Acetabular fractures

1. ACETABULAR FRACTURES
P.ROOPA SAI
1ST YEAR POST GRADUATE.
DEPARTMENT OF ORTHOPAEDICS.

2. CONTENTS
• INTRODUCTION
• ANATOMY
• MECHANISM OF INJURY
• CLASSISFICATION
• CLINICAL FEATURES
• MANAGEMENT

3. INTRODUCTION
EPIDEMIOLOGY:
• There has been a significant reduction in the number and
complexity of the fractures , Since the advent of mandatory seatbelt
use.
• Incidence - 3 patients/100,000/year and has remained stable over
the past few decades
• The mean age - appears to be increasing (>60yrs)

4. Introduction
• Treatment of fractures of the acetabulum is a challenge for orthopaedic surgeons
for several reasons:
1.There are two distinct groups that make up the majority of acetabular fracture
patients.
• High energy trauma in young active patients, frequently associated with poly-
trauma.
• Older patients with poor bone stock who frequently present with complex
fracturepatterns.
2. Irreversible damage to the articular surface.
3.Comprehension of fracture patterns requires a detailed understanding of
complex three-dimensional pathoanatomy.
4.Difficult surgical access.
5. Prolonged rehabilitation.
6. Significant potential post-operative complications.

5. ANATOMY
• The acetabulum is formed by the
ilium, pubis and ischium and during
development they are linked together
to form the triradiate cartilage.
• The triradiate cartilage has its apex in
the floor of the acetabulum and fuses
between 18 and 23 years of age.
• The acetabulum can be described as
an incomplete hemispherical socket
with an inverted horseshoe-shaped
articular surface surrounding the
nonarticular cotyloid fossa.

6.  This articular socket is composed of and
supported by two columns of bone, described by
Letournel and Judet as an inverted Y.
 The anterior column is composed of the bone of
the iliac crest, the iliac spines, the anterior half of
the acetabulum, and the pubis.
 The posterior column is the ischium, the ischial
spine, the posterior half of the acetabulum, and
the dense bone forming the sciatic notch.
 The column concept is used in classification of
these fractures and is central to the discussion of
fracture patterns, operative approaches, and
internal fixation.

7.  The dome, or roof, of the
acetabulum is 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.

8. • QUADRILATERAL PLATE:
• It is a bony plate which forms the lateral wall of the
pelvis.
 The iliopectineal eminence is the prominence in the
anterior column that lies directly over the femoral head.
 Both the quadrilateral surface and the iliopectineal
eminence are thin and adjacent to the femoral head,
limiting the types of fixation that can be used in these
regions
• SCIATIC BUTTRESS:
• It extends posteriorly from the union of the columns to
become the articular surface of the sacroiliac joint.
• attaches the 2 columns to the axial skeleton.

9.  The anterior column is composed of the
bone of the iliac crest, the iliac spines, the
anterior half of the acetabulum, and the
pubis.
 The posterior column is the ischium, the
ischial spine, the posterior half of the
acetabulum, and the dense bone forming
the sciatic notch.
 The column concept is used in classification
of these fractures and is central to the
discussion of fracture patterns, operative
approaches, and internal fixation.

10. • Can be conceptualized as being built
from essentially six principal components
• Anterior column
• Posterior column
• Anterior wall
• Posterior wall
• Acetabular dome or tectum (Latin for roof)
• Medial wall

11.  The neurovascular structures passing
through the pelvis are at risk during the
original injury and subsequent treatment,
and the various surgical approaches are
designed around these structures.
 The sciatic nerve exiting the greater sciatic
notch inferior to the piriformis muscle
frequently is injured with posterior fracture-
dislocations of the hip and fractures with
posterior displacement
 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.

12. IMPORTANT STRUCTURES

13. • CORONA MORTIS:
• vascular anastomosis between
the external iliac artery or
deep inferior epigastric artery
with the obturator artery.

14. RADIOLOGICAL LANDMARKS
1.THE ILIOPECTINEAL LINE :
Anterior 3/4rth - pelvic brim.
Posterior 1/4rth - sciatic buttress .
greater sciatic notch.
2.THE ILIOISCHIAL LINE : posterior portion of
the quadrilateral surface
3.THE ROOF OF THE ACETABULUM :
Narrow portion of the subchondral bone
of the superior acetabulum.

15. 4.THE RADIOGRAPHIC TEAR DROP : not a
true anatomic structure
Medial limb :the obturator canal and the
anteroinferior portion of the quadrilateral
surface
Lateral limb : inferior aspect of the
anterior wall in the acetabulum
5.THE ANTERIOR RIM : lateral margin in
the anterior wall of the acetabulum
6.THE POSTERIOR RIM: lateral margin in
the posterior wall of the acetabulum

16. SPECIAL VIEWS(JUDET VIEWS):
• OBTURATOR OBLIQUE VIEW
• The obturator oblique view is taken with the patient rotated so that
the hemipelvis of interest is rotated 45 degrees towards the x-ray
beam.

17. • ILIAC OBLIQUE VIEW
• The iliac oblique view is taken with the patient rotated so that the
injured hemipelvis is tilted 45 degrees away from the x-ray beam

18. Obturator oblique
view: Positioning of
patient
Obturator oblique
view:
Iliac oblique view:
Positioning of patient
Iliac oblique view:

19. MECHANISM OF INJURY
• Most commonly - high energy trauma.
• Low energy trauma in osteopenic elderly.
• Fracture occur by impact of the femoral head with the acetabular
articular surface.
• Via the greater trochanter
• Via the long axis of the femoral shaft
• Fracture pattern depends on the
a)Position of the hip
b)Location
c)Direction of force applied.

20. • With the force applied along the axis of the
femoral neck,
• external hip rotation - anterior fracture
• internal rotation - posterior fracture
• Force applied along the shaft of femur , with
hip in flexion + adduction head may dislocate
without fracture of posterior rim.
• Magnitude of the force further decides-
• Comminution, Displacement & Articular
impaction

21. ASSOCIATED INJURIUES
• Lower extremity fracture - most commonly associated injury (36%)
• Lungs, retroperitoneum, and upper extremities (21% to 26%).
• Other systemic injuries (2% to 16%)
• Disruption of the pelvic ring – important factor in hemodynamic status of
the patient.
• An alternative source of hemorrhage should always be sought.
• Neurologic injury involving the ipsilateral lower extremity (30%)
• Injury of the sciatic nerve is most common and is usually partial in nature.
• Other peripheral nerves, such as the femoral, obturator, and superior
gluteal nerves, may also be injured .

22. JUDET AND LETOURNEL CLASSIFICATION
• Judet et al. proposed the first systematic classification
• This classification is based on the anatomic pattern of the fracture
• 10 distinct categories
a)5 ELEMENTARY TYPES
b)5 ASSOCIATED TYPES
• AO COMPREHENSIVE CLASSIFICATION

23. 1.Posterior wall Acetabular Fractures.
• Most common type – 25%
• AP view - disruption only in the
posterior rim shadow
• Obturator oblique providing the
best radiograph view
• The iliac oblique view will reveal
that the posterior border of the
innominate bone, the anterior
border of the acetabulum, and
the iliac wing are uninvolved

24. Marginal impaction is a
rotated and impacted
osteochondral fragment
that is displaced as the
femoral head dislocates
and the wall fractures

25. 2.Posterior Column Acetabular Fractures.
• 3 to 5%
• Fracture line detaches the
ischioacetabular segment.
• Fracture line
AP view :disruption of
ilioischial line
posterior rim
inferior ramus
Iliac view : posterior border
Obturator : ischiopubic ramus
iliopectineal line is intact in all 3 views.

26. 3.Anterior wall Acetabular Fractures
• Rare 1 to 2%
• Fracture line
• Ap view: anterior rim and
iliopectineal
• Obturator view: subluxation of
femoral head follows anterior wall
• Iliac view: intact posterior border

27. 4.Anterior column Acetabular Fractures:
• 3 to 5%
• Fracture line
• High AC # : exit at iliac crest
• Intermediate AC # : exit at ASIS
• Low AC # : exit at psoas gutter just
below AIIS.
• Very low AC # : exit above
iliopectineal eminence.

29. 5.Transverse Acetabular Fractures:
• 5 to 9 %
• Only elementary type involving
both borders.
• Fracture line
• Trans tectal type
• Juxta tectal type
• Infra tectal type
• Ap view: both iliopectineal and
ilioischial lines disrupted
• Oblique views : pelvic brim
disruption

31. ASSOCIATED TYPES
1)Posterior Column With Posterior Wall
Fracture
• 3 to 4 %
• The posterior wall component can be
thought of as articular comminution of the
posterior rim where the posterior column
fracture traverses it.
• the femoral head following the
ischioacetabular fragment and dislocating
cranially and posteriorly

32. 2) Transverse With Posterior Wall Fracture
• 20%
• combines the elementary transverse
and posterior wall fracture patterns
• Dislocation of the femoral head is
common in these fractures and the
dislocation may be either posteriorly
through the wall defect or medially
through the transverse fracture.

33. 3)Anterior Column/Wall With Posterior
Hemitransverse Fracture
• 7%
• anteromedial transition of the
femoral head
• The fracture pattern is often
complicated by impaction of the
medial roof of the acetabulum and
has been termed the “gull wing”
• poor prognostic sign

34. 4)T Shaped Fracture
• a transverse fracture with an
associated inferior vertical fracture
line known as the stem of the T
• The T-shaped fracture may also be
associated with a posterior wall
fracture.
• This subgroup of fractures is generally
included in the transverse plus
posterior wall pattern but has been
noted to have the worst prognosis of
any subgroup of fractures

35. 5)Both Column Fracture
• 23%
• Unique -acetabulum completely
disconnected from the axial skeleton
• The radiograph “spur sign” when
present, is pathognomonic for the
associated both column fracture

36. • Type A: Partial articular fractures, one column
involved
A1: posterior wall fracture
A2: posterior column fracture
A3: Anterior wall or anterior column fracture.
• Type B: Partial articular fractures
(transverse or T-type fracture, both columns involved)
B1: Transverse fracture
B2: T-shaped fracture
B3: Anterior column plus posterior hemi transverse
fracture
• Type C: Complete articular fracture (both-column
fracture; floating acetabulum)
C1: Both-column fracture, high variety
C2: both-column, low variety
C3: both-column fracture involving the sacroiliac joint

37. CLINICAL FEATURES
• History
• Contusion to the knee is a red flag, indicating possible hip injury
• Morel–Lavallé lesion:
• Local closed degloving soft tissue injury
• It can harbor pathogenic bacteria and lead to wound breakdown and
deep infection.

38. • Abnormal attitude of the limb may not be present, because
• 1.Dislocation may not be present –
inadvertently reduced while being stabilized for transport to
the hospital
• 2.Even with posterior hip dislocation-
the large posterior wall fracture allows the femoral head to
dislocate directly posterior without forcing the proximal femur
• We must have a high level of suspicion of posterior wall fracture for
any lower extremity injury that potentially causes abnormal loading
to the hip joint.

39. Assessment of nerves
• Sciatic nerve :
patient’s ability to perform active ankle dorsiflexion in addition to toe
dorsiflexion, along with ankle and toe plantar flexion.
• Obturator nerve :
assessed by active firing of the hip adductors
• Femoral nerve :
active firing of the quadriceps femoris muscle.

40. MANAGEMENT OF ACETABULAR
FRACTURES

41. CONTENTS
1.Investigations
2.Management
3.Complications

42. INVESTIGATIONS
Radiological:
1.X-rays:
Anteroposterior view. JUDET views.

43. SPUR SIGN. GULL WING SIGN. FLOATING ACETABULUM

44. ROOF ARC ANGLE:

45. 2.CT scan:
● 3mm interval axial cuts
● Include the entire pelvis to avoid missing a portion of the fracture.
● Compare with opposite hip
● Watch for any :
1. Anterior and posterior wall fragments
2. Marginal impaction
3. Retained bone fragments in the joint
4. Comminution
5. Any dislocations or Any sacroiliac joint pathology.

46. Table of Contents:
-Initial treatment and emergency indications.
-Non operative indications
-Techniques
-Operative indications and contraindications in adults
-standard surgical approaches
-Fracture reduction
-Complications
MANAGEMENT

47. INITIAL TREATMENT:
● Advanced Trauma Life Support (ATLS) protocol
● orthopaedic treatment of the acetabular fracture appropriately integrated into the treatment
plan.
Emergency Indications
Patient is usually placed in skeletal traction to:
1.Allow for soft tissue healing
2.Allow associated injuries to be addressed
3.Maintain limb length
4.Maintain femoral head reduction with in the acetabulum

48. INDICATIONS FOR NONOPERATIVE TREATMENT:
NONDISPLACED AND MINIMALLY DISPLACED FRACTURES
● Fractures that traverse the weight-bearing dome but are displaced less than 2 mm can be treated with non–
weight bearing for 6 to 12 weeks
● Maintenance of medial ,anterior and posterior roof arcs >45 degrees indicates fracture stability
● Distal anterior column or transverse (infratectal)fractures in which femoral head congruency is maintained by
the remaining medial buttress
“In general, all stable concentrically reduced acetabular fractures not involving the superior acetabular dome can
be considered for nonoperative management”

49. Acetabular Fractures Nonoperative Treatment
Indications:
1. Stable nondisplaced fractures
2. Stable and congruous minimally displaced fractures
3. Selected displaced fractures
4. Intact acetabulum maintains stability and congruity
5. Low anterior column fractures
6. Low transverse fractures
7. Low t-shaped fractures
8. Both-column fractures with secondary congruence
9. Wall fracture not compromising hip stability
10. Patients unable to withstand surgery
11.Severe osteoporosis precluding fracture fixation
Relative contraindications:
1. Hip joint instability
2. Hip joint Incongruity

50. ● Short-term bed rest followed by non–weight-bearing ambulation with crutches can be used for
nondisplaced or minimally (≤2 mm) displaced fractures,
Nonoperative Treatment of Acetabular Fractures:
Indications:
● Indicated for simple, nondisplaced fracture patterns.
● Non Weight bearing usually is continued for 6 to 8 weeks.
Operative Treatment of Acetabular Fractures :
Indications:
● Unstable joint
● Incongruent joint
● Malalignment of triradiate cartilage.

51. Techniques
● Bed rest with joint mobilization and eventual progression to full weight
bearing activity.
● Touch-down partial weight-bearing of the affected extremity (less than
10 kg)
● Adequate fracture healing, usually by 6 to 12 weeks, the patient should
gradually progress to full weight bearing.
● Traction should be maintained until fracture healing is sufficient to
allow progressive weight-bearing ambulation and may range from 4 to
12 weeks

52. Operative treatment indications:
Instability:
Hip dislocation associated with:
1.Posterior wall/column fractures (posterior instability)
2.Major anterior wall fractures(anterior instability)
3.Any fracture with significant size quadrilateral plate fracture(central instability)
Incongruity
Alteration or inconsistency in relationship between femoral head and acetabulum
It results in degenerative changes and post traumatic osteoarthritis

53. In congruity
Fractures through the roof or dome:
1. Retained osseous fragments may result in incongruity or an inability to maintain
concentric reduction of the femoral head
2. Femoral head fractures generally require ORIF to maintain sphericity and
congruity
3. Soft tissues interposition may necessitate operative removal of the interposed
Assessment of reduction:
1. Restoration of pelvic lines
2. Concentric reduction on all 3 views
3. The goal of anatomic reduction
Evaluation:
1. Roof arc angle of matta
2. Roof arc measurement by CT

54. Operative treatment contraindications:
1. Local or systemic infection
2. Severe osteoporosis
Relative contraindications:
1. Advanced age
2. Associated medical co morbidities
3. Associated soft tissue and visceral injuries
4. Multiple injured patient not stable for a acetabular surgery
Timing:
Usually performed with in 2 weeks of injury
It requires :
1.A well resuscitated patient
2.Appropriate radiologic workup
3.Appropriate under standing of fracture pattern

56. CHOICE OF SURGICAL APPROACH FOR EACH FRACTURE PATTERN
Fracture type.
Elementary:
1.posterior wall
2.posterior column
3.Anterior wall
4.Anterior column
5.Transverse(Infratectal/juxtatectal)
6.Transverse transtectal
Approach
Kocher-Langenbeck
Kocher-Langenbeck
Ilioinguinal or iliofemoral
Ilioinguinal or iliofemoral
Kocher-Langenbeck or ilioinguinal
Extended ilioinguinal or Kocher-Langenbeck
Associated:
1.posterior column +anterior wall
+posterior hemitransverse.
2.Transverse infratectal/juxtatectal
+posterior wall
3.Transverse transtectal+posterior wall
4.T-shaped infratectal/juxtatectal
5.T-shaped transtectal
6.Both column
Kocher-Langenbeck/ilioinguinal
Kocher-Langenbeck
Extended iliofemoral or Kocher-Langenbeck
Kocher-Langenbeck or Combined
Extended iliofemoral or Combined
Ilioinguinal or extended iliofemoral or Combined

57. Standard Surgical Approaches for Acetabular Fractures
1.The Kocher–Langenbeck Approach
Ideal for posterior wall fractures and posterior column fractures with or without an associated posterior wall
fracture
2.The Ilioinguinal Approach.
Indicated for anterior wall and anterior column fractures, as well as for most anterior column/wall and
posterior hemitransverse fractures and most both-column fractures
3.The iliofemoral approach sufficient for high anterior column fractures in which the main
displacement is cephalad to the hip joint
4.The extended iliofemoral approach
selected complex acetabular fracture type , surgery delayed more than 2 weeks following injury These
include transverse plus posterior wall fractures if the surgeon expects unusual difficulties with reduction
5.Stoppage approach(supine):Allows access to the medial wall of acetabulum,quadrilateral surface &
sacroiliac joint
6.Triradiate approach (prone):Alternative exposure to the external aspect of innominate bone!with
almost same exposure as iliofemoral but visualisation of the posterior part of ilium is not as good

58. The Kocher–Langenbeck Approach
Indications:
1. Posterior wall fractures
2. Posterior column fractures
3. Juxta tectal /infra tectal transverse or transverse
with
4. posterior wall fractures
5. Some T type fractures
:

60. The Ilioinguinal Approach.
Indications:
1. Anterior wall and anterior column fractures,
2. Posterior hemitransverse fractures
3. Most both-column fractures

62. The iliofemoral approach
Indications :
1.Anterior wall fractures
2.Anterior column fractures

63. The Extended iliofemoral approach
Indications:
1.Transverse transtectal fracture
2.Transverse transtectal + Posterior wall fracture
3.T-shaped transtectal

65. REDUCTION TECHNIQUES
Traction
● Traction on the femoral head is essential in obtaining a reduction
● Traction may be obtained by the use of a traction table,useful in allowing the
patient to position either in prone or supine.
● The articular surface of the joint must be adequately visualised by a wide
capsulorrhaphy

66. ● Traction on the femoral head is obtained by :
Cork screw. Sharp hook
● A 5 or 6mm Schanz pin with a T handle is inserted in to the ischial tuberosity in
high transverse or T type fractures.

67. ● Holes should be drilled to accept the pointed forceps.
● Washers with extensions have been developed for use
with the pointed forceps.
● Cerclage wires:inserted through the greater sciatic notch and
Around the anterior inferior iliac spine.

69. Quality of fracture reduction:
● Perfect reduction-all radiographic landmarks restored
● Imperfect reduction-all radiographic landmarks not restored
Anatomical reduction-<1mm displacement
Imperfect reduction-2 to 3 mm displacement
Poor reduction->3mm displacement
Surgical secondary congruency-
“Articular surface around head was internally fixed as perfectly as possible,but there was recognized
malreduction between innominate bone and the joint”
Matta identified three factors with a worse clinical result:
1. An imperfect reduction
2. Traumatic injury to the articular surface or bone of the femoral head
3. Age of the patient >40years

70. Percutaneous screw fixation:
● Displaced acetabular fractures in elderly and minimal
displaced fractures in younger patients
Advantage: minimal invasive nature of approach
“the adequate reductions in the elderly patient population
treated percutaneously attain outcomes equivalent to to
those treated by open reduction and internal fixation,as well
as acute total hip arthroplasty

71. INSTRUMENTS AND IMPLANTS

72. FIXATION BASED ON TYPE OF FRACTURE

73. Implants
Screws:
● 6.5mm cancellous lag screws
● 4.0mm cancellous lag screws and 3.5mm cortical screws
● 6.5mm fully threaded cancellous screws
● For fixation of plate to the bone,fully threaded cancellous screws are
desirable
● The 6.5mm screw For the large reconstruction plate(4.5mm) and 3.5
screw for the 3.5 mm reconstruction plate.
● Cannulated screws are also used.

74. Plates:
● A 3.5mm reconstruction plate is the implant of choice for acetabular
reconstruction.
● Precurved 3.5 mm plates are available for anterior column fixation.
● These plate are fixed with 3.5mm cancellous screws
Large individuals and in pelvic fixation ,4.5mm reconstruction plates are also
useful,with fixation by 6.5 mm fully threaded cancellous screws.

75. Acute total hip arthroplasty
Results usually includes:
1. High rates of loosening of acetabular component
2. Revision surgeries
The predictable results of acute total hip arthroplasty in the setting of
acetabular fracture may be appealing to :
1. Geriatric patients with significant osteoporosis
2. Fracture comminution
3. Articular damage
4. Impaction

76. Complications:
Post traumatic Arthritis and Avascular necrosis of femoral head:
● Primary complications
● Displacement >1mm
● Wear of femoral head against a malreduced fracture will leads to post
traumatic arthritis.
● Damage to femoral head during posterior hip dislocations will lead to
AVN.
● Conversion to total hip arthroplasty or hip fusion.
Neurological injury:
● Preoperative sciatic nerve injury-30% reported, secondary to surgery 16%
● Letournel and judet recommended prone with knee flexed and hip
extended To relax the sciatic nerve.
● Iatrogenic nerve injury /planned transection of lateral cutaneous nerve of
thigh-ilioinguinal approach

77. Infection
● 4 to 12% reported rates
● Perioperative antibiotic prophylaxis
● Careful evaluation of soft tissue envelope
● Avoidance of incisions through the degloved areas
● Meticulous prepping and draping of the patient
● Devatilised muscle should be removed prior to closure ,potential spaces should
be drained,and antibiotics ,Continued until drains are removed.
● Any signs of continued drainage or hematoma should be treated aggressively
with early evacuation and debridement.

78. Morel-lavalle lesion
(skin degloving injury)
● A closed degloving injury over the greater
trochanter.
● Results due to the blunt trauma that caused the
fracture
● The subcutaneous tissue is torn away from the
underlying fascia,and significant cavity results
● Cavity contains hematoma and liquified fat.
● Draining and debridement before or during
surgery to decrease the chance of infection
Advisable to leave this area open through the surgical
incision or a separate incision.

79. Vascular injury:
● Intraoperative injury-packing>>clamping because of risk of injury to superior gluteal nerve
● Superior gluteal artery injury –posterior column fractures
● Preoperative angiography to assess superior gluteal artery patency prior to an extensile approach
● Injury to external iliac artery-ilioinguinal approach
● Prolonged retraction through middle window of the ilio inguinal approach –thrombosis
● “Intra op digital evaluation of the femoral arterial pulse while working in the middle window”.
● Vascular checks every 1 to 2 hours in first 12 hours postoperatively is advised.

80. Heterotopic ossification
● males>females
● Associated with head injuires,fractures where there is a delay to surgery
● Extensile approaches highest rate(extended iliofemoral )
Tx:
● Debriding devitalised skeletal muscle
● Postop oral indomethacin
● Post op radiation:700cgy radiation therapy to high risk patients
Deep vein thrombosis:
● low molecular weight heparin until night before surgery and
begin again on POD 2 for 3weeks.
● Altenative is postop warfarin administration.
● Venacava filters in patients with multiple injuries

81. References:
● Rockwood and Green’s Fractures in Adults 9th
edition
● Campbell's operative orthopaedics 13th edition

82. THANK YOU SIR