• Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns
• Characterized by dissociation of the articular surface from the inonimate bone ; will see "spur sign" on obturator oblique
Transverse + Post. Wall
• Common in elderly patients
• anterior wall and anterior column • both column fracture• posterior hemitransverse
• femoral nerve injury• LFCN injury• thrombosis of femoral vessels• laceration of corona mortis in 10-15%.
• posterior wall and posterior column fx • most transverse and T-shaped• combination of above
• increased HO risk compared with anterior approach
• sciatic nerve injury (2-10%) • damage to blood supply of femoral head (medial femoral circumflex)
• only single approach that allows direct visualization of both columns• associated fracture pattern 21 days after injury• some transverse fxs and T types • some both column fxs (if posterior comminution is present)
• massive heterotopic ossification• posterior gluteal muscle necrosis
Please rate topic.
Average 4.3 of 85 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
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The posterior wall of the acetabulum is best visualized on which of the following radiographic views?
Obturator oblique pelvis
Iliac oblique pelvis
Select Answer to see Preferred Response
The posterior wall is best visualized on the obturator oblique pelvic view.
The obturator oblique and iliac oblique views make up the Judet views that are used to evaluate acetabular fractures, along with a standard AP pelvis radiograph. The obturator oblique pelvic view is best to view the anterior column and posterior wall in detail. The iliac oblique shows the profile of involved iliac wing, the posterior column, and the anterior wall.
Letournel reviewed his classification and treatment protocols, based on his 22 years of experience at that time. He noted that perfect anatomical reduction of the acetabulum led to the best outcomes.
Patel et al reviewed of the Letournel classification, and they found moderate to high inter- and intra-observer reliability with this classification system. The presence of articular displacement, marginal impaction, incongruity, intra-articular fragments and osteochondral injuries to the femoral head were found to have less reliability (intra- and interobserver).
Illustration A shows a right-sided obturator oblique radiograph, while Illustration B shows a right-sided iliac oblique radiograph. Illustration C shows a diagram of the obturator oblique radiograph, with the radiographic lines marked out.
Answers 1: Inlet pelvic imaging is best for assessing pelvic ring injuries (rotation and anterior-posterior or medial-lateral translation).
Answers 2: Outlet pelvic imaging is best for assessing pelvic ring injuries (proximal-distal translation, rotation).
Answers 3: AP pelvis is a good screening tool for pelvic and acetabular fractures.
Answers 5: Iliac oblique pelvis is best for assessing the posterior column and anterior wall of the acetabulum.
Clin Orthop Relat Res. 1980 Sep;(151):81-106. PMID: 7418327 (Link to Abstract)
Letournel, CORR 1980
Patel V, Day A, Dinah F, Kelly M, Bircher M.
J Bone Joint Surg Br. 2007 Jan;89(1):72-6. PMID: 17259420 (Link to Abstract)
Patel, BJJ 2007
Please rate question.
Average 4.0 of 14 Ratings
A 34-year-old male presents with the right posterior wall acetabular fracture shown in Figure A. What is the most accurate method to test for hip stability in this patient?
The Keith method
The Moed method
The Calkins method
Dynamic fluoroscopic examination of the hip under anesthesia
A history of associated hip dislocation
Dynamic fluoroscopic examination of the affected hip under anesthesia is considered the best method of predicting hip stability. Fragment size, which can be calculated using the Keith, Moed, or Calkins method, can be used to predict hip stability radiographically, however they are not as accurate. In general it is thought that posterior wall fractures involving less than 20% of the posterior wall are stable, whereas those involving greater than 40%-50% are unstable. Unfortunately, this leaves an indeterminent zone (20-40%) which does not provide guidance in treatment.
Moed et al retrospectively reviewed 33 patients with posterior wall fractures who underwent dynamic fluoroscopic stress testing and compared the results of this testing to the Moed, Calkins, and Keith method of hip stability prediction. They found that the Moed method is the only reliable technique that is predictive of hip stability for small fracture fragments while also being predictive of instability for large fracture fragments. However, they also stated that there remain a substantial number of fractures involving 20% or more of the posterior wall that are both stable and unstable by examination under anesthesia. Therefore, they recommend dynamic fluoroscopic examination for assessment of hip stability in the presence of a posterior wall fracture.
Tornetta et al conducted a study in which dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management to determine subtle signs of instability. Of the 41 fractures, 38 were found to be stable and 91% of these had good or excellent outcomes at 2.7 years. They concluded that dynamic stress views can identify subtle instability in patients who would normally be considered for non-operative treatment.
1-> Keith Method - Depth of the fracture segment in injured hip is compared to the contralateral intact posterior wall depth at the level of the fovea
2-> Moed - Depth of the fracture segment in the injured hip is compared to contralateral posterior wall depth at the level of the greatest amount of fracture involvement
3-> Calkins - Length of posterior acetabular arc from each hip is compared at the level of the greatest amount of fracture involvement.
Moed BR, Ajibade DA, Israel H
J Orthop Trauma. 2009 Jan;23(1):7-15. PMID: 19104298 (Link to Abstract)
Moed, JOT 2009
Tornetta P 3rd.
J Bone Joint Surg Br. 1999 Jan;81(1):67-70. PMID: 10068006 (Link to Abstract)
Tornetta, BJJ 1999
Average 3.0 of 24 Ratings
A 35-year-old male undergoes closed reduction under sedation in the emergency department for a posterior hip dislocation with an associated posterior wall fracture. The post-reduction CT is seen in Figure A. What is the appropriate next step in management of this injury?
Nonoperative management based on the size of the posterior wall fragment
Operative management based on the size of the posterior wall fragment
Operative management based on the history of hip dislocation
Dynamic fluoroscopic stress exam under anesthesia in the obturator oblique view
Dynamic fluoroscopic stress exam under anesthesia in the iliac oblique view
Joint stability is critical for successful nonoperative management of posterior wall acetabular fractures. Recent evidence has established that dynamic fluoroscopic stress examination is the best method to determine joint stability in the setting of a posterior wall fracture. The obturator oblique view allows for the best evaluation of hip joint stability during examination for posterior wall fractures.
Grimshaw and Moed retrospectively reviewed the results of patients with posterior wall acetabular fractures managed nonoperatively after evaluation with dynamic fluoroscopic stress tests. At two year follow up, all had good to excellent Merle d’Aubigne clinical scores for hip function and no evidence of post-traumatic hip arthritis on AP pelvis radiographs.
Tornetta retrospectively reviewed his results managing patients with dynamic fluoroscopic stress examination for acetabular fractures which met radiographic nonoperative criteria. Good-to-excellent clinical results were seen in 91% of patients managed nonoperatively.
Tornetta reviewed management of acetabular fractures and Tornetta and Mostafavi separately reviewed management of hip dislocations. In both articles, emphasis is placed on dynamic examination of posterior wall fractures as instability has been seen with fractures comprising as little as 15% of the posterior wall.
Illustration A demonstrates two fluoroscopic images from a dynamic stress exam of a patient with a posterior wall fracture. The image obtained in the obturator oblique view clearly demonstrates that the femoral head loses congruency with the acetabular dome.
Answers 1 & 2: Posterior wall fragment size less than 40% was historically used as an indirect measure of stability, however measurements of fragment size may be unreliable and instability has been seen with fractures much smaller than 40%
Answer 3: A history of hip dislocation was thought to indicate a more unstable fracture. In the level IV study by Grimshaw and Moed, patients with an associated hip dislocation who were stable under stress exam had no significant difference in outcome with nonoperative management.
Answer 5: The iliac oblique view is used to evaluate the anterior wall and posterior column. Displacement or instability of the posterior wall would not be seen with this view
Grimshaw CS, Moed BR
J Bone Joint Surg Am. 2010 Dec;92(17):2792-800. PMID: 21123609 (Link to Abstract)
Grimshaw, JBJS 2010
Tornetta P 3rd.
J Am Acad Orthop Surg. 2001 Jan-Feb;9(1):18-28. PMID: 11174160 (Link to Abstract)
Tornetta, JAAOS 2001
Tornetta P 3rd, Mostafavi HR.
J Am Acad Orthop Surg. 1997 Jan;5(1):27-36. PMID: 10797205 (Link to Abstract)
Tornetta, JAAOS 1997
Average 4.0 of 23 Ratings
A 35-year-old male suffers an anterior column acetabular fracture during a motor vehicle collision, and subsequently undergoes percutaneous acetabular fixation. Intraoperatively, fluoroscopy is positioned to obtain an obturator oblique-inlet view while placing a supraacetabular screw. Which of the following screw relationships is best evaluated with this view?
Intraarticular penetration of the screw
Position of the screw cephalad to the sciatic notch
Screw starting point at the anterior inferior iliac spine
Screw starting point at the gluteal pillar
Screw position between the inner and outer tables of the ilium
The obturator oblique-inlet view, as seen in Illustration A, best demonstrates the position of a supra-acetabular screw or pin relative to the tables of the ilium.
Starr et al review their initial results and technique of closed or limited open reduction and percutaneous fixation of acetabular fractures. They defined two groups of patients who may benefit from this technique; elderly patients with multiple comorbidities to facilitate early mobilization and restore hip morphology, and young patients with elementary fracture patterns and multiple associated injuries.
Starr et al describe their operative technique and outcomes for a case series of 3 patients using percutaneous acetabular fixation to augment open reduction of acetabular fractures. The authors state that, for placement of an anterior colum ramus screw, an iliac oblique-inlet (not obturator oblique-inlet) will ensure that the screw is within the medullary canal of the ramus and does not exit anterior or posterior.
Gardner and Nork describe a technique for placement of a large femoral distractor in the supra-acetabular region to compress displaced posterior pelvic ring injuries. They note that the obturator oblique-inlet view is necessary to view the entire length of the pin as well as to ensure that pin remains in bone.
Answer 1: Relationshiop of the screw to the acetabulum is best evaluated with the obturator oblique-outlet view as well as the iliac oblique view
Answer 2: The iliac oblique view is used to ensure the trajectory of the screw is superior to the sciatic notch
Answer 3: The Obturator oblique-outlet view, otherwise known as the "teepee" or "tear drop" view, is used to identify the start for supra-acetabular implant placement
Answer 4: The gluteal pillar is not utilized as a start point when placing supraacetabular fixation, and the obturator oblique-inlet view would not be ideal to visualize this region of the pelvis
Starr AJ, Jones AL, Reinert CM, Borer DS.
Injury. 2001 May;32 Suppl 1:SA45-50. PMID: 11521706 (Link to Abstract)
Starr, INJURY 2001
Starr AJ, Reinert CM, Jones AL
J Orthop Trauma. 1998 Jan;12(1):51-8. PMID: 9447519 (Link to Abstract)
Starr, JOT 1998
Gardner MJ, Nork SE.
J Orthop Trauma. 2007 Apr;21(4):269-73. PMID: 17414555 (Link to Abstract)
Gardner, JOT 2007
Average 3.0 of 28 Ratings
A 74-year-old man falls, sustaining the injury shown in Figures A through C. In surgical planning, what is the best surgical approach to treat this injury?
Figures A through C depict and AP pelvis and Judet views of a T-type fracture of the right acetabulum. The ilioinguinal approach provides access to the anterior wall and anterior column for fracture fixation, in addition to allowing fixation of the nondisplaced posterior transverse fracture line. The lateral femoral cutaneous nerve (LFCN) is at risk in the superficial part of the dissection. Another option for the approach would be the modified Stoppa, which would also allow excellent access to the anterior column as well as the internal aspect of the iliac wing and quadrilateral plate.
Illustration A shows the five basic and 5 associated acetabular fractures.
Answer 1. Kocher-Langenbeck: access for posterior wall and column fractures
Answer 2. Watson-Jones: anterolateral approach best for the hip, not the anterior column of the acetabulum.
Answer 3. Extended iliofemoral: visualization for both column fractures
Answer 5. Hardinge approach: lateral approach for THA
Average 3.0 of 25 Ratings
A 14-year-old presents on the request of her pediatrician for evaluation of her left hip. The patient reports having a recent history of lower abdominal pain, and as part of the work-up a KUB radiograph was obtained. The abdominal work-up was negative, and her pain has since resolved, however, the pediatrician noted an abnormal radiographic finding in the left hip and requested a formal orthopedic evaluation. The patient denies any history of hip trauma or pain. A left hip radiograph is shown in Figure A, and the the abnormality in question is indicated by the white arrow. The radiographic finding is most consistent with which of the following?
Os acetabuli marginalis superior
The patients hip radiograph demonstrates an os acetabuli marginalis superior which is a benign accessory ossification center found in the superior aspect of the acetabulum. This can be commonly confused with an acute fracture or avascular necrosis. Although the os acetabuli marginalis superior occasionally persists into adult life, it usually fuses to the acetabulum by the time an individual reaches age 20.
Caudle et al provide a case report of a a patient with a painful os acetabuli marginalis superior. This was successfully treated with resection of the fragment, and bone grafting. This was noted to be a very unusual source of hip pain in adolescents.
2-The fovea capitis is the depression on the head of the femur where the ligamentum teres inserts. This can appear as a small ossicle on the surface of femoral heads in skeletally immature patients. An example of this is shown in Illustration A.
3-Myositis ossificans is soft tissue calcification which develops after trauma, or more rarely, surgery. An example of myositis ossificans around the hip is shown in Illustration B.
4-Avascular necrosis of the femoral head classically occurs in patient with a history of alcoholism, steroid use, or sickle cell disease. Radiographs can demonstrate femoral head sclerosis, and eventually collapse of the articular surface. An example of femoral head AVN in a patient with sickle cell disease is shown in Illustration C.
5-Acetabular fractures occur in the setting of trauma, and are relatively rare in the pediatric population. An example of a left sided acetabular fracture is shown in Illustration D. Illustration E shows a right sided acetabular fracture through the triradiate cartilage.
Caudle RJ, Crawford AH.
J Bone Joint Surg Am. 1988 Dec;70(10):1568-70. PMID: 3058712 (Link to Abstract)
Caudle, JBJS 1988
Average 4.0 of 38 Ratings
A 32-year-old male sustains a posterior wall acetabulum fracture as the result of a high-speed motor vehicle collision. Improved patient-reported outcomes after surgical treatment are associated with which of the following variables?
Increased hip flexion-extension arc
Increased hip muscle strength
Decreased stride length
Patient functional outcomes after acetabular fractures have been shown to be related to postoperative hip strength, regardless of surgical approach.
The reference by Borrelli et al evaluated muscle strength and outcomes after acetabular surgery via an anterior approach. They report that hip extension strength was affected least (6%), whereas abduction, adduction, and flexion strength was affected to a greater degree. They note that hip muscle strength after operative treatment of a displaced acetabular fracture directly influences patient outcome.
The reference by Engsberg et al is a review of patients that underwent ORIF of acetabular fractures through anterior or posterior approaches. They report that maximizing hip muscle strength may improve gait, and improvement in hip muscle strength and gait is likely to improve functional outcome. Worsening functional outcomes were correlated with decreased gait kinematics and stride length.
Borrelli J Jr, Ricci WM, Anglen JO, Gregush R, Engsberg J.
J Orthop Trauma. 2006 Jul;20(6):388-95. PMID: 16825963 (Link to Abstract)
Borrelli, JOT 2006
Engsberg JR, Steger-May K, Anglen JO, Borrelli J
J Orthop Trauma. 23(5):346-53. PMID: 19390362 (Link to Abstract)
Engsberg, JOT 2009
Average 1.0 of 81 Ratings
A 35-year-old male sustains a posterior column/posterior wall acetabular fracture. Which of the following is the preferred approach for open treatment of this injury?
Modified Stoppa approach
Extended iliofemoral approach
Combined anterior and posterior approach
Operative treatment is indicated for most displaced acetabular fractures to allow early ambulatory function and to decrease the chance of post-traumatic arthritis. Among the various surgical approaches, the Kocher-Langenbeck allows direct exposure of both the posterior column and posterior wall. Indications for using this exposure include posterior wall fractures, posterior column fractures, combined posterior wall/posterior column fractures, and simple transverse fractures.
Average 3.0 of 17 Ratings
When placing a percutaneous retrograde pubic ramus screw for fixation of an acetabular fracture, which of the following radiographic views can best ensure that the screw does not exit the posterior aspect of the superior pubic ramus?
Outlet obturator oblique view
Inlet iliac oblique view
Iliac oblique view
Obturator oblique view
As reviewed in the referenced article by Starr et al, when placing a retrograde pubic rami screw, the pelvic inlet iliac oblique view will best determine the anteroposterior placement of the screw in the pubic ramus. To ensure placement outside of the joint, the outlet obturator oblique is best, but all other views should be incorporated into determination of the position of fixation, as the corridor for this screw placement is quite narrow.
Illustration A shows a left sided inlet iliac view on a pelvic bone model.
Average 2.0 of 70 Ratings
A 78-year-old male undergoes the procedure shown in Figure A for treatment of a femoral neck fracture. As the patient passes through mid-rise during sitting to standing using the affected leg, what portion of the acetabulum experiences the highest contact pressures?
Figure A is an AP radiograph of a hip hemiarthroplasty.
Contact pressures from an insturmented hip endoprosthesis can have important implications in both implant positioning and rehabilitation protocols.
Hodge et al implanted a pressure-measuring Moore-type endoprosthesis in a patient who had sustained a displaced fracture of the femoral neck. They used this prosthesis to determine the measurement and telemetry of contact pressures in the hip for 36 months post-operatively. The highest pressure, eighteen megapascals, was recorded while the patient was getting up from a chair using the affected leg and was localized in the posterior superior portion of the acetabulum. This can be important in the post-operative care of acetabular fractures, as patients are at increased risk of loss of fixation with greater acetabular contact forces. Interestingly, peak pressures in vivo were found to be considerably higher than previously measured pressures in vitro.
1,2,4,5,-These regions of the acetabulum have less contact pressure compared to the posterior superior portion.
Hodge WA, Carlson KL, Fijan RS, Burgess RG, Riley PO, Harris WH, Mann RW.
J Bone Joint Surg Am. 1989 Oct;71(9):1378-86. PMID: 2793891 (Link to Abstract)
Hodge, JBJS 1989
Average 3.0 of 18 Ratings
During the ilioinguinal approach to the pelvis, the corona mortis artery must be identified and ligated if present. The corona mortis artery joins the external illiac artery with which other major artery?
Deep illiac circumflex
The "corona mortis" (translated as “crown of death”) artery is a vascular variant that joins the external illiac and the obturator artery as it crosses the superior pubic ramus. Tornetta et al did a study where "fifty cadaver halves were dissected to determine the occurrence and location of the corona mortis. Anastomoses between the obturator and external iliac systems occurred in 84% of the specimens. Thirty-four percent had an arterial connection, 70% had a venous connection, and 20% had both. The distance from the symphysis to the anastomotic vessels averaged 6.2 cm (range, 3-9 cm)." The corona mortis can be injured in superior ramus fractures and iatrogenically while plating pelvic ring injuries using the ilioinguinal approach.
Tornetta P, Hochwald N, Levine R
Clin. Orthop. Relat. Res.. 1996 Aug;(329):97-101. PMID: 8769440 (Link to Abstract)
Tornetta, JOT 1996
Average 4.0 of 25 Ratings
A 33-year-old male sustains the injury seen in Figure A as a result of a high-speed motor vehicle collision. Based on this image, what is the most likely acetabular fracture pattern?
Anterior column posterior hemitransverse
The radiograph in Figure A shows a transverse acetabulum fracture. The iliopectineal (anterior column) and ilioischial lines (posterior column) are interrupted, revealing bicolumnar involvement; however, this is different than the both column fracture, as a transverse pattern has articular surface still in continuity with the axial skeleton via the sacroiliac joint.
The referenced article by Patel et al showed a wide variation of inter and intra-observer agreement in interpreting radiographs of acetabular fractures, with high agreement for basic radiographic classification and only slight to moderate agreement for other radiologic variables such as impaction.
The other referenced article by Letournel is a great review article regarding the initial classification of these fractures as well as a quick summary of his outcomes.
Average 3.0 of 51 Ratings
The pelvic spur sign on plain radiography is indicative of the following injuries?
Transtectal transverse acetabular fracture
Vertical shear pelvic ring injury
Displaced H-type sacral fracture
Both column acetabular fracture
Anterior-posterior type III pelvic ring injury
The pelvic spur sign is indicative of a both column acetabular fracture. It is best seen on an AP or obturator oblique x-ray. The spur is the intact portion of the ilium, still attached to the axial skeleton and seen posterosuperior to the displaced acetabulum (typically medially displaced).
Illustration A shows the spur sign (arrows) on a CT image, while illustration B shows an obturator oblique of the pelvis and the spur sign is shown with the long tailed arrow (on the left of the image).
Average 4.0 of 26 Ratings
A computed tomography (CT) scan has been shown to be indicated for evaluation of all of the following aspects of acetabular fractures, EXCEPT:
Determination of surgical planning
Intra-articular loose bodies
Fracture piece size and position
Determination of pre-existing degenerative changes
CT scanning is indicated in acetabular fractures for determination of surgical approach and techniques, evaluation of marginal impaction and presence of intra-articular loose bodies (especially after hip dislocation), and evaluation of fracture piece sizes and relative positions.
Kellam et al reviewed their initial experience with CT scanning and acetabular fractures, and noted a 25% change in surgical planning when CT was utilized versus plain radiographs; they also noted the ability to detect marginal impaction and fracture size/position was improved with CT.
Kellam JF, Messer A.
Clin Orthop Relat Res. 1994 Aug;(305):152-9. PMID: 8050224 (Link to Abstract)
Kellam, CORR 1994
Average 2.0 of 43 Ratings
An acetabular fracture with all segments of the articular surface detached from the intact posterior ilium is defined as what fracture pattern?
Posterior column with posterior wall
Anterior column with anterior wall
A both column acetabular fracture is defined as an acetabular fracture with no articular surface in continuity with the remaining posterior ilium (and therefore, axial skeleton). The spur sign is a radiological sign seen with these fractures, and is the posterio-inferior aspect of the intact posterior ilium. The spur sign and other radiographic findings consistent with a both column acetabular fracture can be seen in Illustration A (AP), Illustration B (obturator oblique), and Illustration C (iliac oblique).
Average 3.0 of 38 Ratings
A 25-year-old male is involved in a motor vehicle accident and presents with the injury shown in Figure A. Early fixation of this fracture pattern is associated with all of the following EXCEPT?
Decreased length of hospital stay
Improved functional outcome
Greater organ dysfunction
Higher likelihood of being discharged to home as opposed to a rehab facility
Improved fracture reduction
Early fixation of acetabular fractures is associated with lesser organ dysfunction, so therefore answer three is not true.
Plaisier et al showed the timing of acetabular and pelvic ring fracture fixation greatly impacted patient outcome. Patients who had fixation within 24 hours of injury showed shorter length of stay in the hospital and ICU (decreased number of ventilator days), improved functional outcomes including a highly likelihood of being discharged to home as opposed to a rehabilitation facility, and lesser organ dysfunction.
The reference by Matta et al is a classic article that shows that patients fixed within 3 weeks of injury showed both a higher rate of anatomical reduction and lower overall complication rate than patients with similar fracture patterns treated after 3 weeks.
Plaisier BR, Meldon SW, Super DM, Malangoni MA.
Injury. 2000 Mar;31(2):81-4. PMID: 10748809 (Link to Abstract)
Plaisier, INJURY 2000
J Bone Joint Surg Am. 1996 Nov;78(11):1632-45. PMID: 8934477 (Link to Abstract)
Matta, JBJS 1996
Average 2.0 of 30 Ratings
A 22-year-old female is involved in a motor vehicle collision and sustains the injury shown in Figures A through D. According to these images, what is the acetabular fracture classification?
Transverse with posterior wall
Figures A through D show a comminuted both column acetabular fracture. In this injury, both columns are involved, with the acetabulum losing all connection to the axial skeleton (sacrum). This differentiates it from all other patterns, where at least part of the acetabular cartilage maintains connection to the sacrum.
Figure C shows the ischial spur, which is classically known as the spur sign and most easily seen on the obturator oblique radiograph.
Answer 1: This injury has axial skeleton attachment to the acetabular cartilage through the posterior column.
Answer 3: This injury has axial skeleton attachment to the acetabular cartilage through the anterior and posterior columns.
Answer 4: This injury has axial skeleton attachment to the acetabular cartilage through the anterior column as well as the posterior column, depending on fracture pattern.
Answer 5: This injury has no posterior column involvement, and therefore the posterior column maintains the axial skeleton attachment to the acetabulum.
Average 4.0 of 29 Ratings
A 42-year-old female sustains the injury seen in the computed tomography images seen in Figures A and B. According to the Letournel classification, what is the injury pattern shown?
The axial CT cut and Judet radiographic view shown reveals a transverse fracture pattern according to the Letournel classification system. This can be determined by the fact that the articular surface of the acetabulum is attached to the intact portion of the ilium, which is connected to the axial skeleton posteriorly through the sacroiliac joint. This differs from a both-column fracture, in which the articular surface of the acetabulum has no attachments to the axial skeleton due to fracture line(s). The axial CT scan also shows a vertical fracture line which is typical of a transverse fracture pattern.
Durkee et al review the classification schemes for these injuries, as well as comment on the importance of quality images (Judet views, CT, etc).
Figures A and B show a transverse acetabular fracture with mild displacement.
Durkee NJ, Jacobson J, Jamadar D, Karunakar MA, Morag Y, Hayes C
AJR Am J Roentgenol. 2006 Oct;187(4):915-25. PMID: 16985135 (Link to Abstract)
Durkee, AJR 2006
Average 3.0 of 49 Ratings
Which statement is true with respect to acetabular fracture surgery as the time between injury and surgery increases?
decreased chance of anatomic fracture reduction
decreased risk of heterotopic ossification
decreased rate of neurologic injury
decreased rate of infection
decreased rate of multi-organ failure
Madhu et al showed time to surgery was a significant predictor of radiological and functional outcome for both elementary and associated displaced fractures of the acetabulum. Both anatomic reduction and functional outcome significantly worsened as time to surgery increased. It was found anatomic reduction was more likely when surgery was within 15 days for elementary fracture and 5 days for associated.
2: No data exists showing a decrease in heterotopic ossification as time to surgery increases.
3: Neurologic injury is more associated with the initial injury.
4,5: Multi-organ failure was not commented on, but infection showed a trend towards being more likely with longer time to surgery.
Madhu R, Kotnis R, Al-Mousawi A, Barlow N, Deo S, Worlock P, Willett K.
J Bone Joint Surg Br. 2006 Sep;88(9):1197-203. PMID: 16943472 (Link to Abstract)
Madhu, BJJ 2006
In Figure A, the two red arrows point to which of the following two arteries?
Superior gluteal and pudendal
Internal iliac and medial circumflex
External iliac and deep femoral
Obturator and external iliac
Medial circumflex and inferior gluteal
The external iliac and obturator artery anastomose to form the corona mortis. During the Stoppa or ilioinguinal approach to the pelvis, you need to be careful of the corona mortis because the vessels can cause significant bleeding especially if they retract into the pelvis. In the Tornetta et al article, fifty cadaver halves were dissected to determine the occurrence and location of the corona mortis. Anastomoses between the obturator and external iliac systems occurred in 84% of the specimens. Thirty-four percent had an arterial connection, 70% had a venous connection, and 20% had both. The distance from the symphysis laterally to the anastomotic vessels averaged 6.2 cm. The Okcu et al article showed similar results in 150 cadavers: they found vascular anastomoses between the obturator and external iliac systems in 61% of the sides, and anastomotic veins in 52% of the exposures. The mean distance between the anastomotic arteries and the symphysis pubis was 6.4 cm, and 5.6 cm for the communicating veins. There seemed to be no significant difference between genders in the incidence of corona mortis and the distance between communicating vessels and the symphysis pubis.
Okcu G, Erkan S, Yercan HS, Ozic U.
Acta Orthop Scand. 2004 Feb;75(1):53-5. PMID: 15022807 (Link to Abstract)
Okcu, ACTA 2004
Which of the following associated type acetabular fracture patterns is defined based on the fact that all articular segments are detached from the intact portion of the ilium, which remains attached to the sacrum through the sacroiliac joint?
Posterior wall/ posterior column
Anterior column/ posterior hemitransverse
There are 5 simple and 5 associated fracture types according to the classification system created by Judet and Letournel. The key feature which distinguishes both column fractures from other associated types is that all articular segments are detached from the intact portion of the ilium, which remains attached to the sacrum through the SI joint.
Although the transverse plus posterior wall, T-shaped, and anterior plus posterior hemi-transverse fractures all show involvement of the anterior and posterior columns, they are not “both columns” because a portion of the articular surface remains in its normal position, attached to intact ilium.
The intact ilium is responsible for the "spur sign" noted most prominently on the obturator oblique radiograph.
Illustration A demonstrates the 10 types of acetabular fractures as created by Judet and Letournel. Illustration B is an example of a both column acetabular fractures as seen on the obturator oblique radiograph.
An 74-year-old community-ambulating male presents with complaints of right hip pain for 4 months. He does not recall any specific trauma though his pain is quite severe at this point. A radiograph is shown in Figure A. What is the most appropriate definitive treatment for this patient?
Conservative treatment with delayed physical therapy and shoe lifts
Open reduction and internal fixation
Right hip reconstruction
Closed reduction and percutaneous fixation
The patient described in this question has sustained an insufficiency fracture of the right acetabulum that has been neglected. Total hip arthroplasty (THA), with use of flanged and/or custom acetabular components as needed, is necessary to reconstruct the acetabulum and address the significant femoral head damage.
Total hip arthroplasty as the primary treatment for acetabular fracture remains controversial. Osteopenia, pre-fracture hip arthritis and significant chondral impaction injuries make osteosynthesis difficult and more prone to failure. In the elderly patient with these injury characteristics or delayed presentation, THA may be a preferred first procedure as it can definitively address these issues.
Weber et al reviewed delayed THA in acetabular fractures that had previously undergone open reduction internal fixation, and reported a 78% 10-year survival rate, with worse outcomes in patients < 50 years old, males, weight >80kg, and patients with large residual segmental acetabular defects.
Jiminez et al review the the use of THA after acetabular fractures, either in a delayed or acute fashion. They note that THA as an acute treatment of acetabular fractures is rarely indicated: "Circumstances in which this may be a consideration include certain pathologic fractures, patients with pre-existing symptomatic hip arthritis who are already candidates for hip arthroplasty prior to injury, and rare instances of associated femoral side injuries, including head-splitting fractures that preclude a satisfactory operative result or significantly displaced ipsilateral femoral neck fractures."
Mears reviews acute THA in osteopenic acetabular fractures, with presentation of treatment algorithms and techniques, including conservative treatment, minimally invasive fixation, conventional fixation, acute and delayed THA.
Figure A shows a delayed-presentation right acetabular fracture with significant femoral head impaction injury and acetabular protrusio. Illustration A shows an algorithm for treatment of acetabular fractures in osteopenic patients.
Answer 1: Traction would be acceptable if the patient had an unacceptable medical risk for surgery
Answer 2: Conservative treatment inappropriate unless patient not a surgical candidate for medical reasons
Answer 3: Several injury factors make this choice more prone to failure (1) delayed presentation, (2) osteopenia, (3) femoral head injury, (4) medial roof impaction
Answer 5: Close reduction may improve the protrusio if the fracture is still mobile but cannot address the significant chondral injury.
Weber M, Berry DJ, Harmsen WS.
J Bone Joint Surg Am. 1998 Sep;80(9):1295-305. PMID: 9759814 (Link to Abstract)
Weber, JBJS 1998
Jimenez ML, Tile M, Schenk RS.
Orthop Clin North Am. 1997 Jul;28(3):435-46. PMID: 9208835 (Link to Abstract)
J Am Acad Orthop Surg. 1999 Mar-Apr;7(2):128-41. PMID: 10217820 (Link to Abstract)
Mears, JAAOS 1999
Average 2.0 of 80 Ratings
All of the following have been shown to negatively affect clinical outcomes in treating displaced acetabular fractures, EXCEPT:
Ipsilateral femoral head injury
Involvement of both columns
Non-anatomic fracture reduction
Negative outcome factors have been shown to include: increasing patient age, time from injury to surgery (>3 weeks), intraoperative complications, femoral head bone or cartilage injury, and fracture reduction > 1-2mm from anatomic. Choice of surgical approach has not been shown to affect patient outcomes.
The referenced study by Matta evaluated outcomes of displaced acetabular fractures. The overall clinical result was excellent for 104 hips (40 per cent), good for ninety-five (36 per cent), fair for twenty-one (8 per cent), and poor for forty-two (16 per cent). The clinical result was related closely to the radiographic result. These findings indicate that in many patients who have a complex acetabular fracture the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved.
A 25-year-old patient presents with a posterior wall/ posterior column acetabular fracture. She is scheduled for open reduction internal fixation through a posterior approach. What position of the leg exerts the least amount of intraneural pressure on the sciatic nerve?
hip flexion, knee extension
hip extension, knee extension
hip flexion, knee flexion
hip extension, knee flexion
the pressure does not vary based on position
In the cited study, researchers measured tissue fluid pressure within the sciatic nerve in cadaveric specimens using a pressure transducer. The hip and knee were taken through a combination of ranges and found that the clinically relevant increase in pressure happened with the hip flexed at 90 degrees and the knee fully extended. They concluded that increased intraneural pressure was related to excursion of the nerve as linear distance between the greater sciatic notch and the distal leg increase. Hence, according to the question stem, to avoid traction injury, the reverse position should be implemented (hip extension and knee flexion).
Borrelli J Jr, Kantor J, Ungacta F, Ricci W.
J Orthop Trauma. 2000 May;14(4):255-8. PMID: 10898197 (Link to Abstract)
Borrelli, JOT 2000
Average 4.0 of 15 Ratings
What acetabular component is best appreciated on an obturator oblique radiograph of the pelvis as seen in Figure A?
Letournel and Judet developed a schematic representation of the acetabulum as being contained within asymmetric long anterior and short posterior arms of an inverted “Y”.
On the bony pelvis, the ilioischial component becomes that posterior column and the iliopectineal line becomes the anterior column. The Judet-Letournel classification system is based on this scheme. By careful evaluation of landmarks on a standard AP pelvis radiograph, as well as on 45-degree oblique obturator and iliac views, the extent of injury can be determined accurately.
The AP view usually demonstrates the six fundamental landmarks relatively well as seen in illustration A. The obturator oblique view reveals additional information about the anterior column and posterior wall(see illustration A(B), B). In an obturator oblique view the x-ray beam is centered on and almost perpendicular to the obturator foramen. The iliac oblique view visualizes the posterior column and anterior wall (illustration A(C), C). This view also shows the best detail of the iliac wing as the radiographic beam is roughly perpendicular to the iliac wing. Inclusion of the opposite hip is essential for evaluation of symmetrical contours that may have slight individual variations and to evaluate the width of the normal articular cartilage in each view in a pelvic series (AP, Judet's) .
Average 4.0 of 20 Ratings
A 32-year-old male sustains the injury shown in Figure A through D as the result of a high-speed motor vehicle collision. This particular injury is best treated with which of the following single approaches?
The radiograph and CT images shown in A-D show an acute both column acetabular fracture with segmental posterior column comminution. For difficult fractures with anterior displacement in which access to the entire anterior column is required, the ilioinguinal or Stoppa approach is ideal. These approaches allow access to the anterior column as far as the symphysis and includes the quadrilateral plate.
Most both-column fractures can also be managed through these approaches, but only if the posterior fragment is large and in one piece. In this case, the posterior column is in several pieces and requires either two approaches or an extended approach, such as the iliofemoral.
The original description of the ilioinguinal approach makes intraarticular visualization of the hip impossible. If visualization of the joint is required, a T extension of the incision just medial to the anterior-superior iliac spine can be made. Most surgeons accept that the joint is reduced when the fracture lines inside the pelvis are reduced, and thus this extension is very rarely used.
The extended iliofemoral approach gives excellent visualization of the outer table of the ilium, the superior dome, and the posterior column. The anterior column can be visualized to the iliopectineal eminence. The exposure is similar to that provided by the triradiate approach with the additional benefit of access to the bone above the sciatic notch. The approach can be extended to provide exposure to the iliac fossa; however, this is very rarely necessary and should be avoided. Extending the approach to the inside of the pelvis greatly increases the risk of devascularizing segments of the acetabulum.
Average 2.0 of 63 Ratings
When viewing pelvic injury radiographs, which of the following describes the findings diagnostic of an isolated transverse acetabular fracture?
Fracture line crossing the acetabulum with disruption of the iliopectineal and ilioischial lines
Disruption of the iliopectineal and ilioischial lines, with extension into the iliac wing and obturator ring
Disruption of the iliopectineal and ilioischial lines, with extension into the obturator ring
Isolated disruption of the iliopectineal line, with an intact ilioischial ine
Isolated disruption of the ilioischial line, with an intact iliopectineal ine
Transverse acetabular fractures separate the innominate bone into two fragments, the superior iliac and the inferior ischiopubic, by a single fracture line that crosses the acetabulum horizontally. The iliopectineal and ilioischial lines are disrupted on the AP pelvis radiograph. Axial CT scan of this fracture pattern at the level of the dome will show a vertical anterior to posterior fracture line. Illustrations A-C show AP and Judet pelvic radiographs of a transverse fracture. Illustration D demonstrates the axial CT appearance of this fracture type. Answer choice 2 is describing a both column injury or anterior column posterior hemitransverse, and answer choice 3 describes a T-type fracture pattern. Answer choices 4 and 5 describe an anterior column and posterior column injury respectively. Judet et al provide one of the first comprehensive reviews on acetabular surgical approaches, fracture types, and radiographic anatomy. Illustration E demonstrates the acetabular classification scheme developed by Judet.
JUDET R, JUDET J, LETOURNEL E.
J Bone Joint Surg Am. 1964 Dec;46:1615-46. PMID: 14239854 (Link to Abstract)
JUDET, JBJS 1964
Average 4.0 of 19 Ratings
A 45-year-old male is involved in a motor vehicle accident and sustains the injury shown in Figures A-D. Which of the following is the most appropriate approach for surgical fixation of this fracture?
Stoppa with lateral window
The images demonstrate a posterior column acetabular fracture. These are best surgically treated with a Kocher-Langenbeck approach, which allows access to the posterior column and posterior wall. Figure A shows disruption of the ilioischial line with an intact iliopectineal line which is diagnostic of this fracture pattern. The CT image in Figure D shows the characteristic horizontal (coronal) orientation of the column fracture when viewed on an axial CT. Illustration A shows the radiographic landmarks used in diagnosing acetabular fractures. Illustrations B and C show the orientation of column and wall fractures respectively. Ilioinguinal and Stoppa approaches allow access for anterior column fixation and symphysis fixation respectively. The extended iliofemoral approach can be used to treat both column injuries, but has high rates of post-operative heterotopic ossification.
A 47-year-old male sustains an isolated posterior wall acetabulum fracture after a motor vehicle collision and undergoes open reduction and internal fixation. Post-operative radiographs are shown in Figure A. Which of the following has been shown to correlate most closely with good outcomes following ORIF of posterior wall fractures?
Degree of displacement seen on preoperative AP pelvis view
Degree of displacement seen on preoperative Judet views
Degree of displacement seen on preoperative pelvic CT scan
Degree of displacement seen on postoperative Judet views
Degree of displacement seen on postoperative pelvic CT scan
Moed et al performed a study to determine the clinical outcome in patients in whom a displaced fracture of the posterior wall of the acetabulum had been treated by open reduction and internal fixation. They were able to show good to excellent clinical results for patients who underwent anatomic reduction and internal fixation of posterior wall acetabulum fractures as assessed using radiographs. Fractures in elderly patients and patients who sustained extensive comminution were more likely to have worse clinical result.
In a separate study, Moed et al. evaluated the results of 67 patients who underwent ORIF of a posterior wall fractures by assessing the accuracy of postoperative AP pelvis, obturator oblique films, iliac oblique films, and CT scans. They found that postoperative pelvic CT scan was the most accurate way to judge final fracture reduction and was able to pick up residual fracture displacements that were not seen on postoperative plain radiographs. They concluded that the accuracy of reduction as assessed on postoperative CT scan was the most reliable indicator of clinical outcomes.
Moed BR, WillsonCarr SE, Watson JT
J Bone Joint Surg Am. 2002 May;84-A(5):752-8. PMID: 12004016 (Link to Abstract)
Moed, JBJS 2002
Moed BR, Carr SE, Gruson KI, Watson JT, Craig JG
J Bone Joint Surg Am. 2003 Mar;85-A(3):512-22. PMID: 12637440 (Link to Abstract)
Moed, JBJS 2003
HPI - Run over accident, non-compliant patient who does not speak English
HPI - 66yo F with psych history jumped off approx 12 foot bridge landing on frozen river.
What approach would you use in this case?
HPI - 46yo F in MVC. Presents with severe head injury, thoracic injury and deformity to left hip/thigh.
How would you classify this acetabular fracture pattern?
HPI - The patient presented to ER after RTA with Left hip pain
What is your preferred approach for ORIF of this fracture?
HPI - Patient presents by ambulance following a simple fall from his bicycle.
Unable to ambulate following the fall secondary to pain.
This acetabular fracture is which of the following:
HPI - Patient slipped on kitchen floor at home and fell.
Right hip injury.
Unable to ambulate following the fall secondary to pain.
What fracture type is depicted in the preoperative images?
HPI - Two years post DHS fixation of old proximal femoral fracture.
No signs of infection, CRP 9, WBCs 7000, HB 9.7
Skin is healthy with scar of previous surgery
What is the most suitable surgical option?
HPI - fall on outstretched arm
HPI - fall from a ladder from a height of 2 meters
What system would you use to classify this injury?
HPI - Rt. Hip pain and limping after falling on his rt. Side
Would you obtain a CT scan to help determine your surgical plan?
HPI - Road side accident 3 days back
How will you treat this patient?
HPI - THR done about 20 years before in USA, patient now in Egypt.
Now, pain and limited movements on right side
What do you think the cause of the patient's symptoms is?
HPI - Motor Vehicle Collision, trauma alert. Hemodynamically stable on presentation. Injuries include rib fractures, small lung contusion, left acetabular fracture, right sided pelvic ring disruption, and left distal radius fracture.
HPI - Patient with a history of hip and tibial plateau fracture, this six months ago periprosthetic fracture that was treated with LCP plate and then evolves with this failure osteosintesis
What would be your treatment of choice?
HPI - MBA 6 years ago
Patient isn't the best historian and, as his injury was sustained in another state, we have not been able to access his imaging or notes
Right proximal humerus fracture, treated non-operatively
Associated with brachial plexus injury of uncertain extent (patient describes complete paralysis of right upper extremity)
Plexus treated expectantly with recovery over 12-18 months
States reasonable shoulder function after plexus recovery for 1-2 years, but lasts 4 years has developed increasingly severe right shoulder pain with associated stiffness
Previously a fisherman, unable to work due to pain for 12 months
States had been placed on waiting list for "rotator cuff repair" in the other state 3 years ago, but never called for surgery
Having moved from the other state to NSW, now presents to us "only" wanting more movement and less pain
How would you treat this patient?
HPI - History of fall 2 days ago
How would you classify this acetabular fracture?
HPI - Mild renal failure,motorcycle accident before 5 years this catastrofic injury left untreated
what is the best choice of fixation-reconstruction?
HPI - Otherwise healthy male s/p motorcycle accident
HPI - not known
what is the best choice of fixation ?
HPI - 39 y/o male s/p MVC with left hip pain. No prior hip pain or injury. This appears to be an isolated injury. Transferred from outside hospital after initial evaluation.
What would you classify this acetabular fracture as?
HPI - History of road side accident 3 days back leading to injury left hip joint
How would you classify this fracture?
HPI - History of road traffic accident leading to bilateral fracture dislocation joint
How would you treat this injury?
HPI - RSA two days back leading to injury involving the right acetabulum.
What is the fracture classification
HPI - An active elderly lady. Fall from cot
How would you treat this fracture?
HPI - MVA; bike vs bike.
HPI - h/o of RTO, sustained left distal radius intraarticular fracture. ORIF done with LCP. 1 1/2 month followup xray showing fixation failure. Patient was not immobilized post op.
HPI - Rt. Hip pain post MVA.
what is the best treatment option for this kind of acetabular fracture.
HPI - twisting injury left foot while playing basketball
closed reduction or reduction with fixation
HPI - Acute onset of right hip pain following hyperflexion injury during soccer
How would you approach this case and patient?
Acetabular Fractures and Hip DislocationsCore Currriculum WebinarsBrought to you...
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Educational video describing fracture types of the acetabulum.