Fractures of the Pelvis and Acetabulum

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The transverse and posterior wall fractures often require blood transfusion.

Both column fractures, T-shaped fracture, fracture with extension into the sciatic notch and those fracture associated with pelvic injury are more likely to have greater blood loss and may need blood transfusion [ 11 ]. Accurate classification of acetabular injury is important for its proper treatment. Various classification system have been suggested because of the complex anatomy of the acetabulum. Judet and Letournel classification is the most widely accepted and commonly used classification. Radiograph provides most of the essential information for classifying acetabular fractures.

Computerized tomography with 3D reconstruction imaging is also useful in classifying acetabular fractures [ 12 , 13 , 14 , 15 , 16 ]. The acetabulum is an incomplete hemispherical socket with an inverted horseshoe shaped articular surface surrounding the non-articular cotyloid fossa.

Fractures of the Pelvis and Acetabulum

The anterior and posterior walls are extensions of the respective column and forms the cup of the acetabulum [ 16 , 17 , 18 ]. The anterior column is longer and larger and composed of iliac crest, iliac spine, anterior half of the acetabulum and pubis. The posterior column extends superiorly from the ischiopubic ramus and consists of ischim, ischial spine and the posterior half of the acetabulum and the dense bone forming the sciatic notch.

The anterior and the posterior columns meet at the sciatic buttress. The sciatic buttress extends posteriorly from anterior and posterior column to become the articular surface of the sacroiliac joint thus connecting the columns with the axial skeleton. The roof dome of the acetabulum is the weight bearing area that supports the femoral head.

The quadrilateral plate is flat thin bone which is forming the medial wall of acetabulum. The iliopectineal eminence is the prominent part in the anterior column that lies directly over the femoral head. Columns of acetabulum. Blue—Posterior column. Green—Anterior column. Red—Sciatic buttress. The radiographic evaluation of the acetabulum includes an anterio-posterior AP view and Oblique Judet views [ 19 ].

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Minimal individual variations of the normal articular area can be visualized by comparing the anatomical landmarks of both hips. For example, comparison of the medial clear space between the head and tear drop will give a clue regarding femoral head subluxation. The iliopectineal line represents the anterior column and ilioischial line represents the posterior column.

A line joining the lateral edge of sourcil to lateral edge of the inferior tear drop represents the anterior wall and a line representing the lateral edge of superior acetabulum to the lateral sclerotic area in the inferior margin of acetabulum represents the posterior wall [ 20 ]. In the AP radiograph, we have to look into certain radiological landmarks.

Iliopectineal line. Tear drop formed laterally by inner wall of acetabulum and medially by quadrilateral plate. The iliac oblique view will clearly show anterior wall and posterior column, quadrilateral surface and posterosuperior roof arc. The obturator oblique view will show posterior wall, anterior column and anteriosuperior roof arc. The obturator ring represents parts of both columns, and fracture of the obturator ring may be associated with other pelvic injuries like lateral pelvic compression injury or sacral fracture. Evaluation of the acetabular fracture is made easier by both 2D and 3D CT scan [ 21 ].

The entire pelvis is usually included in the tomogram to avoid missing a fracture and comparison of the opposite side. The newer spiral CT scan of 1. The 3D reconstruction view will help the surgeon to understand the fracture pattern and its anatomical location inter-operatively. Fracture lines in sagittal and coronal planes, marginal impaction, intra-articular loose fragments, concentricity of the reduction, rotation of the articular fragment and other associated pelvic injuries can be very well visualized in CT scan.

Fracture lines in the sagittal plane represent transverse and wall fractures. Fracture lines in the coronal plane represent column fracture and the vertical limb of T-fracture. Magnetic resonance imaging MRI has no value in the immediate evaluation or classification, but is useful in determining the vascularity of femoral head at a later date [ 22 ]. The universally accepted classification of acetabular fracture was described by Judet and Letournel in and later modified by Letournel [ 12 , 14 ].

This classification helps the surgeon to approach acetabular fracture in a more anatomical and fracture biomechanics. The Orthopaedic Trauma Association OTA modified Letournel classification and gave computerized coding according to AO comprehensive classification of fractures of long bones [ 23 ]. According to Judet and Letournel classification, acetabular fractures are divided into two basic groups: simple fracture type and complex fracture type. Each group consists of five types. The simple fracture pattern includes isolated anterior and posterior wall fractures, isolated anterior and posterior column fractures and transverse fracture Figure 2.

The Associated fracture pattern includes T-type fracture, combined fractures of posterior column and wall, transverse fracture with posterior wall fracture, anterior column with posterior hemitransverse fracture and bicolumnar fracture Figure 3.

Principles and Methods of Management

There is one exception in each group. The transverse fracture in the simple group involves both columns and the anterior column with posterior hemitransverse fracture involves only one column in complex group [ 24 ]. Simple acetabular fractures. Associated fractures. A Posterior wall with posterior column fracture B Transverse with posterior wall fracture C T shaped fracture. D Anterior column with posterior hemitransverse fracture.

E Bicolumn fracture.

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This is the most common type of acetabular fracture. It involves disruption of the posterior wall which can be single or multifragmentary. There can be marginal impaction or acetabular depression fracture commonly associated with the posterior dislocation of the hip joint and radiologically identifiable disruption of the posterior wall with break in the sagittal plane of CT scan. Characterized by disruption of the ischial portion of the pelvis and fracture line usually extends through the sciatic buttress.

Fractures of the Pelvis and Acetabulum by Dr Peter Moore

The fracture line usually extends from obturator foramen to greater sciatic notch through weight bearing dome of the acetabulum. The iliac oblique view shows break in the ilioischial line and displaced articular cartilage along with posterior segment with an intact portion of roof, creating an image resembling a flying bird Gull sign [ 11 ].

In CT scan, fracture line will be seen in the posterior column in the coronal plane of axial section. It involves disruption of anterior wall. The radiograph demonstrate disruption in the iliopectineal line which is best seen in iliac oblique view. CT scan demonstrates fracture in sagittal plane of axial cut.

Pelvic Fractures/Acetabular Fractures

The fracture disrupts iliopectineal line. The fracture line extends from anterior iliac crest to superior pubic ramus disrupting the obturator formen. Obturator oblique view will show fracture line disrupting the anterior column. In high or intermediate anterior column fractures, the roof segment usually displaces medially. CT scan shows fracture in coronal plane in the anterior column of axial section.

This fracture separates acetabulum into two segments transversely. It involves both columns with intact obturator foramen.

This fracture is subdivided into three types according to the level of fracture, namely infratectal, juxtatectal and supratectal [ 11 ] Figure 4. Radiographically, both iliopectineal and ilioischial lines will be disrupted. In CT scan, it is characterized by sagittal-oriented fracture line extending through both columns. Types of transverse fractures. T-shaped fracture is a combination of transverse acetabular fracture with vertical extension into obturator ring distrupting it. Sometimes there is extension of fracture into pubic ramus and ischim.

The vertical fracture component differentiates this fracture from transverse fracture. But the superior extension of the fracture does not involve the iliac wing which is an important point to differentiate this fracture from both column fracture.