Acetabualr fracture

1. Acetabular Fracture
Sudarshan Pandey
2nd year Resident
Department of Orthopedics and
Traumatology, KUSMS

2. Table of content
• Anatomy
• Mechanism of injury
• Clinical evaluation
• Imaging
• Classification
• Treatment

3. Anatomy

5. Anatomy
• Inverted Y shaped
• Two columns of bone (Letournel
and Judet)
• Anterior column
• Posterior column

6. • Anterior Column:
• Iliopubis component
• Posterior Column:
• Ilioischial component

8. Mechanism of Injury
• Impact of the femoral head with the acetabular articular surface
• Greater trochanter(direct trauma along the axis of the femoral neck)
• Anywhere along the long axis of the femoral shaft(Indirect trauma
dashboard injury)

9. Clinical evaluation
• ATLS protocol- High energy trauma
• Neurovascular assessment:
• Sciatic nerve injury may be present in up to 40% of posterior column disruptions.
• Associated ipsilateral injuries must be ruled out: ipsilateral knee
instability and patellar fractures
• Soft tissue injuries (e.g., abrasions, contusions
subcutaneous hemorrhage)

10. Imaging
• X-Rays
• Standard AP view
• Judet Views
45 degree obturator oblique view
45 degree iliac oblique view
• Pelvic inlet and outlet view
• CT scan

11. Radiographic Evaluation
• AP pelvic view
• Judet views
1. Iliopectineal line beginning at
greater sciaticnotch of ilium and
extending down to pubic
tubercle.
2. Ilioischial line formed by
posterior four fifths of
quadrilateral surface of ilium.
3. Radiographic teardrop composed
laterally of most inferior and
anterior portion of acetabulum
and medially of anterior flat part
of quadrilateral surface of iliac
bone.
4. Roof of acetabulum.
5. Edge of anterior lip of
acetabulum.
6. Edge of posterior lip of
acetabulum.

12. Obturator Oblique View Iliac oblique view

14. Classification (Letournel and Judet)
• Elementary
(simple)
pattern
• Associated
(complex)
pattern

15. Things to be considered during Classification
• Iliopectineal line
• Ilioischial line
• Obturator ring
• Ilium involvement
• Spur sign

16. AP pelvic radiograph
• Iliopectineal line – Anterior Column
• Anterior rim – Anterior
Wall/column
• Ilioischial line – Posterior Column
• Posterior rim – Posterior
wall/column
• Acetabular roof – anterior/
posterior column
• Teardrop

17. Algorithm
• Ilioischial line
• Iliopectineal line
• Obturator ring
• Ilium involvement
• Spur sign
columns
Transverse
T- shaped
Both column
Obturator ring??
1
2

18. Obturator ring
column
- Wall fracture
Transverse fracture
T shaped

19. Ilium??
• Ilium involvement
• Anterior column
• Both column
• Anterior column + Posterior Hemitransverse
Spur sign
3
4

20. Posterior Wall Fracture
• Involve posterior acetabular rim, which includes the posterior
articular surface
• Quadrilateral plate intact
• Most common fracture mechanism : Dash board injury
• Gull sign

21. Posterior wall fracture

23. Posterior column fracture
• Posterior portion of acetabulum
• Fracture line runs through greater sciatic notch and into
ischiopubic ramus
• Superior gluteal neurovascular bundles – trapped in sciatic notch.

24. Posterior Column fracture

25. Anterior Wall fracture
Least common type of acetabular fracture
Do not involve obturator foramen

26. Anterior Column fracture
Anterior column disconnected from sciatic buttress
Fracture line crosses obturator foramen

27. Transverse fracture

28. Posterior column posterior Wall fracture

29. Transverse and posterior Wall fracture

31. T type fracture

33. Anterior column fracture with posterior
hemitransverse fracture

34. Associated Both column fracture
• Weight bearing acetabulum disconnected from sciatic buttress –
Floating Acetabulum
• Columns are separated from each other
• Spur sign on obturator oblique view
• Secondary congruence

35. Associated Both column fracture
Spur sign

36. CT imaging
• Acetabular wall fracture
• Intraarticular fragments
• Marginal impaction
• Comminution
• Femoral head lesions
• Joint congruence

38. Treatment
Goal
• Anatomic restoration of the articular surface and prevent
posttraumatic arthritis
• Early Mobilization
• Minimise associated complications .

39. Treatment
Indication of Non operative treatment
1. Non displaced and minimally displaced fracture
• Fracture traversing wt bearing Dome and <2mm displaced –NWBM x 6-12
wks
• Periodic radiograph to ensure no displacement
2. Significant displacement in region of joint that is judged to be
unimportant significantly
• Roof arc measurement ARA- 25 degree, MRA- 45 degree, PRA- 70 degree

40. Roof Arc Measurement
To find the amount of INTACT
acetabular roof/ weight bearing
dome to decide treatment
1. Medial Roof Arc (AP pelvis)
2. Anterior Roof Arc (Obturator
oblique)
3. Posterior Roof Arc (Iliac
oblique)
According to Matta et al., if any of the roof arc measurements
in a displaced fracture are less than 45 degrees, operative
treatment should be considered.

41. Treatment
Indication of Non operative treatment
3. Secondary congruency in displaced both column fractures
4. Medical Contraindications to surgery
• Skeletal traction
• Percutaneous fluoroscopic screw fixation

42. Treatment
Indication of Non operative treatment
5. Local soft tissue problems- Infection, wounds, Morel-Lavallee lesion
6. Elderly patients with osteoperotic bone in whom open reduction
may not be feasible

43. Treatment
Indications for Operative treatment
1. Fracture characteristics
• >= 2mm displacement
• Roof Arc measurement < 45 degrees
• Fracture subluxation
• Posterior Wall fracture >50% involvement of posterior wall articular surface
2. Incarcerated fragments in acetabulum after CR of hip dislocation
3. Prevention of nonunion and retention of sufficient bone stock for
later reconstructive surgery

44. Timing of surgery
• Urgent surgical intervention associated with acetabular fracture
• Irreducible hip
• Open fracture
• Vascular compromise
• Neurological deficit
• Ideally ORIF acetabular fracture : 5-7 days of injury (Campbell- 13th
ed)
• Less bleeding
• Anatomical reduction difficult after 5 days in associated and 15 days in
elementary patterns

45. Surgical approach to acetabulum fracture
• Posterior
• Kocher- Langenbeck approach
• Modified Gibson approach
• Anterior
• Ilioinguinal (lateral, middle, medial
windows)
• Iliofemoral approach
• Stoppa (medial window)/Anterior
intrapelvic approach
• Extensile approach
• Extended iliofemoral approach
• Triradiate approach
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.

46. Surgical approach to acetabulum fracture
• Posterior Approach

47. 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

49. Kocher Langenbeck approach
• Steps

50. • Superficial dissection

53. Pitfalls & Challenges
1. Avoid excessive traction.
2. Make sure that the horizontal limb of the incision is not too posterior. This will
help to prevent accidental injury to the sciatic nerve when the fascia is incised
distally.
3. Make sure that the piriformis and conjoined tendons are released from their
trochanteric insertion without compromising the vascular supply of the
femoral head.
4. Dissect very carefully at the supra-acetabular area to avoid injury to the gluteal
neurovascular bundle.
5. Avoid dissection close to the acetabular rim in order to preserve its vascular
supply.
6. Always identify the lesser sciatic notch. This is a safe area for sciatic nerve
retractor placement.

54. Ilioinguinal Approach: Indication
• Anterior wall acetabular fractures.
• Anterior column acetabular fractures.
• Transverse acetabular fractures with
the major displacement occurring at
the anterior column.
• Both-column acetabular fractures.
• Anterior element reduction and
fixation in T-type acetabular fractures.
• High transverse fracture

55. Three windows of the ilioinguinal approach
• Lateral to iliopsoas
• Between iliopsoas and
femoral nerves and vessels
• Medial to femoral vessels

56. Ilioinguinal approach : Complicating factors
• Soft tissue limitations
• Colostomy, suprapubic drainage
• Ex fixator pin tracts, open wounds
• Crush
• Obesity
• Hernia , mesh

57. Other approaches
• Stoppa approach (supine):
• Allows access to the medial wall
of acetabulum, quadrilateral
surface, & sacroiliac joint,
corona mortis at risk.

58. • Pfannenstiel incision
• Ligation of corona mortis
• Stoppa window

59. Iliofemoral approach
• Anterior approach
• Anterior wall fracture
• Anterior column fracture

60. Modified Gibson approach
• Indication
• Posterior wall
• Posterior column
• Transverse, T type fracture

61. Extended Iliofemoral approach
• exposes the entire lateral
innominate bone, by posterior
reflection of the abductors, and
reflection of short external
rotators.
• It can be extended anteriorly
into the first (iliac) window of
the ilioinguinal incision.

62. 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
• Both column fracture
• Associated fracture patterns or transverse
fractures operated on>21 days following injury
highest incidence of ectopic bone formation (HO)
and longest postoperative recovery

63. • 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
• Complication:
• Superior gluteal vessel injury
• Massive ischemic necrosis of hip
abductors

64. Fracture fixation
• Plates
• 3.5 mm and 4.5 mm recon plates
• 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
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

65. Complications
Early:
• Thromboembolism
• Infection
• Neurological injury
• Vascular injury
• Intraarticular hardware
• Malreduction
• Loss of reduction
Late:
• Avascular necrosis
• Heterotopoic ossification
• Pseudoarthrosis
• Post traumatic arthritis

66. Percutaneous screw fixation
Antegrade Posterior Column screw
• Tragectories
• Pelvic brim to ischial tuberosity
• False pelvis to ischial spine
• Iliac crest to sciatic notch

68. Percutaneous screw fixation
• Retrograde percutaneous posterior column screw fixation

69. Percutanous Anterior column screw fixation
• Antegrade
• Bone narrowing at center of
acetabulum and middle of pubis
ramus
• Retrograde
• In out in technique

70. 42 y/F Associated Bicolumnar Fracture
Spur sign

73. 2 yrs follow up

74. Take Home Messages
• Acetabular fracture is an intraarticular fracture requiring anatomical
reduction, rigid fixation and early mobilization
• Classification of acetabular fracture guide the surgeon for best
approach
• Fracture demanding experts for fixation

75. Thank You