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ACETABULAR

FRACTURE
CLASSIFICATION & RADIOLOGY
RADIOGRAPHIC EVALUATION
The
acetabulum
is
evaluated
radiographically with an anteroposterior pelvic view as well as with
the 45-degree oblique views of the
pelvis described by Judet and
Letournel, commonly called Judet
views.
In the iliac oblique view, the radiographic beam is roughly perpendicular
to the iliac wing. In the obturator
oblique view, the radiographic beam
is roughly perpendicular to the
obturator foramen.
Inclusion of the opposite hip in the
radiographic
field
on
the
anteroposterior and Judet views is
essential for evaluation of symmetrical
contours that may have slight
individual variations and to determine
the width of the normal articular
cartilage in each view. The medial
clear space between the femoral
head and the radiographic teardrop
in the injured and uninjured hips
should
be
compared
on
the
anteroposterior view as an indication
of femoral head subluxation.
Fractures that traverse the anterior
column disrupt the iliopectineal
line, whereas fractures that traverse
the posterior column disrupt the
ilioischial line.
Evaluation of the various fracture
patterns
from
the
standard
radiographs requires an understanding
of the three-dimensional implications
of the status of each of the
radiographic landmarks as well as a
three-dimensional grasp of pelvic bony
anatomy and the possible variations of
fracture lines within a given fracture
pattern. In the operating room, the
three standard views can be obtained

with fluoroscopy. The restoration of the


radiographic landmarks is a guide to
the adequacy of fracture reduction.
Borrelli et al. described the use of
Judet view radiographs generated
from CT data that they found to be as
good as or better than conventional
radiographs in identifying fracture
characteristics and classification.
The anatomical dome is a threedimensional structure composed of
subchondral bone and its overlying
cartilage that articulates with the
weight-bearing portion of the femoral
head. Multiple studies have concluded
that the single most important factor
affecting long-term outcome in both
operatively and nonoperatively treated
acetabular fractures is maintenance of
a concentric reduction of the
femoral head beneath an intact or
anatomically reconstructed dome.
The dome, or roof, can be seen on the
anteroposterior and Judet views of the
pelvis, but the subchondral bone
shown on each of these views is only 2
to 3 mm wide and represents only that
small portion of the actual articular
weight-bearing
surface
that
is
tangential to the x-ray beam. Matta et
al. developed a system for roughly
quantifying the acetabular dome after
fracture, which they called the roof
arc
measurements.
These
measurements involve determination
of how much of the roof remains intact
on each of the three standard radiographic views:
1. anteroposterior,
2. obturator oblique, and
3. iliac oblique.
tte medial roof arc is measured on
the anteroposterior view by drawing a
vertical line through the roof of the
acetabulum to its geometric center. A
second line is then drawn through
the point where the fracture line
intersects the roof of the acetabulum
and again to the geometric center of
the acetabulum. The angle thus

formed represents the medial roof arc


(Fig. 56-13A). the anterior and
posterior roof arcs are similarly
determined on the obturator oblique
and iliac oblique views, respectively
(see Fig. 56-13B and C). Although
these are rough quantitations, they
are useful in the assessment of
fractures of the posterior or anterior
column, transverse fractures, T-type
fractures, and associated anterior
column and posterior hemitransverse
fractures; they have limited usefulness
for
evaluation
of
both-column
fractures and fractures involving the
posterior wall. 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.
CT is invaluable in the treatment of
acetabular fractures. Axial cuts should
be taken with thin (3-mm) intervals
and corresponding slice thicknesses.
The entire pelvis generally is included
to avoid missing a portion of the
fracture, and comparison to the
opposite hip is performed routinely.
A plastic pelvic model is helpful in
learning this technique and later for
drawing more complex fractures
directly on the model. In general, the
transverse fracture lines and fractures
of the anterior and posterior walls are
in the sagittal plane, paralleling the
quadrilateral surface when they are
viewed on axial CT images (Figs. 56-14
and 56-15). Anterior and posterior
column fractures usually extend
through the quadrilateral surface and
into the obturator foramen with a
more coronal orientation; variant
fracture types, however, may not
follow these generalities.
Some authors have suggested that
axial CT images overestimate the
extent of comminution of acetabular
fractures; however, in reality, only

existing fracture lines are shown on


the images. For example, in transverse
fractures,
moving
proximally
on
successive cuts, small fragments of
the anterior and posterior walls
enlarge to coalesce through the roof,
becoming the axial cross section of
the ilium. What may appear to be
separate anterior and posterior wall
fracture fragments on more inferior
cuts is in reality the distal extent of a
single proximal fragment. An oblique
fracture line divides the acetabulum,
so the more inferior CT cuts appear to
have three fragments when in reality
there are only two. By studying the
individual fragments on multiple
successive cuts, the entire fracture
can be appreciated, giving a true
mental
three-dimensional
picture.
High-resolution coronal and sagittal
reconstructions of the fracture are
helpful in the preoperative evaluation
of complex fractures by delineating
fractures that lie directly in the plane
of a given axial CT image.
CT scans can give the same
information about the acetabular
dome as the roof arc measurements
on the anteroposterior and oblique
radiographs. 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. Fracture
of the cotyloid fossa does not appear
to jeopardize stability of the femoral
head under the dome if the fossa
extends to within 10 mm of the apex
of the roof and the articular surface is
intact.
Three-dimensional
CT
reconstructions (Fig. 56-16) of a
fracture have become sophisticated
and can be projected in many different
views with subtraction of the femoral
head that show unique features of the
various
fracture
patterns.
Some
surgeons
who
treat
acetabular
fractures find routine use of these

reconstructions
helpful.
We
occasionally obtain three-dimensional
reconstructions
in
complicated
fractures, but we generally rely on
axial CT scans with coronal and
sagittal
reconstructions
correlated
with
the
standard
three
plain
radiographic views.
CLASSIFICATION
The
classification
of
acetabular
fractures described by Letour- nel
and Judet (Fig. 56-17) is the
commonly used classification system.
In this system acetabular fractures are
divided into two basic groups:
1. simple fracture types and
2. the more complex associated
fracture types.
Simple fracture types are isolated
fractures of one wall or column along
with transverse fractures; this type
includes fractures of the posterior wall,
posterior column, anterior wall, or
anterior
column
and
transverse
fractures.

Associated fracture types have more


complex fracture geometries and
include T-type fractures, combined
fractures of the posterior column and
wall,
combined
transverse
and
posterior wall fractures, anterior
column fractures with a posterior
hemitransverse fracture, and bothcolumn fractures.
Although several of the associated
fracture types involve both columns of
the acetabulum, the designation bothcolumn fracture in this classification
denotes that none of the articular
fracture fragments of the acetabulum
maintain bony continuity with the axial
skeleton: a fracture line divides the
ilium, so the sacroiliac joint is not
connected to any articular segment.
The spur sign, shown on the
obturator
oblique
view,
is
pathognomonic of a both-column
fracture. It represents the remaining
portion of the ilium still attached to
the sacrum and is seen projected
lateral to the medially displaced
acetabulum (Fig. 56-18).