Types Of Acetabular Fractures Research Articles

Acetabular Fracture Patterns and Their Associated Injuries

Characterize relationships between acetabular fractures patterns and visceral organ injuries. Retrospective review. : University medical center. Three hundred twenty-three patients with displaced acetabular fractures identified in a prospectively maintained database. Acetabular fractures were classified according to force vector at the time of injury. Posterior wall, posterior column, and posterior column/posterior wall injuries were assumed to have been caused by an axial load. The remaining seven acetabular fracture types were assumed to have resulted from a lateral or trochanteric load. Records were reviewed to establish any relationship between acetabular fracture patterns defined by their force vector and injuries to other skeletal and nonskeletal organ systems. Comparison of organ injury end points of additional skeletal injury; bowel, bladder, brain, kidney, liver, spleen, and lung injury; retroperitoneal hematoma; and vascular injury of the pelvis. Data were analyzed using chi-square, with statistical significance defined as P < 0.05. Acetabular fractures resulting from lateral loads had a statistically higher association with retroperitoneal hematomas (P < 0.001), spleen (P < 0.008), liver (P < 0.002), vascular (P < 0.001), kidney (P < 0.001), and bladder (P < 0.001) injuries than did posteriorly directed acetabular fractures. Transverse posterior wall fractures exhibited intermediate characteristics between axial load and the remaining lateral load patterns. Direction of force is important in the etiology of nonskeletal injury patterns. The possibility of additional nonskeletal injury increases from the rates seen in axial load patterns to those in lateral load patterns involving the anterior column.

Modified and new approaches for pelvic and acetabular surgery

We analysed outcomes of new operative techniques for open reduction and internal fixation in 120 consecutive patients with fractures of the pelvic ring and 164 patients with acetabular fractures treated between 1989 and 1999. An anterior extraperitoneal approach was performed through a low midline incision to fix the anterior and lateral parts of the pelvis and for central involvement of different types of acetabular fractures. The anterior approach was combined with a lateral incision on the lateral crest for fractures of the iliac wing and with a posterior approach for sacroiliac injuries, or with Kocher-Langenbeck approach for posterior acetabular involvements. The complication rate of the new techniques was low. Heterotopic ossification was rare. The functional recovery was good in 66 of the 81 patients with an unstable C-type pelvic injury, in 18 out of the 20 patients with a lateral compression, B-2-type injury and 13 out of 19 patients with a open book, B-1-injury. Neurological recovery was observed after adequate reduction in those patients suffering from lesions of the sacral plexus. The radiographic result was good in 73, 20 and 17 of the patients groups, respectively. The Harris Hip Score was more than 80 in 75% of the 164 patients with an acetabular fracture. The radiological result was good (residual displacement 0-2mm) in 84%, fair (3-5mm) in 9% and poor (more than 5mm) in 7%. The new methods are less invasive than the basic approaches described in the literature. The whole pelvic ring, as well as all the acetabular fracture combinations may be treated with the combination of approaches used in the present study.

Acetabular Fractures Revisited: A New CT-Based Classification

The objective of this investigation is to provide a new CT-based classification of acetabular fractures. The axial CT scans of 112 randomly selected acetabular fracture patients admitted to a Level 1 trauma center between January 1998 and December 2000 were analyzed by an experienced orthopedic trauma surgeon and two experienced emergency radiologists. When available, 3D reformatted images were analyzed as well. The fracture pattern for each acetabular fracture with respect to column(s) wall(s) and extension superiorly and/or inferiorly from the acetabulum, when present, was recorded. Fracture comminution was not a defining characteristic. Analysis of the acetabular fracture patterns showed that each fracture fell into one of four broad categories: Category 0--wall only; Category 1--single column; Category 2--both columns, with extension subcategories of (A) no extension, (B) superior extension only, (C) inferior extension only, and (D) both superior and inferior extension; and Category 3--the "floating" acetabulum. The axial CT display of acetabular fracture patterns provides a basis for a classification of acetabular fractures that is simple, unambiguous, readily understood by both radiologists and orthopedic surgeons, and provides clear direction for both diagnosis and surgical treatment planning. Category and subcategory fracture specificity creates a mechanism for intra- and interdepartmental postoperative assessment of any of the individual acetabular fracture types.

Acetabular fractures revisited: part 2, a new CT-based classification.

The objective of this investigation was to provide a new CT-based classification of acetabular fractures. The axial CT scans of 112 randomly selected acetabular fractures in patients admitted to a level 1 trauma center between January 1998 and December 2000 were analyzed by an experienced orthopedic trauma surgeon and two experienced emergency radiologists. When available, 3D reformatted images were analyzed as well. The fracture pattern for each acetabular fracture, with respect to column walls and extension beyond the acetabulum, when present, was recorded. Fracture comminution was not a defining characteristic. Analysis of the 112 acetabular fracture patterns showed that each fracture fell into one of four broad categories. Category 0 included wall fractures only. Category I included acetabular fractures limited to a single (anterior or posterior) column. Category II fractures included those involving both the anterior and posterior columns; category II fractures were further subdivided into those with no fracture extension beyond the acetabulum, those with superior or inferior extension, and those with both superior and inferior extensions beyond the acetabulum. Category III fractures included only the "floating" acetabulum, which is defined as an acetabular fracture in which the acetabulum is separated from the axial skeleton both anteriorly and posteriorly. The axial CT display of acetabular fracture patterns provides a basis for a classification of acetabular fractures that is simple, unambiguous, readily understood by both radiologists and orthopedic surgeons and provides clear direction for both diagnosis and surgical treatment planning. Category and subcategory fracture specificity creates a mechanism for intra- and interdepartmental postoperative assessment of any of the individual acetabular fracture types.

Improving reliability in the classification of fractures of the acetabulum.

Plain radiographs of the pelvis are routinely used in the initial assessment of patients with suspected fractures of the acetabulum. It is necessary for orthopaedic resident trainees, emergency physicians as well as orthopaedic surgeons who infrequently treat trauma patients to be able to describe these fracture patterns reliably to traumatologist orthopaedic surgeons who ultimately take over the patient care. Our purpose was two-fold: (1) to determine the reliability of the component parts of the Letournel classification of acetabular fractures involving six anteroposterior (AP) radiographic lines, and (2) to examine whether the addition of oblique radiograph views (Judet views) would improve the reliability. Thirty sets of AP and oblique radiographs (Judet views) of the pelvis were selected from a hospital database to represent various types of acetabular fractures. Six reviewers (three orthopaedic trainees and three community orthopaedic surgeons) independently reviewed the radiographs. For each radiograph, the reviewer classified the acetabular fracture according to the Letournel classification. In addition, each reviewer utilized a simplified classification scheme using six radiographic lines on the AP pelvic radiograph. Interobserver reliabilities among reviewers were reported along with the intraclass correlation coefficient (ICC) and kappa values. Agreement for the Letournel classification increased with increasing physician experience (trainees ICC=-0.14 and community surgeons ICC=0.56). Interobserver reliability between trainees and community surgeons improved when the six radiographic lines were used (range kappa=0.09-0.89). The oblique pelvic radiographs (Judet views) did not significantly improve reliability among physicians. In this study we report the following: (1) the reliability of the Letournel classification improves with level of training, (2) physicians with less experience with acetabular fractures have significantly better agreement in identifying fractures using the six radiographic lines on the AP film than the Letournel classification, and (3) agreement among the reviewers for the AP pelvic radiograph is not improved with additional oblique (Judet) views.

The floating hip injury: patterns of injury

Objective: To evaluate the relationship between mechanism of injury, type of femoral fracture and type of acetabular fracture in floating hip injury. Design: Historical retrospective. Patients: Twenty consecutive patients who sustained a floating hip injury, i.e. simultaneous ipsilateral fracture of the acetabulum and the femur. Intervention: Statistical analysis of the correlation between the mechanism of injury and fracture type. Results: Two main patterns of floating hip injury were observed. The first is the posterior type, which occurs due to a longitudinal force along the femur that causes first, a posterior type fracture of the acetabulum and thereafter, a midshaft femoral fracture. The second pattern is the central type, caused by a lateral blow to the greater trochanter, which then causes a central fracture-dislocation of the acetabulum and a proximal fracture of the femur. Conclusions: This observation explains the biomechanical nature of this injury and has treatment related implications.

Posterior wall fractures

The goal of surgical treatment of posterior wall fractures is to obtain stability of the hip by restoring the normal shape of the acetabulum and to restore the normal pressure distribution within the joint by anatomic reduction of the articular surface. Fractures of the posterior wall are the most common type of acetabular fracture and account for approximately one quarter of all acetabular fractures. These fractures typically occur in young patients as a result of a high-energy trauma, such as motor vehicle collisions. Displaced posterior wall fractures create an incongruity in the articular surface and, in some cases, result in instability of the hip. Diagnosis is made on the anteroposterior pelvis, obturator oblique, and iliac oblique radiographs of the pelvis. Computed tomography (CT) is helpful for identifying subtle marginal impaction and osteochondral fragments. Indications for operative treatment include instability of the hip, marginal impaction, and retained osteochondral fragments. Relative indications include articular fractures that encompass more than 33% of the wall width and minimally displaced fractures that are part of the more complex fracture pattern that require an ilioinguinal approach. Surgical reduction is performed through a Kocher-Langenbeck incision in the prone position with the knee bent to relax the sciatic nerve. Three and one-half mm implants are used for fixation of posterior wall fractures. Good to excellent results can be obtained in up to 80% of fractures that have been anatomically reduced and rigidly fixed. Anatomic reduction is a highly significant predictor of an excellent or a good result. Complications include wound infection, iatrogenic nerve palsy, heterotopic ossification, and thromboembolic complications. Posttraumatic arthritis is the most common late complication that can occur.

Classification of acetabular fractures. A systematic analysis of the relevance of computed tomography

The classification of acetabular fractures and especially the diagnosis of additional lesions can be misleading, when the personal experience is limited and the decisions are based only on conventional radiographs. The introduction of Spiral-CT with multiplanar reformations and 3-D views has improved the quality of visualization. Due to their higher costs, the need of these additional diagnostic tools is frequently questioned. This paper discusses the relevance of plain radiographs, 2-D-CTs, 3-D-CTs and Femursubtraction-CTs (FsCT) for the classification of acetabular fractures, based on a controlled study. Methods: Thirty physicians with different levels of experience in acetabular surgery were divided in three groups of 10 each: group I comprised residents without operative experience in acetabular surgery, group II was physicians with 3–10 years of operative experience, and group III was experts in acetabular surgery. A total of 10 complete radiographic cases of high quality providing all levels of preoperative diagnostics (plain radiographs, 2-D-CT, CT with multiplanar reformation, 3-D-CT, Fs-CT) of different acetabular fracture types were prepared. The task for each candidate was to classify the fracture according to Letournel and to identify all additional injuries within the hip joint (e. g. marginal impaction, head fractures, etc.). The different diagnostic “levels” could be ordered stepwise according to personal need and no time limit was given. The case was finished when the candidate presented his final diagnosis. The use of the different radiographs, the preliminary diagnosis, the changes in diagnosis, and the final decisions were recorded. These findings were correlated with the different levels of experience and against a “consensus classification” which was generated by thorough discussion, and the use of intraoperative information and postoperative radiographs not accessible to the candidates. Results: The “correct” fracture classification based on plain radiographs was: group I, 11 %; group II, 32 %; group III, 61 %. Based on 2-D-CT a “correct” diagnosis was reached by 30 % in group I, by 55 % in group II, and by 76 % in group III. With consideration of the “transient forms” in acetabular fractures based on Letournel and the 3-D-CT used mainly by group I, the rate of “correct” classifications rose to 65 % in group I, 64 % in group II and 83 % in group III. The modifiers were diagnosed “correctly” in group I by 37 %, in group II by 56 %, and in group III by 73 %. The use of the 3-D-CT and especially the Fs-CT by group I resulted in an improvement in the rate of correct classifications to 61 %, whereas in group II the Fs-Ct was used only exceptionally. The 2-D-CT was the basis for the diagnosis of the additional lesions in acetabular fractures within all groups resulting in 73 % complete diagnoses in group III. This study showed the importance of CT for the exact analysis and classification of acetabular fractures. In particular, the secondary reformations in CT and the 3-D-views dramatically improved the rate of “correct” classifications in the group of surgeons with limited personal experience in acetabular surgery. This allows the less experienced an acceptable level of “correct” diagnoses, so that the treatment options can be weighed correctly. Among the “experts” a rate of divergent classifcations of approximately 20 % was observed, especially in “transient” forms of acetabular fractures.

Computed tomographic findings after anterior dislocation of the hip

Anterior dislocation of the hip is a rare phenomenon, seen in only 5–10% of all hip dislocations. These dislocations can be divided into two types: superior or subspinous and inferior or obturator dislocations. Osteochondral impaction fractures of the femoral head are a known complication of anterior dislocation, but little has been reported on the types of acetabular and pelvic fractures associated with this dislocation. Five anterior dislocations were studied with radiographs and computed tomographic (CT) imaging, and the CT findings are described. Fractures were seen in the femoral head, acetabular roof, and medial wall, as well as in the anterior inferior iliac spine. The most severe injuries occurred after a superior dislocation, but the obturator dislocations demonstrated impaction fractures of the femoral head as well as an intra-articular bone fragment. CT of the acetabuli is recommended after reduction of these dislocations to identify these complications.

Fractures of the acetabulum: imaging, classification, and understanding.

For the patient with a traumatized acetabulum, accurate radiographic diagnosis and classification are the cornerstone of effective clinical care. The classification system of Judet and Letournel has led to improved management of such injuries. However, trauma-related acetabular fractures are often complex, with multiple fragments and secondary fracture lines. Furthermore, the Judet and Letournel system is complicated and easily misunderstood, reflecting the nature of the anatomy itself. Computed tomography (CT) provides information regarding the extent of the fracture and is complementary to radiography for ascertaining the spatial arrangement of fracture fragments. Three-dimensional (3D) reconstruction of CT data can be helpful in understanding the complex fracture patterns. These are divided into two main types: elementary fractures, which consist of injuries to a single structural component, and associated fractures, which are combinations of the elementary types. Three-dimensional CT is especially helpful in gaining perspective on the fracture orientation. Although questions remain as to its clinical application, 3D CT is a useful teaching tool for demonstrating the different types of acetabular fractures.

Fractures of the Acetabulum A Study of a Series of 75 Cases

Emile Letournel was born on December 4, 1927 in the St. Pierre et Miquelon islands, a French possession in the mouth of the Gulf of St. Lawrence. After his preliminary schooling, he was awarded a scholarship to the French Institute in London. He left his home and family at the age of sixteen, travelling to England on a troop ship in 1944. At the end of the war he was able to go to Paris where he completed his education, receiving his medical degree from the Paris Faculty. Letournel became a protege of Professor Robert Judet at the Hospital Raymond Poincare and this association became the most important factor in the development of his professional life. Because of Judet's interest in the management of pelvic fractures, Letournel focused his attention on this problem also. As a result of his work in this area, major advances have occurred in the surgical techniques used to reduce and fix difficult fractures of the acetabulum. The paper chosen as a classic article is based on his thesis which was completed in 1960. It represents one of the first steps in using the diagnostic radiographs to classify and define the type of acetabular fracture and to determine the proper surgical approach to be used in reducing and fixing the fracture. Letournel continued to expand on this early work and through his numerous lectures, publications and books has become the major authority on the difficult problems posed by fractures of the acetabulum. He is presently a Professor of Surgery of the Hospitals of Paris and has a private practice in Courbevoie, France.

Multiple joint osteonecrosis following short-term steroid therapy. Case report.

The general goals for treating an acetabular fracture are to restore congruity and stability of the hip joint. These goals are no different from those for the subset of fractures of the posterior wall. Nevertheless, posterior wall fractures present unique problems compared with other types of acetabular fractures. Successful treatment of these fractures depends on a multitude of factors. The physician must understand their distinctive radiologic features, in conjunction with patient factors, to determine the appropriate treatment. By knowing the important points of posterior surgical approaches to the hip, particularly the posterior wall, specific techniques can be used for fracture reduction and fixation in these often challenging fractures. In addition, it is important to develop a complete grasp of potential complications and their treatment. The evaluation and treatment protocols initially developed by Letournel and Judet continue to be important; however, the surgeon also should be aware of new information published and presented in the past decade.