AJR:187, October 2006 915

AJR 2006; 187:915925

0361803X/06/1874915
American Roentgen Ray Society
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Durkee et al.
Radiographic and CT
Classification of Acetabular
Fractures
Mus cul os kel et al I magi ng Pi ct or i al Es s ay
Classification of Common
Acetabular Fractures:
Radiographic and CT Appearances
N. Jarrod Durkee
1,2
Jon Jacobson
1
David Jamadar
1
Madhav A. Karunakar
3
Yoav Morag
1
Curtis Hayes
1,4
Durkee NJ, Jacobson J, Jamadar D,
Karunakar MA, Morag Y, Hayes C
Keywords: acetabular fracture, CT, musculoskeletal
imaging, pelvic imaging, radiography, trauma
DOI:10.2214/AJR.05.1269
Received July 21, 2005; accepted after revision
September 18, 2005.
1
Department of Radiology, University of Michigan Medical
Center, 1500 E Medical Center Dr., TC-2910G, Ann Arbor, MI
48109-0326. Address correspondence to J. Jacobson
(jjacobsn@umich.edu).
2
Present address: Department of Radiology, University of
Washington, Seattle, WA.
3
Department of Orthopedic Surgery, University of Michigan
Medical Center, Ann Arbor, MI 48109-0326.
4
Present address: Department of Radiology, Medical
College of Virginia, Virginia Commonwealth University,
Richmond, VA.
CME
This article is available for 1 CME credit. See www.arrs.org
for more information.
OBJECTIVE. Accurate characterization of acetabular fractures can be difficult because of
the complex acetabular anatomy and the many fracture patterns. In this article, the five most
common acetabular fractures are reviewed: both-column, T-shaped, transverse, transverse with
posterior wall, and isolated posterior wall. Fracture patterns on radiography are correlated with
CT, including multiplanar reconstruction and 3D surface rendering.
CONCLUSION. In the evaluation of the five most common acetabular fractures, assessment
of the obturator ring, followed by the iliopectineal and ilioischial lines and iliac wing, for fracture
allows accurate classification. CT is helpful in understanding the various fracture patterns.
ccurate classification of acetabular
fractures is important for determin-
ing the proper surgical treatment
[1, 2]. Because of the complex ace-
tabular anatomy, various classification schemes
have been suggested [35], but the Judet-Le-
tournel classification system remains the most
widely accepted [2, 4, 6]. Although radio-
graphic examination provides essential infor-
mation for acetabular classification, CT, includ-
ing multiplanar reconstruction, is helpful in the
visualization of complex fractures [7].
This article reviews the pelvic bone anat-
omy and the five most common acetabular
fractures: both-column, T-shaped, transverse,
transverse with posterior wall, and isolated
posterior wall [2]. A fracture classification al-
gorithm based on radiography is used, with
correlation made to CT.
Normal Anatomy: Columns and Walls
The acetabulum is formed by anterior and
posterior columns of bone, which join in the
supraacetabular region [2, 6, 8]. The anterior
and posterior walls extend from each respec-
tive column and form the cup of the acetabu-
lum. The anterior and posterior columns con-
nect to the axial skeleton through a strut of
bone called the sciatic buttress. When looking
at the acetabulum en face, the anterior and
posterior columns have the appearance of the
Greek letter lambda () [2, 6] (Fig. 1A). The
anterior column represents the longer, larger
portion, which extends superiorly from the
superior pubic ramus into the iliac wing. The
posterior column extends superiorly from the
ischiopubic ramus as the ischium toward the
ilium. The anterior and posterior columns of
bone unite to support the acetabulum. In turn,
the sciatic buttress extends posteriorly from
the anterior and posterior columns to become
the articular surface of the sacroiliac joint,
A
A
Fig. 1Normal pelvic bone anatomy.
A, Surface-rendering 3D CT of pelvis in lateral view
with femur and right hemipelvis removed shows
anterior column (green), posterior column (blue), and
sciatic buttress (red).
(Fig. 1 continues on next page)
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Durkee et al.
916 AJR:187, October 2006
which attaches the columns to the axial skel-
eton. The anterior and posterior walls, which
extend from the columns and support the hip
joint, are well seen on an axial CT (Fig. 1B).
On radiographs, the iliopectineal (or ilio-
pubic) line represents the border of the ante-
rior column, and the ilioischial line represents
the posterior column [9] (Fig. 1C). The edges
of the anterior and posterior walls are also
identified. The obturator rings are composed
of the osseous structures that surround the ob-
turator foramen, which include the superior
B C
Fig. 1 (continued)Normal pelvic bone anatomy.
B, Axial section through acetabulum shows anterior (arrowhead) and posterior (arrow) walls.
C, Anteroposterior radiograph shows iliopectineal line (green), ilioischial line (blue), anterior acetabular wall (yellow), posterior acetabular wall (pink), and obturator foramen (O).
A B C
Fig. 2Illustrations of classification of five most common acetabular fractures.
A, Both-column fracture.
B, T-shaped fracture.
C, Transverse fracture.
(Fig. 2 continues on next page)
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Radiographic and CT Classification of Acetabular Fractures
AJR:187, October 2006 917
pubic ramus and a combination of the inferior
pubic ramus and ischium (or ischiopubic ra-
mus). Anteroposterior and bilateral oblique
(or Judet) views of the pelvis are important to
adequately assess each of the radiographic
lines for fracture.
Fracture Patterns
The most widely accepted classification
scheme for acetabular fractures is that of
Judet and Letournel [2, 4, 6]. Although this
classification scheme describes 10 types
of acetabular fractures, we have focused
D E
Fig. 2 (continued)Illustrations of classification of five most common acetabular fractures.
D, Transverse with posterior wall fracture.
E, Isolated posterior wall fracture.
Fig. 3Classification
algorithm for five
common acetabular
fractures [2].
ACETABULAR
FRACTURE
IDENTIFIED
OBTURATOR
RING
DISRUPTION?
FRACTURE LINE
EXTENSION INTO ILIAC
WING?
ILIOISCHIAL AND
ILIOPECTINEAL LINE
DISRUPTION?
POSTERIOR
WALL
FRACTURE?
POSTERIOR
WALL
FRACTURE?
NO YES
NO YES
YES NO YES
NO YES
BOTH-COLUMN
FRACTURE
T-SHAPED
FRACTURE
TRANSVERSE
FRACTURE
TRANSVERSE +
POSTERIOR WALL
FRACTURE
ISOLATED
POSTERIOR
WALL FRACTURE
on the most common fracture patterns,
which represent 90% of acetabular frac-
tures [2, 6] (Fig. 2). The five most com-
mon fracture types may be divided into
two groups on the basis of presence or ab-
sence of obturator ring fracture (Fig. 3).
Although fracture of the obturator ring
may be seen in combination with acetabu-
lar fractures, it is important to note that ob-
turator ring fractures may be associated
with other pelvic injuries outside of the ac-
etabulum, such as lateral pelvic compres-
sion injury, where the obturator ring frac-
ture is associated with either an ipsilateral
or contralateral sacral fracture [6].
We first discuss the two acetabular frac-
ture types (both-column and T-shaped)
associated with obturator ring disruption.
Next we discuss the three acetabular frac-
tures types that spare the obturator ring
(transverse, transverse with posterior wall,
and isolated posterior wall).
Both-Column Fracture
A both-column acetabular fracture (Figs. 4
and 5) involves both anterior and posterior col-
umns with extension into the obturator ring
and iliac wing, and is one of the most common
acetabular fractures [4]. On radiographs, frac-
ture involvement of the anterior and posterior
columns is characterized by disruption of the
iliopectineal line and ilioischial line, respec-
tively. However, disruption of these lines may
also be seen with other fracture patterns, such
as a transverse fracture. Obturator ring and il-
iac wing involvement must also be present for
classification as a both-column acetabular
fracture. Fracture extension into the iliac wing
is not always obvious on the anteroposterior ra-
diograph; oblique Judet views or CT often re-
veal this finding.
On CT, fracture involvement of the ante-
rior and posterior columns is seen, and the
fracture may be comminuted. Fracture dis-
ruption of the obturator ring has a variable
appearance; fracture of the superior pubic
ramus may occur at the puboacetabular
junction. In addition, fracture of the inferior
pubic ramus may be difficult to identify if
nondisplaced. The principal fracture line,
which extends superiorly from the acetabu-
lum into the iliac wing, is characteristically
in the coronal plane.
If present, a pathognomonic sign of a
both-column fracture is the spur sign [2]
(Fig. 5). This sign represents posterior dis-
placement of the sciatic buttress of the iliac
wing fracture, which essentially discon-
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Durkee et al.
918 AJR:187, October 2006
nects the roof of the acetabulum from the
axial skeleton. When this occurs, weight
from the torso and upper body can no longer
be supported by the acetabulum. On radio-
graphs and CT, the spur sign appears as a
shard of bone extending posteriorly at the
level of the superior acetabulum. Evaluation
of sequential CT images shows the fracture,
which separates the sciatic buttress from the
acetabular roof.
T-Shaped Fracture
A T-shaped acetabular fracture (Fig. 6) is a
combination of a transverse acetabular frac-
ture with extension inferiorly into the obtura-
tor ring. It is similar to a both-column fracture
A B
C
Fig. 445-year-old man with both-column acetabular fracture.
AE, Anteroposterior pelvic radiograph (A), bilateral oblique pelvic radiographs (B,
C), axial CT scan (D), and sagittal reconstruction CT scan (E) show acetabular
fracture (straight arrows, AC), with break in obturator ring (arrowheads, AC) and
extension into iliac wing (curved arrows). Note coronal plane of fracture on CT and
superior pubic ramus fractured at puboacetabular junction.
(Fig. 4 continues on next page)
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Radiographic and CT Classification of Acetabular Fractures
AJR:187, October 2006 919
in that it disrupts the obturator ring
(Figs. 6A6C). Another similarity is disrup-
tion of both the iliopectineal and ilioischial
lines (Figs. 6A6C). However, the superior
extension of the fracture does not involve the
iliac wing, which allows differentiation from
the both-column fracture.
One area of potential confusion with the T-
shaped fracture is in regard to the transverse
component. The transverse fracture line is not
actually in the anatomic transverse plane, but
rather it is transverse relative to the acetabu-
lum. Because the cup shape of the acetabulum
is normally tilted inferiorly and anteriorly, the
transverse fracture plane assumes a similar
Fig. 4 (continued)45-year-old man with both-column acetabular fracture.
AE, Anteroposterior pelvic radiograph (A), bilateral oblique pelvic radiographs (B,
C), axial CT scan (D), and sagittal reconstruction CT scan (E) show acetabular
fracture (straight arrows, AC), with break in obturator ring (arrowheads, AC) and
extension into iliac wing (curved arrows). Note coronal plane of fracture on CT and
superior pubic ramus fractured at puboacetabular junction.
E D
A
Fig. 535-year-old man with both-column acetabular fracture and spur sign.
A and B, Oblique pelvic radiograph (A) and axial CT image (B) show spur sign (arrow),
which represents displacement of fracture involving sciatic buttress (arrowheads).
Note that sciatic buttress (arrowheads, B) no longer connects to weight-bearing
portion of acetabulum.
B
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Durkee et al.
920 AJR:187, October 2006
orientation. Therefore, on radiographs, the
fracture lines that disrupt the iliopectineal and
ilioischial lines course superiorly and medi-
ally in an oblique plane from the acetabulum.
This is best appreciated by looking at the ac-
etabulum en face (Fig. 6E). On CT, this trans-
verse fracture component is seen as a sagit-
tally oriented fracture coursing medially and
superiorly from the acetabulum.
Transverse Fracture
The transverse fracture of the acetabu-
lum (Fig. 7) is limited to the acetabulum,
without involvement of the obturator ring.
A transverse fracture must involve both the
anterior and posterior aspects of the acetab-
ulum, so the iliopectineal and ilioischial
lines are disrupted on radiography. Similar
to the transverse component of the T-shaped
fracture described previously, this fracture
line extends superiorly and medially from
the acetabulum. On CT, the characteristic
sagittally oriented fracture line can be seen
moving laterally to medially on subsequent
CT images when scrolling from inferior to
superior. Although not anatomically trans-
verse, the fracture plane is transverse rela-
tive to the acetabulum, which is relatively
A B
C
Fig. 640-year-old man with T-shaped acetabular fracture.
AE, Anteroposterior pelvic radiograph (A), bilateral oblique pelvic radiographs (B,
C), axial CT scan (D), and surface-rendering 3D CT scan viewed laterally (E), with
right hemipelvis and femur removed, show obturator ring fractures (arrowheads) and
transverse component (arrows) through acetabulum. Note characteristic
obliquesagittal orientation of transverse acetabular fracture component on CT
scans that is transverse relative to acetabulum on radiographs.
(Fig. 6 continues on next page)
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Radiographic and CT Classification of Acetabular Fractures
AJR:187, October 2006 921
tilted inferiorly and anteriorly. This fracture
plane orientation is best seen on CT recon-
struction images of the acetabulum en face
(Fig. 7E).
Transverse with Posterior Wall
The transverse with posterior wall fracture
(Fig. 8) is a transverse fracture, described pre-
viously, with the addition of a comminuted
posterior wall fracture that is often displaced.
As with an isolated transverse fracture, the
key is recognizing that the obturator ring is
not disrupted, as this excludes both-column
D E
Fig. 6 (continued)
40-year-old man with
T-shaped acetabular
fracture.
AE, Anteroposterior
pelvic radiograph (A),
bilateral oblique pelvic
radiographs (B, C), axial
CT scan (D), and surface-
rendering 3D CT scan
viewed laterally (E), with
right hemipelvis and
femur removed, show
obturator ring fractures
(arrowheads) and
transverse component
(arrows) through
acetabulum. Note
characteristic
obliquesagittal
orientation of transverse
acetabular fracture
component on CT scans
that is transverse relative
to acetabulum on
radiographs.
A B
Fig. 723-year-old woman with transverse acetabular fracture.
AE, Anteroposterior pelvic radiograph (A), bilateral oblique pelvic radiographs (B, C), axial CT scan (D), and surface-rendering 3D CT scan viewed laterally (E), with right
hemipelvis and femur removed, show fracture (arrows) orientation transverse to acetabulum, disrupting iliopectineal and ilioischial lines (arrowheads). Note characteristic
sagittaloblique fracture plane on CT scan (D).
(Fig. 7 continues on next page)
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Durkee et al.
922 AJR:187, October 2006
and T-shaped fractures. As with the simple
transverse fracture, this fracture type does not
extend into the iliac wing.
On radiographs, disruption of both ilio-
pectineal and ilioischial lines is seen as with
the isolated transverse fracture. Unlike an iso-
lated transverse fracture, however, additional
comminution of the posterior wall is seen. In
the absence of displacement, comminution of
the posterior wall may be difficult to identify
on anteroposterior radiographs because the
fragments are superimposed on the femoral
head. Oblique Judet radiographs and CT are
helpful in showing the comminuted posterior
wall component.
Isolated Posterior Wall
The isolated posterior wall fracture
(Fig. 9) is one of the most common types of
acetabular fracture, with a prevalence of
27% [8]. An isolated posterior wall fracture
does not have a complete transverse acetab-
ular component. Therefore, the iliopectineal
line is not disrupted, which excludes classi-
fication of the transverse with posterior wall
fracture. However, disruption of the iliois-
chial line may or may not be present as an
extension of the comminuted posterior wall
component. Oblique (Judet) radiographs
and CT are helpful in showing the isolated
posterior wall fracture.
Conclusion
Common acetabular fractures can easily be
classified using disruption of the obturator ring
as the basis of a decision tree (Fig. 3). Fracture
of the obturator ring indicates both-column or
T-shaped fracture, with additional iliac wing
involvement differentiating the both-column
from the T-shaped fracture. Sparing of the ob-
turator ring commonly indicates transverse,
transverse with posterior wall, or isolated pos-
terior wall fracture. Disruption of both the ilio-
pectineal and ilioischial lines indicates a trans-
verse fracture, and comminution of the posterior
wall indicates a posterior wall fracture. A both-
column fracture is in the coronal plane, whereas
C
D
E
Fig. 7 (continued)23-year-old woman with transverse acetabular fracture.
AE, Anteroposterior pelvic radiograph (A), bilateral oblique pelvic radiographs (B,
C), axial CT scan (D), and surface-rendering 3D CT scan viewed laterally (E), with
right hemipelvis and femur removed, show fracture (arrows) orientation transverse
to acetabulum, disrupting iliopectineal and ilioischial lines (arrowheads). Note
characteristic sagittaloblique fracture plane on CT scan (D).
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Radiographic and CT Classification of Acetabular Fractures
AJR:187, October 2006 923
A B
C
D
E
Fig. 820-year-old man showing transverse with posterior wall acetabular fracture.
AE, Anteroposterior pelvic radiograph (A), bilateral oblique pelvic radiographs (B,
C), axial CT scan (D), and surface-rendering 3D CT scan viewed laterally (E), with
right hemipelvis and femur removed, show transverse fracture (straight arrows)
disrupting iliopectineal and ilioischial lines (arrowheads) with displaced and
comminuted posterior wall fracture fragment (curved arrows).
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Durkee et al.
924 AJR:187, October 2006
A B
C
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Fig. 918-year-old man with isolated posterior wall acetabular fracture.
AF, Anteroposterior pelvic radiograph (A), bilateral oblique pelvic radiographs (B,
C), axial CT images (D, E), and parasagittal reconstruction CT image (F) show
displaced fracture fragments (curved arrows) from isolated posterior wall fracture
(straight arrow, D).
(Fig. 9 continues on next page)
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Radiographic and CT Classification of Acetabular Fractures
AJR:187, October 2006 925
a transverse or T-shaped fracture is in the sagit-
tal oblique plane on CT. The addition of CT
with multiplanar reconstruction and 3D surface
rendering is helpful in understanding and clas-
sifying acetabular fractures.
Acknowledgment
We thank Robert W. Jacobson for the
illustrations.
Fig. 9 (continued)
18-year-old man with
isolated posterior wall
acetabular fracture.
AF, Anteroposterior
pelvic radiograph (A),
bilateral oblique pelvic
radiographs (B, C), axial
CT images (D, E), and
parasagittal
reconstruction CT
image (F) show
displaced fracture
fragments (curved
arrows) from isolated
posterior wall fracture
(straight arrow, D).
F
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F O R Y O U R I N F O R M AT I O N
This article is available for 1 CME credit. See www.arrs.org for more information.
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