Acetabular Fracture
Classification systems
- AO/OTA grouping for the acetabulum
- Descriptive by column and wall involvement, with attention to marginal impaction
Mechanism
The femoral head is driven into the acetabulum, and the position of the hip at impact determines the pattern — a flexed adducted hip in a dashboard injury tends to fracture the posterior wall with or without dislocation, while a laterally directed force through the greater trochanter produces transverse and both-column patterns. Low-energy falls in the osteoporotic elderly produce anterior column patterns with medial displacement and marked comminution.
Age considerations
- Paediatric
- Rare; watch for triradiate cartilage injury which causes progressive acetabular dysplasia as the child grows, demanding long-term follow-up.
- Young adult
- Anatomical restoration of the articular surface is the goal because it is the strongest predictor of avoiding post-traumatic arthritis. These are complex operations best performed by experienced pelvic surgeons through appropriate approaches.
- Elderly
- Comminution, marginal impaction and poor bone often make anatomical fixation unrealistic. Acute total hip arthroplasty, sometimes combined with column fixation or an augment, or a deliberately non-operative plan with early mobilisation, are legitimate strategies.
Management options
Urgent reduction of an associated hip dislocationshowhide
Indication
Every fracture-dislocation — reduction is time-critical to reduce the risk of femoral head osteonecrosis and sciatic nerve injury.
Implant design notes
No implant acutely; skeletal traction may be used to maintain reduction and keep the head out of the fracture zone until definitive surgery.
Approach
Closed reduction under general anaesthesia with muscle relaxation; open reduction if closed fails or if an incarcerated fragment prevents concentric reduction.
Steps overview
- Document sciatic nerve function, especially the peroneal division, before and after reduction
- Reduce urgently under anaesthesia with relaxation using in-line traction and the appropriate manoeuvre
- Confirm concentric reduction and check for intra-articular fragments on cross-sectional imaging afterwards
- Assess stability; apply skeletal traction if the hip is unstable or the head subluxes
- Arrange definitive imaging with fine-cut cross-sections and reconstructions for planning
- Refer to or plan definitive fixation with an experienced pelvic and acetabular team
Notes
A non-concentric reduction after apparent success usually means an incarcerated osteochondral fragment — image and treat it.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Open reduction and internal fixationshowhide
Indication
Displaced fractures with articular incongruity, hip instability, marginal impaction, or intra-articular fragments in a patient fit for major surgery.
Implant design notes
Pelvic reconstruction plates contoured to the columns, with lag screws along the column axes. Spring plates hold small posterior wall fragments. Marginal impaction is disimpacted and bone grafted beneath the articular surface before the wall is reduced over it.
Approach
Kocher-Langenbeck for posterior patterns with sciatic nerve protection and careful handling of the medial circumflex femoral vessels; ilioinguinal or anterior intrapelvic (modified Stoppa) approach for anterior and both-column patterns.
Steps overview
- Plan from fine-cut cross-sectional imaging: define columns, walls, impaction and any femoral head lesion
- Position and select the approach that gives access to the principal displaced element
- Protect the sciatic nerve posteriorly by keeping the knee flexed and the hip extended, and avoid excessive retraction
- Expose the fracture, clear the joint of loose fragments, and disimpact and graft marginal impaction
- Reduce the columns anatomically, checking the reduction along the quadrilateral surface and the articular margin
- Apply lag screws along the column axes and contoured reconstruction plates
- Confirm concentric hip reduction and screw position, and avoid intra-articular screws
- Close in layers, plan thromboprophylaxis, and mobilise with protected weight bearing
Notes
Sciatic nerve injury, heterotopic ossification and infection are the specific risks of these approaches. Screw penetration into the joint is a recognised avoidable error — check with intraoperative views.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Acute total hip arthroplasty (with or without column fixation)showhide
Indication
Elderly patients with comminuted unreconstructable articular surfaces, marked marginal impaction, femoral head damage or pre-existing arthritis.
Implant design notes
Cup supported by an augment, a cage or a multi-hole shell with screws into the intact ilium; column fixation may be added to create a stable bed. The goal is a single operation permitting immediate mobilisation.
Approach
Posterior or anterolateral approach, combined with the fracture approach where fixation is also planned.
Steps overview
- Assess bone stock and articular damage on cross-sectional imaging
- Fix or stabilise the columns sufficiently to create a stable acetabular bed
- Prepare the acetabulum, using graft to fill defects
- Seat a multi-hole shell with screws into the intact ilium, adding an augment or cage if needed
- Prepare the femur and trial for length, offset and stability
- Insert the definitive components, close, and mobilise early with weight bearing
Notes
Complication rates are higher than in elective arthroplasty; the trade-off is early mobilisation in a patient who will not tolerate prolonged restricted weight bearing.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Viva pearls
- Quality of articular reduction is the single strongest predictor of long-term outcome — say it early.
- Document sciatic nerve function, especially the peroneal division, before and after any reduction or surgery.
- A hip fracture-dislocation is an emergency reduction; delay increases osteonecrosis risk.
- Marginal impaction must be disimpacted and grafted; reducing the wall over impacted articular bone leaves an incongruent joint.
- Judet and Letournel is based on columns and walls — be able to name the elementary patterns and identify them on the three standard views.
- In the elderly with an unreconstructable acetabulum, acute arthroplasty with column stabilisation is a legitimate and often better answer than heroic fixation.
Sources for further reading
- Letournel and Judet's principles of acetabular fracture surgery — as summarised in standard trauma texts
- Rockwood and Green's Fractures in Adults — acetabular fractures
- Standard operative orthopaedics textbook — surgical approaches to the acetabulum
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Resident-authored study summary in original wording, not reproduced from copyrighted source text.