Acetabular Fractures

Evaluation, Anatomy and Classification

Muhammad Abdelghani
Normal Anatomy: Columns and
Walls
 From the lateral aspect of the
pelvis, the innominate osseous
structural support of the
acetabulum may be
conceptualized as a two-
columned construct forming an
inverted Y:
1. Anterior column (iliopubic
component): extends from iliac
crest to symphysis pubis and
includes the anterior wall of the
acetabulum.
2. Posterior column (ilioischial
component): extends from
superior gluteal notch to ischial
tuberosity and includes the
posterior wall of the
acetabulum.
 The anterior and posterior walls
extend from each respective
column and form the cup of the
acetabulum.
 The anterior and posterior
columns connect to the axial
skeleton through a strut of bone
called the sciatic buttress.
 When looking at the acetabulum en face, the
anterior and posterior columns have the
appearance of the Greek letter lambda (λ).
 The anterior column represents the longer,
larger portion, which extends superiorly from
the superior pubic ramus into the iliac wing.
The posterior column extends superiorly from
the ischiopubic ramus as the ischium toward
the ilium.
 The anterior and posterior columns of bone
unite to support the acetabulum.
 In turn, the sciatic buttress extends posteriorly
from the anterior and posterior columns to
become the articular surface of the sacroiliac
joint, which attaches the columns to the axial
skeleton.
 The anterior and posterior walls, which extend
from the columns and support the hip joint, are
well seen on an axial CT.
 The anterior and posterior walls, which extend
from the columns and support the hip joint, are
well seen on an axial CT.

Axial section
through
acetabulum
shows anterior
(arrowhead)
and posterior
(arrow) walls.
Acetabular dome: The superior weight-bearing
portion of the acetabulum at the junction of
the anterior and posterior columns, including
contributions from each.
Anterior
coulmn

Sciatic
buttress

Posterior
column
Anterior column in white, posterior column
in red
Mechanism of injury

Like pelvis fractures, these injuries are

mainly caused by high-energy trauma
secondary to a motor vehicle, motorcycle
accident, or fall from a height.
Mechanism of injury

The fracture pattern depends on

 Position of femoral head at the time of injury,
 Magnitude of force, &
 Age of patient.
Mechanism of injury

Direct impact to greater trochanter with:

 Hip in neutral: transverse acetabular fracture
 An abducted hip: low transverse fracture,
 An adducted hip: high transverse fracture.
 Hip externally rotated and abducted:
anterior column injury.
 Hip internally rotated: posterior column
injury.
Mechanism of injury

With indirect trauma, (e.g., a ‘dashboard’

injury to the flexed knee):
 As the degree of hip flexion increases, the posterior
wall is fractured in an increasingly inferior position.
 Similarly, as the degree of hip flexion decreases,
the superior portion of posterior wall is more likely
to be involved.
 Clinical evaluation
 Trauma evaluation: with attention to ABCD, depending on the
mechanism of injury.
 Patient factors (age, degree of trauma, presence of associated
injuries, & general medical condition) affect treatment
decisions as well as prognosis.
 Neurovascular assessment:
 Sciatic nerve injury may be present in up to 40% of posterior column
disruptions.
 Femoral nerve involvement with anterior column injury is rare,
although compromise of the femoral artery by a fractured anterior
column has been described.
 Presence of associated ipsilateral injuries must be ruled out,
with particular attention to the ipsilateral knee in which
posterior instability and patellar fractures are common.
 Soft tissue injuries (e.g., abrasions, contusions, subcutaneous
hemorrhage) may provide insight into the mechanism of injury.
 Radiographic evaluation
 5 Pelvic X-rays:
 AP view
 2 Judet views (iliac &
obturator oblique views)
 Inlet and Outlet Pelvis X-rays
 CT scan
 Anatomic landmarks in AP
view
 Iliopectineal line (limit of anterior
column),
 Ilioischial line (limit of posterior
column),
 Anterior lip,
 Posterior lip,
 Line depicting the superior
weight-bearing surface,
terminating as the medial
teardrop.

Anatomic landmarks in AP view
 Teardrop

 Internal limb = outer

wall of obturator canal
 External limb = middle
1/3 of cotyloid fossa
 Inferior border =
ischiopubic notch
Iliac oblique radiograph
(45-degree external rotation view)

 Taken by rotating the

patient into 45° of external
rotation by elevating the
uninjured side on a wedge.
 This best demonstrates:
 Posterior column (ilioischial
line),
 Iliac wing,
 Anterior wall of acetabulum.
 Iliac-oblique view

1. Border of sciatic
notch
2. Anterior wall
3. Posterior column
4. Iliac wing
5. Posterior wall
Iliac oblique radiograph
Obturator oblique radiograph
(45-degree internal rotation view)

 This is best for evaluating

the anterior column and
posterior wall of the
acetabulum.
 Taken by elevating the
affected hip 45° to the
horizontal by means of a
wedge and directing the
beam through the hip joint
with a 15° upward tilt.
 Obturator-oblique view

1. Ilio-pectineal line.
2. Posterior wall
3. Anterior half of the
joint
4. The iliac wing
profile (the spur
sign site)
Obturator oblique radiograph
AP pelvis Iliac oblique Obturator oblique

AW—anterior wall;
AC—anterior column;
PC—posterior column;
PW—posterior wall;
OR—obturator ring.
Inlet Pelvis X-ray
 Skeletal anatomy
represented on inlet
view
Outlet Pelvis XR
Skeletal anatomy represented on outlet view
Radiological
Study
 Radiographic evaluation
 CT scan
 Provides additional information regarding size
& position of column fractures, impacted
fractures of acetabular wall, retained bone
fragments in the joint, degree of comminution,
and sacroiliac joint disruption.
 Two- and three-dimensional CT scans are
useful in evaluating intra-articular fragments as
well as specific morphologic characteristics of
any given fracture pattern.
 Radiographic evaluation
 CT scan
 Before a 3-dimensional CT
scan is ordered, the fracture
patterns should be drawn on a
3-dimensional model of the
pelvis to compare the 3-
dimensional reconstructions.
 Three-dimensional
reconstruction allows for
digital subtraction of femoral
head, with full delineation of
the acetabular surface.
CT scan transverse cuts through the acetabulum.
3-D CT scan of a both- 3-D CT scan of a both-
column acetabular column acetabular fracture;
fracture; obturator iliac oblique view
oblique view
Line drawing of fracture on a pelvic
model
 Classification

 Accurate classification of acetabular fractures is

important for determining the proper surgical
treatment.
 Although radiographic examination provides
essential information for acetabular classification,
CT, including multiplanar reconstruction, is
helpful in the visualization of complex fractures.
 Classification
(Judet-Letournel)

 Because of the complex acetabular anatomy, various

classification schemes have been suggested, but the
Judet-Letournel classification system remains the
most widely accepted.
 This classification system subdivides acetabular
fractures into
 Elementary Fracture Types (posterior wall, posterior
column, anterior wall, anterior column and transverse)
 Associated Fracture Types (T-shaped, posterior column and
wall, anterior wall or column with posterior hemitransverse,
and both column).
 Classification
(Judet-Letournel)

Elementary fractures
 Poserior wall
 Posterior column
 Anterior wall
 Anterior column
 Transverse
 Classification
(Judet-Letournel)

Associated fractures
 T-shaped
 Posterior column + posterior wall
 Transverse + posterior wall
 Anterior column + posterior
hemitransverse
 Both-column
 Elementary types

Post wall Post column Ant wall Ant column Transverse

 Post. column

Post. wall Transverse

Ant. wall

Othopaedic Review Course

www.pelvisandhip.com Ant. columnJanuary 2010
Classifications
Classification algorithm for 5
common acetabular fractures
Posterior wall fractures

 The isolated posterior wall

fracture is one of the most
common types of acetabular
fracture, with a prevalence of
27%.
 The ischium is disrupted.
 The fracture line originates
at the greater sciatic notch,
travels across the
retroacetabular surface, exits
at the obturator foramen.
 The ischiopubic ramus is
fractured.
 Posterior column fractures

 An isolated posterior wall fracture does not

have a complete transverse acetabular
component.
Therefore, the iliopectineal line is not disrupted,
which excludes classification of the transverse
with posterior wall fracture.
 However, disruption of the ilioischial line may or
may not be present as an extension of the
comminuted posterior wall component.
 Oblique (Judet) radiographs and CT are helpful
in showing the isolated posterior wall fracture.
 AP pelvic radiograph

Bilateral oblique
pelvic radiographs

Axial CT
images

18-year-old man with isolated posterior wall acetabular fracture

 Parasagittal
reconstruction CT
image

18-year-old man with isolated posterior wall acetabular fracture

 Posterior column fractures

 Posterior wall and posterior

column fractures can be
distinguished easily.
 In a posterior column fracture, the
ilioischial line is interrupted.
 In a posterior wall fracture, only
the retroacetabular surface is
disrupted.
Posterior Column Fracture
 Anterior wall and anterior
column fractures
 Anterior wall and anterior column
fractures can be distinguished by
the additional break in the
ischiopubic segment of the pelvis
present in the anterior column
fracture.
Anterior Wall Fracture
Anterior Column Fracture
Transverse Fracture

A transverse acetabular fracture

involves a fracture line that goes
through both columns of the
acetabulum, but a portion of the
dome of the acetabulum remains
attached to the constant
fragment of the iliac wing.
 Obturator oblique Iliac oblique view
view of transverse of transverse
fracture fracture
 Transverse Fracture
Types (depending on the orientation of the fracture line relative to the
dome or tectum of the acetabulum):
1. Transtectal: through the acetabular dome.
2. Juxtatectal: through the junction of acetabular dome &
fossa acetabuli.
3. Infratectal: through the fossa acetabuli.

Transtectal fractures are less forgiving and must be

reduced anatomically, whereas infratectal fractures, if
low enough, can be treated without surgery,
depending on the pattern.

The femoral head follows the inferior ischiopubic

fragment and may dislocate centrally.
Infratectal Juxtatectal Transtectal
 AP pelvic radiograph

Bilateral oblique pelvic

radiographs

Axial CT scan

surface-
rendering
3D CT
viewed
laterally,
with right
hemipelvis
and femur
removed

23-year-old woman with transverse acetabular fracture

 Transverse Fracture

Transverse fractures are sagittal plane

fractures whereas both column
fracturesare coronal plane fractures.
A. Coronal plane fracture
B. Sagittal plane fracture
CT cut of transverse fracture
in the sagittal plane
 Associated types

Post. Wall Transverse & Ant column or

& post. post. Wall or Both
T-shaped wall & post
column column columns
hemitransverse
 T-fracture Transverse/post.wall Ass.both.column

Post.wall/post.column Ant.post.hemitrans.

Othopaedic Review Course

January 2010
Posterior Column-Posterior Wall
T-shaped fracture

Transverse fracture of any type

+
Vertical fr through the isciopubic fragment

The vertical component is best

seen on the obturator oblique
view.
T-shaped fracture
The T-shaped fracture is
similar to a both-column fracture
in that it disrupts the obturator
ring.

Another similarity is disruption of

both the iliopectineal and
ilioischial lines.

However, the superior extension

of the fracture does not involve
the iliac wing, which allows
differentiation from the both-
column fracture.
 T-shaped fracture
One area of potential confusion with the Tshaped
fracture is in regard to the transverse component.
The transverse fracture line is not actually in the
anatomic transverse plane, but rather it is
transverse relative to the acetabulum.
Because the cup shape of the acetabulum is
normally tilted inferiorly and anteriorly, the
transverse fracture plane assumes a similar
orientation.
Therefore, on radiographs, the fracture lines that
disrupt the iliopectineal and ilioischial lines course
superiorly and medially in an oblique plane from
the acetabulum.
This is best appreciated by looking at the
acetabulum en face.
On CT, this transverse fracture component is
seen as a sagittally oriented fracture coursing
medially and superiorly from the acetabulum.
 T-shaped fracture
T-type fractures differ from transverse fractures by the additional
fracture line that runs through the quadrilateral surface.

As a result, the anterior column and posterior column are

separated by fracture lines.

This becomes important when choosing a surgical approach to

the acetabulum.

In a pure transverse fracture, the anterior and posterior columns

may be reduced through a single approach.

Once the anterior column has been reduced, the posterior

column will follow the reduction and can be palpated indirectly.
 Radiograph of
a T-type
fracture.
 Note the
undisplaced
fracture in the
ischiopubic
ramus.
 This break in the
obturator ring
correlates with
an additional
fracture line in
the
quadrilateral
plate.
 T-shaped fracture

In a T-type fracture, the 2 columns must

be reduced independently.

This becomes extremely important when

choosing a surgical approach; therefore,
it is important to recognize the subtle
difference between transverse and T-type
fractures when they are not significantly
displaced.
2-D CT cut of T-type fracture
Note in the T-type fracture the anterior
and posterior columns are disassociated
 AP pelvic radiograph

Bilateral oblique pelvic

radiographs

Axial CT scan

Surface-rendering 3D CT viewed laterally, with right

hemipelvis and femur removed

40-year-old man with T-shaped acetabular fracture

 Transverse and
posterior wall fracture
Transverse fracture
+
Comminuted posterior wall
fracture (usually displaced)

The iliopectineal and

ilioischial lines are
disrupted.

The obturator oblique view

best demonstrates the
position of the transverse
component as well as the
Transverse and posterior wall
fracture
 AP pelvic radiograph

Bilateral oblique pelvic

radiographs

axial
CT
scan

surface-
rendering
3D CT
viewed
laterally,
with right
hemipelvis
and femur
removed

20-year-old man showing transverse with posterior wall acetabular

fracture
Anterior Column-Posterior
Hemitransverse
 Both-column fracture
(formerly called ‘central acetabular fracture’)
Both columns are separated from
each other and from the axial
skeleton, resulting in a ‘floating’
acetabulum

This is the most complex type of

acetabular fracture.

A both columns fracture can be

considered a ‘high’ T-shaped
fracture where both columns have
been separated from the sciatic
buttress.
 Both-column fracture
(formerly called ‘central acetabular fracture’)

The "spur-sign," best seen on the

obturator oblique view, is
pathognomonic for the both-column
fracture.
This sign represents posterior
displacement of the sciatic buttress
of the iliac wing fracture, which
essentially disconnects the roof of
the acetabulum from the axial
skeleton.
When this occurs, weight from the
torso and upper body can no
longer be supported by the "Spur-sign" seen on the
acetabulum. obturator oblique view
 Both-column fracture
(formerly called ‘central acetabular fracture’)

On radiographs and CT, the

spur sign appears as a shard
of bone extending posteriorly
at the level of the superior
acetabulum.
Evaluation of sequential CT
images shows the fracture,
which separates the sciatic
buttress from the acetabular
roof.
 35-year-old man with a both-column fracture
Oblique pelvic radiograph (A) and axial CT image (B) show
spur sign (arrow), which represents displacement of fracture
involving sciatic buttress (arrowheads).

Note that sciatic buttress (arrowheads, B) no longer connects

to weight-bearing portion of acetabulum.

A B
 AP pelvic radiograph

Bilateral oblique pelvic radiographs

sagittal
Axial CT scan reconstruction
CT scan

45-year-old man with both-column acetabular fracture

3-D CT scan of a both-column acetabular fracture; obturator
oblique view
3-D CT scan of a both-column acetabular fracture; iliac oblique view
Line drawing
of fracture on
a pelvic
model
Cases
Case 1
 Disrupción del anillo
obturador + extensión a
pala iliaca  FRACTURA
BICOLUMNARIA
Case 2
 Disrupción del anillo
obturador + SIN extensión
a pala iliaca  FRACTURA
en “T”
 Classification
(The Comprehensive Classification of Fractures of the
Acetabulum)

 Subsequent to the pioneering work of Judet and Letournel,

their classification was then used as the basis for formulating
an alphanumeric computerized format and the Comprehensive
Classification of Fractures of the Acetabulum was developed.
 This effort was spearheaded by SICOT International
Documentation and Evaluation Committee and the AO/ASIF
Foundation under the leadership of Maurice E. Muller.
 Each fracture is classified according to morphological
characteristics, and subdivided into types, groups, and
subgroups.
 The system is especially beneficial for research database
applications.
The Comprehensive Classification of Fractures of the Acetabulum
 References

 Durkee NJ, Jacobson J, Jamadar D, Karunakar MA,

Morag Y, Hayes C: Classification of Common
Acetabular Fractures: Radiographic and CT
Appearances. AJR 2006; 187: 915-925
 Gänsslen A, Oestern HJ: Azetabulumfrakturen. Chirurg
2011; 82:1133–1150
 Jimenez ML: Classification of Acetabular Fractures.
Medscape.com
 Pagenkopf E, Grose A, Partal G, Helfet DL: Acetabular
Fractures in the Elderly: Treatment Recommendations.
HSSJ (2006) 2: 161–171