Durkee et al.

Radiographic and CT Classification of Acetabular Fractures

M u s c u l o s ke l e t a l I m ag i n g P i c t o r i a l E s s ay

C E N T U R Y

O F

MEDICAL

IMAGING

Classification of Common Acetabular Fractures: Radiographic and CT Appearances

OBJECTIVE. Accurate characterization of acetabular fractures can be difficult because of the complex acetabular anatomy and the many fracture patterns. In this article, the five most common acetabular fractures are reviewed: both-column, T-shaped, transverse, transverse with posterior wall, and isolated posterior wall. Fracture patterns on radiography are correlated with CT, including multiplanar reconstruction and 3D surface rendering. CONCLUSION. In the evaluation of the five most common acetabular fractures, assessment of the obturator ring, followed by the iliopectineal and ilioischial lines and iliac wing, for fracture allows accurate classification. CT is helpful in understanding the various fracture patterns. ccurate classification of acetabular fractures is important for determining the proper surgical treatment [1, 2]. Because of the complex acetabular anatomy, various classification schemes have been suggested [35], but the Judet-Letournel classification system remains the most widely accepted [2, 4, 6]. Although radiographic examination provides essential information for acetabular classification, CT, including multiplanar reconstruction, is helpful in the visualization of complex fractures [7]. This article reviews the pelvic bone anatomy and the five most common acetabular fractures: both-column, T-shaped, transverse, transverse with posterior wall, and isolated posterior wall [2]. A fracture classification algorithm based on radiography is used, with correlation made to CT. Normal Anatomy: Columns and Walls The acetabulum is formed by anterior and posterior columns of bone, which join in the supraacetabular region [2, 6, 8]. 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. When looking at the acetabulum en face, the anterior and posterior columns have the appearance of the Greek letter lambda (!) [2, 6] (Fig. 1A). The anterior column represents the longer, larger portion, which extends superiorly from the superior pubic ramus into the iliac wing. The

N. Jarrod Durkee1,2 Jon Jacobson1 David Jamadar1 Madhav A. Karunakar3 Yoav Morag1 Curtis Hayes1,4
Durkee NJ, Jacobson J, Jamadar D, Karunakar MA, Morag Y, Hayes C

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,

Keywords: acetabular fracture, CT, musculoskeletal imaging, pelvic imaging, radiography, trauma DOI:10.2214/AJR.05.1269 Received July 21, 2005; accepted after revision September 18, 2005.
1Department of Radiology, University of Michigan Medical

Center, 1500 E Medical Center Dr., TC-2910G, Ann Arbor, MI 48109-0326. Address correspondence to J. Jacobson (jjacobsn@umich.edu).
2Present address: Department of Radiology, University of Washington, Seattle, WA. 3Department of Orthopedic Surgery, University of Michigan

Medical Center, Ann Arbor, MI 48109-0326.

4Present address: Department of Radiology, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA.

CME This article is available for 1 CME credit. See www.arrs.org for more information. AJR 2006; 187:915925 0361803X/06/1874915 American Roentgen Ray Society

A
Fig. 1Normal pelvic bone anatomy. A, Surface-rendering 3D CT of pelvis in lateral view with femur and right hemipelvis removed shows anterior column (green), posterior column (blue), and sciatic buttress (red). (Fig. 1 continues on next page)

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Fig. 1 (continued)Normal pelvic bone anatomy. B, Axial section through acetabulum shows anterior (arrowhead) and posterior (arrow) walls. C, Anteroposterior radiograph shows iliopectineal line (green), ilioischial line (blue), anterior acetabular wall (yellow), posterior acetabular wall (pink), and obturator foramen (O).

A
Fig. 2Illustrations of classification of five most common acetabular fractures. A, Both-column fracture. B, T-shaped fracture. C, Transverse fracture. (Fig. 2 continues on next page)

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 (Fig. 1B).

On radiographs, the iliopectineal (or iliopubic) line represents the border of the anterior column, and the ilioischial line represents the posterior column [9] (Fig. 1C). The edges

of the anterior and posterior walls are also identified. The obturator rings are composed of the osseous structures that surround the obturator foramen, which include the superior

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Radiographic and CT Classification of Acetabular Fractures on the most common fracture patterns, which represent 90% of acetabular fractures [2, 6] (Fig. 2). The five most common fracture types may be divided into two groups on the basis of presence or absence of obturator ring fracture (Fig. 3). Although fracture of the obturator ring may be seen in combination with acetabular fractures, it is important to note that obturator ring fractures may be associated with other pelvic injuries outside of the acetabulum, such as lateral pelvic compression injury, where the obturator ring fracture is associated with either an ipsilateral or contralateral sacral fracture [6]. We first discuss the two acetabular fracture types (both-column and T-shaped) associated with obturator ring disruption. Next we discuss the three acetabular fractures types that spare the obturator ring (transverse, transverse with posterior wall, and isolated posterior wall). D
Fig. 2 (continued)Illustrations of classification of five most common acetabular fractures. D, Transverse with posterior wall fracture. E, Isolated posterior wall fracture.

ACETABULAR FRACTURE IDENTIFIED OBTURATOR RING DISRUPTION? YES FRACTURE LINE EXTENSION INTO ILIAC WING? NO ILIOISCHIAL AND ILIOPECTINEAL LINE DISRUPTION? YES YES NO POSTERIOR WALL FRACTURE? YES NO TRANSVERSE FRACTURE NO POSTERIOR WALL FRACTURE? YES ISOLATED POSTERIOR WALL FRACTURE

Fig. 3Classification algorithm for five common acetabular fractures [2].

BOTH-COLUMN FRACTURE

T-SHAPED FRACTURE

TRANSVERSE + POSTERIOR WALL FRACTURE

pubic ramus and a combination of the inferior pubic ramus and ischium (or ischiopubic ramus). Anteroposterior and bilateral oblique (or Judet) views of the pelvis are important to adequately assess each of the radiographic lines for fracture.

Fracture Patterns The most widely accepted classification scheme for acetabular fractures is that of Judet and Letournel [2, 4, 6]. Although this classification scheme describes 10 types of acetabular fractures, we have focused

Both-Column Fracture A both-column acetabular fracture (Figs. 4 and 5) involves both anterior and posterior columns with extension into the obturator ring and iliac wing, and is one of the most common acetabular fractures [4]. On radiographs, fracture involvement of the anterior and posterior columns is characterized by disruption of the iliopectineal line and ilioischial line, respectively. However, disruption of these lines may also be seen with other fracture patterns, such as a transverse fracture. Obturator ring and iliac wing involvement must also be present for classification as a both-column acetabular fracture. Fracture extension into the iliac wing is not always obvious on the anteroposterior radiograph; oblique Judet views or CT often reveal this finding. On CT, fracture involvement of the anterior and posterior columns is seen, and the fracture may be comminuted. Fracture disruption of the obturator ring has a variable appearance; fracture of the superior pubic ramus may occur at the puboacetabular junction. In addition, fracture of the inferior pubic ramus may be difficult to identify if nondisplaced. The principal fracture line, which extends superiorly from the acetabulum into the iliac wing, is characteristically in the coronal plane. If present, a pathognomonic sign of a both-column fracture is the spur sign [2] (Fig. 5). This sign represents posterior displacement of the sciatic buttress of the iliac wing fracture, which essentially discon-

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Durkee et al. nects 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. 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. T-Shaped Fracture A T-shaped acetabular fracture (Fig. 6) is a combination of a transverse acetabular fracture with extension inferiorly into the obturator ring. It is similar to a both-column fracture

Fig. 445-year-old man with both-column acetabular fracture. AE, Anteroposterior pelvic radiograph (A), bilateral oblique pelvic radiographs (B, C), axial CT scan (D), and sagittal reconstruction CT scan (E) show acetabular fracture (straight arrows, AC), with break in obturator ring (arrowheads, AC) and extension into iliac wing (curved arrows). Note coronal plane of fracture on CT and superior pubic ramus fractured at puboacetabular junction. (Fig. 4 continues on next page)

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Fig. 4 (continued)45-year-old man with both-column acetabular fracture. AE, Anteroposterior pelvic radiograph (A), bilateral oblique pelvic radiographs (B, C), axial CT scan (D), and sagittal reconstruction CT scan (E) show acetabular fracture (straight arrows, AC), with break in obturator ring (arrowheads, AC) and extension into iliac wing (curved arrows). Note coronal plane of fracture on CT and superior pubic ramus fractured at puboacetabular junction.

Fig. 535-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.

in that it disrupts the obturator ring (Figs. 6A6C). Another similarity is disruption of both the iliopectineal and ilioischial lines (Figs. 6A6C). However, the superior extension of the fracture does not involve the

iliac wing, which allows differentiation from the both-column fracture. 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

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B
Fig. 640-year-old man with T-shaped acetabular fracture. AE, Anteroposterior 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 obliquesagittal orientation of transverse acetabular fracture component on CT scans that is transverse relative to acetabulum on radiographs. (Fig. 6 continues on next page)

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 (Fig. 6E). On CT, this transverse fracture component is seen as a sagittally oriented fracture coursing medially and superiorly from the acetabulum.

Transverse Fracture The transverse fracture of the acetabulum (Fig. 7) is limited to the acetabulum, without involvement of the obturator ring. A transverse fracture must involve both the anterior and posterior aspects of the acetabulum, so the iliopectineal and ilioischial lines are disrupted on radiography. Similar to the transverse component of the T-shaped

fracture described previously, this fracture line extends superiorly and medially from the acetabulum. On CT, the characteristic sagittally oriented fracture line can be seen moving laterally to medially on subsequent CT images when scrolling from inferior to superior. Although not anatomically transverse, the fracture plane is transverse relative to the acetabulum, which is relatively

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Fig. 6 (continued) 40-year-old man with T-shaped acetabular fracture. AE, Anteroposterior pelvic radiograph (A), bilateral oblique pelvic radiographs (B, C), axial CT scan (D), and surfacerendering 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 obliquesagittal orientation of transverse acetabular fracture component on CT scans that is transverse relative to acetabulum on radiographs.

Fig. 723-year-old woman with transverse acetabular fracture. AE, Anteroposterior 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 sagittaloblique fracture plane on CT scan (D). (Fig. 7 continues on next page)

tilted inferiorly and anteriorly. This fracture plane orientation is best seen on CT reconstruction images of the acetabulum en face (Fig. 7E).

Transverse with Posterior Wall The transverse with posterior wall fracture (Fig. 8) is a transverse fracture, described previously, with the addition of a comminuted

posterior wall fracture that is often displaced. As with an isolated transverse fracture, the key is recognizing that the obturator ring is not disrupted, as this excludes both-column

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C
Fig. 7 (continued)23-year-old woman with transverse acetabular fracture. AE, Anteroposterior 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 sagittaloblique fracture plane on CT scan (D).

and T-shaped fractures. As with the simple transverse fracture, this fracture type does not extend into the iliac wing. On radiographs, disruption of both iliopectineal and ilioischial lines is seen as with the isolated transverse fracture. Unlike an isolated transverse fracture, however, additional comminution of the posterior wall is seen. In the absence of displacement, comminution of the posterior wall may be difficult to identify on anteroposterior radiographs because the fragments are superimposed on the femoral head. Oblique Judet radiographs and CT are helpful in showing the comminuted posterior wall component.

Isolated Posterior Wall The isolated posterior wall fracture (Fig. 9) is one of the most common types of acetabular fracture, with a prevalence of 27% [8]. 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.

Conclusion Common acetabular fractures can easily be classified using disruption of the obturator ring as the basis of a decision tree (Fig. 3). Fracture of the obturator ring indicates both-column or T-shaped fracture, with additional iliac wing involvement differentiating the both-column from the T-shaped fracture. Sparing of the obturator ring commonly indicates transverse, transverse with posterior wall, or isolated posterior wall fracture. Disruption of both the iliopectineal and ilioischial lines indicates a transverse fracture, and comminution of the posterior wall indicates a posterior wall fracture. A bothcolumn fracture is in the coronal plane, whereas

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Fig. 820-year-old man showing transverse with posterior wall acetabular fracture. AE, Anteroposterior 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).

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Fig. 918-year-old man with isolated posterior wall acetabular fracture. AF, Anteroposterior 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). (Fig. 9 continues on next page)

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Fig. 9 (continued) 18-year-old man with isolated posterior wall acetabular fracture. AF, Anteroposterior 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).

References
1. Goulet JA, Bray TJ. Complex acetabular fractures. Clin Orthop Relat Res 1989; 240:920 2. Brandser E, Marsh JL. Acetabular fractures: easier classification with a systematic approach. AJR 1998; 171:12171228 3. Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reductionpreliminary report. J Bone Joint Surg Am 1964; 46:16151646 4. Letournel E, Judet R. Fractures of the acetabulum, 2nd ed. Heidelberg, Germany: Springer-Verlag, 1993 5. Harris JH Jr, Coupe KJ, Lee JS, Trotscher T. Acetabular fractures revisited. Part 2. A new CT-based classification. AJR 2004; 182:13671375 6. Hunter JC, Brandser EA, Tran KA. Pelvic and acetabular trauma. Radiol Clin North Am 1997; 35:559590 7. Falchi M, Rollandi GA. CT of pelvic fractures. Eur J Radiol 2004; 50:96105 8. Martinez CR, Di Pasquale TG, Helfet DL, Graham AW, Sanders RW, Ray LD. Evaluation of acetabular fractures with two- and three-dimensional CT. RadioGraphics 1992; 12:227242 9. Saks BJ. Normal acetabular anatomy for acetabular fracture assessment: CT and plain film correlation. Radiology 1986; 159:139145

F a transverse or T-shaped fracture is in the sagittal oblique plane on CT. The addition of CT with multiplanar reconstruction and 3D surface rendering is helpful in understanding and classifying acetabular fractures. Acknowledgment We thank Robert W. Jacobson for the illustrations.

F O R YO U R I N F O R M AT I O N

This article is available for 1 CME credit. See www.arrs.org for more information.

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