Acetabular fractures

Dr. Roshan D.

Introduction

Generally caused by high energy trauma Such high energy injuries usually have a high incidence of major associated injuries The fracture or fracture dislocation produced depends on the magnitude and the direction of the injuring force as well as on the strength of the bone.

Pathoanatomy

Fractures depend on the position of the femoral head at the moment of impact

Fracture location

Position of femoral head

Posterior column #

IR

Anterior column #
Superior dome #

ER
Adduction

Inferior aspect of the Abduction dome #

Acetabulum - Anatomy

Incomplete hemispherical socket with an

inverted horse-shoe shaped articular surface non articulating cotyloid fossa.

The articular surface is composed of and supported by two columns of bone (described by Letournel and Judet) as an inverted Y

Acetabulum Anatomy The Column Concept

Used in the classification of the fractures The anterior column

Iliac crest, iliac spines, the anterior half of the acetabulum and the pubis.

The posterior column

Ischium, ischial spine, posterior half of the acetabulum and the dense bone forming the sciatic notch

The shorter posterior column ends at its intersection with the anterior column at the top of the sciatic notch

Acetabulum - Anatomy

The dome or roof is the weight bearing portion of the articular surface that supports the femoral head The quadrilateral surface is the flat plate of bone forming the lateral border of the pelvic cavity The iliopectineal eminence is the prominence in the anterior column that lies directly over the femoral head.

Acetabulum Anatomy Neurovascular structures

The sciatic nerve The superior gluteal Artery and Nerve Corona mortis

Classification
(Letournel and Judet)

Simple fractures
fractures of the posterior wall, posterior column, anterior wall, anterior column and transverse fractures.

Associated fractures
T-shaped fractures, fractures of the posterior column and posterior wall, transverse + posterior wall fracture, anterior fracture + hemitransverse posterior fracture and both column fracture.

Classification
Comprehensive Classification after Letournel

TYPE A - PARTIAL ARTICULAR ONE COLUMN FRACTURE

A1Posterior wall A2Posterior column A3Anterior wall and/or anterior column

Classification
Comprehensive Classification after Letournel

TYPE B PARTIAL ARTICULAR TRANSVERSE ORIENTED FRACTURE Transverse types with portion of the roof attached to intact ilium
B1Transverse + posterior wall B2T types B3Anterior with posterior hemitransverse

Classification
Comprehensive Classification after Letournel

TYPE C COMPLETE ARTICULAR, BOTH COLUMN FRACTURE - both columns are fractured and all articular segments, including the roof, are detached from the remaining segment of the intact ilium, the floating acetabulum.
C1Both columnanterior column fracture extends to the iliac crest (high variety) C2Both columnanterior column fracture extends to the anterior border of the ilium (low variety) C3Both columnanterior fracture enters the sacroiliac joint

Classification
Comprehensive Classification after Letournel

Qualifiers: Additional information can be documented concerning the condition of the articular surfaces to further define the prognosis of the injury. The information should be, as additional qualifiers, identified by Greek letters.
a1) a2) a3) b1) b2) b3) g1) g2) d1) d2) d3) e1) f1) Femoral head subluxation, anterior Femoral head subluxation, medial Femoral head sublucation, posterior Femoral head dislocation, anterior Femoral head dislocation, medial Femoral head dislocation, posterior Acetabluar surface, chondral lesion Acetabular surface, impacted Femoral head, chondral lesion Femoral head, impacted Femoral head, osteochondral fracture Intra-articular fragment requiring surgical removal Nondisplaced fracture of the acetabulum

Classification

Acetabular anatomy

Anterior column fracture

Anterior column with an anterior wall fracture

Acetabular anatomy

Anterior wall fracture

Associated anterior wall and transverse fractures

Acetabular anatomy

Classic posterior wall fracture

Posterior column fracture

Acetabular anatomy

Posterior wall with posterior column fracture

Posterior wall fracture with a transverse fracture

Acetabular anatomy

Superior dome fracture

Transverse fracture

Acetabular anatomy

T-type fracture

Anterior wall fracture with dislocation

Signs and symptoms

Apart from local examination

Look out for associated life threatening injuries (intra-abdominal injuries) A, B, C first before the rest Older patients
Arrhythmia, transient ischemic attacks may have led to the

fall

SDH can occur when older patients fall.

Radiographic Evaluation

Requires
A CT scan 3 plain radiographic views Antero-posterior view of the hip 45 iliac oblique view 45 obturator oblique view
Judet view 45 oblique view

Plain Radiographs 1 - AP View

Start evaluation with this view Iliopectineal line represents the anterior column; Ilioischial line represents the posterior column; Posterior lip represents the posterior wall; Anterior lip represents the anterior wall; Dome; Tear-drop

Plain Radiographs 2 - The obturator oblique view

Anterior column fracture displacements Posterior wall fragments and their displacement

Plain Radiographs 3 - The iliac oblique view

Posterior border of the posterior column and Continuity of the true posterior column can be determined.

CT Scan

3 mm interval axial cuts Include the entire pelvis to avoid missing a portion of the fracture Compare with opposite hip

Watch for Anterior and posterior wall fragments, marginal impaction, retained bone fragments in the joint, comminution, presence or absence of a dislocations and any sacroiliac joint pathology.

Management

Initial treatment follow ATLS protocols Operative treatment of acetabular fractures are usually not performed as an emergency Normally, a closed reduction Skeletal traction Even a rare true central dislocation is treated that way

Operative Surgical anatomy

Posterior wall fragments

vary in the size and degree of comminution Well appreciated in a CT scan. Unrecognized fracture lines maybe detected at surgery So the posterior wall fracture should never be fixed with lag screw alone. The posterior wall fragment receives its blood supply from the capsule avoid detaching the capsule from its blood supply.

Operative Surgical anatomy

Posterior Column fractures

Can occur anywhere along the posterior column from the ischial spine to the sciatic notch. Typically, the column fragment rotates. It is necessary to derotate the fragment and check the reduction.

Operative Surgical anatomy

Anterior Column fractures

Occur at various levels along the anterior column. Although the pubic ramus is part of the anterior column, ramus fracture usually indicates the presence of a pelvic fracture rather than an acetabular fracture.

Operative Surgical anatomy

Transverse fractures
Run across the acetabulum. The fractures that cross the region of the fovea are called infratectal. The fractures that cross just above the fovea are juxtatectal fractures crossing higher are transtectal.

T-type fractures
Transverse fracture with a fracture line seperating the anterior column from the posterior column

Operative Surgical anatomy

Anterior and posterior hemi-transverse fractures

This is an anterior column fracture with and additional fracture line that runs transversely across the posterior column. Here, the displacement is usually anterior and the posterior column not significantly disturbed. Thus reducing the anterior column usually reduces the posterior column.

Operative Surgical anatomy

Both column fractures

Entire acetabulum is separated from the axial skeleton. Sometimes, it is called as a floating acetabulum. Since the entire acetabulum is separated from the ilium, the actual joint can appear congruent. This radiographic appearance is called the secondary congruence. Spur sign

Spur sign

Pathognomonic of both column fratures. see in obturator oblique view

Surgical Approaches

Iliofemoral Ilioinguinal Kocher Langenbeck Triradiate transtrochanteric Extended iliofemoral Combined anterior and posterior approach

Iliofemoral approach

This approach is sufficient for anterior column fractures where the main displacement is cephalad to the hip joint. It doesnt give access distal to the iliopectineal eminence.

Ilioinguinal approach

It is ideal for difficult fractures with anterior displacement where access to the entire anterior column is required. The anterior approach gives access to the anterior column as far as the symphysis and includes the quadrilateral plate.

Ilioinguinal approach

Triradiate transtrochanteric approach

It is ideal for fractures with both column injuries where in the entire outer table of the pelvis from the anterior superior iliac spine to the top of the sciatic notch can be seen.

Extended Iliofemoral approach

It gives excellent visualization of the ilium, the superior dome and the posterior column. The anterior column can be seen up to the iliopectineal eminence. This exposure is similar to that provided by the triradiate approach with the additional benefit of access to the bone above the sciatic notch.

Kocher Langenbeck approach

It is indicated for posterior wall injuries and posterior column injuries. It allows only to these. In all posterior approaches, the sciatic nerve is in jeopardy. The superior gluteal artery and nerve are likely to get injured in the greater sciatic notch during stripping of the periosteum.

Kocher Langenbeck approach

Combined anterior and posterior approaches

Patient is in lateral position with no fixed support. It allows for the surgeon to roll the patient prone or supine if necessary.

Approaches for specific fractures

Type ASingle wall or column

Type A Partial articular single wall or column; for isolated posterior wall fractures (A1). The best approach is a Kocher-Langenbeck approach with the patient in prone or lateral position. For A2 posterior column on posterior column/posterior wall fracture the Kocher-Langenbeck approach with the patient in prone position. For the anterior wall and anterior column fractures (A3), the anterior iliofemoral approach for low anterior column fractures, the anterior ilioinguinal approach.

Approaches for specific fractures

Type BTransverse and/or T types (partial articular)

B1 Transverse
Posterior displacement kocher langenbeck Associated posterior wall kocher langenbeck Anterior displacement - ilioinguinal Late / severe displacement extensile combined approach

B2 - T types
Posterior displacement kocher langenbeck Associated posterior wall kocher langenbeck Anterior displacement Ilioinguinal Assosiated posterior wall extensile / combined approach

Approaches for specific fractures

Type B
B3 Anterior column and posterior hemitransverse fractures can be fixed through an anterior ilioinguinal approach.

Type C - Complete articular the both column fracture

If the posterior column fracture is a large single fragment, anterior ilioinguinal approach is adopted If significant fracture of the posterior wall, combined posterior and anterior approaches

Indications for non-operative treatment

Non displaced and minimally displaced fratures. Fractures that traverse the wt bearing dome, but with less than 2 mm displacement managed by non wt bearing and or skeletal traction for 8 weeks. Secondary congruence in displaced both column fractures. Closed treatment gives good results.

Indications for non-operative treatment

Fractures with significant displacement but, in which the region of the joint involved is judged to be unimportant prognostically. This can be determined by the roof arc measurement described by Matta and Olson as 45 degrees for each roof arc, medial, anterior and posterior. Another roof arc measurement as proposed by Vrahas, Widding and Thomas is 25 degree fro the anterior roof arc, 45 degree of the medial roof arc and 70 degree for the posterior roof arc. Most authors agree that displaced fractures through the weight bearing dome should be treated with ORIF, regardless of how they line up in traction.

Roof arc measurement

Medical contraindications to surgery

Multisystem injury An open wound in the anticipated surgical field The Morel Lavalle lesion Presence of a suprapubic catheter is a contraindication for ilioinguinal approach. Elderly patients with osteoporotic bone where ORIF may not be feasible.

Indications for operative treatment

In fracture incongruity due to

Posterior column or wall injuries Displaced fractures of the superior dome Retained bony fragments

In the limb
Sciatic nerve injury Fracture of the ipsilateral femur Injury to the ipsilateral knee

In the patient polytraumatised patient

Treatment of specific fracture patterns

Posterior wall fractures

Posterior Langenbeck approach with the patient positioned either prone or lateral using lag screw and a reconstruction plate placed from the ischium over the retro acetabular surface onto the lateral ileum. (If the fracture extends superiorly into the dome, a trochanteric osteotomy may be performed to allow additional exposure) To avoid AVN of the posterior wall, the posterior wall fragments must not be detached from the posterior capsule. The knee must be kept flexed throughout the procedure to avoid injury to the sciatic nerve.

Treatment of specific fracture patterns

Posterior column fracture

Though uncommon if significantly displaced, requires ORIF (Kocher Langenbeck approach). Typical fixation is with a lag screw combined with a contoured reconstruction plate along the posterior column. Rotational deformity must be corrected by placing a Shanz screw in the ischium to control rotation while the fracture is reduced with a reduction clamp

Treatment of specific fracture patterns

Anterior wall and anterior column fracture

Isolated anterior wall fractures are uncommon. Sometimes, they are associated with anterior hip dislocation. Fractures requiring surgery are fixed with a buttress plate applied through an ilioinguinal or iliofemoral approach. Anterior column fractures are approach similarly with fixation by a contoured plate along with a pelvic brim.

Treatment of specific fracture patterns

Transverse fractures
Transtectal fractures have the worst prognosis and accurate reduction is essential. Juxtatectal fractures also usually require reduction. Typical reduction is through a posterior approach using a Farabeuf clamp to reduce the fractures while rotation is controlled by a Shanz screw in the ischium. Posterior fixation typically is with a buttress plate along the posterior column and anterior fixation using a 3.5 mm lag screw placed into the anterior column from a position above the acetabulum.

Treatment of specific fracture patterns

Posterior Column fracture with associated posterior wall fracture

A Kocher-Langenbeck approach is used with or with out a trochanteric osteotomy. The column fracture is reduced first. A short reconstruction plate is placed posteriorly along the posterior edge of the column. A separate plate is used for the wall fragment. T screws through the plate secure rotational reduction on the posterior column fragment.

Treatment of specific fracture patterns

Transverse fracture with associated posterior wall fracture

The common fracture can be difficult to reduce. The posterior wall component requires a posterior exposure, but reduction of the anterior part of the transverse fracture can be difficult through a Kocher-Langenbeck approach and extensile or combined approach is frequently necessary.

Treatment of specific fracture patterns

T-type and anterior column-posterior Hemitransverse fracture

They are treated through an ilioinguinal approach with a contoured plate placed along the pelvic brim and lag screws extending into the posterior column. For a T-type fracture with severe posterior displacement but minimal anterior displacement, posterior approach alone may be sufficient with placement of anterior column lag screw. If both the anterior and posterior components of the fracture are significantly displaced, an extensive or combined approach are required.

Treatment of specific fracture patterns

Both column fractures

These have varying degrees of comminution and can be extremely complex and difficult to treat. Many both column fractures can be treated through an anterior ilioinguinal approach. But a posterior or extensile exposure is required for involvement of the sacroiliac joint, significant posterior wall fracture, or intraarticular comminution. Reduction is begun from the most proximal portion of the fracture and proceed towards the joint.

Implants for acetabular fractures

Post-operative care

Closed suction drain Antibiotic for 48 72 hours Passive motion of the hip on the 2nd or 3rd day. Touch down ambulation & crutches on 2nd to 4th day. The minimal weight bearing status is continued for 8 weeks in patients with simple fractures and 12 weeks in most others. Rehabilitation of the abductor muscle group is needed.

Complications

General
Thromboembolic disease Infection

Specific

Specific Complications

Sciatic nerve injury

Thirty percentage of acetabular fractures have associated sciatic nerve injury. In 2 6 % of patients, it occurs as a result of surgery and is more often associated with posterior fracture pattern treated through a Kocher-Langenbeck and extensile exposures. The peroneal component of sciatic nerve is more often involved than the tibial component. Complete peroneal palsies have the worst prognosis. Tibial component has greater chances of recovery.

Specific Complications

Other nerves
Femoral nerve injury though rare, care to be taken during the anterior ilioinguinal approach. Superior Gluteal nerve injury is vulnerable in the greater sciatic notch, resulting in abductor paralysis. Pudendal nerve injury Injury to the lateral femoral cutaneous nerve causes sensory loss in the lateral aspect of the thigh.

Specific Complications

Post-traumatic arthritis Heterotopic ossification Chondrolysis AVN

Thank You