1) Acetabular fractures are caused by high-energy trauma and require complex treatment due to the anatomy of the acetabulum and risk of joint instability. 2) Surgical treatment is indicated for fractures with over 2mm of displacement or less than 45 degrees of roof arc measurement, while non-operative treatment can be used for minimally displaced fractures or those with secondary congruence. 3) Surgical approaches like the modified Stoppa or Kocher-Langenbeck are selected based on the fracture pattern and aim to reduce and stabilize the displaced columns and walls with plates and screws to restore hip function.

1. Acetabulum Fracture
Dr Sijan Bhattachan
3rd year resident
Orthopaedics & Trauma Surgery, NAMS

2. Introduction
• Treatment of acetabular fractures is a complex area
of orthopaedics that is being continually refined.
• Caused by high energy trauma and associated
injuries are frequent.
• Management of entire patient should follow
accepted ATLS protocol.

3. Anatomy
• Acetabulum; Incomplete hemispherical socket with
an inverted horseshoe shaped articular surface
surrounding the nonarticular cotyloid fossa.
• Articular socket supported by two columns of bone,
described by Letournel and Judet as an inverted Y.

4. Columns

5. Dome

6. Quadrilateral Plate

7. • Sciatic nerve & Superior gluteal vessels

8. Corona Mortis

9. Mechanism of injury
• Impact of femoral head with acetabular articular
surface

10. Radiographic evaluation
• AP view
• Judet views (45 degrees oblique views)
-Iliac oblique view
-Obturator oblique view

13. Roof Arc
• Matta et al developed a system for roughly
quantifying the acetabular dome after fracture, which
they called the ‘Roof arc” measurement.

14. • Determines if the remaining intact acetabulum is sufficient to
maintain a stable and congruous relationship with femoral head.
• If any of the roof arc measurements in a displaced fracture are
less than 45 degrees, operative treatment should be considered

15. • CT scan is invaluable in the treatment of acetabular
fractures.

16. Classification
• Letournel & Judet;

17. Posterior Wall Fracture
• 25% of all acetabular fractures

19. Posterior Column Fracture

21. Both column Fracture
• 23% of all acetabular fractures
• Acetabulum completely disconnected from axial skeleton.
• Central dislocation of femoral head

22. • Spur Sign; External cortex of most caudal portion of
intact ilium.

23. • Secondary congruence

24. Treatment Protocol
• Radiographs allow proper fracture classification
• Fracture location and displacement determine need
for surgery
• Fracture Pattern determines Approach.

25. Non Operative ; Indications
• Nondisplaced and minimally displaced fractures (<2 mm)
• Fractures with significant displacement but in which the region of the joint
involved is judged to be unimportant prognostically (roof arc).
• Secondary congruence in displaced both column fractures
• Medical contraindications to surgery
• Local soft tissue problems, such as infection, wounds and soft tissue lesions
• Elderly patients with osteoporotic bone in whom open reduction may not be
feasible

26. Non Operative Treatment Techniques;
• Bed Rest with joint mobilisation.
• When there is adequate fracture healing , usually by
6-12 weeks , gradually progress to full weight
bearing..
• Prolonged traction treatment for those patients with
operative indications related to fracture displacement
but having contraindications to surgical intervention.

27. Indications for operative treatment
Fracture characteristics:
• With 2 mm or more of displacement in the dome of acetabulum as
defined by any roof arc measurements of less than 45 degrees
• any subluxation of the femoral head from a displaced acetabular
fracture noted on any of the three standard radiographic views
• Posterior wall fractures with more than 50% involvement of the
articular surface of the posterior wall.
• Incarcerated fragments in the acetabulum after closed reduction of
hip dislocation

28. • Urgent surgical interventions
-Irreducible hip dislocation
-Open fracture
-Vascular compromise
-Worsening neurologic deficit
• No delay beyond 15 days for elementary fractures and 10 days
for associated types

29. Surgical Approach
• Anterior
-Ilioinguinal
-Modified Stoppa
• Posterior (Kocher-Langenbeck approach)
• Extensile approaches
-Extended iliofemoral
-Triradiate approach
-T approach
• Combined Anterior & Posterior Approach

30. Selection of Surgical approach
• Fracture type
• Elapsed time from injury to operative intervention
• Magnitude and location of maximal fracture
displacement

31. Fracture Reduction & Fixation;
• First reduce and stabilise the
displaced columns , if present and
then reduce any wall fracture.
• After definitive fixation of the
reduced fragments, the entire
construct is stabilised with
buttress plates.

32. Percutaneous Treatment
• Mini open exposure through lateral window of ilioinguinal
incision.
Indications;
• To prevent potential further fracture displacement.
• Displaced fractures in elderly.
• Simple fractures with minimal displacement
• As an adjunct to standard ORIF techniques
• Severe injuries that prevent formal ORIF

35. Kocher-Langenbeck
Approach
• Indications;

37. Dissection

40. Complications;
• Infection
• Sciatic nerve palsy
• Heterotopic ossification

41. Special considerations
• Transecting the piriformis & obturator internus tendons
1.5 cm from GT.
• Quadratus femoris & obturator externus intact.
• Sciatic nerve directly visualised & protected; Recognize
anatomical variations.

42. • Sciatic nerve & Piriformis;

43. Ilioinguinal Approach
• Developed by Letournel after extensive cadaveric anatomical
study.
• Indications;

44. Access

45. Dissection

47. • Iliopectineal fascia separates Lacuna musculorum and
Lacuna vasorum.

48. • 3 windows;

49. Complications;
• Infection
• Femoral nerve palsy
• Injury to Lateral femoral cutaneous nerve
• Vascular injury

50. Modified Stoppa Approach
• Exposes internal surface of the anterior column and
the quadrilateral surface.
• It can be used for many fractures previously treated
through ilioinguinal approach.

51. Dissection

56. • Use of Stoppa Approach with the Lateral window of
the ilioinguinal approach has been promoted as a
way of avoiding the dissection of the middle window
of the ilioinguinal approach and thus exposure of
femoral vessels and nerve.

57. Complications
• Overall mortality rates (0 - 2.5%)
• Post traumatic arthritis & osteonecrosis of femoral head
• Infections
• Sciatic nerve palsy (10-15% ;2-6%)
• Heterotopic ossification
• Thromboembolic complications
• Intra articular hardware

58. THR
• In older patients with extremely poor prognoses.
• Indications include intraarticular comminution,
full thickness abrasive loss of articular cartilage,
impaction of femoral head, impaction of dome,
associated femoral neck fracture and
preexistent arthritis.
• Fractures can be fixed with percutaneous
screws, plates or cables and fixation augmented
with multiple screw fixation of the ingrowth cup.

59. • 45 yr/M ; Left Acetabulum Fracture

60. • Modified Stoppa with lateral window of Ilioinguinal
Approach

61. References
• Campbell’s operative orthopaedics, 13th edition.
• Rockwood & Green’s Fractures in Adults, 8th
edition.
• OTA lecture series III (Acetabulum Fracture).