Acetabulum Fractures

Dr Digbijoy Roy,PGT 3rd years

Moderator: Dr M.A Barbhuiya (Assistant Professor)
 ANATOMY
The acetabulum is an incomplete
hemispherical socket with an
inverted horseshoe-shaped
articular surface surrounding the
medial nonarticular cotyloid
fossa. The acetabulum can best
be described as a partial ball and
socket joint composed of six
components: (1) anterior, or
iliopubic, column, (2) posterior,
or ilioischial, column, (3)
anterior wall, (4) posterior wall,
(5) ace tabular dome/roof, and
(6) medial wall or quadrilateral
plate.
Anatomy
• Inverted “Y” two column
concept and supports and
transmit load to the remainder
of the pelvis
• Described by Judet and Letournel
(1966)
• Columns connected to SI joint by
thick area of bone above sciatic
notch (sciatic buttress)
• Anatomical roof of acetabulum
forms keystone of arch
• Columns
• Anterior
Anterior
• Posterior column

• Walls
• Anterior
• Posterior
Anterior
Anterior
Posterior
• Quadrilateral wall
wall
wall

surface/medial wall
• Dome
Posterior
column Illustrations courtesy of Alesha N. Scott, D.O.
Anterior column
• Extends from anterior half of
iliac crest to superior pubic
ramus
• 3 segments
• Iliac segment
• Acetabular segment
• Pubic segment

Photo courtesy of Alesha N. Scott, D.O.

Posterior column
• Extends from greater sciatic
notch to inferior ischium Photo courtesy of Alesha N. Scott, D.O.

• 2 segments
• Posteroinferior portion of ilium
• Greater and lesser sciatic notches
• Ischium

Photo courtesy of Alesha N. Scott, D.O.

Anterior wall
• Iliopectineal eminence
• Represents the anterior and
medial boundary of the
acetabulum
Iliopectineal
• Iliopsoas runs just lateral to the eminence
eminence

Photo courtesy of Alesha N. Scott, D.O.

Photo courtesy of Alesha N. Scott, D.O.

Posterior wall
• Most common acetabular
fracture type

Photo courtesy of Alesha N. Scott, D.O.

Medial wall
• Quadrilateral surface +
acetabular fossa
• Commonly involved in
geriatric acetabular
fracture patterns

Illustrations courtesy of Alesha N. Scott, D.O.

Vascular Acetabular
Anatomy
• Lateral (A)
• Superior gluteal artery
• Inferior gluteal artery
• Medial femoral
circumflex artery
• Medial (B)
• Iliolumbar artery
• Obturator artery

A B
Iliolumbar artery
• Origination
• From posterior trunk of internal
iliac artery.
• Divisions
• Superficial branch
• Deep branch
• Nutrient artery to ilium  50% enter
ilium anterior to SIJ, lateral to pelvic
brim; 50% enter medial to pelvic
brim
Obturator artery
• Branches
• Quadrilateral surface
• Superior pubic ramus
• Acetabular branch
• Enters deep to transverse acetabular
ligament
• May be the terminal supply to
acetabulum
• Anastomosis
• With MFCA
Superior gluteal artery
(SGA)
• Most important contribution to
acetabular blood supply
• Branches
• Deep
• Superior
• Inferior
• Supraacetabular
• Acetabular
Superior gluteal artery
(SGA)
• May be lacerated secondary
to injury or retractor
placement in the greater
sciatic notch
 Inferior gluteal artery (IGA)
• Acetabular branches
• Deep to short external rotators
• Between inferior gemellus and
quadratus femoris
• Anastomosis with MFCA
• Medial femoral circumflex
artery (MFCA)-Ascending branch
is main blood supply to femoral head

Berton R. Moed and John A Boudreau. Acetabulum Fractures. In: Tornetta P, Ricci WM, eds. Rockwood and Green's
Fractures in Adults, 9e. Philadelphia, PA. Wolters Kluwer Health, Inc; 2019. Figure 50-34.
Mechanism of injury
• Impact of the femoral head with the acetabular articular surface.
• Greater trochanter (direct trauma along the axis of the femoral neck)
• Anywhere along the long axis of the femoral shaft
• The # pattern depends on the position of femoral head at the time of
injury,magnitude of force and the age of patient.
Clinical evaluation

• ATLS protocol
• Neurovascular Assessment
• Associated injuries must be ruled out.
• Assessment of soft tissue injuries.

Morel Lavalle lesion

Imaging
• X-Rays
• Standadrd AP view
• Judet Views
• 45 degree obturator oblique view
• 45 degree iliac oblique view
• Pelvic inlet and outlet view
• CT Scan
AP Radiograph
• Centered on symphysis
• Neutral rotation
• Symmetric obturator
foramen
• Spinous process in line
with pubic symphysis
• Neutral pelvic tilt
• Coccyx ~1-3cm above
symphysis
Judet Views
• Oriented 45 degrees to
coronal plane
• Obturator ring is
perpendicular (orthogonal) to
iliac wing
• Iliac oblique of one hip is
obturator oblique of
contralateral hip
• Coccyx should be centered
over cotyloid fossa.
Obturator Oblique
• Injured hemipelvis bumped
up, toward XR beam Iliac oblique

• Iliac cross section small as

possible
• Perfectly displays outline of
the obturator ring1
• Best demonstrates
• Anterior column
• Posterior wall

Obturator oblique
Image courtesy of Dr. Raymond Wright, MD
Iliac Oblique
• Contralateral (uninjured) Iliac oblique
hemipelvis bumped up,
toward XR beam
• Exposes surface of the iliac
wing
• Obturator foramen not visible,
obturator ring as thin as
possible
• Best demonstrates
• Posterior column
• Anterior wall
• Iliac wing in profile
Obturator oblique
Letournel’s Radiographic Landmarks
Letournel’s 6 Radiographic
Landmarks
1. Iliopectineal line
2. Ilio-ischial line
3. Teardrop
4. Acetabular roof
5. Anterior wall
6. Posterior wall

*All identified on AP
pelvis radiograph
Iliopectineal line
• Landmark for anterior
column
• Anterior ¾: pelvic brim
• Posterior ¼: sciatic
buttress and roof of
sciatic notch
Ilioischial line
• Landmark for posterior
column
Teardrop
• Not a true anatomic
structure
• Medial limb
• obturator canal and
anteroinferior portion of
quadrilateral surface1
• Lateral limb
• Inferior aspect of anterior
wall

• Represents maintained
relationship between
columns
Acetabular Roof
• “Sourcil” = eyebrow
• Created by beam tangent
to subchondral bone of
superior portion of
acetabulum
• Represents superior
articular surface of the
acetabulum
Border of Anterior & Posterior
Wall
• Acetabulum slightly
anteverted
• Anterior wall appears
medial to posterior wall
• Anterior wall is more
horizontal than posterior
wall2
• Radiographic landmark
for anterior wall is
contiguous w superior
border of obturator
foramen
Letournel’s 6 Radiographic
Landmarks
1. Iliopectineal line
• Anterior Column
2. Ilio-ischial line
• Posterior column
3. Teardrop
• Relationship between
columns
4. Acetabular roof
• Superior articular surface

5. Anterior wall
6. Posterior wall
Fracture Classification
Classification of Acetabular
Fractures
Letournel’s Classification of Acetabular Fractures
• Letournel’s Classification
Elementary Patterns
• Five elementary patterns & five
associated patterns • Anterior wall fracture
• Posterior wall fracture
• Based on anatomic pattern • Anterior column fracture
• Determined by analyzing six • Posterior column fracture
radiographic landmarks • Transverse fracture
Associated Patterns
• Determine which are disrupted
• Transverse + posterior wall fracture
• Variations from these patterns • Posterior column + posterior wall
are common and well- • Anterior column + posterior
hemitransverse fracture
recognized • T-type fracture
• Both column fracture
Classification of Acetabular
Fractures
• Elementary patterns
A
• Separates part or entirety of
single column from A
A
acetabulum
A A
• Transverse fractures are an
exception
• Both columns involved
• Included in elementary family
due to fundamental nature of
fracture line
 Classification of Acetabular
Fractures

• Associated patterns
• Combination of elementary
patterns A A A A
A A A

• Elementary pattern + additional

fracture component
Elementary Fracture
Patterns
Anterior Wall Fractures
• Uncommon as isolated fractures

A
• AP
• AIIS & pubis are not involved
• Typically occurs along upper 1/3
• Obturator Oblique
• Trapezoidal shaped fragment
• Middle portion of anterior column
driven medially by femoral head
• Assess extent of articular surface
involvement
• How much is attached to the wall
fragment
• Iliac Oblique
• Posterior column intact
• Establish point of rupture of
anterior wall
Posterior wall fracture
• Common pattern
• Commonly associated with
• Posterior dislocation of femoral
head1
• Significant marginal impaction
• AP
• Often associated with posterior
dislocation of the femoral head
• PW fragment appears as cap
on dislocated head
• Obturator oblique
• Provides most information
regarding posterior wall fracture
• Depicts fragment size &
displacement
• Any residual subluxation of the
femoral head
• CT
• Fracture line oblique, anteriorly
and peripherally, at ~45 degrees
• Characterizes marginal impaction
• Rule out associated, minimally
displaced transverse fractures not
visible on plain radiographs
Marginal Impaction

• Impacted osteochondral fragment

• Displaced by femoral head as it
dislocates
• Common in posterior wall fractures
• Sometimes visible on plain
radiographs, but more easily
visualized on CT
Anterior Column Fracture

• AP
• Disrupted iliopectineal line
• Any involvement of iliac wing
often visible
• Obturator Oblique
• Clearly shows location of
disruption of iliopectineal line
• Best demonstrates extent of
medial displacement of anterior
column by femoral head
• Iliac oblique
• Confirms integrity of posterior
column
• Best depicts any involvement of
iliac wing
Posterior Column Fractures
• Fracture extends from apex of
greater sciatic notch,travels
across the retroacetabular
surface,and exits at the
obturator foramen.
• Ischiopubic ramus is fractured.
• AP:
• Loss of relationship of teardrop
with iliopectineal line
• Ilioischial line displaced medially by
femoral head
• Iliopectineal line intact
• Obturator Oblique
• Confirms integrity of iliopectineal
line (Black arrow)
• Ischiopubic segment disrupted
(White arrow)
• Iliac Oblique
• Confirms disrupted ilioischial line,
and extent of superior involvement
• Typically angle of greater sciatic notch
• CT
• Fracture line has transverse
(coronal) orientation on axial CT
Transverse Fractures
• Subclassified based on level of
fracture relative to acetabular roof
• A.) Infratectal
• Inferior part of anterior and posterior
walls
• B.) Juxtatectal
• Passes through highest point of cotyloid
fossa
• C.) Transtectal
• At the level of the roof

• Divides innominate bone into ilium

and ischiopubic segments
• AP
• Both ilioischial and iliopectineal
lines disrupted
• Obturator ring intact
• Scrutinize for associated SI joint
injury
• Obturator oblique
• Confirms integrity of obturator
ring
• Aids in evaluation of relative
displacement of the fragments
• Helpful for decision making for
choice of approach
• Iliac oblique
• Depicts point of rupture of greater
sciatic notch (black arrow)
• CT
• Axial view
• Fracture line has vertical (sagittal)
orientation
• Evaluate for concomitant SI joint
widening
• Coronal view
• Useful for characterizing level of
fracture
• ie. Trans/juxta/infra-tectal
• Assess for associated marginal
impaction
Associated Fracture
Patterns
Posterior Column + Posterior Wall
Fractures
• Combination of two
elementary patterns
• Posterior wall portion can be
thought of as comminution of
posterior rim where posterior
column fracture traverses it
• Frequently associated with
femoral head dislocation
• AP
• Ilioischial line disrupted
• “double” ilioischial line (black
arrow)
• Posterior wall fragment
• Typically remains concentric with
femoral head in setting of
dislocation
• Ischiopubic ramus typically
fractured (white arrowhead)
• Iliopectineal line intact (black
arrowheads)
• Obturator oblique view
• Best demonstrates size and
displacement posterior wall
fragment(white arrow)
• Best delineates nature of inferior
exit point of posterior column
fracture(white arrowhead)
• Sometimes does not involve obturator
foramen
• Instead splits the ischium
• Intact iliopectineal line (black
arrowhead)
• Axial CT
• Posterior column fracture
• Can have coronal or oblique (anterior
and central) orientation
• Posterior wall fracture
• Orientation is typically oblique
(anterior and peripheral) at
approximately 45-60 degrees
Anterior Column (or wall) + Posterior
Hemitransverse Fractures

• Common in elderly patients

• Osteopenia
• Low energy mechanism
• Often have associated impaction
of the medial acetabular roof, or
“gull sign”
• Majority involve anterior column
rather than anterior wall
A A
• AP
• Iliopectineal line disrupted
• Medial subluxation of femoral
head with segmental
displacement of iliopectineal line
• Ilioischial line preserved
• Obturator oblique
• Iliopectineal line disrupted
• Femoral head follows anterior
column lesion
• Fracture often multifragmentary
with impaction
• Iliac oblique
• Best demonstrates direction of
posterior part of fracture
• Disrupted posterior column
• Typically exits through greater sciatic
notch
• Demontrates involvement of ilium
when anterior column portion
extends into it
• CT
• Anterior column component has
typical coronal orientation
• Anterior fracture fragment often
highly comminuted
• Posterior hemitransverse fracture
component typically has vertical
(anterior-posterior) direction,
reminiscent of transverse pattern
• On axials, extends posteriorly from
the coronal anterior column fracture
T-Type Fractures
• Transverse fracture with vertical fracture
AAAAAAAAA
line through ischiopubic segment
• On plain films, describe each
component sequentially:
1. Transverse component:
• Transtectal
• Juxtatectal
• Infratectal
2. Vertical fracture line variants
• Vertical: splits obturator ring down center
• Anterior: splits ring anteriorly
• Posterior: splits ring posteriorly
*Obturator ring may maintain its integrity in
anterior and posterior variants
• AP
• Transverse component almost
always has significant
displacement
• Ilioischial line may appear
duplicated(black arrowheads)
• Displacement of vertical component
• Obturator ring disrupted (white
arrow)
T-Type Fractures
• Obturator oblique
• Disruption of the anterior
column
• Best characterizes pattern of
vertical (stem) component of
the fracture
• Vertical
• Anterior
• Posterior
• Best view to evaluate disruption
of obturator ring when present
 T-Type Fractures
• Iliac oblique
• Disruption of greater sciatic notch,
or posterior column (red arrow)
• Best depicts any subluxation of
femoral head
T-Type Fractures
• CT
• Transverse component vertically
(sagittally) oriented on axial cuts
• Best modality for diagnosing
minimally displaced vertical
components
T-Type vs. Anterior Column +
Posterior Hemitransverse Anterior Column +
A
T-Type Posterior Hemitransverse
A

A
Both Column Fractures

• No continuity between axial

skeleton and articular surface of
acetabulum
• Typically very comminuted
• Complexity is variable
Both Column Fractures
• AP
• Disruption of all 6 of Letournel’s
radiographic lines
• Femoral head often remains
congruent with roof & anterior
column
• Commonly associated with fracture
of contralateral pubic body
• Due to displacement of ipsilateral
superior pubic ramus fragment noted.
• Iliac wing fracture visualized when
present
• May be incomplete
Both Column Fractures
• Obturator oblique
• Spur sign
• Spike of non articular intact ilium
• Visible due to medial displacement
of acetabulum
• Confirms secondary congruence
between femoral head and
acetabulum
• Rupture of obturator ring
Both Column Fractures

• Iliac oblique
• Best depicts displacement of
posterior column
• Best depicts any fractures
extending into the ilium of the
ilium
Both Column Fractures
• Axial CT
• Evaluate for any intact strut of
bone extending from sciatic
buttress to articular acetabulum
• Spur sign of the iliac wing
• At level of roof, fracture typically
coronally oriented
• Evaluate for associated
• Marginal impaction
• Intra-articular fragments
• Sacral fracture or SI joint injury
Fracture Characteristics
The Gull Sign
• Represents impaction of the
superomedial acetabular roof
• Reminiscent of gull’s wing
• Indication of osteopenic bone
• Poor prognostic sign
• Predicts failure in patients with
acetabular fractures >60yo
• Inability to achieve anatomic
reduction
• Early loss of reduction
Incarcerated Fragments
• Diagnosis
• Post-reduction films:
non-concentric joint
space
• Fragment often
visualized either:
• Extruded toward
external border
• Partly within cotyloid
fossa A B
 Roof Arc Angle
• Three angles such as medial roof
arc,anterior roof arc,posterior roof A B C
arc measured on AP (A), iliac
oblique (B), and obturator oblique
(C) respectively.
• Vertical line drawn through
roof of the geometric center
of acetabulum
• Another line, from the
fracture line to the geometric
center of the acetabulum.
• Less then 45 degree indicates
fracture line passing through the
weight-bearing dome.
• According to Matta et al., if any of
the roof arc measurements in a
displaced fracture are less than 45
degrees, operative treatment
should be considered.
 Stress Exam Under Anesthesia

• Dynamic stress views

• Typically used to evaluate stability str
of posterior wall fractures e ss
• Assess for congruity while loading
force through the femur
longitudinally:
• Flex >90 degrees
• Flex, internally rotate approximately
20 degrees  assess for congruity
CT Evaluation: Acetabulum
• Better characterizes fractures
• Marginal impaction
• Intra-articular fragments
• Fragment size
• Fragment displacement/rotation
• Reduction of femoral head
• Concentrically reduced, subluxed,
dislocated
• Better identify minimally displaced
fractures
• Femoral head impaction
Subchondral Arc
• Method used to assess articular
continuity
• Superior 10mm of the acetabulum
• Axial CT scan
• Must know thickness of CT cuts
• ie. 2mm cuts  5 “clicks” through the
scan starting at the most superior
portion of acetabular roof
• Each line on the image represents
2mm cut on CT scan
• Analogous to roof arc angle
• If fracture visualized within top 10mm,
considered to involve the
weightbearing dome
CT Evaluation: 3D Recons
• information about fracture
Better

geometry
• Helps to classify #
• Also diagonsis of missed fractures
• Recognizing patterns
a) Column fractures: horizontal
a) Coronal plane
b) Transverse fractures: vertical
a) Sagittal plane
c) Anterior wall: anterior and
midline
d) Posterior wall: anterior and
peripheral
• Classification algorithm
• Develop a systematic process
by which to evaluate imaging
in order to accurately classify
acetabular fractures.
• Evaluate
1. Integrity of liopectineal &
ilioischial lines
2. Integrity of obturator ring
3. Fracture extension into ilium
4. Judet views for associated
wall fracture
Treatment
Goal
• Anatomic restoration of the articular surface and prevent
post traumatic arthritis.
• Early mobilization
• Minimise associated complications.
• Indications of non operative treatment
• Non displaced and minimally displaced fractures
• Fracture traversing weight bearing dome and <2mm displaced- NWBM * 6-12 weeks
• Periodic radiograph to ensure no displacement.
• Significant displacement in region of joint that is judged to be unimportant
significantly
• Roof arc measurement ARA- 25 degree, MRA- 45 degree, PRA- 70 degree.
• Secondary congruency in displaced both column fractures
• Medical contraindications to surgery
• Skeletal traction
• Percutaneous fluoroscopic screw fixation
• Local soft tissue problems.
• Osteoporotic bones.
Indications of Operative
treatment:
• Fracture characteristics
• >=2mm displacement
• Roof arc measurement <45 degrees
• Fracture subluxation
• Posterior wall fracture >50% involvement of posterior wall articular surface
• Incarcerated fragments in acetabulum after CR of hip dislocation.
Timing of surgery
• Acetabular fractures associated with irreducible hip dis location, open
fracture, vascular compromise, or worsening neurologic deficit require urgent
surgical intervention.
• Other cases,Ideally ORIF acetabular fracture: 5-7 days of injury.
• Anatomical reduction difficult after 5 days in associated fracture patterns and
15 days in elementary patterns.
Surgical approach to acetabulum
fracture
• Posterior • Extensile approach
• Kocher- Langenbeck approach • Extended iliofemoral approach
• Modified Gibson approach • Triradiate approach
• Anterior
• Ilioinguinal (lateral, middle, medial
windows)
• Iliofemoral approach
• Stoppa approach ( Medial
window)/Anterior intrapelvic
approach
• Posterior approach
Kocher-Langenbeck approach
Indications
• Posterior wall fractures
• Posterior column fractures
• Posterior column/posterior wall
fractures
• Juxatectal/infratectal transverse or
transverse with posterior wall fractures
• Some T-type fractures
Pitfalls and challenges
1. Avoid excessive traction
2. Make sure that the horizontal limb of the incision is not too posterior. This will help
prevent accidental injury to the sciatic nerve when the fascia is incised distally.
3. Make sure that the pyriformis and conjoint tendons are released from their
trochanteric insertion without compromising vascular supply of the femoral head.
4. Dissect very carefully at the supra-acetabular area to avoid injury to the gluteal
neurovascular bundle
5. Avoid dissection close to the acetabular rim in order to preserve its vascular supply
6. Always identify the lesser sciatic notch. This is a safe area for sciatic nerve retractor
placement.
Ilioinguinal approach:- Indication
• Anterior wall acetabular fractures
• Anterior column acetabular
fractures
• Transverse acetabular fractures
with the major displacement
occurring at the anterior column
• Both column acetabular fractures
• Anterior element a=reduction and
fxation in T type acetabular
fractures
Three windows of the ilioinguinal
approach
• Lateral to iliopsoas
• Between iliopsoas and femoral
nerves and vessel
• Medial to femoral vessels
Ilioinguinal approach:complicating
factors
• Soft tissue limitations
• Colostomy,suprapubic drainage
• Ex fix pin tracts, open wounds
• Crush
• Obesity
• Hernia,mesh
Other approaches
• Stoppa approach (supine)
• Allows access to the medial
wall of acetabulum,
quadrilateral surface &
sacroiliac joint, corona mortis
at risk.
• Pfanenstiel incisions
• Ligation of corona mortis
• Stoppa window
Iliofemoral approach
• Anterior approach
• Anterior wall fracture
• Anterior column fracture
Modified Gibson approach
• Indication
• Posterior wall
• Posterior column
• Transverse, T type fracture
Extended Iliofemoral approach
• Exposes the entire lateral
innominate bone by posterior
reflection of the abductors, and
reflection of short external
rotators
• It can be extended anteriorly into
the first iliac window of the
ilioinguinal incision
• 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.
• Complication
• Superior gluteal vessel injury
• Massive ischemic necrosis of hip
abductors.
 Fracture fixation
• Plates
• 3.5mm and 4.5 mm recon plates
• Screws
• 6.5mm cancellous lag screws with
buttress plate
• 4.0 mm cancellous lag screws and 3.5
mm cortical screws (lengths upto 120
mm)
• 6.5 mm fully threaded cancellous
screws
Great care should be taken to ensure that screws in the central portion of the plate do not penetrate the articular cartilage
of the acetabulum
Complications
Early Late
• Thromboembolism • Avascular necrosis
• Infection • Heterotrophic ossification
• Neurological injury • Pseudoarthrosis
• Vascular injury • Post traumatic arthritis
• Intraarticular hardware
• Malreduction
• Loss of reduction
Retrograde percutaneous posterior column screw
fixation
Percutaneous anterior column screw
fixation
• Antegrade
• Bone narrowing at center of
acetabulum and middle of pubic
rami
• Retrograde
• In out technique
Take home messages
• Acetabular fracture is a intraarticular fracture requiring anatomical
reduction, rigid fixation and early mobilization
• Classification of acetabular fracture guides the surgeon for best
approach.
• Pre and post operative prophylaxis of DVT is mandatory.
• It demands expertise
Thank you