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Acetabular fracture

Broken bone in acetabular portion of hip bone

Field	Value
name	Acetabular fracture
image	AcetabularfracX.png
caption	Acetabular fracture as seen on plain X-ray

Fractures of the acetabulum occur when the head of the femur is driven into the pelvis. This injury is caused by a blow to either the side or front of the knee and often occurs as a dashboard injury accompanied by a fracture of the femur.

The acetabulum is a cavity situated on the outer surface of the hip bone, also called the coxal bone or innominate bone. It is made up of three bones, the ilium, ischium, and pubis. Together, the acetabulum and the head of the femur form the hip joint.

Fractures of the acetabulum in young individuals usually result from a high energy injury like vehicular accident or feet first fall. In older individuals or those with osteoporosis, a trivial fall may result in acetabular fracture.

In 1964, French surgeons Robertt Judet, Jean Judet, and Emile Letournel first described the mechanism, classification, and treatment of acetabular fracture. They classified these fractures into elementary (simple two part) and associated (complex three or more part) fractures.

Judet-Letournel classification

Elementary fracture	Description	Description
Posterior wall	This is the most common variety of acetabular fracture. It typically occurs due to dashboard injury; when a person travelling in a vehicle involved in a head-on collision, the force applied over the flexed knee travels along the femur bone to the head of the femur, breaking the posterior wall of the acetabulum. The head of the femur is dislocated outside the joint.	T shape	When a transverse fracture also had a vertical fracture line, it is called a T shape fracture. Here the innominate bone is broken in such a way that all three parts of it, the ilium, the ischium and the pubis are separated from one another. This is a three part fracture. Though both columns are broken, the weight bearing dome is still attached to the main part of the ilium and hence it is not a true fracture of both columns.
Posterior column	As with posterior wall injury, this also typically occurs due to dash board injury.	Posterior column + Posterior wall	These fractures are extensions of elementary fractures. With the involvement of the posterior wall, the difficulty in treatment increases. These fractures are rarely amenable to non-surgical treatment. Due to posterior wall fracture, the hip is usually dislocated posteriorly, requiring immediate reduction of dislocation and surgical reconstruction after a few days.
Anterior wall	This fracture is uncommon, typically occurring when the injuring force is applied from the side, against the greater trochanter of the femur bone, as in a fall on the side or being hit on the side.	Transverse + posterior wall	These fractures are extension of elementary fractures. With involvement of posterior wall, the difficulty in treatment increases. These fractures are rarely amenable to non-surgical treatment. Due to posterior wall fracture, the hip is usually dislocated posteriorly, requiring immediate reduction of dislocation and surgical reconstruction after few days.
Anterior column	This fracture is uncommon, typically occurring when the injuring force is applied from the side, against the greater trochanter of the femur bone, as in a fall on the side or being hit on the side. Depending on the location, the fractures are described as very low, low, intermediate and high anterior column fracture.	Anterior column + posterior hemi transverse	In this variety of fractures, the posterior or ilio ischial column is broken as a transverse fracture, while the anterior or ilio pubic column is broken into multiple pieces. Part of the weight-bearing dome in this variety of fractures is still attached to that part of the iliac wing, which forms part of the iliac joint. This type of injury has to be differentiated from both column fractures, where the weight-bearing dome is a floating piece not attached directly to the bone-forming sacroiliac joint.
Transverse	In this variety of fracture, the innominate bone is broken such that the upper part consists of ilium with weight bearing dome and the lower part consists of ischium and pubic bones. It typically occurs when the injuring force is applied from the side, against the greater trochanter of the femur bone, as in a fall on the side or being hit on the side. This is a two part fracture, but though both columns are broken, it is not a true both-column fracture, as the weight bearing dome is still attached to main ilium.	Combined both column fractures	These are the most complex injuries. Here the weight bearing roof or dome of the acetabulum is a floating piece. This adds to complexity of management.

Presentation

Associated injuries and complications

The broken bone pieces or the dislocated head of the femur may injure the sciatic nerve, causing paralysis of the foot; the patient may or may not recover sensation in the foot, depending on the extent of injury to the nerve. The posterior wall fragment may be one large piece, or multiple pieces, and may be associated with impaction of the bone. Sciatic nerve injury and stoppage of blood supply to the femoral head at the time of accident or during surgery to treat the injury may occur. Deep vein thrombosis and pulmonary embolism are other complications that may occur in any type of injury to the acetabulum. A common postoperative complication is heterotopic ossification around the injured hip joint.

Anatomy

To understand the fracture pattern of a fractured acetabulum, it is essential to have minimum three x-ray views, though use of CT scan with 3-D reconstruction of images has made understanding of these fractures easier.

Pelvis with both hips antero posterior view. This view shows six important landmarks of the acetabulum, specifically:

Pelvic brim
Ilio ischial line
Tear drop
Anterior wall
Posterior wall
Weight bearing dome

Iliac oblique view. This view shows the whole of the ilium, the posterior column, and the anterior wall
Obturator oblique view. Shows the anterior column and the posterior wall.

[[File:Acet anatomy bone model1.jpg	thumb	White: Anterior column, Red: Posterior column]]	[[File:Acet anatomy bone model obturator view3.jpg	thumb	Obturator view showing Anterior column and Posterior wall]]	[[File:Acet anatomy bone model2.jpg	thumb	Iliac oblique view showing Posterior column and Anterior wall]]

Patterns of fracture

Tile's classification of acetabular fracture:

I - Simple fracture, anterior or posterior wall column
II - Transverse fracture
III - T - Type fracture involving two columns
IV - Both columns fractures, floating acetabulum

Diagnosis

Ideal x-ray visualization of an elementary fracture will depend on the fracture type:

Posterior wall fracture: Iliac oblique and obturator oblique views
Posterior column fracture: Iliac oblique and obturator oblique views
Anterior wall fracture: Iliac oblique view
Anterior column fracture: Obturator oblique view In all cases, CT scan can assist in identifying impacted bone pieces, which may be found within the joint, and MRI may be done to identify the extent of potential injury to the sciatic nerve.

Treatment

If the femur head is dislocated, it should be reduced as soon as possible, to prevent damage to its blood supply. This is preferably done under anaesthesia, following which, leg is kept pulled by applying traction to prevent joint from dislocating.

The final management depends on the size of the fragment(s), stability and congruence of the joint. In some cases traction for six to eight weeks may be the only treatment required; however, surgical fixation using screw(s) and plate(s) may be required if the injury is more complex. The latter treatment will be called for if bone fragments do not fall into place, or if they are found in the joint, or if the joint itself is unstable.

Post-surgery

Depending on the stability achieved via initial treatment, the patient may be allowed to stand and walk with help of support within about six to eight weeks. Full function may return in about three months.

Principles of management

At the site of injury: After stabilizing an injured person and resuscitation, quick examination is done to check injury to vital organs.

If one suspects injury to the hip, it is imperative to immobilise the limb using some kind of support to prevent movements of the injured limb to prevent further damage

A trained paramedic may be able to diagnose hip dislocation by noticing the position of the injured limb. It is essential to document status of nerves and vessels before starting any treatment to protect oneself from litigation

On arrival at the hospital, trained trauma surgeon will assess the patient and prescribe necessary tests including x-rays as described earlier.

Non-surgical management consists of reducing the dislocated joint by maneuver under anaesthesia and applying traction to the limb to maintain position of joint and fractured bones. If non surgical management is preferred it may require six weeks to 3 months for recovery.

Surgical management

The surgical management requires high degree of training and well equipped centre. It should be carried out by experienced surgical team to get best results. The principles laid down for management are;

Anatomic reduction of the fractured fragments
Stable fixation
Congruent joint
Early mobilization
Delayed weight bearing Innominate bone is a flat bone with many curves. In most part the bone is thick enough and has broad surfaces that are amenable to primary fixation using lag screw(s) and to neutralize forces across the bone one needs to add plate(s) on the surface of the fractured fragments for it to heal without deformity.

Before surgery, patient needs tests to check fitness for surgery

Anaesthesia : the surgery may be performed either under regional anaesthesia or general anaesthesia

Surgical approaches. Following are the common approaches;

Kocher Langenbeck approach for posterior injuries
Ili inguinal, Ilio femoral of modified stoppa's approach for anterior or combined injuries Implants : normally lag screws and reconstruction plates are preferred implants

Post operative management: would involve initial period or bed rest, followed by mobilisation by trained therapist

Total time to recover may be up to 3 months

Elderly patients have worse outcomes than other populations. Studies show that over 20 percent will require subsequent total hip arthroplasty.

Gallery

|File:Acetabular Fracture CT.png|Axial CT image (viewed on bone windows) of a complex comminuted left acetabular fracture involving both anterior and posterior columns. |File:AcetabFracSagMark.png|Fracture of the acetabulum

Elementary fractures

| File:Acet High Ant Column 01.jpg|High anterior column fracture 3 D CT scan picture | File:Acet High Ant Column 02.jpg|High anterior column fracture after fixation with screws and plates

| File:Acet Transverse 01.jpg|Transverse fracture showing upper iliac fragment, lower ischial and pubic fragment | File:Acet Transverse 02.jpg|Transverse fracture fixed with screws and plate

Associated fractures

| File:Acet tshape02.jpg|T shape fracture shown on bone model | File:Acet tshape AP.jpg|X-ray of T shape fracture

| File:Acet Post Lip column 01.jpg|Posterior column and wall fracture as seen on 3D CT | File:Acet Post Lip column 02.jpg|Posterior column and wall fixed using screws and plates

References

6.	Tile M, Schatzker J. Rationale of operative fracture care. Berlin, Heidelberg, New York; Springer -Verlag. 1987.

References

Solomon, APLEY'S TRAUMA AND ORTHOPAEDICS, EIGHTH EDITION
Stibolt RD Jr, Patel HA, Huntley SR, Lehtonen EJ, Shah AB, Naranje SM. (Jun 2018). "Total hip arthroplasty for posttraumatic osteoarthritis following acetabular fracture: A systematic review of characteristics, outcomes, and complications". Chin J Traumatol.
Daurka JS, Pastides PS, Lewis A, Rickman M, Bircher MD. (Feb 2014). "Acetabular fractures in patients aged > 55 years: a systematic review of the literature". Bone Joint J..

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