Section I – Pelvic fractures  

Introduction

Fractures of the pelvic ring represent a unique and potentially devastating problem. They often result in
serious long-term functional disability (pain) and death. Soft tissue injuries associated with the fractures
add to short term to medium term morbidity and mortality.

Thanks to improved advanced trauma life support protocol and landmark papers of a number of leaders in
the field (Tile 1996), the management of a pelvic ring fracture is now a more logical and comprehensive
one, with a markedly decreased morbidity and mortality. The classification system used recognises that
diagnosis and treatment may be improved when force vector analysis and fracture patterns are studied.

The classification systems used in treatment of pelvic fractures consider the following:

• Understanding of the relevant anatomy

• Re-create and understand mechanisms and forces involved in injury;

• Knowledge of the diagnostic options and the relevant investigations that may be performed;

• Understanding of the associated soft tissue injuries;

• Familiarity with the various treatment options;

• Experience with potential complications and the need for rehabilitation and other interactions.

Key points

• In pelvic fractures, it is the complexities of fracture and soft tissue injury, combined with the
potential for mortality, that make these fractures such a specialised field.

• A good surgical text for this material is Fractures. DA Wiss Ed, 1998. Master techniques in
Orthopaedic Surgery, Chapters 35-42, Lippincott-Raven, Philadelphia.

Surgical anatomy

Bony pelvis

The pelvic ring is composed of two innominate bones and the sacrum, joined at the anterior and posterior
iliac joints, while the innominate bones are joined at the pubic symphysis.

The hip bone per se is formed from three bones that fuse in a Y shaped epiphysis involving the
acetabulum. The pubis and ischium form an incomplete wall for the pelvic cavity. The ilium forms the brim
between the acetabulum and sacrum (McMinn 1994).

It is important to note the correct anatomical position of the bone. The pubic tubercle and anterior superior
iliac spines lie in the same vertical plane, whereas the upper borders of symphysis pubis and ischial spines
lie in the same horizontal plane. Thus the position of the whole sacrum is often described as oblique.

The cavity of the bony pelvis is divided into two subcavities by the arcuate lines of the sacrum posteriorly
and the upper part of pubis bone anteriorly – this is known as the brim of the pelvis. The true pelvis below
the brim houses the pelvic viscera, whereas the false pelvis above the brim forms part of the abdominal
cavity.

The weight bearing arches are columns of thick bones within the innominate bones. These transfer weight
from the L5 vertebra to the upper 3 pieces of sacrum, then to the sacroiliac joint. Weight is then transferred
to the thick, weightbearing pieces of ilium ,thence to the roof of the acetabulum or the ischial tuberosity,
depending upon whether the person is standing or sitting. It can thus be stated that the ilium is the primary
transference element in transmission of weight forces from the spine to the lower extremities when
standing, whereas the ischium serves as the terminal point of weight transmission within the sitting
position.

The pubic body forms the anterior border of the true pelvis and forms part of the origin for the adductor
muscles.

The sacrum is a part of the pelvic ring in that not only does it have the sacral nerves from the pelvic
plexus, but it also is involved in the transmission of weight to the acetabulum from the spine.

Pelvic joints and ligaments

Sacroiliac complex

The stability of the bony pelvis is dependent upon the posterior sacroiliac joint complex. This consists of

• interosseous sacroiliac ligaments (sacrospinous and sacrotuberous)

• iliolumbar ligaments

• anterior and posterior transverse sacroiliac ligaments

• The effect of these ligaments is to prevent superior and anterior displacement of the complex,
and includes some of the strongest ligaments in the body. It is also important to note that the
anterior sacroiliac joint helps to prevent external rotation.

Pubic symphysis

This joint complex is covered with hyaline cartilage and composed of superior pubic ligament above and
arcuate pubic ligament below.

Soft tissues of the pelvis

Consider the bladder and rectum. It is beyond the scope of this chapter to describe in detail the contents of
the true pelvis. It is vitally important to recognize and quantify the types of injury to soft tissues when
interpreting an X-ray of an acute fracture.

It is possible to estimate clinically the amount of vascular damage to the vessels of the pelvis via the type
of fracture. Force-vector analysis of the fracture pattern has been shown to be predictive of the patient
population at high risk for massive haemorrhage. Note that approximately 50 to 70% of those with unstable
pelvic fractures will require 4 or more units of blood and 30 to 40% will require 10 units or more (Levine
1996).

Mechanism of injury

The recognition and analysis of direction and intensity of force involved is important in order to determine
possible outcomes in trauma management. The details of force may be recovered from various sources –
patient, witnesses, scene investigators and paramedics, as well intuitive analysis.
Pelvic fractures can be classified into 2 major types:

• low energy : for the most part resulting in isolated bony fracture

• high energy: most likely to lead to pelvic ring disruption.

• As a part of this analysis, two other factors must be considered:

• impact vs. crush injury

• direction of forces involved.

Low energy fracture

Usually domestic falls and avulsion injuries of the muscular apophyses in skeletally immature patients.

About one third of all pelvic fractures are fractures of single element of the pelvic ring. Recently with the
aid of more impressive imaging and analysis, it has been shown that if the pelvic ring is fractured in one
area it must be broken in another (the only exception is a greenstick injury). It is extremely important to
recognise this in initial trauma assessment. Pubic ramus fractures often associated with ipsilateral ramus
fracture and posterior ring injury; sacral fractures with pelvic ring fracture and iliac injury with abdominal
and thoracic injuries.

High energy fracture (Fig 17.1)

Such forces result in more severe injury to the pelvic ring, associated soft tissues, and viscera. Pelvic
fractures vary in the degree of stability and this related to the direction of the injurious force. Force analysis
leads to the following classification:

• External rotation forces

• Internal rotation forces

• Shearing forces.
External rotation forces
This acts through either:

• an intact femur

• the anterior or posterior iliac spines via anteroposterior compression forces.

External rotation forces through the pelvic ring, in order of decreasing severity of injury, tend to:

• cause open book type fractures of the pelvis via disruption of symphysis pubis or fracture of rami.

• rupture the pelvic floor

• tear the anterior sacroiliac ligaments

• cause rotation of the pelvis unilaterally or bilaterally, but with the pelvic ring remaining stable by
virtue of an intact posterior sacroiliac joint complex.

Lateral rotational forces

Also known as internal rotational forces. Firstly the anterior rami often break with pelvis rotating internally.
The next injury depends upon the strength of the posterior ligament versus the sacrum: there may be
fracture of the sacrum if the ligaments are stronger or if the sacrum is stronger, then the ligaments may
tear. In both scenarios the pelvic floor and its ligaments remain intact, and thus major posterior and vertical
translation is impossible. However these forces are more likely to cause puncture wounds to viscera.

Shearing forces

These are generally perpendicular to soft tissue structures and bony trabeculae. Thus the forces may
overcome the sacroiliac joint complex and result in an unstable hemipelvis. Note that external rotation and
shearing forces: disrupt the ligaments more commonly than lateral compression forces and are more likely
to cause visceral, nerve and vascular injuries.

Evaluation

Use EMST/ATLS principles (see page 00). Evaluation in the emergency department consists of the ABC’s
of trauma management. A primary survey of the patient is performed, along with baseline observations,
and insertion of monitoring and resuscitative devices.
Physical examination includes:

• inspection for fresh blood from rectum/anus, and penis/vagina;

• gentle palpation at ASIS, looking for instability in internal/external rotation, and instability with
superior/inferior distraction/compression/springing;

• digital rectal examination and perineal examination (note position of prostate). Destots sign is
blood above inguinal ligament or in scrotum; Roux's sign is decrease distance from greater
trochanter to pubic tubercle and Earle's sign is tender swelling on PR

• Depending upon the result of rectal examination, may need:

 • IDC placement +/- urethrogram

• inspection with proctoscope

Detailed neurological and vascular examination. Note there is a 50% incidence of plexus injuries in the
patient with unstable pelvic fracture or fractures that involve sacral ala or foramina. (6)

Key points

• Early haemorrhage (in the unstable patient, bleeding into the intra-abdominal space must be
ruled out either by CT if haemodynamically normal, DPL if haemodynamically unstable. However
if DPL is to be used then the entry point must be placed supraumbilically to prevent
decompression of tamponade haematoma).

• Fluid resuscitation

• Open wounds-use sterile dressing

Radiology
Standard x-rays include:

• AP radiograph. This should be taken in all patients with blunt trauma; special care should be
taken with possible sacral fractures that are easily missed.

• If this is abnormal, then,

• Inlet views (40 caudad) are best for sacral fractures or displacement of posterior elements.

• Outlet views (40 cephalad) are best for vertical displacement/assessment of pelvic ring.

• CT scan.

This helps clinicians to further interpret fracture patterns and indeed helps in diagnosis of posterior
element fracture, especially sacral fracture. CT scanning helps with subclassification of fracture with
reference to various classification systems. The MRI is not routinely used in the acute setting.

Key points:

• AP pelvis

• 40 caudad

• 40 cephalad

• CT scan

• The MRI is not routinely used in the acute setting.

Classification

Burgess et al (1990), Tile (1996) and the AO group have produced a classification system which
incorporates "vector forces" involved, stability and fracture configuration (Table 17.1)(Wiss 1999).

The aim of any classification system is to quantify and standardize treatment and decision-making in the
management and subsequent follow up of patients. However all fractures must be individualized in terms
of soft tissue injury, compound injury and associated non-pelvic injury.

Key points:

• All fractures must be individualized in terms of soft tissue injury, compound injury and associated
-non-pelvic injury.

• Stress fractures of the pubis / pubic rami are not uncommon in osteoporotic patients

• Type A fractures do not fracture through the pelvic ring.

• Type B fractures are partially stable, and no posterior or vertical displacement is possible. This is
often difficult to determine on the initial radiograph, and other imaging modalities may be
required, in order to fully visualize this area.

• Type C fractures are inherently unstable because of posterior disruption, leading to the possibility
of posterior or vertical movement.

These are generally high-energy injuries, with gaps of the posterior elements of greater than one
centimetre on initial views, associated with severe disruption of the anterior elements, leading to an
unstable hemipelvis.

• The radiographic signs of pelvic instability include:

• displacement of the posterior sacroiliac complex more than 5mm in any plane

• fracture gap posteriorly.

• presence of a fracture(avulsion) of :

the transverse process of L5 (where iliolumbar and lateral lumbosacral legs attached and so indicates
vertical instability); ischial spine (attachment of the sacrospinous ligament; resists external rotation of
hemipelvis); ischial tuberosity (attachment of sacrotuberous lig; resists sagittal rotation).

Finally, note that by far the great majority of the fractures are of the Type A or B variety.

Treatment
The management of pelvic fracture is split into:

• Early-initial resuscitative management and the control of haemorrhage

• Definitive management of the fracture(s).

Early

Immediate resuscitation must proceed along EMST/ATLS guidelines. The multi-trauma patient may have
other life-threatening injuries apart from the pelvic fracture.

In the patient in which pelvic fracture is the leading injury, initial assessment must address notable
associations:

• retroperitoneal haemorrhage

• pelvic ring instability

• soft tissue injury (especially lower bowel and genito-urinary)

• open fracture.

Key points

• Haemorrhage has been shown to be the leading cause of death in the patient with a pelvic
fracture (approximately 60%). Most of the blood loss is from fracture site or retroperitoneal veins,
not arterial injury (Levine 1996). The unstable patient has a 10x chance of dying. Also exclude the
chest and abdomen as sites of bleeding.

• The multi-trauma patient may have other life-threatening injuries apart from the pelvic fracture.

• Open wounds require aggressive I&D/remove communication with GI tract/consider a diverting

colostomy for rectal or vaginal injuries/temporary external fixation.

• Closed degloving injuries(Morel-Lavalle lesion) where skin and subcutaenous tissue are
separated from fascia creates a huge potential space and surgical exposure may compromise
flaps

• GU disruption requires PRIMARY bladder and urethral repair via Pfannenstiehl incision. Urologist
works via ant pelvic disruption. Foley catheter 6 weeks post urethral tear. Do NOT use supra-
pubic catheter. ORIF as required.

A positive peritoneal aspirate in the face of pelvic fracture warrants laparotomy to assess the extent of
abdominal injury. Provisional stabilisation of the pelvic fracture prior to laparotomy can be obtained by
application of an external fixateur, pelvic clamp or MAST suit (easy and safe to apply; deflate slowly in ER
after large bore IV lines placed).

External fixateur

pelvic volume; temporary simple frames↓Advantages Maybe life saving; available.

Disadvantages Not suitable for all fractures/pin tract problems/limits abdominal access/does not control
posterior pathology.

Author's preferred technique

 • Pelvic (Ganz) Clamp(Fig. 17.2)

• Entry point is 3 to 4 finger breadths anterolateral to PSIS, along line from ASIS to PSIS. Assistant
holds the clamp, then slide Steinmann pins onto outer cortex of ilium. and drive in 1cm.Sidearms
are pushed centrally and threaded bolts advanced with wrench to engage and compress fracture
diastasis.

• External Fixateur

2 pins placed percut in Iliac crest. Both sides. 1 at ASIS, 1 at iliac tubercle, at ~ 45º to each other.
Complete frame as anterior rectangle

The orthopaedic team must be present at the time of laparotomy to aid in assessment and management of
fracture. Remember-opening the abdomen may decompress the tamponaded pelvic haematoma and allow
expansion, a further hypotensive episode and closure of the abdomen may become impossible.

Have an interventional radiologist and an angiography suite on stand-by in case urgent embolectomy
required. If the haemorrhage is uncontrollable then temporary cross clamping of the aorta may be
necessary to allow for packing of the retroperitoneal space or for transport to the angiography suite.

The orthopaedic team may also decide to continue with definitive stabilisation of the fracture after the
laparotomy is performed. The aims of management in this case are to decrease haematoma via
decreasing pelvic volume (due to stabilisation of the fracture) and thus causing a retroperitoneal
tamponade, as the strong pelvic fascia limits the rupture of blood into the peritoneal cavity.

Key points

• Control venous bleeding

• Give fluid and blood replacement

• Use simple external fixateur

• Apply pelvic C-clamp

• May need angiographic embolization

Consider early/urgent internal fixation under these circumstances:

• At time of exploratory laparatomy

• Where urethral relaignment or bladder repair

• When ongoing haemorrhage

• If open wounds

• Where loss of nerve function

• If under GA for other orthopaedic injuries

Definitive (Table 17.3) (Tile 1988).

In the haemodynamically normal patient, definitive stabilization should be attempted. The timing of this
procedure is critical in determining the outcome, and must be individualised.

Type A fracture

The need for definitive fixation in these fractures is small, apart from the displaced iliac wing fracture, with
or without involvement of the greater sciatic notch area. Angiographic evaluation of blood supply is
required prior to open reduction of these fractures.

Use the iliac wing approach is performed via an external or internal iliac exposure ,use lag screws and
plates.

Type B fracture

ORIF is often needed.

Type B1

• anterior symphyseal disruption < 2.5 cm results in a good functional outcome without operative
intervention.

• anterior symphyseal disruption > 2.5 cm is best treated with anterior fixation via plate and screws
(generally done through a Pfannensteil incision and two 4.5 reconstructive plates; one anteriorly
the other along the superior border, each 4-6 holes or via external fixation for at least 8 to 12
weeks.

Types B2&B3

Usually treated with rest and symptomatic care unless concern re LLD and may consider application of
external fix. to externally rotate pelvis and restore leg length.

The so-called locked symphysis may occur in this type of injury, and is usually reduced via closed means.
Most patients can tolerate some internal rotation of the hemipelvis.

Type C

Difficult. In essence either: sacral fracture(s) +-SI dislocation.

Definitive stabilization of these unstable injuries is required, viz.:

• anterior fixation AND

• posteriorly fixation (technique below).

Technique: Operate usually within the first 5 to 7 days/antibiotic cover/haemodynamic monitoring +/- cell
saver /consider SSEP/neurologic monitoring/type of approach is dependant upon soft tissue injury/use
image intensification(fluoroscopy)

Surgical options include: for Sacral Fx-iliosacral screws; posterior

spanning plate, transiliac screws/rods(sacral bars); for SI dislocation - anterior with DCP plate, easy but
puts L5 nerve root at risk, or posterior stabilization with iliosacral screws,transiliac rods/plates. Detail in
foot note1). Do NOT over-tighten (especially where sacral fractures).

1 Fixation SI dislocation: posterior approach, junction of lower/middle thirds, screws from ilium to sacral
ala, index finger in incisura ischium to aim drill, fluroscopic control (need lateral sacral image), avoid sacral
formina/spinal canal/great vessesl, two x 6.5 cannulated screws, the guide wire is guided via fluroscopy
through the ilium and into the S1 body; consider percutaeous technique (J Matta et al 1989 Internal fixation
of pelvic ring fractures. Clin. Ortho 242 83-89); further detail read ML Chipp Routt et al Chap 37 Post
Pelvic-Ring Disruptions: Iliosacral Screws Chap 37 p. 602 in Fractures DA Wiss Ed, 1998. Master
techniques in Orthopaedic Surgery Lippincott-Raven, Philadelphia

or anterior approach, strip iliac muscle from inner wall ilium to expose SI, fix with two x short DCPs. Only
ONE screws into sacrum to avoid L5 nerve .

Trans-iliac rods (Harrington) are easy to put in, but prominence of rod end and subsequent wound break-
down is a problem. Use 2x.Consider putting a plate on end of rod contoured onto posterior ilium. Also use
4.5mm recon plate across iliac crests (through windows) and contoured onto post ilium.

Key point

• Iliosacral screws require good knowledge of spatial anatomy. Ideally left to expert in pelvic
fractures. Transiliac rods(sacral bars)/plates not so difficult.

Author's preferred technique(Fig. 17.3).

• Ant pelvic (open book) go to recon plate x two via Pfannenstiel incision. Expose linea alba in
midline. Divide linea alba and retract laterally two heads of rectus abdominus. Pubic bone now
visible. Use pointed retractors or Matta's two screw technique to reduce.

• Post ORIF with vertical displacement. Apply skeletal traction up to 40 ibs for 2 to 3 days to bring
hemi-pelvis down then place prone, two vertical lateral para-iliac incisions(off the prominence).
Keep skeletal traction on. Pass recon plate 3.5 or 4.5mm from window in one post iliac crest
across post sacrum to window in other and contour onto post ilium and fix.

Postoperative

Standard wound care/antibiotics/NWB 8 to 12 weeks or on less affected side for transfers/reduce to 3-6
weeks for stable configuration and increase for disrupted posterior element/post-operative x-rays done
weekly x4 then monthly x3 then 3 monthly x4.

Prognosis

Prognosis has been directly shown to be due to degree of injury.

Severe fractures lead to: worse post-operative pain; inability to return to pre-fracture work; altered sexual
function. Mortality is with age, over 70 yr is↑5 - 20%,up to 42% for open fractures( > 50%).Pedestrians
have 50% mortality and in pregnancy there is 33% foetal loss(20 - 40% of females subsequently need
Caesarean section).

Complications

Complications are: infection (0 to 25%, especially where bowel injury); nerve palsy (usually peroneal
component of sciatic nerve in 11.2% or 17.4% of posterior fractures; thromboembolism (vs. risk of early
haemorrhage), use compression stockings/calf compression devices/anti-coagulation/+/- IVC filter;
malunion (this can be devastating and cause low back pain/sitting problems/limb length differences with
gait problems; nonunion (rare but crippling), tends to occur in younger patients and may require bone
grafting.

Ectopic bone formation occurs in about 20%, use indomethicin and consider ? carcinogenic effect of
radiation in young people. Post traumatic osteoarthritis is seen in 4 - 15%,depends on quality of reduction.
Also: nearly 1/3 of unstable fractures,13% overall, have a urethral injury, therefore do retrograde
urethrogram prior to IDC with cystogram and IVP if indicated; bladder rupture usually extra-peritoneal and
form vesico colic and vesical fistulas. Impotence is evident in about 40%.

Conclusion
Pelvic fracture diagnosis and management has improved markedly over the past decades, but future
directions such as percutaneous pin fixation with image intensification and the development of guidance
systems for pin fixation, make this one of the most exciting areas in trauma management.

Section II – Acetabular fractures

Introduction

Fractures of the acetabulum are a major challenge to the orthopaedic surgeon. Many important matters
remain to be resolved in their management, including:

• Decision making (i.e., whether to operate- either in the acute setting or at a planned stage),

• The details of surgical technique, and

• The avoidance of complications.

Articular fractures, especially in weight-bearing joints of the lower extremity, require anatomical reduction,
either via closed or open means, for good long-term function. Complicated anatomy of the acetabulum
makes exposure of the fracture difficult, and severe comminution is often part of the personality of the
fracture, making reduction and fixation difficult. Also, fractures of the acetabulum frequently occur in
polytraumatized patients with major associated injuries and have a high morbidity and disability rate no
matter what the treatment. Anatomical reduction may not be possible even in the best circumstances. In
the young patient, the benefits of open reduction and internal fixation are worth the risks, but in the older
patient, other forms of operative care such as early total hip arthroplasty may be preferable.

Surgical anatomy

The acetabulum forms an inverted Y, when viewed from lateral aspect, one limb forming the anterior
column and one the posterior column. The anterior column extends from the iliac crest to the symphysis
pubis and includes the anterior wall of the acetabulum.

The posterior column begins at the superior gluteal notch and descends through the acetabulum, obturator
foramen, and inferior pubic ramus and includes the posterior wall of the acetabulum and the ischial
tuberosity. The superior weight-bearing area, which includes a portion of both the anterior and posterior
columns, has been called the acetabular dome or roof.

The pathoanatomy of any acetabular fracture depends on the position of the femoral head at the moment
of impact. The femoral head acts like a hammer, shattering the acetabulum on impact. Fractures of the
posterior column are produced when the femoral head is rotated internally and those of the anterior
column are produced when the head is rotated externally. If the femoral head is adducted, the superior
aspect of the dome is involved; and if it is abducted, the inferior aspect is involved. The actual fracture or
fracture–dislocation produced depends on the magnitude of the force causing it, as well as on the strength
of the bone. High-energy injuries from motor vehicles or motorbikes may occur at any age and produce
fractures of any anatomical variety, depending on the force direction. Comminution with articular impaction
fractures is common. Older patients with osteopenia may fracture the acetabulum with relatively low
forces, such as simple falls.

High-energy injuries have a high incidence of major associated injuries, whereas low-energy injuries are
usually isolated.

Key points

• Complex fractures of major weight-bearing joint.

• Anatomy and Surgery is difficult

• Often require ORIF (Matta et al. 1994)

• Sub-specialist help often needed.

Evaluation
After initial resuscitation, a complete physical examination is required to determine the associated injuries.
The extremity should be examined for soft-tissue injury, which may give insight into the mechanism of
injury. Especially important are local bruises in the area of the greater trochanter and areas of massive
subcutaneous hemorrhage. The ipsilateral knee must be carefully examined for posterior instability and
patellar fracture, both common in posterior-type patterns. Because nerve injury is relatively common,
careful documentation of any neurologic deficit is essential. Sciatic nerve involvement may be present in
up to 40% of posterior types, whereas femoral nerve involvement with anterior column fractures is rare but
not unknown. Also, vascular examination of the limb is mandatory to rule out penetrating injuries to the
femoral artery by the anterior column.

Patient factors

General medical fitness of the patient, and the type of trauma involved, affect the choice of management.
Anatomical open reduction and stable fixation is important in young, fit patients. Choices are not so clear in
older patients. If there is a strong indication for open reduction and internal fixation exists and the surgery
is relatively straightforward (such as a posterior wall fracture in isolation or with a transverse or column
fracture), then go to open reduction. However, with severe comminution in osteoporotic bone, especially if
secondary congruence can be achieved by traction in a both-column fracture (C type), nonoperative care
with traction is the preferred option. Good outcomes can be expected in some cases, and if not, do a total
hip replacement (Duwelius et al. 1998).

If surgery is NOT planned then traction should be continued until healing has occurred, usually at 8 to 12
weeks. If the pain has diminished at that time, the patient should be rehabilitated. A reconstructive
procedure such as arthroplasty or arthrodesis can be performed at this time or later as directed by
patient’s symptoms. In older patients with fractures that clearly would be difficult to fix and maintain
anatomically, early arthroplasty may be the best choice especially if a fracture of the femoral head or neck
is present.

Radiology
Often hard to read. Need standard and special views as well as CT scan.

Standard views

AP inlet and outlet views will determine whether the pelvic ring is involved in the acetabular fracture.

Special views (Judet et al. 1964)

To the standard anteroposterior view of the hip joint have been added a 45° internal rotation view
(obturator oblique view obtained by onto the unaffected side) and a 45° external rotation view rotating
patient 45 onto the side of the fracture) (Fig. 17.4). By°(iliac oblique view; rotate; 45 examining these three
views, two of which are at 90° to each other, the clinician can determine the overall pattern of the fracture.

Another useful view is roof angle- a measurement of how much dome is intact. On the AP draw line
vertically from acetabulum roof to centre of femoral head, draw second line from edge of fracture to centre
of head. The roof angle is below these lines. If roof angle more than 45º rarely need operative treatment.

Computed tomography

Computed tomography is useful for showing the fine detail in the acetabular fracture but not for viewing the
overall pattern. It shows with great precision fragments of the anterior or posterior wall, marginal impaction,
retained bone fragments in the joint, comminution, the presence or absence of a dislocation, and sacroiliac
pathology. 3-D reconstruction looks good, though not always adds much, and will assist in understanding
acetabular comminution (subtract the femoral head to see the interior of the acetabulum).

Classification

Judet et al. (1964) have divided all the fractures into elementary/simple and associated/complex types,
published the first comprehensive classification. All further attempts to classify these fractures stem from
their efforts.

The current classification is based on the AO comprehensive fracture classification, which groups all
fractures into A, B, and C types with increasing severity toward the C types (Fig. 17.5). The types are
anatomical, based on the Letournel-Judet classification, and modifiers are added in Table 17.3 to denote
prognostic indicators (with Greek letters).

Key points

• Each injury is different, and each fracture has its own personality. The ability to interpret pelvis
and acetabulum x-rays and CT scans is essential for individual decision making.

Classification:

• Simple: ant wall/ant column/post wall/post column/transverse

• Complex: post column-post wall/transverse-post wall/T-shaped/ant column-post

hemitransverse/both columns

Treatment

Primary URGENT closed reduction for ALL fracture dislocations (with sedation/muscle relaxant).
Then assess stability:

-For posterior fracture dislocations: cautiously flex and slightly adduct hip whilst checking for subluxation;
for anterior extend and abduct.

If the femoral head dislocates the fracture is unstable and surgery is required.
Monitor sciatic nerve function
Check the adequacy of reduction with x ray.
Non-operative management

Non-operative management may be indicated for injuries where congruity of the hip joint is maintained.
These include:

• Displacement of less than 2 to 5 mm in the dome, depending on the location of the fracture and
patient factors

• Distal anterior column fractures

• Distal transverse fractures (infratectal) in which congruity of the hip is maintained by the large
remaining medial buttress

• Both-column fractures with secondary congruence without major posterior column displacement.

• <20% posterior wall involved.

Surgery
Indications for surgery:

• Deteriorating sciatic nerve function post closed reduction

• Incarcerated fragment preventing congruent reduction

• Failure to achieve closed reduction

• Presence of femoral neck fracture

• Associated vascular injury

• Open injury

• Roof arc measurements<°45

• Fracture displacement>3mm

• Unstable hip

Operative treatment is generally indicated for the unstable or incongruous joint. Emergency surgery is
rarely indicated because these procedures are difficult and must be done under optimal conditions.

Unstable hip

Posterior instability

Fractures of the posterior wall of the acetabulum are the most common acetabular fracture (50%), often
thought to be easy but poor outcomes are not unusual (Baumgaertner 1999) (up to 80% of those treated
non-operatively).Usually occur in MVA from indirect force applied to knee from dashboard impact(may
have associated knee injury and sciatic nerve injury, up to 22%).Any acetabular fracture containing a
posterior wall fragment large enough (generally accepted to involve >50% of posterior wall; <20% are
stable) to cause instability of the joint in the normal resting position must be operated on to stabilize the
hip.
Central instability

Central instability may occur when the quadrilateral plate fracture is large enough to allow the femoral
head to sublux medially. In such cases some form of medial buttress with a spring plate or cerclage wire is
required to restore stability.

Anterior instability

Large anterior wall fragments either in isolation with an associated anterior dislocation or as part of an
anterior type with posterior hemitransverse pattern (type B3) may be large enough to allow anterior hip
instability and therefore require operative fixation.

Prepare for ORIF within the first 7 days. Surgery is difficult and ideally experienced surgeons undertake it.
Strive for anatomical reduction of all fractures and stable fixation, so as to allow early motion.

Postoperative mobilization depends on the quality of the bone/adequacy of reduction/degree of stability in

the internally fixed fracture. In general, postoperative traction is for 7 days with continuous passive motion
(CPM). If stability is good and the bone adequate, the traction may be removed and the patient allowed out
of bed. Weight bearing is not started until signs of union are present usually 6 to 8 weeks postoperatively.

If concern re the quality of the bone or gross comminution present, maintain traction for 6 to 8 weeks until
the fragments have healed. Then ambulate followed by progressive weight bearing at about 12 weeks.

Surgical approaches are varied and specialized2.

2 Kocher-Langenbeck-prone/post wall&column/transverse &combination/some T-shaped; Ilio-inguinal-ant

column +-post hemitransverse/transverse-high ant,low post/both column/cosmetic inc/less
morbidity/minimal muscle stripping/faster recovery/less hetero-bone; extended ilio-fem->3 weeks/both
columns/extension into SI joint/transverse-trantectal/T-shaped

Surgery for Posterior Wall Fractures (Levine 1996)

Instruments required (Fig. 17.6):

• Spiked-ball pusher (to reduce fragments)

• T-handled universal chuck with Schanz screw (place in greater trochanter to distract the head)

• plate template

• 3.5 mm reconstructive plates

• bending irons

• pliers.

Technique
Blood loss usually>700mls so consider use of blood cell savers. The need for somatosensory evoked
potentials monitoring is controversial (not used by authors). Use OR table which allows fluoroscopic
imaging. Place patient on side or prone. Maintain skeletal traction. Use the Kocher-Langenbeck posterior
approach. Centre incision at posterosuperior corner of greater trochanter. Split gluteus maximus proximally
until first crossing branches of the inferior gluteal nerve reached (otherwise denervate). Release the deep
half of the lower half of glut max from femur. Identify sciatic nerve under haematoma. Preserve quadratus
femoris (carries medial circumflex art which supplies femoral head). Dissect piriformis and obturator
internus tendons from capsule and divide mid substance. Elevate glut min from ilium (care near sciatic
notch to avoid damage to superior gluteal a/n/v). Examine joint, distract with Schanz screw in trochanter.
Remove free cartilaginous bits. Use concentrically reduced femoral head as template to guide replacement
of fragments (including the marginally impacted fragments). Fill gaps with cancellous bone graft. Slight
abduction/external rotation releave capsule tension to allow reduction. Use spiked-ball pusher. Usually use
buttress reconstructive plate (6 to 9mm from rim) as well as lag screws to hold reduction (seldom are 3 to
5 lag screws enough). May place plate (slightly underbent to aid reduction) down to ischium. Direct screws
away from joint (i.e. parallel or posterior to coronal plane). Check at end with fluroscopy. Need post-op
DVT prophylaxis.

Key points

Post wall/column fx:

• Kocher-Langenbeck approach

• Prone or lateral

• Neutralize with plate

Surgery for anterior wall (also accesses iliac wing/ant SI joint/pubic symphysis) (Helfet et al. 1997).

Ilioinguinal approach, patient supine on fluorscopic table. Incision from mid iliac crest to ASIS, parallel to
inguinal ligament to end 2cm above symphysis pubis. Release lateral aspect of external oblique then
subperiosteal dissection to expose internal iliac fossa. External oblique aponeurosis is incised 5mm from
insertion into inguianl ligament. Protect ilioinguinal nerve and contents of inguinal canal. Incise conjoint
tendon from inguinal ligament. Protect lateral femoral cutaneous nerve. Rect abg released from pubic tub
to symphysis pubis (now see bladder and space of Retzius). Mobilize iliopsoas muscle and femoral nerve
with Penrose drain. Isolate and dissect iliopectineal fascia off pelvic brim (from pect eminence to SI joint).
Ligate corona mortis a if present. Penrose drain around fem vessels, lymphatics and conjoint tendon.
Access to acetabulum now created via 3 windows (medial, middle, lateral. Now via medial and middle
windows, stepwise reduction of fx from margin. Schanz screw in lat fem head allows distraction. Flex hip to
improve access. Remove loose fragments. Start at iliac crest (for ant column).

Restore the normal concavity to the internal iliac fossa. Use above instruments AND reduction clamps, lag
screws, 3.5mm (carefully moulded) recon plates. Stabilize iliac crest and reduce ant wall/column to intact
iliac wing. Fluroscopy check. Drains into space of Retzius, re-attach rect abd to pubis. Repair floor and
roof of ing canal. Re-attach ext oblq to ing lig.

Same approach for both-column fractures (details beyond scope of this text. See footnote3 or access
OrthoSearch at www.orthosearch.com). Other acetabular fractures are specialized and beyond many
surgeons3.

3 For Transverse (=-posterior wall), T-shaped and Both columns-use Kocher-Langenbeck incision for most
cases/if mainly anterior displacement use ilioinguinal/if trantectal use extended iliofemoral;

For more detail read JM Matta,MC reilly Acetabula Fratcure:Ilioinguinal Approach Chap 40, p657-674 in
DA Wiss Ed, 1998. Fractures Master Techniques in Orthopaedic Surgery Lippincott-Raven, Philadelphia.

Prognosis and complications (Letournel and Judet 1993)

The prognosis for an acetabular fracture depends on both the fracture and the treatment. These factors
are:

• degree of violence—high energy versus low energy

• location—superior roof of the acetabulum or the posterior wall or column allowing instability

• degree of articular comminution on both the femoral head and acetabulum, including
osteochondral fractures, chondral fractures, and marginally impacted fragments

• degree of displacement

• presence of joint dislocation—anterior, central, or posterior

• associated injuries in the patient and the limb

Key points

• Quality of the reduction restoring both congruity and stability to the joint is the most important
factor in the prognosis.

Complications (not uncommon) associated with acetabular fractures and influencing prognosis are:
- Thromboembolic disease
- Infection
- Nerve Injury
- Heterotophic Ossification
- Avascular Necrosis (of fem head = acetabular fragments)
- Chondrolysis

Nerve injury

Sciatic nerve

The sciatic nerve may be injured at the time of trauma or during surgery. The reported incidence is 16% to
33%.

Femoral nerve

Rarely, the spike of the anterior column or during surgery injures the femoral nerve.

Superior gluteal nerve

The superior gluteal nerve is vulnerable in the greater sciatic notch, where it may be injured during trauma
or during surgery, resulting in paralysis of the hip abductors. Paralysis of the hip abductor mechanism is a
major disability.

Other nerves

Other nerves can be injured. The pudendal nerve can be compressed on the traction table, but it usually
recovers. Also, the lateral femoral cutaneous nerve of the thigh is commonly stretched or cut during
anterior approaches. The patient usually tolerates sensory loss in the lateral aspect of the thigh.

Heterotopic ossification

Heterotopic ossification is one of the major unsolved problems in acetabular surgery; 3% to 69%.

Avascular necrosis

Avascular necrosis of the femoral head is a devastating complication. Avascular necrosis of the acetabular
segment may also occur, causing collapse of the joint.

Chrondrolysis

Chrondrolysis after acetabular trauma can occur with or without surgical intervention; may lead to early
osteoarthritis. After open reduction and internal fixation, the surgeon must suspect infection or metal in the
joint. Occasionally, avascular necrosis of acetabular fragments causes early collapse and chondrolysis
may ensue. Causative factors are:

• injury related (the amount of articular damage to the femoral head or acetabulum, the
development of avascular necrosis, or the onset of other complications) or

• surgeon related (whether reduction is adequate and iatrogenic complications exist).

Fractures with hip instability or significant incongruity, especially posterior types, high transverse or T types
involving the dome, or fractures with a triangular dome fragment, require accurate open reduction and
stable internal fixation allowing early motion. If anatomical reduction is achieved and complications are
avoided, good to excellent results can be expected.