Acetabular Fractures

Presentor : Dr. Momin mohammad

farhan
Normal Anatomy
Normal Anatomy
Normal Anatomy
• All three parts of the innominate
bone contribute to form the
acetabulum
• The margin is deficient inferiorly and
this deficiency is called the
acetabular notch , bridged by the
transverse acetabular ligament.
• The nonarticular roughened floor is
called the acetabular / COTYLOID
fossa.
• A horse-shoe shaped articular
surface or lunate surface is seen on
the anterior, superior and posterior
parts of the acetabulum.
(ACETABULAR dome)
• It is lined by hyaline cartilage and
articulates with the head of femur;
the articular cartilage is thickest
here.
Normal Anatomy: Letournel –Judet Columns and Walls
Bony Anatomy

• Anterior Column
• Anterior column
(iliopubic component):
• The anterior column is
composed of the
anterior half of the iliac
crest, the iliac spines,
the anterior half of the
acetabulum, and the
pubis.
Bony Anatomy
• Posterior Column
• The posterior column is the
ischium, the ischial spine, the
posterior half of the
acetabulum, and the dense
bone forming the sciatic
notch.
• When looking at the acetabulum en
face, the anterior and posterior
columns have the appearance of
the Greek letter lambda (λ).
• The anterior column represents the
longer, larger portion.
• The anterior and posterior columns
of bone unite to support the
acetabulum.
• In turn, the sciatic buttress extends
posteriorly from the anterior and
posterior columns to become the
articular surface of the sacroiliac
joint, which attaches the columns to
the axial skeleton.
The anterior and posterior columns connect to the axial skeleton
through a strut of bone called the sciatic buttress
• The anterior and posterior walls, which extend
from the columns and support the hip joint,
are well seen on an axial CT.

Axial section
through
acetabulum
shows anterior
(arrowhead) and
posterior (arrow)
walls.
•Acetabular dome:The
weight bearing portion of
the articular surface that
supports the femoral head.
•Anatomical restoration of
the dome with concentric
reduction of the femoral
head beneath this dome is
the goal of both operative
and nonoperative
treatment.
•The quadrilateral
surface is the flat plate
of bone forming the
lateral border of the
true pelvic cavity and
thus lying adjacent to
the medial wall of the
acetabulum.
Mechanism of injury
• These injuries are mainly caused by high-
energy trauma secondary to a motor vehicle,
motorcycle accident, or fall from a height.

• The fracture pattern depends on

 Position of femoral head at the time of injury,
 Magnitude of force, &
 Age of patient.
Mechanism of injury

Direct impact to greater trochanter with:

 Hip in neutral: transverse acetabular fracture
 An abducted hip: low transverse fracture,
 An adducted hip: high transverse fracture.
 Hip externally rotated and abducted: anterior
column injury.
 Hip internally rotated: posterior column
injury.
Mechanism of injury

•With indirect trauma, (e.g., a ‘dashboard’

injury to the flexed knee):
 As the degree of hip flexion increases, the posterior
wall is fractured in an increasingly inferior position.
 Similarly, as the degree of hip flexion decreases, the
superior portion of posterior wall is more likely to be
involved.
 Clinical evaluation
• Trauma evaluation: with attention to ABCD, depending on the
mechanism of injury.
• Patient factors (age, degree of trauma, presence of associated
injuries, & general medical condition) affect treatment decisions
as well as prognosis.
• Neurovascular assessment:
– Sciatic nerve injury may be present in up to 40% of posterior column
disruptions.
– Femoral nerve involvement with anterior column injury is rare,
although compromise of the femoral artery by a fractured anterior
column has been described.
• Presence of associated ipsilateral injuries must be ruled out,
with particular attention to the ipsilateral knee in which
posterior instability and patellar fractures are common.
• Soft tissue injuries (e.g., abrasions, contusions, subcutaneous
hemorrhage) may provide insight into the mechanism of injury.
Clinical evaluation
• The sciatic nerve has frequent
variation in its relationship to
the piriformis muscle as it exits
the sciatic notch, with common
separation of tibial and
peroneal branches at this level.
• The superior gluteal artery and
nerve exit the greater sciatic
notch at its most superior
aspect and can be tethered to
the bone at this level by
variable fascial attachments.
Clinical evaluation
• Large anastomosis between
the external iliac artery or
inferior epigastric artery and
the obturator artery known
as the corona mortis
• Failure to ligate this vascular
connection during the
ilioinguinal approach can
lead to significant
hemorrhage that is difficult
to control.
Radiographic evaluation

• 3 Pelvic X-rays:
 AP view
 2 Judet views (iliac &
obturator oblique views)
• CT scan
 Radiographic landmarks in AP view
1. Iliopectineal line (limit of anterior
column), beginning at greater sciatic notch
of ilium and extending down to pubic
tubercle
2. Ilioischial line (limit of posterior
column), posterior four fifths of
quadrilateral surface of ilium
3. Teardrop - laterally of most inferior
and anterior portion of acetabulum and
medially of anterior flat part of
quadrilateral surface of iliac bone
4. Roof of acetabulum,
5. Anterior lip,
6. Posterior lip
•
Iliac oblique radiograph
(45-degree external rotation view)

• Patient rotated so that the

injured hemipelvis is tilted
45 degrees away from the x-
ray beam.
• This best demonstrates:
 Posterior column (ilioischial
line),
 Iliac wing,
 Anterior wall of acetabulum.
Iliac oblique radiograph
Obturator oblique radiograph
(45-degree internal rotation view)

• The patient rotated so that

the hemipelvis of interest is
rotated 45 degrees toward
the x-ray beam.
• This is best for evaluating -
anterior column ( iliopectineal
line) and posterior wall of
the acetabulum.
Obturator oblique radiograph
Inlet Pelvis X-ray
 Skeletal anatomy
represented on inlet
view
Outlet Pelvis XR
Skeletal anatomy represented on outlet view
 Radiographic evaluation

• CT scan
Provides additional information regarding size
& position of column fractures, impacted
fractures of acetabular wall, retained bone
fragments in the joint, degree of comminution,
and sacroiliac joint disruption.
Two- and three-dimensional CT scans are useful
in evaluating intra-articular fragments as well as
specific morphologic characteristics of any
given fracture pattern.
 Roof Arc Angle(MATTA)
• The medial, anterior, & posterior roof arcs.

• The roof arc is formed by the angle

between two lines, one drawn vertically
through the geometric center of the
acetabulum, the other from the fracture
line+ roof intersection to the geometric
center.

• Roof arc angles are for evaluation of both

column fractures and posterior wall
fractures. To find the amount of INTACT
acetabular roof to decide treatment
1. Medial Roof Arc (AP pelvis)
2. Anterior Roof Arc (Obturator oblique)
3. Posterior Roof Arc (Iliac oblique)
 Classification
• Accurate classification of acetabular fractures
is important for determining the proper
surgical treatment.
• Although radiographic examination provides
essential information for acetabular
classification, CT, including multiplanar
reconstruction, is helpful in the visualization of
complex fractures.
 Classification
(Judet-Letournel)
• Because of the complex acetabular anatomy, various
classification schemes have been suggested, but the
Judet-Letournel classification system remains the
most widely accepted.
• This classification system subdivides acetabular
fractures into
– Simple Fracture Types (posterior wall, posterior column,
anterior wall, anterior column and transverse)
– Associated Fracture Types (T-shaped, posterior column and
wall, transverse and posterior wall, anterior column with
posterior hemitransverse, and both column).
 Classification
(Judet-Letournel)

Simple fractures
• Poserior wall
• Posterior column
• Anterior wall
• Anterior column
• Transverse
 Classification
(Judet-Letournel)

Associated fractures
 T-shaped
 Posterior column + posterior wall
 Transverse + posterior wall
 Anterior column + posterior
hemitransverse
 Both-column
Posterior wall fractures

 The isolated posterior wall fracture

is one of the most common types of
acetabular fracture, with a prevalence
of 25%.
 The ischium is disrupted.
 The fracture line originates at the
greater sciatic notch, travels across
the retroacetabular surface, exits at
the obturator foramen.
 The ischiopubic ramus is fractured.
 Posterior wall fractures
 An isolated posterior wall fracture does not have a
complete transverse acetabular component.
Therefore, the iliopectineal line is not disrupted,
which excludes classification of the transverse with
posterior wall fracture.
 However, disruption of the ilioischial line may or
may not be present as an extension of the
comminuted posterior wall component.
 Obturator Oblique (Judet) radiographs and CT are
helpful in showing the isolated posterior wall
fracture.
AP pelvic radiograph

Bilateral oblique
pelvic radiographs

Axial CT
images
 Posterior column fractures
 Fractures of the posterior column involve detachment of the
entire ischioacetabular segment from the innominate bone
and represent 3-5% of acetabular fractures.

The fracture begins near the apex of the greater sciatic notch
and descends across the articular surface, quadrilateral
surface, ischiopubic notch (roof of the obturator canal), and
finally across the inferior ramus.

Iliac oblique radiograph - fracture crossing the posterior

border of the bone.
The fracture of the ischiopubic ramus and posterior rim are
confirmed on the obturator oblique.
Posterior Column Fracture
 Anterior wall fractures

 Anterior wall and anterior column fractures can be

distinguished by the additional break in the ischiopubic
segment of the pelvis present in the anterior column
fracture.
It begins below the anterior inferior iliac spine, crosses
the articular surface to the pelvic brim, and proceeds
down the quadrilateral surface to the ischiopubic notch.
A secondary fracture line through the superior ramus
detaches the anterior wall portion.
Anterior wall fractures are rare, and constitute only 1%
to 2% of all fractures.
Anterior Wall Fracture
 Anterior column fractures
•Anterior column fractures make up to 3-5% of all acetabulum
fractures.
•Anterior column fractures separate the anterior border of the
innominate bone from the intact ilium.
•High anterior column fractures exit the iliac crest, intermediate
fractures exit the anterior superior iliac spine, low fractures exit the
psoas gutter just below the anterior inferior iliac spine, and very
low anterior column fractures exit the bone at the iliopectineal
eminence.
•All anterior column fractures, regardless of where they exit the
bone superiorly, cross the pelvic brim, proceed down the
quadrilateral surface, and enter the ischiopubic notch, ultimately
ending in a fracture of the inferior ramus.
Anterior Column Fracture
Transverse Fracture

•Transverse fractures comprise 5- 19% of

acetabular fractures.
•They are the only elementary fracture
pattern that breaks both the anterior and
posterior border of the innominate bone.
•The fracture separates the innominate bone
into two pieces: The upper iliac piece and
the lower ischiopubic segment.
 Iliac oblique view
Obturator oblique view of of transverse
transverse fracture fracture
 Transverse Fracture
Types (depending on the orientation of the fracture
line relative to the dome or tectum of the
acetabulum):
1. Transtectal: through the acetabular dome.
2. Juxtatectal: cross the articular surface at the
level of the top of the cotyloid fossa
3. Infratectal: through the fossa acetabuli.

Transtectal fractures are less forgiving and

must be reduced anatomically, whereas
infratectal fractures, if low enough, can
be treated without surgery, depending
on the pattern.

The femoral head follows the inferior

ischiopubic fragment and may dislocate
centrally.
AP pelvic radiograph

Bilateral oblique pelvic

radiographs

Axial CT scan
A. Coronal plane fracture
B. Sagittal plane fracture
 Associated types

Post. Wall Transverse & Ant column or

& post. post. Wall or Both
T-shaped wall & post
column column columns
hemitransverse
Posterior Column-Posterior Wall
T-shaped fracture
Transverse fracture of any type
+
Vertical fr through the isciopubic fragment

•The vertical component is best seen

on the obturator oblique view.
T-shaped fracture
The T-shaped fracture is similar to
a both-column fracture in that it
disrupts the obturator ring.

Another similarity is disruption of

both the iliopectineal and
ilioischial lines.

However, the superior extension

of the fracture does not involve
the iliac wing, which allows
differentiation from the both-
column fracture.
 T-shaped fracture
•One area of potential confusion with the
Tshaped fracture is in regard to the
transverse component.
•The transverse fracture line is not actually
in the anatomic transverse plane, but
rather it is transverse relative to the
acetabulum.
•Because the cup shape of the acetabulum
is normally tilted inferiorly and anteriorly,
the transverse fracture plane assumes a
similar orientation.
•Therefore, on radiographs, the fracture
lines that disrupt the iliopectineal and
ilioischial lines course superiorly and
medially in an oblique plane from the
 AP pelvic radiograph

Bilateral oblique pelvic

radiographs

Axial CT scan

Surface-rendering 3D CT viewed laterally, with right

hemipelvis and femur removed
Transverse and posterior
wall fracture

•The iliopectineal and ilioischial lines

are disrupted.

•Makes up approximately 20% of all

fractures

•The obturator oblique view best

demonstrates the position of the
transverse component as well as the
posterior wall element.
AP pelvic radiograph

Bilateral oblique pelvic

radiographs

axial
CT
scan

surface-
rendering
3D CT
viewed
laterally,
with right
hemipelvis
and femur
removed
 Anterior column and posterior
hemitransverse fracture
•It accounts for 7% of
fracture.
•The fracture pattern is
often complicated by
impaction of the medial
roof of the acetabulum
and has been termed
the “gull wing” sign
based on the radiograph
appearance on the AP
radiograph
Ap view

Obturator oblique

Iliac oblique
 Both-column fracture
(formerly called ‘central acetabular fracture’)
Both columns are separated from each
other and from the axial skeleton, resulting
in a ‘floating’ acetabulum

This is the most complex type of acetabular

fracture.

A both columns fracture can be

considered a ‘high’ T-shaped
fracture where both columns have
been separated from the sciatic
buttress.
 Both-column fracture
(formerly called ‘central acetabular fracture’)

•The "spur-sign," best seen on the

obturator oblique view, is pathognomonic
for the both-column fracture.

•This sign represents posterior

displacement of the sciatic buttress of the
iliac wing fracture, which essentially
disconnects the roof of the acetabulum
from the axial skeleton.

•When this occurs, weight from the torso

and upper body can no longer be "Spur-sign" seen on the
supported by the acetabulum. obturator oblique view
 Both-column fracture
(formerly called ‘central acetabular fracture’)

•On radiographs and CT, the

spur sign appears as a shard
of bone extending posteriorly
at the level of the superior
acetabulum.
•Evaluation of sequential CT
images shows the fracture,
which separates the sciatic
buttress from the acetabular
roof.
 AP pelvic radiograph

Bilateral oblique pelvic radiographs

sagittal
Axial CT scan reconstruction
CT scan
3-D CT scan of a both-column acetabular fracture; obturator
oblique view
3-D CT scan of a both-column acetabular fracture; iliac oblique view
 Indications for Nonoperative Treatment

1. Nondisplaced and minimally displaced fractures

2. Fractures with significant displacement but in which the
region of the joint involved is judged to be unimportant
prognostically
3. Secondary congruence in displaced both-column
fractures
4. Medical contraindications to surgery
5. Local soft tissue problems, such as infection, wounds,
and soft tissue lesions from blunt trauma
6. Elderly patients with osteoporotic bone in whom open
reduction may not be feasible
 Indications for Operative Treatment

1. Fracture characteristics
2. Incarcerated fragments in the acetabulum after closed
reduction of a hip dislocation
3. Prevention of nonunion and retention of sufficient bone
stock for later reconstructive surgery
Posterior wall fracture
•These fractures are treated through a Kocher-
Langenbeck approach with the patient positioned either
prone or in the lateral decubitus position on a fracture
table or with the leg free.
•To avoid osteonecrosis of the posterior wall, the
posterior wall fragments must not be detached from the
posterior capsule during exposure.
•If the fracture extends superiorly into the dome, a
trochanteric osteotomy may be performed to allow
additional exposure.