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26. acetabular fractures anatomy, evaluation and classification - muhammad abdelghani

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Part 1 of a lecture on acetabular fractures (Anatomy, Evaluation and Classification) by Dr Muhammad Abdelghani

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26. acetabular fractures anatomy, evaluation and classification - muhammad abdelghani

  1. 1. Acetabular FracturesAcetabular Fractures Evaluation, Anatomy and ClassificationEvaluation, Anatomy and Classification Muhammad Abdelghani
  2. 2. Normal Anatomy: Columns and Walls
  3. 3.  From the lateral aspect of the pelvis, the innominate osseous structural support of the acetabulum may be conceptualized as a two- columned construct forming an inverted Y: 1. Anterior column (iliopubic component): extends from iliac crest to symphysis pubis and includes the anterior wall of the acetabulum. 2. Posterior column (ilioischial component): extends from superior gluteal notch to ischial tuberosity and includes the posterior wall of the acetabulum.
  4. 4.  The anterior and posterior walls extend from each respective column and form the cup of the acetabulum.  The anterior and posterior columns connect to the axial skeleton through a strut of bone called the sciatic buttress.
  5. 5.  When looking at the acetabulum en face, the anterior and posterior columns have the appearance of the Greek letter lambda (λ).  The anterior column represents the longer, larger portion, which extends superiorly from the superior pubic ramus into the iliac wing. The posterior column extends superiorly from the ischiopubic ramus as the ischium toward the ilium.  The anterior and posterior columns of bone unite to support the acetabulum.  In turn, the sciatic buttress extends posteriorly from the anterior and posterior columns to become the articular surface of the sacroiliac joint, which attaches the columns to the axial skeleton.  The anterior and posterior walls, which extend from the columns and support the hip joint, are well seen on an axial CT.
  6. 6.  The anterior and posterior walls, which extend from the columns and support the hip joint, are well seen on an axial CT. Axial section through acetabulum shows anterior (arrowhead) and posterior (arrow) walls.
  7. 7. Acetabular dome: The superior weight-bearing portion of the acetabulum at the junction of the anterior and posterior columns, including contributions from each.
  8. 8. Anterior coulmn Posterior column Sciatic buttress
  9. 9. Anterior column in white, posterior column in red
  10. 10. Mechanism of injury Like pelvis fractures, these injuries are mainly caused by high-energy trauma secondary to a motor vehicle, motorcycle accident, or fall from a height.
  11. 11. Mechanism of injury The fracture pattern depends on  Position of femoral head at the time of injury,  Magnitude of force, &  Age of patient.
  12. 12. Mechanism of injury Direct impact to greater trochanter with:  Hip in neutral: transverse acetabular fracture  An abducted hip: low transverse fracture,  An adducted hip: high transverse fracture.  Hip externally rotated and abducted: anterior column injury.  Hip internally rotated: posterior column injury.
  13. 13. Mechanism of injury With indirect trauma, (e.g., a ‘dashboard’ injury to the flexed knee):  As the degree of hip flexion increases, the posterior wall is fractured in an increasingly inferior position.  Similarly, as the degree of hip flexion decreases, the superior portion of posterior wall is more likely to be involved.
  14. 14. Clinical evaluation  Trauma evaluation: with attention to ABCD, depending on the mechanism of injury.  Patient factors (age, degree of trauma, presence of associated injuries, & general medical condition) affect treatment decisions as well as prognosis.  Neurovascular assessment:  Sciatic nerve injury may be present in up to 40% of posterior column disruptions.  Femoral nerve involvement with anterior column injury is rare, although compromise of the femoral artery by a fractured anterior column has been described.  Presence of associated ipsilateral injuries must be ruled out, with particular attention to the ipsilateral knee in which posterior instability and patellar fractures are common.  Soft tissue injuries (e.g., abrasions, contusions, subcutaneous hemorrhage) may provide insight into the mechanism of injury.
  15. 15. Radiographic evaluation  5 Pelvic X-rays:  AP view  2 Judet views (iliac & obturator oblique views)  Inlet and Outlet Pelvis X-rays  CT scan
  16. 16. Anatomic landmarks in AP view  Iliopectineal line (limit of anterior column),  Ilioischial line (limit of posterior column),  Anterior lip,  Posterior lip,  Line depicting the superior weight-bearing surface, terminating as the medial teardrop.
  17. 17.
  18. 18. Anatomic landmarks in AP view
  19. 19. Teardrop  Internal limb = outer wall of obturator canal  External limb = middle 1/3 of cotyloid fossa  Inferior border = ischiopubic notch
  20. 20. Iliac oblique radiograph (45-degree external rotation view)  Taken by rotating the patient into 45° of external rotation by elevating the uninjured side on a wedge.  This best demonstrates:  Posterior column (ilioischial line),  Iliac wing,  Anterior wall of acetabulum.
  21. 21. Iliac-oblique view 1. Border of sciatic notch 2. Anterior wall 3. Posterior column 4. Iliac wing 5. Posterior wall
  22. 22. Iliac oblique radiograph
  23. 23. Obturator oblique radiograph (45-degree internal rotation view)  This is best for evaluating the anterior column and posterior wall of the acetabulum.  Taken by elevating the affected hip 45° to the horizontal by means of a wedge and directing the beam through the hip joint with a 15° upward tilt.
  24. 24. Obturator-oblique view 1. Ilio-pectineal line. 2. Posterior wall 3. Anterior half of the joint 4. The iliac wing profile (the spur sign site)
  25. 25. Obturator oblique radiograph
  26. 26. AP pelvis Iliac oblique Obturator oblique AW—anterior wall; AC—anterior column; PC—posterior column; PW—posterior wall; OR—obturator ring.
  27. 27. Inlet Pelvis X-ray
  28. 28. Skeletal anatomy represented on inlet view
  29. 29. Outlet Pelvis XR
  30. 30. Skeletal anatomy represented on outlet view
  31. 31. Radiological Study
  32. 32. Radiographic evaluation  CT scan Provides additional information regarding size & position of column fractures, impacted fractures of acetabular wall, retained bone fragments in the joint, degree of comminution, and sacroiliac joint disruption.  Two- and three-dimensional CT scans are useful in evaluating intra-articular fragments as well as specific morphologic characteristics of any given fracture pattern.
  33. 33. Radiographic evaluation  CT scan  Before a 3-dimensional CT scan is ordered, the fracture patterns should be drawn on a 3-dimensional model of the pelvis to compare the 3- dimensional reconstructions.  Three-dimensional reconstruction allows for digital subtraction of femoral head, with full delineation of the acetabular surface.
  34. 34. CT scan transverse cuts through the acetabulum.
  35. 35. 3-D CT scan of a both- column acetabular fracture; obturator oblique view 3-D CT scan of a both- column acetabular fracture; iliac oblique view
  36. 36. Line drawing of fracture on a pelvic model
  37. 37.  Accurate classification of acetabular fractures is important for determining the proper surgical treatment.  Although radiographic examination provides essential information for acetabular classification, CT, including multiplanar reconstruction, is helpful in the visualization of complex fractures. Classification
  38. 38.  Because of the complex acetabular anatomy, various classification schemes have been suggested, but the Judet-Letournel classification system remains the most widely accepted.  This classification system subdivides acetabular fractures into  Elementary Fracture Types (posterior wall, posterior column, anterior wall, anterior column and transverse)  Associated Fracture Types (T-shaped, posterior column and wall, anterior wall or column with posterior hemitransverse, and both column). Classification (Judet-Letournel)
  39. 39. Elementary fractures  Poserior wall  Posterior column  Anterior wall  Anterior column  Transverse Classification (Judet-Letournel)
  40. 40. Classification (Judet-Letournel) Associated fractures  T-shaped  Posterior column + posterior wall  Transverse + posterior wall  Anterior column + posterior hemitransverse  Both-column
  41. 41. Elementary types Post wall Post column Ant wall Ant column Transverse
  42. 42. www.pelvisandhip.comwww.pelvisandhip.com Othopaedic Review CourseOthopaedic Review Course January 2010January 2010 Post. wall Post. column Ant. wall Ant. column Transverse
  43. 43. Classifications
  44. 44. Classification algorithm for 5 common acetabular fractures
  45. 45.  The isolated posterior wall fracture is one of the most common types of acetabular fracture, with a prevalence of 27%.  The ischium is disrupted.  The fracture line originates at the greater sciatic notch, travels across the retroacetabular surface, exits at the obturator foramen.  The ischiopubic ramus is fractured. Posterior wall fractures
  46. 46.  An isolated posterior wall fracture does not have a complete transverse acetabular component. Therefore, the iliopectineal line is not disrupted, which excludes classification of the transverse with posterior wall fracture.  However, disruption of the ilioischial line may or may not be present as an extension of the comminuted posterior wall component.  Oblique (Judet) radiographs and CT are helpful in showing the isolated posterior wall fracture. Posterior column fractures
  47. 47. 18-year-old man with isolated posterior wall acetabular fracture AP pelvic radiograph Bilateral oblique pelvic radiographs Axial CT images
  48. 48. 18-year-old man with isolated posterior wall acetabular fracture Parasagittal reconstruction CT image
  49. 49.  Posterior wall and posterior column fractures can be distinguished easily.  In a posterior column fracture, the ilioischial line is interrupted.  In a posterior wall fracture, only the retroacetabular surface is disrupted. Posterior column fractures
  50. 50. Posterior Column Fracture
  51. 51.  Anterior wall and anterior column fractures can be distinguished by the additional break in the ischiopubic segment of the pelvis present in the anterior column fracture. Anterior wall and anterior column fractures
  52. 52. Anterior Wall Fracture
  53. 53. Anterior Column Fracture
  54. 54. A transverse acetabular fracture involves a fracture line that goes through both columns of the acetabulum, but a portion of the dome of the acetabulum remains attached to the constant fragment of the iliac wing. Transverse Fracture
  55. 55. Obturator oblique view of transverse fracture Iliac oblique view of transverse fracture
  56. 56. Types (depending on the orientation of the fracture line relative to the dome or tectum of the acetabulum): 1. Transtectal: through the acetabular dome. 2. Juxtatectal: through the junction of acetabular dome & fossa acetabuli. 3. Infratectal: through the fossa acetabuli. Transtectal fractures are less forgiving and must be reduced anatomically, whereas infratectal fractures, if low enough, can be treated without surgery, depending on the pattern. The femoral head follows the inferior ischiopubic fragment and may dislocate centrally. Transverse Fracture
  57. 57. Infratectal Juxtatectal Transtectal
  58. 58. 23-year-old woman with transverse acetabular fracture AP pelvic radiograph Bilateral oblique pelvic radiographs Axial CT scan surface- rendering 3D CT viewed laterally, with right hemipelvis and femur removed
  59. 59. Transverse fractures are sagittal plane fractures whereas both column fracturesare coronal plane fractures. Transverse Fracture
  60. 60. A.Coronal plane fracture B.Sagittal plane fracture
  61. 61. CT cut of transverse fracture in the sagittal plane
  62. 62. Associated types Post. Wall & post. column Transverse & post. Wall or column T-shaped Ant column or wall & post hemitransverse Both columns
  63. 63. Othopaedic Review CourseOthopaedic Review Course January 2010January 2010 T-fracture Transverse/post.wall Post.wall/post.column Ant.post.hemitrans. Ass.both.column
  64. 64. Posterior Column-Posterior Wall
  65. 65. Transverse fracture of any type + Vertical fr through the isciopubic fragment The vertical component is best seen on the obturator oblique view. T-shaped fracture
  66. 66. The T-shaped fracture is similar to a both-column fracture in that it disrupts the obturator ring. Another similarity is disruption of both the iliopectineal and ilioischial lines. However, the superior extension of the fracture does not involve the iliac wing, which allows differentiation from the both- column fracture. T-shaped fracture
  67. 67. One area of potential confusion with the Tshaped fracture is in regard to the transverse component. The transverse fracture line is not actually in the anatomic transverse plane, but rather it is transverse relative to the acetabulum. Because the cup shape of the acetabulum is normally tilted inferiorly and anteriorly, the transverse fracture plane assumes a similar orientation. Therefore, on radiographs, the fracture lines that disrupt the iliopectineal and ilioischial lines course superiorly and medially in an oblique plane from the acetabulum. This is best appreciated by looking at the acetabulum en face. On CT, this transverse fracture component is seen as a sagittally oriented fracture coursing medially and superiorly from the acetabulum. T-shaped fracture
  68. 68. T-type fractures differ from transverse fractures by the additional fracture line that runs through the quadrilateral surface. As a result, the anterior column and posterior column are separated by fracture lines. This becomes important when choosing a surgical approach to the acetabulum. In a pure transverse fracture, the anterior and posterior columns may be reduced through a single approach. Once the anterior column has been reduced, the posterior column will follow the reduction and can be palpated indirectly. T-shaped fracture
  69. 69.  Radiograph of a T-type fracture.  Note the undisplaced fracture in the ischiopubic ramus.  This break in the obturator ring correlates with an additional fracture line in the quadrilateral plate.
  70. 70. In a T-type fracture, the 2 columns must be reduced independently. This becomes extremely important when choosing a surgical approach; therefore, it is important to recognize the subtle difference between transverse and T-type fractures when they are not significantly displaced. T-shaped fracture
  71. 71. 2-D CT cut of T-type fracture
  72. 72. Note in the T-type fracture the anterior and posterior columns are disassociated
  73. 73. 40-year-old man with T-shaped acetabular fracture AP pelvic radiograph Bilateral oblique pelvic radiographs Axial CT scan Surface-rendering 3D CT viewed laterally, with right hemipelvis and femur removed
  74. 74. Transverse fracture + Comminuted posterior wall fracture (usually displaced) The iliopectineal and ilioischial lines are disrupted. The obturator oblique view best demonstrates the position of the transverse component as well as the Transverse and posterior wall fracture
  75. 75. Transverse and posterior wall fracture
  76. 76. 20-year-old man showing transverse with posterior wall acetabular fracture AP pelvic radiograph Bilateral oblique pelvic radiographs axial CT scan surface- rendering 3D CT viewed laterally, with right hemipelvis and femur removed
  77. 77. Anterior Column-Posterior Hemitransverse
  78. 78. Both columns are separated from each other and from the axial skeleton, resulting in a ‘floating’ acetabulum This is the most complex type of acetabular fracture. A both columns fracture can be considered a ‘high’ T-shaped fracture where both columns have been separated from the sciatic buttress. Both-column fracture (formerly called ‘central acetabular fracture’)
  79. 79. The "spur-sign," best seen on the obturator oblique view, is pathognomonic for the both-column fracture. This sign represents posterior displacement of the sciatic buttress of the iliac wing fracture, which essentially disconnects the roof of the acetabulum from the axial skeleton. When this occurs, weight from the torso and upper body can no longer be supported by the acetabulum. Both-column fracture (formerly called ‘central acetabular fracture’) "Spur-sign" seen on the obturator oblique view
  80. 80. On radiographs and CT, the spur sign appears as a shard of bone extending posteriorly at the level of the superior acetabulum. Evaluation of sequential CT images shows the fracture, which separates the sciatic buttress from the acetabular roof. Both-column fracture (formerly called ‘central acetabular fracture’)
  81. 81. 35-year-old man with a both-column fracture Oblique pelvic radiograph (A) and axial CT image (B) show spur sign (arrow), which represents displacement of fracture involving sciatic buttress (arrowheads). Note that sciatic buttress (arrowheads, B) no longer connects to weight-bearing portion of acetabulum. A B
  82. 82. 45-year-old man with both-column acetabular fracture AP pelvic radiograph Bilateral oblique pelvic radiographs Axial CT scan sagittal reconstruction CT scan
  83. 83. 3-D CT scan of a both-column acetabular fracture; obturator3-D CT scan of a both-column acetabular fracture; obturator oblique viewoblique view
  84. 84. 3-D CT scan of a both-column acetabular fracture; iliac oblique view3-D CT scan of a both-column acetabular fracture; iliac oblique view
  85. 85. Line drawing of fracture on a pelvic model
  86. 86. Cases
  87. 87. Case 1
  88. 88. Disrupción del anillo obturador + extensión a pala iliaca  FRACTURA BICOLUMNARIA
  89. 89. Case 2
  90. 90. Disrupción del anillo obturador + SIN extensión a pala iliaca  FRACTURA en “T”
  91. 91.  Subsequent to the pioneering work of Judet and Letournel, their classification was then used as the basis for formulating an alphanumeric computerized format and the Comprehensive Classification of Fractures of the Acetabulum was developed.  This effort was spearheaded by SICOT International Documentation and Evaluation Committee and the AO/ASIF Foundation under the leadership of Maurice E. Muller.  Each fracture is classified according to morphological characteristics, and subdivided into types, groups, and subgroups.  The system is especially beneficial for research database applications. Classification (The Comprehensive Classification of Fractures of the Acetabulum)
  92. 92. The Comprehensive Classification of Fractures of the Acetabulum
  93. 93. References  Durkee NJ, Jacobson J, Jamadar D, Karunakar MA, Morag Y, Hayes C: Classification of Common Acetabular Fractures: Radiographic and CT Appearances. AJR 2006; 187: 915-925  Gänsslen A, Oestern HJ: Azetabulumfrakturen. Chirurg 2011; 82:1133–1150  Jimenez ML: Classification of Acetabular Fractures. Medscape.com  Pagenkopf E, Grose A, Partal G, Helfet DL: Acetabular Fractures in the Elderly: Treatment Recommendations. HSSJ (2006) 2: 161–171
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Part 1 of a lecture on acetabular fractures (Anatomy, Evaluation and Classification) by Dr Muhammad Abdelghani

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