Module 4 - Evaluation of the Lower Extremity

Lower Extremity Conditions

Condition: Acetabular Fracture
I. Diagnostic Imaging
A. X-ray
Frontal view

Case courtesy of Dr Henry Knipe, <a

href="http://radiopaedia.org/">Radiopaedia.org</a>. From the case <a
href="http://radiopaedia.org/cases/35345">rID: 35345</a>
II. ABC (X-ray)
Alignment:
-gross normal size of bones
-normal number of bones
- displaced and comminuted fracture of the left acetabulum extending to the left
superior pubic rami
Bone Density:
-sufficient contrast soft tissue shade of gray and bone shade of gray
-sufficient contrast within each bone, between cortical shell and cancellous center
-normal trabecular architecture
-sclerosis at areas of increased stress, such as weight-bearing surfaces or sites of
ligamentous, muscular, or tendinous attachments
Cartilage Spaces:
-smooth surface
-normal size relative to epiphysis and skeletal age
Soft tissues:

-normal size of soft tissue image

-radiolucent crescent parallel to bone

-radiolucent lines parallel to length of muscle

-normally indistinct joint capsules

-normally indistinct periosteum

-soft tissues normally exhibit a water density shade of gray

B. CT Scan
Coronal view
Comminuted left acetabular fracture with medial and superior displacement of the
femoral head

Case courtesy of Dr Henry Knipe, <a

href="http://radiopaedia.org/">Radiopaedia.org</a>. From the case <a
href="http://radiopaedia.org/cases/35345">rID: 35345</a>
C. MRI
Ti-weighted MRI showing fracture of posterior wall of acetabulum

III. Mechanisms of injury for the condition and the appropriate course of
action
 In young adults, this type of fracture occur primarily as a result of high energy
trauma.
 Involve the hip joint: may be displaced and non-displaced
 can result from falls, automobile accidents or other traumatic events

IV. Classification and Radiologic Findings

The AP pelvic radiograph demonstrates distinctly the landmark lines that
designate the intact borders of the acetabulum. Oblique pelvic views can also be used to
display the anterior or posterior columns of acetabulum without superimposition. To
identify fracture configuration, the degree of fracture and associated fractures, CT scans
are valuable.
Determination of the proper surgical management of acetabular fractures depend
on accurate classification. Different classifications of these fractures have been
suggested but the Judet-Letournel classification is still the most widely accepted.3
 a. Both-Column fracture
-involves both anterior and posterior columns
-extends into the obturator ring and iliac wing
-one of the most common acetabular fractures
 On radiographs: fracture involvement of the anterior and posterior
columns is characterized by disruption of the iliopectineal line and
ilioischial line, respectively
: Obturator ring and iliac wing involvement must also be present to be
classified as a both-column acetabular fracture
 Pathognomonic sign: spur sign
b. T-shaped fracture
-combination of a transverse acetabular fracture with extension inferiorly
into the obturator ring
-disrupts the obturator ring
-superior extension of the fracture does not involve the iliac wing
 On radiographs: disruption of both the iliopectineal and ilioischial lines;
the fracture lines that disrupt the iliopectineal and ilioischial lines course
superiorly and medially in an oblique plane from the acetabulum
 c. Transverse fracture
-limited to the acetabulum
-no involvement of the obturator ring
-must involve both the anterior and posterior aspects of the acetabulum
-fracture line extends superiorly and medially from the acetabulum
 On radiographs: iliopectineal and ilioischial lines are disrupted
On CT: characteristic sagittally oriented fracture line can be seen moving
laterally to medially on subsequent CT images when scrolling from inferior
to superior
d. Transverse with Posterior Wall
-transverse fracture with the addition of a comminuted posterior wall fx
-often displaced
-obturator ring is not disrupted
-does not extend into the iliac wing
-additional comminution of the posterior wall is seen
 On radiographs: disruption of both iliopectineal and ilioischial lines is
seen
e. Isolated Posterior Wall
-one of the most common types of acetabular fracture (prevalence of 27%)
- does not have a complete transverse acetabular component
-iliopectineal line is not disrupted
-disruption of the ilioischial line may or may not be present as an
extension of the comminuted posterior wall component
Another classification of acetabular fracture is one related to anatomic position6.
The iliopubic area composes the anterior column while the ischial area composes the
posterior column. These divisions meet at the center of the acetabulum. Acetabular
fractures are defined as the ff:
1. Anterior column fracture
2. Posterior column fracture
3. Transverse fracture (involves both columns)
4. Complex fractures (involves a T-shaped configuration)
**most common acetabular fractures: Posterior lip and Posterior column**
-frequently associated with femoral head impaction or post dislocation of femoral
head
-often called dashboard fractures as they result from the knee striking the
dashboard on motor vehicle accidents

V. Surgical vs. Conservative management

 Operative management is the mainstay of treatment for displaced
acetabular fractures (displacement of the fragment is greater than 3mm,
operation—ORIF is primarily suggested)8
 Elderly patients may not always be good candidates for ORIF d/t
possibility of Osteoporosis
 Primary reason for surgery: to allow early ambulatory function
o Also, to decrease the chance of posttraumatic arthritis (Displaced
intraarticular fractures that are allowed to heal in an abnormal
position may lead to posttraumatic arthritis4)
 The accepted treatment is surgical reduction of the fracture and internal
fixation with metallic screws and plates
o Hardware is placed outside of the hip joint and acts as an "internal
cast" until the bone heals. The plates and screws are not routinely
removed.
**most common complications with surgical treatment of acetabular
fractures are:
- Iatrogenic nerve palsy
- Heterotopic bone formation
- Thromboembolic complications
 Nonsurgical treatment indications:
o when there is tolerable incongruity noted on radiographic analysis
 includes incongruity in a non–weight-bearing position of the
acetabulum
 incongruity of less than 1mm
o if there are contraindications to surgery
 these might include ongoing local or systemic infection,
severe osteoporosis, associated soft-tissue and visceral
injuries, and critical medical co-morbidities
 Advanced age is a relative contraindication to surgery
 However, many elderly patients benefit from surgical
fixation of acetabular fractures
  Skeletal traction and close monitoring are advocated for non-displaced
acetabular fracture with good congruity of the hip joint
VI. Physical Therapy and Rehabilitation
 This non-operative management is advised to patients with undisplaced or with
minimal displacement (ex: low ant column or low transverse fx) or the superior
part of the acetabulum should be intact8
 Rehabilitation is focused on maintaining ROM and progressive ambulation with
protected weight bearing as well as pain control, functional PT, stabilization
exercises and mobility training and radiographic follow up
 After internal fixation, patients are encouraged to ambulate with protected
weight bearing until radiographic healing is shown, at which point weight bearing
is increased.1
o Those who underwent surgery have to start with PROM exercises followed
by AROM with no weight bearing such as a series of flexion/extension
o Partial weight-bearing usually starts 6 weeks postoperatively and full
weight bearing is eventually allowed at around the 10th week8

References:

1. About OA: Southern Maine orthopedic specialists for foot pain, ankle pain, hand pain,
shoulder pain, back pain, bone fractures, MRI, physical therapy, and sports medicine.
http://www.orthoassociates.com/SP11B26/. Accessed July 3, 2016.
2. Pagenkopf E, Grose A, Partal G, Helfet DL. Acetabular fractures in the elderly:
Treatment recommendations. HSS J. 2006 Sep; 2(2): 161–171.
3. Durkee NJ, Jacobson J, Jamadar D, Karunakar MA, Morag Y, Hayes C. Classification
of common Acetabular fractures: Radiographic and CT appearances. American Journal
of Roentgenology. 2006;187(4):915–925.
4. Tile, M. Fractures of the pelvis and acetabulum. Baltimore:Williams & Wilkins; 1984
5. Potter HG, Montgomery KD, Heise CW, Helfet DL. MR imaging of acetabular
fractures: Value in detecting femoral head injury, intraarticular fragments, and sciatic
nerve injury. American Journal of Roentgenology. 1994;163(4):881–886.
6. Mckinnis LN. Fundamentals of Musculoskeletal Imaging. 4th ed. Philadelphia, PA:
F.A Davis; 2014: 381-383
7. Kisner, C, Colby, LA. Therapeutic Exercise: Foundations and Techniques. 6 th edition.
F.A. Davis Co.; 2012.
8. Buxton S, Delagrange L, Lowe T, Rozenbergs D. Acetabulum fracture - Physiopedia,
universal access to physiotherapy knowledge. http://www.physio-
pedia.com/Acetabulum_fracture. Accessed July 8, 2016.