Acetabular Fractures

Author: Brian Weatherford

Topic updated on 07/15/13 7:04pm

Introduction

Epidemiology
o bimodal distribution
o high energy blunt trauma for young patients
o low energy (fall from standing height) for elderly patients
Pathoanatomy
o fracture pattern determined by
force vector
position of femoral head at time of injury
Associated conditions
o 50% will have injury to another organ system
o associated lower extremity injury most common (36%)

Anatomy

Osteology
o inclination & anteversion
mean lateral inclination of 40 to 48 degrees
anteversion of 18 to 21 degrees
o column theory
acetabulum is supported by two columns of bone
form an "inverted Y"
connected to sacrum through sciatic buttress
posterior column
comprised of
quadrilateral surface
posterior wall and dome
ischial tuberosity
greater/lesser sciatic notches
anterior column
comprised of
anterior ilium (gluteus medius tubercle)
anterior wall and dome
iliopectineal eminence
lateral superior pubic ramus
Vascular
o corona mortis
anastamosis of external iliac (epigastric) and internal iliac
(obturator) vessels

at risk with lateral dissection over superior pubic ramus

Letournel Classification
Illus. AP Obt.Obl. Iliac.Obl. CT
Elementary

Posterior wall
Posterior column
Anterior wall
Anterior column

Transverse

x
x

x x

x
x
x

Comments
Most common
"gull sign" on obturator
oblique view
check for injury to superior
gluteal NV bundle
Very rare

x More common in elderly

patients with fall from
standing
x Axial CT shows anterior to
posterior fx line
Only elementary fx to
involve both columns

Associated
Associated Both
Column

Transverse + Post.
Wall
T Shaped
Anterior column or
wall + Post.
hemitransverse
Post. column + Post.
wall

x
x

x x

Characterized
by dissociation of the
articular surface from the
inominate bone
will see "spur sign" on
obturator oblique
Most common associated
fx
May need combined
approach
Common in elderly patients

x Only associated fracture

that does not involve both
columns

Imaging

Radiographs
o recommended views
AP pelvis, Judet views, inlet and outlet if concerned for
pelvic ring involvement

6 radiographic landmarks of the acetabulum

iliopectineal line (anterior column)
ilioischial line (posterior column)
anterior rim
posterior rim
teardrop
weight bearing roof
o superior acetabular rim may show os acetabuli marginalis superior
which can be confused for fracture in adolescents
o Judet views (45 degree oblique views)
obturator oblique
shows profile of obturator foramen
shows anterior column and posterior wall
iliac oblique
shows profile of involved iliac wing
shows posterior column and anterior wall
o roof arc measurements
show intact weight bearing dome if > 45 degrees on AP,
obturator, and iliac oblique
not applicable for associated both column or posterior
wall pattern because no intact portion of the acetabulum to
measure
CT scan
o important to
define fragment size and orientation
identify marginal impaction
identify loose bodies
look for articular gap or step-off
o

Treatment
Nonoperative
o protected weight bearing for 6-8 weeks
indications
minimally displaced fracture (< 2mm)
< 20% posterior wall fractures
treatment based on size of posterior wall is
controversial
exam under anesthesia using fluoroscopy
best method to test stability
femoral head remains congruent with weight
bearing roof (out of traction)

both column fracture with secondary congruence

(out of traction)
displaced fracture with roof arcs > 45 degrees in
AP and Judet views
relative contraindications to surgery
morbid obesity
open contaminated wound
presence of DVT
technique
close radiographic follow-up
skeletal traction rarely indicated as definitive
treatment
Operative treatment
o open reduction and internal fixation
indications
displacement of roof (>2mm)
posterior wall fracture involving > 40-50%
marginal impaction
intra-articular loose bodies
irreducible fracture-dislocation
outcomes
clinical outcome correlates with quality of articular
reduction
earlier operative treatment associated with
increased chance of anatomic
reduction
postoperative CT scan is most accurate
way to determine posterior wall accuracy of
reduction which has greatest correlation
with clinical outcome
greatest stress on acetabular repair occurs when
rising from a seated position using the affected
leg, and occurs in the posterior superior portion of
the acetabulum
functional outcomes most strongly correlate with
hip muscle strength and restoration of gait
postoperatively
o open reduction and internal fixation with acute total hip
arthroplasty
indications

significant osteopenia and/or significant

comminution
outcomes
up to 78% 10-year implant survival noted
worse outcomes in males, patients <50 years old
or >80kg, or if a significant acetabular defect
remains
percutaneous fixation with column screws
indications
anterior column screws

Techniques
Percutaneous fixation with column screws
o approach
anterograde (from iliac wing to ramus)
retrograde (from ramus to iliac wing)
posterior column screws
o imaging
obturator oblique best view to rule out joint penetration
inlet iliac oblique view best to determine anteroposterior
position of screw within the pubic ramus
inlet obturator oblique view best to determine position
of a supraacetabular screw within tables of the ilium
ORIF
o approaches
approach depends on fracture pattern
two approaches can be combined
Approaches
Anterior
Approach (Ilioinguinal)

Posterior
Approach (KocherLangenbach)

Indications
anterior wall and
anterior column
both column fracture
posterior
hemitransverse

Risks
femoral nerve injury
LFCN injury
thrombosis of femoral
vessels
laceration of corona mortis
in 10-15%.
posterior wall and
increased HO risk
posterior column fx
compared with anterior
most transverse and T- approach
shaped
combination of above
sciatic nerve injury (210%)
damage to blood supply of
femoral head (medial

Extensile
Approach (extended
iliofemoral)

Modified Stoppa
Approach

femoral circumflex)
massive heterotopic
ossification
posterior gluteal muscle
necrosis

only single approach

that allows direct
visualization of both
columns
associated fracture
pattern 21 days after
injury
some transverse fxs and
T types
some both column fxs (if
posterior comminution is
present)
access to
Corona mortis must be
quadrilateral plate to
exposed and ligated in this
buttress comminuted medial approach
wall fractures

Complications
Post-traumatic DJD
o most common complication
o anatomic reduction essential to prevent
o treat with hip fusion or THA
Heterotopic Ossification
o highest incidence with extensile approach
treat with
indomethacin x 5 weeks post-op
low dose external radiation (no difference shown
in direct comparison)
o lowest incidence with anterior ilioinguinal approach
Osteonecrosis
o 6-7% of all acetabular fractures
o 18% of posterior fracture patterns
DVT and PE
Infection
Bleeding
Neurovascular injury
Intrarticular hardware placement
Abductor muscle weakness