Introduction
Fractures of the acetabulum occur primarily in young adults as a result of high-velocity trauma. These fractures are often associated with other life-threatening injuries.
Displacement of the fracture fragments leads to articular incongruity of the hip joint that results in abnormal pressure distribution on the articular cartilage surface. This can lead to rapid breakdown of the cartilage surface, resulting in disabling arthritis of the hip joint. Anatomic reduction and stable fixation of the fracture, such that the femoral head is concentrically reduced under an adequate portion of the weightbearing dome of the acetabulum, is the treatment goal in these difficult fractures.
Posterior wall fracture with a posterior dislocation of the hip.
Three-dimensional (3-D) CT scan showing a posterior wall fracture.
Anterior wall fracture.
Transverse fracture.
Recent studies
In one study of patients with posterior wall fractures and late revision surgery with the Kocher-Langenbeck approach, 3 of the 4 patients eventually required total hip arthroplasty. According to Dean et al, if salvage procedures are delayed more than 3 weeks, total hip arthroplasty is more likely to be ultimately required, especially in older patients.1
Mehin et al, in a study of 5 cadaveric acetabula with transverse acetabular fractures, found that the locking plate construct was as strong as plate plus interfragmentary lag screw for repair of transverse acetabular fractures. The authors feel locking plates my provide an advantage in that fractures may be displaced during lag-screw tightening.2
Boraiah et al found that in 18 patients (mean age, 71 years) who underwent combined open reduction/internal fixation (ORIF) and total hip arthroplasty (THA) for acetabular fractures (1 transverse; 1 anterior-column posterior hemitransverse; 1 both-column; 15 posterior wall), only 1 patient required revision surgery, because of failure of the acetabular component. The authors concluded that in appropriately selected patients, ORIF/THA can be an acceptable treatment approach.3
History of the Procedure
Fractures of the acetabulum were treated nonoperatively until the middle of the 20th century. The Judet brothers and, subsequently, Emile Letournel studied acetabular fractures extensively and were responsible for popularizing the surgical management of these challenging injuries.4,5,6 Pioneering work, such as the development of the ilioinguinal approach by Letournel, led to acetabular surgery becoming the accepted standard of care for virtually all displaced fractures of the acetabulum.
With advances in imaging technologies, performing acetabular fracture surgery through smaller incisions is now possible. In the future, computer-assisted surgery may contribute to the operative management of these injuries, as well.
Problem
Fractures of the acetabulum usually occur as a result of high-velocity injury and often affect the young and economically productive portion of the population. These intra-articular fractures can lead to considerable morbidity, especially if not correctly treated. Intra-articular malunion and joint incongruity lead to rapid destruction of the articular cartilage and, ultimately, to hip arthrosis.7
Frequency
The exact incidence of acetabular fractures in various parts of the world is not known. Studies at level I trauma centers have shown an admission rate for pelvic and acetabular fractures of 0.5-7.5%.
Relative Frequency of Acetabular Fracture Types in Various Studies
Open table in new window
Table
| Fracture type | Letournel, 5 % (n = 567) | Matta, 8 % (n = 255) | Dakin et al, 9 % (n = 85) |
| Both columns | 27.9 | 33.3 | 14.1 |
| Transverse with posterior wall | 20.6 | 23.5 | 35.3 |
| Posterior wall | 22.4 | 8.6 | 12.9 |
| T-shaped | 5.3 | 12.2 | 3.5 |
| Transverse | 3.7 | 3.5 | 8.2 |
| Anterior column | 3.9 | 4.7 | 1.2 |
| Anterior column with posterior hemitransverse | 8.8 | 5.9 | 3.5 |
| Posterior column with posterior wall | 3.5 | 3.9 | 18.8 |
| Posterior column | 2.3 | 3.1 | 1.2 |
| Anterior wall | 1.6 | 1.2 | 1.2 |
| Fracture type | Letournel, 5 % (n = 567) | Matta, 8 % (n = 255) | Dakin et al, 9 % (n = 85) |
| Both columns | 27.9 | 33.3 | 14.1 |
| Transverse with posterior wall | 20.6 | 23.5 | 35.3 |
| Posterior wall | 22.4 | 8.6 | 12.9 |
| T-shaped | 5.3 | 12.2 | 3.5 |
| Transverse | 3.7 | 3.5 | 8.2 |
| Anterior column | 3.9 | 4.7 | 1.2 |
| Anterior column with posterior hemitransverse | 8.8 | 5.9 | 3.5 |
| Posterior column with posterior wall | 3.5 | 3.9 | 18.8 |
| Posterior column | 2.3 | 3.1 | 1.2 |
| Anterior wall | 1.6 | 1.2 | 1.2 |
Peltier reported an incidence of 24% acetabular fractures in his series of adult pelvic fractures.10 Reed documented that approximately 5-10% of pediatric pelvic injuries involve the acetabulum.11
Etiology
Acetabulum fractures usually occur as a result of high-velocity trauma, such as vehicular accidents or falls from heights.
Pathophysiology
Fractures of the acetabulum occur as a result of the force exerted through the head of the femur to the acetabulum. The femoral head acts like a hammer and is the last link in the chain of forces transmitted from the greater trochanter, knee, or foot to the acetabulum. The position of the femur at the time of impact and the direction of the force determine the type and displacement of the fracture.
The point of impact and the resulting fracture patterns
Although it is difficult to pinpoint the exact relationship between the point of impact and the mechanism of injury in acetabulum fractures, certain relationships are well recognized. These can help in understanding the forces involved in creating the fracture, the direction of displacement, and the fracture patterns involved.
Force applied to the greater trochanter in the axis of the femoral head
The point of impact of the femoral head is decided by the degrees of adduction and abduction and rotation of the femur.
- Hip in neutral adduction-abduction: External rotation of the hip predisposes to anterior column injury and internal rotation predisposes to posterior column injury with the hip in neutral adduction-abduction. Rotations and associated fractures are as follows:
- Neutral - Central/anterior column
- External (about 25°) - Anterior column
- External (about 50°) - Anterior lip
- Internal (about 25°) - Transverse/T-shaped/bicolumnar, depending upon the degree of force applied
- Internal (about 50°, extreme) - Posterior column with transverse element
- Differing degrees of adduction and abduction: With the hip in neutral rotation, the greater the degree of adduction of the femur, the higher the level of the fracture (greater involvement of the roof). The greater the degree of abduction, the lower (more inferior) is the fracture line. Positions of the femur and associated fractures are as follows:
- Neutral adduction-abduction - Transverse or T-shaped fracture beginning at the inner margin of the roof of the acetabulum
- Increasing adduction - Transverse or T-shaped fracture with increasing involvement of the roof of the acetabulum
- Increasing abduction - Transverse or T-shaped fracture with progressively inferior shift of the fracture line
Force applied to the flexed knee in the axis of the femoral shaft
Acetabulum fracture morphology depends on the degrees of flexion or extension and adduction or abduction. The degree of hip rotation generally does not contribute significantly to the fracture pattern.
- Hip flexed to 90°: Positions of the femur and associated fractures are as follows:
- Neutral adduction-abduction - Posterior wall
- Maximum abduction - Posterior column with transverse element
- Mild (about 15°) abduction - Posterior column
- Adduction - Posterior dislocation of the hip, with or without posterior wall fracture
- Different degrees of hip flexion: Positions of the femur and associated fractures are as follows:
- Increasing flexion - Progressively lower involvement of the posterior column
- Decreasing flexion (<90°) - Involvement of the posterosuperior portion of the acetabulum
Force applied to the foot with the knee extended
Positions of the femur with associated acetabulum fractures are as follows:
- Hip extended (eg, fall from a height) - Transtectal transverse fracture
- Hip flexed (eg, frontal collision in a vehicle, with force transmitted through the foot pedal) - Depending on the position, similar to force acting through a flexed knee
Force applied to the lumbosacral region
A force applied to the lumbosacral region is a rare cause of acetabular fractures.
In actuality, however, it is very difficult to pinpoint the exact site of impact and the mechanism of injury. These mechanisms are important, as they help in understanding the acting forces, direction of displacement, and the fracture patterns involved.
Classification
Various classifications of acetabular fractures have been propounded, but the easiest classification is that of Judet and Letournel, who classified acetabular fractures according to the fracture morphology as elementary fracture patterns.4,5 These have only 1 fracture line and include the following:
- Posterior wall fractures (see Images 1-3): These fractures typically involve the rim of the acetabulum, a portion of the retroacetabular surface, and a variable segment of the articular cartilage. The articular cartilage may also be impacted. Impacted articular cartilage should be diagnosed preoperatively on CT scan, as these impacted fragments require elevation at the time of surgery. Extended posterior wall fractures can involve the entire retroacetabular surface and include a portion of the greater or lesser sciatic notch, the ischial tuberosity, or both. The ilioischial line, however, remains intact on the anteroposterior (AP) view.
Posterior wall fracture with a posterior dislocation of the hip.
Posterior wall fracture preoperative obturator view.
Three-dimensional (3-D) CT scan showing a posterior wall fracture.
- Posterior column fractures: These fractures include only the ischial portion of the bone. The entire retroacetabular surface is displaced with the posterior column. As the vertical line separating the anterior column from the posterior column traverses inferiorly, it most commonly enters the obturator foramen. An associated fracture of the inferior pubic ramus is present. Sometimes, the fracture line traverses just posterior to the obturator foramen, splitting the ischial tuberosity. The ilioischial line typically is displaced and disassociated from the teardrop. However, when a large portion of the quadrilateral surface remains intact with the posterior column, the teardrop and a portion of the pelvic brim displace with the posterior column.
- Anterior wall fractures (see Images 4-5): These fractures are uncommon injuries and often occur in conjunction with anterior dislocations.
Anterior wall fracture.
Anterior wall fracture: Three-dimensional reconstruction.
- Anterior column fractures: Low fractures involve only the superior ramus and pubic portion of the acetabulum. High fractures can involve the entire anterior border of the innominate bone. The pelvic brim and iliopectineal line are displaced. Medial translation of the entire roof or a portion of the roof is typical of displacement of a high or intermediate anterior column fracture.
- Transverse fractures (see Image 6): These fractures divide the innominate bone into 2 portions. A horizontally displaced fracture line crosses the acetabulum at a variable level. The innominate bone is then divided into a superior part and a lower part. The superior part is composed of the iliac wing and a portion of the roof of the acetabulum. The lower part of the bone, the ischiopubic segment, is composed of an intact obturator foramen with the anterior and posterior walls of the acetabulum. Letournel subclassified transverse fractures as follows:
Transverse fracture.
- Transtectal, in which a transverse fracture line crosses the superior acetabular articular surface
- Juxtatectal, in which a transverse fracture line crosses at the junction of the superior acetabular articular surface and superior cotyloid fossa
- Infratectal, in which a transverse fracture line crosses through the cotyloid fossa
Fracture patterns
Associated acetabulum fracture patterns are the more complicated fracture patterns and include the following:
- Anterior with posterior hemitransverse fractures: These fractures combine an anterior wall or anterior column fracture with a horizontal transverse component, which traverses the posterior column at a low level. The distinction between the associated anterior column and associated posterior hemitransverse and T-shaped patterns is often subtle. In the anterior plus posterior hemitransverse fracture, the anterior component typically is at a higher level and is more displaced than the posterior component.
- Posterior column with posterior wall (see Images 7-8): This pattern divides the posterior column into a larger posterior column component and an associated posterior wall component. The ilioischial line typically is displaced and disassociated from the teardrop.
Posterior lip with posterior column injury, anteroposterior view.
Posterior wall with posterior column fracture, 3-D reconstruction.
- Transverse with posterior wall (see Image 9): This pattern combines a normal transverse configuration with 1 or more separate posterior wall fragments. A fracture of the inferior pubic ramus typically is not seen.
Transverse with posterior lip fracture.
- T-shaped fracture (see Images 10-11): This fracture is similar to the transverse fracture except for the addition of a vertical split along the quadrilateral surface and acetabular fossa (the stem of the T), which divides the anterior column from the posterior column. An associated fracture of the inferior pubic ramus typically is present.
T-shaped fracture (break in the margins of the obturator foramen).
T-shaped fracture, obturator view.
- Both-column fractures (see Images 12-14): In these fractures, the anterior and posterior columns are separated from each other, and all articular segments are detached from the intact portion of the posterior ilium, which remains attached to the sacrum. A fracture of both columns is associated with the spur sign, in which the fractured edge of the intact posterior iliac wing is seen prominently relative to the medially displaced articular segments on the obturator oblique radiographic view. This sign is pathognomonic of an injury to both columns.
Both-column fracture, 3-D reconstruction, anteroposterior view.
Both-column fracture, 3-D reconstruction, iliac view.
Both-column fracture, 3-D reconstruction, obturator view.
- The Arbeitsgemeinschaft für osteosynthesefragen–Association for the Study of Internal Fixation (AO-ASIF) classification is more comprehensive and is shown in the figure below (see Image 15). This can be simplified as follows:
The Arbeitsgemeinschaft fur osteosynthesefragen–Association for the Study of Internal Fixation (AO-ASIF) classification.
- Type A fractures - Involving either a single wall or column (anterior or posterior)
- Type B fractures - Include both anterior and posterior columns but not bicolumnar fractures (transverse, T-shaped, anterior with posterior hemitransverse type injuries)
- Type C fractures - Bicolumnar fractures, with the roof as a separate fragment
Presentation
History
The nature and mechanism of injury help predict the fracture pattern and the associated injuries. The premorbid level of function and status of the joint should be established. In the presence of preexistent arthrosis, a total hip replacement may be a better option than open reduction of the acetabular fracture.12,13
Associated injuries are also important to assess. Patients often have multiple traumatic injuries, and a high likelihood of associated injury exists (in up to 50% of patients).14 One must diligently look for these injuries, as some are subtle and can be missed.
Physical examination
Assess the following:
- Vital parameters: Life-threatening injuries to the chest, abdomen, and cranium must be the first priority. The basic principles of trauma care and resuscitation apply because many acetabular fractures are associated with severe trauma.
- Associated injuries: Associated limb injuries may be in the form of a patella or upper tibial fracture or a posterior cruciate ligament (PCL) injury, indicating the mechanism of injury. Associated femoral shaft fractures may also be present, which could have a bearing on the management of the acetabular fracture. Associated concomitant pelvic fractures may be present in up to 20% of patients.
- It is also important to exclude injury to the bowel and the urinary tract, as such injuries influence decision-making about an open reduction of the acetabular fracture.
The local orthopedic examination includes an assessment of the following:
- Position of the lower limb
- It is adducted, flexed, and internally rotated in a posterior dislocation.
- It is is abducted and externally rotated in an anterior dislocation.
- Eversion of the iliac wing, with the anterior superior iliac spine on the affected side being more laterally placed, is a subtle clue to a central dislocation.
- Skin - Including local wounds, abrasions, and closed degloving injury
- Morel-Lavele lesion - A closed degloving injury occurring over the greater trochanter, in which the subcutaneous tissue is torn from underlying fascia creating a cavity, which places this tissue at risk for infection and/or poor healing
- Abduction and adduction of the hip - To detect instability (manual traction can aid in determination of vertical instability)
- Limb-length inequality - May be a subtle clue to the presence of incarcerated intra-articular fragments
- Neurologic examination - To exclude preoperative sciatic/lateral popliteal nerve palsy
Indications
Indications for open reduction and internal fixation include the following15,16 :
- All displaced fractures (>2 mm articular step).
- Intact roof-arc angle less than 30°.
- Failure to achieve or maintain concentric reduction by closed means.
- Fractures that have a medial roof-arc angle of 45° or less, an anterior roof-arc angle of 25° or less, or a posterior roof-arc angle of 70° or less across the weight-bearing portion of the acetabulum, according to Vrahas et al, on the basis of a cadaveric study; persistent instability after closed reduction.17
- Incarcerated intra-articular fragments or impaction of the articular surface.
- Emergency open reduction and internal fixation (ORIF) if associated vascular injury or sciatic palsy develops after a closed reduction.
Nonoperative treatment should be considered in the following circumstances:
- Undisplaced fractures.
- Displaced fractures if the following conditions are met:
- A large portion of the acetabulum remains intact and the femoral head remains congruous with this portion of the acetabulum.
- A secondary congruence is present after only moderate displacement of a both-column fracture and the patient presents late (>3 wk after injury).
- Small posterosuperior wall fractures that are associated with a stable hip joint and a congruent reduction. (Careful follow-up is needed to monitor for signs and symptoms of late instability in the initial months after injury.)
- A posterior wall injury that is minimally displaced or nondisplaced and is part of a more complex pattern requiring an ilioinguinal approach
- If surgery is contraindicated (see Contraindications).
Relevant Anatomy
The acetabulum is formed by a portion of the innominate bone. It lies at the point where the ilium, ischium, and pubis are joined by the triradiate cartilage, which later fuses to form the innominate bone. The acetabulum is enclosed by the anterior and the posterior columns like the 2 limbs of an inverted Y (see Images 16-18). The anterior column comprises the anterior border of the iliac wing, the entire pelvic brim, the anterior wall of the acetabulum, and the superior pubic ramus. The posterior column makes up the ischial portion of the bone, including the greater and lesser sciatic notch, the posterior wall of the acetabulum, the majority of the quadrilateral surface, and the ischial tuberosity. The roof of the acetabulum is the thick, weightbearing portion, and forms a separate fragment in bicolumnar fractures. The thin quadrilateral plate forms the medial wall or the floor of the acetabulum.
Columns of the acetabulum, anteroposterior view. The white area is the anterior column, the red area is the posterior column, and the purple area is the tie beam (inferior pubic ramus).
Columns of the acetabulum, iliac view.
Columns of the acetabulum, obturator view.
The innominate bone is irregular in shape and has differing thickness in cross section in different areas. The posterior column and sciatic buttress provide the best purchase for screws. The areas suitable for implant placement are shown in Images 28-38.18
Fixation of posterior wall fracture: Bone model showing the direction of screws and application of neutralization/buttress plate.
Posterior wall fracture: Postoperative anteroposterior (AP) view.
Posterior lip fracture: Postoperative iliac view.
Posterior wall fracture: Postoperative obturator view.
Transverse fracture.
T-shaped fracture (note the use of the anterior-to-posterior lag screw to hold the posterior column).
Both-column fracture.
Quadrilateral surface comminution: Use of a T-plate.
Use of femoral distractor during surgery.
Total hip replacement in posttraumatic arthritis after an acetabular fracture.
Intra-articular screw as seen on the axial cut of the CT scan.
An intimate knowledge of the nerves and vessels in the area is essential to prevent iatrogenic complications at the time of surgery. Details of the relevant anatomy are elaborated further in the discussion on surgical approaches.
Contraindications
Contraindications to surgery include the following:- General - Severe systemic illness or secondary multiorgan failure secondary to polytrauma; systemic infections or sepsis
- Local - Local infection; extreme osteoporosis
- Relative - Severe comminution; preexisting arthrosis
Surgical intervention may be carried out in these cases to facilitate a salvage procedure later.
More on Acetabulum Fractures |
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Further Reading
Related eMedicine topics
Acetabulum, Fractures (Radiology)
Acetabular Wear in Total Hip Arthroplasty
Femoral Osteotomy
Femoral Head Avascular Necrosis
Intertrochanteric Hip Fractures
Subtrochanteric Hip Fractures
Clinical guidelines
ACR Appropriateness Criteria® developmental dysplasia of the hip. American College of Radiology - Medical Specialty Society. 1999 (revised 2005). 8 pages. [NGC Update Pending] NGC:004788
ACR Appropriateness Criteria® imaging after total hip arthroplasty (THA). American College of Radiology - Medical Specialty Society. 1998 (revised 2005). 8 pages. NGC:004649
ACR Appropriateness Criteria® chronic hip pain. American College of Radiology - Medical Specialty Society. 1998 (revised 2003). 6 pages. [NGC Update Pending] NGC:003896
Clinical studies
Role of Vacuum Assisted Closure (VAC) Device in Postoperative Management of Pelvic and Acetabular Fractures
Multi-Center Comparative Trial of the ASR™-XL Acetabular Cup System vs. the Pinnacle™ Metal- on- Metal Total Hip System
Unipolar or Bipolar Hemiarthroplasty in the Treatment of Displaced Femoral Neck Fractures. A Randomized Trial of RSA Measurements of Acetabular Wear
Keywords
acetabulum fractures, acetabulum trauma, acetabular trauma, femur trauma, femoral trauma, fractures of the hip socket, intra-articular fractures of the hip, hip fracture, broken hip, hip pain, Arbeitsgemeinschaft für osteosynthesefragen–Association for the Study of Internal Fixation, AO-ASIF, femoral head fractures, femoral neck fractures, intertrochanteric fractures, trochanteric fractures, subtrochanteric fractures, hip joint, iliofemoral ligament, pubofemoral ligament, ischiofemoral ligament, intracapsular fracture, extracapsular fracture, anterior dislocation, posterior dislocation, single fragment fracture, comminuted fracture, stress fracture, incomplete fracture, impacted fracture, partially displaced fracture, completely displaced fracture, single fracture lines,multiple fracture lines, nondisplaced fracture
