HIP AND ACETABULUM

FRACTURE

HIP ANATOMY
AMALESHWAREE
012011100118

ANATOMY OF THE HIP

Hip bones
Flat bones, form bony pelvis along with
sacrum and coccyx
Posteriorly articulate with the sacrum at
the sacroiliac joint
Anteriorly articulate with each other at a
joint called pubic symphyses
Contains 3 parts pubis, ilium and
ischium

Bony pelvis
- formed by sacrum, coccyx and pair of hip bones
Hip bone

sacrum

Acetabulum
coccyx
Obturator
foramen

Pubic symphysis

Posterior
Hip bone

Anterior

lateral view

Iliac crest

Posterior superior
iliac spine
Posterior inferior
iliac spine
Greater sciatic
notch

Tuberosity of
iliac crest

Anterior superior
iliac spine
Anterior inferior
iliac spine
Acetabulum

Ischial spine
Lesser sciatic
notch
Ischial tuberosity

Obturator foramen

Hip bone medial view

Anterior

Posterior

Anterior superior
iliac spine
Anterior inferior
iliac spine

Auricular surface
(articulates with
Sacrum to form
Sacroiliac joint)

Hip joint

Hip
bone

Hip Joint
Type: Synovial joint
Subtype: Ball and socket
Articular surfaces:
Head of femur and acetabulum of hip
bone
Head of femur:
Forms two thirds of a sphere
Is covered by the articular cartilage except
at the fovea capitis

Fovea capitis
(Pit for ligament of head of femur)
Head of femur

Lunate
surface

Acetabular
margin

Acetabular
Fossa

Acetabular
notch

Acetabulum

Head of femur

 Acetabulum:
Hemispherical hollow on the lateral surface of hip bone
It is limited by the acetabular margin
Acetabulum has two parts lunate surface and acetabular
fosaa
Lunate surface: C shaped articular area covered by the
hyaline cartilage
Acetabular fossa: Deep non-articular part filled with
acetabular pad of fat
Acetabular margin is absent on the inferior aspect, here it is
replaced by the acetabular notch

 Acetabular labrum:
Fibrocartilaginous ring attached to the
margins of acetabulum
Increases the depth of acetabulum
Replaced inferiorly at the acetabular notch
by the transverse acetabular ligament

Ligaments of the hip joint

1.
2.
3.
4.
5.

Iliofemoral ligament ( of Bigelow)

Pubofemoral ligament
Ischiofemoral ligament
Transverse acetabular ligament
Ligament of head of femur

Acetabular labrum

Lunate surface
Fibrous capsule
Acetabular fossa

Transverse acetabular
ligament

Ligament of head of femur

Lunate surface lined

by hyaline cartilage
Acetabular fossa
with acetabular
pad of fat
Ligament of head
of femur
Transverse
Acetabular
Ligament

Fibrous capsule:
Surrounds the joint
Its inner surface is lined by the synovial
membrane
Medial attachment: to the hip bone
Attached to the acetabular margin and
transverse acetabular ligament
Lateral attachment: to neck the femur
Anteriorly to the intertrochanteric line
Posteriorly to the posterior surface of neck
of femur, just medial to intertrochanteric
crest

 Capsule contains outer longitudinal fibres and

inner circular fibres (zona orbicularis)
Some longitudinal fibres reflected back along the
neck of femur
These are called retinacula or cervical ligaments
These contain blood vessels supplying the head
and neck of femur

Blood supply of the hip joint

Relation of the hip joint

CLINICAL ASSESSMENT

MURUGAN MANIAM
0120090075

 Fracture of the pelvis

should be suspected in every patient with serious abdominal

or lower limb injuries
history of a road accident or a fall from a height or crush
injury.
Often the patient complains of severe pain and feels as if he
has fallen apart, and there may be swelling or bruising of the
lower abdomen, the thighs, the perineum, the scrotum or the
vulva.

the first priority, always, is to assess the patients general condition

and look for signs of blood loss. It may be necessary to start
resuscitation before the examination is completed.

The abdomen should be carefully palpated. Signs of irritation

suggest the possibility of intraperitoneal bleeding.
Tenderness over the sacroiliac region is particularly important and
may signify disruption of the posterior bridge.

Rectal examination
carried out in every case.
The coccyx and sacrum can be felt and tested for tenderness.
If the prostate can be felt, which is often difficult due to pain
and swelling, its position should be gauged; an abnormally
high prostate suggests a urethral injury.

Enquire when the patient passed urine last and look for
bleeding at the external meatus.
An inability to void and blood at the external meatus are the
classic features of a ruptured urethra.

The patient can be encouraged to void; if he is able to do so,

either the urethra is intact or there is only minimal damage
which will not be made worse by the passage of urine.
No attempt should be made to pass a catheter, as this could
convert a partial to a complete tear of the urethra.
If the urethral injury is suspected, this can be diagnosed
more accurately and more safely by retrograde
urethrography.

A ruptured bladder should be suspected in patients who do

not void or in whom a bladder is not palpable after adequate
fluid replacement.
the physical findings initially can be minimal, with normal
bowel sounds, as extravasation of sterile urine produces little
peritoneal irritation.

Neurological examination is important; there may be damage

to the lumbar or sacral plexus.
If the patient is unconscious, the same routine is
followed. However, early x-ray examination is
essential in these cases.

ACETABULAR FRACTURE
Buaneswaran Magendaran
012011100010

Mechanism of Injury
Occurs when head of femur is driven
into the pelvis, 2 mechanisms involved:
Fall from height (blow on the side)
Dashboard injury (blow on the front of
the knee

Patterns of Fracture
- Depends on the : Position of the femoral head at the
time of injury
- Hip externally rotated and abducted
( anterior column injury)

Magnitude of force
Age of patient

Classification of Fracture
Judet & Letournel Classification
5 elementary fracture types
5 associate fracture types

Classification of Fracture
5 main elements:
Acetabular wall fractures (ant or
post)
Anterior column fractures
Posterior column fractures
Transverse fractures

Types of Fracture
Acetabular wall fractures (ant or
post)
affects the depth of the socket
leads to hip instability unless
properly reduced
and fixed
Post wall fracture is the commonest
(dashboard injury)

Types of Fracture
Anterior column fractures
Runs through anterior part of
acetabulum, separating a segment
between anterior inferior iliac
spine & obturator foramen
Does not involve weightbearing area
Good prognosis
Uncommon

Types of Fracture
Posterior column fractures
Runs upwards from the obturator
foramen into the sciatic notch
Separates posterior ischiopubic column
of bone & breaking the weight-bearing
part of acetabulum
Associated with posterior dislocation
of hip may injure sciatic nerve
Treatment is more urgent

Types of Fracture
Transverse fractures
Uncomminuted fractures
Runs transversely through
acetabulum, separates iliac
portion above from pubic & ischial
portions below
May be associated with sacroiliac
joint injury

Types of Fracture
Associated fractures
Are combination of elemental fractures
Articular surface are more severely
disrupted

Associated Fractures
Type 1 - Posterior Column + Posterior
Wall
Type 2 - Transverse + Posterior wall
Type 3 - T-shape fracture
Type 4 - Anterior Column + Posterior
hemitransverse
Type 5 - Both column fractures

Associated Fractures

Clinical Features
Chernissha a/p Elan Cheliyan
012011100133

Clinical Features
- Severe injury (traffic accident/fall from height)
- Associated fractures
* any case of fractured femur, calcaneum or
severe knee injury
- Severe shock
- Skin local wounds, abrasion, bruising
- Attitude of the limb - lying in internal rotation
(if hip dislocated)
- Neurovascular assessment (Sciatic nerve
palsy )

Imaging
1) Plain X-Ray Pelvis
AP view : 6 cardinal lines of pelvis
Obturator oblique view
Iliac oblique view
2) CT Pelvis

X-ray (AP view)

Start evaluation with this view

X-ray (Obturator Oblique)

45o internal rotation
view
Best demontrates the
anterior column (iliopectineal line) and the
posterior wall.

Obturator Oblique View radiograph

1. Pelvic brim or Iliopectinial (Iliopubic) line - again, represents the anterior column
2. Anterior lip of acetabulum - represents the anterior wall of the acetabulum
3. Posterior lip of acetabulum - represents the posterior wall of the acetabulum

X-ray (Iliac Oblique)

45o external rotation
view.

Best demonstrates
posterior column (ilioishcial line) and
anterior wall.

 Iliac Oblique View radiograph

1. Ilioischial line - this line represents the posterior column
2. Anterior lip of acetabulum - represents the anterior wall of the acetabulum
3. Posterior lip of acetabulum - represents the posterior wall of the
acetabulum

 Posterior wall acetabular

fracture. Anteroposterior
radiograph of the pelvis. The
posterior wall of the left
acetabulum is disrupted (arrow).

Posterior wall acetabular

fracture. A left obturator oblique
radiograph of the pelvis. The
posterior wall fracture (arrow) is
better depicted on this view
than on the anteroposterior
view.

CT Scan
Provide additional information
- size and position of column fractures
- impacted fractures of acetabular wall
- retained bone fragement in a joint
- degree of communition
- sacroiliac joint disruption
2D and 3D CT scans useful (evaluate intraarticular fragements as well as specific
morphologic characteristics of any given fracture
pattern)

 Computed tomography (CT) scan of a posterior wall acetabular

fracture. The oblique fracture of the left acetabulum is clearly
depicted. The degree of displacement and marginal impaction can be
determined more accurately with CT scanning than with radiography.

Treatment
Christina a/p Jayaraj Paul
012011100134

Management
Goal of treatment
The goal of treatment is anatomic restoration of
the articular surface to prevent posttraumatic
arthritis.

Initial management
The patient is usually placed in skeletal traction
to 1. allow for initial soft tissue healing,
2. allow associated injuries to be addressed,
3. maintain limb length,
4. maintain femoral head reduction within the
acetabulum.

Definitive treatment :
2-5 days post injury
delay should not exceed 7 days

Emergency Treatment
Priority
a

counteract shock and reduce

dislocation.
1) Skeletal traction applied to distal femur
(10kg will suffice)
2) Next 3-4 days, patients general condition
is brought under control.

Treatment Option
Non operative
Operative

Non- operative treatment

Absolute contraindication
Local or systemic infection
Severe osteoporoses

Relative contraindication
Advanced age
Associated medical condition
Associated soft tissue and visceral injuries
Multiple injured patient not stable for a big
acetabular surgery

Non-operative
Protected weight bearing for 6-8 weeks
- Longitudinal traction, if necessary,
supplemented by lateral traction
- Hip movement and exercises are
encouraged
- Patient then allowed up, using crutches
with minimal weight bearing for a further 6
weeks
*close monitoring

Indications
Minimal displacement of fracture

<3mm

Less than 20 % posterior wall fractures

Femoral head remains congruent with weight
bearing roof ( out of traction)

 Both column fracture

Fractures in elderly where closed
reduction seems feasible
Medical conditions to operative treatment
( including local sepsis)

Criteria by Matta and Merritt if conservative

treatment is suceeded :
1) When traction is released, hip should
remain congruent
2) Weightbearing portion of the acetabular
roof should be intact
3) Associated fractures of the posterior wall
shoud be excluded by CT scan.

Operative
Hip may be dislocated :
centrally, anteriorly and posteriorly

Open reduction internal

fixation

Open reduction internal fixation

Indication :

Displacement of roof > 3mm

Posterior wall fracture involving 40 50%
Marginal impaction
Irreducible fracture- dislocation

Approaches
Kocher-Langenbeck (Posterior): best access to
posterior wall and column (prone)
Ilioinguinal (Anterior): best access to anterior wall and
column fractures
and inner aspect of innominate bone (supine)

Extended iliofemoral (Lateral): best simultaneous acces

to the two columns (lateral)
~No single approach provides ideal exposure of all

fracture types.
~Proper preoperative classification of the fracture
configuration is essential to selecting the best surgical approach

Kocher-Langenbeck Approach

Indications

Posterior wall fractures

Posterior column fractures
Posterior column/posterior wall fractures
Some T-type fractures

Areas accessible by Kocher-Langenbeck

approach

Ilioinguinal approach

Indications
Anterior wall and
Anterior column
Transverse with significant anterior
displacement
Both-column fracture

Extended iliofemoral approach

Indications
Transverse fractures with extended posterior wall
T-shaped fractures with wide separations of the vertical
stem of the T or those with associated pubic symphysis
dislocations
Certain associated both column fractures
Associated fracture patterns or transverse fractures
operated on >21 days following injury

Extended iliofemoral approach has the

highest incidence of
ectopic bone formation (HO)
and
longest postoperative recovery

Other approaches
Stoppa approach (supine): Allows access
to the medial wall of acetabulum,
quadrilateral surface, & sacroiliac joint
Triradiate approach (prone): Alternate
exposure to the external aspect of
innominate bone, with almost same
exposure as iliofemoral but visualization of
the posterior part of ilium is not as good

 The fracture(fractures) is fixed with lag

screwes or special buttressing plates
which can be shaped in the OT.
.

**Patients with isolated posterior wall

fractures and dislocation may require
immediate open reduction and
stabilization.
In other cases , operation usually deferred
for 4-5 days

 Prophylactic antibiotics are used

Indomethacin given- prophylaxis against
heterotopic ossification
Postoperative hip movements started as
as soon as possible
Patient allowed up, partial weightbearing
with crutches, after 7 days
Exercise continued for 3 -6 months

Operative treatment contraindication

Absolute contraindication
Local or systemic infection
Severe osteoporoses

Relative contraindication
Advanced age
Associated medical condition
Associated soft tissue and visceral injuries
Multiple injured patient not stable for a big
acetabular surgery

Surgical emergencies include:

Open acetabular fracture
New-onset sciatic nerve palsy after closed
reduction of hip dislocation
Irreducible posterior hip dislocation

Complications
Surgical wound infection: Risk is increased
secondary to the presence of associated
abdominal and pelvic visceral injuries.
Nerve injury
Sciatic nerve: Kocher-Langenbach approach
with prolonged or forceful traction.
Femoral nerve: Ilioinguinal approach may result
in traction injury to femoral nerve. Rarely, the
nerve may be lacerated by an anterior column
fracture.

 Avascular necrosis: This devastating

complication occurs mostly with posterior
types associated with high-energy injuries.
Osteoarthritis
Heterotopic bone formation

Pelvic
Fracture
Juanita a/p Henry
012011100159

Types of fracture
Isolated
fractures with an intact pelvic ring
Pelvis
fracture

Isolated Fractures
Isolated
Avulsion
Fractures
fractures

Avulsion Fracture
A piece of bone is pulled off by violent
muscle contraction.
Seen in sports participants and athletes.
Tx: Rest for few days and reassurance.

Avulsion Anterior
Superior
Iliac Spine (ASIS)

Avulsion Anterior
Inferior
Iliac Spine (AIIS)

Avulsion Ischial Tuberosity

Direct fracture

A direct blow to the pelvis

Fall from a height
Fracture ischium or illiac blade
Tx: bed rest until pain subsides.

Fracture at the right illium

Stress fracture
Severely osteoporotic or osteomalacic
patients.
Fracture of the pubic rami (common &
painless)

Fracture at the pubic rami and pubic

tubercle in an osteoporotic patient

Fractures of pelvic ring

( mechanism of injury)

Tile classification

A: stable

B - rotationally unstable,
vertically stable

C - rotationally and
vertically unstable

A1: fracture not involving the

ring (avulsion or iliac wing
fracture)

B1: open book injury

(external rotation)

C1: unilateral

A2: stable or minimally displaced

fracture of the ring

B2: lateral
compression injury
(internal rotation)

C2: bilateral with one

side type B and one
side type C

A3: transverse sacral fracture

(Denis zone III sacral fracture)

B3: bilateral

C3: bilateral with both

sides type C

Anteroposterior
compression

Seen in MVAs
Pubic symphysis disrupted, continue
to posterior SIJ open book injury
Increase pelvic volume
May be torn SI ligaments, fracture
post. Ilium, vertical sacral fracture

Lateral compression
Side to side
compression of pelvic
ring
Side impact in
accidents
Anteriorly, pubic rami
fractured ( one/both),
Posteriorly SI
strain/fracture
If displaced, becomes
unstable

Vertical shear
Innominate bone vertically
displaced, fracturing pubic
rami and disrupt sacroiliac
region of same side
Fall from height on one leg
Severe, unstable, gross soft
tissue and retroperitoneal
hemorrhage

Combination injuries

Combination of either
type of injuries
Ex : lateral compression
with vertical shear/
anteroposterior
compression with
vertical shear
Hit from the front and
fall on the side

CLINICAL FEATURES
PRESHEELA KUMARAN
012010090125

ISOLATED FRACTURES and STABLE INJURIES

Not severely shocked

Pain on attempt to walk
Localized tenderness but seldom damage of
the pelvic viscera

UNSTABLE INJURIES
Severely shocked
Pain and unable to stand
Unable to pass urine
Blood loss the external meatus
Tenderness
Attempt to move the ilium will be painful
Foot drop due to L5 injury
Partial numbness of one side of the leg due to
sciatic nerve
High risk of visceral damage

Its only the mechanically unstable fracture

led to hamodynamic instability
If patient has stable pelvic fracture but
hemodynamically unstable, look for other
source of bleeding e.g chest or abdomen

OPEN PELVIC FRACTURE

Severe blood loss

log roll patient to ensure there is no
external blood loss.

TREATMENT OF HIP
FRACTURE
SHANGEETHA NAGARAJAN
O12011050742

PELVIC FRACTURES

Lateral
Compressio
n (LC)

Anteroposterior
Compression
(APC)

Vertical Shear
(VS)

LATERAL COMPRESSION

ANTEROPOSTERIOR
COMPRESSION

LATERAL COMPRESSION
Undisplaced ring fracture
Lateral compression involving pubic ramus
fracture anteriorly and undisplaced sacral
fracture posteriorly
Pain usually subsides after a few days
4 wks bed rest combined with traction
Allow using crutches for another few weeks

ANTEROPOSTERIOR
COMPRESSION
Ant disruption without sacroiliac
displacement
Open book injury (gap of <2cm): bed rest about
6 week, with post sling or elastic girdle to help
to close the book
IF > 2 cm, severe injury: External fixation (8-12
weeks)
-pubic ramus fracture: bed rest
-if the patient need laparotomy,so open
reduction and internal fixation by plates
and screws or by K. wire.

Displaced with sacroiliac disruption

2 techniques are used to stabilize
-anterior external fixation and posterior
stabilization using screw across the s/i joint
-plating the symphysis anteriorly and screw
across the s/i joint posteriorly

VERTICAL SHEER AND DISPLACED

LATERAL COMPRESSION FRACTURE
Fracture must be reduced and stabilized
Posteriorly, reduction is done by traction or
illiosacral screw fixation, open reduction
and internal fixation
Anteriorly, open reduction and internal
fixator of the symphysis or external fixator

EARLY MANAGEMENT
OF HIP FRACTURE
SATISH KUMAR
012011100187

EARLY STEPS

Resuscitation (advanced trauma life support)

"Log roll" patient to ensure no external blood loss
posteriorly.
Intesive resuscitation as bleeding may be
dramatic.
Find out mechanism of injury (high/low energy)
Any patient with a suspected pelvic fracture
should have a pelvic compression binder applied
during 1st aid in order to provide immediate
stability.
Routine chest x-ray to look for any haemothorax
(treat with drain)
FAST scan to exclude intraperitoneal hemorrhage

If fluid is found in abdomen, it should be explored

via laparotomy (attempt to find and deal with
source of haemorrhage)
Examination to exclude intraabdominal injury and
neurological deficit.
Assess the stability of pelvis
-rotational= firmly grip both iliac crests
to squeeze them together
and push them apart.
-vertical = 2 people, one holds both
iliac crests to detect
movement, other applies
longitudinal traction and comp
through legs.

Check for wounds in pelvic area PR and VE.

Patient who cannot pass urine must NOT be
catheterized, consider suprapubic
catheterization or cystotomy. Retrograde
urethrogram useful to show urethral tear.
X-ray of pelvis : ideally 5 views, AP
mandatory, Inlet, outlet, 2 oblique views.

BLEEDING

Pelvic Packing if uncertain of source during 1st aid.

Aggressive fluid resuscitation is critical in the
patient who is hemodynamically unstable. The
severity of blood loss can be determined by
assessing the pulse, blood pressure, and capillary
refill. These indicators can be used to evaluate a
patient's response to the resuscitative effort. Two
large-bore (16-gauge) intravenous catheters should
be placed.
Replacement volume is estimated by using the
formula of 3 mm of crystalloid for each 1 mm of
blood loss. A minimum of 2 L of crystalloid solution
is given over 2 minutes, or more rapidly if the
patient is in shock.

Most incidents of blood loss from a pelvic

injury arise from cancellous bone at the
fracture site or from a retroperitoneal lumbar
plexus venous injury. Only 20% of deaths
from pelvic hemorrhage are attributed to a
major arterial injury. Posterior arterial
bleeding is more common in patients with
unstable posterior pelvic fractures, and
anterior arterial bleeding (pudendal or
obturator) is more common in patients with
lateral compression (LC) injuries.
The arterial vessel most frequently injured
with a posterior fracture is the superior
gluteal artery

Supraumbilical diagnostic peritoneal lavage

(DPL) can be used as a quick and accurate
diagnostic tool.
Continued unexplained blood loss despite
fracture stabilization and aggressive
resuscitation mandates angiographic
exploration to look for continued arterial
bleeding.

Complications of
Pelvic Fracture
By :
Vignavinashini
Mahaeswarren

Complications of Pelvic
Fracture
Hemorrhage and Shock

1. Hemorrhage and Shock

Seen in a serious pelvic injury, especially an

open pelvic fracture.

Hemorrhage, either intraperitoneal or

retroperitoneal.
Intraperitoneal hemorrhage is best managed by direct
surgical intervention at laparotomy.
Intrapelvic retroperitoneal hemorrhage is best managed
by rapid and continuing blood replacement and by
immediate external stabilization of the pelvic fractures.

2. Urogenital damage
APC are the common cause!!
Symphyseal widening is associated with
urethal injury
Displaced rami fractures may cause bladder
injury

Urinary drainage by suprapubic cystostomy

Late complications include : Urethral stricture

Incontinence
Impotence

3. Bowel injury
Defunctioning colostomy

(not to contaminated the pelvis)

A re-anastomosis is performed at 6-12
months once healing has occurred.

4. Vaginal injury
Displaced pubic ramus fractures can tear
the lateral wall of the vagina

Washed out and repaired

5. Infection

6. Nerve injury

Displacement of the sacroiliac joint or

fracture of the sacrum may injure the
lumbosacral plexus (L5* nerve root).

7. Persistent sacroiliac pain

Occurs when the SIJ injury has been left

untreated.
Fusion if symptoms are severe.

8. Venous thromboembolic
disease

Especially when they undergo operative fixation

!!
Prophylaxis is initiated at diagnosis, and continued
for 6-12 weeks.

9. Malunion of the fracture

May

result in an abnormal gait, difficulty sitting,

and back pain.
A deformed pelvis can interfere with future
vaginal deliveries and necessitate a Caesarean
delivery.

REFERENCES : Apleys and Solomons Concise System of

Orthopaedics and Trauma
http://www.medscape.com/
http://www.mdguidelines.com/oldhome