This document discusses acetabulum fractures, which involve the articular surface of the hip joint. It covers the anatomy, incidence, etiology, classification, evaluation, treatment, surgical approaches, and complications of these fractures. The key points are: 1) Acetabulum fractures can involve one or both columns of the hip joint and have a bimodal distribution, occurring most often in younger patients due to high-energy trauma and elderly patients due to low-energy falls. 2) Treatment depends on the fracture pattern and degree of displacement, with nonoperative management for minimally displaced or stable fractures and operative treatment for displaced or unstable fractures. 3) Surgical approaches include anterior, posterior, and

1. ACETABULUM FRACTURE
DR MOHSIN PARVEZ
IGIMS PATNA

2. ANATOMY : incomplete hemispherical socket with horshoeshaped
Articular surface surrounding the medial nonarticular cotyloid fossa
partial ball n socket joint ,six components :

4. Posterior column :
quadrilateral surface,posterior wall and dome,ischial tuberosity
greater/lesser sciatic notches
Anterior column :
anterior ilium (gluteus medius tubercle),anterior wall and dome
iliopectineal eminence,lateral superior pubic ramus

5. Anatomic reconstruction of the dome/roof with the concentric reduction
of the femoral head beneath this dome is the goal of both the operative
and nonoperative treatment.

6. Acetabulum fractures are pelvis fractures that involve the articular
surface of the hip joint and may involve one or two columns, one or two
walls, or the roof within the pelvis
Incidence
~ 4 per 100,000 per year
Demographics
fractures occur in a bimodal distribution
high energy trauma in younger patients (e.g., motor vehicle accidents)
low energy trauma in elderly patients (e.g., fall from standing height)
Etiology
Pathoanatomy
fracture pattern predominately determined by force vector
position of femoral head at time of injury
bone quality (e.g., age)
Associated conditions
orthopaedic manifestations
lower extremity injury (36%) ,nerve palsy (13%)
most commonly seen in transverse + posterior wall fracture patterns

7. Radiographic evaluation: AP pelvic view , Judet view –iliac and obturator
Iliac oblique view –posterior column and anterior wall
Obturator oblique---anterior column and posterior wall

9. If any of the roof arc measurement in a displaced fracture are less than
45 degrees operative treatment should be considered
roof arc angle : angle between vertical line through femoral head and line
through fracture
stable- if the fracture line exits outside the weight bearing dome of the
acetabulum
not applicable for associated both column or posterior wall pattern
because no intact portion of the acetabulum to measure

10. On CT : transverse and anterior and posterior wall fracture are in sagittal
plane; anterior and posterior column fractures extend through the
quadrilateral surace and into obturator foramen with a more coronal
orientation

12. Optional views
inlet/outlet if concerned for pelvic ring involvement
examination under anesthesia (EUA)
used to assess posterior wall stability
hip positioned in flexion, adduction and axial load
obtain obturator oblique view
opening of the medial clear space suggests instability of the posterior
wall fracture

14. Axial CT scans showing the superior 10 mm of the acetabular roof to be
intact have been shown to correspond to radiographic roof arc
measurements of 45 degrees.
gull sign :represents impaction of superomedial roof
seen on iliac oblique view,pathognomic for posterior wall fractures
spur sign :represents most caudal part of intact ilium due to
medialization of articular components,seen on obturator oblique
view,pathognomic for ABC fractures

15. Judet and Letournel classification system
classifed as 5 elementary and 5 associated fracture patterns
most common fracture patterns
Younger:posterior wall,transverse fracture "family"
Elderly:anterior column (e.g., quadrilateral plate fractures)
anterior column, posterior hemitransverse
assoicated both column fractures

16. COMPLEX /ASSOCIATED PATTERNS

20. ANTERIOR COLUMN FRACTURE

27. TREATMENT: Follow ATLS protocol
urgent operative intervention within 1-24 hours if it is a part of
open fracture or associated with an irreducible dislocation of the hip
Nonoperative
protected weight bearing for 6-8 weeks
Indications: patient factors high operative risk (e.g., elderly patients,
presence of DVT) morbid obesity ,open contaminated wound
late presenting > 3 weeks
fracture characteristics-minimally displaced fracture (< 2 mm)
< 20% posterior wall fractures
treatment based on size of posterior wall is controversial
recommend an exam under anesthesia (EUA) using fluoroscopy best
method to test stability -femoral head congruency with weight bearing
roof (out of traction)
both column fracture pattern with secondary congruence (out of traction)
displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm
on axial CT cuts

28. Operative treatment
open reduction and internal fixation
indications
< 3 weeks from date of injury,physiologically stable
adequate soft-tissue envelope,no local infection
pregnancy is not contraindication to surgical fixation
displacement of roof (> 2 mm)
unstable fracture pattern (e.g. posterior wall fracture involving > 40-
50%)
marginal impaction,intra-articular loose bodies
irreducible fracture-dislocation
Approaches
Anterior-ilioinguinal,iliofemoral,modified stoppa
Posterior-Kocher-Langenbach
Combined-extended iliofemoral

29. total hip arthroplasty
indications
usually elderly patients with
significant osteopenia and/or significant comminution
pre-existing arthritis
post-traumatic arthritis in all ages
column fixation strategies
reconstruction bridging plate and screws
percutaneous column screws
cable fixation
wall fixation strategies
bridge plate and screws
lag screw and neutralization plate
spring (butress) plate

30. MEDICAL CONTRAINDICATIONS TO SURGERY
On occasion, the severity of the medical condition mandates that
operative intervention be
delayed. If deemed needed, the articular cartilage of the hip should be
protected during these delays with the patient in skeletal traction. On
occasion, severe head trauma with a
tenuous, evolving spectrum of injury may preclude a surgical procedure.

31. Approaches :
Anterior approaches – Ilioinguinal in Anterior wall and anterior column
Both column fracture
Posterior hemitransverse fracture
Posterior Kocher Langenbach - Posterior wall and posterior column fx
Most transverse and T-shaped
Combination of above fracture
Extended ilioinguinal approach - 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)
Modified Stoppa - Access to quadrilateral plate to buttress comminuted
medial wall fractures

36. KOCHER LANGENBACH APPROACH

40. Post-traumatic DJD most common complication
Heterotopic ossification
highest incidence with extensile approach
treat with
lowest incidence with anterior ilioinguinal approach
Osteonecrosis
DVT and PE
Infection
Bleeding
Neurovascular injury
risk factor
highest incidence with transverse + posterior wall fractures
Intraarticular hardware placement
Abductor muscle weakness

41. THANK YOU
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