Fractures of the Acetabulum

At the request of our publishers, I accepted the task of preparing this second edition. I felt this was necessary for several reasons: new imaging technologies such as CT scanning and 3-D reconstructions are now used routinely, the in­ dications for employing improved approaches are clearer, and reconstructions are facilitated by new internal fixation devices. Above all, I thought it was time to report the long-term results of the 940 acetabular fractures, 90070 of which were treated surgically - a unique series. In spite of the experience acquired from the three previous reviews of cases (1966, 1971, and 1978), I failed to foresee the amount of time this revision would need. In fact, it took more than 3 years to follow up the larger number of cases, and 159 patients (out of 800, i. e. 22. 7%) were not included as they had moved since their last review and simply could not be located. At a time when it is in fashion to evaluate the cost of health care, it is strange to see how public administrators, so keen on evaluating the immediate cost of our opera­ tions, do not care about the quality of their long-term results, which appears to us, however, to be the best basis for the choice of the initial treatment.

Introduction: History and Development of Our Methods of Classification and Treatment of Acetabular Fractures.- 1 Anatomy of the Acetabulum.- 1.1 Columns of the Acetabulum.- 1.2 Posterior Column.- 1.3 Anterior Column.- 1.3.1 Iliac Segment.- 1.3.2 Acetabular Segment.- 1.3.3 Pubic Segment.- 1.4 Structure of the Innominate Bone in Relation to Load-Bearing...- 1.5 Vascular Supply.- 1.5.1 Internal Surface.- 1.5.2 External Surface.- 1.5.3 Acetabulum.- 2 Mechanics of Acetabular Fractures.- 2.1 Force Applied to the Greater Trochanter in the Axis of the Femoral Neck.- 2.1.1 Neutral Abduction-Adduction.- 2.1.2 Abduction and Adduction.- 2.2 Force Applied to the Flexed Knee in the Axis of the Femoral Shaft.- 2.2.1 Hip Joint Flexed 90°.- 2.2.2 Different Degrees of Hip Flexion.- 2.3 Force Applied to Foot with Knee Extended.- 2.3.1 Hip Flexed.- 2.3.2 Hip Extended.- 2.4 Force Applied to Lumbo-sacral Region.- 2.5 Comment.- 2.6 Clinical Correlation.- 2.6.1 Blow on Knee or Dashboard Injuries.- 2.6.2 Blow on Greater Trochanter.- 2.6.3 Blow Under Foot.- 2.6.4 Blow on Sacro-iliac Region.- 2.6.5 Antero-posterior Compression.- 3 Radiology of the Normal Acetabulum.- 3.1 Standard Radiography.- 3.1.1 Anterior-posterior Radiograph of Pelvis.- 3.1.2 Anteroposterior Radiograph of Acetabulum.- 3.1.3 Obturator-oblique Radiograph.- 3.1.4 Iliac-oblique Radiograph.- 3.2 Computed Tomography.- 3.2.1 CT of a Normal Acetabulum.- 3.2.2 Special Advantages of CT.- 3.2.3 Disadvantages of CT.- 3.3 Tomography.- 3.4 Stereo-radiography.- 3.5 Interpreting the Radiographs.- 3.5.1 Interpreting the Standard Views.- 3.5.2 Interpreting the CT Sections to Aid or Complete the Diagnosis.- 4 Classification.- 5 Posterior Wall Fractures.- 5.1 Typical Posterior Wall Fractures.- 5.1.1 Morphology.- 5.1.2 Radiology.- 5.2 Postero-superior Fractures.- 5.2.1 Morphology.- 5.2.2 Radiology.- 5.3 Postero-inferior Fractures.- 5.3.1 Morphology.- 5.3.2 Radiology.- 5.4 Special Forms of Posterior Wall Fractures.- 5.4.1 Extended Posterior Wall Fractures.- 5.4.2 Horizontal Extension of Fracture Line.- 5.4.3 Massive Posterior Wall Fractures.- 5.4.4 Posterior Wall and Incomplete Transverse Fractures.- 5.5 CT Study of Posterior Wall Fractures.- 6 Fractures of the Posterior Column.- 6.1 Typical Posterior Column Fractures.- 6.1.1 Morphology.- 6.1.2 Radiology.- 6.2 Extended Posterior Column Fractures.- 6.2.1 Morphology.- 6.2.2 Radiology.- 6.3 Atypical Posterior Column Fractures.- 6.3.1 Other Associated Pelvic Ring Fractures.- 6.3.2 Epiphyseal Injury.- 6.4 Transitional Posterior Column Fractures.- 6.4.1 Partial Superior Fractures.- 6.4.2 Partial Inferior Fractures.- 6.5 CT Study of Posterior Column Fractures.- 7 Anterior Wall Fractures.- 7.1 Morphology.- 7.2 Radiology.- 7.2.1 Antero-posterior View.- 7.2.2 Obturator-oblique View.- 7.2.3 Iliac-oblique View.- 7.3 Atypical Examples.- 7.4 CT Study of Anterior Wall Fractures.- 8 Fractures of the Anterior Column.- 8.1 Morphology.- 8.1.1 Very Low Fractures.- 8.1.2 Low Fractures.- 8.1.3 Intermediate Fractures.- 8.1.4 High Fractures.- 8.1.5 Atypical Examples.- 8.2 Radiology.- 8.2.1 Very Low Fractures.- 8.2.2 Low Fractures.- 8.2.3 Intermediate Fractures.- 8.2.4 High Fractures.- 8.2.5 Atypical Examples.- 8.3 CT Study of Anterior Column Fractures.- 9 Pure Transverse Fractures.- 9.1 Morphology.- 9.1.1 Orientation of Fracture.- 9.1.2 Displacement in Transverse Fractures.- 9.2 Radiology.- 9.2.1 Antero-posterior View.- 9.2.2 Obturator-oblique View.- 9.2.3 Iliac-oblique View.- 9.3 Atypical Cases.- 9.4 CT Scan Study of Transverse Fractures.- 10 T-shaped Fractures.- 10.1 Morphology.- 10.1.1 Transverse Component.- 10.1.2 Stem Component.- 10.1.3 Displacement.- 10.2 Radiology.- 10.2.1 Transverse Component.- 10.2.2 Stem Component.- 10.3 Atypical Examples.- 10.3.1 Additional Vertical Fracture of Obturator Ring.- 10.3.2 Additional Fracture Line in Cotyloid Fossa.- 10.3.3 Association of a Posterior Column and an Anterior Hemitransverse Fracture.- 10.4 CT Study of T-Shaped Fractures.- 11 Associated Posterior Column and Posterior Wall Fractures.- 11.1 Morphology.- 11.1.1 Posterior Wall Component.- 11.1.2 Posterior Column Component.- 11.2 Radiology.- 11.2.1 Antero-posterior View.- 11.2.2 Obturator-oblique View.- 11.2.3 Iliac-oblique View.- 11.3 Atypical Examples.- 11.4 Comment.- 11.5 CT Study of Associated Posterior Column and Posterior Wall Fractures.- 12 Associated Transverse and Posterior Wall Fractures.- 12.1 Cases with Posterior Dislocation.- 12.1.1 Morphology.- 12.1.2 Radiology.- 12.1.3 Atypical Examples.- 12.2 Cases with Central Dislocation.- 12.2.1 Morphology.- 12.2.2 Radiology.- 12.3 Comment.- 12.4 Very Large Postero-superior Fragment Extending to the Iliac Crest.- 12.5 CT Study of Associated Transverse and Posterior Wall Fractures.- 13 Associated and Posterior Hemitransverse Fractures.- 13.1 Morphology.- 13.1.1 Anterior Fractures with Associated Complete Posterior Hemitransverse Fracture.- 13.1.2 Anterior Fractures with Associated Incomplete Posterior Hemitransverse Fractures.- 13.1.3 Important Remarks.- 13.2 Radiology.- 13.2.1 Anterior Fracture.- 13.2.2 Posterior Column Fracture.- 13.2.3 A Special Feature of this Group.- 13.3 Atypical Examples.- 13.4 Radiological Differential Diagnosis.- 13.5 CT Study of Associated Anterior and Posterior Hemitransverse Fractures.- 14 Associated Both-Column Fractures.- 14.1 Morphology.- 14.1.1 Posterior Column Components.- 14.1.2 Additional Posterior Components.- 14.1.3 Anterior Column Component.- 14.1.4 Result of Both-Column Fracture.- 14.1.5 Displacement of the Fragments and the Femoral Head ..- 14.1.6 Atypical Examples.- 14.1.7 The Key to Reconstruction.- 14.2 Radiology.- 14.2.1 Antero-posterior View.- 14.2.2 Obturator-oblique View.- 14.2.3 Iliac-oblique View.- 14.3 Summary.- 14.4 Atypical Examples.- 14.5 Differential Radiological Diagnosis.- 14.6 CT Study of Associated Both-Column Fractures.- 15 Transitional and Extra-articular Forms.- 15.1 Transitional Forms.- 15.2 Extra-articular Forms.- 16 Associated Injuries.- 16.1 Injury of the Femoral Head.- 16.1.1 Macroscopic Injury.- 16.1.2 Vascular Injury.- 16.1.3 Molecular Injury.- 16.2 Capsular Injury.- 16.3 Vascular Injury.- 16.3.1 Acetabular Wall.- 16.3.2 Pelvic Vessels.- 16.3.3 Retro-peritoneal Haematoma.- 16.4 Other Pelvic Injuries.- 16.5 Associated Hip Injuries.- 16.6 Other Skeletal Injuries.- 16.7 Urinary Tract Injuries.- 16.8 Other Visceral Injuries.- 16.9 Associated Skull Trauma.- 16.10 Sciatic Nerve Injuries.- 17 Distribution of the Clinical Series.- 17.1 Distribution According to Age.- 17.2 Distribution According to Sex.- 17.3 Distribution According to Time After Injury.- 18 Clinical Presentation.- 18.1 Clinical Findings.- 18.1.1 Posterior Dislocation.- 18.1.2 Central Dislocation.- 18.2 Early Complications.- 18.2.1 Traumatic Shock.- 18.2.2 Retro-peritoneal Haematoma.- 18.2.3 Pre-operative Sciatic Nerve Injury.- 18.2.4 Morel-Lavallé Lesion.- 18.2.5 Intra-articular Incarceration of Bone Fragments.- 18.2.6 Other Types of Palsies.- 18.3 Special Cases.- 18.3.1 Children.- 18.3.2 Elderly Patients.- 18.3.3 Pathological Fractures.- 19 General Principles of Management of Acetabular Fractures.- 19.1 Conservative Treatment.- 19.1.1 Indications.- 19.1.2 Methods.- 19.1.3 Results.- 19.2 Justification for Operative Treatment.- 19.3 Indications for Operative Treatment.- 19.4 Timing of Surgery.- 20 Surgical Approaches to the Acetabulum.- 20.1 Classical Approaches.- 20.2 Kocher-Langenbeck Approach.- 20.2.1 Technique.- 20.2.2 Application.- 20.2.3 Closure.- 20.2.4 Dangers.- 20.2.5 Complications.- 20.3 Ilio-femoral Approach.- 20.3.1 Technique.- 20.3.2 Application.- 20.3.3 Closure.- 20.3.4 Dangers.- 20.3.5 Complications.- 20.4 Ilio-inguinal Approach.- 20.4.1 Technique.- 20.4.2 Application.- 20.4.3 Closure.- 20.4.4 Dangers.- 20.4.5 Complications.- 20.5 Combined Anterior and Posterior Approaches.- 20.6 Extended Ilio-femoral Approach.- 20.6.1 Technique.- 20.6.2 Application.- 20.6.3 Closure.- 20.6.4 Dangers.- 20.6.5 Complications.- 20.7 Post-operative Care.- 20.8 Summary of the Use of Different Surgical Approaches.- 20.9 Addendum: The Kocher-Langenbeck Extended to a Triradiate Approach.- 21 Operative Treatment of Displaced Fractures Within Three Weeks of Injury.- 21.1 Pre-operative Care.- 21.2 Choice of Surgical Approach.- 21.2.1 Kocher-Langenbeck Approach.- 21.2.2 Ilio-femoral Approach.- 21.2.3 Ilio-inguinal Approach.- 21.2.4 Fracture Types for Which There Is a Choice of Approach.- 21.3 Operative Details.- 21.3.1 Where and How to Insert Screws.- 21.3.2 Special Instruments.- 21.3.3 Implants for Osteosynthesis.- 21.3.4 Method of Internal Fixation.- 21.3.5 Reduction of Dislocation.- 21.3.6 Reduction of Fracture.- 21.4 Post-opertive Care.- 21.4.1 Local Care.- 21.4.2 Physiotherapy.- 21.4.3 Medical Treatment. JEAN-PIERRE MOULINIE.- 22 Operative Treatment of Specific Types of Fracture.- 22.1 Posterior Wall Fractures.- 22.1.1 Postero-superior Fractures.- 22.1.2 Postero-inferior Fractures.- 22.1.3 Special Features.- 22.2 Posterior Column Fractures.- 22.2.1 Special Features.- 22.3 Anterior Wall Fractures.- 22.4 Anterior Column Fractures.- 22.4.1 Middle and Low Fractures.- 22.4.2 High Fractures.- 22.4.3 Special Features.- 22.4.4 Insertion of Screws Along the Pelvic Brim.- 22.5 Pure Transverse Fractures.- 22.5.1 Pure Juxta-tectal or Infra-tectal Transverse Fractures.- 22.5.2 Pure Trans-tectal Transverse Fractures.- 22.5.3 Special Features.- 22.6 Associated Posterior Column and Posterior Wall Fractures.- 22.7 Associated Transverse and Posterior Wall Fractures.- 22.7.1 Kocher-Langenbeck Approach.- 22.7.2 Extended Ilio-femoral Approach.- 22.7.3 Special Features.- 22.8 T-shaped Fractures.- 22.8.1 Special Features.- 22.9 Associated Anterior and Hemitransverse Posterior Fractures.- 22.10 Both-Column Fractures.- 22.10.1 Approach.- 22.10.2 Reduction and Fixation Through Posterior Approach.- 22.10.3 Reduction and Fixation Through Ilio-inguinal Approach.- 22.10.4 Reduction Necessitating Both Approaches.- 22.10.5 Reduction and Fixation Through Extended Ilio-femoral Approach.- 22.10.6 A Particular Both-Column Fracture.- 22.11 Special Examples.- 22.11.1 Incarcerated Intra-articular Fragments.- 22.11.2 Bilateral Acetabular Fractures.- 22.11.3 Fractures of Paralysed Hips.- 23 Anatomical Results of Operation Within Three Weeks After Injury.- 23.1 Analysis of the Immediate Radiological Results.- 23.2 Analysis of Imperfect Radiological Reductions.- 23.3 The Learning Curve.- Appendix: CLAUDE MARTIMBEAU’S Method of Assessing Displacement in Acetabular Fractures.- 24 Early Complications of Operative Treatment Within Three Weeks of Injury.- 24.1 Death.- 24.2 Infection.- 24.2.1 Analysis of Post-operative Infections.- 24.2.2 Cause of Infection.- 24.2.3 Prophylaxis.- 24.2.4 Treatment.- 24.3 Nerve Damage.- 24.3.1 Sciatic Nerve Damage.- 24.3.2 Other Nerve Damage.- 24.4 Secondary Displacement of Fracture Site.- 24.5 Thrombo-embolism.- 24.6 Wound Complications.- 24.7 Miscellaneous Complications.- 25 Late Complications of Operative Treatment Within Three Weeks of Injury.- 25.1 Pseudarthrosis.- 25.2 Cartilage Necrosis.- 25.3 Avascular Bone Necrosis.- 25.3.1 Aetiology.- 25.3.2 Time of Presentation.- 25.3.3 Clinical and Radiological Course.- 25.3.4 Clinical and Radiological Results.- 25.3.5 Conclusion.- 25.4 Post-traumatic Osteoarthritis.- 25.4.1 Osteophytes.- 25.4.2 Osteoarthritis.- 25.5 Post-operative Ectopic Ossification.- 25.5.1 Clinical and Radiological Presentation.- 25.5.2 Aetiology.- 25.5.3 Treatment.- 25.5.4 Prevention.- 25.5.5 Results of Surgical Excision of Ectopic Bone.- 25.5.6 Ectopic Ossification and Cranio-cerebral Trauma.- 25.5.7 Ectopic Ossification and Type of Fracture.- 26 Clinical and Radiological Results of Operation Within Three Weeks of Injury.- 26.1 Clinical Results.- 26.1.1 Type of Fracture.- 26.1.2 Age of Patient.- 26.2 Radiological Results.- 26.3 Late Overall Clinical Results and Quality of Reduction.- 26.3.1 Perfect Reductions.- 26.3.2 Imperfect Reductions.- 26.3.3 Conclusions.- 26.4 Summary of Results.- 26.4.1 Early Results.- 26.4.2 Late Results.- 26.5 Conclusions.- 26.6 Comment.- 27 Reassessment of Patients Treated Operatively Within Three Weeks of Injury.- 27.1 Evolution in Patients Operated on Before 1966.- 27.2 Evolution in Patients Operated on 1966-1971.- 27.3 Evolution in Patients Operated on 1971 -1978.- 27.4 Assessment of Patients Operated on 1978-1990.- 27.5 Longitudinal Assessment of All Excellent or Very Good Results.- 28 Operative Treatment Between Three Weeks and Four Months After Injury.- 28.1 Condition of Fracture Healing.- 28.2 Surgical Approach.- 28.3 Surgical Technique.- 28.3.1 Cases with Visible Fracture Lines.- 28.3.2 Mal-union.- 28.3.3 Non-union/Mal-union.- 28.3.4 Neglected Posterior Dislocations of the Femoral Head...- 28.3.5 Incarcerated Fragments.- 28.3.6 Review of Surgical Techniques.- 28.4 Intra-operative Complications.- 28.5 Early Post-operative Complications.- 28.6 Late Post-operative Complications.- 28.7 Results.- 28.8 Conclusion.- 29 Operative Treatment More Than Four Months After Injury.- 29.1 General Considerations and Condition of Fracture Healing.- 29.2 Preconditions for Surgery.- 29.3 Time of Operation After Injury.- 29.4 Choice of Surgical Approach.- 29.5 Surgical Techniques Employed.- 29.5.1 Cases in Which Reconstruction Was Impossible.- 29.5.2 Cases in Which Reconstruction Was Possible.- 29.6 Overview of the 123 Cases Treated More Than Four Months After Injury.- 29.6.1 Reconstruction Impossible (49 Cases).- 29.6.2 Repositioning of Posteriorly Dislocated Femoral Head (11 Cases).- 29.6.3 Missed Incarcerated Fragment (16 Cases).- 29.6.4 Mal-unions, Non-unions, Mal-union/Non-unions.- 29.7 Conclusion.- 30 Exercises in Radiographic Diagnosis.