Acetabular

Fractures

Moderator : Dr Pravakar Parajuli

Presenter: Dr Kamlesh Kumar Yadav
 Acetabular Osteology

• Inverted “Y” two column concept

• 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
Acetabular Osteology
• Columns
• Anterior
Anteri
• Posterior or
colum
• Walls n

• Anterior
• Posterior
Anteri
Poste
• Quadrilateral rior
oror
wall
wall
wall
surface/medial wall
• Dome
Poster
ior Illustrations courtesy of Alesha
N. Scott, D.O.
colum
n
Acetabular Osteology
Anterior column
• Extends from anterior
iliac crest to pubic
symphysis
• 3 segments
• Iliac segment
• Acetabular segment
• Pubic segment

Photo courtesy of Alesha N.

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

ischium
• 2 segments
• Posteroinferior portion
of ilium
• Greater and lesser
sciatic notches
• Ischium
Photo courtesy of Alesha N.
Scott, D.O.
 Acetabular Osteology
Anterior wall
• Iliopectineal eminence
• Represents the anterior
and medial boundary of
the acetabulum
• Iliopsoas runs just Iliopecti
neal
lateral to the eminence eminenc
e

Photo courtesy of Alesha N.

Scott, D.O.

Photo courtesy of Alesha N. Scott,

D.O.
Acetabular Osteology
Posterior wall
• Most common
acetabular fracture
type

Photo courtesy of Alesha N.

Scott, D.O.
Acetabular Osteology
Medial wall
• Quadrilateral
surface +
acetabular fossa
• Commonly
involved in
geriatric
acetabular
fracture patterns
Illustrations courtesy of Alesha
N. Scott, D.O.
Ligamentous
Acetabular Anatomy
• Capsule
• Labrum
• Ligamentum teres
• Transverse acetabular
ligament
Neural Acetabular
Anatomy
• Sciatic nerve
• Recognize variant
anatomy!

CRANIAL
CAUDAL

Michael S. Kain and Paul Tornetta III. Hip Dislocations and Femoral Head
Fractures. In: Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures in Adults, 9e.
Berton R. Moed and John A Boudreau. Acetabulum Fractures. In: Tornetta P, Ricci Philadelphia, PA. Wolters Kluwer Health, Inc; 2019. Figure 51-14.
WM, eds. Rockwood and Green's Fractures in Adults, 9e. Philadelphia, PA. Wolters
Kluwer Health, Inc; 2019. Figure 50-50.
Vascular Supply
• Lateral (A)
• Superior gluteal
artery
• Inferior gluteal
artery
• Medial femoral
circumflex artery
• Medial (B)
• Iliolumbar artery
• Obturator artery

A B
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
• Mainly caused by high-energy
trauma secondary to a motor
vehicle, motorcycle accident, or
fall from a height
• The fracture pattern depends
on
• Position of the femoral head at
the time of injury
• Magnitude of force
• Age of the patient
 MECHANISM OF INJURY
• Direct impact to the greater trochanter with the hip in
neutral position- transverse type of acetabular fracture
• An abducted hip causes a low transverse fracture
• An adducted hip causes a high transverse fracture
• An externally rotated and abducted hip- anterior
column injury
• An internally rotated hip- posterior column injury
• With indirect trauma (e.g., a “dashboard”-type injury to
the flexed knee), as the degree of hip flexion increases,
the posterior wall is fractured in an increasingly inferior
position
 CLINICAL EVALUATION
• ATLS protocol
• Patient factors (patient age, degree of trauma,
presence of associated injuries, and general
medical conditions) are important
• Careful assessment of neurovascular status
• Presence of associated ipsilateral injuries must be
ruled out
 ASSOCIATED CONDITIONS
• Orthopaedic manifestations
• Lower extremity injury (36%)
• Nerve palsy (13%)
• Most commonly seen in transverse + posterior wall fracture
patterns
• Most commonly affects the peroneal division of the sciatic nerve
• Spine injury (4%)
• Systemic injuries
• Head injury (19%)
• Chest injury (18%)
• Abdominal injury (8%)
• Genitourinary injury (6%)
Radiographic Evaluation
Standard Pelvic Radiographs

Three views
should be
routinely
obtained:
• AP
• Judets (oblique)
• Obturator
oblique
• Iliac oblique
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 Iliac oblique
beam
• Iliac cross section small as
possible
• Perfectly displays outline
of the obturator ring
• Best demonstrates
• Anterior column
• Posterior wall

Obturator oblique
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 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
• Created by beam
tangent to
posterior portion
of quadrilateral
surface
Teardrop
• Not a true anatomic
structure
• Medial limb
• obturator canal and
anteroinferior
portion of
quadrilateral surface
• 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 wall
• 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
• Letournel’s Classification Fractures
• Five elementary patterns Elementary Patterns
& five associated patterns
• Anterior wall fracture
• Based on anatomic • Posterior wall fracture
pattern • Anterior column fracture
• Determined by analyzing • Posterior column fracture
six radiographic landmarks • Transverse fracture
• Determine which are Associated Patterns
disrupted • Transverse + posterior wall
fracture
• Variations from these • Posterior column + posterior
patterns are common and wall
well-recognized • Anterior column + posterior
hemitransverse fracture
• T-type fracture
• Both column fracture
Classification of Acetabular
Fractures
• Elementary patterns
A
• Separates part or
entirety of single A
A
column from
acetabulum A A
• Transverse fractures
are an exception
• Both columns involved
• Included in
elementary family due
to fundamental nature
of fracture line Tornetta III, P et al. Rockwood & Greens Fractures in Adults.
Philadelphia: Lippincott Williams & Wilkins, 2019
 Classification of Acetabular
Fractures

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

• Elementary pattern +
additional fracture
component1

Tornetta III, P et al. Rockwood & Greens Fractures in Adults.

Philadelphia: Lippincott Williams & Wilkins, 2019
Elementary Fracture Patterns
Anterior Wall Fractures
• Uncommon as
isolated fractures

Tornetta III, P et al. Rockwood & Greens Fractures in

Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
Anterior Wall Fractures
• AP
• AIIS & pubis are not
involved
• Typically occurs along
upper 1/3

Tornetta III, P et al. Rockwood & Greens Fractures in

Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
Anterior Wall Fractures
• 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
Tornetta III, P et al. Rockwood & Greens Fractures in
the wall fragment Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
Anterior Wall Fractures

• Iliac Oblique
• Posterior column intact1
• Establish point of
rupture of anterior wall

Tornetta III, P et al. Rockwood & Greens Fractures in

Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
Posterior Wall Fractures
• Common pattern
• Commonly associated
with
• Posterior dislocation of
femoral head
• Significant marginal
impaction

Tornetta III, P et al. Rockwood & Greens Fractures in

Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
Posterior Wall Fractures
• AP
• Often associated with
posterior dislocation of
the femoral head
• PW fragment appears as
cap on dislocated head
• Once reduced, fracture
may be difficult to
identify

Image courtesy of Dr. Raymond Wright,

MD
Posterior Wall Fractures
• Obturator oblique
• Provides most
information regarding
posterior wall fracture
• Depicts fragment size &
displacement
• Any residual subluxation
of the femoral head

Image courtesy of Dr. Raymond Wright,

MD
Posterior Wall Fractures
• Iliac oblique
• Typically not
particularly useful in
characterizing posterior
wall fractures
• Fracture may not be
visualized at all

Image courtesy of Dr. Raymond Wright,

MD
Posterior Wall Fractures
• CT
• Fracture line oblique,
anteriorly and
peripherally, at ~45
degrees
• Characterizes marginal
impaction
• Rule out associated,
minimally displaced
transverse fractures not Image courtesy of Dr. Raymond Wright,
visible on plain MD

radiographs
Anterior Column Fractures
• Subclassified based on where
cranial extent of fracture line
exits
• A.) Very low: anteroinferior
acetabulum
• Large portion of acetabular roof
usually left intact
• Often reduces spontaneously,
remains stable
• B.) Low: Psoas gutter
• Inferior to AIIS
• C.) Intermediate: Anterior
interspinous notch
• Between AIIS and ASIS
• D.) High: Iliac crest Tornetta III, P et al. Rockwood & Greens Fractures in
• Posterior to ASIS Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
Anterior Column Fractures

• AP
• Disrupted iliopectineal line
• Any involvement of iliac
wing often visible

Tornetta III, P et al. Rockwood & Greens Fractures in Adults.

Philadelphia: Lippincott Williams & Wilkins, 2019
Anterior Column Fractures

• Obturator Oblique
• Clearly shows location of
disruption of iliopectineal
line
• Best demonstrates extent of
medial displacement of
anterior column by femoral
head

Tornetta III, P et al. Rockwood

& Greens Fractures in Adults.
Philadelphia: Lippincott
Williams & Wilkins, 2019
Anterior Column Fractures

• Iliac oblique
• Confirms integrity of
posterior column
• Best depicts any
involvement of iliac wing

Tornetta III, P et al. Rockwood &

Greens Fractures in Adults.
Philadelphia: Lippincott Williams &
Wilkins, 2019
Posterior Column Fractures
• Fracture extends from
posterior column near
apex of greater sciatic
notch
• Continues caudally
through inferior ramus
• Separates entire
ischioacetabular
segment from
innominate bone Tornetta III, P et al. Rockwood & Greens Fractures in
Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
Posterior Column Fractures

• AP:
• Loss of relationship of
teardrop with
iliopectineal line
• Ilioischial line displaced
medially by femoral
head
• Iliopectineal line intact

Tornetta III, P et al. Rockwood &

Greens Fractures in Adults.
Philadelphia: Lippincott
Williams & Wilkins, 2019
Posterior Column Fractures

• Obturator Oblique
• Confirms integrity of
iliopectineal line (Black
arrow)
• Ischiopubic segment
disrupted (White arrow)

Tornetta III, P et al. Rockwood

& Greens Fractures in Adults.
Philadelphia: Lippincott
Williams & Wilkins, 2019
Posterior Column Fractures

• Iliac Oblique
• Confirms disrupted
ilioischial line, and extent
of superior involvement
• Typically angle of greater
sciatic notch

Tornetta III, P et al.

Rockwood & Greens
Fractures in Adults.
Philadelphia: Lippincott
Posterior Column Fractures

• CT
• Fracture line has
transverse (coronal)
orientation on axial CT

Tornetta III, P et al. Rockwood & Greens

Fractures in Adults. Philadelphia:
Lippincott Williams & Wilkins, 2019
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
Tornetta III, P et al. Rockwood & Greens Fractures in
• Divides innominate bone into Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
ilium and ischiopubic segments
Transverse Fractures
• AP
• Both ilioischial and
iliopectineal lines
disrupted
• Obturator ring intact
• Scrutinize for associated
SI joint injury

Tornetta III, P et al. Rockwood & Greens Fractures in

Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
Transverse Fractures

• Obturator oblique
• Confirms integrity of
obturator ring
• Aids in evaluation of
relative displacement of
the fragments
• Helpful for decision
making for choice of
approach
Tornetta III, P et al. Rockwood &
Greens Fractures in Adults.
Philadelphia: Lippincott Williams &
Wilkins, 2019
Transverse Fractures

• Iliac oblique
• Depicts point of rupture
of greater sciatic notch
(black arrow)

Tornetta III, P et al.

Rockwood & Greens
Fractures in Adults.
Philadelphia: Lippincott
Williams & Wilkins, 2019
Transverse Fractures
• 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 Tornetta III, P et al. Rockwood & Greens Fractures in
marginal impaction Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
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
Tornetta III, P et al. Rockwood & Greens Fractures in
with femoral head Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
dislocation
Posterior Column + Posterior Wall
Fractures
• AP
• Ilioischial line disrupted
• “double” ilioischial line
(black arrow)
• Sometimes posterior column
component is minimally
displaced and not readily
visible on AP view
• Posterior wall fragment
• Typically remains concentric
with femoral head in setting
of dislocation
• Ischiopubic ramus typically
fractured (white arrowhead) Tornetta III, P et al. Rockwood & Greens Fractures in
• Iliopectineal line intact Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
(black arrowheads)
Posterior Column + Posterior Wall
Fractures
• 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)
Tornetta III, P et al. Rockwood & Greens
Fractures in Adults. Philadelphia:
Lippincott Williams & Wilkins, 2019
Posterior Column + Posterior Wall
Fractures
• Iliac oblique view
• Best depicts
displacement of
posterior column
fragment (white arrow)
• Disruption of greater
sciatic notch
• Posterior wall fragment
appears superimposed
on roof of acetabulum
(black arrow)
Image courtesy of J. Chad Martin, DO
Posterior Column + Posterior Wall
Fractures
• 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
Image courtesy of J. Chad Martin, DO
Transverse + Posterior wall
• Transverse component
• Transtectal
• Juxtatectal
• Infratectal

Tornetta III, P et al. Rockwood & Greens Fractures in

Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
Transverse + Posterior wall

• AP
• Teardrop is only
remaining intact
radiographic landmark
• Obturator ring intact
• Ischiopubic segment
driven medially by
femoral head

Image courtesy of Dr. Raymond Wright, MD

Transverse + Posterior wall
• Obturator oblique
• Best demonstrates
posterior wall fragment
size and displacement
• Best way to evaluate for
any persistent femoral
head subluxation
• Obturator ring intact

Image courtesy of Dr. Raymond Wright, MD

Transverse + Posterior wall

• Iliac oblique
• Fracture line exiting
greater sciatic notch
• Posterior wall fragment
superimposed on roof
of acetabulum

Image courtesy of Dr. Raymond Wright, MD

Transverse + Posterior wall
• Axial CT
• Transverse component
• vertical (sagittal) fracture
orientation (black arrow)
• Posterior wall component
(white arrow)
• typical oblique (anterior
and peripheral) fracture
orientation
• Assess for associated
pelvic ring injury

Tornetta III, P et al. Rockwood &

Greens Fractures in Adults.
Philadelphia: Lippincott Williams &
Wilkins, 2019
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 A A
Tornetta III, P et al. Rockwood & Greens Fractures in
Adults. Philadelphia: Lippincott Williams & Wilkins,
2019
anterior column rather
than anterior wall
Anterior Column (or wall) + Posterior
Hemitransverse Fractures
• AP
• Iliopectineal line
disrupted
• Medial subluxation of
femoral head with
segmental displacement
of iliopectineal line
• Ilioischial line preserved

Tornetta III, P et al. Rockwood & Greens Fractures in Adults.

Philadelphia: Lippincott Williams & Wilkins, 2019
Anterior Column (or wall) + Posterior
Hemitransverse Fractures

• Obturator oblique
• Iliopectineal line
disrupted
• Femoral head follows
anterior column lesion
• Fracture often
multifragmentary with
impaction

Tornetta III, P et al. Rockwood &

Greens Fractures in Adults.
Philadelphia: Lippincott Williams &
Wilkins, 2019
Anterior Column (or wall) + Posterior
Hemitransverse Fractures

• 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 Tornetta III, P et al. Rockwood &
portion extends into it Greens Fractures in Adults.
Philadelphia: Lippincott Williams &
Wilkins, 2019
Anterior Column (or wall) + Posterior
Hemitransverse Fractures
• 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 Tornetta III, P et al. Rockwood & Greens Fractures
from the coronal anterior in Adults. Philadelphia: Lippincott Williams &
column fracture Wilkins, 2019
T-Type Fractures
• Transverse fracture with vertical
AAAAAAAAA
fracture 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 Tornetta III, P et al. Rockwood & Greens Fractures in
Adults. Philadelphia: Lippincott Williams & Wilkins,
*Obturator ring may maintain its
2019
integrity in anterior and posterior
variants
T-Type Fractures
• AP
• Transverse component
almost always has
significant displacement
Image courtesy of Dr. Raymond Wright,
• Ilioischial line may
appear duplicated
(black arrowheads)
• Displacement of vertical
component
• Obturator ring
disrupted(white arrow)

Tornetta III, P et al. Rockwood & Greens Fractures

in Adults. Philadelphia: Lippincott Williams &
Wilkins, 2019
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
Image courtesy of Dr. Raymond Wright, MD
 T-Type Fractures
• Iliac oblique
• Disruption of greater
sciatic notch, or
posterior column (red
arrow)
• Best depicts any
subluxation of femoral
head

Tornetta III, P et al. Rockwood & Greens

Fractures in Adults. Philadelphia:
Lippincott Williams & Wilkins, 2019
T-Type Fractures
• CT
• Transverse component
vertically (sagittally)
oriented on axial cuts
• Best modality for
diagnosing minimally
displaced vertical
components

Images courtesy of Dr. Raymond Wright, MD

T-Type vs. Anterior Column +
Posterior Hemitransverse
Anterior Column +
A
T-Type Posterior Hemitransverse
A

Tornetta III, P et al. Rockwood & Greens Fractures Tornetta III, P et al. Rockwood & Greens Fractures
in Adults. Philadelphia: Lippincott Williams & in Adults. Philadelphia: Lippincott Williams &
A
Wilkins, 2019
A
Wilkins, 2019
Both Column Fractures

• No continuity between
axial skeleton and
articular surface of
acetabulum
• Typically very
comminuted
• Complexity is variable Tornetta III, P et al. Rockwood & Greens
Fractures in Adults. Philadelphia: Lippincott
Williams & Wilkins, 2019
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
Image courtesy of Dr. Raymond Wright, MD
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
Image courtesy of Dr. Raymond
Wright, MD
Both Column Fractures

• Iliac oblique
• Best depicts
displacement of
posterior column
• Best depicts any
fractures extending into
the ilium of the ilium

Image courtesy of Dr. Raymond

Wright, MD
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 Image courtesy of Dr. Raymond Wright, MD
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 Tornetta III, P et al. Rockwood & Greens Fractures in Adults.
Philadelphia: Lippincott Williams & Wilkins, 2019
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
Image from Laura Blum
Incarcerated Fragments
• Diagnosis
• Post-reduction films:
non-concentric joint
space
• Fragment often
visualized either:
• Extruded toward
external border
• Partly within
cotyloid fossa A B
Tornetta III, P et al. Rockwood & Greens Fractures in Adults.
Philadelphia: Lippincott Williams & Wilkins, 2019
 Roof Arc Angle
A B C
• Three angles measured
on AP (A), iliac oblique
(B), and obturator
oblique (C)7
• Vertical line drawn
through center of
acetabulum
• Another line, 45 degrees
from that starting at the
center of the
acetabulum
• If fracture falls within the
angle drawn on any of
the views, considered to
be in weight-bearing
Images from Laura Blum, MD
dome
• Relative indication for
surgery
 Stress Exam Under Anesthesia

• Dynamic stress views

• Typically used to
str
evaluate stability of e ss
posterior wall fractures
• Assess for congruity
while loading force
through the femur Images courtesy of
longitudinally: Luke Harmer, MD

• Flex >90 degrees

• Flex, internally rotate
approximately 20
degrees  assess for
congruity
CT Evaluation
CT Evaluation: Associated
Injuries
• Soft tissue
• Morel-Lavallee
• Genitourinary
• Orthopaedic
• Pelvic hematoma
• Bladder often shifts away from Tornetta III, P et al. Rockwood & Greens
midline Fractures in Adults. Philadelphia: Lippincott
• Can indicate subtle pelvic ring Williams & Wilkins, 2019
or acetabular injury
• Pelvic ring
• Sacral fracture
• Sacroiliac joint disruption
• Contralateral rami fractures
• Proximal femur/femoral head
Image courtesy of Dr. Laura Blum, MD
CT Evaluation: Acetabulum
• Dedicated pelvic CT
• 2-3mm cuts
• Used only in
conjunction with plain
pelvic radiographs
• Axial cuts provide the
most information
regarding relationship
of fracture line to Image courtesy of Dr. Raymond Wright, MD

articular surface
CT Evaluation: Acetabulum
A B
• Recognizing patterns
• Axial view
• A.) Column fractures:
Horizontal (coronal)
orientation
• B.) Transverse: Vertical
(sagittal orientation)
• C.) Anterior wall: Oblique C D
• Travels anteriorly and
medially
• ~45 degrees
• D.) Posterior wall: Oblique
• Travels anteriorly and
laterally
Images from Laura Blum, MD
• ~45 degrees
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
Images courtesy of Dr. Raymond
Wright, MD
Suchondral Arc
• Method used to assess
articular continuity8
• 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
Tornetta P 3rd. Displaced acetabular fractures:
• If fracture visualized within top
indications for operative and nonoperative
10mm, considered to involve management. J Am Acad Orthop Surg. 2001 Jan-
the weightbearing dome Feb;9(1):18-28. doi: 10.5435/00124635-200101000-
00003. PMID: 11174160.
CT Evaluation: 3D Recons
• Help to visualize how
the fracture pattern will
appear intra-
operatively
• Can be helpful to plan
reduction maneuvers
and lag screw
placement
• Improves 3D
understanding of
fracture
Images courtesy of Dr. Raymond
Wright, MD
Classification
Algorithm
 Classification Algorithm
• Systematic
Both Disrupted Transverse
approach for Transverse + posterior wall
classifying T-type
Both column
acetabular fractures Anterior column + posterior
based on plain hemitransverse
radiographs Only ilioischial disrupted Posterior column
Posterior column + posterior wall
• AP + judets Only iliopectineal Anterior column
• First step is disrupted
Neither disrupted Posterior wall
determining the Anterior wall
involvement of
ilioischial and
iliopectineal lines
Classification Algorithm:
Both lines disrupted
2. Evaluate obturator ring
1. Both lines disrupted • Intact
• Fracture must be: • Disrupted
• Transverse
• Transverse + posterior 3. Evaluate for
wall involvement of the ilium
• T-type
• Iliac oblique view
• Both column
• Anterior column + 4. Evaluate for spur sign
posterior • Obturator oblique view
hemitransverse
Classification Algorithm: Transvers
e+
Both lines disrupted
Is there a
yes posterior
wall
posterior
wall
fracture? no
yes (obturator Transverse
Both iliopectineal oblique)
and ilioischial Is
Both
lines disrupted obturat Is there a y column
or y spur sign? e
ring no e (obturator s
intact? Is the s oblique)
ilium no
fracture
d? no Anterior colum
posterior
T-type hemitransver
Classification Algorithm:
Only iliopectineal line disrupted
Posterior
column
• If only the ilioischial
line is disrupted
no
• Fracture must be
either:
• Posterior column Only ilioischial Is there a
line disrupted
• Posterior column +
posterior
posterior wall
wall
fracture? y
• Differentiate based on e
presence of posterior s
wall fracture
Posterior
• Obturator oblique
column +
view posterior
wall
Classification Algorithm:
Neither line disrupted Anterior
wall
• If neither iliopectineal Fracture
seen on
or ilioischial line is iliac
disrupted oblique
• Both columns must Neither
ilioischial or
therefore be intact
iliopectineal
• The fracture is either: lines
• Anterior wall disrupted Fracture seen
on obturator
• Posterior wall
oblique
• Evaluate judet views to Posterior wall
determine which
Classification Algorithm:
Only iliopectineal line disrupted

If only the
iliopectineal line is Only iliopectineal
Anterior column
line disrupted
disrupted, the only
possibility is an
isolated anterior
column fracture!
Classification Algorithm: Put it all
together
Both iliopectineal Neither
Only ilioischial
and ilioischial Only
lines disrupted
line disrupted ilioischial or
iliopectineal
iliopectineal
line
lines
disrupted
disrupted
Is
obturat
or Is there a
yes ring posterior
no Anterior column Fracture Fracture seen
intact? wall
seen on on obturator
fracture?
Is there iliac oblique
a Is the no yes oblique
posterio ilium
r wall fracture Posterior column
fracture d? Posterio
yes? yes no r column
+ posterior wall
no
Posterior wall
Anterior
Transver wall
Is there a
se + Transverse spur sign? T-type
posterio
r wall no
yes

Anterior
Both
column +
colu
posterior
mn
hemitransv
Management
 GENERAL PRINCIPLES
• Goal of treatment is to restore joint congruency,
provide fracture stability and prevent osteoarthritis
• Undisplaced fractures are usually stable and can be
managed conservatively
• If the hip is dislocated, reduction is urgent,
followed by the application of skeletal traction until
definitive surgery
• Fractures with more than 2 mm of displacement of
the articular surface should be anatomically
reduced and stabilized
Non-Operative Management
Indications
Non-Operative Management
 PERCUTANEOUS
FIXATION WITH
COLUMN SCREWS
• Indications
• To prevent potential further fracture
displacement and for elderly
patients with displaced acetabular
fractures in whom a less than
anatomic reduction could be
accepted
• Simple fractures with minimal
displacements
• Approach
• Anterograde (from iliac wing to
ramus)
• Retrograde (from ramus to iliac
wing)
• Posterior column screws
Open reduction and internal
fixation : Indications
• patient factors • fracture factors
• < 3 weeks from date of • displacement of roof (>
injury 2 mm)
• physiologically stable • unstable fracture
• adequate soft-tissue pattern (e.g. posterior
envelope wall fracture involving >
• no local infection 40-50%)
• pregnancy is not • marginal impaction
contraindication to • intra-articular loose
surgical fixation bodies
• irreducible fracture-
dislocation
 SURGICAL
APPROACHES
• Posterior Approach (Kocher-Langenbach)
• Indications
• Posterior wall fractures
• Posterior column fractures
• Posterior column/posterior wall fractures
• Juxtatectal/infratectal transverse or transverse
with posterior wall fractures
• Some T-type fractures (more displaced
posteriorly than anteriorly)
• Access
• Entire posterior column
• Greater and lesser sciatic notches
• Ischial spine
• Retroacetabular surface
• Ischial tuberosity
• Ischiopubic ramus
 SURGICAL
APPROACHES
• Posterior
Approach (Kocher-
Langenbach)
• Limitations
• Superior acetabular region
• Anterior column
• Fractures high in greater
sciatic notch
• Trochanteric osteotomy
required to extend exposure
• Complications
• Sciatic nerve palsy
• Infection
• Heterotopic ossification
 SURGICAL
APPROACHES
• Anterior approach (Ilioinguinal)
• Indications
• Anterior wall
• Anterior column
• Transverse with significant anterior
displacement
• Anterior column/posterior hemitransverse
• Associated both columns
• Access
• Sacroiliac joint
• Internal iliac fossa
• Pelvic brim (anterior wall)
• Quadrilateral surface
• Superior pubic ramus
• Limited access to external iliac wing
 SURGICAL
APPROACHES
• Anterior approach
(Ilioinguinal)
• Complications
• Direct hernia
• Significant lateral femoral
cutaneous nerve injury
• External iliac artery thrombosis
• Hematoma
• Infection
 SURGICAL APPROACHES
• Modified Stoppa Approach
• Indications
• Anterior wall
• Anterior column
• Transverse with significant anterior displacement
• Anterior column/posterior hemitransverse
• Associated both columns
 SURGICAL APPROACHES
• Modified Stoppa Approach
• Access
• Sacroiliac joint
• Internal iliac fossa
• Pelvic brim
• Quadrilateral surface
• Superior pubic ramus
• Limited access to external iliac wing
• Complications
• Rectus hernia
• Hematoma
• Infection
• Obturator nerve palsy
 SURGICAL APPROACHES
• Extended iliofemoral and combined
approach
• Indications
• Transtectal transverse plus posterior wall or
T-shaped fractures
• Transverse fractures with extended
posterior wall
• T-shaped fractures with wide separations
of the vertical stem of the “T” or those
with associated pubic symphysis
dislocations
• Certain associated both-column fractures
• Associated fracture patterns or transverse
fractures operated on more than 21 days
following injury
 SURGICAL APPROACHES
• Extended iliofemoral and combined approach
• Access
• External aspect of the ilium
• Anterior column as far medial as the iliopectineal eminence
• Posterior column to the upper ischial tuberosity
• Complications
• Infection: 2% to 5%
• Sciatic nerve palsy: 3% to 5%
• Heterotopic ossification: 20% to 50% without prophylaxis
Techniques
Factors considered for fixation methodology
• location (column and/or wall) and level (high or low) of the
fracture pattern
• amount of displacement
• marginal impaction
• associated injury
Fixation modalities
• Column fixation strategies
• reconstruction bridging plate and screws
• percutaneous column screws
• cable fixation
• Wall fixation strategies
• bridge plate and screws
• lag screw and neutralization plate
• spring (butress) plate
Timing
Fixation Principles
Primary THR
Post-operative Management
Complications
References
• Rockwood and Greens Fractures in Adults, 9th
edition
• Handbook of Fractures, 6th edition
• Fractures of pelvis and acetabulum 4th edition
• Pevic and acetabular fractures – OTA
• Acetabular Fractures – Axel Ganslen