Acetabular Fractures

BY
Tarek EL-KHADRAWE
Ass. Prof. of Orthopaedics and
Traumatology
Overview
 Radiographs
 Classification
 Treatment Options
 Surgical Approaches
Radiographic Evaluation
 From the lateral,
acetabulum is
inverted Y
 Anterior column
 Posterior column
 Sciatic notch through
obturator and inferior
pubic ramus
 AP
 6 Lines
 Iliopectineal

 Ilioischial

 Posterior wall

 Anterior wall

 Dome

 Teardrop
Radiographs
 6 Lines
 Iliopectineal
 Ilioischial
 Posterior wall
 Anterior wall
 Dome
 Teardrop

AP
Oblique
Iliac Oblique

 Posterior column
 Anterior wall
Iliac Oblique

 Posterior column
 Anterior wall
Iliac Oblique

 Posterior column
 Anterior wall
Oblique
Obturator

 Anterior column
 Posterior Wall
Obturator Oblique
The Dome
The Dome
Classification: Letournel and Judet
Classification: Special Notes
 Both column
 essentially a T
type occurring
proximal to the
joint
 No portion of the
articular surface
is attached to
axial skeleton
 SPUR SIGN
 Division of
both columns
ABOVE the
acetabulum
 Secondary
congruence
Posterior Wall

AP view
Posterior Wall

Obturator oblique view

Posterior Wall

Iliac oblique view

Representative CT cuts of the fracture, demonstrating
that approximately 50 percent of the posterior wall is affected.
 Beware posterior hip
dislocation
 Sometimes completely
unstable
 Traction to maintain
reduction until fixation
 Osteochondral fx
common: require
fixation/reduction if in
weight bearing portion
Biomechanics
 Weight bearing
portion:
 Primarily posterior and
superior
 Hip stable
 <20% of posterior wall
 Hip unstable
 >40% of posterior wall
Posterior Wall Fracture

 Blood supply
is from
capsule: do
not detach
 Flip over
leaving
capsule if
possible
Anterior column + posterior
hemitransverse vs. T type
 Reducing anterior column
usually reduces posterior
column, post capsule is
not usually disrupted
 In contrast, in the T type,
reducing the anterior
does not reduce the
posterior and the post
capsule is disrupted
T type
T type
T type
 Must involve
obturator foramen
Both Column
Both Column
Treatment options
 Nonoperative  Operative
 Traction  ORIF
 NWB  ORIF w/ THA
 Indicated if  Absolute indication is
displacement < 2mm hip instability /
subluxation out of
traction
Operative vs. Non-op
 Classic Articles  Current Literature
 Rowe and Lowell: non-
op is preferred
 Judet et. al: 90% good
result if anatomic
reduction, 74% good
result overall
 Rowe and Lowell
 2 groups of fractures
 High energy forces,
incongruous joint
 Operative
management is better
 Low energy, minimal
displacement
 Non-op management
is satisfactory
Surgical Considerations
 Timing  Approaches
 Surgery should be  Iliofemoral
completed within 7 d  Ilioinguinal
 results deteriorate  Kocher-Langenbach
after 3 weeks  Triradiate
 Extended Iliofemoral
 Combined
Iliofemoral

 Anterior column or anterior wall fractures

w/ displacement cephalad to hip joint
 Lag screws into anterior column
 Plate only fits on crest of ilium, not on
pelvic brim
Ilioinguinal
 Commonly sacrifice
 For anterior fractures
where access to entire
lateral cutaneous
anterior column nerve of the thigh
 Can be used for both
 Divide external
column fx only if oblique from inguinal
posterior piece is large ligament, expose
and intact spermatic cord/round
ligament
 Don’t see articular
surface, only fx lines
 Ligate inferior
in pelvis epigastric vessels
Ilioinguinal
 Complications:
 Femoral nerve injury
 LFCN
 Thrombosis in femoral
vessels
Ilioinguinal

 Sling 1: iliopsoas
 Sling 2: external iliac
artery and vein (aka
femoral sheath)
 Sling 3: spermatic
cord
Kocher-Langenbach
 Isolated posterior wall  Complications:
or posterior column  Sciatic nerve 2-10%
injuries only  Damage to femoral
 Exposure limited head blood supply via
superiorly by superior medial femoral
gluteal vessels and circumflex a.
greater trochanter
 High incidence of HO
and sciatic injury
 May consider troch
osteotomy
Approach by fracture type
 Kocher-Langenbach
 Posterior column
 Prone is best
 Weight of leg in lateral
position causes rotation
of posterior column
 Posterior wall
 Lateral is OK
 Posterior column +
posterior wall
 Prone is best
 Anterior column +
posterior
hemitransverse
 Ilioinguinal approach
usually adequate
 Transverse fxs
 Depends on location of
displacement
 T type is most difficult
Approach by fracture type
 Both Column
 If posterior column is a
single large fragment, then
ilioinguinal approach is
preferred
 If posterior column is not
reduced, then add Kocher-
Langenbach
 If significant posterior wall
fracture, choose extensile
or combined approach
Reduction
 Traction
 Fracture table
 Direct pull on femoral
neck
 Corkscrew into femoral
neck
 T handled bone hook
on greater troch
 External distractors
 5 or 6 mm Schanz
threaded pin through
the ischial tuberosity
as joystick for T type
or posterior column
fxs
 Farabeuf clamps on
screws inserted on
either side of fx
Fixation
 Interfrag lag screws  3.5 mm recon plate
 3.5 mm cortical contoured
screws, even in
cancellous bone
 No tap necessary
except in dense bone
of sciatic butress
Outcomes
 THA after ORIF of
acetabulum does
better than THA after
unreduced
acetabulum fx
Complications
 Thromboembolism: 60%  Post-traumatic DJD
of cases  Abductor weakness
 HO
 Use XRT or indomethacin
 Intra-articular
peri/post op for prophylaxis hardware
w/ Kocher-Langenbach
approach
 Neurologic injury
 AVN
 18% of posterior fracture
patterns
THANK YOU