fractures of acetabulum- anatmy and orthopedic management

2. Acetabular Fractures,imaging and
management
Presented by : Harjot Singh Gurudatta
Moderator : Dr. Gagan Khanna

3. A
N
A
T
O
M
Y
Directed laterally, downwards and forwards. lateral inclination of 40 to 48
degrees , anteversion of 18 to 21 degrees
The margin is deficient inferiorly and this deficiency is called the acetabular notch
, bridged by the transverse acetabular ligament.
The nonarticular roughened floor is called the acetabular / COTYLOID fossa It
contains a pad of fat lined by synovial membrane.
A horse-shoe shaped articular surface or lunate surface is seen on the
anterior, superior and posterior parts of the acetabulum.(ACETABULAR dome)
It is lined by hyaline cartilage and articulates with the head of femur; the articular
cartilage is thickest here.
•
•
•
•
All three parts of the innominate bone
contribute to form the acetabulum.
o Pubis -------- anterosuperior part of
the articular surface -------- 1/5th.
o Ischium ----- posteroinferior part of
nonarticular surface -------- 2/5th.
o Ilium -------- rest of acetabulum -------2/5th
• corona mortis
• At risk over superior pubic ramus

4. the quadrant of death

5. Normal Anatomy: Letournel –Judet Columns and
Walls
From the lateral aspect of
the pelvis, the innominate
osseous structural support
of the acetabulum may be
conceptualized as a twocolumned construct
forming an inverted Y.
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

6. Bony Anatomy
• Anterior Column
• Anterior column (iliopubic
component): extends from
iliac crest to symphysis
pubis and includes the
anterior wall of the
acetabulum.

7. Bony Anatomy
• Posterior Column
• Posterior column
(ilioischial component):
extends from superior
gluteal notch to ischial
tuberosity and includes
the posterior wall of the
acetabulum

8. •
•
•
•
•
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.

9. •
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.

10. Acetabular dome: The superior weight-bearing portion of the acetabulum
at the junction of the anterior and posterior columns, including
contributions from each.

11. Anterior column in white, posterior column
in red

12. 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.
The fracture pattern depends on Position of femoral
head at the time of injury, Magnitude of force, &
Age of patient.
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

13. 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.

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. IMAGING
•
Radiographic evaluation
5 Pelvic X-rays:
•
•
•
•
:
AP view
2 Judet views (iliac & obturator oblique views)
Inlet and Outlet Pelvis X-rays
CT scan

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.

18. 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, border of sciatic notch

* Anterior rim of acetabulum.

19. Obturator oblique radiograph
(45-degree internal rotation view)
• This is best for evaluating the anterior column and
posterior wall of the acetabulum(iliac wing and
spur sign(both colum # seen here)
• 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.
beam is roughly perpendicular to the obturator
foramen

20. AP pelvis
Iliac oblique
AW—anterior wall;
AC—anterior column;
PC—posterior column;
PW—posterior wall;
OR—obturator ring.
Obturator oblique

21. Inlet Pelvis X-ray
• Best demonstrates ring configuration of pelvis
• Evaluates for posterior displacement of pelvic ring or opening of pubic
symphysis
• Patient lies supineThe central ray is directed 40 to 60 caudal and enters at
the level of the anterior superior iliac spine. This view will demonstrate the
pelvic inlet in its entirety. A properly positioned inlet view of the pelvis should
demonstrate the superior and inferior ramus of the pubic bones
superimposed medially, near superimposition of the superior pubic ramus
and ischial ramus, and symmetry of the ischial spines

22. Outlet Pelvis XR
The patient is placed supine on the radiographic table with the midsagittal plane aligned
to the center of the grid. The central ray is directed 20 to 45 cephalic at the level 2
inches below the symphysis pubis.
A properly positioned outlet view will demonstrate the superior and inferior rami of the
pubis the superior and inferior rami of the pubis and the ischia, sacroiliac joint and
vertical displacement

23. Teardrop
• Internal limb = outer
wall of obturator canal
• External limb = middle
1/3 of cotyloid fossa
• Inferior border =
ischiopubic notch
• Radiographic teardrop
composed laterally of most inferior
and anterior portion of acetabulum
and medially of anterior flat part of
quadrilateral surface of iliac bone

24. 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.
Three-dimensional reconstruction allows for digital subtraction of femoral
head, with full delineation of the acetabular surface

25. 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 3dimensional reconstructions
and to aid Classification
• If sup glutel artery flap is
planned, an angiogrphy
should be done to ensure its
continuity especially in post.
Column #

27. Classification
• Accurate classification based on radiographs
, CT, Associated injuries of acetabular fractures is important
for determining the proper surgical treatment. Various
classification system
• Judet-Letournel
• Harris coupe
• Comprehensive syetem of classification

28. Classification
(Judet-Letournel)
•
•
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).

29. MC,Ischium+
ischiopubic
Ilioischial line#
rami
additional break in
the ischiopubic
segment
Part of dome
attached to
ilium

30. Classifications

31. Transverse Fracture
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.
Transverse fractures are sagittal plane
fractures whereas both column
fracturesare coronal plane
fractures.
The femoral head follows the inferior
ischiopubic fragment and may
dislocate centrally.

32. T-fracture
Transverse/post.wall
Post.wall/post.column
Associated types
Ass.both.column
Ant.post.hemitrans.
Othopaedic Review Course
January 2010

33. T-shaped fracture
Transverse fracture of any type
+
Vertical fr through the isciopubic fragment
The vertical component is best
seen on the obturator oblique
view.

34. T-shaped fracture
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.
In a pure transverse fracture, the
anterior and posterior columns may
be reduced through a single
approach In a T-type fracture, the 2
columns must be reduced separate
However, the superior extension
of the fracture does not involve
the iliac wing, which allows
differentiation from the bothcolumn fracture.

35. Both-column fracture
(formerly called ‘central acetabular fracture’)
Both columns are separated from
each other and from the axial
skeleton, resulting in a ‘floating’
acetabulum
This is the most complex
acetabular fracture.
type
A both columns fracture can be
considered a ‘high’ T-shaped
fracture where both columns have
been separated from the sciatic
buttress.
of

36. Both-column fracture
(formerly called ‘central acetabular fracture’)
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.
"Spur-sign" seen on the obturator oblique view

37. Both-column fracture
(formerly called ‘central acetabular fracture’)
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.

38. 3-D CT scan of a both-column acetabular fracture; obturator
oblique view

39. Classification
(The Comprehensive Classification of Fractures of the Acetabulum)
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 by SICOT International and AO/ASIF.
Each fracture is classified according to morphological characteristics, and
subdivided into types, groups, and subgroups.
The system is especially beneficial for research database applications.

40. The Comprehensive Classification of Fractures of
the Acetabulum

41. Roof Arc Angle(MATTA)
The medial, anterior, &
posterior roof arcs are
measured on AP, obturator
oblique, and iliac oblique
views, respectively.
The roof arc is formed by the
angle between two lines, one
drawn vertically through the
geometric center of the
acetabulum, the other from the
fracture line+ roof intersection
to the geometric center.
Roof arc angles are of limited
utility for evaluation of both
column fractures and posterior
wall fractures. To find the
amount of INTACT acetabular
roof to decide treatment
1. Medial Roof Arc (AP pelvis)
2. Anterior Roof Arc (Obturator
oblique)
3. Posterior Roof Arc (Iliac
oblique)

42. Roof arc measurement

43. Question 1
Classify the following acetabular
frx
Letournel Acetabular Frx Classification
Elementary
1. Anterior wall
2. Anterior column
3. Posterior wall
4. Posterior column
5. Transverse
Associated
1. T-shaped
2. Anterior wall/column plus posterior
hemitransverse
3. Transverse plus posterior wall
4. Posterior column plus posterior wall
5. Both-column

44. Question 2
Classify the following acetabular
frx
Letournel Acetabular Frx Classification
Elementary
1. Anterior wall
2. Anterior column
3. Posterior wall
4. Posterior column
5. Transverse
Associated
1. T-shaped
2. Anterior wall/column plus posterior
hemitransverse
3. Transverse plus posterior wall
4. Posterior column plus posterior wall
5. Both-column

45. MCQ 3
• Which two quadrants of the acetabulum are most at risk for
injury by screws during fixation of total hip arthroplasty
(THA):
1.
2.
3.
4.
5.
Anterior-inferior and posterior-superior
Anterior-superior and posterior-superior
Anterior-superior and anterior-inferior
Anterior-superior and posterior-inferior
Posterior-superior and posterior inferior

46. Answer 3
• Which two quadrants of the acetabulum are most at risk for
injury by screws during fixation of total hip arthroplasty
(THA):
1.
2.
3.
4.
5.
Anterior-inferior and posterior-superior
Anterior-superior and posterior-superior
Anterior-superior and anterior-inferior
Anterior-superior and posterior-inferior
Posterior-superior and posterior inferior

47. Explanation
•
The acetabular quadrant system described by Wasielewski and
colleagues is useful for determining the location of planned
acetabular screw fixation in THA to avoid neurovascular
complications. The quadrants are formed by drawing a line from the
anterior-superior iliac spine through the center of the acetabulum
and bisecting that line at the center of the acetabulum to form four
equal quadrants. The line from the anterior-superior iliac spine to
the center of the acetabulum serves as the dividing line between
anterior and posterior, and the bisecting line as the division between
superior and inferior.
In cadaver studies, the posterior-superior and posterior-inferior
quadrants were shown to have the thickest bone and best potential
for obtaining secure fixation with the least risk for injury to vessels.
The anterior-superior quadrant (the quadrant of death) and the
anterior-inferior quadrant were shown to be the most dangerous
quadrants for fixation due to the thin bone and close proximity of
the vessels to bone in that region.

48. • TO BE CONTINUED

50. Acetabular Fractures,imaging and
MANAGEMENT 2
Presented by : Harjot Singh Gurudatta
Moderator : Dr. Gagan Khanna

51. TILL NOW
PT CAME>>>>>>ABCD>>>>>STABILISATION>>>>>>>>>CLINICAL EXAMINATION
>>>>>>>NEUROVASCULAR ASSESSMENT>>>>>>XRAYS 5 VIEWS>>>>>>>CT
HIP
>>>>>CLASSIFICATION OF ACETABULUM # >>>>>> Presence of associated
ipsilateral injuries, 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, MORELL
LOVELLE LESION)
ROOF ARC MEASUREMENTS DONE AS DESCRIBED
>>>>>WAIT AND WATCH AND DECIDE FURTHER>>>>>

52. Goal of Treatment
• The goal of
treatment is
anatomic
restoration of the
articular surface
, prevent
posttraumatic
arthritis, Mobilise
patient, minimise
asso. Compl.

53. Initial Management
The patient is usually placed in
skeletal traction to
1. allow for initial soft tissue
healing,
2. allow associated injuries to be
addressed,
3. maintain limb length, &
4. maintain femoral head
reduction within the
acetabulum.

54. Non-operative treatment(MATTAMERITT CRITERIA)
Indications:
• Displacement <5mm in the dome, or articular step-off of <2mm
(with maintanance of femoral head congruency out of traction, &
absence of intraarticular osseous fragments).
N.B. If a fracture is displaced <2mm, no matter what the anatomical
type, nonoperative treatment should yield good results.
No # in CT Subchondral bone with in 10cm of joint.
• # in non weight bearing dome: Low anterior column fractures
Distal anterior column or transverse (infratectal) fractures in
which femoral head congruency is maintained by the remaining
medial buttress.# Low transverse fractures Low T-shaped
fractures. Even both column # with sec congruence
• Maintenance of medial, anterior and posterior roof arcs >45
(indicating fracture stability)
• Pt, is unfit for surgery

55. Operative treatment
Indications
• Head unstable and/or
incongruous joint
• Guidelines to be correlated to
patient factors. Hip dislocation
associated with:
• Posterior wall or column fractures
(posterior instability)
• Major anterior wall fractures
(anterior instability)
• Any fracture with significant size
quadrilateral plate fracture (Central
instability)

56. Incongruity
•
Displaced dome fractures:
•
•
High transverse or T-type fractures
•
•
•
•
•
surgery is usually necessary to restore the
weight-bearing surface.
These are shearing injuries that are grossly
unstable when they involve the
superior, weight-bearing dome.
Displaced both-column fractures (floating
acetabulum):
Retained osseous fragments may result in
incongruity or an inability to maintain
concentric reduction of the femoral head..
Femoral head fractures generally require ORIF
to maintain sphericity and congruity.
Soft tissue interposition may necessitate
operative removal of the interposed tissues.
•
Fractures through the roof or dome

57. Operative treatment
Timing
•
•
Surgery should usually be performed within 2
weeks of injury and usually after 1 week.
It requires
•
•
•
•
A well-resuscitated patient.
Appropriate radiologic workup.
Appropriate understanding of the fracture
pattern.
Appropriate operative team.
Surgical emergencies include:
Open acetabular fracture.
New-onset sciatic nerve palsy after
closed reduction of hip dislocation.
Irreducible posterior hip dislocation.
Medial dislocation of femoral head
against cancellous bone surface of
intact ilium

58. Assessment of reduction
Assessment of reduction
includes:
• Restoration of pelvic lines.
• Concentric reduction on
all 3 views.
• The goal of anatomic
reduction.

59. Operative treatment
Contraindications?/ Relative non operative
•
•
•
•
•
•
Operative contraindications
local or systemic infection,
severe osteoporosis
Relative contraindications
advanced age,
associated medical conditions
associated soft tissue and visceral
injuries,
multiply injured patient not
stable for a big acetabular
surgery

60. Morel–Lavallé lesion
(Skin Degloving Injury
• A closed degloving injury over the greater trochanter.
The subcutaneous tissue is torn away from the underlying fascia, and a significant
cavity containing hematoma and liquified fat forms
• These areas must be drained and debrided before or during definitive fracture
surgery to decrease the chance of infection.
• Advisable to leave this area open through the surgical incision or a separate
incision with regular care.
• Primary excision of the necrotic fat and closure over a drain has not been
routinely successful.

61. Complications
• Infection 6-10%
• Nerve palsy
•
Sciatic nerve: Kocher-Langenbach approach with
prolonged or forceful traction.
• Femoral nerve: Ilioinguinal approach may
result in traction injury to femoral nerve.
Rarely, the nerve may be lacerated by an
anterior column fracture.
• Superior gluteal nerve: most vulnerable in the
greater sciatic notch. Injury during trauma or
surgery may result in paralysis of hip
abductors with severe disability.
Thromboembolic

62. Complications
• Heterotopic bone formation
•
•
•
•
•
•
Extensile approaches
Young patient with muscle split
Kocher-Langenbeck
Indocin 25mg TID
Low Dose Radiation
Excision after 15-18 mo: 80% of
normal motion if no arthritis
Avascular necrosis, arthritis

63. Surgical Approaches
Kocher-Langenbeck (Posterior): best access to posterior column
(lateral/prone)
• Ilioinguinal (Anterior): best access to anterior column and inner aspect of
innominate bone (supine)
• Extended iliofemoral (Lateral): best simultaneous access to the two
columns (lateral)
Combined approaches performed concurrently or successively is less
desirable
No single approach provides ideal exposure of all fracture types.
Proper preoperative classification of the fracture configuration is essential to
selecting the best surgical approach.
Intraoperatively, corkscrew, schanz pin, reduction forceps help to achieve
reduction
•

64. Surgical approaches:
FRACTURE TYPE
APPROACH
ELIMENTARY FRACTURES
1 Posterior wall
2 Posterior column
3 Anterior wall
4 Anterior column
5 Transverse
Infratectal/Juxtatectal
Transtectal
Kocher-Langenbeck
Kocher-Langenbeck
Ilioinguinal
Ilioinguinal
Kocher-Langenbeck
Extended iliofemoral
or Kocher-Langenbeck

65. Surgical Approaches:
ASSOCIATED FRACTURES
1 Posterior column + wall
2 Anterior + posterior
Hemitransverse
3 Transverse + posterior wall
Infratectal/Juxtatectal
Transtectal
4 T – shaped
Infratectal/Juxtatectal
Transtectal
5 Associated both
Kocher-Langenbeck
Ilioinguinal
Kocher-Langenbeck
Extended iliofemoral
or Kocher-Langenbeck
Kocher-Langenbeck or
combined
Extended iliofemoral
or combined
Ilioinguinal.

66. Kocher-Langenbeck Approach

67. Kocher-Langenbeck Approach
1 M. glutaeus maximus
2 M. glutaeus medius
3 M. glutaeus minimus
4 M. piriformis
5 M. gemellus
Superior
6 M. obturatorius internus 7 M.
gemellus inferior
8 M. quadratus femoris
9 Lig. Sacrotuberale
10, N.,A.,V., glutea inferior
11 N.,A.,V., glutea superior

68. Kocher-Langenbeck Approach
Indications
•
•
•
•
•
•
•
Posterior wall fractures
Posterior column fractures
Posterior column/posterior wall fractures
Juxtatectal/infratectal transverse or transverse
with posterior wall fractures
Some T-type fractures
Trochantric osteotomy may be needed for good
exposure in high T and posterior wall or post
column # extending to supracetabular
ilium, for exposing superior dome of
acetabulum.
acetabular fractures with cranial extension and
dome involvement.

69. Areas accessible by KocherLangenbeck approach
• Entire
posterior
column
•Greater &
lesser sciatic
notches
•Ischial spine
•Retroacetabul
ar surface
•Ischial
tuberosity
•Ischiopubic
ramus

70. The room is set up such that the x-rays and CT scans are
available for viewing during the procedure. The patient is
prone on a radiolucent table.

71. The affected extremity is positioned with a distal femoral
pin to allow for traction on the table with the hip in slight
extension and the knee flexed to relax the sciatic nerve.

72. GREATER
TROCHANTER
The incision is midline over the femur, and angles posteriorly
at the posterior aspect of the greater trochanter to end slightly
superior to the posterior iliac spine.

73. GLUTEUS FASCIA
TENSOR
FASCIA
LATA
The skin incision is brought down to the level of the tensor
fascia lata, which is divided in line with the incision. The
gluteus maximus fascia is then divided.

74. GLUTEUS MAXIMUS
The gluteus maximus muscle is identified.

75. The maximus muscle is gently separated digitally until
the first traversing branches of the nerve are visible.

76. GLUTEAL NERVE BRANCH
Dividing the gluteus maximus too far
proximally will denervate a significant
portion of it.

77. GLUTEUS MAXIMUS
TROCHANTERIC BURSA
The trochanteric bursa is divided.

78. SHORT EXTERNAL
ROTATORS
QUADRATUS
FEMORIS
GLUTEUS
MEDIUS
VASTUS LATERALIS
View of the deep musculature with the Charnley retractor in place.

79. PIRIFORMIS
GLUTEUS
MEDIUS
With gentle retraction anteriorly of the gluteus
medius, the piriformis tendon comes into view.

80. OBTURATOR INTERNIS
PIRIFORMIS
After minimal dissection along the posterior aspect of the
short external rotators the obturator internis tendon is identified
between the gamelli.

81. TAG SUTURES
Both the piriformis and obturator internis are tagged and resected
approximately 1cm away from their insertion in the femur. It is helpful
before this is performed, to identify the sciatic nerve in an area
of healthy tissue, usually at the level of the quadratus femoru

82. PIRIFO
RMIS
OBTURATOR
INTERNIS
The piriformis and obturator internis are
being gently elevated using the sutures.

83. SCIATIC NERVE
OBTURATOR
INTERNIS
With the piriformis being held back digitally, the sciatic nerve
is visualized running posterior to the obturator internis tendon.

84. BLUNT COBRA
RETRACTOR
OBTURATOR INTERNIS
SCIATIC
NERVE
Knowing that the nerve is safe and can be protected by
the obturator internis muscle, a Letournel retractor, or
blunt cobra, is placed anteriorly to the obturator
internus tendon into the lesser sciatic notch.

85. BLUNT COBRA
RETRACTOR
OBTURATOR INTERNIS
SCIATIC
NERVE
Once in the lesser sciatic notch, posterior leverage on the retracto
allows exposure of the posterior aspect of the acetabulum while
protecting the nerve.

86. POSTERIOR ACETABULUM

87. DISPLACED POSTERIOR WALL
FEMORAL
HEAD
The femoral head and displaced portion
of the posterior wall are easily identified.

88. After the fracture and fracture bed are cleaned, the posterior
wall is reduced and fixed in place with a buttress plate.

89. REDUCED FRACTURE
After the fracture and fracture bed are cleaned, the posterior
wall is reduced and fixed in place with a buttress plate.

90. Ilioinguinal approach

91. Ilioinguinal Approach
1 M. psoas major
2 M. iliacus
3 Pecten ossis pubis
4 A. iliaca communis
5 A. iliaca interna
6 A. iliaca externa
7 Aa. Vv. Testiculares
8 V. iliaca communis
9 V. iliaca externa
10 N. ilioinguinalis
11 N. genitofemoralis
12 N. obturatorius
13 N. femoralis
14 N. cutaneus femoris lateralis
15 Ductus spermaticus
16 Ductus deferens

92. Ilioinguinal Approach
Indications
•
•
•
•
•
Anterior wall
Anterior column
Transverse with significant anterior
displacement
Anterior column/posterior hemitransverse
Both-column

93. Setup: The patient is supine on a radiolucent
table with skeletal traction holding the affected
extremity in slight flexion. A perineal post is
used to allow for traction if needed.

94. SYMPHYSIS
ASIS
ASIS
A
B
The incision is drawn out. Figure A shows the location of the
incision with respect to the symphysis and ASIS. Figure B shows
the patient from the side as one would observe during surgery. The
incision is curvilinear towards the posterior aspect of the ilium. The
surgery begins by approaching the iliac crest along
the area shown in figure B.

95. Sharp retractors are used to identify the interval
between the abductor and abdominal musculature.

96. The iliac crest is indicated by purple lines. The interval between the
abdominal and abductor musculature occurs towards the posterior
aspect of the iliac crest as the abdominal musculature hangs over
the crest (dotted line)

97. The interval is taken with a Bovie down to the iliac crest
and the abdominal musculature is reflected anteriorly.

98. ILIACUS
ILIUM
After the iliacus is released from the inside of the
ilium a large key elevator is used to elevate
subperiosteally to the SI joint.

99. After this dissection is complete, the posterior aspect of the
iliac fossa is packed off with a lap and attention to brought
to the anterior portion of the incision.

100. EXTERNAL OBLIQUE
FASCIA
Gelpi retractors are used to retract the skin and soft
tissue after the external oblique fascia is identified.

101. EXTERNAL
OBLIQUE
FASCIA
The external oblique fascia is divided in line with
the incision and the fascia is reflected distally.

102. VAS DEFERENS, SPERMATIC
CORD, + ILIOINGUINAL NERVE
EXTERNAL
OBLIQUE
FASCIA
EXTERNAL
OBLIQUE
FASCIA
INGUINAL LIGAMENT
After this is performed, the vas deferens, spermatic cord,
and ilioinguinal
nerve are identified and protected with a Penrose drain. Allis
c lamps are
used to retract the the external oblique fascia.

103. An incision is made in the inguinal ligament, allowing
1 to 2mm of the ligament to reflect medially with the
musculature (dotted line).

104. Incision through the inguinal ligament.

105. LATERAL FEMORAL
CUTANEOUS NERVE
ASIS
As the dissection extends toward the ASIS, one needs
to identify the lateral femoral cutaneous nerve, which is
immediately under the inguinal ligament. typically located
approximately 1cm medial to the ASIS

106. EXTERNAL
ILIAC
VESSELS
ILIOPECTINEAL
FASCIA
ASIS
PSOAS
FEMORAL
NERVE
At this point, the identification of the iliopectineal fascia is performed,
allowing for retraction of the exteral iliac vessels and lymphatics medial

107. TRUE PELVIS
ILIOPECTINEAL
FASCIA
ILIOPSOAS
MUSCLE
FEMORAL NERVE
The psoas muscle and femoral nerve are retracted
laterally. The army-navy retractor protects the vasculature
while the Allis clamp is holding the iliopectineal fascia.

108. FEMORAL NERVE
PSOAS
Closeup of the iliopectineal fascia demonstrating the psoas and femora
nerve on the lateral side of the fascia in the false pelvis. The true pelvis
is located medial to the iliopecineal fascia over the pelvic brim.

109. FEMORAL NERVE
PSOAS
Once the iliopectineal fascia is excised, access to the true pelvis is
obtained. The medial window of the approach is utilized when buttress
plating to the symphyseal body or symphyseal fixation is necessary.

110. ILIAC FRACTURE
LATERAL FEMORAL
CUTANEOUS NERVE
View from the opposite side of the table demonstrating
the lateral window and iliac wing fracture.

111. PSOAS
LATERAL FEMORAL
CUTANEOUS NERVE
VESSELS
PELVIC BRIM
View of the middle window demonstrating the pelvic brim.

112. ILIOPSOAS
SI JOINT
This figure demonstrates the lateral window and
exposure of the anterior column from the iliac crest and
S
SI joint proximally to the psoas gutter and pelvic
brim distally.

113. VESSELS
PELVIC
BRIM
PSOAS
This figure demonstrates the pelvic brim and displacement
of the fracture as seen through the middle window.

114. SUPERIOR RAMUS
FRAGMENT
DISPLACED ANTERIOR
COLUMN
Closeup of the fracture.

115. Extended iliofemoral approach

116. Extended Iliofemoral Approach
1 M. gemellus superior
2 M. obturatorius internus
3 M. gemellus inferior
4 M. piriformis
5 M. quadratus femoris
6 Sehne des M. obturatorius externus
7 Tuber ischiadicum
8 A. circumflexa femoris medialis, tiefer
Abzweig
9 N. ischiadicus

117. Extended iliofemoral approach
Indications
Transtectal transverse + posterior wall or T-shaped fractures
Transverse fractures with extended posterior wall
T-shaped fractures with wide separations of the vertical stem of
the ‘T’ or those with associated pubic symphysis dislocations
Certain associated both column fractures
Associated fracture patterns or transverse fractures operated on
>21 days following injury

118. Extended iliofemoral approach
Extended
iliofemoral
approach has the
highest incidence
of ectopic bone
formation (HO)
and longest
postoperative
recovery

119. Other approaches
• Stoppa approach (supine):
Allows access to the medial wall
of acetabulum, quadrilateral
surface, & sacroiliac joint.corona
mortis at risk.
• Triradiate approach (prone):
Alternate exposure to the
external aspect of innominate
bone, with almost same
exposure as iliofemoral but
visualization of the posterior
part of ilium is not as good

120. Implants
Screws
– 6.5-mm cancellous lag screws with buttress plate
– 4.0-mm cancellous lag screws and 3.5 mm cortical screws (lengths up to 120 mm)
– 6.5-mm fully threaded cancellous screws
• For fixation of the plate to bone, fully threaded cancellous screws are desirable, the
6.5-mm screw for the large reconstruction plate (4.5-mm) and the 3.5-screw for the
3.5-mm reconstruction plate.
• Cannulated screws may also be helpful.

121. Implants
Plates
•
•
•
•
•
A 3.5-mm reconstruction plate is the implant of
choice for acetabular reconstruction.
These plates can be molded in two planes and
around the difficult areas such as the ischial
tuberosity.
Also, precurved 3.5-mm plates are available for
anterior column fixation.
These plates are fixed with the 3.5-mm cancellous
screws.
In large individuals, and in pelvic fixation, the 4.5mm reconstruction plates are also useful, with
fixation by the 6.5-mm fully threaded cancellous
screws; however, they are rarely used at this time.
The 3.5-mm and 4.5 mm reconstruction plates for pelvic fixation

122. Plates
Sites of Application
•
•
•
•
•
•
The plates may be applied to the anterior column
from the inner table of the ilium to the symphysis
pubis.
Plates may also be applied to the posterior column
and the superior aspect of the acetabulum.
The distal screw should be anchored in the ischial
tuberosity.
Great care should be taken to ensure that screws in the
central portion of the plate do not penetrate the
articular cartilage of the acetabulum.
In most instances, no screws should be put into
that danger area, but if screws are necessary for
stable fixation, they should be directed away from
the joint. Screws within the joint are a not
uncommon cause of chondrolysis.
Plates may be nested to buttress small fragments.

123. Internal fixation with lag screw
• Stable fixation is best achieved by interfragmental compression using lag
screws.
• After provisional fixation of all fractures with K-wires, or cerclage
wires, screw fixation of the fractures is essential. The joint must be
visualized at all times to ensure that anatomical reduction has been
achieved and that no screw penetrates the articular cartilage.
• After fixation by interfragmental lag screws, plates may be used to
neutralize the fracture.
• Plates may be placed either on the anterior or posterior column,
depending on the approach.

124. Closed reduction and percutaneous fixation – proposed for
elderly patients &
Simple fractures with minimal displacements.
No long term results available yet

125. Example Case
• 48 y/o female
• Fx dislocation of L acetabulum displaced
• Left SI joint injury
• R non-displaced acetabular fx
• L:ORIF and Perc SI - FFWB
• R:Perc - WBAT

126. Postoperative Care
•
Indomethacin or irradiation: for heterotopic ossification
prophylaxis.
•
A variety of treatments has been proposed to decrease the amount of
heterotopic bone including the use of diphosphonates, radiation and
indomethacin.
• Diphosphonates prevent the mineralisation of osteoid, but this begins
again after withdrawal of the drug, and their use has been questioned.
• There have been several reports of the use of indomethacin after
operation for acetabular fractures.
• Local radiation therapy has also been used after reports of successful
results in hip arthroplasty.
•
•
•
Chemical prophylaxis, sequential compression devices, and
compressive stockings for thromboembolic prophylaxis.
Mobilization out of bed is indicated as associated injuries allow.
Full weight bearing on the affected extremity should be withheld
until radiographic signs of union are present (generally by 8-12
weeks postoperatively).