Acetabulum AOSR ENG

ELEMENTAL FRACTURE TYPES
Acetabulum - Posterior wall fracture
1. Introduction and epidemiology
Posterior wall
Posterior wall fractures are the most common acetabular fractures and account for approximately
24% of acetabular fractures.
They typically involve the rim of the acetabulum, a portion of the retroacetabular surface, and a
variable segment of the articular cartilage.
The fracture line leaves undisturbed the major portion of the posterior column. A posterior
dislocation is usually associated.
Posterior wall fractures are partial fractures of the posterior column.
Epidemiology
Acetabular fractures are rare: Of approximately 37 per 100,000 pelvic fractures in the USA annually,
only 10% involve the acetabulum with an estimated 4000 per year among the elderly. High-energy
trauma is the primary cause in younger individuals and association with other fractures and pelvic
ring disruptions are common. Fractures secondary to moderate or minimal trauma are increasingly
of concern in those over 35 years because of osteoporotic changes. Acetabular fractures are most
often associated with lower limb fractures resulting from falls, particularly, in older individuals.
Posterior wall
2. AO classification: 62-A1
In the AO classification, posterior wall fractures are classified as A1. Type A fractures are partial
articular fractures, involving only one of the two columns.
3. Definition: Posterior wall
Typically, fractures of the posterior wall involve the rim of the acetabulum, a portion of the
retroacetabular surface, and a variable segment of the articular cartilage.
The fracture line leaves undisturbed the major portion of the posterior column. A posterior
dislocation is usually associated.
Thus, posterior wall fractures are partial fractures of the posterior column.
4. Mechanism of the injury

Posterior wall type fractures, including those of the posterior wall and the posterior column, with or
without transverse T-configuration, occur in motor vehicle crashes. An unrestrained, seated
occupant's flexed knee strikes the dashboard. If the force vector is directed appropriately, the
femoral head strikes the posterior wall, resulting in a fracture, the exact location of which depends
upon the position of the hip at the time of impact. If the hip is sufficiently adducted, a posterior
dislocation may occur without a posterior wall fracture.
Note
Search for associated knee injuries.
5. Posterior dislocation
When a posterior dislocation is associated with a posterior wall fracture, open reduction and internal
fixation is virtually always indicated because the posterior wall defect renders the hip unstable.
Posterior dislocations also increase the risks of sciatic nerve injury and of avascular necrosis of the
femoral head.
6. Comminution of posterior wall

If the posterior wall fragment is comminuted, reduction and fixation will be more difficult, and the
prognosis is poorer.
7. Marginal impaction
Crushing of the posterior acetabular surface (marginal impaction) creates a condition of incongruity
and instability. Reduction requires elevation of the impacted articular surface and bone grafting of
the resulting defect.
The reduced femoral head is a helpful template.
If a satisfactory and stable reduction can be achieved, the final outcome may be better. Otherwise,
prognosis is poor. Unreduced impaction, which not only leaves an incongruent area of joint surface
but also prevents proper reduction of adjacent displaced wall fragments, adversely affects prognosis.
8. Femoral head contusion and abrasion
Femoral head contusions and abrasions are both extremely difficult to repair and increase the risk of
posttraumatic arthritis.
9. Loose bodies
Loose bodies (intraarticular fracture fragments) produce incongruity and instability. If interposed
between the joint surfaces, they cause arthritis. The need to remove such loose bodies is thus an
indication for acetabular surgery.
10. Duration of dislocation
The more time that passes before the hip is relocated, the higher the risk of avascular necrosis.
Greater displacement of the dislocated hip also adversely affects the outcome.
Nonoperative
Indications
Undisplaced fractures
Congruently reduced hip joint
Stable hip joint through range of motion
Very small posterior wall fragment(s)
No evidence of progressive displacement
Contraindications
Displaced fractures
Incongruent hip joint
Unstable hip joint
Irreducible dislocation
Progressive sciatic nerve deficit
Large posterior wall fragments
Advantages
Avoidance of potential surgical complications, if indications are met
Disadvantages
Risk of bad outcome
Residual displacement may compromise hip replacement
Note
Posterior wall fractures usually result from posterior hip dislocation. The sciatic nerve may be injured.
CT, after reduction of any dislocation, is essential for evaluating fracture, reduction, and/or possible
intraarticular fragments.
Operative
Indications
Displaced posterior wall fracture
Unstable hip joint
Larger posterior wall fragment
Progressive loss of reduction
Possible contraindications
Physiologic instability
Local infection
Advantages
Restores congruity and stability of hip
Anatomical reconstruction of articular surface
Reduces risk of fracture displacement
Disadvantages
Risks of surgery
Sciatic nerve injury
Heterotopic bone formation
Infection
Note
Surgery is urgent for
irreducible dislocation
increasing sciatic nerve deficit
hip joint incongruity with risk of femoral head damage
Consider total hip replacement for severe arthritis and possibly for severe osteoporosis.
Kocher-Langenbeck
The Kocher-Langenbeck approach is a nonextensile approach to the posterior acetabular column.

It allows direct visualization of the posterior column, including the posterior acetabulum either
through the fracture gap or after capsulotomy.
Somewhat greater exposure can be obtained with osteotomy of the greater trochanter and
displacement of the abductor muscles (trochanteric flip).
Indications
ORIF of fractures of the posterior wall or posterior column
Combined fracture types in which the posterior column or wall needs to be reduced under
direct vision
Transverse juxta- and infratectal fractures
Contraindications
Use of the Kocher-Langenbeck approach alone is contraindicated if it does not permit

adequate reduction and fixation.
Trochanter flip extension
The trochanter flip (digastric trochanteric osteotomy) can be used to extend the exposure of the
Kocher-Langenbeck approach superiorly and anteriorly.
This exposure can be combined with a surgical dislocation of the hip in more complex injury
patterns.
The most common use for this variation of the Kocher-Langenbeck approach is the postero-superior
wall fracture.
Posterior column
1. Fracture morphology
Posterior column
Posterior column fractures originate at the greater sciatic notch, pass through the roof or weight
bearing dome and exit through the obturator ring. The result is a complete detachment of the
posterior column.
Occasionally the fracture is limited to the ischium.
Isolated posterior column fractures are rare (2.4% - 3.2% of acetabular fractures [Matta, Letournel])
and are usually associated with a posterior dislocation of the hip. Even associated with a posterior
wall fragment, the prevalence of this lesion is not so high (3.4% [Matta, Letournel]).
The fracture is usually displaced posteriorly, medially, and in internal rotation, as the posterior
column rotates about the ischial tuberosity.
As the femoral head is driven through the posterior column and fractures it, it tends to open up the
posterior column like a swinging door, moving posteriorly into the pelvis.
The superior gluteal vessels and nerves can be at risk from displaced fragments.
Posterior column
62-A2 Posterior column
In the AO classification, posterior column fractures are classified as A2. Type A fractures are partial
Nonoperative
Indications
No evidence of progressive displacement (frequent radiographic monitoring is required)
Contraindications
Displaced fractures
Unstable hip joint
Advantages
Disadvantages
Risk of bad outcome
Operative
Indications
Displaced posterior column fracture
Unstable hip joint
Possible Contraindications
Local infection
Advantages

Disadvantages
Risks of surgery
Sciatic nerve injury
Infection
Note
increasing sciatic nerve deficit
Consider total hip replacement for severe arthritis and possibly for severe osteoporosis.
Kocher-Langenbeck

It allows direct visualization of the posterior column, including the posterior acetabulum either
through the fracture gap or after capsulotomy.
Somewhat greater exposure can be obtained with osteotomy of the greater trochanter and
displacement of the abductor muscles (trochanteric flip).
Indications
ORIF of fractures of the posterior wall or posterior column
Combined fracture types in which the posterior column or wall needs to be reduced under
direct vision
Transverse juxta- and infratectal fractures
Contraindications
Use of the Kocher-Langenbeck approach alone is contraindicated if it does not permit
adequate reduction and fixation.
patterns.
Anterior wall
1. Definition
Anterior wall
Fractures of the anterior wall are segmental fractures of the anterior column and typically involve
the anterior segment of the acetabulum.
They contain the anterior lip and a varying amount of the middle third of the anterior column.
At the inside, they involve the anterior articular facet and a variable portion of the acetabular fossa.
The distal fracture line exits in the region below the femoral vessels and iliopsoas muscle.
2. AO classification: 62-A3.1
62-A3
In the AO classification, anterior wall fractures are classified as A3.1. Type A fractures are partial
3. Fracture characteristics
Dislocation
Dislocation
The femoral head is dislocated anteriorly and medially, pushing the avulsed anterior wall fragment(s)
in the same direction. The anterior wall fragment typically is rotated externally around its long axis.
Fragment(s)
The displaced head detaches a part of the acetabular fossa together with a variable part of the
quadrilateral surface. This plate of bone usually keeps a posterior hinge, but it may also be a free
fragment.
4. Intraarticular fracture fragments and marginal impaction

Impaction and articular fragments
Part of the internal portion of the roof may appear isolated or be impacted into the underlying
cancellous bone. Intraarticular fracture fragments and marginal impaction create a condition of
incongruity and instability.
Femoral head damage

Due to dislocation, the femoral head may show areas of contusion, abrasion, or indentation.
These conditions can not be reversed and worsen the prognosis.
Note
The anterior wall fracture is a rare fracture pattern. Among other fracture patterns it is typical in
elderly persons and a result of low-energy injury. The bone involved is commonly osteoporotic.
Nonoperative
Indications
Very low fractures of the anterior wall (acetabular roof arc angle > 45)
Contraindications
Displaced fractures
Unstable hip joint
Large anterior wall fragment
Advantages
Disadvantages
Risk of bad outcome
Note
CT, after reduction of any dislocation, is essential for evaluating fracture, reduction, and/or possible
intraarticular fragments.
Operative
Indications
Displaced anterior wall fracture (large or high fragment)
Unstable hip joint
Local infection
Advantages
May provide better support for late hip arthroplasty
Disadvantages
Risks of surgery
Nerve or vessel injury
Infection
Note
Ilioinguinal approach
The ilioinguinal approach was developed by Emile Letournel based on cadaveric dissections to
provide anterior access for fractures of the acetabulum.
It provides exposure of the inner aspect of the innominate bone from the sacroiliac joint to the pubic
symphysis.
The surgical exposure requires development of three wound intervals. Mobilization of the femoral
vessels and nerve, as well as the spermatic cord (male) or round ligament (female), is key to the
development of these intervals.
Articular reductions, using the ilioinguinal approach, are done indirectly. They are based on
meticulous restoration of extraarticular anatomy, since the joint can not be directly visualized with
this approach.
Indications
Virtually all fractures of the anterior wall and anterior column
Associated anterior plus posterior hemi-transverse patterns
Both column fractures
Occasional transverse or T-shape fractures may be treated using this approach
Anterior column
1. Definition
Anterior column
Anterior column fractures separate a segment of anterior acetabulum from the rest of the
innominate bone. The fracture starts from the middle of the ischiopubic ramus below, then passes
through the anterior acetabulum. The proximal extension of this fracture passes variably through the
innominate bone, at different levels above the acetabulum, as far upwards as the middle third of the
iliac crest.
Anterior column fractures are classified by the level of their proximal end. Depending on this level,
we distinguish very low, low, intermediate, and high fracture types.
Low, intermediate, and high anterior column fractures
62-A3
In the AO classification, anterior column fractures are classified as A3.
High anterior column fractures, with the fracture line extending to the iliac crest, are classified as
A3.2.
Low anterior column fractures, with the fracture line extending approximately to the level of the
psoas gutter, are classified as A3.3.
Type A fractures are partial articular fractures, involving only one of the two columns.
3. Morphology: Low and very low fractures
Low fracture
In low fractures, the upper margin of the fracture extends to the level of the psoas gutter. The
anterior wall of the acetabulum and a small amount of its roof are separated from the remaining
anterior column (see figure).
In very low fractures, the displaced fragment comprises the lowest part of the anterior wall, adjacent
anterior column, and the related acetabular surface. The superior fracture line transsects the
anterior wall and descends through the fovial notch (not illustrated).
4. Morphology: Intermediate fractures
Intermediate fracture
The upper margin of the fracture extends to the level between the anterior superior and inferior iliac
spines. This fracture separates a larger portion of the anterior column and wall from the intact
acetabulum.
Often, a comminuted portion of the quadrilateral surface is detached and hinged posteriorly.
5. Morphology: High fractures
High fracture
The upper margin of the fracture extends to the level of the iliac crest, as far backwards as its middle
third.
This fracture separates a massive segment of the anterior column, containing the anterior wall with
its related articular surface. It involves nearly all of the roof, and the front part of the iliac wing.
Anterior column fractures are often comminuted, splitting the free part into several pieces.
6. Dislocation of the femoral head

Head dislocation
Displacement of the anterior column fragment always is the result of an anterior femoral head
displacement or dislocation. The head of the femur pushes the fragments anteriorly and typically
remains displaced anteriorly and medially, dislocated from the posterior articular surface.
The head is easily visible in the fracture gap. The pelvic brim fragment is rotated externally around
its long axis. The quadrilateral plate is rotated internally.
The CT view reminds us of the swinging doors of traditional style Western saloons.
Femoral head damage
Due to dislocation, the femoral head may show areas of contusion, abrasion, or indentation.
These conditions can not be reversed and worsen the prognosis.
7. Intraarticular fracture fragments and marginal impaction
Articular fragments & marginal impaction
Part of the internal portion of the roof may appear isolated or be impacted into the underlying
cancellous bone. Intraarticular fracture fragments and marginal impaction create a condition of
incongruity and instability.
Nonoperative
Indications

Contraindications
Displaced fractures
Unstable hip joint
Large anterior column fragment
Advantages
Disadvantages
Risk of bad outcome
Operative
Indications
Displaced anterior column fracture
Unstable hip joint
Prophylactic stabilization of undisplaced anterior column fracture
Local infection
Advantages
Disadvantages
Risks of surgery
Infection
Note
symphysis.
this approach.
Iliofemoral approach
The iliofemoral approach and the approach named after Smith-Peterson share a similar skin incision
but differ markedly, since the iliofemoral is directed to intrapelvic exposure, while the Smith-
Peterson incision exposes the hip joint anteriorly.
Access
This approach provides access to the iliac crest and the entire internal iliac fossa.
The fossa exposure incorporates full visualization of the anterior aspect of the sacroiliac joint, if
needed.
The medial limit of the exposure is expanded medially to the iliopectineal eminence when the
ipsilateral limb is prepped free and the hip can be flexed to 60-90 degrees and adducted.
This approach also provides digital and limited visual access to the quadrilateral surface and greater
sciatic notch.
Indications
Some fractures of the anterior column can be operated through the iliofemoral approach. The best
candidates are those where the fracture pattern extends to the crest and there is a single large
anterior column component.
Transverse fractures
1. Definition
Transverse fracture
Transverse acetabular fractures involve a single fracture line which crosses the acetabulum through
both posterior and anterior columns. Such fractures divide the acetabulum into an upper portion
(ilium with the roof), and a lower portion (ischium and pubis).
The transverse fracture can cross the columns at different levels, and is variable in its inclination in
sagittal and coronal planes. Occasionally, comminution is present.
The lower portion of a transverse fracture typically is displaced medially, with more or less rotational
malalignment. It is usually more displaced posteriorly, but occasionally the greater displacement is
anterior.
If the fracture line involves the weight-bearing superior dome, a perfect reduction is required for a
good result. However, transverse fractures may be difficult to reduce. Through the Kocher-
Langenbeck approach, the surgeon has direct access only to the posterior end of the fracture.
2. AO Classification: 62-B1
In the AO classification, transverse fractures are classified as B1. Type B fractures are partial articular
fractures with a transverse component.
3. Morphology
Transverse fracture levels
Transverse fractures may run at different levels through the acetabulum.

Transverse fractures are classified according to their relationship to the roof of the acetabulum:
Transtectal dividing the roof of the acetabulum (1, yellow fracture line)
Juxtatectal diving the fossa acetabuli and the roof (2, red fracture line)
Infratectal cutting the fossa acetabuli in the middle (3, brown fracture line)
Note
The transtectal transverse fracture has the worst prognosis because it involves the most critical part
of the weight-bearing dome.
4. Radiology: AP view
AP view
On the AP view, all the vertical lines of the acetabulum are disrupted by the fracture: the anterior
and posterior borders, and the iliopectineal and the ilioischial lines, as well as the roof.
With transverse fractures involving the medial roof and juxtatectal area, the femoral head may be
dislocated into the pelvis, or medially displaced with articular incongruity.
The inferior acetabular segment is displaced medially and rotated internally around an antero-
posterior axis, hinging on the pubic symphysis.
Note:
Transtectal fracture lines are more unstable in that they frequently allow femoral head displacement
and joint incongruity.
The image below shows
1. (green line) posterior wall
2. (orange line) anterior wall
3. (yellow line) roof (dome or tectum)
4. (brown line) teardrop
5. (red line) ilioischial line (posterior column)
6. (blue line) iliopectineal line (anterior column)
Note
The obturator ring is still intact, thus eliminating the possibility of an associated T-type fracture.
Radiographic landmarks in AP view
5. Radiology: Iliac oblique view

Iliac oblique view
These images demonstrate three different transverse acetabular fractures on the iliac oblique view.
The fracture lines cross the posterior column at different levels:
1. Transtectal (left)
2. Juxtatectal (below, left)
3. Infratectal (below, right)
Note that it may be possible to see where the fracture crosses the anterior wall, unless this view is
obstructed by the femoral head.
Iliac oblique view
6. Radiology: Obturator oblique view

Transtectal - obturator oblique view
This view demonstrates the location of the fracture relative to the acetabular roof.
These images show two different transverse fractures. The first is transtectal (left), and the second
juxtatectal (below).
The obturator oblique view confirms the integrity of the obturator foramen, and thus excludes the
possibility of a T-type fracture.
Notice the medial dislocation of the femoral head along with the lower portion of the acetabulum.
Also, note that the obturator oblique view demonstrates the posterior acetabular wall. It is intact on
these images. However, posterior wall fractures may be associated with transverse fractures.
Juxtatextal - obturator oblique view
7. Radiology: CT scan
CT scan - lower sacroiliac joint
Level of lower sacroiliac joint
In transverse fractures, the ilium can be slightly externally rotated, with medial dislocation of the
femoral head. In this example, anterior sacroiliac ligament tearing is present, with SI joint widening.
8. CT scan - level of acetabular roof
CT scan - cut through the acetabular roof
The transverse fracture can be seen crossing anterior and posterior columns, dividing the
acetabulum into lateral-superior and medial-inferior portions.
The anteroposterior orientation on CT scan is a diagnostic feature of transverse fractures.
9. Radiology: 3D CT reconstruction
3D CT reconstruction
This image demonstrates medial displacement of femoral head and medial displacement with
internal rotation of the distal acetabular segment, as well as slight opening of the ipsilateral
sacroiliac joint.
Nonoperative treatment
Indications
Caution
Transtectal transverse fractures significantly involve the weight-bearing articular surface, so that any
displacement or gap may compromise outcome. Thus, surgical repair is relatively more indicated.
Contraindications
Displaced fractures
Unstable hip joint
Advantages
Disadvantages
Risk of bad outcome
Operative treatment
Indications
Displaced transverse fracture, especially transtectal or juxtatectal types
Unstable hip joint
Prophylactic stabilization of undisplaced fracture
Local infection
Advantages
Disadvantages
Risks of surgery
Infection
Note

Kocher-Langenbeck approach
Introduction
It allows direct visualization of the dorsocranial part of the acetabulum either through the fracture
gap or after capsulotomy.
Transverse fracture treatment with the Kocher-Langenbeck approach

Most transverse acetabular fractures can be reduced and fixed through the Kocher-Langenbeck
approach. This may be difficult if repair is delayed, or if anterior displacement is greater. In either
case, an extended iliofemoral approach may permit a better reduction.
Through the Kocher-Langenbeck approach, the lower portion of the pelvis can be manipulated with
a Schanz screw in the ischium, aided by lateral traction and appropriately placed reduction clamps.
However, visualization and direct manipulation of the anterior part of the fracture is limited.
Advantages
Simpler approach if reduction can be obtained
Faster functional recovery
Excellent visualization of posterior column
Disadvantages
Less access to anterior portion of fracture
Exposure for fixation somewhat limited
Extended iliofemoral approach (EIF)

The extended iliofemoral approach exposes the entire lateral innominate bone, by posterior
reflection of the abductors, and reflection of short external rotators. It can be extended anteriorly
into the first (iliac) window of the ilioinguinal incision.
The extended iliofemoral approach involves significant stripping of the bone, is associated with
heterotopic bone formation, and a prolonged recovery period. Abductor weakness is to be expected.
When necessary, this approach may be used to achieve reductions which are otherwise impossible.
Indications
Transverse fractures, particularly displaced transtectal types
Transtectal associated transverse + posterior wall fractures
When ORIF is delayed by three or more weeks
Contraindications
Aged patients
Obese patients
Patients who are not committed to a long recovery process
Advantages
Simultaneous visualization of both posterior and anterior columns
Reduction and fixation are usually straightforward
Disadvantages
Technically this approach is demanding
Highest complication rate
Heterotopic bone formation is common (prophylaxis should be planned).
Abductor muscle weakness with prolonged rehabilitation must be expected.
Dangers of the extended iliofemoral approach
This approach risks injury to the vessels and nerves that exit through the greater sciatic notch. The
superior gluteal artery and its accompanying veins lie on the deep surface of the gluteal muscles.
During elevation and posterior reflection of the glutei, the vessels may be torn, typically where they
lie against the ilium at the top of the notch. If torn, they may retract into the pelvis. Bleeding from
the superior gluteal vessels may be difficult to control. The surgeon should remember that packing
the notch may help, followed by angiographic embolization, or, alternatively, the use of an anterior
vascular approach.
Additionally, the superior gluteal nerve runs with the superior gluteal vessels, and is itself at risk of
injury during exposure, retraction, and during efforts to control bleeding. Furthermore, the sciatic
nerve, which usually exits the notch distal to the piriformis muscle, is also at risk of injury, typically
from retractors or prolonged stretching.
Neurovascular injury is more likely during exposure of older fractures, and when fracture lines run
parallel to the course of vessels and nerves.
patterns.
Introduction
symphysis.
this approach.
Transverse fracture treatment with the ilioinguinal approach

Rarely, an occasional very high anterior transverse fracture may best be reduced through an
ilioinguinal approach. This is particularly worth considering when anterior displacement is greater
than posterior.
Advantages
Excellent access to anterior column

Rapid rehabilitation
Disadvantages
Transverse fractures rarely present a suitable pattern for reduction and/or fixation through
this approach
Must be done early, before consolidation begins
Anterior column/ posterior hemitransverse fractures
1. Definition
Anterior column/posterior hemitransverse
In this group of acetabular fractures, an anterior column fracture is associated with a posterior
hemitransverse fracture.
In addition, the femoral head is usually medially subluxed. Variations in this fracture pattern are
based on whether the anterior column fracture exits at the iliac crest or inferior to the anterior
inferior iliac spine.
The posterior column component varies on the basis of level of involvement in the greater sciatic
notch.
The posterior column fracture morphology usually follows an oblique sagittal orientation unlike the
posterior column involvement in a T-shape fracture.
Anterior column / posterior hemitransverse
2. AO classification
62-B
In the Mller AO classification, anterior column and posterior hemitransverse fractures are classified
as B3. Type B fractures are partial articular fractures with a transverse component.
Nonoperative
Indications

Contraindications
Displaced fractures
Unstable hip joint
Disadvantages
Risk of bad outcome
Operative
Indications
Unstable hip
Loss of congruence
All displaced fractures especially with weight-bearing dome involvement
Incongruence or diastasis of articular surface
Interposition of soft tissue
Hip displacement
Contraindications
Local infection
Advantages
Early mobilization

Disadvantages
Risks of surgery
Infection
The ilioinguinal approach provides exposure of the inner aspect of the innominate bone from the
sacroiliac joint to the pubic symphysis.
this approach.
Indications
Indicated for almost all anterior column plus posterior hemitransverse fractures.
It provides optimal exposure to the anterior column component, but is rarely insufficient for the
posterior hemitransverse component. In such a case, a supplementary Kocher-Langenbeck incision
would be required.
Both-column fracture
1. Fracture anatomy Type I (Letournel)

Both-column fracture
Both-column fractures are formed by the association of two elementary fractures, the posterior
column, and the anterior column fractures. The level of the posterior column fracture may vary.
No part of the joint surface remains attached to the stable proximal part of the iliac wing.
The anterior column fracture line reaches the top of the crest at a level varying from the anterior
superior iliac spine to the most posterior portion of the iliac wing.
Most of the acetabular roof stays with the anterior column fragments.
Associated fracture lines in comminuted fractures may create more complex patterns.
Type I (Letournel)
In type I both-column fractures, per Letournel, the anterior column fracture line crosses the iliac
crest.
2. Type II (Letournel)
Letournel type 2
In type II both-column fractures, the anterior column fracture line exits through the anterior portion
of the iliac wing, at variable levels.
As in type I fractures, the posterior column fracture may be comminuted and/or at different levels.
3. Mller AO classification
62-C1
In the Mller AO classification, both-column fractures are classified as Type C. Type C fractures are
complete articular, involving both columns.
62-C1 fractures are high fractures extending to the iliac crest.
62-C2 fractures are low fractures, extending to the anterior border of the ilium.
62-C3 fractures extend into the sacroiliac joint.
4. Radiographic landmarks
Initial radiographic evaluation using three standard (Judet) views (AP, obturator- and iliac oblique) is
mandatory. Recognition of the radiographic landmarks and disruption by fracture lines is crucial to
understanding the fracture pattern.
AP view
This view shows fracture lines crossing the iliopectineal line and anterior wall, iliac crest, and
posterior wall and posterior column. There is medialization of the whole joint, with tilting of the free
roof segment. There is also a fracture line through the obturator foramen.
Legend
blue - iliopectineal line
green - ilioischial line
black - teardrop
red - roof of acetabulum
yellow - anterior border of acetabulum
orange - posterior border of acetabulum
5. AP view of Type I - variation
The iliopectineal line can be broken as well as the ilioischial line in several places. This indicates
comminution with additional fractures along the anterior column or posterior column respectively.
6. Obturator oblique view

This view typically reveals the spur sign (images right, arrows, and below, right).
Typical both-column fractures displace the hip joint medially. The spur sign is the radiographic
projection of the most distal (stable) part of the iliac wing, that which remains attached to the axial
skeleton through the sacroiliac joint.
The obturator oblique view clearly shows anterior column disruption along the iliopectineal line.
Accessory posterior wall fragment

Fractures of the posterior wall, producing free fragments of the wall can usually be visualized best in
the obturator oblique radiograph.
CT imaging with multiplanar views or 3D reconstructions also aid evaluation of the posterior wall.
7. Iliac oblique view
The iliac oblique view shows where the anterior column fracture ends along the iliac crest or
anterior border (arrow 1).
It demonstrates the location and orientation of fracture lines within the posterior column (arrows 2
and 3).
Disruption of the acetabular roof is through the widely displaced fracture line indicated by arrow 3.
8. Variations of both-column fracture patterns

Additional valuable information about acetabular fractures is provided by CT scans with thin
transaxial cuts and 3D reconstructions.
These illustrations demonstrate fracture lines and displacement clearly.
Deviations from the classical fracture pattern may be present.
The most common variants are:
an additional pie-shaped fragment proximally in the iliac wing
a posterior wall fragment or additional fractures along the posterior column
a fracture line through the anterior wall that can result in a separated anterior wall
fragment.
Nonoperative
Indications
Adequate secondary congruence
Secondary congruence exists when the articular surface fragments of a both-column fracture remain
well juxtaposed to the femoral head, in spite of some medial wall gaping. Because the articular
surface is congruent, except for a medial gap, when this is small and the weight-bearing dome is
largely intact, nonoperative management might be considered.
Contraindications
Displaced fractures (unless secondarily congruent)
Unstable hip joint
Advantages
Possiblity of healing in secondary congruence
Disadvantages
Risk of bad outcome
Operative
Indications
Unstable hip
Loss of congruence
All displaced fractures especially with transtectal or juxtatectal fracture line
Incongruence or diastasis of articular surface
Interposition of soft tissue
Hip displacement
Contraindications
Local infection
Advantages
Early mobilization
Disadvantages
Risks of surgery
Heterotopic bone formation (with extended iliofemoral approach)
Infection
The ilioinguinal approach provides exposure of the inner aspect of the innominate bone from the
sacroiliac joint to the pubic symphysis.
this approach.
Indications
Almost all both-column fractures may be treated using this approach.
Contraindications
Posterior wall or column comminution
Fracture involves sacro-iliac joint
Very high posterior column involvement
Delayed reduction (>3 weeks)
Advantage
Generally well tolerated with little effect on abductor muscle recovery
Extended iliofemoral approach
Indications
Fracture not likely to be reducible through ilioinguinal approach
Delayed surgery (>3 weeks), since callus must be removed
The extended iliofemoral approach exposes the entire lateral innominate bone, by posterior
reflection of the abductors, and reflection of short external rotators. It can be extended anteriorly
into the first iliac window of the ilioinguinal incision.
The extended iliofemoral approach involves significant stripping of the bone, is associated with
heterotopic bone formation, and an extended recovery period. Prolonged abductor weakness is to
be expected. When necessary, this approach may be used to achieve reductions which are otherwise
impossible.
Contraindications
Aged patients
Obese patients
Patients who are not committed to a long recovery process
Disadvantages
Technically this approach is demanding
Highest complication rate
Heterotopic bone formation is common (prophylaxis should be planned).
Abductor muscle weakness with prolonged rehabilitation must be expected.
Dangers of the extended iliofemoral approach
This approach risks injury to the vessels and nerves that exit through the greater sciatic notch. The
superior gluteal artery and its accompanying veins lie on the deep surface of the gluteal muscles.
During elevation and posterior reflection of the glutei, the vessels may be torn, typically where they
lie against the ilium at the top of the notch. If torn, they may retract into the pelvis. Bleeding from
the superior gluteal vessels may be difficult to control. The surgeon should remember that packing
the notch may help, followed by angiographic embolization, or, alternatively, the use of an anterior
vascular approach.
Additionally, the superior gluteal nerve runs with the superior gluteal vessels, and is itself at risk of
injury during exposure, retraction, and during efforts to control bleeding. The sciatic nerve, which
usually exits the notch distal to the piriformis muscle, is also at risk of injury, typically from retractors
or prolonged stretching.
The risk of neurovascular injury is increased during exposure of older fractures, and when fracture
lines run parallel to the course of vessels and nerves.

Acetabulum AOSR ENG

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Acetabulum AOSR ENG

Uploaded by

Copyright:

Available Formats

ELEMENTAL FRACTURE TYPES

Acetabulum - Posterior wall fracture

1. Introduction and epidemiology

3. Definition: Posterior wall

4. Mechanism of the injury

6. Comminution of posterior wall

The reduced femoral head is a helpful template.

8. Femoral head contusion and abrasion

10. Duration of dislocation

Congruently reduced hip joint

Stable hip joint through range of motion

Very small posterior wall fragment(s)

No evidence of progressive displacement

Incongruent hip joint

Unstable hip joint

Progressive sciatic nerve deficit

Large posterior wall fragments

Avoidance of potential surgical complications, if indications are met

Risk of bad outcome

Residual displacement may compromise hip replacement

Displaced posterior wall fracture

Incongruent hip joint

Unstable hip joint

Larger posterior wall fragment

Progressive loss of reduction

Restores congruity and stability of hip

Anatomical reconstruction of articular surface

Reduces risk of fracture displacement

Sciatic nerve injury

Heterotopic bone formation

Surgery is urgent for

increasing sciatic nerve deficit

hip joint incongruity with risk of femoral head damage

The Kocher-Langenbeck approach is a nonextensile approach to the posterior acetabular column.

Transverse juxta- and infratectal fractures

Use of the Kocher-Langenbeck approach alone is contraindicated if it does not permit

Trochanter flip extension

Occasionally the fracture is limited to the ischium.

62-A2 Posterior column

Congruently reduced hip joint

No evidence of progressive displacement (frequent radiographic monitoring is required)

Incongruent hip joint

Unstable hip joint

Avoidance of potential surgical complications, if indications are met

Risk of bad outcome

Residual displacement may compromise hip replacement

Displaced posterior column fracture

Incongruent hip joint

Unstable hip joint

Progressive loss of reduction

Restores congruity and stability of hip

Anatomical reconstruction of articular surface

Sciatic nerve injury

Heterotopic bone formation

Surgery is urgent for

increasing sciatic nerve deficit

hip joint incongruity with risk of femoral head damage

The Kocher-Langenbeck approach is a nonextensile approach to the posterior acetabular column.

ORIF of fractures of the posterior wall or posterior column

Transverse juxta- and infratectal fractures

Trochanter flip extension

4. Intraarticular fracture fragments and marginal impaction

Femoral head damage

These conditions can not be reversed and worsen the prognosis.