Acetabular Fractures

Evan Watts Brian Weatherford Ben Taylor

Introduction
 Acetabulum fractures can involve one or more of the two columns, two walls or roof
within the pelvis
 Epidemiology
o demographics
 fractures occur in a bimodal distribution
 high energy trauma in younger patients (e.g., motor vehicle accidents)
 low energy trauma in elderly patients (e.g., fall from standing height)
 Pathoanatomy
o fracture pattern predominately determined by
 force vector
 position of femoral head at time of injury
 bone quality (e.g., age)
 Associated conditions
o orthopaedic manifestations
 lower extremity injury (36%)
 nerve palsy (13%)
 spine injury (4%)
o systemic injuries
 head injury (19%)
 chest injury (18%)
 abdominal injury (8%)
 genitourinary injury (6%)
 Prognosis
o poor outcomes are associated with:
 multi-system trauma
 increasing age
 poor articular congruency
 associated femoral head articular injury
 post-traumatic arthritis

Anatomy
 Osteology
o acetabular inclination & anteversion
 mean lateral inclination of 40 to 48 degrees
 anteversion of 18 to 21 degrees
o column theory
 acetabulum is supported by two columns of bone
 form an "inverted Y"
 connected to sacrum through sciatic buttress
 posterior column
 comprised of
 quadrilateral surface
 posterior wall and dome
  ischial tuberosity
 greater/lesser sciatic notches
 anterior column
 comprised of
 anterior ilium (gluteus medius tubercle)
 anterior wall and dome
 iliopectineal eminence
 lateral superior pubic ramus
 Vascular
o corona mortis
 anastomosis of external iliac (epigastric) and internal iliac (obturator)
vessels
 at risk with lateral dissection over superior pubic ramus

Letournel Classification
o Judet and Letournel
o most common referenced classification system
o classifed as 5 elementary and 5 associated fracture patterns

Illus. AP Obt.Obl. Iliac.Obl. CT Comments

Elementary
Posterior wall x • Most common
• "gull sign" on obturator oblique
view
Posterior column • check for injury to superior
gluteal NV bundle
Anterior wall x x • Very rare
Anterior column x x x • More common in elderly
patients with fall from standing
(most common in elderly is
"anterior column + medial wall")
Transverse x x x x • Axial CT shows anterior to
posterior fx line
• Only elementary fx to involve
both columns
Associated
Associated Both • Characterized by dissociation of
Column the articular surface from the
inonimate bone ; will see
"spur sign" on obturator
oblique
Transverse + Post. Wall x • Most common associated fx

T Shaped x x • May need combined approach

Anterior column or x x • Common in elderly patients
wall + Post.
hemitransverse
Post. column + Post. x x x x • Only associated fracture that
wall does not involve both columns
Imaging
 Radiographs
o recommended views
 AP pelvis
 Judet views (45 degree oblique views)
 obturator oblique
 shows profile of obturator foramen
 shows anterior column and posterior wall
 iliac oblique
 shows profile of involved iliac wing
 shows posterior column and anterior wall
o additional views
 inlet and outlet if concerned for pelvic ring involvement
 examination under anesthesia (EUA)
 assess posterior wall stability
 obturator oblique view
 hip postition in flexion, adduction and axial load
 opening of the medial clear space suggests instability of the
posterior wall fracture
o findings
 radiographic landmarks of the acetabulum
 iliopectineal line (anterior column)
 ilioischial line (posterior column)
 anterior wall
 posterior wall
 teardrop
 weight bearing roof
 superior acetabular rim may show os acetabuli marginalis
superior which can be confused for fracture in adolescents
 Shenton's line
 roof arc measurements
 help to define fracture pattern stability
 considered stable if the fracture line exits outside the weight
bearing dome of the acetabulum
 defined as > 45 degrees on AP, obturator and iliac oblique
views
 not applicable for associated both column or posterior
wall pattern because no intact portion of the acetabulum
to measure
 most common fracture patterns
 younger
 posterior wall
 transverse fracture "family"
 transverse
 T-type
 transverse + posterior wall
 elderly
 anterior column (e.g., quadrilateral plate fractures)
  anterior column, posterior hemitransverse
 assoicated both column fractures
 CT scan
o indications
 now considered a gold standard in management
o findings
 fracture pattern orientation
 define fragment size and orientation
 identify marginal impaction
 identify loose bodies (e.g., post-reduction)
 look for articular gap or step-off
o roof arm measurements
 view
 2mm fine cuts on axial view
 findings
 assess stability of the weight bearing dome based on the exiting
fracture line
 defined as an intact subchonral ring in the superior 10 mm of the
acetabulum
 >2mm incongruity in the articular segment is considered unstable
 Duplex doppler ultrasound
o indications
 delayed presentation to treating hospital
 rule out DVT

Treatment
 Nonoperative
o protected weight bearing for 6-8 weeks
 indications
 patient factors
 high operative risk (e.g., elderly patients, presence of
DVT)
 morbid obesity
 open contaminated wound
 late presenting > 3weeks
 fracture characteristics
 minimally displaced fracture (< 2mm)
 < 20% posterior wall fractures
 treatment based on size of posterior wall is
controversial
 recommend an exam under anesthesia (EUA)
using fluoroscopy best method to test stability
 femoral head congruency with weight bearing roof (out of
traction)
 both column fracture pattern with secondary
congruence (out of traction)
 displaced fracture with roof arcs > 45 degrees in AP and
Judet views or >10 mm on axial CT cuts
 technique
  skeletal traction NOT required if stable fracture pattern, outside
the weight-bearing dome
 activity as tolerated with crutches/walker
 weight-bearing
 lowest joint reactive forces seen with toe-touch weight
bearing and passive hip abduction
 greatest joint contact force seen when rising from a
chair on the affected extremity
 DVT prophylaxis if slow to mobilize
 close radiographic follow-up
 Operative treatment
o open reduction and internal fixation
 indications
 patient factors
 <3 weeks from date of injury
 physiologically stable
 adequate soft-tissue envelope
 no local infection
 pregnancy is not contraindication to surgical
fixation
 fracture factors
 displacement of roof (>2mm)
 unstable fracture pattern (e.g. posterior wall fracture
involving > 40-50%)
 marginal impaction
 intra-articular loose bodies
 irreducible fracture-dislocation
 approaches
 anterior
 ilioinguinal
 iliofemoral
 modified stoppa
 posterior
 Kocher-Langenbach
 combined
 extended ilifemoral
 techniques
 factors considered for fiaxtion methodology
 location (column and/or wall) and level (high or low) of
the fracture pattern
 amount of displacement
 marginal impaction
 assoicated injury
 fixation modalities
 column fixation strategies
 reconstruction bridging plate and screws
 percutaneous column screws
 cable fixation
 wall fixation strategies
  bridge plate and screws
 lag screw and neutralization plate
 spring (butress) plate
 outcomes
 timing
 associated hip dislocations should be reduced within 12
hours for improved outcomes
 worse outcomes with fixation of fracture > 3 weeks from
time of injury
 earlier operative treatment associated with
increased chance of anatomic reduction
 peri-operative
 clinical outcome correlates with quality of articular
reduction
 postoperative CT scan is most accurate way to
determine posterior wall accuracy of reduction
which has greatest correlation with clinical
outcome
 ideally articular reduction <2mm
 post-operative
 greatest stress on acetabular repair occurs when rising
from a seated position using the affected leg, and occurs
in the posterior superior portion of the acetabulum
 functional outcomes most strongly correlate with hip
muscle strength and restoration of gait postoperatively
o total hip arthroplasty
 indications
 usually elderly patients with
 significant osteopenia and/or significant comminution
 pre-existing arthritis
 post-traumatic arthritis in all ages
 techniques
 timing
 immediate vs. delayed THA
 immediate THA (with, or without, fracture fixation)
 wall fractures
 butress plate with multi-hole cup
 column fracture
 cage and cup constructs
 delayed THA
 outcomes
 patients older than 60 years have approx. a 30% late
conversion rate to THA after acetabular fractures
 10-year implant survival noted to be around 75-80%

Techniques
 Percutaneous fixation with column screws
o approach
 anterograde (from iliac wing to ramus)
  retrograde (from ramus to iliac wing)
 posterior column screws
o imaging
 obturator oblique best view to rule out joint penetration
 inlet iliac oblique view best to determine anteroposterior position of
screw within the pubic ramus
 obturator oblique inlet view best to determine position of a
supraacetabular screw within tables of the ilium
 ORIF
o approaches
 approach depends on fracture pattern
 two approaches can be combined

Approaches Indications Risks

Anterior • anterior wall and anterior • femoral nerve injury
Approach (Ilioinguinal) column • LFCN injury
• both column fracture • thrombosis of femoral vessels
• posterior hemitransverse • laceration of corona mortis in
10-15%.
Posterior Approach (Kocher- • posterior wall and posterior • increased HO risk compared
Langenbach) column fx with anterior approach
• most transverse and T-
shaped • sciatic nerve injury (2-10%)
• combination of above
• damage to blood supply of
femoral head (medial femoral
circumflex)
Extensile • only single approach that • massive heterotopic
Approach (extended allows direct visualization of ossification
iliofemoral) both columns • posterior gluteal muscle
• associated fracture pattern necrosis
21 days after injury
• some transverse fxs and T
types
• some both column fxs (if
posterior comminution is
present)
Modified Stoppa Approach • access to quadrilateral plate to • Corona mortis must be exposed
buttress comminuted medial and ligated in this approach
wall fractures

Complications
 Post-traumatic DJD
o most common complication
o 80% survival noted at 20 years for patients s/p ORIF
o risk factors for DJD include
 age >40
 associated fracture patterns
 concomitant femoral head injury
o treat with hip fusion or THA
 Heterotopic Ossification
 o highest incidence with extensile approach
 treat with
 indomethacin x 5 weeks post-op
 low dose external radiation (no difference shown in direct
comparison)
o lowest incidence with anterior ilioinguinal approach
 Osteonecrosis
o 6-7% of all acetabular fractures
o 18% of posterior fracture patterns
 DVT and PE
 Infection
 Bleeding
 Neurovascular injury
 Intraarticular hardware placement
 Abductor muscle weakness