ota resident core curriculum: radiographic evaluation ...–exits greater sciatic notch with...
TRANSCRIPT
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OTA Resident Core Curriculum:
Radiographic Evaluation, Anatomy
and Classification of Acetabular
Fractures
Paul W. Perdue Jr., MD
April 2016
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Anatomy and Osteology of the
Acetabulum• Judet and Letournel
– JBJS 1964: “Fractures of the Acetabulum:
Classification and Surgical Approaches for Open
Reduction”
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Anatomy and OsteologyIliac
wing
and
fossa
ASIS
AIIS
Pubic
tubercle
Iliopectineal
eminence
Ischiopubic ramus
Sacro-iliac
joint
Sacral nerve
foramen
Sacral ala
Obturator foramen Paul Perdue, MD
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Anatomy and Osteology
ASIS
AIIS
Posterior rim
Anterior
rim
Anterior
column /
iliopectineal
line
Iliopectineal
eminence
Pubic
tubercles
Iliac
wing
Ischiopubic ramus Obturator foramenCotyloid fossaPaul Perdue, MD
Psoas gutter
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Anatomy and Osteology
Greater
sciatic notch
Ischial spine
Quadrilateral
surface
Pelvic
brim
Lesser sciatic notchPubic tubercle
AIIS
Iliopectineal
eminence
Paul Perdue, MD
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Anatomy and Osteology
Paul Perdue, MD
Pubic tubercle
Iliopectinea
l eminence
AIIS
ASIS
Obturator
canal
Obturator
foramen
Ischial spine
Quadrilateral
surface
Pelvic brim
Greater sciatic
notch
Sacro-iliac
articulation
Psoas gutter
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Anatomy and Osteology
• Judet and Letournel
– Inverted “Y” 2 column concept
Anterior
column
Posterio
r
column
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Osteology and Muscle Origins
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Osteology
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Posterior Column
(Ilio-ischial column)
• Internal surface: quadrilateral plate continuous with inner surface of ischial spine
• Posterior surface: convex area comprising retro-cotyloidsurface (part of posterior wall); sub-cotyloid groove (obturator externus tendon) and ischial tuberosity
• Antero-lateral surface: posterior part of acetabular articular surface superiorly; body of ischium inferiorly
• Posterior border formed by posterior edge of innominate bone with greater and lesser sciatic notches separated by ischial spine
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Posterior Column
Posterior Column Paul Perdue, MD
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Anterior Column
(Ilio-pubic column)
• Extends from anterior iliac crest to pubic
symphysis
• 3 segments:
– Iliac
– Acetabular
– Pubic
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Iliac Segment
• Anterior aspect of iliac wing
• Anterior border marked by ASIS and AIIS
• 2 surfaces
– Pelvic surface
• Concave superior to inferior and extends to ilio-
pectineal line
– External surface
• Roughened and forms large part of gluteal surface
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Acetabular Segment
• Postero-lateral surface:– Supports anterior articular segment and front of
cotyloid fossa
• Internal surface: – Formed by anterior aspect of quadrilateral surface and
extends to the obturator canal
• Antero-superior surface:– Gutter of ilio-psoas tendon below AIIS and ilio-
pectineal eminence; inferior limit of ilio-pectineal eminence is at same level as anterior horn of acetabulum
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Pubic Segment
• Superior pubic ramus
– Antero-superior surface:
• Pectineus m. insertion
• Spiral configuration bounded posterior by brim of true pelvis
• Medial insertion of rectus abdominus m.
– Internal surface:
• Concave posterior and superior
– Inferior surface:
• Roof of obturator canal, anterior limit ends at pubic spine
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Anterior Column
Anterior Column Paul Perdue, MD
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Vascular Anatomy
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Obturator Artery Variation
CORONA MORTISCourt-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Vascular Anatomy
• Ascending Branch of Medial femoral circumflex artery:
– Main blood supply to femoral head
– Deep to quadratus femoris, obturator internus, and piriformis
– Superficial to obturator externus
Copyright by AO Foundation, Switzerland; "Fractures of the Pelvis and Acetabulum—Principles and Methods of Management- 4th Edition”
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Vascular Anatomy
• Superior Gluteal artery:
– Exits greater sciatic
notch
– May be lacerated
secondary to injury or
during superior/lateral
retraction during
Kocher-Langenbeck
approach
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Neural Anatomy
• Sciatic nerve:
– Most commonly injured (traumatic and iatrogenic)
– Variable proximal anatomy at level of piriformis
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Neural anatomy
• Superior gluteal nerve:
– Exits greater sciatic notch with superior gluteal artery
– May be lacerated secondary to injury or aggressive retraction
• Inferior gluteal nerve:
– Innervates gluteus maximus m.
– Branches innervating superior 1/3 located halfway between PSIS and greater trochanter
– Proximal and superior extension of KL approach may cause iatrogenic injury
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Mechanism of Injury
• Fractures caused by forces that drive femoral head into the acetabulum– Damage to articular surface of femoral head and
acetabular surface
• Type of fracture depends on the position of the femoral head within acetabulum on impact AND the direction of the force
• Variables affecting type of fracture– Sitting position, impact, axis of loading, internal vs
external rotation , abduction vs adduction, and flexion vs extension
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Mechanism of Injury
Copyright by AO Foundation, Switzerland; "Fractures of the Pelvis and Acetabulum—Principles and
Methods of Management- 4th Edition”
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Radiographic Evaluation of the
Acetabulum
• Radiological lines are produced by rays
tangential to a bony surface or crossing a
border
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Radiographic Evaluation
• Anteroposterior pelvis
• Judet views
• CT scan +/- 3D reconstructions
• Fluoroscopic dynamic stress exam
OUT OF
TRACTION
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Anteroposterior Pelvis• Associated pelvic
ring injuries
• Bilateral acetabular
fx’s
• Femoral head fx’s
• Fx displacement
• Congruency of
femoral head within
acetabulum
David Helfet, MD
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DON’T FORGET TO LOOK FOR ASSOCIATED PELVIC RING INJURIES ON AP VIEW
David Helfet, MD
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AP Pelvic Radiographic
Landmarks
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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AP Pelvic Radiographic
Landmarks
1) Iliopectineal line➔anterior column
2) Ilioischial line➔posterior column
3) Teardrop➔cotyloid fossa and quadrilateral
surface/obturator canal; column involvement
4) Sourcil➔ acetabular roof;
anterior/posterior column
5) Anterior rim➔anterior wall/column
6) Posterior rim➔posterior wall/column
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AP Pelvis
• Iliopectinal line:
– Anterior ¾ (pubic symphysis to ilioischial line):
radiological pelvic brim and anatomical brim
correlate
– Posterior ¼: lower half of sciatic buttress and
roof of sciatic notch
• Ilioischial line:
– Quadrilateral surface
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Iliopectineal and Ilioischial Lines
David Helfet, MD
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AP Pelvis
• Teardrop/Radiologic “U”:
– Lower border➔ischipubic notch/superior obturator foramen
– External limb➔tangential to middle 1/3rd cotyloid fossa
– Internal limb➔confluence of outer wall obturator canal and quadrilateral surface
• Internal and external limbs are not in same coronal plane
– Variation in shape among patients
– Most case the limbs are parallel and form a “U”
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Radiologic “U” or teardrop
David Helfet, MD
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AP Pelvis
• Sourcil/Acetabular roof:
– Superior weight bearing portion of acetabulum
– 45-60 degree arc
• Anterior/Posterior walls:
– Extensions of the articular surface
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Sourcil and Anterior/Posterior Walls
David Helfet, MDDavid Helfet, MD
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Judet Oblique Radiographs
• Iliac oblique and obturator oblique
– 45 degree oblique views
– Plane of ilium roughly 90 degrees to plane of
obturator foramen
– Demonstrates column anatomy
– Tip of coccyx should be above center of
cotyloid fossa/femoral head
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Obturator (Internal) Oblique
• Injured side bumped up 45 degrees
• Obturator foramen/ring visualized fully
• Visualization of:
– Pelvic brim
– Anterior column
– Posterior wall
– Demonstrates posterior fracture dislocations
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Obturator Oblique
David Helfet, MD
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Iliac (External) Oblique
• Injured side down/good side bumped up 45
degrees
• Iliac wing visualized fully
• Visualization of:
– Posterior column
– Anterior wall
– Posterior border of innominate bone
– Quadrilateral plate
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Iliac Oblique
David Helfet, MD
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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CT Imaging
• Useful adjunct to radiographic imaging
• Not a replacement for good quality
AP/oblique radiographs
• 2-3mm cuts
• Utilize the CT to better interpret the plain
radiographs and understand the fracture
lines
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CT Imaging• Acetabular wall fractures
• Intra-articular fragments
• Marginal impaction
• Comminution
• Femoral head lesions
• Joint congruence
• Evaluation of posterior
pelvic ring
“Rockwood and Green’s Fractures in Adults-8th Edition”
David Helfet, MD
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2-D CT Imaging
Column
fracture
Transverse
fracture
Anterior
Wall
Posterior
WallCourt-Brown, C. et al. Rockwood & Greens Fractures in Adults.
Philadelphia: Lippincott Williams & Wilkins, 2014
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2-D CT
Column fx lineTransverse fx
line
Wall fx lineDavid Helfet, MD
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3-D CT
• Creates a realistic 2-D image that conveys 3-D relationships
• 3-D images present findings of a study that are easier to interpret for less-experienced
• May help with pre-operative planning and as teaching tool
• Allows for rotation and osseous subtraction
• Limitations of detail based on averages used to construct 3-D images
• STILL NOT AS ACCURATE AS PLAIN 2-D CT FOR EXAMINING MARGINAL IMPACTION, SUBTLE FRACTURE LINES, OR SMALL OSSEOUS FRAGMENTS IN JOINT
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3-D CT
David Helfet, MD
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3-D CT
David Helfet, MD
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Surface versus Volume Rendered 3-
D CT Imaging• Surface rendered:
– Demonstrates gross 3-D anatomy most effectively
– MORE ARTIFACT; simplifies data to binary form
– Does not demonstrate lesions/pathology hidden behind or underneath overlying bone cortex
• Volume rendered:– Little artifact; accurately depicts reality
– Incorporates all of the data of the contained volume into the displayed image
– Demonstrates sub-cortical lesions and minimally displaced fractures better than surface rendered
– Ability to demonstrate 3-D relationship varies based on degree of surface shading/opacity
– Increased cost
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Surface Rendered 3-D CT
David Helfet, MD
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Volume Rendered 3-D CT
David Helfet,
MD
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Volume Rendered 3-D CT
David Helfet, MD
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Surface vs Volume Rendering
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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CT-simulated XR
David Helfet, MD
• Opaque volume rendered
• Possible replacement for traditional plain radiographs
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Roof Arc Measurements
• Matta (1986)
• Angle between vertical line through
femoral head and line through fracture site
on all 3 views
• Used to determine whether fracture line
has violated weight bearing dome
• Determines if remaining intact acetabulum
can maintain a stable and congruent joint
• Marker of non-operative vs operative
treatment
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Roof Arc Measurements
• Medial, anterior, and posterior roof arcs– Arcs are lines that represent the portion of the subchondral bone tangent to the XR beam in the AP, obturator oblique, and iliac
oblique projections
Copyright by AO Foundation, Switzerland;
"Fractures of the Pelvis and Acetabulum—
Principles and Methods of Management- 4th
Edition”
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Roof Arc Measurement• Roof arcs
– Medial arc >30 degrees on AP
– Anterior arc >40 degrees on obturator oblique
– Posterior arc >50 degrees on iliac oblique
• Associated Both Column and Posterior wall➔DOES NOT APPLY
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Revised Roof Arc Measurements
• Vrahas et al. JBJS 1999– Biomechanical study, sufficient acetabulum with:
• Medial roof arc >45 degrees
• Anterior roof arc >25 degrees
• Posterior roof arc >70 degrees
• Matityahu et al. JOT 2012– Biomechanical study, sit to stand loads higher than
single leg stance and require:• Medial roof arc >90.9 degrees
• Anterior roof arc >67.3 degrees
• Posterior roof arc >101.4 degrees
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Failure of Roof Arc
Measurement
Court-Brown, C. et al. Rockwood & Greens
Fractures in Adults. Philadelphia: Lippincott
Williams & Wilkins, 2014
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Subchondral Roof Arc on CT
• Olson and Matta JOT 1993
– Superior 10mm of the acetabular articular
surface evaluates an area equivalent to the 45
degree roof arc measurements
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Subchondral Roof Arc on CT
Copyright by AO Foundation, Switzerland; "Fractures of the Pelvis and Acetabulum—Principles
and Methods of Management- 4th Edition”
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Dynamic Fluoroscopic Stress
Examination• Various methods to determine posterior wall stability:
– Calkins
– Keith
– Moed
• Historically if fragment <20% (stable), 20-50% (indeterminate stability) and >50% (unstable)
• Recent literature has demonstrated that wall size <20% is not a reliable indicator of stability
• If stable per EUA a non-operatively treated PW acetabulum fx maintains congruity and leads to good to excellent early clinical and functional outcomes (McNamara et al. JOT 2015)
Copyright by AO Foundation, Switzerland; "Fractures of the Pelvis and Acetabulum—Principles and Methods of
Management- 4th Edition”
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EUA Technique (Moed)
• Patient supine on a radiolucent table
• Hip in full extension and neutral rotation
• Hip slowly flexed past 90° with progressive manual force
• Examiner employs entire body weight to axially load the hip
• Hip is visualized using C-arm fluoroscopic imaging
• Performed twice - using AP and obturator oblique views
• If stable, repeat adding 20° adduction and 20° internal rotation
• Posterior subluxation of the femoral head or loss of joint parallelism on either view indicates dynamic hip instability; do not need frank dislocation to diagnose instability
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Posterior Wall Instability during
EUA
Intra-operative views with hip in full extension and 90 degrees of
flexion with neutral rotation demonstrate congruent hip joint. Then the
hip is axially loaded in 90 degrees of flexion demonstrating gross
subluxation and loss of joint congruency
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Acetabular Fracture
Classification
Elementary AssociatedCourt-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Acetabular Fracture
Classification
• Classification system developed by Judet
and Letournel
• Elementary and associated patterns
– Based on column and wall disruptions
• OTA/AO classification (62-A, -B, -C) based
on this system
– Allows for standardization for coding and
research
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OTA Classification
“OTA Fracture and Dislocation Compendium”
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“OTA Fracture and Dislocation Compendium”
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Acetabular Fracture
Classification
• Elementary Patterns
– Anterior wall
– Anterior column
– Posterior wall
– Posterior column
– Transverse
Part or all of ONE column
fractured
Transversely cuts BOTH
columns into upper and
lower segments
Elementary due to
“simplicity” of the fracture
line
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Elementary Fracture Patterns
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Acetabular Fracture
Classification
• Associated Patterns
– Combination of elementary patterns
• Posterior column + posterior wall
• Transverse + posterior wall
• Anterior wall/column + posterior hemitransverse
• T-Type
• Both column
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Associated Fracture Types
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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ELEMENTARY
FRACTURE
PATTERN
EXAMPLES
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Posterior Wall Fractures
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Posterior Wall Fractures
• Most common➔25% of acetabular
fractures
• Separation of posterior articular surface
• Majority of posterior column undisturbed
• Commonly associated with posterior hip
dislocation
• Simple appearance on plain XR
underestimates complexity
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Posterior Wall Fractures
• Fracture subtypes
– Confined below the roof
– Postero-superior
• Part of roof separated
– Postero-inferior
• Detached fragment inferior horn of articular surface,
sub-cotyloid groove, and superior ischium
Copyright by AO Foundation, Switzerland; "Fractures of the Pelvis and Acetabulum—Principles and
Methods of Management- 4th Edition”
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Posterior Wall Fractures
Pure posterior wall
fracture
Posterior wall fracture
with marginal impaction
Copyright by AO Foundation, Switzerland; "Fractures
of the Pelvis and Acetabulum—Principles and Methods
of Management- 4th Edition”
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Posterior Wall Fractures
Capsule disrupted
from wall
fragment➔avascul
ar
Capsule attached
to wall
fragment➔viable
fragment
Capsule attached to
peripheral
fragment➔peripheral
fragment viable and
intercalary fragment
avascularCopyright by AO Foundation, Switzerland; "Fractures of the Pelvis and Acetabulum—Principles and
Methods of Management- 4th Edition”
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Posterior Wall Fractures
AP radiograph
Disruption of posterior wall/rim
Femoral head dislocation
David Helfet, MD
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Posterior Wall Fractures• Be aware that
sometimes the
femoral head will be
or appear to be
reduced on AP XR
• Scrutinize AP view
for disruptions of 6
lines
• Consider that
although femoral
head may be reduced
there still may be
instability . . .David Helfet, MD
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Posterior Wall Fractures
David Helfet, MD
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Posterior Wall Fractures
Judet Radiographs
• Obturator oblique
– Posterior wall displacement
– Demonstrates congruency of femoral head within acetabulum
– obturator ring intact
• Iliac oblique
– Posterior border of innominate bone and iliac wing intact
– Anterior wall intact
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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David Helfet, MD
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David Helfet, MD
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CT scan
Marginal impaction
Incarcerated fragments
ComminutionDavid Helfet, MD
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Marginal Impaction
Marginal Impaction: segment of articular surface and underlying cancellous bone is impacted away from joint surface causing incongruity
Also note intra-articular fragment
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Marginal Impaction
David Helfet, MD
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Posterior Column Fractures
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Posterior Column Fractures
• 3-5% of all acetabulum fractures
• Detachment of entire ischioacetabular segment from innominate bone
• Fracture begins at posterior border of innominate bone near apex of greater sciatic notch
• Fracture continues inferior across articular surface, quadrilateral surface, ischiopubic notch, and inferior pubic ramus
• Femoral head follows column fragment medially and posteriorly
• Unstable injuries, commonly requires skeletal traction to maintain hip reduction
• Superior gluteal neurovascular bundle may become entrapped
** “Gull sign”➔ originally described by Letournel and Judet for variations of posterior column fractures where the posterior column displaces and takes the hind portion of acetabular roof; therefore the posterior segment loses its normal relationship with the segment still attached to anterior column and forms “an image like a gull in flight”. This is not the same as the “gull sign” described for AC/PHT injuries representing impacted subchondral bone of the medial roof**
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Posterior Column Fractures
AP Radiograph
Ilioischial, posterior rim, and inferior ramus disrupted
Ilioischial line displaced medially
Iliopectineal line intact
Note:
Normally ilioischial line displaces relative
to teardrop; if large portion of quadrilateral
surface is part of column fragment, teardrop
will displace WITH ilioischial line
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Posterior Column Fractures
Judet Radiographs
• Obturator oblique
– Intact anterior column
– Ischiopubic ramus fracture identified
• Iliac Oblique
– Delineates posterior column fracture
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Posterior Column Fractures
Judet Radiographs
Court-Brown, C. et al.
Rockwood & Greens
Fractures in Adults.
Philadelphia: Lippincott
Williams & Wilkins, 2014
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CT scan
Column fracture line
orientation
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Posterior Column Fractures
Case #2 . . .
Note subtle disruption of ilioischial line and intact iliopectineal line; also note posterior rim disruption
David Helfet, MD
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Posterior Column Fractures
Posterior column fx
visualized
Intact anterior column,
fx of inferior ramus
visualized
David Helfet, MD
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Remember . . .
• Superior gluteal
NV bundle exits at
greater sciatic
notch and may
become tethered at
fx site
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Posterior Column Fractures
Case #3 . . .
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Anterior Wall Fractures
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Anterior Wall Fractures
• 1-2% of acetabulum fractures
• Fracture begins below the AIIS, crosses the
articular surface to the pelvic brim, and
proceeds down the quadrilateral surface to the
ischiopubic notch
• Secondary fracture line through superior
ramus; ischiopubic ramus intact
• Most of anterior column intact
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Anterior Wall Fractures
Anterior wall fracture associated
with plate of bone from cotyloid
fossa and quadrilateral surface and
involving inner border or posterior
wall Copyright by AO Foundation, Switzerland; "Fractures of the Pelvis and Acetabulum—Principles and
Methods of Management- 4th Edition”
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Anterior Wall Fractures
AP Radiograph
Disruption of iliopectineal line at 2 points
Anterior rim disrupted, upper 1/3rd
Femoral head may dislocate anteriorly and externally rotated
Ilioischial line intact
Court-Brown, C. et al. Rockwood & Greens
Fractures in Adults. Philadelphia: Lippincott
Williams & Wilkins, 2014
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Anterior Wall Fractures
Judet Radiographs• Obturator oblique
– Anterior wall/column fracture visualized
– Confirms posterior border of acetabulum intact
– Demonstrates obturator ring fracture to be at level of ischiopubicnotch and roof of obturator canal
– Displays trapezoidal shape of detached fragment driven medially by femoral head
• Iliac oblique– Posterior border of innominate bone intact
– Establishes anterior wall point of rupture
– Commonly demonstrates elevated quadrilateral bone plate on inner aspect of pelvis; appears as “thinning” or re-duplication of ilioischial line
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Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Anterior Wall Fracture Variant
• Very rare, 1.5% acetabular fractures
• Morphologic equivalent of posterior wall
fracture
• Letournel and Judet did not have a
morphologically similar fracture in their
series
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Anterior Wall Fracture Variant
No inner table (pelvic brim) involvementCourt-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Anterior Wall Fractures
Case #2 . . .
Case #2 . . .
David Helfet, MD
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David Helfet, MD
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Anterior Column Fractures
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Anterior Column Fractures
• 3-5% of acetabulum fractures
• Separates anterior border of innominate bone from intact ilium
• Fractures cross the pelvic brim, propagate down quadrilateral surface, enter ischiopubicnotch and end in an inferior ramus fracture
• Quadrilateral surface may be detached as separate fragment but posterior border of innominate bone remains intact
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Anterior Column Fractures
• Subtypes based on location where fracture
exits innominate bone anteriorly
– High➔iliac crest
– Intermediate➔ASIS
– Low➔psoas gutter below AIIS
– Very low➔iliopectineal eminence
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Anterior Column Fractures
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Anterior Column Fractures
AP Radiograph
Disruption of iliopectineal line
Fracture of ischiopubic ramus
+/- fracture line in superior ilium
Ilioischial line intact
High
subtype
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults.
Philadelphia: Lippincott Williams & Wilkins, 2014
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Anterior Column Fractures
Judet Radiographs• Obturator oblique
– Anterior column
disruption
– Illustrates anterior
column displacement by
femoral head
– Ischiopubic ramus
fracture
• Iliac oblique
– Iliac wing fx extension
– Posterior border
innominate bone intact
– May demonstrate
quadrilateral plate
fracture Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Anterior Column Fractures
Case #2. . . Low subtype
David Helfet, MD
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Anterior Column Fractures
Low Subtype
David Helfet, MD
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Anterior Column Fractures
Low Subtype
David Helfet, MD
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Transverse Fractures
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Transverse Fractures
• 5-19% acetabular fractures
• Fracture line traverses anterior and posterior border (columns) of innominate bone– Upper iliac segment➔intact to ilium
– Lower ischiopubic segment➔rotates about pubic symphysis• Medial and superior displacement of femoral head as it follows
ischiopubic segment
• Femoral head may also remain under intact portion of remaining roof
• Rotation causes greater posterior translational displacement than anterior
• As location of fracture moves superior on articular surface– Orientation of fracture becomes more vertical
– Size of intact remaining articular surface decreases
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Transverse Fractures
• Subtypes based on where fracture crosses
articular surface
– Transtectal➔crosses weight bearing dome
– Juxtatectal➔crosses articular surface at level of
the top of cotyloid fossa
– Infratectal➔crosses at level of cotyloid fossa
Court-Brown, C. et al. Rockwood & Greens
Fractures in Adults. Philadelphia: Lippincott
Williams & Wilkins, 2014
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Transverse Fractures
Variations in the plane/obliquity of transverse fractures
-horizontal and vertical
-anterior to posterior
-medial to lateral
Copyright by AO Foundation, Switzerland; "Fractures of the Pelvis and Acetabulum—Principles and
Methods of Management- 4th Edition”
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Transverse Fractures
AP Radiograph
Iliopectineal and ilioischial lines disrupted
Anterior and posterior rims disrupted
+/- disruption of sourcil/roof depending on level of fracture
Court-Brown, C. et al. Rockwood
& Greens Fractures in Adults.
Philadelphia: Lippincott Williams
& Wilkins, 2014
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Transverse Fractures
Judet Radiographs
• Obturator oblique– Disruption of anterior
column/pelvic brim
– Demonstrates displacement of ischiopubic segment
– Confirms uninjured obturator ring
• Iliac oblique– Demonstrates where the fracture
exits greater sciatic notch and fracture of quadrilateral surface
– Demonstrates posterior displacement
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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CT Scan
Antero-posterior fracture orientation
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Transverse Fractures
Case #2 . . .
Iliopectineal and ilioischial lines disrupted
Anterior and posterior rims disrupted
Sourcil/roof disrupted
Roof
involvement;
displacement of
femoral head
with ischiopubic
segment
Court-Brown, C. et al. Rockwood & Greens
Fractures in Adults. Philadelphia: Lippincott
Williams & Wilkins, 2014
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Transverse Fractures
Judet Radiographs
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Transverse Fractures
Case #3 . . .
David Helfet, MD
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Associated Fracture
Pattern Examples
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Posterior Column plus Posterior
Wall Fractures
David Helfet, MD
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Posterior Column + Posterior Wall
Fractures
• 3-4% of fractures; combination PC + PW
• Posterior wall fragment– articular comminution of acetabular rim with traversing
posterior column fracture line
– Travels with femoral head during dislocation and remains displaced after femoral head reduction
– May block reduction of femoral head
• Posterior column fragment– Divides posterior border of innominate bone and
ischium➔free ischioacetabular fragment
– Femoral head component follows ischioacetabular fragment and dislocates cranially/posteriorly
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Posterior Column + Posterior Wall
AP Radiograph
Disrupted Ilioischial line
Disrupted posterior rim
Ischiopubuc ramus disruption (variable)
Intact Iliopectineal line
Femoral head dislocation/subluxation
Court-Brown, C. et al. Rockwood &
Greens Fractures in Adults.
Philadelphia: Lippincott Williams &
Wilkins, 2014
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Posterior Column + Posterior Wall
Judet Radiographs
• Obturator oblique– Anterior column intact
– Demonstrates posterior wall fragment
– Inferior fracture line delineated as either splitting ischiopubic ramus or splitting ischium and leaving obturator foramen intact
• Iliac oblique– Anterior wall intact
– Demonstrates displacement of posterior column and level of rupture of greater sciatic notch
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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CT scan
Black arrow: posterior column fx line
White arrow: posterior wall fragment
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Posterior Column + Posterior Wall
Case #2 . . .
Ilioischial line disrupted
Posterior rim disruption
No obvious ischiopubic ramus/obturator foramen disruption
Iliopectineal line intact
David Helfet, MD
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Posterior Column + Posterior
Wall
Posterior Wall fragment David Helfet, MD
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Posterior Column + Posterior
Wall
Posterior column exit and greater sciatic notchDavid Helfet, MD
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Transverse + Posterior Wall
Fractures
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Transverse + Posterior Wall
Fractures
• 20% of acetabulum fractures
• Combines elementary transverse and posterior wall patterns
• Posterior wall component:– Single or multi-fragmentary
– +/- marginal impaction
• Transverse component – Infra-, juxta-, or trans-tectal
– Fracture line travels from posterior wall segment towards posterior border of innominate bone and greater sciatic notch
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Transverse + Posterior Wall
Fractures• Rotation similar to pure transverse fractures
– Rotation around vertical axis passing through pubic symphysis
– Rotation around horizontal axis passing from pubic symphysis to point of disruption on posterior border of innominate bone
– Posterior displacement/translation more common
• Obturator foramen intact
• Dislocation common– Central
• Commonly obvious and severe
• Few cases femoral head spontaneously reduced for first XR
– Posterior• Large posterior capsular ruptures common
• Rarely, with cases of marginal impaction, separated fragment remains attached to capsular remnant
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Transverse + Posterior Wall
Fractures
• Atypical examples:
– T-shaped fracture with posterior wall fracture
• Fracture of posterior wall and transverse component
• Additional vertical splint of ischio-pubic fragment
with a vertical T-shaped fracture configuration or T
with posterior directed oblique branch
– Incarcerated posterior wall fragment
– Transverse fracture with fracture of iliac wing
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Transverse + Posterior Wall
AP Radiograph
All vertical and oblique landmarks disrupted
Anterior/Posterior rim disruption
Obturator ring intact
Central vs. posterior dislocation
Wide displacement of inferior ischiopubic segment
Court-Brown, C. et al. Rockwood & Greens
Fractures in Adults. Philadelphia:
Lippincott Williams & Wilkins, 2014
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Transverse + Posterior Wall
Judet Radiographs• Obturator oblique
– Posterior wall size visualized
– Posterior vs. central dislocation
– Obturator ring intact
– Degree of obliquity of transverse fracture line
• Iliac oblique
– Iliac wing intact
– Confirms posterior column disruption
– May demonstrate superimposed posterior wall fragment with roof
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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CT scan
Typical anterior to posterior transverse fracture line (black arrow)
Posterior wall fragment (white arrow)
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Transverse + Posterior Wall Fracture
Case #2 . . .
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Judet RadiographsIschiopubic fragment
Posterior wall
fragment
Impacted articular surface
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Transverse + Posterior Wall
Fractures - Case #3 . . .
David Helfet, MD
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Judet Radiographs/CT
David Helfet, MD
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T-Type Fractures
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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T-Type Fractures
• 7% of acetabulum fractures
• Transverse fracture line with associated inferior vertical fracture line➔stem of “T”
• Vertical stem propagates from transverse fracture line➔across quadrilateral surface and cotyloid fossa➔enters obturator foramen➔fracture of ramus/ischiopubic ramus
• Fracture may also propagate posteriorly to ischium or anteriorly to pubis
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T-Type Fractures
• Cranial iliac segment– Superior to transverse fracture
• Caudal ischiopubic segment– Anterior articular segment (pubic)
– Posterior articular segment (ischial)
• Femoral head displaces medially with caudal anterior and posterior column segments rotating around head
• PORTION OF ARTICULAR SURFACE MAINTAINS ATTACHMENT TO ILIAC WING; DIFFERENTIATING FROM ASSOCIATED BOTH COLUMN FRACTURE
• RADIOGRAPHICALLY➔TRANSVERSE FRACTURE LINE IN PRESENCE OF ISCHIAL RAMUS FRACTURE➔T-TYPE
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T-Type Fractures
Possible directions of “stem” in T-type fracturesCopyright by AO Foundation, Switzerland; "Fractures of the Pelvis and Acetabulum—Principles and
Methods of Management- 4th Edition”
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T-Type Fractures
“T-shaped” may also be associated with posterior wall fragment; these types often placed into transverse plus posterior wall category
Copyright by AO Foundation, Switzerland; "Fractures of the Pelvis and Acetabulum—Principles and
Methods of Management- 4th Edition”
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T-Type Fractures
AP Radiograph
All vertical landmarks disrupted
+/- roof involvement based on level of transverse fracture
Ischiopubic ramus fracture
Court-Brown, C. et al. Rockwood & Greens
Fractures in Adults. Philadelphia:
Lippincott Williams & Wilkins, 2014
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T-Type Fractures
Judet Radiographs• Obturator oblique
– Anterior column disruption
– Ischiopubic notch disruption
– Ischiopubic/obturator ring disruption
– Visualization of vertical stem of fracture as it enters obturator foramen
• Iliac oblique– Fracture through posterior
column/greater sciatic notch
– Quadrilateral plate disruption
– Femoral head dislocation/subluxation
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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T-Type Fractures
Case #2 . . .
Vertical landmarks disrupted
Posterior wall fracture
Ischiopubic ramus fracture
Transtectal roof involvement
Dislocation of femoral head and SI joint
Court-Brown, C. et al. Rockwood & Greens Fractures in
Adults. Philadelphia: Lippincott Williams & Wilkins,
2014
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Judet Radiographs
Stem of “T” entering obturator
foramen and ischiopubic
ramus disruption
Posterior wall
fragment
Disruption of greater
sciatic notch and femoral
head dislocationCourt-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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T-Type Fractures
Case #3. . .
T-Type with intact obturator ring and ischial posterior exitDavid Helfet, MD
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Obturator Oblique
Note intact obturator ring David Helfet, MD
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Iliac Oblique
David Helfet, MD
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T-Type
Case #4 . . .
David Helfet, MD
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Obturator Oblique
David Helfet, MD
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Iliac Oblique
David Helfet, MD
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CT scan
Transverse fracture
line
Vertical stem of “T” separating anterior
pubic segment and posterior ischial segment
David Helfet, MD
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Anterior Column or Wall Fracture +
Posterior Hemitransverse Fracture
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Anterior Column or Wall Fracture +
Posterior Hemitransverse Fracture
• 7% of acetabulum fractures
• Primary fracture line: anterior wall or column
– ¾ involve anterior column
• Associated transverse fracture propagates from anterior fracture➔articular surface to posterior innominate bone
• Posterior hemitransverse fracture is identical to posterior half of transverse fracture and may be infra-, juxta, or trans-tectal
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“Gull” Sign
Impaction of acetabular roof
Poor prognostic sign; Anglen et al. JOT 2003
***original “gull” sign described by Letournel and Judet in Posterior Column fractures; represented posterior and superior fragment displacement ***
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Anterior Column or Wall Fracture +
Posterior Hemitransverse Fracture
• Anterior displacement>posterior
displacement
• Femoral head dislocated anteriorly
• Ischiopubic ramus fracture variable
• A PORTION OF ARTICULAR SURFACE OF
THE ROOF AND POSTERIOR WALL
ALWAYS MAINTAIN ATTACHMENT TO
ILIAC WING; DIFFERENTIATES FROM
ASSOCIATED BOTH COLUMN FRACTURE
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Anterior Column or Wall Fracture +
Posterior Hemitransverse Fracture
AP Radiograph
Iliopectineal (segmental) and ilioischial disruption
Anterior and posterior rim disruption
Anterior lesion is same as its elementary component
Femoral head follows anterior lesion
Court-Brown, C. et al. Rockwood & Greens Fractures
in Adults. Philadelphia: Lippincott Williams &
Wilkins, 2014
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Anterior Column or Wall Fracture +
Posterior Hemitransverse Fracture
Judet Radiographs• Obturator oblique
– Anterior column/wall lesion illustrated
– Posterior rim disruption
– Femoral head dislocation/subluxation follows anterior fragment
• Iliac oblique
– Posterior fracture line illustrated through posterior column
– May visualize quadrilateral surface connected to displaced posterior column fragment
– Iliac wing fracture in high anterior column fragments
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults.
Philadelphia: Lippincott Williams & Wilkins, 2014
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Anterior Column or Wall Fracture +
Posterior Hemitransverse Fracture
Case #2 . . .
David Helfet, MD
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David Helfet, MD
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David Helfet, MD
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CT scan
High anterior
column
Posterior
hemitransverseDavid Helfet, MD
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Both Column Fractures
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Both Column Fractures
• Most common associated pattern➔23% of all acetabulum fractures
• COMPLETE SEPARATION OF ACETABULUM FROM AXIAL SKELETON
• No portion of the articular surface remains attached to innominate bone
• Split between anterior and posterior columns
– Common to have numerous secondary fractures and comminution involving columns
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Variations of Associated Both
Column Fractures
Copyright by AO Foundation, Switzerland; "Fractures of the Pelvis and Acetabulum—Principles and
Methods of Management- 4th Edition”
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Both Column Fracture
• “Secondary congruence”
– Central dislocation/medialization
of femoral head secondary to
muscular pull; labrum intact
– With medialization the articular
fragments rotate around each
other and maintain congruency to
femoral head
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Secondary Congruence
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Both Column Fracture
• “Spur Sign”
– Obturator oblique
– Represents most caudal portion
of intact ilium
– Due to medialization of all
articular components with
femoral head
– Pathognomonic for associated
both column fracture
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Both Column Fracture
AP Radiograph
All 6 radiographic lines disrupted
Central dislocation/medialization of femoral head
Iliac wing fracture
Ischiopubic ramus fracture
Inward displacement of posterior column
Roof tilted and displaced to look downwards and inwards
Court-Brown, C. et al. Rockwood & Greens Fractures in
Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Both Column Fracture
Judet Radiographs• Obturator oblique
– Anterior column/iliopectineal line disruption
– Anterior rim disrupted
– Roof/sourcil tilted
– Posterior rim disrupted
– Ischiopubic ramus disrupted
– “spur” sign
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Obturator Oblique
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Both Column Fracture
Judet Radiographs
• Iliac oblique
– Posterior innominate bone/column disruption
and displacement
– Fracture line separating columns through
quadrilateral surface
– Anterior rim disruption
– Iliac wing fracture lines
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Iliac Oblique
Court-Brown, C. et al. Rockwood & Greens
Fractures in Adults. Philadelphia: Lippincott
Williams & Wilkins, 2014
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CT Scan
White arrow: anterior column
White arrow head: superior extent of posterior column
Black arrow: “spur” sign
Black arrow head: posterior wall fragment
Court-Brown, C. et al. Rockwood & Greens
Fractures in Adults. Philadelphia: Lippincott
Williams & Wilkins, 2014
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Both Column Fracture
Case #2 . . .
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Both Column Fracture
Case #2
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Both Column Fracture
Case #2
Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014
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Both Column Fracture
Case #3 . . .
David Helfet, MD
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Both Column Fracture
Case #3
David Helfet, MD
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Both Column Fracture
Case #3
David Helfet, MD
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Summary Slide• Inverted “Y” 2 column concept; know borders/anatomy of anterior and posterior columns
• Know osseous anatomy of acetabulum and how to correlate to radiographs/CT
• Beware corona mortis and sciatic nerve anatomy variations
• Know how to obtain judet/oblique radiographs
• Good quality AP/obturator oblique/iliac oblique radiographs for EVERY ACETABULUM FRACTURE; classify pattern based on radiographs
• CT +/- 3D reconstructions to further understand fracture lines, evaluate marginal impaction, and confirm classification pattern
• Consider MRI for pediatric posterior wall fractures to evaluate fragment size
• Understand roof arc/subchondral CT measurements and how applied to treatment of acetabulum fractures
• Know elementary and associated classification patterns
– Understand primary components/fracture lines of each pattern
– Be able to identify the 6 radiographic lines on AP radiograph
– Understand what lines/landmarks disrupted or intact on AP and judet radiographs for each elementary and associated pattern
– Understand that there are many variations/sub-types for each classification pattern
– ASSOCIATED BOTH COLUMN FRACTURES HAVE COMPLETE SEPARATION OF THE ARTICULAR SURFACE FROM THE INNOMINATE BONE
• WHEN EVALUATING AN ACETABULUM FRACTURE ALWAYS START WITH PLAIN RADIOGRAPHS
– IDENTIFY THE INTACT AND DISRUPTED LINES AND LANDMARKS ON EACH VIEW AND DETERMINE A PRELIMINARY CLASSIFICATION
– DRAW THE FRACTURE LINES ON A SAW BONE PELVIS
– USE THE CT IMAGING TO CONFIRM CLASSIFICATION
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Acknowledgements
• I would like to thank Dr. David Helfet and
Dr. David Wellman for their support and
case contributions. I would also like to
thank Craig Klinger for his assistance with
the imaging and illustrations in the
presentation.
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ReferencesAnglen JO, Burd TA, Hendricks KJ, Harrison P. The “Gull Sign”: a harbinger of failure for internal fixation of geriatric acetabular fractures. J OrthopTrauma. 2003; 17:625-634
Bucholz R, Heckman J. Rockwood and Green’s Fractures in Adults. 6th edition. Lippincott Williams and Wilkins: Philadelphia. 2006.
Bucholz R, Heckman J. Rockwood and Green’s Fractures in Adults. 7th edition. Lippincott Williams and Wilkins: Philadelphia. 2010.
Butterwick D, Papp S, Gofton W, Liew A, Beaulé P. Acetabular Fractures in the Elderly: Evaluation and Management. J Bone Joint Surg Am. 2015; 97: 758-768.
Court-Brown C, Heckman J, McQueen M, Ricci W, Tornetta P. Rockwood and Green’s Fractures in Adults. 8th edition. Lippincott Williams and Wilkins: Philadelphia. 2015.
Firoozabadi R, Spitler C, Schlepp C, Hamilton B, Agel J, Routt MC, Tornetta P. Determining Stability in Posterior Wall Acetabular Fractures. J OrthopTrauma. 2015; 29:465-469.
Grimshaw CS, Moed BR. Outcomes of Posterior Wall Fractures of the Acetabulum Treated Nonoperatively After Diagnostic Screening with Dynamic Stress Examination Under Anesthesia. J Bone Joint Surg Am. 2010; 92: 2792-2800.
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