ACETABULUM FRACTURES-

AN ENIGMA
CONTENTS
• Introduction
• Anatomy
• Classification
• Mechanism of injury
• Investigations
• Nonoperative & Operative management of anterior, posterior,
combined #s
• Complications
• Message
NTRODUCTION
• In past, fracture acetabulum
was uncommon injury.
• Due to modernization there is increase incidence of high velocity
trauma like fracture acetabulum.
• Pelvi-acetabular fractures are devastating injuries causing
problems to treating surgeon.
 ENIGMA
• Complex anatomy.

• Radiological interpretation difficult.

• Delayed presentation, old age.

• Association with polytrauma.

ENIGMA
• Difficult surgical approaches.

• Perfect anatomic reduction necessary as major weight bearing joint

• Less space for operative maneuverability.

• Fear of neurovascular damage.

ANATOMY OF ACETABULUM
Letournel E, Judet R, #s of acetabulum,
New York:Springer-Verlag,1964.

• Two pillars
• Inverted Y
• Posterior column: Begins at greater sciatic
notch  ischial tuberosity inferior pubic
ramus part of obturator foramen.
ANATOMY OF ACETABULUM
• Anterior column: From iliac crest
to the superior pubic ramus.

• Three segments
Ilial
Acetabular
Pubic
 MECHANISM OF INJURY

• Dashboard injury
• Fall from height
• Others

• Type of # depends upon position of limb &

femoral head

Tile M, #s of pelvis &acetabulum

Baltimore:Williams&Wilkins,1984
 Common Mechanisms With
Associated Patterns
• Femoral Head acts like a hammer, thus the injury is
dependent on its’ position
–
Internally rotated
posterior column injury
Externally rotated –
anterior column injury
Adducted –
superior aspect of dome
Abducted –
inferior aspect of dome
RADIOGRAPHY
• Conventional views:
AP
• Special investigations:
1. Obturator oblique (Judet) view: Anterior
column & posterior lip
2. Iliac oblique (Judet view) : Posterior column
and anterior lip
3. CT scan with 3D images
4. Pelvic model
Obturator Oblique
Obturator oblique view
Iliac Oblique
Iliac oblique view
CT SCAN
3 D SCAN
 CLASSIFICATION
• Anatomical

• Comprehensive by Letournel and Judet

• AO classification developed with the help of Letournel, Matta,

Helfet and others and recognized by SICOT, OTA and AO group.
 CLASSIFICATION
•Letournel and Judet - 1964 in JBJS “Fractures
of the acetabulum: Classification and surgical approaches for open reduction”
Integrates pelvic anatomy, biomechanics, and aids in planning surgical approach

Has stood the test of time as the Gold Standard

Divides Acetabular Fractures into 2 major categories

• five simple patterns

• five associated patterns (combinations of the simple)

LETOURNEL CLASSIFICATION
• Elementary types :
1. Posterior wall
2. Posterior column
3. Anterior wall
4. Anterior column
5. Transverse
Posterior wall Posterior column
Anterior wall

Low Anterior column

High Anterior column

 TRANSVERSE
• Involves both columns
• Best seen on iliac oblique
• Obturator ring is intact
• Transtectal - passes through the
weight
bearing dome
• Juxtatectal - passes just superior
to the cotyloid fossa
• Infratectal - passes well below
the dome
Transverse
 LETOURNEL CLASSIFICATION
• Associated types:
1. Posterior column+ wall
2. Transverse+post.wall
3. T type
4. Anterior column +post. hemi
transverse
5. Both column #
Posterior wall
+
Posterior column
T-TYPE
• Transverse fracture with a vertical component
splitting the cotyloid fossa

• Portion of the weight bearing dome may be still

intact and congruent with the ilium and SI joint
T type
AO type Type of # Surgical Approach
A1 Posterior wall K-L approach

A2 Posterior column K-L approach

A3 Anterior wall/ Ilioinguinal

column
B1 Transverse Post KL approach with
osteotomy/ Ilioinguinal
B2 T type Combined /Extensile
iliofemoral / Triradiate.
B3 Ant + Post Hemi Iliofemoral / Ilioinguinal
transverse
C Both column Combined.
 IMMEDIATE MANAGEMENT PROTOCOL
• Hemodynamic stabilization

• Radiology ,3 D - C.T. Scan.

• Reduce dislocation

• Immobilisation
 COMMONLY ASSOCIATED INJURIES

• Pelvic ring
• Ipsilateral leg
• Neurovascular
• Urogenital
 Acetabular Fracture

Haemodynamically Unstable

Fluid & Blood replacement

Becomes Stable Unstable

Pelvis UnStable
Pelvis Stable
Definitive Management

? Vascular Injury External Fixator

Angiography Stable
Unstable

Iliac Vessel Injury Small Vessel Injury

Surgical repair / Ligation Embolisation

 TREATMENT GOALS

• JOINT CONGRUENCY
• ANTOBICAL REDUCTION
• ABSOLUTE STABILITY
 TREATMENT OPTIONS
Treatment modalities are:
• Conservative treatment.
• Open reduction Internal fixation
• Primary Total hip replacement (THR) with augmentation
technique.
• Delayed THR.
(Rommnes and Lewallen study)
 NON OPERATIVE TREATMENT
• Un-displaced fractures WITH NO HIP INSTABILITY

• DISPLACED ANT COLUMN # IN WHICH JT IS CONGRUENT

• ROOF ARC ANGLE <45 DEGREE ANT/POST/MEDIAL IN OBT/ILIAC/AP VIEW

• POST WALL # FRAG SIZE <20% (>50% SURGICAL M/N)

• Medical contra-indications

• Late presentation

• Local infection

• Gross osteoporosis / comminution

• Lack of facilities / expertise

NON OPERATIVE TREATMENT
Indications

• Adequate Roof arc angle

( Matta)

• Congruent reduction

• > 45 degrees

• # LINE >2CM AWAY FROM

APEX IN CT
ROOF ARC ANGLE

. .
.

AP VIEW JUDET VIEWS

AVERAGE IF MORE THAN 45 DEG CONSERVATIVE TREATMENT
Lateral pin traction

After 6 months
 INDICATIONS FOR SURGERY

• DISPLACED #
• .INCONGRUENCY >2MM DIPLACEMENT
• LARGE POST WALL FRAG >50 %
• POST INSTABILITY ON STRESS TEST
• INTRA-ARTICULAR FRAGMENT(EXCEPT IN FOVEA)
• # DISLOCATION UREDUCED BY CLOSED REDUCTION

OPTIMAL TIMING OF SURGERY

• WINTH IN 2 WKS
 Special Instruments
Femoral Distractor
Farabauf Reduction forceps.
Pelvic Reduction Forcep (Weber)
Reduction forcep ( AO)
King tong
Queen tong
Schanz screw
Plate Benders .
Farabauf Reduction forceps
IMPLANTS
• 3.5 mm cortical screws ( 10 to 120 mm)
• 4 mm +/- canulated screws.
• 4.5 mm cortical screws.
• 6.5 mm cancellous screws
• 3.5 mm recon Plate
• 3.5 mm DCP
• K- Wires
BOTH COLUMN #es

• EXTENDED APPROACH

• FIRST POST FIXATION IN LATERAL

THEN ANT COLUMMN FIXATION IN SUPINE
Anterior column fixation

Avoid screws
Ilioinguinal Approach
Three windows

Iliac
Crest

Psoas

Vessels Cord

Three windows
62 yrs old,
Transverse #
Obturator oblique,
immediate post op
Iliac
oblique,
immediate
post op
6 months post op
T#
RTA
3 D Scan
Immediate post op
Combined approach
52 yr MALE
Quadrilateral plate fracture
Quadrilateral plate fracture
Quadrilateral plate fracture
MANAGEMENT OF POSTERIOR #s
SURGICAL APPROACH

KOCHER LANGENBECK

• Patient in the lateral position with the affected

hip uppermost. If a fracture table and a
supracondylar femoral traction pin are used,
keep the knee joint in atleast 45 degrees of
flexion to prevent excessive traction on the
sciatic nerve.
• Skin incision over the greater trochanter and
extend it proximally to within 6 cm of the
posterior superior iliac spine . The incision can be
extended distally over the lateral surface of the
thigh for approximately 10 cm as necessary.
 POSITION

Posterior
Lateral

Floppy Lateral Position

ADE:K-L APPROACH
BDE:GIBSONS APPROACH
CDE:MOEDS APPROACH
• Divide the fascia lata in line with the skin incision and bluntly split the
gluteus maximus in line with its muscle fibers for a distance of no
more than 7 cm, protecting the branch of the inferior gluteal nerve to
the anterosuperior portion of the gluteus maximus to avoid
denervating that part of the muscle.
POSTERIOR FIXATION
 INDICATIONS FOR PRIMARY THR IN
ACETABULAR FRACTURES
• Irreversible destruction of acetabulum and femoral head.
• Extensive impaction of acetabulum and femoral head.
• Gross comminution.
• Patient age > 65 years
• Severe comminution with osteoporosis
• Articular step > 4 mm
PRIMARY THR FOR ACETABULAR
FRACTURES

Challenging because
• Difficulty in reducing gross displacement of fractures to provide a bed
for acetabular cup.
• Multiple fragments.
• Poor hold of implants.
Complications

IMMEDIATE
• Thromboembolism
• Mal reduction.
• Intra-articular implants.
• Sciatic nerve injury.
• Vascular injury
Complications
LATE
• Heterotopic
ossification.
• Chondrolysis.
• AVN
• Post traumatic
arthritis.
• Infection
 Malreduction
Prevention:
• Proper preop. Planning
• Good intraoperative imaging.
• Proper instrumentation.
• Skills and expertization.

Management:
• Re-fixation.
• Replacement.
Sciatic nerve injury
Incidence: 6%

Prevention:
• Proper isolation of the nerve.
• Proper retraction with cover of ext. rotators.
• Proper positioning: Hip extension, knee flexion (Letournel & Judet, #s of
the acetabulum1993.)
 Heterotopic ossification

seen mainly in extensile approach

Prevention :
• Irradiation 700cGy single dose / multiple low doses.
(Moed B, Letournel E, JBJS,1994,76B(6)

• Indomethacin 25 mg t.d.s. x 2 months (Matta JM, JBJS, 1996,

78A)
Heterotopic ossification + AVN
 AVN
incidence 8-12%
Prevention:
• Early hip reduction
• Less soft tissue damage

Treatment:
• Physiotherapy
• Drugs
• THR
 PROGNOSIS
Factors not in our control Factors in our
• Comminution control
• Polytrauma • Reduction accuracy
• Dislocation • Operative time
• Impaction • Soft tissue handling
• Delayed presentation • Intra articular metal
• Neuro-vascular injury.
CONCLUSION
• High learning curve.

• Expertise is essential.

• Results of inadequate fixation are comparable or at times even

worse than those results obtained by non-operative
treatment modality.