Acetabular FracturesAcetabular Fractures
Evaluation, Anatomy and ClassificationEvaluation, Anatomy and Classification
Muha...
Normal Anatomy: Columns and
Walls
 From the lateral aspect of the
pelvis, the innominate osseous
structural support of the
acetabulum may be
conceptualized...
 The anterior and posterior walls
extend from each respective
column and form the cup of the
acetabulum.
 The anterior a...
 When looking at the acetabulum en face, the
anterior and posterior columns have the
appearance of the Greek letter lambd...
 The anterior and posterior walls, which extend
from the columns and support the hip joint, are
well seen on an axial CT....
Acetabular dome: The superior weight-bearing
portion of the acetabulum at the junction of
the anterior and posterior colum...
Anterior
coulmn
Posterior
column
Sciatic
buttress
Anterior column in white, posterior column
in red
Mechanism of injury
Like pelvis fractures, these injuries are
mainly caused by high-energy trauma
secondary to a motor veh...
Mechanism of injury
The fracture pattern depends on
 Position of femoral head at the time of injury,
 Magnitude of force...
Mechanism of injury
Direct impact to greater trochanter with:
 Hip in neutral: transverse acetabular fracture
 An abduct...
Mechanism of injury
With indirect trauma, (e.g., a ‘dashboard’
injury to the flexed knee):
 As the degree of hip flexion ...
Clinical evaluation
 Trauma evaluation: with attention to ABCD, depending on the
mechanism of injury.
 Patient factors (...
Radiographic evaluation
 5 Pelvic X-rays:
 AP view
 2 Judet views (iliac &
obturator oblique views)
 Inlet and Outlet ...
Anatomic landmarks in AP
view
 Iliopectineal line (limit of anterior
column),
 Ilioischial line (limit of posterior
colu...

Anatomic landmarks in AP view
Teardrop
 Internal limb = outer
wall of obturator canal
 External limb = middle
1/3 of cotyloid fossa
 Inferior border ...
Iliac oblique radiograph
(45-degree external rotation view)
 Taken by rotating the
patient into 45° of external
rotation ...
Iliac-oblique view
1. Border of sciatic
notch
2. Anterior wall
3. Posterior column
4. Iliac wing
5. Posterior wall
Iliac oblique radiograph
Obturator oblique radiograph
(45-degree internal rotation view)
 This is best for evaluating
the anterior column and
post...
Obturator-oblique view
1. Ilio-pectineal line.
2. Posterior wall
3. Anterior half of the
joint
4. The iliac wing
profile (...
Obturator oblique radiograph
AP pelvis Iliac oblique Obturator oblique
AW—anterior wall;
AC—anterior column;
PC—posterior column;
PW—posterior wall;
OR...
Inlet Pelvis X-ray
Skeletal anatomy
represented on inlet
view
Outlet Pelvis XR
Skeletal anatomy represented on outlet view
Radiological
Study
Radiographic evaluation
 CT scan
Provides additional information regarding size
& position of column fractures, impacted...
Radiographic evaluation
 CT scan
 Before a 3-dimensional CT
scan is ordered, the fracture
patterns should be drawn on a
...
CT scan transverse cuts through the acetabulum.
3-D CT scan of a both-
column acetabular
fracture; obturator
oblique view
3-D CT scan of a both-
column acetabular fractur...
Line drawing of fracture on a pelvic
model
 Accurate classification of acetabular fractures is
important for determining the proper surgical
treatment.
 Although r...
 Because of the complex acetabular anatomy, various
classification schemes have been suggested, but the
Judet-Letournel c...
Elementary fractures
 Poserior wall
 Posterior column
 Anterior wall
 Anterior column
 Transverse
Classification
(Jud...
Classification
(Judet-Letournel)
Associated fractures
 T-shaped
 Posterior column + posterior wall
 Transverse + poster...
Elementary types
Post wall Post column Ant wall Ant column Transverse
www.pelvisandhip.comwww.pelvisandhip.com
Othopaedic Review CourseOthopaedic Review Course
January 2010January 2010
Post. w...
Classifications
Classification algorithm for 5
common acetabular fractures
 The isolated posterior wall
fracture is one of the most
common types of acetabular
fracture, with a prevalence of
27%.
...
 An isolated posterior wall fracture does not
have a complete transverse acetabular
component.
Therefore, the iliopectin...
18-year-old man with isolated posterior wall acetabular fracture
AP pelvic radiograph
Bilateral oblique
pelvic radiographs...
18-year-old man with isolated posterior wall acetabular fracture
Parasagittal
reconstruction CT
image
 Posterior wall and posterior
column fractures can be
distinguished easily.
 In a posterior column fracture, the
ilioisc...
Posterior Column Fracture
 Anterior wall and anterior column
fractures can be distinguished by
the additional break in the
ischiopubic segment of t...
Anterior Wall Fracture
Anterior Column Fracture
A transverse acetabular fracture
involves a fracture line that goes
through both columns of the
acetabulum, but a portion ...
Obturator oblique
view of transverse
fracture
Iliac oblique view
of transverse
fracture
Types (depending on the orientation of the fracture line relative to the
dome or tectum of the acetabulum):
1. Transtectal...
Infratectal Juxtatectal Transtectal
23-year-old woman with transverse acetabular fracture
AP pelvic radiograph
Bilateral oblique pelvic
radiographs
Axial CT s...
Transverse fractures are sagittal plane
fractures whereas both column
fracturesare coronal plane fractures.
Transverse Fra...
A.Coronal plane fracture
B.Sagittal plane fracture
CT cut of transverse fracture
in the sagittal plane
Associated types
Post. Wall
& post.
column
Transverse &
post. Wall or
column
T-shaped
Ant column or
wall & post
hemitransv...
Othopaedic Review CourseOthopaedic Review Course
January 2010January 2010
T-fracture Transverse/post.wall
Post.wall/post.c...
Posterior Column-Posterior Wall
Transverse fracture of any type
+
Vertical fr through the isciopubic fragment
The vertical component is best
seen on the o...
The T-shaped fracture is
similar to a both-column fracture
in that it disrupts the obturator
ring.
Another similarity is d...
One area of potential confusion with the Tshaped
fracture is in regard to the transverse component.
The transverse fractur...
T-type fractures differ from transverse fractures by the additional
fracture line that runs through the quadrilateral surf...
 Radiograph of
a T-type
fracture.
 Note the
undisplaced
fracture in the
ischiopubic
ramus.
 This break in the
obturator...
In a T-type fracture, the 2 columns must
be reduced independently.
This becomes extremely important when
choosing a surgic...
2-D CT cut of T-type fracture
Note in the T-type fracture the anterior
and posterior columns are disassociated
40-year-old man with T-shaped acetabular fracture
AP pelvic radiograph
Bilateral oblique pelvic
radiographs
Axial CT scan
...
Transverse fracture
+
Comminuted posterior wall
fracture (usually displaced)
The iliopectineal and
ilioischial lines are
d...
Transverse and posterior wall
fracture
20-year-old man showing transverse with posterior wall acetabular
fracture
AP pelvic radiograph
Bilateral oblique pelvic
r...
Anterior Column-Posterior
Hemitransverse
Both columns are separated from
each other and from the axial
skeleton, resulting in a ‘floating’
acetabulum
This is the m...
The "spur-sign," best seen on the
obturator oblique view, is
pathognomonic for the both-column
fracture.
This sign represe...
On radiographs and CT, the
spur sign appears as a shard
of bone extending posteriorly
at the level of the superior
acetabu...
35-year-old man with a both-column fracture
Oblique pelvic radiograph (A) and axial CT image (B) show
spur sign (arrow), w...
45-year-old man with both-column acetabular fracture
AP pelvic radiograph
Bilateral oblique pelvic radiographs
Axial CT sc...
3-D CT scan of a both-column acetabular fracture; obturator3-D CT scan of a both-column acetabular fracture; obturator
obl...
3-D CT scan of a both-column acetabular fracture; iliac oblique view3-D CT scan of a both-column acetabular fracture; ilia...
Line drawing
of fracture on
a pelvic
model
Cases
Case 1
Disrupción del anillo
obturador + extensión a
pala iliaca  FRACTURA
BICOLUMNARIA
Case 2
Disrupción del anillo
obturador + SIN extensión
a pala iliaca  FRACTURA
en “T”
 Subsequent to the pioneering work of Judet and Letournel,
their classification was then used as the basis for formulatin...
The Comprehensive Classification of Fractures of the Acetabulum
References
 Durkee NJ, Jacobson J, Jamadar D, Karunakar MA,
Morag Y, Hayes C: Classification of Common
Acetabular Fractur...
26. acetabular fractures   anatomy, evaluation and classification  - muhammad abdelghani
26. acetabular fractures   anatomy, evaluation and classification  - muhammad abdelghani
26. acetabular fractures   anatomy, evaluation and classification  - muhammad abdelghani
26. acetabular fractures   anatomy, evaluation and classification  - muhammad abdelghani
26. acetabular fractures   anatomy, evaluation and classification  - muhammad abdelghani
26. acetabular fractures   anatomy, evaluation and classification  - muhammad abdelghani
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26. acetabular fractures anatomy, evaluation and classification - muhammad abdelghani

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Part 1 of a lecture on acetabular fractures (Anatomy, Evaluation and Classification) by Dr Muhammad Abdelghani

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  • Röntgendiagnostik in konventioneller Technik: Nach der Beckenübersichtsaufnahme weitere Differenzierung der dorsalen Beckenringläsion durch die Inlet- und Outletaufnahmen, Differenzierung der Acetabulumfraktur durch die Obturator- und Alaaufnahmen
  • 􀁺 Iliopectineal line (1) 􀁺 Ilioischial line (2) 􀁺 Teardrop (the medial portion of the teardrop represents the quadrilateral surface and the lateral portion represents the medial aspect aspect of the acetabular floor) (3) 􀁺 Dome (4) 􀁺 Anterior wall (5) 􀁺 Posterior wall (6)
  • Landmarks on the obturator oblique view
  • 18-year-old man with isolated posterior wall acetabular fracture. A–F, AP pelvic radiograph ( A ), bilateral oblique pelvic radiographs ( B, C ), axial CT images ( D, E ), and parasagittal reconstruction CT image ( F ) show displaced fracture fragments ( curved arrows ) from isolated posterior wall fracture ( straight arrow, D ).
  • 18-year-old man with isolated posterior wall acetabular fracture. A–F, AP pelvic radiograph ( A ), bilateral oblique pelvic radiographs ( B, C ), axial CT images ( D, E ), and parasagittal reconstruction CT image ( F ) show displaced fracture fragments ( curved arrows ) from isolated posterior wall fracture ( straight arrow, D ).
  • 23-year-old woman with transverse acetabular fracture. A–E, AP pelvic radiograph ( A ), bilateral oblique pelvic radiographs ( B, C ), axial CT scan ( D ), and surface-rendering 3D CT scan viewed laterally ( E ), with right hemipelvis and femur removed, show fracture ( arrows ) orientation transverse to acetabulum, disrupting iliopectineal and ilioischial lines ( arrowheads ). Note characteristic sagittal – oblique fracture plane on CT scan ( D ).
  • 40-year-old man with T-shaped acetabular fracture. A–E, AP pelvic radiograph ( A ), bilateral oblique pelvic radiographs ( B, C ), axial CT scan ( D ), and surface-rendering 3D CT scan viewed laterally ( E ), with right hemipelvis and femur removed, show obturator ring fractures ( arrowheads ) and transverse component ( arrows ) through acetabulum. Note characteristic oblique – sagittal orientation of transverse acetabular fracture component on CT scans that is transverse relative to acetabulum on radiographs.
  • 20-year-old man showing transverse with posterior wall acetabular fracture. A–E, AP pelvic radiograph ( A ), bilateral oblique pelvic radiographs ( B, C ), axial CT scan ( D ), and surface-rendering 3D CT scan viewed laterally ( E ), with right hemipelvis and femur removed, show transverse fracture ( straight arrows ) disrupting iliopectineal and ilioischial lines ( arrowheads ) with displaced and comminuted posterior wall fracture fragment ( curved arrows ).
  • 35-year-old man with both-column acetabular fracture and spur sign. A and B, Oblique pelvic radiograph ( A ) and axial CT image ( B ) show spur sign ( arrow ), which represents displacement of fracture involving sciatic buttress ( arrowheads ). Note that sciatic buttress ( arrowheads, B ) no longer connects to weight-bearing portion of acetabulum.
  • 45-year-old man with both-column acetabular fracture. A–E, AP pelvic radiograph ( A) , bilateral oblique pelvic radiographs ( B, C ), axial CT scan ( D ), and sagittal reconstruction CT scan ( E ) show acetabular fracture ( straight arrows , A–C ), with break in obturator ring ( arrowheads , A–C ) and extension into iliac wing ( curved arrows ). Note coronal plane of fracture on CT and superior pubic ramus fractured at puboacetabular junction.
  • 26. acetabular fractures anatomy, evaluation and classification - muhammad abdelghani

    1. 1. Acetabular FracturesAcetabular Fractures Evaluation, Anatomy and ClassificationEvaluation, Anatomy and Classification Muhammad Abdelghani
    2. 2. Normal Anatomy: Columns and Walls
    3. 3.  From the lateral aspect of the pelvis, the innominate osseous structural support of the acetabulum may be conceptualized as a two- columned construct forming an inverted Y: 1. Anterior column (iliopubic component): extends from iliac crest to symphysis pubis and includes the anterior wall of the acetabulum. 2. Posterior column (ilioischial component): extends from superior gluteal notch to ischial tuberosity and includes the posterior wall of the acetabulum.
    4. 4.  The anterior and posterior walls extend from each respective column and form the cup of the acetabulum.  The anterior and posterior columns connect to the axial skeleton through a strut of bone called the sciatic buttress.
    5. 5.  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, which extends superiorly from the superior pubic ramus into the iliac wing. The posterior column extends superiorly from the ischiopubic ramus as the ischium toward the ilium.  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 walls, which extend from the columns and support the hip joint, are well seen on an axial CT.
    6. 6.  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.
    7. 7. Acetabular dome: The superior weight-bearing portion of the acetabulum at the junction of the anterior and posterior columns, including contributions from each.
    8. 8. Anterior coulmn Posterior column Sciatic buttress
    9. 9. Anterior column in white, posterior column in red
    10. 10. Mechanism of injury Like pelvis fractures, these injuries are mainly caused by high-energy trauma secondary to a motor vehicle, motorcycle accident, or fall from a height.
    11. 11. Mechanism of injury The fracture pattern depends on  Position of femoral head at the time of injury,  Magnitude of force, &  Age of patient.
    12. 12. 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.
    13. 13. 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.
    14. 14. 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.
    15. 15. Radiographic evaluation  5 Pelvic X-rays:  AP view  2 Judet views (iliac & obturator oblique views)  Inlet and Outlet Pelvis X-rays  CT scan
    16. 16. Anatomic landmarks in AP view  Iliopectineal line (limit of anterior column),  Ilioischial line (limit of posterior column),  Anterior lip,  Posterior lip,  Line depicting the superior weight-bearing surface, terminating as the medial teardrop.
    17. 17.
    18. 18. Anatomic landmarks in AP view
    19. 19. Teardrop  Internal limb = outer wall of obturator canal  External limb = middle 1/3 of cotyloid fossa  Inferior border = ischiopubic notch
    20. 20. Iliac oblique radiograph (45-degree external rotation view)  Taken by rotating the patient into 45° of external rotation by elevating the uninjured side on a wedge.  This best demonstrates:  Posterior column (ilioischial line),  Iliac wing,  Anterior wall of acetabulum.
    21. 21. Iliac-oblique view 1. Border of sciatic notch 2. Anterior wall 3. Posterior column 4. Iliac wing 5. Posterior wall
    22. 22. Iliac oblique radiograph
    23. 23. Obturator oblique radiograph (45-degree internal rotation view)  This is best for evaluating the anterior column and posterior wall of the acetabulum.  Taken by elevating the affected hip 45° to the horizontal by means of a wedge and directing the beam through the hip joint with a 15° upward tilt.
    24. 24. Obturator-oblique view 1. Ilio-pectineal line. 2. Posterior wall 3. Anterior half of the joint 4. The iliac wing profile (the spur sign site)
    25. 25. Obturator oblique radiograph
    26. 26. AP pelvis Iliac oblique Obturator oblique AW—anterior wall; AC—anterior column; PC—posterior column; PW—posterior wall; OR—obturator ring.
    27. 27. Inlet Pelvis X-ray
    28. 28. Skeletal anatomy represented on inlet view
    29. 29. Outlet Pelvis XR
    30. 30. Skeletal anatomy represented on outlet view
    31. 31. Radiological Study
    32. 32. 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.
    33. 33. Radiographic evaluation  CT scan  Before a 3-dimensional CT scan is ordered, the fracture patterns should be drawn on a 3-dimensional model of the pelvis to compare the 3- dimensional reconstructions.  Three-dimensional reconstruction allows for digital subtraction of femoral head, with full delineation of the acetabular surface.
    34. 34. CT scan transverse cuts through the acetabulum.
    35. 35. 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
    36. 36. Line drawing of fracture on a pelvic model
    37. 37.  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
    38. 38.  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  Elementary Fracture Types (posterior wall, posterior column, anterior wall, anterior column and transverse)  Associated Fracture Types (T-shaped, posterior column and wall, anterior wall or column with posterior hemitransverse, and both column). Classification (Judet-Letournel)
    39. 39. Elementary fractures  Poserior wall  Posterior column  Anterior wall  Anterior column  Transverse Classification (Judet-Letournel)
    40. 40. Classification (Judet-Letournel) Associated fractures  T-shaped  Posterior column + posterior wall  Transverse + posterior wall  Anterior column + posterior hemitransverse  Both-column
    41. 41. Elementary types Post wall Post column Ant wall Ant column Transverse
    42. 42. www.pelvisandhip.comwww.pelvisandhip.com Othopaedic Review CourseOthopaedic Review Course January 2010January 2010 Post. wall Post. column Ant. wall Ant. column Transverse
    43. 43. Classifications
    44. 44. Classification algorithm for 5 common acetabular fractures
    45. 45.  The isolated posterior wall fracture is one of the most common types of acetabular fracture, with a prevalence of 27%.  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
    46. 46.  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.  Oblique (Judet) radiographs and CT are helpful in showing the isolated posterior wall fracture. Posterior column fractures
    47. 47. 18-year-old man with isolated posterior wall acetabular fracture AP pelvic radiograph Bilateral oblique pelvic radiographs Axial CT images
    48. 48. 18-year-old man with isolated posterior wall acetabular fracture Parasagittal reconstruction CT image
    49. 49.  Posterior wall and posterior column fractures can be distinguished easily.  In a posterior column fracture, the ilioischial line is interrupted.  In a posterior wall fracture, only the retroacetabular surface is disrupted. Posterior column fractures
    50. 50. Posterior Column Fracture
    51. 51.  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. Anterior wall and anterior column fractures
    52. 52. Anterior Wall Fracture
    53. 53. Anterior Column Fracture
    54. 54. A transverse acetabular fracture involves a fracture line that goes through both columns of the acetabulum, but a portion of the dome of the acetabulum remains attached to the constant fragment of the iliac wing. Transverse Fracture
    55. 55. Obturator oblique view of transverse fracture Iliac oblique view of transverse fracture
    56. 56. 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: through the junction of acetabular dome & fossa acetabuli. 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. Transverse Fracture
    57. 57. Infratectal Juxtatectal Transtectal
    58. 58. 23-year-old woman with transverse acetabular fracture AP pelvic radiograph Bilateral oblique pelvic radiographs Axial CT scan surface- rendering 3D CT viewed laterally, with right hemipelvis and femur removed
    59. 59. Transverse fractures are sagittal plane fractures whereas both column fracturesare coronal plane fractures. Transverse Fracture
    60. 60. A.Coronal plane fracture B.Sagittal plane fracture
    61. 61. CT cut of transverse fracture in the sagittal plane
    62. 62. Associated types Post. Wall & post. column Transverse & post. Wall or column T-shaped Ant column or wall & post hemitransverse Both columns
    63. 63. Othopaedic Review CourseOthopaedic Review Course January 2010January 2010 T-fracture Transverse/post.wall Post.wall/post.column Ant.post.hemitrans. Ass.both.column
    64. 64. Posterior Column-Posterior Wall
    65. 65. 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
    66. 66. 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
    67. 67. 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 acetabulum. This is best appreciated by looking at the acetabulum en face. On CT, this transverse fracture component is seen as a sagittally oriented fracture coursing medially and superiorly from the acetabulum. T-shaped fracture
    68. 68. T-type fractures differ from transverse fractures by the additional fracture line that runs through the quadrilateral surface. As a result, the anterior column and posterior column are separated by fracture lines. This becomes important when choosing a surgical approach to the acetabulum. In a pure transverse fracture, the anterior and posterior columns may be reduced through a single approach. Once the anterior column has been reduced, the posterior column will follow the reduction and can be palpated indirectly. T-shaped fracture
    69. 69.  Radiograph of a T-type fracture.  Note the undisplaced fracture in the ischiopubic ramus.  This break in the obturator ring correlates with an additional fracture line in the quadrilateral plate.
    70. 70. In a T-type fracture, the 2 columns must be reduced independently. This becomes extremely important when choosing a surgical approach; therefore, it is important to recognize the subtle difference between transverse and T-type fractures when they are not significantly displaced. T-shaped fracture
    71. 71. 2-D CT cut of T-type fracture
    72. 72. Note in the T-type fracture the anterior and posterior columns are disassociated
    73. 73. 40-year-old man with T-shaped acetabular fracture AP pelvic radiograph Bilateral oblique pelvic radiographs Axial CT scan Surface-rendering 3D CT viewed laterally, with right hemipelvis and femur removed
    74. 74. Transverse fracture + Comminuted posterior wall fracture (usually displaced) The iliopectineal and ilioischial lines are disrupted. The obturator oblique view best demonstrates the position of the transverse component as well as the Transverse and posterior wall fracture
    75. 75. Transverse and posterior wall fracture
    76. 76. 20-year-old man showing transverse with posterior wall acetabular fracture AP pelvic radiograph Bilateral oblique pelvic radiographs axial CT scan surface- rendering 3D CT viewed laterally, with right hemipelvis and femur removed
    77. 77. Anterior Column-Posterior Hemitransverse
    78. 78. 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’)
    79. 79. 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 supported by the acetabulum. Both-column fracture (formerly called ‘central acetabular fracture’) "Spur-sign" seen on the obturator oblique view
    80. 80. 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. Both-column fracture (formerly called ‘central acetabular fracture’)
    81. 81. 35-year-old man with a both-column fracture Oblique pelvic radiograph (A) and axial CT image (B) show spur sign (arrow), which represents displacement of fracture involving sciatic buttress (arrowheads). Note that sciatic buttress (arrowheads, B) no longer connects to weight-bearing portion of acetabulum. A B
    82. 82. 45-year-old man with both-column acetabular fracture AP pelvic radiograph Bilateral oblique pelvic radiographs Axial CT scan sagittal reconstruction CT scan
    83. 83. 3-D CT scan of a both-column acetabular fracture; obturator3-D CT scan of a both-column acetabular fracture; obturator oblique viewoblique view
    84. 84. 3-D CT scan of a both-column acetabular fracture; iliac oblique view3-D CT scan of a both-column acetabular fracture; iliac oblique view
    85. 85. Line drawing of fracture on a pelvic model
    86. 86. Cases
    87. 87. Case 1
    88. 88. Disrupción del anillo obturador + extensión a pala iliaca  FRACTURA BICOLUMNARIA
    89. 89. Case 2
    90. 90. Disrupción del anillo obturador + SIN extensión a pala iliaca  FRACTURA en “T”
    91. 91.  Subsequent to the pioneering work of Judet and Letournel, their classification was then used as the basis for formulating an alphanumeric computerized format and the Comprehensive Classification of Fractures of the Acetabulum was developed.  This effort was spearheaded by SICOT International Documentation and Evaluation Committee and the AO/ASIF Foundation under the leadership of Maurice E. Muller.  Each fracture is classified according to morphological characteristics, and subdivided into types, groups, and subgroups.  The system is especially beneficial for research database applications. Classification (The Comprehensive Classification of Fractures of the Acetabulum)
    92. 92. The Comprehensive Classification of Fractures of the Acetabulum
    93. 93. References  Durkee NJ, Jacobson J, Jamadar D, Karunakar MA, Morag Y, Hayes C: Classification of Common Acetabular Fractures: Radiographic and CT Appearances. AJR 2006; 187: 915-925  Gänsslen A, Oestern HJ: Azetabulumfrakturen. Chirurg 2011; 82:1133–1150  Jimenez ML: Classification of Acetabular Fractures. Medscape.com  Pagenkopf E, Grose A, Partal G, Helfet DL: Acetabular Fractures in the Elderly: Treatment Recommendations. HSSJ (2006) 2: 161–171

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