This is a retrospective study with elements of innovation during the series
Make sure from X rays.
This depended on the personality of the fracture i.e. whether displaced or not and the quality of bone. All operated patients in this series had open reduction and internal fixation. No Hip replacements were done.
A1-posterior column A2-anterior column,B-Transverse involving both columns but part of the dome is still connected to the ilium. Type C is a floating acetabulum where both the columns are fractured above the acetabulum
AO classification used
Get this from the internet.
Trochanteric osteotomy and Use of hooked buttress plate,
Useful when there is comminution of the posterior wall and screws are difficult to place
Obturator oblique showing posterior wall and anterior colu
Transverse fracture starting above iliopectineal eminence and running into the posterior column. Posterior wall fracture is also seen.
Step still visible in the posterior column
Pathomechanics of transverse fractures. Insert more slides.
Post op X-ray Six hours operating time
Showing the hooked buttress plate to fix the roof.
Surgical treatment of Acetabular Fractures at MJRC.
My tenure at IBRI HOSPITAL is
from 01 July 2002
Period of this series-2002
Number of patients-12(2 before June 2002)
Number of fractures-13(One bilateral)
Age group- Range 19-62 years.
Mean age- 34.58 years.
All were healthy except one female who had
Sickle cell disease.
Bone quality was good in all.
Side of injury-Right-6, left-5, Bilateral-1
9 patients sustained their injuries during the
Ramadan season. Most were towards the
Mechanism of injury
• Road traffic accidents-11
• Fall of debris on the back-1
• Of patients involved in RTA’s 6 were
drivers of the car and 5 were passengers
• All males in this series were drivers. The
females were seated in the front
• One passenger was in harness.
• Posterior dislocation of hip-8
• Central dislocation of hip-1
• Pelvic injuries-2 – 1 APC III, 1 APC II
• Femoral head fracture-1
• Ipsilateral knee injuries-2(One combined
ACL and PCL, another yet to be
• Intra-abdominal injury-1
• Chest injuries-2
• Other injuries-medial malleolar fracture-1,
fracture femur-1 and fracture scapula-1
Period of follow up
All operated cases were reviewed by
calculation of hip scores and x rays(5
Three conservatively managed cases were
also evaluated along the same lines.
Three patients are lost to follow up
One patient is dead
• Early management • Subsequent
Immediate resuscitation management-
for all patients. One • Conservative treatment-5
patient was in severe patients( 2 before June
hypovolemic shock. 2002, 3 afterwards)
• Open reduction and
• Reduction of internal fixation-5
dislocations-7 patients patients, 6 fractures,
• All patients had an X-ray Pelvis AP as part of
the primary survey
• Seven patients had Judet internal and external
views and CT scans.
• Image intensification used routinely per-
• Check X ray in the ward the same day or the
• Further X rays at 6 weeks and three months
• One patient had a post operative CT scan
Classification of the fractures in
this series ( Letournel)
• Type A-9
• Type B-3
• Type C-0
Associated posterior dislocation of hip in 8
fractures (Seven patients)
Central dislocation of the hip in 1 patient
No dislocation in 4 patients
Total- 12 patients
Classification of Operated fractures
in this series
Classification of Non operated
fractures in this series
IMK B1 +A1 β3
KSK LAMA (X-rays not
SSA A1β3Not available for
follow up<June 2002)
SK A1(No follow up, <June
KK B 1 +A1(undisplaced)
Interval between injury and surgery
• Range-4-10 days
• Mean-6.8 days
Indications for surgery
• Obvious instability
• Presence of intra-articular loose bony
fragments( to be distinguished from
avulsion of bony attachments of the
• Significant displacement of posterior wall
as seen on CT and 3 D CT reconstruction
• Loss of congruity
• All patients were positioned in the lateral
• Routine General anaesthesia in all patients
except for the sickler where precautions were
taken to prevent Vaso occlusive crisis(VOC)
• Kocher Langenbeck approach
• Trochanteric osteotomy in two patients.
• Debridement of the necrotic gluteus minimus in
• Anatomic reduction obtained in transverse
fracture by manipulation of the anterior
column first, then the posterior column
was manipulated. In posterior wall
fractures the reduction was obtained by
reduction forceps or manipulation and
fixed with screws.
• Intra-articular loose fragments-5
• Acetabular impaction-2
• Degloving of articular cartilage-1
• Femoral head and acetabular abrasions -3
• 3.5mm reconstruction plates were used in
• Screws alone used in one posterior wall
• Hooked buttress plate was used in two
patients. Thus all posterior wall fractures
had fixation with some kind of plate.
• Cancellous screw fixation of the anterior
column in one.
Harris hip score for operated
• Case 1- 96(Excellent)
• Case 2- 92( Excellent)
• Case 3-89 (Good)
• Case 4-38 (Poor) due to refracture more
time to union and myositis
• Case 5- 92(Excellent)
Harris hip scores of non operated
NM (Operation refused 96
Dr.SM (undisplaced 100 Excellent (Pipkin
fracture) type II femoral head
KK (Undisplaced 70.92 (Fair)
Post operative management
• Immobilization or traction was not used
• Non weight bearing crutch walking
progressing to full weight bearing by six to
• In one patient with re-fracture and second
operation skeletal traction was used for 3
• Prophylaxis for DVT and myositis
• Myositis ossificans-3
• Re-fracture in one patient in the post-op
period due to a slip and sudden weight
bearing on the affected leg.
• One screw loosening from the plate
Case 4 25 female A 1 β 3 Harris
hip score at 3.5 months-92
• 42 Male A1 + A 2 β3
He had a re-fracture in the second post op
week Fracture reduced again.
Major posterior wall fragment was intact.
Re-fracture through the roof. Difficult to fix
using screws again. Another use of the
hooked buttress plate ( Multiple prongs) to
reduce and fix the fracture.
• Posterior column and posterior wall fractures are
the commonest in this series.
• Pre-op CT scan is essential to determine the
presence of loose fragments and 3D CT is best
to determine the fracture anatomy.
• Preoperative planning is absolutely essential.
• Kocher Langenbeck approach is the easiest to
manage posterior and transverse fractures.
• Dissection of the fragments should be
atraumatic to minimize the incidence of Myositis.
• Special instruments like modified Farabeuf
forceps,sciatic nerve retractor, Matta’s
clamps are useful.
• Hooked buttress plate has a role in
comminuted posterior wall fragments,
fixation of wall fragments in lieu of screws
and in re-fractures without disturbing the
original hardware. Advantage is that screw
placement is distant from the acetabulum
• Screw placement should be away from the joint
in the safe corridor which is 10mm away from
the lip. Screws should be in bone and not
protrude into the hip joint or pelvis.
• Avoid screw placement into the danger
zone(10mm from the lip). Beyond the danger
zone the screws should be angled posteriorly
and never at right angles into the acetabulum.
Safe zone of the posterior wall for
• Red-danger zone
• Green- safe zone
• Long (100mm-120mm 3.5mm cortical
screws or 6.5mm cancellous screws may
be needed to fix the anterior column
through the posterior approach
• Myositis remains the unconquered
complication.incidence upto 100% ? role
of debridement of the necrotic muscle.(Rath
et al Injury Vol 33,number 9, November 2002)
• Good results are achieved by a focused
surgeon doing more cases as there is a
learning curve for achieving perfect
reduction and mastering the approaches.
• Dis-impaction of
and bone grafting
from the femur.
• Fibrin glue to stick
Fossils showing that life is not as
we thought that it was
• The first comprehensive classification was
proposed by Judet and Letournel in 1964
Judet, R., Judet, J., and Letournel, E.: Fractures of the Acetabulum:
Classification and Surgical Approaches for Open Reduction. J. Bone
Joint Surg., 46A:1615–1647, 1964.
• Salient points- elementary and associated types.
• The present Universal classification is
based on the AO classification which
divides all fractures into three types A,B
and C with increasing severity towards C
• Developed with the help of Letournel,
Matta, Helfet and others. Has been
recognised by SICOT, OTA (Orthopaedic
trauma associatio) and the AO group
• Some deficiencies are that some B type
fractures are high energy, shearing
fractures with worse prognosis than C
types. Muller, M.E., Allgower, M., Schneider, R., and Willeneger, H.:
AO Manual on Internal Fixation, 3rd ed. New York, Springer-Verlag, 1990.