence. The ilio-psoas precludes any further ac- incidence is no higher than that seen following
cess to the superior pubic ramus; routine Smith-Petersen and Kocher-Langenbeck
- the pelvic brim, which can be dealt with to a operations. Obviously, some of the dangcrs relat-
limited extent by stripping the ilio-psoas from ing to the other approaches described earlier could
the internal iliac fossa and anterior aspect of be enumerated.
the hip joint (Fig. 172B). Although visual access
is poor, it is possible to reduce fractures crossing
the brim by touch, and plate them along the
pelvic brim with difficulty (Fig. 172 C). 19.8 Summary of Use of Different
Thus the approach is suitable for both-column Surgical Approaches
fractures especially when osteosynthesis of the
superior ramus, or body of the pubis, is not re-
The operations on 302 recent fractures of the ace-
quired. The iliac wing and posterior column com-
tabulum have been performed through the various
ponents can be especially welJ managed.
operative approach es described, as detailed in Ta-
ble 20. The 30 cases treated by the extended ilio-
femoral approach are not included in the statistics.
19.7.3 Closure
Closure is simple and anatomical. The gluteal mus- Table 20
cles are re-attached to their trochanteric insertions
by suture of the tendons and at the iliac crest Approach Number of
by sutures inserted through the abdominal mus- operations
cles. Suction drains are important in all raw areas
Kocher-Langenbeck 213
where haematoma formation is very likely. Ilio-femoral 11
Gluteal muscle power is restored to normal Ili 0- inguinal 53
within 2-3 months of the operation. In general, Double approach 15
this is the time for progressive weight-bearing exer- Extended ilio-femoral
cises, the fracture usualJy being sufficiently consoli- Smith-Petersen 2
Ollier 2
dated at this time. Other anterior approach 3
Other posterior approach 3
Total 302
19.7.4 Dangers and Complications
aThe operations using the extended ilio-femoral approach are
At the time of writing the original French edition not included because at the time of assessment, the follow-up
of this volume in 1974, we had used the cxtended period was too short.
20 EarIy Treatment of Dispiaced Fractures
Recent fractures comprise those operated upon
within the first 3 weeks following the accidcnt. Ex-
perience shows that repair of fractures of the pelvis
is rapid so that beyond the 21 st day there are
pröblems imposed by fairly advanced union, the
fracture lines becoming obscured by abundant
callus which fixes the fragments in malposition.
The perfect cleaning of the fracture surfaces, an
absolute requirement for an anatomical reduction,
is much more difficult. In practice, until the 14th
post-accident day, operative intervention is gen er-
ally straightforward, but progressively less so dur-
ing the third week.
20.1 Justification for Operative
Treatment
It is far from ideal to leave an important load-
bearing joint in astate of subluxation or articular
incongruence of which the long-term consequence
cannot be other than arthrosis. The relatively few
examples of long-lasting comfort and good func-
tion associated with hips radiologically dislocated
or subluxed do not compensate for the immense
n~mber of disastrous results which have to be
salvaged by arthrodesis or by total arthroplasty,
the consequences of which remain uncertain 111
young patients.
It is often difficult to compare the rcsults of
conservative and surgical treatment, for the
methods of assessment utilised by different authors
are so variable. Even if the grading of D' AUBIGNE
is used, there is always a subjective element which
cannot be judged by the reader. Further, the over-
all grading of the range of motion of the hip is
fallible because, for example, total loss of extern al
rotation can exist in a hip graded 6 or perfect,
whereas it is not by any means a normal hip.
By our definition, a normal hip is one with a
fu11 range of movement in all directions.
Most surgeons would agree that the best guar-
antee of restoration to normal function of any
injured joint, must relate to accurate rcconstruc-
tion of the surfaces. The hip is no exception. The
reason for the relatively infrequent use of open
reduction of acetabular fractures is simply that
it is difficult to gain access to the part; this has
apparently justified the rejection of the rule for
all other joints, viz. that anatomical rcstoration
of the surfaces is essential. The difficulty of access
is due, in our view, to failure to recognise the
exact lesion, understanding of which can be
achieved only following study of properly orien-
tated radiographs and a knowledge of the possibil-
ities. Certainly, our early attempts werc not so
successful, and as in all things, experience improves
quality of performance and results. The difficulty
of access and the complexity of the morphology
of the pelvic bone are poor excuses for abstaining
from surgery. We believe that a11 examples can
be diagnosed radiologically and the best approach
chosen.
The aims of surgical management are, in sum-
mary:
- exact restoration of the articular surface of the
acetabulum with respect to the femoral head,
this restoration being a corollary of perfect ana-
tomical restoration of the bone as a whole;
- solid internal fixation, thereby dispensing with
the need for post-operative splinting and allow-
ing early post-operative movements.
The surgery is often difficult, long and only
achieved with patience. It can be performed only
if the correct route of access is chosen and it cannot
be justified unless the desired perfection of the
osteosynthesis is achieved. Faults of surgical reduc-
tion are errors to be put at the surgeon's door
rather than to be blamed on the method.
246
Tablc 21 Type of fracture
Quality of c10sed reduction Posterior
wall
Not specified 15
Dislocation weil reduced 51
No improvement of fracture displacement
Reduction followed by re-dislocation
Re-dislocation and fresh reduction 3 5
No improvement of fracture-dislocation
Negligible re-subluxation 8 6
Acetabulum not reduced
Reduction of dislocation accompanicd 6 6
by fracture of the neck
lmperfect reduction due to 11
incarcerated fragment
lmperfect reduction of the hip
and of the acetabulum
Posterior dislocation converted
to central dislocation
Total
20.2 Indications
For recent fractures, the indications for operative
treatment are c1ear: All fractures of the acetabu-
lum with displacement, seen within the first
3 weeks after the injury, should be operated upon,
with the exception of patients in whom there exists
a strong medical contra-indication.
The time at which the injured person arrives
is critical. Arrival is sometimes delayed and when
seen a few days later, the patient may be febrile
and operation must be delayed until the tempera-
ture has become normal and the leucocytosis which
frequently accompanies the fever has settled.
Only one feature is really urgent and that is
the recognition of a posterior dislocation and its
reduction; once this has been achieved further
management of the fractured acetabulum can fol-
low electively. We recommend that it is safer to
delay operation for 24 h to 36 h in order to prepare
the injured person. Furthermore, during this time,
the natural haemostasis of the deep bleeding facili-
tates the operation and reduces the blood loss.
The radiological results of reduction of posterior
dislocations of the hip have been listed in Table 21
in terms of the type of fracture with which they
were concerned.
Early Treatment of Displaced Fractures
Total
Posterior Transverse Posterior
column and column and
posterior wall posterior wall
14 4 34
33 3 88
2
15
2 13
3 4
6 6
173
20.3 Pre-operative Care
With regard to the fractured acetabulum itself,
leaving aside aspects of treatment of other injuries
and general resuscitation, pre-operative care and
preparation comprise:
(a) Local ca re ofinjured limb. If a posterior dislo-
cation has been reduced simple maintenance of
the limb in light extern al rotation prevents redislo-
cation. If the reduction is irreducible or completely
unstable from the start, operation must be
performed as soon as possible. Perhaps while wait-
ing the leg can be put on to light skin traction,
although simple bed rest with the leg on a splint
which allows slight flexion of the hip and the knee
usually enables the patient to wait comfortably
far the operation. In our view, apart from the
rare case of the irreducible dislocation, traction
is unnecessary. If the head is stable after the c10sed
reduction of a posterior dislocation, traction does
nothing further. If the dislocation is central, trac-
tion has no useful effect, even for transport pur-
poses.
(b) Skin preparation is similar to that for all
arthopaedic operative procedures but it must be
Fracture Types with Uncertain Choice of Approach
emphasised again that when we anticipate an ilio-
inguinal approach, 24-48 h should be allocated for
scrupulous preparation by shaving, repeated wash-
ing and application of iodine, and antibiotics.
(c) Radiographie study. During the period of
preparation of the injured person, the study of
the four standard views must not be rushed. Poor
films must be repeated, the surgeon contributing
in the radiology department if difficulty in posi-
tioning the patient is encountered. Only by this
discipline will an exact anatomical diagnosis be
possible.
20.4 Choice of Surgical Approach
This is a fundamental issue and the errors of ap-
proach which we have committed have been re-
peated reminders for care. The aim is to choose
a surgical approach which permits the complete
repair of the acetabulum, or at least, to choose
that which will give the best chance of achieving
this aim. Sometimes the ideal cannot be achieved,
and as stated in the preceding chapter it is not
possible to be certain that the whole osteosynthesis
can be performed through one incision; a second
operation may be necessary, preferably imme-
diately but sometimes delayed.
The right choice of the approach is determined
by the type of fracture and it is here that a knowl-
edge of the classification is indispensable. The
various approaches we recommend are each partic-
ularly suitable for certain groups of fracture types.
20.4.1 Kocher-Langenbeck Approach
This is suitable for:
all varieties of fractures of the posterior wall
of the acetabulum;
- all fractures of the posterior column;
- associated fractures of the posterior column and
the posterior wall;
- all associated transverse and posterior wall frac-
tures in which the dislocation may be either cen-
tral or posterior.
20.4.2 Ilio-femoral Approach
This is the approach of choice for high fractures
of the anterior column involving one separated
fragment. These can be treated just as weil through
247
the ilio-inguinal approach. However, the ilio-femo-
ral approach is used if it is certain from the ra-
diological diagnosis that an easy reduction is possi-
ble.
20.4.3 Ilio-inguinal Approach
This is suitable for:
- anterior wall fractures;
- anterior column fractures at the low and middle
levels;
- complex anterior column fractures, all of which
in general can be managed successfully through
this approach;
- anterior fractures associated with a posterior
hemitransverse element, which until now have
never necessitated a two-stage approach.
20.5 Fracture Types with Uncertain
Choice of Approach
The choice of approach is not clear-cut in three
types of fracture: transverse, T -shaped, and both-
column. One approach having been chosen, it must
be accepted that a second may yet be required.
The problem is which to perform first. Whenever
possible the posterior approach should be the first
choice, for it is easy to perform and it offers repair
of the massive posterior column that provides a
very advantageous and stable base. The surface
is simple to restore and screws find a very solid
purchase in it.
20.5.1 Transverse Fractures
These have been approached in 11 cases by the
Kocher-Langenbeck incision, in one case by the
simple Smith-Petersen approach and in two cases
by the ilio-inguinal approach, i.e. in the majority
of cases the posterior approach has been used.
As is most common whenever the greater dis pI ace-
ment of the ischio-pubic fragment is significant
and posterior, the choice of the Kocher-Langen-
beck operation is simple. In a very small number
of cases the displacement of the transverse fracture
line is absent or only slight posteriorly, while the
displacement at the level of the pelvic brim is
marked; this is the situation when rotation of the
ischio-pubic fragment has occurred around a
248 Early Treatment of Displaced Fractures

roughly horizontal axis. In the latter instance, it will be amenable to management from the extern al
is plainly logical to choose the ilio-inguinal ap- aspect. For example, any fracture of the anterior
proach. column is appropriate, provided there is no signifi-
cantly displaced secondary split involving the ante-
rior articular surface; if such a fracture line is
20.5.2 T-shaped Fractures below the anterior notch, even if displaced, the
inferior fragment of articular surface will not be
These can pose the most difficult problem of reduc- important and it will be inaccessible. Apart from
ti on (as we shall see) but the dis placement of the this exception, the extended ilio-femoral approach
inferior fragment of the posterior column is nearly is suitable for both-column, anterior column and
always significant even in the fractures in which posterior hemitransverse, and some trans-tectal T-
the stem of the T is oblique and anteriorly dis- shaped fractures. An associated fracture-disloca-
posed. Accordingly, we always commence with the tion of the sacro-iliac joint can be reached easily.
posterior approach. If the reduction of the segment Table 22 shows a resume of these approaches
of the an terior column cannot be achieved we must with respect to the different fracture types.
use the ilio-inguinal approach subsequently.
In 11 instances we have approached these frac-
tures by the Kocher-Langenbeck incision, three
times by the ilio-inguinal and twice by a double 20.6 Operative Details
incision. On one early occasion we used the Ollier
inclslOn.
20.6.1 Princip1es of Osteosynthesis
Before an operation on a fracture of the acetabu-
20.5.3 Both-Co1umn Fractures
lum, in addition to the gross architecture of the
innominate bone, its finer structure must be
The solution to the problem of choice of approach
studied relevant to the fixation of screws to be
is fairly clear. If the fracture line in the iliac wing
used alone or with plates. The bone is so variable
does not re ach the iliac crest but goes to the ante-
in form and structure that a thick dense zone can
rior border of the iliac bone, it is possible at the
change to something much thinner and less solid
price of some stripping of the lower part of the
within 1-2 cm.
extern al iliac surface to control it from behind
The pelvic bone is of spongy texture of varying
through the posterior approach. Nevertheless, in
thickness limited by two rather thin cortices, ex ce pt
a few such cases, the ilio-inguinal approach has
for the posterior part of the iliac wing which is
been used with success.
fairly uniformly thick to within 4-5 cm anterior
If the fracture line extends to the iliac crest,
to the posterior iliac spines; their inferior part of-
reduction is almost always impossible by the poste-
fers a zone even more solid and dense (the sciatic
rior route and the ilio-inguinal approach must be
buttress).
employed in the first instance. Certainly, if there
The most solid areas of den se bone are shown
is a fracture-separation of the sacro-iliac joint and
in Fig. 173 A; these are:
this requires fixation, the posterior route is indi-
- iliac crest and its immediate neighbourhood;
cated.
- sciatic buttress superior aspect which corre-
There are a few exceptions to these rules. For
sponds to the last 2-3 cm of the arcuate line
example, in the case of incarceration of the poste-
in front of the sacro-iliac joint and the adjacent
rior column inside the pelvis or interposition of
bone of the internal iliac fossa in an area
a bone fragment which impedes mobilisation of
1.5-2.0 cm wide;
the posterior column through the ilio-inguinal ap-
- brim of the true pelvis and its immediate neigh-
proach it would be better to begin with the
bourhood (taking special care when using the
posterior approach. There are occasions when
section related to the acetabulum);
radiological assessment is difficult but it is rarely
- anterior border of the iliac wing and strips of
impossible.
the adjacent surfaces ab out 3 cm wide.
It is in some of these uncertain cases that the
extended ilio-femoral approach is of value. Usually Figure 173 B shows the thickest parts, compris-
it is obvious whether the fracture configuration ing mostly cancellous bone. Screws hold weil but
Operative Details 249

Table 22

Type of fracture Approach Total

Kocher- Other Ilio- Ilio- Smith- Other Consec- Interval Ollier

Langen- postcrior femoral inguinal Petersen anterior utive anterior
bek anterior and
and posterior
posterior

Posterior wall 73 2 75
Posterior column 9 9
Anterior wall 3 3 7
Anterior column 5 7 13
Transverse 11 2 14
Posterior column and 11 11
posterior wall
T-shaped 11 3 2 17
Transverse and 60 2 63
posterior wall
Anterior and posterior 4 3 10 2 19
hemitransverse
Both-column 31 29 3 8 74

Total 212 3 11 54 2 3 7 8 2 302

they must be long, properly sited and accurately
orientated, as follows:
- posterior column - at the level of the posterior
wall of the acetabulum and the ischial tuberos-
ity;
- roof ofthe acetabulum - in a zone limited above
by a line extending from one finger-breadth
above the posterior limit of the pelvic brim (or
one finger-breadth above the superior margin
of the greater sciatic notch as seen from the
outer aspect of the bone), to the upper pole
of the anterior inferior iliac spine. This zone
is easy to demarcate when operating through
tEe posterior approach but by the ilio-inguinal
route it is more difficult to locate; one is certain
to be extra-articular if above the line joining
the inferior pole of the anterior inferior iliac
spine to the upper border of the greater sciatic
notch; below it, near the pelvic brim, it is safe
to place screws but they must be disposed an-
tero-posteriorly obliquely from above inwards.
- posterior part of internal iliac fossa (Fig. 173)
- along a strip about 1 cm broad just external
to the sacro-iliac joint. This zone is easy to de-
marcate by the ilio-inguinal approach but by
the posterior approach much more difficult. It
is situated above the greater sciatic notch behind
a line joining the superior pole of the ischial
tuberosity to the angle of the greater sciatic
notch; it will be remembered that the iliac sur-
face faces postero-laterally, whereas the retro-
acetabular surface looks directly posteriorly.
Plates used here must be bent on the flat in
order to span the two parts and lie accurately
on the bone surface.
- body of the pubis.
20.6.2 Special Instruments
(a) Operating table. The advantages of the ortho-
paedic table and traction have been al ready em-
phasised in descriptions of the various surgical ap-
proaches (Chap. 19).
(b) Forceps. We have tried many types of bone-
holding forceps for these operations. Almost exclu-
sively, we favour the Farabeuf pattern, with or
without a ratchet. Both large and small models
are used. It is very useful to have an asymmetrical
pair of forceps and we have modified the Farabeuf
model (Fig. 174). With this, it is possible to apply
its larger jaw to the quadrilateral surface, where
it gains a good purchase, and its smaller jaw to
250
-rOne
_ finger-breadth
Sciatic buttres
(last 2-3 cm of pelvic
brim and 1.5-2.0cm
broad)
the external surface of either column. A more re-
cently developed instrument with curved jaws has
proved useful.
Bone forceps have to be applied at various an-
gles to the surfaces of the columns and are likely
to skid. A useful device is to insert temporarily
suitable screws of the Phillips or Venable type at
an appropriate site, leaving the heads proud. The
jaws of the Farabeuf forceps can be modified to
apply accurately to the screw heads thereby afford-
ing excellent control of the part desired (Fig. 175).
Sometimes two screws, one in each fragment, can
be used in this manner to maintain reduction while
definitive screws and plates are inserted .
(c) Ball spike. This is a useful instrument
(Fig. 174) with which to hold temporarily a bone
fragment awaiting fixation. It is simply a long
pointed spike on which a sphere is fixed about
0.5 cm from its extremity so that despite the con-
siderable force often exercised on the point, there
is little danger of uncontrolled perforation of the
fragment.
(d) Retractors. Several types must be available:
- Steinmann pins can be driven into the internal
iliac fossa in the anterior approach to maintain
retracted muscles and viscera; they are very
helpful. Their usefulness is enhanced by using
a malleable strip applied alongside. A supply
of such copper strips of various sizes should
be at hand.
- Sciatic nerve retractor has been developed spe-
cifically for these operations (Figs. 161 and 174).
Its point is applied in one or other of the sciatic
notches.
Early Treatment of Displaced Fractures
Fig. 173. Schemes showing areas
of dense bone suitable for internal
fixation
- Laminectomy spreader has permitted us to dis-
impact numerous fracture lines and facilitates
their cleaning.
- Femoral head extractor (Fig. 174). The instru-
ment used to extract a femoral head during ar-
throplasty operations (a "corkscrew") can be
driven into the ischial tuberosity in order to con-
trol and man oeuvre the posterior column, or
into the greater trochanter, through a secondary
incision in order to reduce a central dislocation.
- Chiseis, straight and curved, can be used to ad-
vantage like tyre levers for disimpaction and
then reduction of some types of fracture line.
20.6.3 Implants für Osteüsynthesis
We have tried many varieties of possible fixation
device adapted to the pelvic bone. Almost exclu-
sively, we find the only agents of consistent value
to be (1) Phillips or Lambotte-type screws, or less
often the Venable screw or spongiosa screws; and
(2) Shermann-type plates with holes spaced reg-
ularly throughout their length; a Y -shaped plate
is sometimes useful. We have developed special
plates provided in two radii of curvature, having
6-12 holes (Fig. 174B), adapted to the mean curva-
ture of the pelvic brim.
The size and design of plate chosen is of impor-
tance for in many instances it must be bent ac cu-
rately to fit the bone contours . If it is too strong
or thick, this will be difficult. Conversely, it is
useless to use material which is brittle, or too weak
to maintain fixation . Chrome-cobalt is favoured
since it does not have to be removed.
Operative Details
A B
c D
Fig. 174A-E. Special instruments. A (top) Femoral head extrac-
tor, (middle) ball spike, (bottom) curved chisei, B detail of
ball spike, C (top) modified Verbrugge's forceps, (bottom)
asymmetrical Farabeuf forceps, D stainless steel sciatic nerve
retractor (see also Fig. 161), E ordinary and specially curvcd
chrome-cobalt Shermann plates
20.6.4 Method of Internal Fixation
Where long screws are inserted into the posterior
column from the pelvic brim, or into the anterior
column from the retro-acetabular surface, they
must run parallel to the quadrilateral surface of
the ischium. Occasionally they can perforate and
traverse the cotyloid fossa and yet not impede rota-
tion of the femoral head.
251
3cm
E
While the A 0 system does not include plates
be nt on the flat, plates can be shaped appropriately
with special plate benders, the p.c.d., and
either 3.5 mm or 4.5 mm screws used according
to the size of the bone fragments to be fixed
(MAURICE MÜLLER, Berne, pers. comm. 1978).
There is another special forceps designed to obtain
purchase on the heads of temporarily inserted
screws during manoevres designed to secure reduc-
ti on of the fracture.
252
B With practice, using strong forceps or Mole-type
Fig. 175A, B. Two examples of application of Farabeuf force ps
by means of screws temporarily inserted into the bone
While for spongy bone screws larger in diameter,
such as Venable or the spongiosa type, would un-
doubtedly have a more solid purchase, they have
a difficult tendency to twist and displace the bone
during insertion when the large thread bears
against a nearby cortex. Generally, large screws
have only been utilised with success at the level
of the iliac wing. Every case is individual and in
some, two types of screw have been used together.
Early Treatment of Displaced Fractures
B
Fig. 176A, B. Method ofbending Shermann plate "on the !lat"
During development of our technique, we have
found that internal fixation by screws alone has
become less common and plates are nearly always
required. In practice, the aim is to apply these
to surfaces already perfectly reduced and they must
be moulded appropriately at the time of operation
to fit the area. Obviously, if their curvature is not
perfectly adapted to the bone, during screwing a
partial displacement of the fracture site will occur.
wrenches, the plates can be given a spiral set, or
curved on the flat, so as to fit any surface required
(Fig. 176). One particular long Shermann-type
plate, curved in the plane of the plate, conforms
to the middle segment of the superior pelvic brim
as has been mentioned already.
20.6.5 Reduction of Dislocation
In the case of a persistent posterior dislocation
it is usually easy to obtain areduction of the femo-
ral head after cleaning the acetabulum, removing
Post-operative Care
possible incarcerated fragments, and with the aid
of traction afforded by the orthopaedic table com-
bined when necessary with direct manipulation.
The reduction of a central or of an anterior
dislocation is the first thing to achieve if there
exists a segment of roof in situ large enough for
the head to rest against and to be stable. Longitudi-
nal traction can be combined with lateral traction
which is exercised by a Lambotte hook passed
under the lesser trochanter or under the femoral
neck, or by using the extractor screw driven into the
greater trochanter. If there is no segment of the
roof of sufficient size, the head must be maintained
in the proper position of future reduction while
the fragments are progressively reassembled
around it, and fixed. This is achieved by adjust-
ment of both lateral and longitudinal traction. Ab-
sence of any roof fragment in its correct location
constitutes one of the major difficulties in the treat-
ment of both-column fractures. The first action
necessary is to reduce the anterior fragment of
the iliac wing with respect to the posterior frag-
ments thereof and it is under these that the femoral
head will be orientated correctly during further
reconstruction of the columns.
20.6.6 Reduction of Fracture
The plan adopted is always peculiar to the case
concerned and no particular scheme can be
offered. It is not amiss to remember that here,
as for all osteosyntheses, extreme care is necessary
to preserve what remains of soft tissue attachment
to the bone fragments, and to reduce to a minimum
periosteal stripping.
All fracture lines must be reduced and to achieve
this it may be necessary first to mobilise impacted
fragments and then to secure a hold on these by
direct application of forceps or through the heads
of temporary screws. Again, the orthopaedic table
is valuable in aiding manipulation of inferior frag-
ments of either column by direct traction.
It is necessary at all stages to be extremely care-
ful about the quality of reduction and not to accept
approximations. When several fracture lines are
to be reduced, negligence during the reduction of
the first will lead to a progressive deterioration
in the quality of reduction of all the others. Frac-
tures range from those in which one reduction
corrects everything in that action, to those in which
one is obliged to proceed by steps, reducing one
column first and then the other, or perhaps one
253
fragment with respect to a column and then
proceeding to complete the ensemble by matching
the rest of the bone. Frequently the various stages
of reduction can be fixed by isolated screws,
achieving a sufficiently solid assembly to allow re-
mo val of the clamps and so free the operative
field for the application of a plate.
It is exceptional for impaction or crushing of
bone of the walls of the acetabulum to create
empty spaces requiring bone graft from the iliac
crest posteriorly or from the greater trochanter.
The osteosynthesis achieved, it is necessary to
verify the solidity of the assembly and the total
absence of mobility of the fragments when the
hip is moved in all directions. During these manip-
ulations, in total silence, if grating is heard or
feit, this may indicate that a screw is protruding
into the acetabulum.
20.7 Post-operative Care
Suction drainage is maintained for four to five
days, the tubes being removed one by one when
they are not draining more than 10 ml of fluid
per 24 h.
Anticoagulants are administered routinely after
the third day.
Post-operative immobilisation is not required.
Assuming that the osteosynthesis, verified during
the operation, is sound, the patient is simply put
to bed.
Active mobilisation of the operated hip is insti-
tuted immediately. Physiotherapy sessions can be-
gin on the second or third day. They constitute
positioning the knee and hip in flexion and main-
taining this by cushions or on a suitable splint
for 2-3 h at a time. These periods should be re-
peated two to three times per day in increasing
degrees of flexion of the hip. Gentle, progressive
weight-relieved exercises in bed and quadriceps ex-
ercises are encouraged.
Walking using crutches without weight-bearing
or with partial weight-bearing can start at about
2 weeks in most cases unless the hip is particularly
fragile due to osteoporosis or poor fixation. Full
weight-bearing is achieved in 10-12 weeks. We
have not regarded a longer period of protected
weight-bearing as of value in preventing avascular
bone necrosis.
21 Treatment of Specific Types of Fracture
21.1 Posterior Wall Fractures
(a) Approach. The operation is always through
the Kocher-Langenbeck incision. If there is a per-
sisting posterior dislocation the reduction is rarely
difficult but it should be delayed until after the
cleaning and inspection of the interior of the ace-
tabulum. If reduction has been performed before
the open operation, it is necessary, by means of
traction on the orthopaedic table, to displace the
head inferiorly and examine the interior of the
joint, and to evacuate bone fragments or muscle
and capsular debris which can remain therein. The
femoral head should be inspected and any damage
found recorded. The round ligament sometimes
remains attached to an osteocartilaginous frag-
ment avulsed from the head; it should be removed.
After reduction of the dislocation an appraisal of
the acetabular lesion itself can be made; the possi-
bility of marginal impaction must be borne in
mind.
(b) Reduction. In the case of a fracture with
marginal impaction the impacted fragments should
be detached with care using a small spatula or
curved chiseI. They can be correctly replaced
against the femoral head and then be held there
by repositioning the surrounding fragments. Occa-
sionally we have been left with a cavity in the
posterior wall after repositioning the impacted
fragments, likely to produce instability during
post-operative mobilisation; the defect has been
filled using cancellous bone graft taken from the
posterior part of the iliac crest, or in some cases,
bank bone has been used.
When the fracture separates a large single frag-
ment, this is as a rule easy to reduce. A problem
is posed sometimes when there are several pieces
not always easy to reassemble, especially when one
fragment, the key, is difficult to find. It is necessary
to be very painstaking in the restoration of the
retro-acetabular surface for on its quality depends
the success of reduction of the articular surface
which it supports posteriorly.
During all manipulation, care is necessary to
preserve soft-tissue attachments to all fragments.
A little stripping of 1-2 cm is all that should be
allowed, sufficient to clean the edges and make
possible a perfect reduction, while avoiding exces-
sive devascularisation.
(c) Fixation. For a long time, fixation has been
satisfactorily achieved using Phillips screws. Iso-
lated screws are adequate for a long fragment when
the bone is of good quality and when there is
a large soft-tissue pedicle which needs to be
preserved (Fig. 177). By carefully siting sufficient
screws (three to five) so that they diverge from
each other, a solid fixation can be achieved which
permits post-operative movements immediately. In
contrast, when there is a posterior dislocation asso-
ciated with a marginal fracture of the posterior
wall, one screw may be sufficient for the fixation.
Whenever necessary, in comminuted posterior
wall fractures, a plate should be used. One or two
screws maintain the reduction during moulding
and fitting the plate. These screws are inserted
from the posterior acetabular surface and find a
variable hold in the cortex of the quadrilateral
surface of the ischium. The plate chosen should
be as long as possible. It is moulded on the flat
and twisted along its axis so as to lie accurately
on the restored surface of the posterior column
bridging the one or more fragments. The middle
screws in the plate traverse the fragments and
should be directed so as to re ach the quadrilateral
surface of the ischium. lnferiorly, the plate is
always modelled to lie in the sub-cotyloid groove
and on the upper pole of the ischium; in this region
the screws are placed obliquely and diverge, being
256
of varying length (35-45 mm). They find an excel-
lent purchase in the tuberosity of the ischium
(Fig. 178). Superiorly, the plate must extend to
the supra-cotyloid region or just in front of the
sacro-iliac joint above the greater sciatic notch,
where there is ample bone for the screws. WeH
constructed, the assembly should be very solid.
21.1.1 Postero-superior Fractures
The procedure is similar but in order to bridge
the fragment, the plate must be placed more ante-
riorly in the supra-cotyloid region. Inferiorly it must
reach the ischium (as before, Fig. 179) and it is
often useful to curve the plate lightly on the flat
or to utilise the specially prepared curved acetabu-
lar plate.
21.1.2 Postero-inferior Fractures
A fragment of the ischial tuberosity is detached;
the fracture surface must be defined clearly. This
necessitates stripping of the quadratus femoris in
order to control the ischial fragment which is
usually in one piece with the detached segment
of the posterior wall. A perfect reduction of the
ischial tuberosity is accompanied therefore auto-
matically by restoration of the articular surface.
Fixation generally comprises local screws joining
the superior pole of the tuberosity of the ischium
to the rest of the ischium, and a moulded plate on
the tuberosity and the retro-acetabular surface ex-
tending above the fracture line (Fig. 180). Commi-
nuted examples are difficult but are dealt with simi-
larly.
21.1.3 Special Features
When the anterior border of the greater sciatic
notch is detached, in order to make the reduction
easier it may be found helpful to reduce and fix
this first.
Large posterior wall fragments including the
anterior border of the greater sciatic notch do not
offer any particular difficulty. They can be reduced
and fixed easily by means of a plate.
Very extended fractures can be fixed simply with
screws alone (Fig. 181) or by screws and a plate.
Treatment of Specific Types of Fracture
21.2 Posterior Column Fractures
(a) Approach. Routinely the Kocher-Langenbeck
approach is used. The reduction of the dislocation
which accompanied the fracture has never been
difficult, and the interior of the joint is easy to
inspect.
(b) Reduction. The column is reduced using bone
forceps of which one jaw is applied to the anterior
border of the greater sciatic notch or the angle
thereof, depending on the site of detachment. The
other jaw grips the area of bone above the roof
of the acetabulum, if necessary by means of a tem-
porarily inserted screw. A finger passed through
the greater sciatic notch on to the inner aspect
of the quadrilateral surface verifies the reduction
of the fracture line here. Very frequently, there
is a rotation of the column about its vertical axis
that is gene rally easy to control in recent fractures;
only restoration of the endopelvic fracture line as-
sures the correction of this vertical rotation. Occa-
sionally, forceps or a rugine can be applied to
the endopelvic surface through the sciatic notch.
Restoration of the quadrilateral surface and of the
shape of the greater sciatic notch guarantees ana-
tomical reduction of the posterior column. If the
rotation is particularly difficult, the femoral head
extractor can be inserted into the ischial tuberosity
thereby achieving full control of the detached frag-
ment of the column.
(c) Fixation. Solid fixation necessitates a plate
extending from the posterior part of the iliac wing
above the greater sciatic notch down to the ischial
tuberosity. It may be situated fairly externally and
astride the fracture line and the screws must be
placed very obliquely in order not to penetrate
the articular surface; the middle screws will gain
purchase only through that part of the quadri-
lateral surface of the ischium which has been
detached with the posterior column (Figs. 182 and
183). Alternatively, the plate may lie near the
greater sciatic notch; long screws can reach
through the fracture line alongside the vertical face
of the quadrilateral surface of the ischium and
gain excellent fixation in the anterior column
(Fig. 182). Plates at both sites may be required
(Fig. 184).
Anterior Column Fractures
21.2.1 Special Features
Fractures of the posterior column in which the
endopelvic line detaches the teardrop (four cases),
i.e. those which are very extended anteriorly, may
be difficult to reduce. A finger introduced along
the inner wall of the true pelvis can reach the
anterior part of the fracture line and control the
reduction. It is particularly useful in these cases
to place long Lambotte screws parallel to the qua-
drilateral surface of the ischium; they will gain
a hold in the anterior or superior surface to the
innominate line (Fig. 185).
Two epiphyseal separations did not present any
particular problem. The plate which bridged the
epiphyseal cartilage was applied in the usual fash-
ion (Fig. 186), and subsequently removed.
21.3 Anterior Wall Fractures
(a) Approach. This is always by the ilio-inguinal
route.
(b) Reduction. As a rule, reduction of the ante-
rior dislocation wh ich accompanies these fractures
is easy and is obtained by traction on the orthopae-
dic table. In the occasional difficult case, a femoral
head extractor in the greater trochanter provides
additional control. After the head, the fragments
of the acetabulum can be reduced, only two diffi-
culties sometimes presenting. Possibly the fracture
of the superior pubic ramus cannot be seen or
palpated; in this circumstance it is necessary to
elevate the pectineus muscle and if necessary the
pectineal part of the inguinal ligament. The other
problem is that the main outlines of the anterior
wall fragments may be complicated by secondary
longitudinal or transverse fracture lines, making
control awkward.
(c) Fixation. Having obtained the reduction, if
possible using one or two screws to fix the frag-
ments together temporarily, a long curved plate
is applied perfectly congruently to the surface of
the anterior column. It bridges the detached frag-
ment and extends superiorly to the iliac fossa near
the anterior border of the wing or even further
along the posterior part of the pelvic brim. Infer-
iorly it extends to the intact part of the superior
pubic ramus and the body of the pubis (Figs. 187
257
and 188). Other screws are sometimes necessary
to fix longitudinal fracture lines but much atten-
tion must be paid to their direction in order to
avoid their perforating the joint. When there exists
a displaced and elevated plaque of bone from the
quadrilateral surface, itcan be pushed back into
position by means of a rugine and fixed by screws
which extend from the plate or from the surface
of the ilio-pectineal region. Although it does not
bear articular cartilage, anatomical reduction helps
in the overall stability of the osteosynthesis (Figs.
187 and 189).
In all cases of fractures of the anterior wall as
well as of theanterior column, it is important
to ensure that the quality of reduction is good.
Even a small step at the fracture line on the ante-
rior surface of the bane will be accompanied by
incongruence of the joint space.
21.4 Anterior Column Fractures
21.4.1 Middle and Low Fractures
(a) Approach. These fractures require the ilio-
inguinal approach.
(b) Reduction of the anterior dislocation is ob-
tained as for anterior wall fractures and is gener-
ally stable. On the occasions when we have used
the ilio-femoral approach, it was twice necessary
to cut the ilio-femoral ligament at the level of the
acetabilum in order to obtain an adequate re-
duction.
(c) Fixation. This is achieved (Figs. 190, 191 and
192) by means of moulded p1ates along the pelvic
brim from the pubic symphysis to the posterior
part of the internal iliac fossa. Very 10ng plates
are required. Accessory screws serve to fix a dis-
placed zone of bone on the quadrilateral surface
and also accessory fractures of the anterior wall
of the acetabulum which are sometimes difficult
to see on the radiograph and very difficult to fix.
A fracture of the superior pubic ramus is easily
bridged by the plate but fractures of the ischio-
pubic ramus are reduced automatically; they are
inaccessible and no attempt is made to fix them.
For middle fractures, an assembly comprising
two plates has been used occasionally. One is at
the level of the iliac fossa to bridge the upper
fracture line, and the other at the level of the supe-
rior pubic ramus to span the inferior fracture line.
258 Treatment of Specific Types of Fracture

21.4.2 High Fractures moulding of the plate, two isolated screws can
be inserted to advantage, one into the iliac crest
(a) Approach. The choice may be debatable. If and the other into the medial angle of the fragment
there is one large fragment comprising part of the in the iliac fossa.
anterior part of the iliac wing, the ilio-femoral
approach is easy and simple. It must be certain,
however, that only fixation of the upper part of
the column will be hecessary otherwise this ap- 21.5 Pure Transverse Fractures
proach will be insufficient. In cases with multiple
fragments or if there' is doubt, the ilio-inguinal (a) Approach. The fracture line can be reached
approach must be chosen. from either extremity. In practice, the decision de-
pends on the relative dis placements of the posterior
(b) Reduction of the dislocation can be difficult
and anterior ends as assessed from the oblique
and unstable, for with the anterior wall, the frag-
views. The approach chosen, Kocher-Langenbeck
ment takes a large segment of the roof. For this
or ilio-inguinal, is appropriate for the site of
reason, the head has to be held reduced against
greater dis placement. If the displacement is similar
the posterior wall during the reduction and fixation
at the greater sciatic notch and at the pelvic brim,
of the anterior column. It can be maintained by
we always choose the posterior approach. It facili-
simple traction, perhaps combined with internal
tates good fixation of the posterior column on
rotation, and aided by lateral traction on the
which, after reduction, it is easy to place a plate
greater trochanter. It is helpful to manipulate the
across the fracture line.
fragment of the iliac wing by gripping it with a
sm all pair of Farabeuf forceps placed across the (b) Reduction. The central dislocation can
interspinous notch. usually be corrected easily, and the head comes
to lie under the intact segment of roof, or what
(c) Fixation may be maintained by two Venable
remains thereof, and is stable (Fig. 195).
screws (Fig. 193) inserted from in front backwards,
Rotation of the inferior fragment in fresh frac-
one into the interspinous notch and the other into
tures does not offer any particular difficulty of
the crest. They give solid fixation but may be diffi-
reduction. The asymmetrical forceps are very valu-
cult to place in the wing. In general, we prefer
able for manipulating the ischio-pubic fragment.
to use plates placed according to the fracture con-
In case of difficulty, the femoral head extractor
figuration. One may be screwed and modelled on
inserted into the ischial tuberosity gives even
to the internal iliac fossa bridging the fragment
greater control of the fragment.
and extending from the sacro-iliac joint as far as
Red uction of the pelvic brim is assessed by a
the superior pubic ramus well beyond the point
finger introduced into the pelvis through the
of the anterior fracture line.
greater sciatic notch, if the posterior approach has
Alternatively, two plates can be used, one on
been used; it should be remembered that if the
the internal iliac fossa along the pelvic brim, and
greater sciatic notch is reduced and the head lies
the other on the convexity of the iliac crest span-
in place under the roof, and yet the pelvic brim
ning the fracture line.
remains displaced inwards, this is likely to result
Further screws will fix the accessory fragments
from rotation of the fragment about its horizontal
or a fracture of the quadrilateral surface.
axis and not from simple inward displacement of
the whole fragment. It is necessary to try to rotate
the ischio-pubic segment by press ure directed me-
21.4.3 Special Features
diallyon the ischial tuberosity (Figs. 196, 197 and
198).
In a few examples of anterior column lesions, the
iliac fracture line was incomplete, failing to re ach (c) Fixation. Posteriorly, there is no problem
the iliac crest or the anterior border of the bone, in the placing of plates and screws. Anteriorly,
and yet reduction was difficult. It was greatly facili- a plate is fixed along the pelvic brim. Whatever
tated after deliberately completing the fracture. the manner and site, it is wise to use long screws
In high fractures of the anterior column which and if possible to arrange one or more to run
detach a large part of the iliac fossa and in which obliquely across the fracture line, parallel to the
the reduction is difficult to maintain during the quadrilateral surface of the ischium (Fig. 195 C).
Associated Transverse and Posterior Wall Fractures
21.5.1 Special Features
In the case of a pure transverse fracture associated
with a vertical anterior fracture of the pelvis, the
posterior approach alone does not allow complete
reduction of the anterior fracture line (Fig. 197).
21.6 Associated Posterior Column
and Posterior Wall Fractures
(a) Approach. The posterior approach is always
used.
(b) Reduction. After the posterior dislocation has
been reduced and the acetabulum cleared of debris
it is first necessary to reduce the posterior column
and ensure a perfect alignment both at the angle
of the greater sciatic notch and along the quadri-
lateral surface. The posterior column may be mini-
mally displaced but nevertheless it bears the lower
part of the posterior wall of the acetabulum and
must be reduced accurately.
Secondarily impacted fragments must be reposi-
tioned against the femoral head and held in place
by the overlying posterior wall.
(c) Fixation. It is sometimes possible, especially
if the posterior column is displaced little or not
at all, to achieve fixation using one plate bridging
the posterior fragment and assuring fixation of
the posterior column to the posterior part of the
iliac wing at the same time (Fig. 200).
If the column is significantly displaced, re duc-
tion may be more difficult, requiring fixation in
two stages. It is best to fix the posterior column
into a good position using a short plate positioned
just outside the angle of the greater sciatic notch
where screws find a good purchase. The posterior
associated fragment may be fixed by a screw but
much more frequently requires another plate
(Fig. 201). Soft-tissue attachments ofthe fragments
should be preserved.
If the angle of the greater sciatic notch is
detached together with the posterior column, it
is possible to insert a long screw from the angle
of the greater sciatic notch and to drive this for-
wards into the substance of the ilium. This isolated
screw obtains good fixation and maintains the col-
umn in place, permitting at leisure the final osteo-
synthesis with a plate.
259
21.7 Associated Transverse and
Posterior Wall Fractures
(a) Approach. The dislocation may be central
or posterior. In either case, and whatever the dis-
placement of the transverse fracture line, the poste-
rior approach is unquestionably the best. It allows
reduction and fixation of the posterior associated
fracture whereas the anterior approach does not
allow reduction of this component, and therefore
is an illogical choice. The routine use of both ante-
rior and posterior approaches seems to us dis pro-
portionate with respect to the lesion to be treated.
(b) Reduction. The trans verse component does
not pose any particular problem other than those
associated with the pure lesion which have been
detailed earlier. The acetabulum is cleaned and
the central or posterior dislocation reduced by the
usual manoeuvres. As a rule the head remains sta-
ble underneath the roof.
The transverse fracture must be reduced first.
By retracting the posterior fragments, care being
taken with respect to soft-tissue attachment,
through the gap afforded and by traction on the
orthopaedic table which separates the head of the
femur from the roof of the acetabulum, a view
of the inside of the acetabulum is obtained which
allows the transverse fracture line to be controlled
under vision. The reduction of the trans verse frac-
ture is obtained by traction and direct manipula-
tion of the ischio-pubic fragment using Farabeuf
or asymmetrical forceps perhaps applied by me ans
of temporary screws. During this process, the
sciatic nerve should be observed carefully. Reduc-
tion is verified by palpation of the inner wall of
the pelvis, particularly at the level of the pelvic
brim. When the greater sciatic notch has been
reduced perfectly, should the pelvic brim remain
displaced, it is almost certainly due to a horizontal
rotation, as described earlier.
(c) Fixation. When the transverse fracture de-
taches the angle of the greater sciatic notch with
the inferior fragment (Fig. 202) it is valuable to
insert a Phillips screw directly into the angle in
an anterior direction which will maintain the re-
duction of the transverse fracture (Fig. 204). If this
is not possible the transverse component must be
fixed by means of a plate applied very near to
the greater sciatic notch; in the superior fragment,
the screws need be only fairly short (20-25 mm)
but their hold in this dense bony area is extremely
260
firm. Along the margin of the greater sciatic notch,
the screws need to be progressively longer, some
being parallel to the quadrilateral plate surface
and able to gain attachment to the pelvic brim,
while the majority are directed obliquely inwards,
so as to gain purchase on the quadrilateral surface
of the ischium (Fig. 203). The posterior wall frag-
ment or fragments are then reduced and fixed pos-
teriorly by another plate or some simple screws.
We no Ion ger risk the fixation of these fractures
with screws alone for fear of loss of stability during
early passive movements; we have, however, a
number of good results from such simple fixations,
performed some ten years aga (Fig. 204).
21. 7 .1 Special F eatures
Fractures of the posterior wall are sometimes asso-
ciated with an incomplete hemitransverse element
(12 cases). If this hemitransverse component is not
displaced, it suffices to perform an osteosynthesis
of the posterior wall with a plate which also bridges
the hemitransverse component. If the hemitrans-
verse component is displaced, even by only a few
millimetres, this must be corrected by using forceps
or levering one fragment on the other, and then
fixed by at least two of the screws wh ich hold
the plate spanning the posterior fragment.
T-shaped fractures associated with a fracture of
the posterior wall are rare (five cases) and the
vertical branch of the T is rarely displaced signifi-
cantly. Their reduction is difficult. The posterior
approach is essential but sometimes a secondary
anterior operation has been necessary. As in the
transverse and posterior associated fractures, the
posterior column segment is reduced first and
brought into alignment with the wing. Then the
fragments of the posterior wall, sometimes with
marginal impaction, are repositioned with respect
to the posterior column. Finally the segment of
the anterior column must be reduced.
In one case associating a T-shaped fracture with
a posterior wall fracture, a posterior dislocation
was converted into a central dislocation during
reduction. The anterior approach was wrongly
chosen for the reduction and subsequently it was
necessary to perform a posterior approach during
the same operative procedure because the reduc-
tion was not perfect posteriorly (Fig. 206). The
significance of the original posterior dislocation
had not been appreciated.
Treatment of Specific Types of Fracture
21.8 T -shaped Fractures
It is necessary to repair the inferior fragment of
both columns with respect to each other, and then
reposition the repaired inferior fragments with the
iliac wing.
(a) Approach. Our T-shaped fractures have been
approached routinely by the posterior route,
whatever the obliquity of the vertical fracture line,
because the posterior component isolates a large
segment of the posterior column which is always
displaced and comprises the posterior segment of
the articular surface. Reduction of this fragment
and its fixation is not always possible through the
anterior route.
(b) Reduction. The position of the head is res-
tored under the sector of the remaining roof, by
simple traction. The posterior column fragment
can be retracted in order to examine the interior
of the acetabulum and to remove debris, carefully
detaching the capsule at the level ofthe acetabulum
if it is thought necessary to check the reduction
from the acetabular aspect.
(c) Fixation. After its reduction, the posterior
fragment is fixed with a moulded plate on the
back of the posterior column. The screws inserted
are chosen carefully so as to fix only the posterior
column and to remain confined therein and not
impede the reduction of the anterior column frag-
ment which is performed as a second stage.
Reduction of the anterior column fragment can
be assessed by means of a finger inserted from
the posterior aspect through the greater sciatic
notch, alongside the quadrilateral surface. If reduc-
tion is possible and can be maintained in a satisfac-
tory manner with the finger or by means of a
rugine, it is possible, from the posterior aspect
and from the posterior iliac wing above the frac-
ture line, to achieve fixation of the anterior frag-
ment by means of long screws (Fig. 207). These
may be inserted into the retro-acetabular surface,
or sometimes through the plate, some of the holes
of which had been left deliberately empty at the
time it was used to fix the posterior column com-
ponent. These various long screws may be directed
parallel with the quadrilateral surface thereby
reaching the pelvic brim. Some pierce and hold
the quadrilateral surface itself (Figs. 207, 208 and
209).
If reduction of the anterior column segment is
not possible through the posterior approach and
Associated Anterior and Hemitransverse Posterior Fractures
if the state of the patient permits, he can be turned
over and, through an ilio-inguinal approach, the
anterior column reduction can be completed and
held by a moulded plate laid along the pelvic brim
(Figs. 210 and 211). Solidarity is enhanced by long
screws inserted parallel to the quadrilateral sur-
face.
21.8.1 Special Features
In T-shaped fractures with astern posteriorly dis-
posed and trans-ischial, the posterior approach
always suffices; it has been necessary to expose
the inferior part of the ischium in order to achieve
a good reduction, at the price of total detachment
of the quadratus femoris muscle origin. The ante-
rior fragment, which includes with the anterior
column a large part of the quadrilateral surface
and even part of the posterior column, is fairly
accessible through the posterior approach.
If it is not possible to reduce the two main frac-
ture lines at the same time, it may be easier to
concentrate on joining the two inferior fragments
and then to complete the reduction and fixation
of what now amounts to a pure transverse fracture
(Fig. 212).
T-shaped fractures in which the stern is oblique
and directed forwards can also be approached, at
least initially, through the posterior route. The re-
duction of the somewhat slender anterior column
fragment has not always been perfect even though
accepted as sufficient. Sometimes this fragment
carried the anterior wall of the acetabulum which
stayed slightly displaced, the loss of congruence
above the joint being seen on the post-operative
radiographs, and even allowing a slight central
protrusion.
21.9 Associated Anterior and
Hemitransverse Posterior Fractures
The majority of lesions in the anterior column
necessitate an anterior approach. The ilio-inguinal
approach gives access to the whole anterior column
ofwhich the repair can and must be perfect. Access
is available to the posterior hemitransverse com-
ponent, wh ich must not be neglected. It can be
assessed by palpation as far backwards as the ante-
rior border of the greater sciatic notch. The lesion
261
of the anterior column or wall is repaired exactly
as would be the case for the simple fractures. These
can be reduced and fixed by a long moulded plate
applied along the brim of the pelvis and may be
supplemented by isolated screws used originally
to hold the reduction while the plate was applied
or to fix secondary fracture lines, sagittal in direc-
tion, which the plate does not span (Fig. 213).
The fractures of the upper part of the anterior
column have on occasions been fixed by long Ve-
nable screws (Fig. 214), inserted from the anterior
aspect of the iliac crest or through the interspinous
notch and driven posteriorly into the thickest part
of the iliac wing. The assembly is solid but during
insertion there is a tendency for telescoping to oc-
cur, with consequent loss of anatomical reduction.
The lower part of the column or the lower frag-
ments thereof (Fig. 214) were fixed by isolated
screws.
The anterior lesion having been reduced and
fixed, there remains the problem of the hemitrans-
verse posterior element. If this is situated low, split-
ting longitudinally the spine or cutting the lesser
sciatic notch, it is as a rule little or not displaced.
The inferior fragment of the posterior column is
difficult to manipulate from the anterior aspect
and its small displacement can be neglected; it
is not related to a significant amount of the poste-
rior wall and will consolidate quickly, perhaps with
a slight articular incongruence at the lower part
of the posterior wall. This little posterior fault does
not justify a subsequent posterior operation.
If the fracture is high, cutting the greater sciatic
notch at a variable level, perhaps at the inferior
or the superior third, it is not to be neglected,
even though the displacement may appear only
slight. It crosses the posterior wall of the acetabu-
lum and it must be reduced. If the screws of the
anterior column have been placed with care so
as not to protrude from its posterior margins, it
may be possible by means of a Lambotte rugine
or with the jaws of the asymmetrical forceps
applied, one on the long plate screwed to the pelvic
brim, and the other on the posterior column, to
obtain reduction of the hemitransverse posterior
fracture line. This is maintained by screws which
can be conveniently inserted somewhat vertically
downwards from the posterior third of the upper
aspect of the pelvic brim while working external
to the psoas. The reduction can be controlled with
a finger and when boring holes for screws, perfora-
tion of the quadrilateral surface of the ischium
can be feIt. Thus, the screws gain fixation inferiorly
262
in the quadrilateral surface of the posterior column
inferior fragment. Additionally, long screws paral-
lel to the quadrilateral surface and crossing the
fracture line can be driven so as to reach the retro-
acetabular surface (Figs. 213 and 215).
Since 1975, the extended ilio-femoral approach
has been used to great advantage for middle and
high anterior column fractures, provided no ante-
rior wall component is present or the latter is very
inferiorly located.
21.10 Both-Column Fractures
The surgical complexity of these fractures is the
result of the fact that the articular surface of the
acetabulum is detached in several pieces which be-
long to different fragments and which no longer
have any connection with the undisplaced part of
the iliac wing. Unlike the T-shaped fracture, there
is no sector of roof under which the head can be
brought as a first step in the reduction procedure.
The advocates of conservative management (e.g.
MAZAS 1968), describe the appearance of apparent
congruence on the standard radiographs because
of a rough clustering of the various articular frag-
ments around the head. This can only amount
to a false congruence, very far from anormal ana-
tomical configuration. Subsequently, the frag-
ments join and create an acetabulum with a narrow
irregular mouth due to collapse and overlap of
the margins of the fracture segments.
Recently, DECOULX (1975) has reported cases
of conservative reduction by traction which they
themselves have called "sauvage ". Indisputably,
severe central dislocation has been reduced almost
completely and the reductions have appeared re-
markably good; nevertheless, they have rarely been
anatomical. We admit that the results of DECOULX
(1975) appear superior, both radiologically and
clinically, to those achieved by an incomplete sur-
gical attempt and accordingly, before embarking
on these complicated fractures, the surgeon should
be equipped with the necessary technical require-
ments in all ways.
21.10.1 Approach
In both-column fractures, it is never possible to
be sure that the reconstruction of the acetabulum
can be achieved through one approach. The initial
Treatment of Specific Types of Fracture
problem centres about the choice of first approach.
This depends upon a comparison of the displace-
ments as shown on the standard radiographs and
the decision as to which column appears more
displaced. Practical experience has led us to the
following recommendations:
(a) The Kochcr-Langenbeck approach can be
applied to both-column fractures ofwhich the frac-
tured iliac wing reaches the anterior border of the
bone (at the anterior superior iliac spine, the inter-
spinous notch or lower down) and so long as the
anterior fragment is not split at the level of the
anterior wall of the acetabulum, for a fracture line
he re is never accessible through the posterior route.
Another advantage of the posterior exposure is
that there exists commonly an isolated fragment
of the posterior or postero-superior wall of the
acetabulum which has not been detected ra-
diographically, and which could not be reached
from the anterior aspect.
The Kocher-Langenbeck incision is always
preferred in one very precise circumstance, namely,
the existence of a fracture of both columns together
with a fracture-dislocation of the related sacro-iliac
joint. It would also be indicated in cases of incar-
ceration within the pelvis of the posterior column
or of a fragment of the posterior wall which would
render impossible the reduction of the posterior
column by the anterior route; this is difficult to
assess radiographically.
(b) The Wo-inguinal approach is chosen first,
when the fracture of the iliac wing reaches the
iliac crest. The enormous fragment of the anterior
column is only exceptionally in one piece, and it
cannot be controlled by the posterior route. Dur-
ing four years of work, the ilio-inguinal route has
allowed us, in eight cases out of ten, to re du ce
correctly the two columns with fracture lines reach-
ing the crest, and a second approach has not been
required. The disadvantage of missing a possible
posterior fragment or postero-superior fragment
has been mentioned.
(c) The extcnded Wo-femoral approach has an
important place in the management of both-col-
umn fractures, allowing complete control of the
iliac wing fracture as weil as the posterior column,
but it does not allow access to the inferior part
of the anterior column.
We will consider the technique of reduction and
fixation according to the choice of first approach.
Both-Column Fractures
21.10.2 Reduction and Fixation
Through Posterior Approach
The Kocher-Langenbeck incision has been used
31 cases. It must reach to within about 6 cm of
the posterior superior iliac spine. The gluteus max-
imus is divided while trying to preserve to a maxi-
mum the nerve filaments encountered medially.
In extreme cases the incision will have to extend
right to the posterior superior iliac spine, the disad-
vantages of which have been discussed already
(Chapt. 19). An immediate striking featme is the
extreme mobility of the fragments and of the head.
Traction in abduction and in different degrees of
rotation is necessary, and by trial and error, it
can be established wh at best leads to extraction
of the head from the pelvis, and to realignment
of the profile of the greater sciatic noteh.
Next, it is necessary to reduce the posterior col-
umn. There are several ways of checking the qual-
ity of this reduction:
- by the reduction of the retro-acetabular fractme
line which separates the posterior column from
the iliac wing fragment above, the latter remain-
ing in its proper place;
- by the restoration of the normal profile of the
greater sciatic noteh, which one must learn to
recognise in order to avoid an excessive angula-
tion;
- by endopelvic palpation of the reduction of the
column with respect to the posterior part of the
pelvic brim (which remains in pi ace) and to the
upper part of the fractme line which cuts the
quadrilateral smface of the ischium.
Rotation ofthe posterior column around a verti-
cal axis may exist and must be corrected.
It is necessary to be very careful about the initial
reduction of the posterior column for if it is not
exact the subsequent reconstruction of other frac-
tu re components will be compromised and become
successively more difficult and inaccmate.
The posterior column is manipulated using
forceps applied if necessary to one or two screw
heads. Correction of central dislocation may be
difficult to maintain; a Lambotte hook placed un-
der the neck can be used to exert traction, but
it is often much more effective to use the head
extractor inserted into the greater trochanter.
Once the column has been reduced, it is fixed
with a plate suitably moulded along the anterior
border of the greater sciatic notch (Fig.216A),
and extending above the angle and to the posterior
263
part of the iliac wing in front of the sacro-iliac
joint. This plate is fixed definitively after it has
been verified that a possible posterior or postero-
superior fragment has been positioned exactly. It
is screwed with care so that the screws remain
confined in the posterior column, reaching only
that part ofthe quadrilateral smface which belongs
to the posterior column (Fig. 216 A); they must
not impede the reduction of the anterior columns
subsequently. Inferiorly, the plate should reach as
far as the superior pole of the ischial tuberosity
where the hold is excellent. In the iliac wing, at
least three screws are required, and accordingly,
plates with six to eight holes are required to span
the whole distance adequately.
After the posterior column has been fixed, it
remains to reduce the iliac fractme wing as weIl
as a posterior wall fragment if present. To reduce
an iliac wing fractme which reaches the anterior
border of the ilium, it is necessary to have access
to its whole length and verify the perfect reduction
otherwise while the back part may be satisfactory,
in front, the reduction of the pelvic brim will be
imperfect. In order to assess the fractme line it
is possible to elevate the lower part of the gluteal
muscle origins and introduce a narrow bone lever
as far forwards as the anterior interspinous noteh.
It is perhaps less damaging however, to cut their
tendons of insertion a few millimetres from the
greater trochanter and then to elevate them from
the lower part of the iliac wing as far as the fractme
line.
In order to reduce the iliac fractme line, it may
be possible to disimpact the fragments by levering
them apart, and then reduce them, or it may prove
necessary to use a screw inserted into the supra-
acetabular region of the anterior column, and by
means of forceps the anterior column can be drawn
backwards. As before, the anterior border of the
iliac bone can be reached with a finger, and a
Lambotte hook slid into the interspinous noteh,
so that the anterior column can be drawn poster-
iorly. Having achieved reduction, we have usually
fixed the anterior and posterior columns together
with a plate bent so as to run approximately par-
allel to the postero-superior margin of the acetabu-
lum (Fig. 216B). This plate may have no contact
with the part of the iliac wing wh ich has remained
in its proper pi ace.
The reduction of the anterior column is checked
by a finger introduced into the inside of the pelvis
where it can detect the fractme line separating
264 Treatment of Specific Types of Fracture

the two columns at the level of the quadrilateral pubis is necessary on account of comminution in
surface, as weIl as at the pelvic brim. the region of the angle of the ipsilateral pubis.
In the majority of cases approached by this
(a) Reduction when fi"acture fine reaches iliac
route, there exists an isolated fragment of the
crest (28 cases). After the iliac lesion has been ex-
posterior wall of the acetabulum. If this comprises
plored and after the displacement of the posterior
a mid-posterior fragment, it can be reduced
column has been judged, the latter must be left
straight away with respect to the posterior column
for the time being.
and held in place with one or two screws. The
The p.rimary objective of reduction is the perfect
entire posterior surface of the pelvic bone is there-
restoratlOn of the anterior column, applied first
f?re complete again, 'and subsequently, the poste-
to the iliac wing. Experience has demonstrated re-
nor fragment will be bridged by one or the other
peatedly that an approximate and therefore inade-
of two plates (Fig. 217).
quate reduction is almost always due to an error
. If the fragment is postero-superior, we reduce
of rotation of the iliac wing. It is necessary to
It after the reduction of the posterior column,
attempt to restore the normal concavity of the
usually at the same time as the anterior column·
iliac fossa which is always much greater than one
it is bridged by the plate and may be maintained
realises. When the iliac fossa is properly reduced
by one or two supplementary screws (Fig. 217).
the a?terior superior iliac spine is practically per:
Finally, it may be wise to reinforce further the
pendlcularly above the nutrient foramen of the
:-"hole reconstruction using one or two long screws,
posterior 'part of the ~liac wing. Unfortunately,
mserted parallel to the quadrilateral surface per-
:-"hen left Improperly ahgned so that the concavity
haps through the plate fixing the posterior column
IS not restored, it is much easier to fit a plate
(by r:placing one short screw, inserted earlier) or
along the posterior part of the pelvic brim and
near It.
if this situation is accepted, the appearance on
Never forget to verify in silence that during
the standard antero-posterior radiograph will be
movements of the hip, which should be free there
similar to that seen on the iliac-oblique view. To
is no grating sensation indicating contact b~tween
re-establish the concavity, firm hold on the ante-
the head and intra-articular screws.
rior column is required in its middle part, using
We have used the posterior route for one both-
Farabeuf forceps astride the interspinous notch or
column fracture in which there was a fracture line
the crest.
extending to the iliac crest. There was much more
!he fracture lines are reduced by direct pressure
difficulty than would have been the case through
usmg a pusher perhaps after disimpaction by
the anterior route but despite this, it was possible
means of a chis el used like a tyre lever. The action
to co pe with the situation by this single approach
of reduction of the iliac wing is only possible after
(Fig.218).
a central dislocation of the head has been reduced.
In one rare case, when the posterior column
For this reason, the head must be maintained
took with it a segment of the pelvic brim (Fig. 136)
red~ced, more or less extracted from the pelvis,
and in which the fracture line reached the anterior
dunng attempts at reduction and fixation of the
border of the ilium, the po.sterior route allowed
anterior column. It is sometimes possible to do
a very good reduction which could be fixed easily
this by combining longitudinal continuous traction
(Fig.219).
on the orthopaedic table and the application of
a ball spike on the inner aspect of the wing which
21.10.3 Reduction and Fixation at the same time controls the head. Often it has
appeared preferable and much more convenient
Through Ilio-inguinal Approach to exert traction on the head from outside by
means of a femoral head extractor inserted into
The extent of the incision depends on the anatomi-
the trochanter along the axis of the neck through
cal type of fracture. It must always extend beyond
an external counter-incision.
the convexity of the crest posteriorly, being taken
The possible difficulties of reduction may be
further if the fracture li ne in the iliac wing is very
manifold:
posterior or if there is a loose triangular fragment.
Anteriorly, it reaches the median line but it must (i) Triangular iliac wing fi"agment. Fairly often,
be prolonged beyond this if access to the pubic the fracture line of the iliac wing bifurcates and
symphysis is required, or if fixation to the opposite isolates a tri angular fragment of variable size
Both-Column Fractures 265

which intro duces an element of instability of reduc- two screws for each component of the fracture.
tion. There is no special procedure except that This plate, curved on the flat, must be perfectly
the fragment must from the start be fixed, perhaps aligned and it assures the reduction of the convex-
first to the posterior part of the iliac wing, or ity. It cannot alone control the reduction of the
sometimes to the anterior part, so recreating the lower part of the iliac wing. By loosening the
normal concavity thereof; subsequently the re- screws subsequently, it is possible to rectify mal-
maining fracture can be reduced as if it were the alignment ofthe lower part ofthe column fragment,
single fracture line concerned (Fig. 220). for in certain cases, it will not be possible to reduce
perfectly the upper and lower parts of the column
(ii) Posterior fi"agment of the pelvic brim. In a
simultaneously. The plate loosely applied to the
few cases the posterior part of the pelvic brim,
crest permits correction in two steps, firstly ensur-
between the fracture line which detaches the ante-
ing that the concavity of the iliac fossa can be
rior column and the sacro-iliac joint, becomes
restored, and secondly preventing upward dis-
detached as a separate fragment (Fig. 216C). The
placement of the anterior column.
reduction of the anterior column may entail rota-
In order to fix the other fracture lines in the
tion about the postero-inferior angle of the iliac
internal iliac fossa further plates are applied. A
wing fracture line at the level of the internal iliac
long plate, twisted appropriately along its axis and
fossa; it may prove impossible due to the instabil-
on the flat, can be applied so as to extend from
ity introduced by the accessory fragment of the
the posterior part of the internal iliac fossa as
pelvic brim considered here. Once recognised, this
far anteriorly as the body of the pubis. It bridges
fragment should be reduced and fixed with screws.
the iliac wing fracture line and that through the
Thereafter, further repositioning proceeds as be-
anterior column, which traverses the anterior wall
fore. If the accessory fragment is located on the
of the ace tabu lu m or may be extra-acetabular
sloping superior surface of the pelvic brim, the
(Fig. 226). This plate could if necessary span the
same procedure applies.
sacro-iliac joint. In other cases, it may be neeessary
(iii) Fracture line reaches the anterior interspi-. to use two plates, one extending from the posterior
nous noteh. The split affects the upper part of part of the iliac fossa, near the sacro-iliac joint,
the anterior column, which is in general displaeed towards the solid bone near the anterior iliac
and slightly mobile. In all cases, it has been easy spines, while the other is placed on the pelvic brim
to reduce and to maintain with a screwed plate and need not be long (Fig. 223).
applied along the anterior border. In a few cases we have fixed a short plate in
the posterior part of the internal iliac fossa, in
(iv) Dislocation of the sacro-iliac joint. This may
order to bridge the lower part of the iliac wing
be complete or comprise a simple anterior gaping
fracture line; another plate is applied along the
due to rupture of the anterior ligament. It has
body of the pubis and the superior pubic ramus
always been reduced, but on a few occasions it
to stabilise the lower part of the anterior column
has been necessary to place a temporary screw
(Fig.222).
into the sacrum and to apply a plate across the
Finally, we have used a mixture of one or two
joint. The screw head offers useful purehase for
plates for the upper part of the anterior column
a suitable forcep blade.
and screws to maintain the lower part (Figs. 220
(b) Osteosynthesis of the anterior column. On a and 221).
few occasions Venable screws have been used, Osteosynthesis of the anterior column in these
inserted in a roughly horizontal direction penetrat- circumstances must be checked so as not to leave
ing the iliac wing in the region of the interosseous screws which are intra-articular, and not to have
notch or from the crest, thereafter crossing the used screws which are so long as to impede later
fracture lines to gain purehase in the posterior reduction of the posterior column.
part of the iliac wing. They give a solid fixation
but are difficult to place. Sometimes, they spoil (c) Fixation of the posterior column. Onee the
an initially anatomical reduction by telescoping anterior column ha~ been reduced and fixed it may
or deforming the fragments at the moment of final be surprising to discover with the finger or an
impaction. instrument that the posterior column can easily
We prefer therefore to mould on to the convexity be drawn outwards to its proper position, and that
of the crest, a short four-hole plate (Fig. 220) with the profile of the greater sciatic notch is restored
266
sufficiently to make a posterior approach unneces-
sary.
The posterior column reduction can be main-
tained with the finger, a rugine, the asymmetrical
forceps or using a Lambotte hook; it is then fixed
by long screws some of which may pass through
holes in a. plate or be inserted elsewhere indepen-
dently in order to gain fixation in the quadrilateral
surface of the posterior column or in the retro-
acetabular surface after having passed parallel to
the quadrilateral surface. By inserting one screw
from the ilio-pectineal eminence towards the is-
chial spine, and another from the hindmost part
of the internal iliac fossa converging with the pre-
ceding one, an excellent fixation of the posterior
column can be obtained (Fig. 225). Certainly, this
is not as strong as the osteosynthesis of the anterior
column described above, but it has always been
sufficient to resist the stress of immediate post-
operative movement.
(d) Reduction when fi'acture fine reaches anterior
border of ilium. Osteosynthesis has been performed
using a plate moulded along the pelvic brim to-
gether with Phillips screws or two spongiosa screws
which, inserted from the anterior inferior iliac
spine, fix the upper part of the anterior column
fragment. Long screws, from the plate or nearby,
fix the posterior column (Figs. 225, 226 and 227).
Difficulties in reduction of the posterior column
can be associated with the screws in the anterior
column being too long, protruding, and preventing
closure of a fracture line. Sometimes, additional
fracture lines of the posterior column, in particular
those which isolate the upper part of the anterior
border of the greater sciatic notch, render manipu-
lation with the finger-tip or an instrument difficult,
and therefore it is impossible to restore the profile
of the greater sciatic notch. Isolated osseous frag-
ments, with or without associated sectors of articu-
lar cartilage, which become interposed between the
two columns and sometimes impacted into the
spongiosa of the posterior column or the posterior
part ofthe roof, can also vitiate a perfect reduction
and necessitate a second approach: in one instance,
the result was that the acetabulum was displaced
with some degree of protrusion (Fig. 228) and yet
the various fragments of articular surface remained
congruent with the femoral head.
Treatment of Specific Types of Fracture
21.10.4 Reduction Necessitating Both
Approaches
In 11 cases out of 74 we have had to employ both
approaches, immediately during the same opera-
tive procedure (3 cases) or as two staged operations
(8 cases). Of these, the Kocher-Langenbeck ap-
proach was performed first, followed by an ilio-
femoral operation (two ca ses) or an ilio-inguinal
procedure (5 cases). In four ca ses, the ilio-inguinal
approach was performed first followed by the Ko-
cher-Langenbeck operation. The indications for
these double approaches were as follows:
(a) Failure (0 achieve an adequate reduction of
the opposite column. If, through the approach
chosen initially, it soon becomes apparent that re-
duction of the opposite column is difficult, rather
than prolong the operation fruitlessly with conse-
quent risks of infection or damage to soft tissue,
it is better to close the incision, turn the patient
over, and expose the opposite column. The cause
ofthe difficulty in reduction may be quickly found.
Further, the second approach is in general rapid
for in effect it entails only the reduction of an
isolated fracture of a column which will be easy
and anatomical assuming that the other column
had been reduced perfectly during the first stage.
If the state of the patient does not permit a second
approach at once, it must be delayed 8-10 days.
(b) Fracture-dislocation of the sacro-iliac joint.
Fractures of both c01umns together with a fr ac-
ture-dis10cation of the sacro-iliac joint have neces-
sitated two approaches. The posterior approach
is the one of choice with which to begin (Figs. 229
and 230). Then fragment comprising the lower part
of the articular surface carries also the posterior
inferior iliac spine, the superior border of the
greater sciatic notch and the sciatic buttress. It
is reduced by proper alignment with the remaining
part of the iliac wing and held by means of a
short Venable screw or by a plate. The the reduc-
tion of the posterior column is achieved by estab-
lishing a proper relationship between this and the
posterior segment of the restored iliac wing. In
this extensive posterior repair, the Kocher-Langen-
beck incision has to be very extended medially
with consequent risk to the gluteal muscles. Per-
haps two posterior approaches would be prefer-
able, one along the posterior part of the iliac crest
to restore the anatomy of the sacro-iliac joint and
the other a short Kocher-Langenbeck incision
Special Examples
through which the acetabulum could be repaired;
we have not used two such incisions.
We have treated four both-column fractures
with involvement of the sacro-iliac joint. One was
through the anterior approach first, and it was
of course impossible to cope with the sacro-iliac
fragment; a second approach was necessary but
an unsatisfactory reduction was achieved which
led to a post-traumatic osteoarthrosis. The three
others have been treated by posterior approach
first; the reduction of the fragment was obtained
without too much difficulty, the posterior column
reduced, and then an ilio-inguinal approach was
necessary in order to reduce the anterior column
(Figs. 229, 230 and 231). Now we would recom-
mend the use of the extended ilio-femoral ap-
proach.
21.10.5 A Particu1ar Both-Column
Fracture
In one case of a both-column fracture with an
iliac wing fracture line extending to the crest and
treated by the ilio-inguinal approach, the reduction
of the posterior column was extraordinarily diffi-
cult. The cause was incarceration within the pelvis
of the posterior column. The posterior column was
fractured in its upper part, a little below the angle
of the greater sciatic noteh. It was totally inside
the pelvis and had elevated so that its upper frac-
ture surface was in contact with the sacro-iliac
joint. Also, it had rotated some 60° so that the
retro-acetabular surface rested against the remain-
ing anterior part of the quadrilateral surface. Once
recognised radiologically, this situation should be
approached through the Kocher-Langenbeck inci-
sion (Fig. 232).
21.11 Special Examples
21.11.1 Incarcerated Intra-articular
Fragments
The intra-articular entrapment of fragments recog-
nised after reduction of a dislocation (13 cases)
constitutes a strong indication for open operation.
It is not urgent provided the posterior dislocation
267
is reduced and stable. When reduction of a disloca-
tion associated with entrapment of fragments can-
not be achieved the situation is more urgent, for
the removal of the incarcerated fragments offers
the only chance of reducing the femoral head in
the cavity and minimising the risk of avascular
necrosis of the head.
It is very easy to extract a pedunculated frag-
ment, after gentle traction on the lower li mb on
the orthopaedic table and following exposure
through the posterior approach. It is necessary to
check that the acetabulum is clear of other incar-
cerated fragments or debris; multiple fragments
are common, particularly in the cotyloid fossa and
the anterior part of the joint. Having ensured that
the joint is clear, the traction is relaxed. A large
loose fragment should be fixed in the usual man-
ner; similarly, a pedunculated fragment can be
reduced and held by a single screw. If a loose
fragment is small and impossible to fix, it is prefer-
able to remove it.
Diagnosed and treated early, the incarceration
of fragments does not impair the pro gnosis of frac-
tures of the acetabulum. It is the neglected incar-
cerations which can produce such bad results
(Figs. 233 and 234).
21.11.2 Bilateral Acetabular Fractures
We have met three bilateral fractures of the acetab-
ulum. One case eomprised a symmatrieal bilateral
transverse fracture assoeiated with a posterior wall
fraeture and a posterior dislocation. Both sides
were operated upon at the same time and by two
teams. The reduetion was good on both sides but
one femoral head underwent some necrosis
(Fig.235).
21.11.3 Fractures of Paralysed Rips
Two ca ses of fraeture of the aeetabulum on hips
afflicted with poliomyelitis have been operated
upon. They offered an easy approach because of
the atrophied muscle but there were diffieulties
in reduction on aeeount of the poor quality of
the bone and deformity of the pelvis. The fraetures
uni ted without problems.
268 Treatment of Specific Types of Fracture

Fig. 177. Fixation of solitary posterior wa ll fragment with

screws. See Fig. 24 for pre-operative state

B
Fig. 178A, B. Suitable site for application of a plate and screws oblique radiograph showing moulding of plate in the region
for fixation of a posterior wall fracture. AScheme, B obturator- of the ischial tuberosity
Special Examples 269

A B
Fig. 179 A, B. Osteosynthesis of a postero-superior fraeture with posterior radio graph, B obturator-oblique radiograph. See
marginal impaction by means of a plate and serews. A Antcro- Fig. 30 for pre-operative state

A B c
Fig. 180 A-C. Osteosynthesis of a postero-inferior fraeture by B obturator-oblique radiograph. C iliac-oblique radiograph. all
means 01' a plate and serews. A Antero-posterior radio graph. taken 4 years after operation. See Fig. 33 for pre-operative state
270 Treatment of Specific Types of Fracture

A B

Fig. 181 A-C. Osteosynthesis of an extended posterior wall frac-

ture by means of screws. A antero-posterior radiograph, B 0 b-
turator-oblique radiograph, C iJiac-obJique radiograph, all tak-
c en 6 years after operation. See Fig. 36 for pre-operative state
Special Examples 271

Fig. 182. Diagram of method of inserting screws holding plates

against the posterior wall so as to gain purchase on the quadri-
lateral surface of the ischium on both sides of a fracture line

Fig. 183. Osteosynthesis of a posterior column fraeture by

means of a plate and screws. A Antero-posterior radiograph
after operation. See Fig. 39 for prc-operative state

A B
Fig. 184A, B. Osteosynthesis of a posterior column fraeture mo\al of the plates. See Fig. 40 for pre-operativc state. The
by mcans of two plates. A Antero-posterior radiograph at time operation was performed in 1960: now we would tend to use
of operation, B antero-posterior radiograph 10 years after re- only one plate
272 Treatment of Specific Types of Fracture

A B

Fig. 185A-C. Osteosynthesis of an extended posterior column radio graph, C iliac-oblique radio graph, all taken 6 years after
fracture. A Antero-posterior radiograph, B obturator-oblique operation. See Fig. 43 for pre-operative state
Special Examples 273

Fig. 186. Osteosynthesis of epiphyseal separation of posterior

column. Antero-posterior radiograph 10 years after operation.
See Fig. 45 for pre-operative state
c

Fig. 187. Scheme 01' method of fixing an anterior wall fracture

associated with elevation of a plate of bone from the quadrilat-
eral surface of the ischium. The latter is held with two supp1e-
mentary screws
 274 Treatment of Specific Types of Fracture

Fig. 188
A-C Fig.189
C
 Special Examples 275

Fig. 190. Scheme of three methods

of fixation for anterior column
fractures

A B
Fig. 191 A, B. Osteosynthesis 01' a low anterior column fracture operation, B antero-posterior radiograph 4 ycars after opera-
(ilio-inguinal approach). A Antero-posterior radiograph before tion

<J Fig. 188A-C. Osteosynthesis 01' an anterior wall fracture (ilio- Fig. 189. Osteosynthesis 01' an anterior wall fracture associated
inguinal approach). A Antero-postcrior radiograph, B obtura- with a fracture 01' the ischio-pubic ramus (ilio-inguinal ap-
tor-oblique radiograph, C iliac-obliquc radiograph, all taken proach). Antero-posterior radiograph 4 years after operation.
4 years after operation. See Fig. 49 for pre-operative state See Fig. 52 for pre-operative state
276 Treatment of Specific Types of Fracture

C
Fig. 192A-C. Osteosy nthesis of middle anterior column frac- B obturator-oblique radiograph , C iliac-oblique radiograph, all
ture (ilio-inguinal approach). A Antero-posterior radiograph. taken 5 years after operation. See Fig. 58 for pre-operative state
Special Examples 277

Fig. 193A, B. Osteosynthesis of high anterior column fracture graph. B obturator-oblique radiograph. See Fig. 63 for pre-op-
not involving the obturator ring. A Antero-posterior radio- erative state
 278 Treatment of Specific Types of Fracture

Fig. 194A-C. Osteosynthesis of a high anterior column fracture

involving the sacro-iliac joint (ilio-inguinal approach). A An-
tero-posterior radiograph. B obturator-oblique radiograph,
C iliac-oblique radiograph. See Fig. 62 for pre-operative state.
The anterior column fragment took with it the upper part
of the sacro-iliac surface. For this reason. despite involvement
of the sacro-iliac joint, operation was performed through the
ilio-inguinal approach. A long plate applied to the pelvic brim
c would have been preferable
Special Examples 279

Fig.195A-C. Scheme of three methods of fixation for transverse fractures:

A through the Kocher·Langenbeck approach. B, C through the ilio-inguinal
approach

A B
Fig. 196A, B. Osteosynthesis of a transverse fracture with ante- after operation. See Fig. 74 for pre-operativc state. Operating
rior dislocation (posterior approach). A Antero-postcrior radio- through the posterior approach was an crror
graph, B obturator-oblique radiograph, both taken 3 months
280 Treatment of Specific Types of Fracture

Fig. 197 A B

Fig. 198A
B
 Special Examples 281

A B

Fig. 199 A, B. Osteosynthesis of a juxta-tectal transverse frac- bcfore operation, B antero-posterior radiograph 5 years after
ture (ilio-inguinal approach). A Antero-posterior radiograph operation. The displacement was greatest at the pelvic brim

<J Fig. 197 A, B. Osteosynthesis of a transverse fracture (posterior
approach). A Antero-posterior radiograph, B obturator-ob-
lique radiograph, both taken 6 months after operation. See
Fig. 73 for pre-operative state. The anterior fracture of the
obturator ring was not explored
Fig, 198A, B. Osteosynthesis of a severely displaced tran sverse
fracturc, well reduced through the posterior approach. A An-
tero-posterior radio graph before operation, B antero-posterior
radiograph 2 years after operation
282 Treatment of Specific Types of Fracture

A B

Fig. 200 A-C. Osteosynthesis of an associated posterior column B iliac-oblique radiograph. C obturator-oblique radiograph. all
and posterior wall fracture. A Antero-posterior radio graph. taken 6 years after operation. See Fig. 92 for pre-operative state
Special Examples 283

c
284 Treatment of Specific Types of Fracture

C D
Fig. 201 A-D
 Special Examples 285

Fig. 202. Scheme of two methods of fixation through the poste-

rior approach for associated transverse and posterior wall frac-
tures

A B
Fig. 203A, B. Osteosynthesis of an associated transverse and See Fig. 95 for pre-operative state. Clinically the result was
posterior wall fracture. A Antero-posterior radiograph , B ob- very good, but note the collar of osteophytes around the femor-
turator-oblique radiograph, both taken 7 years after operation. al head margins

<J Fig, 201 A-D. Osteosynthesis of an associated posterior column C obturator-oblique radiograph, und D iliac-oblique radio-
and posterior wall fracture. A obturator-oblique radiograph, graph, taken after operation. The small plate holds the posterior
and B iliac-oblique radiograph, both taken before operation. column and the long plate bridges the posterior wall fragment
 286 Treatment of Specific Types of Fracture

A B

Fig. 204A-C. Osteosynthesis of an assoeiated transverse and

posterior wall fraeture. A Antero-posterior radiograph, B iliae-
oblique radiograph, C obturator-oblique radiograph, all taken
9 years after operation. See Fig.94 for pre-operative state. A
scrcw (A, arrow) has bcen inserted direetly into the angle of
c thc sciatic notch
 Special Examples 287

A ~ ____________ ~~ __ ~~

Fig. 205A-C. Osteosynthesis of an assoeiated ineomplete trans-

verse and postcrior wall fraeture (posterior approach). A An-
tero-posterior radiograph bcfore operation, B antero-posterior
radiograph, and C iliae-oblique radio graph after operation.
Both fraelure components are weil fixcd by the platc bcnl 10
fit the posterior surfaee of the bone C
288 Treatment of Specific Types of Fracture

~~
//
//
---,#-=::.;:.;:.
-- -=--
::::::: = _-4.:_2-::'~ ____ ----
-- ---~---- ----

c
Fig. 206 A-C. Osteosynthesis of an associated T -shaped and
posterior wall fracture (anterior and posterior approaches con-
secutively). A Antero-posterior radiograph. B obturator-ob-
lique radiograph, C iliac-oblique radio graph. See Fig. 99 for
prc-operative state Fig. 207. Scheme of methods of fixation for T -shaped fractures
Special Examples 289

A B
Fig. 208A, B. Osteosynthesis of T-shaped fracture (posterior Fig. 88 for pre-operative state. Note in B the long screws ex-
approach). A Antero-posterior radiograph, B obturator-ob- tending from the plate to the pelvic brim
lique radiograph, both taken one year after operation. See

Fig. 209 A, B. Osteosynthesis of a T-shaped fracture (posterior

approach). A Antero-posterior radio graph before operation,
B anteroposterior radiograph 3 years after operation B
 B

Fig. 2IOA-D. Osteosynthesis of a T-shaped fraeture (Kocher- graph, and D obturator-oblique radio graph after completion
Langenbeck and ilio-inguinal approaches). A Antero-posterior of the second stage. Note thc special long plate designed to
radio graph before operation, B antero-posterior radio graph follow aecurately the surface of the middlc part of the pelvic
after completion of the first stage, C antero-posterior radio- brim
Fig. 211 A-C. Osteosynthesis of an anterior T-shaped fracture
(Kocher-Langenbeck approach fo11owed by ilio-inguinal) A An-
tero-posterior radiograph. B obturator-oblique radiograph.
C iliac-oblique radiograph. a11 taken 3 years after operation.
Sec Fig. 82 for prc-opcrative state
292 Treatment of Specific Types of Fracture

Fig. 212. Osteosynthesis ofa posterior T-shaped fracture (poste-

rior approach). Antero-posterior radio graph 9 years after oper-
ation. See Fig. 85 for pre-operative state

Une of associated
anterior column
and posterior hemi -transverse
fractures \

Associated anterior wall

and posterior hemi -transverse
fractures

Fig. 213. Diagram of method of

fixation for associated anterior
wall and posterior hemitrans-
verse fractures through the ilio-
inguinal approach
Special Examples 293

A
B

Fig. 214A-C. Osteosynthesis of an extended anterior column

fracture associated with a posterior hemitransverse fracture.
A Antero-postcrior radiograph. B obturator-oblique radio-
graph, C iliac-oblique radiograph. all taken 8 years after opera-
tion. See Fig. 109 for pre-operative state C
A B

Fig. 2ISA-C. Osteosynthesis of an associated anterior wall and Fig. 216. Diagram of methods of fixation for both-column frac-
posterior hemitransverse fracture (ilio·inguinal approach). tures. See text
A Antero-posterior radiograph. B obturator-oblique radio-
graph. C iliac-oblique radiograph after operation. See Fig. 113
for pre-operative state
A

E
Fig. 217 A-E. Osteosynthesis of a both-column fracture (poste-
rior approach). A fracturc linc rc,lChing the interspinous notch
and a posterior fragment were discovered only at operation.
A Antero-posterior radiograph before operation. B antero-pos-
terior radio graph after operation. C sehe me showing fracture
configuration. D antero-postcrior radiograph. and E iliac-ob-
lique radiograph 7 years after operation. One plate was used
to fix the posterior column to the posterior part of the iliac
wing. and another to fix the iliac wing to the anterior eolumn.
Two isolated serews hold the postero-sllperior fragment whieh
was not bridged by a plate. Dcspite eelopie bone formation
D a very good clinical reslilt was obtaincd
296 Treatment of Specific Types of Fracture

Fig. 2I8A-D. Osteosynthesis of a both-column fracture (poste-

rior approach). A fracture line reaches the crest and splits
from the anterior column towards the antero-inferior iliac spine,
and there are several accessory fragments. A Scheme of fracture
configuration, B antero-posterior radiograph, and C obturator-
oblique radiograph, both taken before operation, D antero-
posterior radio graph after operation. Two screws fix the isolat-
cd posterior fragment, a plate for the posterior column and,
applied along the anterior border of the greatcr sciatic notch,
a plate bridges the posterior fragment and the upper part of
the anterior column, and a short horizontal plate fixes the
fracture line directed towards the iliac crest D
Special Examples 297

Fig. 219 A, B. Osteosynthesis of a both-column fracture. A good notch. The posterior column took with it a segment of the
reduction was obtained through the posterior approach. A An- pelvic brim. One screw fixes the posterior component to the
tero-posterior radiograph. B iliac-oblique radiograph after op- iliac wing; a plate spans the two columns. See Fig. 142 for pre-
eration. A fracture component extends to the interspinous operative state
298 Treatment of Specific Types of Fracture

A B

Fig. 220 A, B. Osteosynthesis of a both-column fracture with tive state. One plate fixes the iliac wing component. a Y -shaped
a component extcnding to the crest (ilio-inguinal approach). plate spans another. more posterior iliac wing component. and
A Antcro-posterior radio graph. B iliac-oblique radiograph. two screws fix the posterior column
both taken 5 years after operation. See Fig. 125 for pre-opera-
 Special Examples 299

A - - --

Fig. 221 A--C. Osteosynthesis of a both-column fracture with

an iliac component extending to the iliac crest. A Antero-poste-
rior radiograph. B obturator-oblique radiograph. C iliac-ob-
lique radiograph 4 years after operation. See Fig. 139 far pre-
operative state. One plate fixes the iliac crest fracture. another
directed towards the anterior inferior iliac spine re-establishes
the concavity of the fossa. two screws cross the split in the
anterior column. and a Lambotte screw immobilises the posteri-
c or column
 300 Treatment of Specific Types of Fracture

Fig. 222 A-C. Osteosynthesis of a both-column fracture with

an iliac wing component extending to the iliac crest (ilio-inguin-
al approach). A Antero-posterior radiograph, B obturator-ob-
lique radiograph, C iliac-oblique radiograph, all taken 8 years
after operation. See Fig. 138 for pre-operative state. One plate
spans the fracture reaching the iliac crest, another ex tends to-
wards the anterior inferior iliac spine, a third spans the split
in the anterior column, and two Lambotte screws fix the posteri-
c or column
 Special Examples 301

Fig. 223A-C. Osteosynthesis 01' a both-eolumn [raeture with

an iliae wing eomponent extending to the iliae crest (ilio-inguin-
al approach). A Antero-posterior radiograph, B iliac-oblique
radio graph, C obturator-oblique radiograph, all taken 4 ycars
after operation. See Fig. 127 for pre-operative state. One plate
is applied to the crest, a second in the iliac fossa extends towards
the anterior inferior iliac spine, a third bridges the fracture
01' the anterior column, and some screws have been inscrted
from the iliac fossa to fix the posterior eolumn. A short plate
c applied along the crest has been removed
302 Treatment of Specific Types of Fracture

Fig. 224A-C. Osteosynthesis of a both-column fraeture with

an iliae eomponent extending to the iliae crest. Reduction
through the ilio-inguinal approach was simple but difficult to
maintain. A Antero-posterior radiograph, B iliac-oblique radio-
graph. C obturator-oblique radiograph, all taken 9 years after
operation. See Fig. 130 for pre-operative state. The method
of fixation is similar to that in Fig. 223. A plate applied along
c the crest has been removed
Special Examples 303

Fig.225A

B
Fig. 225A, B. Osteosynthesis of a both-column fracture with
an iliac wing component extending to the interspinous notch
and with a split in the anterior column. A Antero-posterior
radiograph, B iliae-oblique radiograph . both taken two years
after operation. See Fig. 133 for pre-operative state. One plclte
was used for the pelvic brim and two Lambotte screws for
the posterior column

Fig. 226. Osteosynthesis of a both-column fracture with an iliac

wing component extending to the anterior superior iliae spine.
The ilio-inguinal approach was chosen because of a fracture
of the anterior column at the level of the anterior wall. The
posterior column took with it a short segment of the pelvic
brim. A Antero-posterior radiograph 4 years after operation.
See Fig. 131 for pre-operative statc. Three Philips screws held
the fraeture during lateral traction on the femur: fixation was
completed by the long plate on the pelvic brim
A
Fig. 227 A, B. Osteosynthesis of a both-column fraeture with
an iliac component extending to the anterior superior iliac
spine. The high part of the anterior column fracture could
be fixed with two screws through the ilio-inguinal approach.
A
Fig. 228A, B. Osteosynthesis of a both-eolumn fracture with
an iliac component extending to the crest. typieal but eommi-
nuted. A Antero-posterior radiograph before operation, B an-
tero-posterior radio graph after operation. lt was impossible
to mobilise the posterior column through an inguinal incision.
Two weeks later, the cause was found through a Kocher-Lan-
A Antero-posterior radiograph before operation, B antero-pos-
tcrior radiograph after operation. Two long screws inserted
through the plate on the pelvic brim reach the posterior column
genbeck approach: fragments of cortical bone from the cotyloid
fossa and of the postero-superior articular surface were wedged
between the eolumns. Finally false congruence was achieved:
really a mal union of the pelvic bone, but forming a congruent
joint around the centrally displaced head
A

c
Fig. 229 A-D. Osteosynthesis of a both-column fracture with
an iliac componenl eXlending to the crest and with involvement
of the sacro-iliac joint (consecut ive posterior and then anterior
ilio-femoral approaches). A Antero-posterior radiograph after
first stage of operation through Kocher-Langenbeck approach.
B Antero-posterior C iliac-o blique and D obturator-oblique ra-
diographs 5 years after completed operation. See Fig. 136 for
pre-operative state. The posterior approach was chosen first
because of the sacro-iliac joint involvement. The most inferior
fractures of the anterior column were not accessible through
the ilio-femoral approach, but was adequate for the completion
of the reduction of the ant e rior part of the fracture complex D
 306 Treatment of Specific Types of Fracture

____________________ ~ ______ ~:. B

Fig. 230 A-C. Osteosynthesis of a both-column fracture with

an iliac wing component extending to the crest with involvement
of the sacro-iliac joint (consccutive posterior and ilioinguinal
approaches). A Antero-posterior radiograph. B iliac-oblique ra-
diograph, C obturator-oblique radiograph. all taken 2 years
after operation. See Fig. 137 for pre-operative state. lt was
very difficult to reduce the sacro-iliac fragment through the
first approach: it was fixed with a spongiosa screw inserted
into the crest and a platc on the external iliac surface astride
the fracture line. This complicated but effective fixation was
comp1eted through the second approach with a plate adjacent
to but not on the iliac crest (because it was still cartilaginous
in this young patient), a screw in thc angle of the anterior
column fragment at the level of the internal iliac fossa. a plate
extending from the sacro-iliac region to the anterior inferior
iliac spine, and finally a plate across the inferior fracture of
the anterior column. The screws from the latter plate reach
the posterior column and gain a hold on the quadrilateral
c plate
 Special Examplcs 307

Fig. 231 A-C. Osteosynthesis of a both-column fraeture with

sacro-iliac involvement (two approaehes). A Antero-posterior
radiograph be fore operation. B antero-postcrior radiograph.
and C obturator-oblique radiograph after operation C
 308 Treatment of Specific Types of Fracture

B
Fig. 232 A, B. Osteosynthesis of a both-eolumn fraeture with
an iliae component extending to the iliac crest (ilio-inguinal
approach). A Antero-posterior radio graph, B iliac-oblique ra-
A
diograph, both taken 10 years after operation. See Fig. 140
for pre-operative state. Two plates restore the anterior column
and two Venable screws are implanted into its anterior border.
Another plate bridges the split in the lower anterior column.
Long serews reach and fix the posterior column

Fig. 233. Primary incarceration of a posterior wall fragment.

A Antero-posterior radio graph taken 3 years after simple re-
moval. See Fig. 152 for pre-operative state
Special Examples 309

Fig.234A-C. Osteosynthesis of an associatcd T-shaped and

posterior wall fraeture with posterior disloeation and seeondary
inearceration of a posterior wall fragment (Koeher-langenbeck
approach). A Antero-posterior radio graph. 8 obturator-ob-
lique radiograph, C iliac-oblique radiograph, all taken 6 years
after operation. See Fig. 153 for pre-operative state. The incar-
8 cerated fragment was fixed with a single serew
310 Treatment of Specific Types of Fracture

Fig. 235 A, B. Bilateral aceatabular fraclures (simultaneous operations by two teams). A An-
tero-posterior radio graph before operation, B antero-posterior radio graph after operation
22 EarIy Complications of Operative Treatment
In the present series of 302 operations, 216 patients
suffered no significant complication. Our gross
complication rate is therefore 28%. The results
refer to the condition of the patient at the time
of assessment for the purpose of the French edition
of this book (l UDET and LETOURNEL, 1974).
The early complications directly related to the
operation will be considered under the headings
of death, infection, nerve damage, secondary dis-
placement at the fracture site, and thrombo-embol-
1sm.
22.1 Death
During the period of hospitalization there were
11 deaths (3.6%). These were attributed to the
following causes:
- 1 brain stern damage
- 3 massive pulmonary emboli sm
- 2 inadequate post-operative resuscitation
- 2 unexplained circulatory collapse
- 1 myocardial infarction
- 1 septieaemia due to Candida albicans
- 1 thrombosis of the external iliac artery
Seven of the operated patients were more than
60 years old and therc was a mortality of 12.7%
for these elderly peoplc.
From a more analytical point of view two of
these deaths were directly attributable to surgery
of the acetabulum, viz. the cases with septicaemia
and arterial thrombosis. Four deaths could pro ba-
bly have been avoided by more efficient resuscita-
tion. Five deaths (1.6%) were associated with a
surgical complication which could affect any
procedure
22.2 Infection
There were 20 post-operative infections of all types
(6.6%). This high incidence relates to 15 years of
surgery of the acetabulum, but there were two
peaks. The first was during the early stages when
we were inexperienced. The pathological anatomy
had not always been thoroughly understood before
the operative treatment, and errors of surgical ap-
proach led to long surgical procedures which were
followed by several bad infections. The second
peak of incidence followed early utilisation of the
ilio-inguinal approach when there were 8 infections
out of 53 operations, that is, 13.2%. Better under-
standing of this approach, precautions to preserve
the lymphatics, and the use of antibiotics during
the peri-operative period have contributed consid-
erably to reduce the frequency of this complica-
tion. It should be emphasised that there has been
no example of suppurative arthritis of the hip fol-
lowing the post-operative infections after using the
ilio-inguinal approach.
Among more recent cases, not included in the
1972 statistics, there has been an example of septic
arthritis of the hip due to a deep infection of the
interna 1 iliac fossa.
22.2.1 Analysis of Post-operative
Infections
I nfections ha ve occurred after:
- 10 Kocher-Langenbeck incisions out of 213
(4.6%) ;
- 8 ilio-inguinal approaches out of 53 (13.2 0;'));
- 1 Smith-Petersen approach out of 2;
- 1 double approach (staged) out of 8.
312
These post-operative infections have been very
variable in type and in c1inical presentation and
seriousness. We have regrouped them schemati-
cally according to their site with respect to the
operated hip.
(a) Infections of the retro-pubic space. Two of
these occurred following the ilio-inguinal approach
and one of these was associated with an infection
of a subcutaneous injury over the greater trochan-
ter. In one the femoral h~ad underwent necrosis
which was treated 2 years later by a total hip arth-
roplasty. Both patients now have good results in
that the hip is not infected.
(b) Supeljicial infections. Of five of these, three
followed Kocher-Langenbeck incisions and two
followed ilio-inguinal incisions. They were sited
superficially to the gluteus maximus and external
oblique respectively. A wide excision of the area
was performed and the results 3 and 8 years later
respectively are very good.
(c) Infected haematomata in the Wac fossa. Four
of these followed the ilio-inguinal approach and
were recognised from the 12th to the 30th post-
operative day. One ca se was preceded by a Morel-
La valle lesion.
Infected haematomata were excised together
with their lining membranes and eures were ob-
tained without hip infections. In the long term,
c1inically there have been one very good result;
two fair results, despite malunion of the acetabu-
lum in one and a significant stiffness of the hip
in the other with anormal radiograph ; and one
case, very good at 10 months post-operative1y, but
subsequently lost to follow-up.
(d) Early suppurative arthritis of the hip. There
were seven cases, of which six followed Kocher-
Langenbeck incisions and one followed a Smith-
Petersen approach.
The infection manifested between the 8th and
18th day, but in all seven cases the hip appears to
have been involved from the start. An excision of
the infected area was performed, but the accounts
do not mention c1eaning of the joint itself. Healing
was never obtained and two or more operative
excisions were subsequently necessary. Clearly, the
excisions were not as radi ca 1 as we would now
judge necessary.
Following these infections one patient died from
Candida albicans septicaemia. Four cases remain
with abnormal radiographie appearances having
a joint space which is wide and irregular, the head
Early Complications of Operative Treatment
of the femur being in poor alignment, and three
of these have had repeated inflammatory episodes
which indicate the probability of further operative
treatment. Two cases have been dry for years but
on the radio graph the sequelae of a suppurate arth-
ritis are apparent and they have very mediocre
function.
(e) Late infections. Two cases presented late:
one followed a Kocher-Langenbeck incision for
a both-column fracture in a patient with poliomye-
litis in whom the early post-operative course had
been accompanied by pyrexia over a long period :
and one was associated with two operative ap-
proaches performed consecutively. There was a
post-operative pyrexia but a fistula did not appear
unti! after one year. These are two poor results.
One is stiff and subluxed and the other is anky-
losed.
Of the total, apart from the patients who died,
19 with infected hips followed over a long period
had the following results:
- 6 very good results;
- 2 good results with a total hip replacement;
- 4 acceptable reslllts (despite malunion with post-
traumatic coxarthrosis, significant stiffness, and
sequelae from suppurative arthritis which has
been dry for six years);
- 7 poor results.
The outlook from infection is poor. Note that
although the inguinal approach procedures led to
more infections, none of these was accompanied
by involvement of the hip joint itse1f or by loss
of function.
22.2.2 Cause of Infection
This was not known in the majority of cases. On
one occasion, a sinusitis was probably responsible,
otherwise, the difficulty and length of the oper-
ation, and errors of approach may be invoked.
The lymphatics draining the foot, genital organs,
the groin, the perineum and the anal canal, which
are damaged during the ilio-inguinal approach, are
probably a significant source of infection espe-
cially in the presence of haematoma formation.
22.2.3 Prophylaxis
(a) Do not operate on febrile patients or on those
having a leucocytosis. First look for and treat the
focus responsible for the condition.
Nerve Damage
(b) Recognise and evacuate a Morel-Lavalle le-
sion over the greater trochanter.
(c) U se multiple suction drains in all recesses
of the operation wound so as to prevent haema-
toma formation.
(d) Look for post-operative haematomata, par-
ticularly in the internal iliac fossa; evacuate them
surgically.
(e) Administer prophylactic antibiotics 24 h be-
fore operation and continue these, especially after
the ilio-inguinal approach, for 10-15 days.
22.2.4 Treatment
Once an infection is recognised, drainage from as
many sites as necessary is a matter of urgency.
Vigorous antibiotic therapy starts as soon as mate-
rial has been taken for culture.
As soon as the inflammation of the cells around
a fistula has been controlled (usually necessitating
6-8 days of antibiotic therapy) early excision of
the infected area should be performed. This com-
prises complete removal of all the necrotic and
infected tissue, beginning at the incision, of which
the two margins should be excised together with
the fistula. It is necessary to follow the fistula into
its depths, excising its wall and the deep recesses
of the abscess, but leaving any healthy tissue.
This excision procedure is easy when the infec-
tion is confined to the soft tissue superficial to
the gluteus maximus or the externaioblique. Hav-
ing established with certainty that the abscess cav-
ity does not communicate with the hip by manipu-
lating the joint, and that haemostasis is adequate,
numerous suction drains extending to the depth
of the abscess cavity and its recesses are inserted,
and the wound sutured.
Sometimes deeper exploration has led to the ex-
posure of plates or the heads of screws. Curettage
of the bone on the surface is necessary in order
to remove all aponeurotic devitalised tissue; then
the plate should be partially loosened in order to
clean under it. After checking that the hip joint
itself is not involved, and inserting multiple suction
drains, the wound can again be closed.
Finally, if a communication with the joint is
discovered, the prognosis becomes much less cer-
tain. It is essential to clean the joint. If operating
through the posterior approach, we would advise
a capsulo-synovectomy and division of the trans-
313
verse acetabular ligament in order to clean tho-
roughly and drain the deep part of the joint. From
the anterior aspect, it is probably preferable to
supplement the ilio-inguinal approach by a vertical
anterior approach in order to reach the joint and
to perform the capsulo-synovectomy. After co-
pious lavage with Dakin's fluid, the wound is
closed in layers with suction drainage is as many
planes as necessary.
22.3 Nerve Damage
The majority ofinstances concern the sciatic nerve,
only one post-operative paralysis of the femoral
nerve having been observed. The cause for the
latter was never clear but strong traction on the
knee which is flexed beyond 70° can without doubt
pull on the femoral nerve.
Of the sciatic paralyses there were 34 post-opera-
tive cases (11.2 %) but their extent and duration
were very variable. Thus we had 30 early sciatic
nerve palsies, as follows:
- 1 total sciatic;
- 7 total external popliteal component;
- 12 partial extern al popliteal;
- 5 severe mixed sciatic;
- 2 slight mixed sciatic;
- 1 post-operative deterioration of a known pre-
operative sciatic weakness;
- 2 pure sensory impairments.
In all, we have seen four secondary scmtlc
palsies, that is to say they were not associated
with the immediate operative procedure which was
followed by an interval during which there was
apparently normal function of the sciatic nerve.
22.3.1 Immediate Post-operative
Sciatic Palsy
We deplore the fact that of the 30 patients with
post-operative sciatic palsy, 11 had not been exam-
ined adequately pre-operatively. In view of the fre-
quency of pre-operative paralysis of the sciatic
nerve (17.4%, in cases with posterior lesions of
the acetabulum) a certain number of these pa-
ralyses now recorded as post-operative probably
existed before the interventions. The need for pre-
operative clinical examina ti on of sciatic nerve
function cannot be underestimated.
314
Post-operative sciatic nerve damage occurred af-
ter 29 Kocher-Langenbeck approaches out of 214
(14%), and one ilio-inguinal approach out of 53.
The importance, when operating through the
posterior approach, of maintaining the knee flexed,
and of extreme vigilance with the use of retractors
has been stressed duriri.g the description of the
Kocher-Langenbeck operation (Chap. 20). The
predominant involvemenfof the external popliteal
component fits in with the mechanism of stretch-
ing, as in pre-operative paralyses. Of nine patients
with post-operative palsies studied by quadriceps
electromyography, three were abnormal, suggesting
involvement of the lumbar plexus.
Before the use oftranscondylar femoral traction,
out of 126 Kocher-Langenbeck approaches we had
23 sciatic palsies (18.4%) and since the use of trac-
tion, out of 88 Kocher-Langenbeck approaches we
have eight immediate sciatic palsies (9%). Thus
the precautions advocated have not eliminated the
complication. The eight patients concerned
presented as folIows:
- 1 total sciatic palsy;
- 1 total extern al popliteal palsy;
- 2 partial extern al poplitcal nerve palsies;
- 3 scattered but not severe sciatic palsies;
- 1 post-operative extension of a known pre-oper-
ative palsy.
We believe that these neurological deficits which
occurred despite transcondylar femoral traction
are due to direct trauma to the sciatic nerve at
operation. The total sciatic paralysis was the result
of complete division of the sciatic nerve with scis-
sors and this was at the beginning of our use of
transcondylar femoral traction. The nerve was very
relaxed and was not recognised during splitting the
fibres of the gluteus maximus. It was repaired and
a partial recovery has occurred - more than
expectcd, for the triceps surae has regained grade
4 strength.
Other ca ses are due to damage of the nerve by
retractors in two different circumstances: (1) when
the sciatic nerve lies near an ordinary retractor
under which it readily skids; or (2) when the tip
of our special sciatic nerve retractor is not main-
tained against the bone, so that the nerve becomes
caught and pinched or scraped against the retro-
acetabular surface.
Sciatic paralysis after the ilio-inguinal approach
can be explained by direct damage with the drill
introduced from the internal iliac fossa and reach-
ing the angle of the greater sciatic noteh. Alterna-
tively, in the case mentioned earlier, there may
Early Complications of Operative Treatment
have been a~ sciatic palsy which was not detected
pre-operatively; the electromyogram in this in-
stance suggested a lumbar plexus lesion of a rather
patchy distribution.
The types of fracture associated with sciatic
nerve damage were as folIows:
- 8 posterior wall fractures;
- 1 posterior column fracture;
- 1 associated posterior wall and posterior column
fracture;
- 9 associatcd transverse and posterior wall frac-
tures;
- 3 pure transverse fractures;
- 8 both-column fractures.
The frequency of paralysis after operations on
both-column fractures by the posterior approach
(9 cases out of 42, 21 %) suggests that operation
is particularly hazardous, because pre-operative
sciatic weakness was detected in only one case out
of 91 both-column lesions.
22.3.2 Prognosis
The treatment of the post-operative paralyses has
comprised only the maintenance of passive mobil-
ity of the joints of which the nerves were involved.
Wc have not explored any ofthe nerves subsequent
to the main operation to which the damage relates.
At the time of the 1972 report 27 cases had been
reviewed (25 were mixed and two were purely
sensory). Three cases with external popliteal le-
sions were not reviewed: one is lost to follow-up
and two are recent, still improving.
With regard to progress:
- 6 cases have totally recovered;
- 8 have a good recovery;
- 7 have only partially recovered;
- 4 retain pure sensory residua;
- 2 cases have not shown any recovery.
Out of 25 mixed lesions, 14 cases have total
or significant recovery (56%) whatever the distri-
bution of the dysfunction. Only two cases have
not shown any improvement.
Functionally, 18 cases (76%) have a function
compatible with anormal life, two ca ses have to
wear a drop-foot splint, and seven retain a very
slight disability.
It is seen that, while serious, the pro gnosis of
post-operative sciatic nerve palsy is not especially
gloomy. Recovery takes place over a variable
period. One case is still continuing to improve
three years after the operation.
Thrombo-embolism
22.3.3 Delayed Sciatic Palsy
We have seen four cases of sciatic palsy appearing
from the 14th to the 90th day after posterior ap-
proach operations. These comprise one patient
with severe sciatic pain without muscular deficit,
two with partial external popliteal lesions, purely
motor, and one with partial paralysis of the exter-
nal popliteal component associated with sciatic
sensory loss.
The patient with sciatic pain was operated upon
on the 58th day after injury and the nerve was
found to be enveloped by bone formation and fi-
brous tissue; neurolysis improved the clinical state.
The three other cases have recovered to varying
degrees.
22.4 Secondary Displacement
of Fracture Site
There have been six instances in which the internat
fixation has failed. We shall refer to these later;
none has justified further surgical intervention.
315
22.5 Thrombo-embolism
Apart from the massive pulmonary embolisms re-
sponsible for three deaths, we have observed three
severe cases of thrombo-phlebitis before the rou-
tine use of prophylactic anticoagulants, four severe
cases of thrombo-phlebitis that appeared during
anticoagulant treatment, and five minor pulmo-
nary embolie complications. There was a total of
12 significant instances out of302 operations (4%).
All our operations have been conducted under
some anticoagulant regime and this has been
started at a variable time, chosen according to
the degree of the displacements and severity of
operation. We were somewhat apprehensive of the
possibility of haemorrhagic complications: usually
it commenced at the third day. Four post-operative
haematoma formations have been attributed to an-
ticoagulant treatment; they were controlled with-
out serious sequelae. A significant number of post-
operative haematomata became infected and so me
ofthese were probably influenced by anticoagulant
therapy.
23 Late Complications of Operative Treatment
23.1 Pseudarthrosis
Two of the 302 patients with fractures of the ace-
tabulum operated upon within 21 days after the
accident developed pseudarthroses. These occurred
in both-column fractures. The first had been oper-
ated upon by the posterior approach and at
6 months a pseudarthrosis of the posterior column
component was recognised; the plate had broken
away with respect to the fracture line. Another
operation has been performed through the poste-
rior approach, the pseudarthrosis being excised
and the fracture line maintained by a plate put
under compression. Consolidation was achieved
after 3 months. The second pseudarthrosis was rec-
ognised recently in a both-column fracture oper-
ated upon through the ilio-inguinal approach; the
plate had broken away from the anterior column
fracture, at the level of the anterior wall of the
acetabulum. There remains no pain and function
is excellent. We have not judged further interven-
tion necessary.
It is cogent that we have observed two other
examples of pseudarthrosis of the acetabulum fol-
lowing conservative treatment: one was in a frac-
ture of the posterior column in a patient with
Paget's disease of the pelvis and the other followed
a pure trans verse fracture.
23.2 Cartilage Necrosis (0.4%)
This occurred in only one case of our series of
early operations but it is necessary to include an
identical case amongst the delayed-operation
group. Between the third and the sixth month,
pain developed in the hip and on radiographs we
detected progressive narrowing of the joint space
without alterations in the head or acetabular bone.
At 2 years, the space remains regular but very nar-
row and the head is perfectly spherical apart from
slight osteophyte formation at the margin; clini-
cally the hips maintain a good range of movement.
We regard both cases as having developed a pure
cartilage necrosis.
23.3 Avascular BOlle N ecrosis
Of 302 fractures operated upon during the first
3 weeks after injury, we have observed 20 necroses
of various types (6.6%). These comprised:
- 5 superior segmental femoral head necroses;
- 4 extensive femoral head necroses;
- 3 massive femoral head necroses;
- 2 partial necroses of the anterior column, appar-
ently isolated;
- 3 mixed necroses of the femoral head and of
the posterior part of the acetabulum;
- 2 femoral head necroses associated with os-
teoarthrosis ;
1 anterior wall necrosis associated with os-
teoarthrosis.
Weshall not enlarge on the clinical and mac-
roscopic aspects of femoral head avascular necrosis
which are in no way exceptional.
(a) Necrosis of the anterior column (3 cases). Af-
ter surgical treatment of one extended fracture of
the anterior column by the ilio-femoral approach,
and of a both-column fracture with two surgical
approaches performed in the same session, pain
developed about 13 weeks after the operation with
stiffening of the hip and an extern al rotation defor-
mity. Radiography showed the joint space to be
gene rally reduced and while the head remained
318
spherical or had only very slight irregularities in
its contour, it had risen and there was progressive
protrusio acetabulae indicated by deformity in-
wards of the ilio-ischialline. The upward displace-
ment was not due to a loss of substance of the
head and could be related only to bone destruction
due to post-operative necrosis of a segment of the
anterior column.
In the second case we were able to verify surgi-
cally that the plate used fqr fixation, which res ted
initially on the anterior column, had developed
an altered relationship to the bone, and the ante-
rior wall had partially disappeared. A good result
was attained until after 3 years when a significant
impairment of range of movement developed due
to a post-traumatic osteoarthrosis which will re-
quire further treatment. In the third case, a ne-
crosis of the anterior wall, 16 months after reposi-
tioning of an anterior wall fragment, is the possible
cause of an arthrosis but another factor may be
articular wear due to a screw wh ich strayed into
the joint and was removed 14 weeks after oper-
ation.
(b) Associated necrosis of the posterior wall and
the femoral head (3 cases). In two instances after
a satisfactory reduction, and in one after a correct
reduction but failure to remove an incarcerated
fragment, pain and stiffening developed that were
associated on the radiograph with progressive up-
ward and outward displacement of the head due
to a progressive erosion of the posterior wall. The
radiological acetabular involvement was ac-
companied in these three cases by a destruction
of the femoral head. At revision operation, it was
found that this damage was due at least partly
to the fact that some of the screws were becoming
intra-articular, a consequence of the crumbling of
the wall. Also, in one case, the plate was exposed
and was bearing against the femoral head. Thus
there were am pIe mechanical reasons for the head
erosion. It is difficult to apportion the roles of
osteonecrosis and mechanical wear in these exam-
pIes.
We reported osteonecrosis of segments of the
acetabulum which could be isolated or associated
with an involvement of the femoral head (lUDET
and LETOURNEL 1966). They are probably the di-
rect consequence of surgical trauma and appear
more commonly after difficult operations ac-
companied by extensive stripping and devitalising
fragments of bone, or after the repositioning of
fragments detached completely at the time of the
Late Complications of Operative Treatment
accident. The necessity to preserve to the maxi-
mum, musculo-aponeurotic pedicles of bone frag-
ments and muscular origins on the columns them-
selves, cannot be over-stressed.
Subsequent arthroplasty, if necessary, may be
difficult on account of loss of bony acetabular
structure.
23.3.1 Etiology
(a) Type of dislocation. It is weil known that
necrosis commonly accompanies posterior disloca-
tions of the head: 18 posterior dislocations were
followed by 16 isolated head necroses and 2 asso-
ciated osteonecroses of the head and of the poste-
rior column; and 2 central dislocations and one
posterior dislocation were followed by necroses of
the anterior column or of the anterior wall.
(b) Surgical approach. It is not surprising that
necroses were more frequent after the Kocher-Lan-
genbeck incision since all the posterior dislocations
are approached by this route. Out of 21 necroses,
18 followed Kocher-Langenbeck incisions while
only three anterior approaches (one ilio-femoral
and two ilio-inguinal) were followed by necrosis
of the column or of the anterior wall. It must
be recognised that a small risk of the anterior ap-
proach is avascular necrosis of a segment of the
anterior column.
(c) Type ofJracture. As would be expected most
necroses occurred after elementary or associated
fractures accompanied by a posterior dislocation.
There were:
11 posterior wall fractures;
- 2 posterior column fractures with posterior wall
fractures;
- 4 transverse fractures with posterior wall frac-
tures;
- 2 anterior wall or anterior column fractures;
2 both-column fractures.
(d) Time of reduction of the posterior dislocation.
It has often been stated that avascular necrosis
of the femoral head is more likely if reduction
is delayed but since 1966 we have discounted the
prognostic value of the time of reduction of the
posterior dislocation. In this series, the relation-
ships for posterior dislocations were as folIows:
- 3 necroses (5%) out of 60 reduced within the
first 6 h;
- 6 necroses (10%) out of 60 reduced 6-24 h after
the acciden t;
Avascular Bane Necrosis
- 2 necroses (12.5%) out of 16 reduced on the
second day;
- 3 necroses (33%) out of 9 reduced on the third
day;
- 1 necrosis (17%) out of 6 reduced on the fourth
day;
- 1 necrosis (20%) out of 5reduced on the sixth
day.
It would appeal' that the incidence is lowest fol-
lowing reduction performed within the first 24 h.
This is not axiomatic however since there was no
subsequent necrosis in eight dislocations reduced
surgically on the 7 day, ten dislocations reduced
surgically on the 8th to the 14th day, and six disloca-
tions reduced surgically on the 15th to 25th day.
Some very late reductions performed from the
third to the 14th week were again not complicated
by osteonecrosis.
Thus necrosis is far from inevitable if the reduc-
tion takes place after 24 h. The destiny of the femo-
ral head appears to be decided from the outset,
because its vessels are damaged 01' not damaged
at the moment of the accident. Intact vessels can
nevertheless be jeopardised while the fracture re-
mains unreduced and would perhaps recover their
patency if the reduction took place fairly early.
This must be a rare circumstance.
Surgery does not seem to augment the frequency
of femoral head necrosis, whereas there probably
is a relationship with acetabular necrosis.
(e) Quality ofthe reduction. This does not appear
to have any influence on the evolution of necrosis.
Femoral head necrosis has appeared after 17 per-
feet reductions of the dislocated head, after three
in which there existed a slight loss of congruence
in the upper part, and after one correct reduction
without recognition that there was a fragment
entrapped within the joint. Femoral head necrosis
appeared after 16 perfeet red uctions of the acetab-
ulum, after three perfeet in one column and bad
in the other, and there were mixed head and ace-
tabular necroses in two technical failures to reduce
at all.
(f) Conclusion. We must accept that femoral
head necrosis occurs and it seems practically im-
possible to prevent or to avoid it. The trauma
of accident practically always determines the future
of the femoral head in destroying or sparing all
or part of the vessels, and whatever the quality
of the surgical reduction, the necrosis may occur.
In contrast, during the operation the avoidance
of stripping of periosteum helps to diminish the
319
frequency especially of anterior column osteone-
crosis and somewhat less of necrosis of fragments
of the posterior wall. In the latter, devitalised frag-
ments are commoner.
23.3.2 Time of Presentation
Our 21 cases of necrosis all appeared after a delay
of 3-18 months and very often, the date of the
clinical diagnosis was anticipated by radiological
changes several months earlier.
This concept, contrary to classical views, has
been confirmed by the study of necroses after treat-
ment of old lesions. It is logical that necrosis, a
consequence of devascularisation created by the
injury or by the surgical treatment, does not wait
years to manifest itself. This belief is substantiated
by the time of presentation in the cases operated
upon later than 3 weeks after the accident when
the incidence of osteonecrosis of the femoral head
was higher. All of the 21 necroses have been recog-
nised within 11 / 2 years after the operation.
23.3.3 Clinical and Radiological Course
The evolution and clinical course is variable and
unpredictable. In a few cases, despite marked ra-
diological changes, there is little pain 01' further
deterioration. The extent of the necrosis is difficult
to assess or to relate to those instances where func-
tion is tolerable and involves little pain.
At the time of the first report (1970-1972) two
necroses had been diagnosed only radiologically,
six were apparently static, five had already reached
the stage of a post-traumatic coxarthrosis, six had
been subjected to arthroplasty and two had been
lost to follow-up.
Medical treatment has not appeared to influence
the evolution of osteonecrosis and we are forced
merely to observe their spontaneous course. If they
have reached the stage of coxarthrosis, surgical
management along conventionallines must be con-
sidered.
23.3.4 Clinical Results
The clinical evaluation of patients who developed
osteonecrosis was as folIows:
- 3 very good results ofwhich one underwent head
arthroplasty after 7 years;
320
- 7 good results of wh ich two underwent femoral
head arthroplasty and two had total hip replace-
ments;
- 4 fair or mediocre results;
- 5 bad results where a post-traumatic osteoar-
throsis has supervened;
- 2 cases were lost to follow up.
Of these, six cases will tequire surgical treatment
for osteoarthrosis at some time in the future.
23.4 Post-traumatic Osteoarthrosis
23.4.1 Osteophytes
After nearlyone-third of our operations on the
acetabulum we have seen the rapid development
of osteophytes. These are situated in two-thirds
of the cases around the periphery of the femoral
head and form a collar of variable dimensions.
In the majority the base measures less than 3 mm
and the height less than 2 mm. As far as we can
judge, the radiographic appearance is without any
functional effect and can accompany a very good
clinical result. The reduction of the fracture can
be excellent in the presence of these osteophytes.
The significance of factors responsible for the for-
mation of the collar is not clear; it must be admit-
ted that the long-term prognosis must remain spec-
ulative. It is encouraging however, that DUPARC
and FICA T (1960), in their paper on articular frac-
tures of the upper end of the tibia, have noted
the frequency of small osteophytes on the tibia;
these appeared to have no ill-effect on function.
In one case out of six, the collar comprises osteo-
phytes which are larger and thicker, but the clinical
result is excellent.
In total, there are 90 cases of post-operative
osteophytosis: 74 after Kocher-Langenbeck ap-
proach, 13 after anterior approach, and 3 after
double approach. In terms of overall function:
- 52 hips with small discrete femoral head osteo-
phytes achieved 44 very good results and 8 good
results;
- 16 hips with marked femoral head osteophytoses
achieved 8 very good results, 6 good results and
2 fair results;
- 2 hips with marked osteophytes around the ace-
tabulum achieved 2 fair results;
- 20 hips with osteophytes affecting the acetabu-
lum and the femoral head achieved 3 very good
results, 2 good resllits and 15 fair results.
Late Complications of Operative Treatment
23.4.2 Osteoarthrosis
Osteoarthrosis developed in 16 (6%) out of the
244 hips operated upon and subsequently re-
viewed. These exclude the group with post-trau-
matic osteoarthrosis associated with osteonecrosis
(six hips) which we studied in the preceding sec-
tion. We think that these are due in part to incon-
gruence and loss of stability brought about by the
collapse of the acetabulum or femoral head. It
was steadily progressive in five of the six cases
and was sometimes recognisable at the same time
as the bone necrosis but occasionally presented
later.
The 16 hips included examples with inadequate
reduction or very good reduction. It is possible,
in view of the frequency of idiopathic arthrosis
of the hip, that a certain number of the patients
included would have developed this disease
anyway; we have not attempted to evaluate this
possibility statistically and have included all exam-
pies even if they appeared years after the surgical
treatment. There was no peculiar characteristic dis-
tinguishing them from idiopathic osteoarthrosis
except the presence of the plates and screws.
23.4.3 Analysis of Clinical Progress
Of the 16 hips showing post-traumatic osteoar-
throsis there were 8 with progressive and 3 with
static post-traumatic osteoarthrosis. Five had po-
tential osteoarthrosis, i.e. purely radiographic signs
with good or very good clinical results (grade 5-6
in all categories of the d'Aubigne scale). Clearly,
this is a fluid situation and the non-progressive
and potential cases may become progressive in due
course.
Osteoarthrosis appeared after operative reduc-
tions of variable quality:
(a) After a pelfeet reduetion of the head into
the acetabulum in 172 hips, there were at the time
of review 7 post-traumatic osteoarthroses (4%).
These can be divided into 2 potential osteoar-
throses and 5 obvious osteoarthroses (three pro-
gressive and two static).
These osteoarthroses developed after an interval
of 3 or 4 years. Their occurrence alone, despite
the low incidence (4%), has sufficed nevertheless
to cause us concern because at this stage we must
accept the possibility of similar changes in others
among our good and excellent surgical results.
Para-articular Ectopic Bone Formation
(b) After an impelfect reductiol1 of varying
degree, in 62 hips there were 9 post-traumatic os-
teoarthroses (14.5%). These comprise three poten-
tial osteoarthroses and six obvious osteoarthroses
(Five were progressive and one static). The ra-
diographic appearance is clearly superimposed on
the malunion of the fractured acetabulum. The
nine osteoarthroses are secondary to these imper-
fect reductions of a column or in three cases to
gene rally insufficient reductions, presenting radio-
10gica11y with a malunion of the acetabulum.
23.4.4 Treatment
Treatment is conventional and it is comforting to
know that if a total hip arthroplasty eventua11y
proves necessary, the shape of the acetabulum is
adequately restored.
23.5 Para-articular Ectopic Bone
Formation
Of our 302 operations performed within 3 weeks
of the inj ury , 61 hips developed ectopic calcifica-
tion or bone formation. The site and extent varied:
- 27 hips had limited superior ossification;
- 20 hips had extensive superior ossification;
- 6 hips had extensive anterior and posterior ossi-
fication;
- 6 hips had ossification inside the pelvis;
- 2 hips had significant posterior ossification.
Ectopic bone formation appears early on radiog-
raphy and maturity is reached from 6 months to
a year after the operation. We have seen on three
occasions spontaneous regression of the bone for-
mation and there was improvement in the range
of motion.
23.5.1 Clinical Results
In the 27 cases with limited superior formations,
the two with posterior formations and the six with
intrapelvic formations, no clinical effect has been
seen and no reduction in mobility noted.
Of the 20 cases with extensive superior forma-
tions, four suffered no obvious clinical impair-
ment, eight developed a slight diminution in mobil-
ity and eight had significant loss of motion.
321
The six significant formations affecting the ante-
rior and posterior aspects of the joint are ac-
companied by diminished mobility; three under-
went surgical excision and did not recur.
23.5.2 Etiology
The development of any degree of ectopic bone
formation is unpredictable. It appears unrelated
to the difficulty of the operation. Stripping of the
gluteal muscles from the extern al iliac fossa has
been accompanied by a higher incidence, but we
have not seen ossification in the internal iliac fossa,
despite the frequency of complete stripping of the
iliac muscle. Intra-pelvic formations were infre-
quent. relative to the number of occasions when
we have had to elevate the obturator internus mus-
cle.
The complication has appeared after a11 methods
of approach. After 211 operations using the Ko-
cher-Langenbeck approach there were 42 forma-
tions (19%); and after 53 ilio-inguinal approaches
there were five formations (9%). One of the latter
was extensive, and a11 of them developed at the
level of the extern al iliac fossa (explained perhaps
by the fact that there had been cause to apply
forceps repeatedly into the iliac fossa astride the
crest or the interspinous notch during the course
of the operation). The six most serious formations
a11 followed the Kocher-Langenbeck incision.
Double-approach operations were accompanied
by a high incidence of ectopic bone formation of
variable severity. Thus after double approaches
performed during one operative session, there were
4 instances out of 7 and after double approaches
at separate operations, there were 7 out of 10.
The clinical results accompanying the various
types of para-articular ossification are summarised
in Table 23.
Table 23
Type of osteophytic Clinical result
formation
Very Good Fair Bad
good
Superior localised 20 4 3
Superior extensive 9 5 2 4
Gross 1 1 I
Removed surgically 2
Endopelvic 4 I
Posterior
24 Anatomical Results of Operation Within
Three Weeks of Injury
In Tables 24-27 we present a summary of the qual-
ity of reduction of the femoral head and related
acetabular reconstruction obtained in our
302 operations, according to the type of fracture
and how long after the accident the operation was
performed.
In order to avoid clashes of nomenclature with
the terms used to describe the overall results
(Chap. 25), the anatomical results of operation (as
shown by the immediate radiological results) have
been assessed according to the quality of centring
of the femoral head inside the acetabulum (i.e.
its congruence) and according to the quality of
the acetabular reconstruction itself:
Femoral head reduction
- perfect congruence
- slight loss of superior congruence
- slight medial protrusion
- significant medial protrusion
Acetabular reconstruction
- perfect (= ana tomical)
- almost perfect
- imperfect (one column perfect, other column
imperfect or poor)
- poor
- technical failure
24.1 Reduction of Femoral Head
We have separated the very slight losses of congru-
ence in the upper joint space (Tables 24 and 26). AI-
though this could be interpreted as failure to re-
duce adequately, it is a feature sometimes observed
in radiographs of normal adult hips which are free
of any clinical signs, and have not been subjected
to trauma.
24.2 Acetabular Reconstruction
The quality of reduction is not perfect in 8.4%
of hips operated upon within one week of injury,
in 7.8% operated upon during the second week,
and in 17% of hips operated upon in the third
week, there is significant deterioration.
Out of 302 cases, we have obtained 209 reduc-
tions (69%) that we regard critically as perfeet (Ta-
ble 25). By this we mean an anatomical reduction
of both the acetabulum and of the pelvic bone
accompanied by restoration of articular con-
gruence, confirmed by the re-establishment of all
the radiological landmarks on the three standard
radiographs.
In 11 ca ses a small fault of reduction persisted
at one of the radiological landmarks, apparently
without serious consequence to the reduction of
the femoral head or the congruence of the joint.
We describe these as almost perfeet reductions. We
have 220 (72.8%) perfect and almost perfect reduc-
tions.
There were two cases in wh ich an approximately
congruent reduction around a somewhat displaced
femoral head was possible. In one, operated upon
20 days after injury, new bone formation was ad-
vanced, and in the other, the posterior column
was rotated and entrapped; it presented extreme
difficulties in reduction (Figs. 140 and 232). The
clinical results at 5 and 4 years respectively were
very good.
We had 19 poor reductions and 6 technical fail-
ures, i.e. 8.2%. They were in some instances the
consequence of errors of choice of approach; in
others, the poor quality of osteoporotic bone preju-
diced the fixation of implants for osteosynthesis.
Undoubtedly, inability to interpret the radiographs
led to problems, for good reduction cannot be
obtained unless it is known in advance where the
324 Anatomieal Results of Operation Within Three Weeks of Injury

Table 24

Time of Quality of immediate radiologieal result Total

operation
after Perfeet Slight Slight Signifi- Missed Femoral
InJury eongruenee loss of medial eant ineareer- head
( days) superior protrusion medial ation arthro-
eongruenee protrusion plasty

1 11 13
2 22 3 28
3 24 1
2 2 29
4 27 28
5 20 22
6 24 4 1 30
7 9 3 3 16
8-14 69 3 4 2 78
15-21 46 2 8 2 58

Total 252 17 22 8 2 302

Table 25

Time of Quality of immediate radiologieal result Total

operation
after Perfeet Almost Very good Very good Poor Technieal Aeetabu1um
injury perfeet one e01umn one eolumn both failure eongruent but
(days) but im perfeet but poor eolumns mal union
other eolumn" other column" of eolumns

1 10 2 13
2 21 3 2 28
3 22 3 2 29
4 26 1 28
5 18 3 22
6 19 3 4 1 2 30
7 7 4 3 2 16
8-14 52 4 12 2 7 78
15-21 34 4 8 5 4 2 58
Total 209 11 40 15 19 6 2 302

a The numbers shown here side by side should be added together to give the number of imperfect results.

fracture lines are to be found. It is dangerous to
attempt to understand the fracture at operation
without having understood the radiographs. Ra-
diography during operation is a poor substitute
for the good-quality standard views we advocate.
There were examples of POOf reductions due
to insufficient understanding of the pre-operative
radiographs which, even post-operatively, it was
not possible to interpret because of advanced re-
pair processes obscuring the landmarks. These
examples were commoner, as would be expected,
in cases encountered long after the injury. Thus
after operation in the second week there were
11.5% ofpoor reductions, in the third week 10.3%,
but in the first week only 6.6% (11 out of 166).
There were 55 imperfect reductions (15.0%).
These cases are grouped as follows:
22 transverse fractures, weil reduced at one ex-
tremity of the fracture line but with a slight
persistent displacement at the other end. The
transverse component could be isolated, or oc-
cur in a T -shaped fracture, or be associated with
a posterior wall fracture. (The latter cases have
been included with the associated fractures in
Table 27.)
Aeetabular Reeonstruetion 325

Table 26

Type of fraeture Quality of immediate radiologieal result Total

Perfeet Slight Slight Signifieant Missed Femoral

eongruenee loss of medial medial ineareeration head
superior protrusion protrusion arthroplasty
eongruenee

Posterior wall 71 2 75
Posterior column 9 9
Anterior wall 6 7
Anterior eolumn 11 13
Transverse 10 3 14
Posterior eolumn and 11 11
posterior wall
Transverse and 52 3 2 58
posterior wall
T-shaped and 5 5
posterior wall
T-shaped 10 4 3 17
Anterior and posterior 11 3 4 19
hemitransverse
Both-eolumn 56 5 10 3 74
Total 253 17 22 8 2 302

Table 27

Type of fraetme Quality of immediate radiologieal rcsult Total

Perfeet Almost Very good Very good Poor Technical Acctabulum

perfeet one column one column both failure congruent but
but imperfect but poor columns malunion
other other of columns
column" column"

Posterior wall 71 3 75
Posterior column 8 9
Anterior wall 5 7
Anterior column 9 2 13
Transverse 10 3 14
Posterior column 11 11
and posterior wall
Transverse and 33 16 7 58
posterior wall
T -shaped and 3 2 5
posterior wall
T-shaped 8 7 17
Anterior and 10 2 4 19
posterior
hemitransverse
Both-eolumn 41 2 11 12 5 2 74
Total 209 11 40 15 19 6 2 302

a The numbers shown he re side by side should be added together to give the number of imperfeet results.
326
- 18 associated fractures in which the reduction
is perfect at the level of one column but a small
fault of reduction of the other column persists
(the columns are slightly displaced relative to
each other). In 14 of these ca ses, reduction of
the posterior column was perfect but of the ante-
rior column imperfecL In 4 cases reduction of
the anterior column was perfect but of the poste-
rior column imperfecL ~
- 15 associated fractures in which the reduction
of one column is perfect,' that of the other col-
umn being poor. In 12 cases reduction of the
posterior column was perfect but of the anterior
column bad, while in 3 cases reduction of the
anterior column was perfect but of the anterior
column bad.
24.3 Reduction After Various Types
of Fracture
Table 26 relates the quality of reduction of the
femoral head to the type of fracture. Faults of
reduction of the femoral head were commoner in
the more complex fractures and occurred in 17%
of both-column fractures, 18% of T-shaped frac-
tures, 7.5% of associated transverse and posterior
fractures, and 16% of anterior column fractures.
Table 27 shows the quality of reduction of the
acetabulum in relation to the type of fracture.
Among the simple fractures, those of the anterior
column are less well reduced, probably due to the
necessity of using the anterior approach which is
more difficult to perform, and to the fact that
Anatomical Results of Operation Within Three Weeks of Injury
internal fixation of the slender anterior column
is much more demanding; there were 2 particularly
poor reductions out of 13 cases.
In 4 cases out of 14, the transverse fracture lines
were imperfectIy reduced; more precisely the frac-
ture line is well reduced at one of its extremities
but remains slightly displaced at the other (always
opposite) end to the approach used.
In the associated fractures, the incidence of poor
reductions rises from 7% for simple fractures to
38%, i.e. 72 imperfect reductions out of 185 oper-
ations. This figure includes all imperfections and
the more severe examples numbered 20 cases out
of 185 (10.5%).
Among these fractures, the results from asso-
ciated anterior and posterior hemitransverse fr ac-
tures appear particularly bad, there being a 25%
failure rate. It is in this type of fracture that we
made most errors of interpretation of the radio-
graphs and therefore chose the wrong operative
approach.
The order of increasing difficulty of the various
fracture types is: the associated transverse and
posterior wall fracture (in which reduction of the
transverse component can be imperfect at the pel-
vic brim, leading to loss of congruence and slight
protrusion), the associated anterior and transverse
fracture, and the both-column fracture. Both-col-
umn fractures are the most complicated and for
these we had the following results: 58 % were very
good reductions; 14.8% were perfect reductions
of one column but imperfect of the other (always
opposite the site of operative approach); 16.2%
were perfect reductions of one column but poor
of the other; 8 % were technical failures.
25 Clinical Results of Operation Within Three Weeks of Injury
By 1 January 1971, we had operated upon 302 pa-
tients with aeetabular injuries within three weeks
of the aeeident, and of these, 278 had a minimum
follow-up period of 2 years. However, 11 patients
had died so on after operation, and at the time
of review in 1971 (the results of whieh are
presented in this Chapter) 4 had died from other
eauses and 19 had been lost to follow-up for
various reasons, so that 244 hips were available
for evaluation. The follow-up periods ranged from
2 to 14 years.
In Chap. 27 we shall take the opportunity of
presenting the results in a third review eondueted
between 1976 and 1978 for the present edition of
this book.
25.1 Assessment of Results
The overall clinieal results have been assessed for
pain, mobility and gait, aeeording to the method
of D'AuBIGNE and POSTEL (1954), and on the ana-
tomieal and radiologieal eriteria deseribed in
Chap. 24. Other features sueh as trophie ehanges,
searring and nerve eomplieations are included in
our assessment when neeessary. For overall assess-
ment, the results are graded as:
Very good
- The hip is clinieally normal and radio10gieally
perfeet.
Good
- The patient has normal aetivity despite a clinieal
imperfeetion or a radiologieal abnormality of
the hip.
Intermediate
- The hip is painful, aetivity is diminished, there
are radiologieal blemishes, but the joint is never-
theless tolerable.
Bad
- All other eases. The bad resltlts have been fur-
ther subdivided into those amenable to further
operative treatment, and those that are untreat-
able.
Tab1e 28 shows the progressive yearly aeeumula-
tion of our results with the eorresponding' follow-
up period.
In 1966 we reviewed our first 125 eases whieh
included 40 fraetures of the posterior wall. We
found that 81 % were funetionally good or very
good, 16% intermediate and 6% were poor. When
in 1971 we reviewed the entire 244 eases, 84.3%
were graded very good or good, 8.6% were inter-
mediate and 7% were poor results (Table 28). In
this larger group, there was a mueh higher propor-
tion of eomplieated types of fraeture.
The overall results may be eonsidered under the
following headings:
25.1.1 Type of Fracture
In Table 29 it is seen that despite a high rate (95%)
of perfeet reduetions of the posterior fraetures (Ta-
ble 27), only 82 % aehieved very good eliniea1 re-
sults. This is due to the frequent oeeurrenee of
osteoneerosis in this group. The most eomplex
fraetures (T-shaped, assoeiated transverse and
posterior, and both-eolumn fraetures) eaeh have
their quota (about 65%) of very good results.
25.1.2 Quality of Reduction
From Table 30, among the 244 hips there were
172 perfeet reduetions. Clinieally 139 (80.8 %) of
these were very good, 13 (8%) were good, and
20 (11 %) were intermediate or poor results (two
328 Clinieal Rcsults of Operation Within Three Weeks of Injury

Tablc 28

Year of Follow-up Clinieal result Total

operation period
(years) Very Good Intcr- Poor but Poor and
good mediate treatable untreatable

1970 2.0 5 I 8
1969 2.5 12 3 17
1968 3.0 ~22 3 2 29
1967 4.0 28 2 7 39
1966 5.0 ';'7 9 6 2 55
1965 6.0 26 6 2 35
1964 7.0 22 3 3 32
1963 8.0 13 I 15
1961-2 9.0-10.0 I 3 5
1956-60 11.0+ 7 2 9

Total 173 33 21 11 6 244

Incidcnce 70.9% 13.4% 8.6'Yo 4.5% 2.5%

Tablc 29

Type of fraeture Clinical result Total

Very good Good Inter- Bad but Bad and

mediate treatable untreatable

Posterior wall 53 (82%) 2 6 2 64

Posterior eolumn 6 7
Anterior wall 3 2 6
Anterior column 7 3 11
Transverse 8 9
Posterior eolumn and 5 4 9
posterior wall
T-shapcd 10 (62%) 5 16
T - or trans verse and 33 (64%) 8 4 4 2 51
posterior wall
Anterior and posterior 9 (68%) 2 2 14
hemitransverse
Both-column 39 (68%) 7 7 2 2 57

Total 173 (71%) 33 21 11 6 244

of the latter soon had femoral head replaeement
arthroplasties) .
Of 34 fraetures (whieh include T -shaped, asso-
eiated transverse and posterior, and both-eolumn
types), one eolumn was weH redueed while the
other was imperfeet; clinieaHy, 21 (6l. 7 %) of these
were very good and 9 (26%) were good. The poorer
results whieh foHowed imperfeet reduetions are sig-
nifieant. In 9 eases one eolumn was very weH
redueed but the other was badly redueed; these
yielded 3 very good and 3 good results. From
15 eases with poor reduetions of both eolumns
there were 3 very good and 5 good results. From
the 4 eases that were teehnieal failures there was
only one good result.
Radiologieal Results 329

Table 30

Quality of reduetion Clinieal result Total

Very Good Inter- Bad but Bad and

good mediate treatable untreatable

Perfeet 139 13 12" 6 2 172

Almost perfeet 5 2 8
Very good one column but 21 9 2 34
imperfeel other column b
Very good one eolumn but 3 3 2 9
poor other column
Poor both columns 3 5 3 3 15
Teehnieal failure 4
Acetabulum congruent but 2 2
mal union of columns

Total 173 33 21 II 6 244

a Including two femoral head arthroplasties.

b Including transverse fraetures imperfectly reduced at one end.

Table 31 Table 33 relates quality of radiological appear-

ance to the type of fracture.
Clinical Age (years) Table 34 compares the quality of immediate and
result
10-19 20-29 30-39 40-49 50-59 60-69 70-79 late radiological appearances. It shows that among
181 hips (74.2% of the total 244 hips) we could
Very good 6 34 53 32 26 14 8 distinguish in 130 cases (53.3%) that the hip was
Good 9 9 10 3 normal, (i.e. radiologica11y perfect) and that in
Fair 5 3 7 5 51 cases (20.9%), there was only a sma11 blemish
Bad 4 4
(treatable) on the radiograph, i.e. the hip was almost perfecL
Bad 5 It can be seen that 172 formerly perfect anatomical
(untreat- reductions of the acetabulum have diminished in
able) number to 141 as indicated by the development
of some later radiological deterioration.
With further reference to Table 34, the box
marked (a) encloses 70 defects of reduction of a11
25.1.3 Age of Patient types and of variable significance; box (b) corre-
sponds and reveals that in the later survey there
The grade of result according to the patients' ages were eventually 38 hips that were radiologically
is shown in Table 31. perfect or almost perfect (54%). This apparent
paradox is due to the fact that the reductions were
judged immediately post-operatively before heal-
25.2 Radiological Results ing of some persistent displacement had obliterated
the imperfection. After aperiod, the hip with a
The post-operative radiological results have been parallel normal joint space, without osteophytes
discussed in Chap. 24 but numerous additional fea- and without irregularity of the density of the head
tures have had to be taken into account in the or the acetabular bone, becomes classed as radio-
later assessment and it is difficult to produce a 10gica11y normal or of very good quality, even if
comprehensive classification. These late radio log- a slight alteration persists in the outline of certain
ical features are listed in Table 32. landmarks outside the joint components.
330 Clinical Rcsults of Operation Within Three Weeks of Injury

Tablc 32 arthroplastyof the femoral head has led to accept-

able results.
Late radiologieal Description
Ofthe remainder, there were 10 cases with inter-
result
mediate results which comprise 2 with cir-
Perfeet A normal hip 130 cumscribed femoral head necrosis which is not pro-
Almost perfeet Only same small defect 51
gressive, 2 with progressive osteoarthroses, 1 with
static post-traumatic osteoarthrosis, 1 with post-
Cartilage (see text)
neerOSlS
traumatic osteoarthrosis and osteonecrosis, 1 with
massive ectopic bone formation, 1 with residual
Ostconecrosis Femoral head (limitcd) 4
Femoral head i'lJ1d postcrior
bone fonnation after attempted excision, and 2
acctabulum with asymptomatic osteoarthrosis.
Assoeiated with ostcoarthrosis 6 Finally, there remain 8 cases with bad results:
Treated (femoral head arthroplasty) 5 1 with progressive post-traumatic osteoarthrosis, 4
Treatcd (total hip arthroplasty) 3 with post-traumatic osteoarthrosis with osteone-
Post-traumatic Asymptomatic 6 crosis, and 3 with sequelae from suppurative ar-
osteoarthrosis Non-progressive 4 thritis.
Progressive 6
In 12 ca ses, post-traumatic osteoarthroses ap-
Malunion Slight 6 peared despite a perfect reduction of the head and
Severe 6
of the acetabulum. Five of these are associated
Post-infective 6 with femoral head necrosis, an unforeseeable com-
arthrosis
plication. One of the two asymptomatic osteoar-
Para-artinIlar With good acetabldar reduction 3
throses is associated with an intra-articular screw.
bane formation With malunion I
Recurrent after excision 2
The cause of the non-progressive osteoarthrosis
and of the four progressive osteoarthroses remain
Other Ankylosis
Failed arthrodesis 2
unclear. One of these was treated successfully
7 years after the injury, by a McMuRRAY oste-
Total 244 otomy.
In summary, it must be accepted that in 5 cases
the complication described was independent of the
quality of reduction, and that 6 hips with eventual
osteoarthrosis (which became 0 bvious 2-14 years
25.3 Late Clinical Results and Quality after operation) had anatomical reductions. This
of Reduction is an incidence of 3.5% which is higher than that
of idiopathic osteoarthrosis and must therefore be
related to the injury.
The overall results are re la ted in Table 35 to the
quality of reduction.
25.3.2 Imperfect Reduction
25.3.1 Perfeet Reduction We have been stringent in the assessment of the
quality of our operative reductions. There is no
From very good reductions of the acetabulum, of question that the quality of reduction is incompar-
the innominate bone as a whole and of the femoral ably superior in the vast majority of cases to that
head, i.e. anatomically perfect reductions, we have which could be obtained by conservative manage-
139 cases (82 %) with functionally very good re- ment even at its best. That conservative treatment
sults, 13 (7.6%) with good results, 10 with inter- can result in good or even very good clinical re-
mediate results and 8 with bad results. In two cases sults, in spite of an imperfect reduction and a
(not included in Table 35) a congruent reconstitu- sometimes astonishing radiographic appearance,
tion of the acetabulum was achieved at the price cannot be denied. This explains without doubt why
of mal union of the pelvic bone; in the long term less than perfect surgical reductions can also fur-
the clinical reslllts are very good. In two other nish good or very good clinical results.
ca ses (also not included in Table 35) anatomical For the purposes of analysis of all inferior clini-
reduction of the acetabulum associated with early cal results, we have re-grouped the qualities of
Late Clinieal Results and Quality of Reduetion 331

Table 33
Late radiologieal Type of fraeture
appearanee
Poste- Poste- Ante- Anle- Trans- Posterior T-shaped T-shaped Anterior Both-
rIor rior rior rior verse wall and or + eolllmn
wall eolumn wall eolumn posterior transverse posterior
column and hemi-
poslerior transverse
wall

Perfeet 39 5 3 6 8 5 6 22 7 29
Almost perfeet 13 6 13 2 15
Limited femoral head 3
osteonecrosis
Femoral head and
posterior column
osteonecrosis
Cartilage necrosis
Osteonecrosis and 3
osteoarthrosis
Femoral head 3 2
arthroplasty
Total hip arthroplasty
Asymptomatic 2
oSleoarthrosis
Non-progressive 2
osteoarthrosis
Progressive 2
osteoarthrosis
Slight malunion 2 2
Severe mal union
Post-infective 2 2
arthrosis
Para-articular forma-
tion in well reduced
acetabulum
Para-articular bone
in malllnion
Residual bone for-
mation
Other 2

Total 64 7 6 II 9 9 16 51 14 57

Incidence of 18% 37% 23%

imperfect
appearances

reduction of the femoral head under the roof seg-
ment, the acetabulum itself, and the relationship
of these according to the headings (a)-(h) which
follow:
(a) Almost perfect reduction of the acetabulum
(8 cases). This was accompanied in 6 cases by a
perfeet reduction of the femoral head from which
we have 4 very good and 2 good results, and in
2 cases by slight loss of congruence, from which
we have one clinically very good result and one
intermediate result owing to post-traumatic os-
teoarthrosis.
(b) Perfect reduction of one column and impelject
of the other (34 cases). This was accompanied in
332 Clinical Results of Operation Within Three Weeks of Injury

Tablc 34

Quality of late radiological Quality of early radiological result

result and presence of other
abnormalities Perfect Almost Perfect Perfeet Poor Technical Acetabulum Total
perfect one column one column reduction failure congruent,
but imperfect but poor both malunion
for other for other columns of columns
column a column"

Perfect 114 b3 10 2 130

Almost perfeet 27 3 14 2 4 51

Limited femoral head necrosis 4 4

Femoral head and posterior
columns necrosis
Cartilage necrosis
Osteonecrosis and
osteoarthrosis
Femoral head arthroplasty
Total hip arthroplasty
Asymptomatic osteoarthrosis
Non-progressive osteoarthrosis
Progressive ostcoarthrosis
Slight malunion
Severe malunion
Post-infective arthrosis
Para-articular bone formation
in well-reduccd acetabulum
Para-articular bone
in malunion
Residual bone formation
Other
5 6
5 5
2 3
3 2 6
2 4
3 6
2 6
3 2 6
3 2 6
3 3
2
2 3

Total 172 "8 34 9 15 4 2 244

" The numbers shown here side by side should be added together to give the number of imperfect results.
b See text (Sect. 25.2) for explanation of box (b).

, See text (Sect. 25.2) for explanation of box (c).

Table 35

Quality of reduction Number of Overall results

operations
Acetabulum Femoral head Very good Good Very good
and good

Perfect Centred 170 139 (82%) 13 (8%) 152 (90%)

Slight imperfection of one column Centred 32 21 (67%) 7 (28%) 28
Poor reduction of one column Centred 5 2 2 4
Slight imperfection of one column Superior loss of congruence 3 8
Poor reduction of one column Superior loss of congruence
9
3 ~} 58% 2
Slight imperfection of one column Slight central protrusion I 1
Poor reduction of one column Slight central protrusion 14 6 7
Poor reduction of both columns Significant protrusion 8 2 2
Late Clinical ResuIts and Quality of Reduction
26 cases by a perfect reduction ofthe femoral head.
From these there have been 17 very good results
(64%), 5 good results, 2 intermediate results (1
with residua from suppurative arthritis and 1 with
non-progressive post-operative osteoarthrosis),
and 2 bad results (1 with residual from suppurative
arthritis and 1 with post-traumatic osteoarthrosis).
From 7 cases with slight loss of congruence of
the superior joint space there have been 4 very
good and 3 good results, and the result from one
case with slight central protrusion was good.
Thus the slight faults of reduction of a column
(if one exeludes the patients who developed infec-
tive arthritis) have been followed by osteoarthrosis
in only two hips. Out of 32 such cases there were
21 very good and 9 good results.
c) Almost perfect reduction of one column and
poor of the other (8 cases). In two instances this
was accompanied by a congruent reduction of the
femoral head and there was I very good and
I good result. In 2 cases there was a slight loss
of congruence which gave I good result and I in-
termediate (following osteonecrosis of the femoral
head and posterior wall). In 4 cases there was slight
central protrusion which gave 2 good results, I in-
termediate (with progressive post-traumatic os-
teoarthrosis) and I bad result (following suppura-
tive arthritis). Exeluding the latter case, from
7 cases with significant faults of reduction affecting
one oftwo fractured columns, we have 2 very good
results, 3 good results and 2 intermediate results.
Even though the group is small, the proportion
of very good results is seen to diminish as the
quality of the reduction deteriorates.
(d) Poor reduction of the acetabulum (15 cases).
With the femoral head perfectly centred, there was
I very good result, I good result, and I bad result
(with progressive post-traumatic osteoarthrosis).
In one hip with slight loss of articular congruence
the elinical result was very good. Eight hips with
slight central protrusion led to I very good result,
3 good results, 3 intermediate results (1 potential
osteoarthrosis and 2 significant malunions), and
1 bad result (a failed arthrodesis). With significant
central protrusion, there was 1 good result and
2 bad results Cl complete ankylosis and 1 static
post-traumatic osteoarthrosis).
Thus 15 significant faults of reduction relate as
follows to the quality of reduction of the femoral
head: when the head was centered there were 2 very
good results and 1 good result; when there was
some degree of protrusion there was 1 very good
333
result and 4 good results; 3 intermediate and 4 bad
results made up the balance.
(e) Techllicalfailures (6 cases). With slight cen-
tral protrusion there was 1 bad result following
ectopic bone formation superimposed on a mal-
union. With significantcentral protrusion there was
I good result, 3 intermediate results (1 significant
malunion and 2 femoral head arthroplasties) and
1 bad result due to a failure of arthrodesis.
Thus only one elinically good result was
achieved out of the six technical failures.
(f) Malunion of the acetabulum (12 cases). Early
operative treatment was followed by insignificant
mal union in 6 cases and there were 5 good results.
It was followed by significant malunion in 6 cases
and there were 3 good and 3 intermediate results.
There was not a single very good result, and the
likelihood of posttraumatic osteoarthrosis was
high.
(g) Loss of congruence of the superior joint space
(11 cases). In one, the acetabulum had apparently
been weil reduced; the elinical result was interme-
diate. In 7 cases the acetabulum was very weil
reduced at the level of one column but imperfectly
at the other; there were 4 very good and 3 good
results. In 2 cases the acetabulum was very weil
reduced at the level of one column but poorly
at the other; I result was very good and the other
intermediate (on account of a femoral head and
posterior acetabular osteonecrosis). In one case of
insufficient reduction the result was very good.
Exeluding the hip with osteonecrosis (a signifi-
cant complication unrelated to loss of congruence)
there were 10 cases from wh ich we have 6 very
good and 3 good results. We conelude that minor
incongruence of the superior joint space does not
have any serious deleterious effect. Furthermore,
we have been surprised occasionally to find that
this alteration of joint space has disappeared dur-
ing the later follow-up period.
(h) Faults ofreduction ofthe acetabulum. In spite
of known faults of reduction at the time of oper-
ation, the late radiological and elinical results are
surprisingly good in many cases. Thus, among 63
defective acetabular reductions (mentioned in (b)
to (e) above and ineluding all types) there were
14 radiologically perfect and elinically very good
results, 15 radiologically almost perfect and elini-
cally very good results, and 8 radiologically perfect
or almost perfect and elinically good results, a
total of 37 somewhat surprising findings (Ta-
ble 35).
334 Clinical Results of Operation Within Three Weeks of Injury

Tablc 36 ing injury, the results of operations in respeet of

restoration of joint eongruenee were that 252 hips
Quality of Quality of late result
were perfeeL Of these, 209 had perfeet reduetions
immediate
result Radiologically Radiologically Radiologically of both the acetabulum and the innominate bone
perfeet, clini- almost perfect, imperfect, as a whole (69%). The differcnee between the two
cally very good clinically vcry clinically good figures is explained by the fact that the reeentring
good of the femoral head underneath the roof does not
neeessitate aperfeet reconstruetion of the lV/wIe
Almost 3 2~ 2
pcrfect acetabulum. We have fulfilled our aim of perfeet
9
reduetion in all ways in 69% of eases; in other
Ycry good onc 9 1 5
column, but words surgery has failed in the 31 % imperfect re-
imperfect duetions of the aeetabulum, and in 17% of the
other column total, this was assoeiated with faulty centring of
Yery good one 2 the femoral head. It should be noted that the faults
column, but of reduction are, in the immense majority of eases,
poor other less signifieant than those resulting from eonserva-
column
tive treatment and also that a good proportion
Poor red uc- - 3 of them have been followed by a very good or
tion both
columns
good clinieal result. At the same time, failure to
aehieve perfeetion must not be aeeeptcd co m-
Total 14 15 8 plaeently espeeially when put into eontext with
thc undoubted risks of operation. These have been
discussed in Chap. 22 but will be mentioncd again
In order to try to explain these apparently para- brietly.
doxieal results, we have rearranged the eases as
in Table 35, relating the very good and good clini- (a) Mortality (3.6%). Of the 11 post-operative
eal results to the quality of femoral head and aee- deaths, 2 were directly related to operation on the
tabular reduetions, Despite the small numbers hip and 9 were due to general eomplieations of
eoneerned, in some series there is evidenee that the surgery.
main aim should be to obtain aperfeet fitting of
the head into the acetabulum, in whieh ease 82% (b) Post-operative inlection (6.6%). This was un-
very good clinieal results ean be expeeted in the long aeeeptably frequent during our early experienee
term. If a slight imperfeetion of reduetion persists in especially of the ilio-inguinal approach. The rate
one eolumn or at one end of a transverse fraeture, of infeetion has fallen during the subsequent part
and yet the head is perfeetly centred under the of this series. Early vigorous treatment is impor-
roof, the percentage of very good results (67%), tant and while there has been signifieant functional
although a little lower, remains pleasing. At the loss in 9 hips, all the other eases have aehieved
same time, it should be emphasised if any impair- good or very good results.
ment of quality of aeetabular reeonstruetion eo-
exists with a protrusio aeetabuli loeation of the (e) Post-operative sciatic palsy (11.2%). Variable
femoral head, the elinieal result is unlikely to be in distribution and severity, onset was immediate
good; out of 23 examples only one was very good in 30 eases and delayed in 4 eases. Before the util-
while nine were good. There is no doubt that per- isation of transeondylar femoral traetion with the
feet restoration of the anatomy in a11 ways gives knee tlexed, the frequeney was 18.4%. Subse-
the best chance of aehieving a normal hip. quently the ineidenee has been 9%, in most eases
due to eompression of the nerve with retraetors
and therefore avoidable.
25.4 Summary of Results The prognosis is fairly good: out of 25 eases
with motor impairment there were 6 eomplete re-
25.4.1 Early Results eoveries, and 8 very signifieant improvements. Thus
two eases out of three improve suffieiently to allow
Of 302 fraetures of the aeetabulum whieh were normal aetivity. Two patients need an applianee
opcrated upon during the first three weeks follow- while 7 are left with some small disability.
Cornrnent
25.4.2 Late Results
For the 244 hips followed up for at least 2 years,
the results are summarised as folIows:
Clinically, 70.9% have a very good result (82%
for fractures of the posterior wall and 68% for
both-column fractures), 13.4% have good results
(making the total 84.3% of good and very good
results), 16% have intermediate results, and 6%
have pOOl' results.
Radiologically, 129 hips are perfect, and 49 hips
are left with a slight blemish; thus there are 178
practically normal hips, representing 73 % of our
operations.
The radiologically normal hips correspond weil
to clinically very good results and it is our conten-
tion that early operation leads to a three-out-of-
four chance of achieving such a good outcome.
Late complications must not be ignored:
(a) Pseudarthrosis (2 cases)
(b) Osteonecrosis of all types (21 cases; 7%). Ex-
cluding 16 cases of femoral head necrosis, which
is probably unavoidable, 5 cases were most likely
to have been associated with surgery. Some in-
stances of osteonecrosis of the acetabulum were
associated with necrosis of the femoral head.
(c) Post-traumatic osteoarthrosis (21 cases). Of
these, 5 were purely radiological findings and
asymptomatic while the other 16 hips were with
symptoms. Eight examples appeared after perfect
reduction of the head and of the acetabulum and
9 appeared after imperfect reduction; a number
of the latter could perhaps have been avoided.
(d) Ectopic bone formation (6 cases). This
number embodies the severe examples including
the three necessitating surgical removal which
eventually achieved good results.
POOl' and intermediate results are in most in-
stances related to one of the complications whether
335
early (such as infection) 01' la te (osteoarthritis and
osteonecrosis), perhaps related to inferior reduc-
tions of the joint surface. 32 hips with minor defects
yielded 21 very good results, 15 serious defects of
reduction were associated with only 2 good results,
and yet one out of six marked failures of reduction
paradoxically ended with a good clinical outcome.
The persistence of a loss of congruence of the
superior joint space, even when associated with
imperfection of the acetabular reduction, does not
seem to have such a deleterious effect as might
be expected: 7 out of 12 cases were very good.
In contrast, if the fault of reduction caused a me-
dial protrusion of the head, the results over the
long term were very uncertain. A slight central
protrusion was associated with only one very good
result and 7 good results (out of 15 cases) but of
8 examples with a significant protrusion there were
only 2 good results.
25.5 Conclusions
A single element appears to us paramount : the
relocation of the head und er a sector of roof must
be adequate. This is the practical prerequisite for
all good results. We cannot prove that obtaining
this result excludes the need for good reduction
of the columns supporting the acetabulum.
25.6 Comment
Surgery of the acetabular fracture should not be
undertaken lightly. Full study of the diagnostic
methods and operative techniques demands much
time and effort; without adequate preparation in
this way, it is better to pursue a conservative course.
26 Surgical Management More Than
Three Weeks After Injury
In patients seen more than three weeks after injury
extensive callus formation and difficulties in surgi-
cal approach reduce the ease of open reduction
of fractures of the acetabulum. Formerly, the ma-
jority of cases were left for eventual salvage by
total hip arthroplasty.
Since 1962, we have attempted to restore the
acetabulum in these late cases. In principle, the
operation and approach is similar to that for recent
fractures, but there are additional aspects:
(a) Fracture lines are obscured by early callus
and yet, when this is carefully removed, they can
be identified.
(b) In later ca ses, actual osteotomy may be re-
quired to separate displaced fragments.
(c) Non-union may be encountered.
(d) Incarcerated fragments may require removal.
(e) Fracture lines heal at different rates and mix-
tures of all the preceding features may be found.
The operative approaches are precisely as de-
scribed for the re cent operations. Sometimes bone
grafts are required to fill defects in the acetabular
wall.
26.1 Aim of Surgery
As would be expected, complete restoration of the
articular surface and of the pelvic bone architec-
ture is attempted but the fundamental requirement
is centring of the femoral head under the roof
segment. In selected cases, the aim must be
restricted to a crude restoration of the acetabular
boundaries.
26.2 Prerequisites for Operation
(a) The femoral head must be of normal bone
density. Localised surface damage is not a contra-
indication (Fig. 236).
(b) Osteoarthrosis should not have developed,
but a collar of small osteophytes is not a contra-
indication.
(c) On the standard radiographs, it is important
that the components of the sub-articular bone
should still be clear. It is impossible to reconstruct
unrecognisable topography (Fig. 237).
26.3 Specific Fracture Types
Specific examples from our series are shown in
the appropriate figures. Under each heading, par-
ticular problems encountered will be mentioned.
26.3.1 Posterior Wall Fractures
There were 32 cases, most of which were associated
with persistent posterior dislocation. It is necessary
to operate through the Kocher-Langenbeck ap-
proach and excise all the dense fibrous tissue; this
is the difficult phase of the procedure and must
include removal of tissue binding the front of the
femoral head to the acetabulum as well as that
occupying the cavity created by the incongruous
surfaces of the joint itself. Progressive internal ro-
tation of the hip joint is a helpful manoeuvre.
The femoral head may be superiorly located and
it may be necessary to divide the psoas, adductors,
rectus femoris and femoral insertions of gluteus
maximus. Subsequently, the posterior wall is re-
constructed and fixed internally. If there is a persis-
tent defect, it can be filled by an iliac graft. Fig-
ure 238 A-C shows a fracture-dislocation operated
upon 160 days after injury.
Sometimes the head is not stable because of gross
deficiency of the posterior wall of the acetabulum
and in these cases traction may be advisable.
338
The prognosis for hips allowed to remain dislo-
cated for more than 3 weeks was poor. Avascular
necrosis ofthe femoral head occurred in two-thirds
of cases (Fig. 239), and yet in one-quarter of the
cases with very good clinical results the hip had
been dislocated for 24-100 days. All heads left
dislocated for more than 160 days developed os-
teonecrosis.
Some examples were not dislocated but a poste-
rior wall fragment remainec\ displaced. In 6 cases
in which there was no osteoarthrosis, very good
results have been achieved; in others, degenerative
changes were present already and restoration of
the posterior wall fragment has not avoided a poor
result.
Post-operatively, two out of 32 cases were com-
plicated by sciatic palsy, but recovery was excel-
lent.
26.3.2 Posterior Column Fractures
The fracture line was seen from inside the hip
after detaching the posterior capsule from the ace-
tabular margin and exerting traction (12 cases).
The fractured column may be united by discrete
bars of bone to the sacrum or to some part of
the greater sciatic notch (Fig. 240A). These must
be divided together with fibrous tissue. It may be
necessary to osteotomise the ischio-pubic ramus
near the body of the ischium. The posterior column
is fixed with a plate as usual.
In 10 examples operated upon between 4 weeks
and 80 weeks, 9 perfect reductions led to 8 very
good results (Fig. 240 Band C); one imperfect re-
duction was accompanied 2 years later by os-
teoarthrosis and the patient underwent total hip
replacement after 9 years.
26.3.3 Anterior Fractures
These are very difficult fractures, occurring often
in elderly osteoporotic patients, and few operations
have been performed. Nevertheless, some pleasing
results can be obtained (Fig. 241).
26.3.4 Transverse Fractures
Eight hips have been treated operatively, 6 from
the posterior aspect, and 2 from the lateral. The
Surgical Management More Than Three Weeks After Injury
broad, fIat fnlcture surfaces unite quickly and os-
teotomy, removing a slice of bone slightly wedged
with the base inwards, may be necessary (Fig. 242).
This is performed from the back, having detached
the capsule from the upper fragment and exerting
traction so as to see inside the joint. ChiseI, saw
or gouge may be used. The osteotomy becomes
increasingly difficult as the brim of the pelvis is
approached; depending on the amount of scar
tissue the resection may be complete or the brim
may be split. Fixation is by a plate on the posterior
column (Fig. 243).
From 8 cases there were 4 very good and 2
good clinical results. Two patients were lost to
follow-up. In one case, non-union was 150 days
old when the operation was carried out (Fig.
244A-C); 4 years later the result is excellent (Fig.
244 D-F). There was one post-operative sciatic
palsy and one gluteal paralysis.
26.3.5 T-shaped Fractures
Ten examples have been treated, 9 from the poste-
rior aspect and one requiring two approaches. Os-
teotomy of the displaced segment of the posterior
column component has been required from the
back and the inside of the joint as in the case of
transverse fractures. Additional osteotomy of the
ischio-pubic ramus near the ischial tuberosity is
necessary if the stern component is displaced.
Usually, the femoral head reduces after the joint
has been cleared and the capsule divided alongside
the acetabular roof.
The anterior column component may be left if
its articular surface is small and its displacement
slight (Fig. 245) but when either is of significant
size, it has to be mobilised either from the back
or through a second anterior approach (Fig. 246).
From 10 cases operated upon through posterior
approaches there were 3 very good, 3 good, 2 inter-
mediate and I bad result. One patient was lost
to follow-up. The appearance of the hip operated
upon through the lateral approach on the 30th
day is shown in Fig. 247.
26.3.6 Associated Anterior and
Hemitransverse Fractures
Our only example (Fig. 248) was operated upon
using the extended ilio-femoral approach.
Specific Fracture Types 339

26.3.7 Associated Transverse and 26.3.8 Both-Column Fractures

Posterior Column Fractures
The complex fractures, especially the both-column
(a) Central femoral head dislocatiol1. We have had variety, have, as would be expected, presented
experience with 11 cases. After the posterior wall greater problems. In general, the extended ilio-
fragment had been freed, the joint capsule was femoral approach has been most appropriate un-
divided along its attachment to the superior lip, less access is required to the inferior part of the
the joint cavity evacuated, and usually the femoral anterior column.
head could be reduced. The space created by the There is no assurance that reconstruction is pos-
posterior fracture makes access to the trans verse sible in these complicated fractures and we have
component easier. After osteotomy (see Fig. 242 b) not succeeded in an effective restoration later than
~n order to mobilise the ischio-pubic component,
35 days after injury. Our present attitude is based
lt was fixed by a plate, and the posterior wall on the following considerations:
fragment by isolated screws or another plate (a) The fracture fragments are congruent with
(Fig.249). the femoral head. Up to 35 days after injury, if
Three out of 11 operations were complicated the fracture fragments are fairly c1early deiineated
by a lateral peroneal palsy, but two were conducted and related to the femoral head, reconstruction
before we had realised the importance of skeletal should be attempted (Figs.251 and 252). Later
femoral traction with the knee flexed. There was than 35 days after injury, .whenever the fracture is
one avascular osteonecrosis of the head and of complex in terms of configuration or displacement,
the posterior wall. it is probably wiser to err towards a conservative
(b) Posterior femoral head dislocation. Oper- choice of management.
ations on 20 patients were performed through the (b) The fracture fragments are not congruent
posterior approach 23 days to 9 months after in- with the femoral head in one or more standard
jury. radiographs : The head may displace with the ante-
The head of the femur was in general surrounded rior component, thereby rendering the main incon-
by new bone formation and after its rem oval there gruence posterior. If possible, from judgement of
was insufficient material to reconstitute the ~oste­ the c1arity of the individual fragments, operation
rior wall; bone grafting was usually necessary. Af- should be attempted. Should the joint be con-
ter removal of the bony debris from the posterior gruent, conservative treatment is probably wiser.
wall region, the interior of the joint could be ex- It may be better to be contented only with an
plored and ifnecessary, an osteotomy in the region approximate reconstruction of the acetabular
of the transverse component performed in order boundaries, if only to facilitate a safe and stable
to restore the vertical alignment of the columns total hip arthroplasty in the future (Fig.253).
(Fig.242b).
The outcome is poorer than for fractures with 26.3.9 Incarceration
persistent central displacement. Seven developed
avascular necrosis of the femoral head and one There have been 11 cases in which fragments of
of the latter was associated with posterior wall bone in the joint itself have been missed. Months
osteonecrosis. after injury, the hip became painful and stiff and
(c) Results. The immediate radiological results in some an abduction deformity developed.
of the 31 cases of this association were perfect Unless these fragments are removed, arthrosic
in 20 and imperfect in 11. changes are inevitable. In 9 out of the 11 cases,
The c1inical results of 30 cases we were able the original injury was a posterior dislocation with
to follow up were: 12 very good, 8 good (Fig. 250), an unrecognised small fracture of the posterior
4 fair, 6 bad. The 10 intermediate and bad results wall and in two cases there was a trans verse frac-
inc1ude 8 with osteonecrosis of the femoral head ture without dislocation.
associated or not with osteonecrosis of the poste- Some fragments retain a soft-tissue connection
rior wall. which tethers them not far from the edge of the
acetabulum and therefore they maintain the head
in an inferiorly displaced position; they soon be-
come adherent to the articular cartilage. These can
be removed posteriorly (Fig. 254).
340
When they are free from attachments, the frag-
ments often locate in the cotyloid fossa and may
be difficult to see. These produce local trauma
of the head. They can be removed through an
anterior Smith-Petersen type incision, taking great
ca re to avoid further cartilage damage. A T-shaped
capsular incision aids access (Fig. 255). Fragments
associated with a transvers~ fracture may be better
approached posteriorly. In some instances, the dis-
placed fragment has been observed to increase in
size (Fig. 256). The results of late rem oval of incar-
cerated fragments are in general good.
Surgical Management More Than Three Weeks After Injury
26.4 Summary
Roughly 50% of operations classed as late have
been followed by very good clinical and radio log-
ical results. Radiologically there is osteoarthrosis
in 20% of cases but they maintain good clinical
results. Hip arthroplasty will be necessary one day,
but the acetabulum will be in a good condition
for cementing the implant. Many of the patients
are young, and late reconstructions are worthwhile
if only for this reason.
Summary 341

Fig. 236A, B. Posterior column fracture with localised surface A Antero-posterior radiograph before operation, B antero-pos-
damage to the femoral head, operated on 120 days after injury. terior radiograph at 2 years (evaluated as 5.6.5)
342 Surgical Management More Than Three Weeks After Injury

Fig. 237 A-C. Both-column fracture seen 2 years after injury radiograph, B obturator-oblique radiograph, C iliac-oblique ra-
and obviously impossible 10 reconstruct. A Antero-posterior diograph
Summary 343

B c
344 Surgical Management More Than Three Weeks After Injury

Fig. 238A-F. Posterior wall fracture with posterior dislocation are preoperative x-rays. D-F Post-operative x-rays, taken 2 1 / 2
of the femoral head, operated on 160 days after injury. A-C years after operation
Summary 345

B c
 346 Surgical Management More Than Three Weeks After Injury

E Fig.238D-F
A B

o
Fig. 239 A-D. Posterior wall fraeture with posterior dislocation
of the femoral head. operated on 9 months after injury. A An-
tero-posterior radiograph be fore operation. B antero-posterior
radiograph, and C iliac-oblique radiograph after operation
showing the femoral head osteonecrosis. 0 The total hip re-
placement (" L.L" prothesis), undergonc 3[/2 years after rc-
c positioning of the head
 348 Surgical Management More Than Three Weeks After Injury

Fig.240. A Diagram showing the discrete bars of bone which

may unitc a displaced posterior column with other parts of
the pelvic bone. B Anterio-posterior radiograph. C Obturator-
oblique radiograph. D lliac-obliquc radiograph of a posterior
column fracture opcratcd upon 4S days after injury. E Antero-
postcrior radiograph. F Obturator-oblique radiograph. G lliac-
oblique radiograph taken 9 years after operation

C D
 Summary 349

F Fig.240E-G
350 Surgical Management More Than Three Weeks After Injury

Fig. 241 A-F. Pure anterior wall fraeture , operated on 40 days

after injury. A Antero-posterior radiograph , B obturator-ob-
lique radiograph, and C iliae-oblique radiograph taken before
operation, D antero-posterior radiograph, E obturator-oblique
radiograph, and F iliae-oblique radio graph taken 3 years after
operation
 Summary 351

D
352 Surgical Management More Than Three Weeks After Injury

Fig. 242A, B. Schemes of the trapezoid-shaped slice of bone of A a transverse fracture , and B an associated transverse and
that ha s to be removed in order to reconstruct a mal union posterior wall fracture
Summary 353

A B c

D E F

Fig.243A-F. Juxta-tectal transverse fracture. operated on before operation, D antero-posterior radio graph, E obturator-
45 days after injury. A Antero-posterior radio graph, B obtura- oblique radiograph, and F iliac-oblique radiograph taken
tor-oblique radiograph, and C iliac-oblique radio graph taken II years after operation. (evaluated 5.6.5)
354 Surgical Management More Than Three Weeks After Injury

}<'ig. 244A-F. Transverse fracture showing non-union ISO days radiograph, E obturator-oblique radiograph, and F iliac-ob-
after injury. A Antero-posterior radiograph, B obturator-ob- lique radio graph taken 4 years after operation (hip function
lique radiograph, and C iliac-oblique radiograph laken before excellent)
operation (hip funclion evaluated as 2.5.3), D antero-poslerior
Summary 355

B c
356 Surgical Management More Than Three Weeks After Injury

Fig.244D-F
Summary 357

E F
358 Surgi cal Managem ent M o re Than Three Weeks Aft er Injur y

c D
Summary 359

Fig. 245A-F. T-shaped fracture operated on 120 days after inju- taken before operation, D antero-posterior radiograph, E ob-
ry (posterior approach). A Antero-posterior radio graph, B ob- turator-obliquc radiograph, and F iliac-obliquc radio graph
turator-oblique radiograph , and C iliac-oblique radiograph taken 4 years after operation
360 Surgical Management More Than Three Wecks After lnjury

A C

Fig. 246A-G. T-shaped fracture operated on 40 days after inju-

ry (posterior and anterior approaches eonsecutively). A Antero-
posterior radiograph, B obturator-oblique radiograph, and C
iliac-oblique radiograph befOl'e operation, 0 antero-posterior
radiograph after operation, E Antero-posterior radiograph.
F obturator-oblique radiograph. G iliac-oblique radiograph ,
taken 8 years after operation, showing evidence of osteoarthrosis E
Summary 361

F G
362 Surgieal Management More Than Three Weeks After Injury

Fig. 247 A-F. T-shaped fracture, associated with a fracture line

running through the wing and involving the sacro iliae joint,
approached laterally 30 days after injury. A Antero-posterior
radio graph, B obturator-oblique radiograph, and C iliae-ob-
liquc radiograph taken be fore operation, 0 antero-poslerior ra-
diograph, E obturator-oblique radiograph and F iliac-oblique
B radio graph taken 2 years after operation
Summary 363

F
364 Surgical Management More Than Three Weeks After Injury

E
 365

c o

Fig. 248A-E. Associated anterior and hemitransverse posterior graph taken be fore operation, C antero-posterior radiograph,
fracture, operated on 30 days after injury (lateral appro ach). o obturator-oblique radiograph , and E iliac-oblique radio-
A Antero-posterior radiograph, and B obturator-oblique radio- graph taken 6 months after operation
 366 Surgical Management More Than Three Wecks After Injury

B D
 Summary 367

A
Fig. 250 A-F. Associated Iransverse and posterior fracture with posterior
dislocation, operated on 120 days after injury. A Antero-posterior ra-
diograph, B obturator-oblique radio graph, and C iliac-oblique radio-
graph taken before operation, D antero-posterior radiograph, E obtu-
rator-oblique radiograph, and F iliac-oblique radio graph taken 7 years
after operation (c1inical result still good)

<l Fig. 249 A-D. Associated trans verse and posterior wall fracture radio graph, B obturator-oblique radiograph and C iliae-oblique
with central dislocation of the femoral head, operated on radio graph taken be fore operation, D antero-posterior radio-
90 days after injury (posterior approach). A Antero-posterior graph taken 3 years after operation
368 Surgica l Ma nage ment M o re Th an Three Weeks After Injur y

B c

Fig.250B-F
Summary 369

o F

E
370 Surgical Management More Than Three Weeks After Injury

A B C

D E F

Fig. 251 A-F. BOlh-column fracture operated on 35 days after graph taken before operation, D antero-posterior radio graph,
injury (anterior approach). A Antero-posterior radio graph, E obturator-oblique radio graph, and F iliac-oblique radio graph
B obturator-oblique radiograph, and C iliac-oblique radio- laken 4 years after operation
Summary 371

Fig. 252A-F. Both-column fraeture operated on 30 days after graph taken before operation, D antcro-posterior radio graph,
injury (anterior approach). A Antero-posterior radio graph, E obturator-oblique radio graph, and F iliac-oblique radio graph
B obturator-oblique radio graph, and C iliae-oblique radio- taken 4 years after operation
372 Surgical Management More Than Three Wecks After Injury

B c

Fig.252B-F
 Summary 373

D ______________ ~ __________ ~ _________________

E F
374 Surgical Management More Than Three Weeks After Injury

A B

c D E

Fig. 253A-E. Both-column fracture operated on 40 days after radiograph taken 8 years after operation. Complete reconstruc-
injury. A Antero-posterior radiograph, and B obturator-oblique tion was impossible, and we were content with an approximate
radiograph laken before operation, C antero-posterior radio- reconstruction ofthe acetabulum around the centrally displaced
graph, D obturator-oblique radiograph , and E iliac-oblique femoral hea d. The clinical result is very good.
Summary 375

A B

Fig. 254A, B. An incarcerated fragment, 180 days after injury.

A Antero-posterior radio graph before operation, B antero-pos-
terior radio graph after operation
376 Surgica l Management Mo re Than Three Weeks After Injury

A B

Fig. 255A-F. An incarcerated fragment , 9 months after injury. the operation. 0 Antero-posterior radiograph , and E obturator-
A Tomograph before the operation. B Antero -posterior radio- oblique radiograph, and F iliac-oblique radiograph taken 13
graph and C iliac-oblique radiograph taken immediately after years after operation
Summary 377

D E F
 378 Surgical Management More Than Three Wecks After Injury

Al A2, A3

A4 A5 Fig.256AI-A5
 Fig. 256 A-D. An incarcerated fragment in the acetabttlar fossa
that increased in size progressively. A l-A5 Serial antero-poste-
rior radiogra ph showing an incarceratcd fragment in thc ace-
tabular fossa increasing in size. B Antero-posterior radio graph ,
and C obturator-oblique radiograph taken beforc operation.
o iliac-oblique radiograph ta ken 6 years after operation

C o
27 Reassessment ofPatients Treated Before 1971
The preparation of an English edition of this book
has afforded us the opportunity of including an
up-to-date account of our patients' progress. Addi-
tionally, it has been advantageous to expand some
of our current views and to record the continuation
of our operative treatment of fractures of the ace-
tabulum.
27.1 Recent Follow-up of Patients
Between 1976 and 1978 we were able to re-examine
215 of the 302 patients whose hips were treated
operatively within three weeks of injury. The pa-
tients were last assessed in 1971, and the results
at that time are reported in Chap. 24. The criteria
of assessment, both clinical and radiological, are
unchanged. It has appeared most meaningful to
present the clinical results at the present time
(March 1979) according to the grades found in
1971, i.e. very good, good, intermediate and bad.
27.1.1 Clinical Condition Very Good
In 1971, 173 patients' hips were assessed as very
good, and 164 were available for recent follow-up.
Of these, 159 remain very good; 4 have deterio-
rated to good (2 associated transverse and poste-
rior wall, 2 both-column fractures); and 1 has de-
teriorated to bad (associated transverse and poste-
rior wall fracture).
27.1.2 Clinical Condition Good
Of the 33 patients whose hips were assessed as
good in 1971, 28 were available for recent follow-
up. Of these, 14 remain good; 8 have improved
to very good (2 anterior column, 1 T-shaped, 1
associated anterior column and posterior hemi-
transverse, and 4 both-column fractures); 5 have
deteriorated to intermediate (1 posterior wall, 1
anterior column, 1 associated posterior wall and
posterior column, and 2 both-column fractures);
and 1 has deteriorated to bad.
27.1.3 Clinical Condition Intermediate
or Poor
All the patients whose hips were assessed in 1971
as fair were available for recent follow-up. Of
these, 11 remain intermediate ; 1 has improved to
very good (posterior wall fracture); 4 have
improved to good (1 associated transverse and
posterior wall, 1 associated anterior column and
posterior hemitransverse, and 2 both-column fr ac-
tures); and 5 have deteriorated to bad (1 posterior
column, 3 associated transverse and posterior wall,
and 1 both-column fractures). Deterioration was
always associated with progressive osteoarthrosis.
27.2 Indications for Operative Treatment
We continue in the belief that, given the right facil-
ities, operative treatment of the displaced acetabu-
lar fracture remains the method of choice. Our
most recent follow-up of hips treated routinely by
open reduction and internal fixation confirms that
a satisfactory outcome can be expected if perfect
reduction is obtained. But the reverse is also true,
and in some instances it would have been better
to accept the result that might have been obtained
by conservative methods. The choice must always
382 Reassessment of Patients Treated Before 1971

take into consideration the available facilities and
experience of the surgeon.
The result of surgical treatment of fractures of
the acetabulum is determined finally by any re-
maining incongruence between the femoral head
and the acetabulum. We now classify this as total
incongruence, partial incongruence, or apparent
congruence.
constituting displaced acetabular fragments
around the femoral head while accepting the over-
all displacement ; seven of these attained a very
good clinical result. It should be empasised that
it has seI dom been necessary to resort to operative
apparent incongruence.

27.3 Operative Treatment 1971-1978

27.2.1 Total Incongruence
The distribution of all the fractures of the acetabu-
This is found in persistent posterior or central dis- lum that we have now treated is shown according
locations in which the fragments of the acetabulum to type of fracture in Table 37. The total number
are seen separated from the femoral head on all is 568 and 406 of these were operated upon within
three standard radiographs. The situation may ex- 3 weeks of the time of the injury. The other 162
ist from the moment of trauma or it may arise were operated upon 3 weeks to 3 years after the
from attempts at reduction. In all instances opera- injury. A further 64 fractures were treated conser-
tive treatment is indicated. vatively; the majority of these occurred early in
the series.
The percentages recorded in Table 37 reflect a
27.2.2 Partial Incongruence false distribution after 1971, because since then,
the more complicated types of fracture have been
The femoral head lies well centred beneath an un- referred to us with increasing frequency; as a con-
displaced fragment of roof, while other fragments sequence, the figures do not represent the incidence
of articular surface remain displaced. We can state of the various types of fracture but offer only a
with confidence that a very good clinical result measure of our experience to date.
can be expected in no more than 55% of hips
left in this state (disregarding operative complica-
tions), and the same can be expected following
conservative management. A small degree of in-
congruence can be accepted, but one of the diffi-
culties lies in determining the size of the fragment Table 37
of roof left in situ as was explained in Figs. 14a
Type of fracture 1971 1971-1978 Total
and b. Certainly, congruence seen on one standard
radio graph and not on the others must not be Simple Posterior wall 126 (27%) 30 (18%) 156
accepted, and surgical treatment is indicated. Posterior column 21 ( 5%) 6 ( 4%) 27
Anterior wall 10 ( 2%) 5 ( 3%) 15
Anterior column 22 ( 5%) 5 ( 3%) 27
27.2.3 Apparent Congruence
Transverse 43 ( 9%) 12 ( 7%) 55
This is the term we have applied to the condition Associated T-shaped 30 ( 6%) 12 ( 7%) 42
prevailing when the fragments of a shattered ace- Transverse and 95 (20%) 35(21%) 130
tabulum have regrouped around a displaced femo- posterior wall
ral head and exhibit a fair degree of congruence Anterior and 23 ( 5%) 11 (7%) 34
in this displaced position (see Sect. 14.1.5). Such posterior hemi-
hips can often be treated conservatively. Surgery transverse
may or may not achieve better congruence and it Posterior column 12 ( 3%) 5( 3%) 17
will be accompanied by the risks of operation. and posterior wall
Further , the result of surgery could be worse! Both-column 87 (19%) 42 (26%) 129
In nine fractures of the acetabulum we have
Total 469 163 632
deliberately achieved apparent congruence by re-
Conclusion 383

27.4 Conclusion for good-quality standard radiographs which the

surgeon must assess meticulously before operating.
Our indications for operative treatment of frac- We now recognise that in some particularly COlTI-
tures of the acetabulum are seen to have changed minuted fractures, astate of apparent congruence
little since 1971. We stress the need in every case may be accepted.
28 Exereises in Radiographie Diagnosis
The following examples offraetmes ofthe aeetabu-
lum are from the authors' eollection. This Appen-
dix is designed to improve the reader's ability to
define the morphology of the various fraetme eom-
plexes.
The radiographs are aeeompanied by deserip-
tions and illustrated by line drawings. In order
to derive the greatest benefit from these examples,
the reader should study the radiographs and reaeh
a eonclusion before eonsulting the deseriptions and
line drawings.
1 Assoeiated posterior wall and posterior eolumn
fraetmes. The main fraetme line detaehing the pos-
terior eolumn passes inferiorly through the body
of the isehium and the obtmator foramen remains
intaet. A segment of the quadrilateral smfaee of
the isehium has been elevated separately.
2 J uxta-teetal trans verse fraetme. There is a frae-
tme of the opposite pubie rami.
3 Intermediate anterior eolumn fraetme asso-
eiated with an ineomplete hemi-transverse poste-
rior fraetme. The ineomplete hemi-transverse eom-
ponent is most clearly seen in the antero-posterior
view. It runs obliquely upwards and inwardly and
does not cut the posterior border of the pelvie
bone.
4 Juxta-teetal transverse fraetme assoeiated with
a posterior wall fraetme. Initially there was a pos-
terior disloeation of the hip and the views here
show the eondition after reduetion of this disloea-
tion.
5 Both-eolumn fraetme. The iliae wing eomponent
reaehes the iliae erest. The anterior eolumn eompo-
nent extends in one piece from the anterior
superior iliae spine to the superior pubie ramus.
The margin of the greater selalle noteh presents
unusually having pivotted about 90° in both
antero-posterior and iliae wing views. The saero-
iliae joint is not distmbed.
6 Posterior wall fraetme with marginal impaction.
The impaeted fragment is seen in the anterior pos-
terior view lying parallel to the supero-medial
margin of the femoral head.
7 Both-eolumn fraetme. The iliae wing eomponent
extends to the iliae erest and isolates a triangular
fragment of the wing. The posterior eolumn frag-
ment is in one piece and includes the inferior part
of the saeroiliae joint (more frequently this eonsti-
tutes aseparated fragment. See Chapter 14.4, a).
No spm sign is visible whieh is again unusual.
8 Low anterior column fraetme assoeiated with
a hemi-transverse posterior fraetme. The anterior
eolumn fragment is fmther sub-divided into three
parts: the anterior wall fragment itself, the body
of the pubis and a segment of the isehio-pubie
ramus.
9 Posterior eolumn fraetme assoeiated with an
undisplaeed anterior hemi-transverse eomponent.
This assoeiation is similar but not identieal to a
"T-shaped" fraetme (see page 140).
10 Juxta-teetal transverse fraetme. There is some
eomminution in the posterior part of the fraetme
!ine whieh cuts the edge of the pelvis bone just
above the isehial spine.
11 Vertieal T-shaped fraetme assoeiated with a
posterior wall fraetme. The posterior fragment
appears superimposed on the inner part of the
roof overlying the upper part of the femoral neck.
386
12 Low fraeture of the anterior eolumn. There
are two supplementary fragments, one eomprising
a posterior segment of the iliopeetineal line and
the other eomprising part of the quadrilateral sur-
face of the isehium whieh has been elevated and
is hinged posteriorly.
13 Infra-teetal trans verse fraeture. There IS mml-
mal displacement.
14 Vertieal T-shaped fraeture. There is a double
fraeture in the isehio-pubie ramus and additionally
a segment of the anterior wall has been separated.
Marginal impaetion of the inner part of the roof
is seen on the antero-posterior view.
15 Posterior wall fraeture assoeiated with undis-
plaeed low trans verse fraeture. The trans verse frae-
ture eomponent eros ses the posterior border of
the pelvie bone inferior to the isehial spine.
16 Exeeptional example not included in our classi-
fieation. The head of the femur has disloeated een-
trally having fraetured the inferior part of the floor
of the aeetabulum but the ilio-peetineal line and
the anterior and posterior walls remain intaet. The
inferior part of the ilio-isehial line is seen to be
fraetured.
17 Juxta-teetal transverse fraeture, assoeiated with
a troehanterie fraeture of the femur. Additionally,
there is a small detaehed posterior wall fragment.
An undisplaeed fraeture line extending to the iliae
erest ean be seen whieh does not involve the roof
of the aeetabulum whieh remains intaet. The head
of the femur is posteriorly disloeated and was but-
tonholed through a dcfieieney in the posterior eap-
sule.
18 Both-eolumn fraeture. The iliae wing eomplex
eomprises a 'Y' eonfiguration. The posterior limb
of this does not reaeh the iliae erest. The fraeture
at the root of the superior pubie ramus involves
the roof of the obturator eanal and enters the hip
joint.
19 Assoeiated anterior wall and posterior hemi-
transverse fraetures. The fraeture line through the
isehio-pubie ramus has isolated the lower part of
the anterior eolumn. Marginal impaetion has
oeeurred at the inner part of the roof of the aeeta-
bulum.
Exereises in Radiographie Diagnosis
20 Extended anterior eolumn fraeture. There is
a seeondary fraeture line whieh divides the wing
segment of the anterior eolumn and extends to
the anterior border of the bone between the
anterior iliae spines. There is some eomminution
of the inner table of the iliae wing and, from the
quadrilateral surfaee of the isehium, a posteriorly
hinged plaque of bone has been elevated. Inferi-
orly, the anterior eolumn is interrupted by fraeture
lines through the root of the superior pubie ramus,
the body of the pubis and the isehio-pubie ramus.
The posterior border of the aeetabulum and the
posterior border of the pelvie bone are eaeh intaet.
21 Both-eolumn fraeture with iliae wing eompo-
nent extending to iliae erest. The anterior eolumn
is split through the anterior wall and there is a
detaehed fragment from the internal iliae fossa.
22 Assoeiated posterior eolumn and postero-
superior wall fraetures. There is an assoeiated frae-
ture of the superior pubie ramus; this ease was
eomplieated by a rupture of the urethra.
23 Juxta-teetal transverse fraeture assoeiated with
a fraeture line extending from the retro-aeetabular
surfaee to the iliae crest. The upper segment of
the artieular surfaee is assoeiated with the anterior
fragment of the wing whieh itself is split seeondar-
ily by a fraeture line reaehing the interior interspi-
nous noteh. This fraeture should be eompared with
the typieal fraeture line of a both-eolumn fraeture.
24 Undisplaeed infra-teetal transverse fraeture
assoeiated with a postero-superior wall fraeture.
The femoral head is disloeated posteriorly.
25 Both-eolumn fraeture with iliae wing eompo-
nent extending to the iliae erest. The spur sign
is obvious in the obturator oblique view. The pos-
terior eolumn, markedly diplaeed inwardly, was
ineareerated in the true pelvis and res ted against
the saeroiliae joint. Two operative approaehes
were needed in order to reduee this fraeture.
26 T-shaped fraeture. There is marked marginal
impaction of the inner part of the roof.
27 Posterior eolumn fraeture. Typieally, the tear-
drop is not involved.
28 Both-eolumn fraeture with iliae wing eompo-
nent extending to the erest and involving the sae-
Exereises in Radiographie Diagnosis
roiliac joint. The posterior column includes the
inferior half of the sacroiliac joint. (See also Exam-
pie 7). Two operative approaehes were needed for
reduction in this case.
29 Anterior T -shaped fracture. There was eommi-
nution of the anterior eomponent of this fracture.
Two approaches were necessary for reduction, the
Koeher-Langenbeek being employed first.
30 Anterior T-shaped fracture. In the obturator
oblique view, the ilio-pectineal line seems undis-
turbed but in the antero-posterior view a fraeture
through this line is obvious. A sm all segment of
the ilio-peetinealline is separated by a double frae-
ture of the pelvic rim.
31 High anterior eolumn fracture. The detached
anterior column has been split into two main frag-
ments. The outer one includes the posterior
superior segment of the articular surface and
anterior pillar of the iliac wing while the inner
387
one includes the cotyloid fossa, the medial half
of the posterior wall of the acetabulum and the
inner margin of the ischium. The inner aspeet of
this inner fragment includes a segment of the ilio-
pectinealline and most of the quadrilateral surface.
The inner fragment should be compared with that
seen in Example 16.
32 ] uxta-tectal trans verse fracture associated with
an extended posterior wall fraeture. The posterior
wall is comminuted and the inferior fragment
thereof includes the upper pole of the ischial tuber-
osity. The femoral head is dislocated posteriorly.
33 Anterior column fracture assoeiated with a pos-
terior hemi-transverse component. The hemi-trans-
verse eomponent splits the ischial spine. The ar-
ticular segment of the anterior column is further
fractured at two points and there is an undisplaced
fracture line dividing the sacroiliac joint, merging
with the iliac wing fracture line. There are two
impacted marginal fragments.
388 Exereises in Radiographie Diagnosis

Case 1. Associated posterior wall and posterior eolumn frae-

tures.
The fraeture line detaching the posterior column runs inferi-
orly through the ischium leaving undisturbed the obturator
foramen. A split through the quadrilateral surfaee isolates a
plaque of bone
Exereises in Radiographie Diagnosis 389

Case 2. Juxta-tectal transverse fraeture

390 Exereises in Radiographie Diagnosis

Case 3. Intermediate anterior eolumn fraeture associated with

an ineomplete hemi-transverse posterior fraeture.
The incomplete hemi-transverse component is clearly seen
on the antero-posterior view, running obliquely upwards and
inwards. lt does not cut the posterior border of the pelvic
bone
Exercises in Radiographie Diagnosis 39\

Ca se 4. Juxta-tectal transverse fracture associated with a poste-

rior wall fracture.
Initially the head was posteriorly dislocated
392 Exereises in Radiographie Diagnosis

Case 5. Complete both-column fracture .

The wing fracture line reaches the iliac crest. The anterior
column is detached in a single piece from the anterior superior
iliac spine up to the superior pubic ra mus. An uncommon
fragment comprising the angle of the greater sciatic notch and
the upper part of the posterior column has pivoted about 90°
on the antero-posterior view; the sacro-iliac joint is undisturbed
Exereises in Radiographie Diagnosis 393

Case 6. Posterior wall fracturc with marginal impaction.

The impaeted fragment is parallel to the supero-medial part
of the head in the antero-posterior view
394 Exereises in Radiographie Diagnosis

Case 7. Complete both-eolumn fraeture.

The iliac wing fracture line extends to the iliae crest, isolating
a triangular fragment of the wing. The posterior co lu mn frag-
ment brings with it, in a single piece, the inferior part of the
saero-iliac joint, which most frequently eonstitutes aseparated
fragment. See Chapt. 14.4(a). Exeeptionally, there is no spur
sign
Exercises in Radiographie Diagnosis 395

Case 8. Low anterior column fracture associated with a hemi-

transverse posterior fracture.
Two seeondary fraeture line divide the antcrior eolumn frag-
ment into three parts: the anterior wall fragment, the body
01' the pubis and a segment of the isehio-pubic ramus
396 Exercises in Radiographie Diagnosis

Case 9. Posterior column fracture associated with an undis-

placed anterior hemitransverse component.
This association is similar to a "T shaped" fracture (see
p.140)
Excreises in Radiographie Diagnosis 397

Case 10. Juxta-tectal transverse fracture, with so me eomminu-

tion in the posterior part of the fracture line.
The fracture line is lower posteriorly and cuts the edge of
the pelvie bone just above the ischial spine
398 Exereises in Radiographie Diagnosis

Case 11. Vertical T-shaped fraeture assoeiated with a posterior

wall fraeture.
The posterior fragment outline is superimposed on the inner
part of the roof and also overlies the upper part of the femoral
neck.
Exercises in Radiographie Diagnosis 399

Case 12. Low fracture of the anterior column.

There are two supplementary fragments, one comprising a
posterior segment of the iliopectineal line, and the other asso-
ciated with a minor fracture of the quadrilateral surface elevat-
ing a posteriorly hinged plaque of bone
400 Exereises in Radiographie Diagnosis

Case 13. Infra-tectal transverse fracture with little displaeement

Exereises in Radiographie Diagnosis 401

Case 14. Vertical T-shaped fracture.

There are two fraeture lines through the isehio-pubic ramus
and an isolated fragment of anterior wall. Marginal impaction
of the inner part of the roof is clearly seen on the antero-
posterior view
402 Exereises in Radiographie Diagnosis

Case 15. Posterior wall fracture associated with an undisplaced

low transverse fraeture, eutting the posterior border of the
pelvie bone under the isehial spine
Exereises in Radiographie Diagnosis 403

Case 16. This is a very special ease, unique in the series and
not in OUf elassifieation.
The centrally disloeated head has fraetured the inferior floor
on the aeetabulum, sparing the borders and also the ilio-peeti-
neal line. The inferior part of the ilio-ischial line is involved
Case 17. Juxta-tectal transverse fracture .
There is a small posterior wall fragment, and an undisplaced
fracture line of the iliac wing delineates a big fragment of
wing to which the whole roof is attached. See Chap. l2.1.3(d).
A pertrochanteric fracture of the femur was also present, and
the head, posteriorly dislocated, was entrapped through a hole
in the posterior capsule
Exereises in Radiographie Diagnosis 405

Case 18. Complete both-column fracture.

The iliac wing component ofthis complex fracture comprises
a ' Y' configuration. The posterior limb does not reach the
iliac crest. In the root of the pubic ramus there is comminution
involving the roof of the obturator canal.
406 Exereises in Radiographie Diagnosis

Case 19. Assoeiated anterior wall and posterior hemi-transverse

fractures.
A fracture line through the ischio-pubic ramus isolates the
inferior part of the anterior column. Marginal impaction has
involved the inner part of the roof of the acetabulum
Exercises in Radiographie Diagnosis 407

Case 20. Extended anterior column fracture.

A secondary fracture line divides the wing segment of the
column extending to the anterior border of the iliac wing
between the anterior iliac spines. There is some comminution
of the inner table of the iliac wing and, from the quadrilateral
surface of the ischium, a posteriorly hinged plaque of bone
had been elevated. Inferiorly, the anterior column is interrupted
by fracture lines through the root of the superior pubic ra mus,
body of the pubis, and through the ischio-pubic ramus. The
posterior border of the acetabulum and the posterior border
of the pelvic bone are each intact
408 Exercises in Radiographie Diagnosis

Case 21. Both-eolumn fraeture with iliac wing fracture line

extending to the iliac crest.
The anterior eolumn is split through the anterior wall and
there is a fragment of the internal iliae fossa
Exereises in Radiographie Diagnosis 409

Case 22. Assoeiated posterior column and postero-superior wall

fracture.
There is an associated fraeture of the superior pubic ra mus,
and the urethra was ruptured
410 Exercises in Radiographie Diagnosis
Exereises in Radiographie Diagnosis 411

Case 23. Juxta-teetal transverse fraeture assoeiated with a frae-

ture line extending from the retro-aeetabular surfaee to the
erest.
All the upper part q[ the artieular surfaee belongs to the
anterior fragment of the wing, whieh is also divided by a split
reaehing the interspinous noteh. Compare with the fraeture
line of a both-eolumn fraeture
412 Exereises in Radiographie Diagnosis

Case 24. Assoeiated undisplaeed infra-teetal trans verse and pos-

terior wall fraetures.
The main trans verse eomponent is assoeiated with a eompo-
nent whieh detaehes the outer half of the roof of the aeetabu-
lum. The femoral head is disloeated posteriorly
Exereises in Radiographie Diagnosis 413

Case 25. Both-eolumn fracture with iliae wing fracture extend-

ing to the iliae crest.
The spur sign is obvious on the obturator-oblique view.
The posterior column. markedly displaced inwards, was
entrapped in the tme pelvis, resting against the sacro-iliae joint.
Two operative approaches were needed
414 Exereises in Radiographie Diagnosis

Case 26. T-shaped fraeture with extensive marginal impaetion

of the inner part of the roof
Exercises in Radiographie Diagnosis 415

Case 27. Typical posterior column fracture, not involving the

teardrop
416 Exereises in Radiographie Diagnosis

Case 28. Both-column fracture with iliac wing fraeture line

extending to the crest and involving the sacro-iliae joint.
The posterior column takes with it the inferior half of the
sacro-iliac joint. See also Case 7. Two operative approaehes
were needed
Exereises in Radiographie Diagnosis 417

Case 29. Anterior T-shaped fracture, with several splits of the

anterior eolumn component.
Two approaches (KOCHER-LANGENBECK first) wcre required
418 Exercises in Radiographie Diagnosis

Case 30. Anterior T-shaped fracture.

The ilio-peetinealline seems undisturbed on the obturator-
oblique view, but its fracture is obvious on the antcro-posterior
view. A small segment of the ilio-peetineal line is delineated
by the two breaks of the pelvic brim
Exerciscs in Radiographie Diagnosis 419

Case 31. High anterior column fracture.

Special features are the detachment of two large fragments.
A postero-superior piece of the articular surface includes an
extended portion of the anterior pillar of the iliac wing. The
other separates from the inner aspect of the bone, the acetabular
fossa, the medial half of the posterior wall, and the inner margin
of the ischium; its inner aspect comprises a segment of the
ilio-pectineal line and most of the quadrilateral surface. Com-
pare the latter fragment with that seen in Case 16
420 Exereises in Radiographie Diagnosis
Exereises in Radiographie Diagnosis 421

Case 32. Juxta-teetal transverse fraeture assoeiated with an

extended posterior wall fracture.
The posterior wall is in several pieces, the inferior one of
which inc1udes the upper pole of the ischial tuberosity. The
femoral head is dislocated posteriorly
Case 33. Complete anterior column fractures associated with
a posterior hemi-transverse component dividing the sciatic spine.
The articular segment of the anterior column is split in
at least two points. There is an undisplaced fracture li ne divid-
ing the sacro-iliac joint and merging with the iliac wing fracture
line. There are two impacted marginal fragments
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Subject Index
Acetabulum, anatomy of 1
Anterior column, fractures 69,
74
Anterior wall fractures 61
Associated fractures
anterior with posterior hemi-
transverse 137
both columns 151
posterior column and pos-
terior wall 117
transverse and posterior wall
123
T-shaped 101
Avascular necrosis 317
Blood supply, acetabulum 4
Both-column fracture 151
Capsular injuries 205
Cartilage necrosis 317
Children 217
Classification of fractures of the
acetabulum 32
Columns of the acetabulum 1
Complications early post-opera-
tive 311
Conservative management
221
Elderly patients 217
Epiphyseal separation of the
posterior column 54
Extra-acetabular fractures of
pelvis 202, 207, 208
Femoral head injury 205
Incarceration 215
Infection, post-operative
311
Internal fixation 250
Line, acetabulo-obturator 15
ilio-ischial 18
Marginal impaction 33
Mechanism of injury 7
Morel-Lavalee lesion 275
Mortality, post-operative 311
Neurological complications
373
Nutrient arteries of the ace tabu-
lum 5
Operating table 249
Osteoarthrosis, post-traumatic
320
Osteonecrosis, post-operative
317
results 319
Osteophyte, post-operative 320
Para-articular ossification 321
Pathological fractures 278
Pelvic bone, structure 4
vascular supply 4
Posterior column fractures 49
Posterior wall fracture, mor-
phology 33
radiography 36
Post-operative care 253
Post-operative osteoarthrosis
320
Prognosis in relation to opera-
tive reduction 329
Pseudarthrosis 317
Radiography normal 29
Radiography of the fractured
acetabulum 13
Radiological differential diag-
nosis 30
Radiology
antero-posterior view 15
articular surface 17
iliac-oblique view 25
technique 14
obturator-oblique view 22
technique 14
roof of acetabulum 17
Results, late 330
overall of surgical manage-
ment 328, 331, 332, 334
reduction acetabulum and an-
atomical type 325
reduction acetabulum 323
reduction of the femoral
head 323
Retractor, sciatic nerve 249
Sciatic nerve lesions, post-oper-
ative 314,315
pre-operative 212
Sign, curved image 180
gull 54
spur 160
Stereo-radiography of the aceta-
bulum 27
Teardrop
Technique, anterior column
fractures 15
associated anterior and poste-
rior hemi-transverse frac-
tures 261
associated both-column frac-
tures 262
associated posterior column
and posterior wall frac-
tures 259
associated transverse and
posterior wall fractures
259
428
anterior wall fractures 257
approach, choice 247
bilateral fractures of the
acetabulum 267
combined approach 240
extended ilio-femoral ap-
proach 240
ilio-femoral approach 232
ilio-inguinal approach 233
instruments, special 249
paralysed hip 267
posterior approach (Kocher-
Langenbeck) 225
posterior column 256
posterior wall fractures 255
transverse fractures 258
reduction, methods 252
sacroiliac joint injury 266
surgical, general 246
T-shaped fractures 260
Thrombosis 315
Tomography 27
Subject Index
Transitional fractures
200
Transverse fractures 87
mechanism of dis placement
89
T-shaped fracture 101
Urinary tract injuries 208
Vascular injuries 206, 212
Visceral injury 208
 J.Charnley

Low Friction Arthroplasty

ofthe Hip
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One ofthe world's leading authorities and innovators in hip

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Total hip replacement is considered to be the treatment of choice
in degenerative osteoarthritis. Lang term results testify to thc
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Advances in Artificial Hip

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Editors: M. Schal dach, D. Hohmann
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1976.525 figures. XII, 525 pages. (Engineering in Medicine 2)
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RBombelli

Springer-Verlag Osteoarthritis of the Hip

Berlin Pathogenesis and Consequent Therapy
Heidelberg With a Foreword by M. E. Müller
1976. 160 figures, 70 in color. X, 136 pages
NewYork ISBN 3-540-07842-8
Current Concepts of Internal
Fixation of Fractures
Editor: H. K Uhthoff
Associate Editor: E. Stahl
1980.287 figures, 51 tables. IX, 452 pages
ISBN 3-540-09846-1
F. Freuler, W. Wiedmer, D. Bianchini
Cast Manual for Adults and
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Forewords by A Sarmiento, B. G. Weber
Translated from the German by P. A Casey
1979. 121 figures in 352 separate illustrations,
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ISBN 3-540-09590-X
RLiechti
Hip Arthrodesis and Associated
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Foreword by M. E. Müller, B. G. Weber
Translated from the Gemlan edition
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A Sarmiento, L. L. Latta
Closed Functional Treatment
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1981. Approx. 2500 figures. Approx. 650 pages
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ManualofInternalFixation
Techniques Recommended by the AG Group
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2nd, expanded and revised edition 1979.
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Contributions to the Functional Anatomy ofthe
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Distribution rights for Japan: Nankodo, Tokyo
F.Pauwels
Biomechanies of the Normal
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Theoretical Foundation, Technique and Results
ofTreatment. An Atlas
Translated from the German by R 1. Furlong,
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1976. 305 figures (in 853 separate illustrations).
VIII, 276 pages
ISBN 3-540-07428-7

Treatment of Fractures in
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ISBN 3-540-09313-3
Heidelberg Distribution rights for Japan: Igaku Shoin Ud.,
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