FRACTURES OF THE ACETABULUM*

W. RUSSELLMACAUSLAND, M.D. AND HAROLD G. LEE, M.D.

Surgeon-in-Chief, Orthopedic Department, Carney Orthopedic Surgeon, Carney Hospital
Hospital
BOSTON, MASSACHUSETTS

A
MONG the varieties of fractures of out the fact that the prognosis in such
the acetabuIum that present prob- injuries must be guarded, regardIess of the
Iems in treatment, and which from accuracy of reduction and the care taken

FIG. I. Case I. L. H. Roentgenogram taken one week after

manipuIation and traction, showing the acetabuIar frag-
ment stil1 disptaced and the femora1 head incompIeteIy
reduced.

a prognostic standpoint are of specia1 in- to protect the joint from weight-bearing
terest are: (I) Fracture of the upper and unti1 consoIidation is compIete.
posterior rim of the acetabuhrm associated
CASE REPORTS
with disIocation of the femoraI head and
dispIacement of a fragment, and (2) com-
CASEI. L. H., a man forty-two years of age,
was injured in a raihoad accident on December
minuted fractures of the acetabuIar floor
24, 1943, sustaining a posterior dislocation of
with intrapeIvic penetration of the femora1
the right hip which was compIicated by a
head. fracture of the upper and posterior rim of the
In the folIowing case reports, ihustrative acetabulum. A roentgenogram taken at the
methods of handling these types of frac- time of the injury showed the femoral head
tures are presented. Late evahration of the disIocated upward and backward, and the
. .
end resuIts in these cases cIearIy brought upper posterror rrm of the acetabuhrm torn
* From the MacAusIand Orthopedic Clinic.
213
214 American Journal of Surgery MacAusIand, Lee-AcetabuIum AUGUST, 1945

away and dispIaced in the same direction as crest. A subperiosteal dissection was carried
the femoraI head. An attempt was made by a out, exposing the fracture. The blood cIots
IocaI surgeon to reduce the disIocation by were removed. The disIocated femora1 head was

FIG. 2. Case I. L. H. AcetabuIar fragment fixed in place

with a screw.

manipuration and the use of Iongitudinal readily reduced. The Iip fragment was replaced
skeIeta1 traction, which was estabhshed by and fixed in position with a screw. (Fig. 2.)
introducing a pin in the lower femur and appIy- The gIutea1 ffap was repIaced, and the peri-
ing forty pounds of weight. After twenty-four osteum sutured aIong the iIiac crest. The skin
hours, the weight was reduced to thirty pounds, was cIosed with interrupted sutures. A tightIy
and Iater to fifteen pounds. Although the fitted fIanne1 spica was applied to provide
reduction of the hip was maintained by this compression.
means, the dispIaced fragment was not affected Traction was estabIished by means of a
and upon the release of the traction, the femoral Steinmann pin, which had been pIaced in the
head again disIocated. (Fig. I.) Iower femur prior to the surgical interference,
Operative treatment was as foIIows: On and the appIication of ten pounds of weight,
January 5, 1944, the patient was placed prone the object of this traction being to prevent the
on the operating tabIe, with the right hip femora1 head from pressing against the re-
sIightIy elevated. General anesthesia was used. placed acetabular fragment. This traction was
The upper posterior rim of the acetabuIum maintained for a period of six weeks. During
was approached by an incision that started just this time, roentgenograms were taken at
beIow the anterior superior spine, and folIowing reguIar intervals to check the position of the
the Iine of the iIiac crest, extended to the femora1 head and the acetabular fragment.
posterior superior spine. The incision was Because of the complications of phlebitis and
carried down through the periosteum of the an emboIus to the lung, this patient remained
NEW SERIES VOL. LXIX. No. 2 MacAusIand, Lee-AcetabuIum American Journal uf Surgery 213

in bed for three weeks after the traction had poor condition of the patient, interference had
been removed. No motion at the hip was per- to be postponed for a week.
mitted during the entire two months that the At operation a straight incision was made
patient remained in bed.
On March 8, 1944, the patient began to waIk
with the aid of crutches, and was encouraged
to practice muscle contractions. At the end of
March, he was touching the toe of the injured
extremity to the floor.
By May, 1944, the motion at the hip was
normal. The patient was walking well with the
aid of a cane. On August 9, 1944, when the
patient was last examined, he was walking we11
without support; there was no limp and the
motion at the hip was normaI. A roentgenogram
showed the fragment in excehent position. (Fig.
3.) AIthough up to this writing, the functional
recovery has been exceheut, it is too earIy to
determine the fIna outcome, in view of the
possibility of the later development of degen-
erative changes foIlowing such injuries.
CASE II. E. B., a maIe nineteen years of
age, was injured in an automobiIe accident on
January 31, 1942, sustaining a fracture of the
FIG. 3. Case I. L. H. Roentgenogram taken seven
upper acetabular rim associated with a pos- months after fixation of the acetabuIar frag-
terior disIocation of the femoral head. (Fig. 4.) ment.

FIG. 4. Case II. E. B. Roentgenogram FIG. pi. Case II. E. B. Postoperative roent-
showing posterior disIocation of the genogram showing perfect position four
hip with dispIacement of a Iarge frag- days after reduction of the disIocation and
ment of the acetabular rim. fixation of the acetabular fragment.

Because of the size of the fragment, operative posterior to the greater trochanter, in the line
reduction was advised, but on account of the of the femur. The muscles were separated,
216 American Journal of Surgery MacAusIand, Lee-Acetabuhm

FIG. 6. Case III. J. S. Roentgenogram taken folIowing manipuIation,

showing acetabular fragment stiI1 dispIaced.

FIG. 7. Case III. J. S. Postoperative roentgenogram
taken two years after reduction, showing mottIing,
necrosis, and Aattening of the femora1 head.
FIG. 8. Case 111.J. S. Postoperative roent-
genogram taken nearly six years after
reduction, showing mottIed density of
the femora1 head with distortion,
and increased density of the entire
acetabulum.
NEW VOL.LXIX, No. z?
SERIES MacAusIand,
exposing the fracture. The disIocated femoraI
head was readiIy reduced, and the fragment
replaced and fixed in position with a screw,
FIG. 9. Case IV. E. G. Fracture of the acetabular floor
with intrapelvic penetration of the femoral head.
which was directed upward and backward.
(Fig1 5.) The wound was cIosed. A plaster
spica extending from the rib Iine to the ankle
was appIied, with the extremity in the position
of slight eversion and abduction of twenty-five
degrees.
Within two weeks the patient w:*s walking
with the aid of crutches. Eight weeks after the
operation, the Iower part of the plaster cast
from the knee down was removed, and three
months from the time of the injury, the
remainder of the cast was removed. At that
time weight-bearing was resumed.
This patient has perfect function of the hip
at the present time (October Ig44), and for
two years he has been in the Air Force in
Europe.
CASE III. J. S., a man forty-five years of
age, on March 26, 1938, was thrown from a
wagon, and one of the wheels ran over him.
His right hip was dislocated posteriorly, and a
Lee-AcetabuIum American Journal or surgery 2 I7
large fragment was broken off from the upper
posterior rim of the acetabulum, and dispIaced.
On the same day as the injury, when the patient
had recovered suffIcientIy from shock, an
attempt was made to reduce the fracture dis-
location by manipuIation. The broken acetabu-
Iar segment failed to faI1 into pIace. (Fig. 6.)
At operation on April I, 1938, reduction and
fixation of the fragment were carried out
according to the technic that has been de-
scribed under Case II, except that a bone screw
was used to anchor the fragment. Weight-
bearing was begun in three months after the
operation.
The hip recovered good function, there being
only a slight Iimitation of motion in abduction
and rotation. However, a roentgenogram
taken in March, 1940, two years after the
injury, showed evidence of mottling, necrosis,
and flattening of the femora1 head. (Fig. 7.)
Another check roentgenogram taken on Feb-
ruary 18, 1944, nearly six years after the
injury, showed a mottled density of the femoral
head with a smaI1 amount of distortion, and
218 A me&an Journal of Surgery MacAusIand, Lee-AcetabuIum AUGUST, rgq~

increased density of the entire acetabuIum. operative indications were recognized im-
There was aIso partiaI destruction of the joint mediateIy. Surgical fixation is practicaIIy
consistent with degenerative arthritis. (Fig. aIways indicated in fractures at a depend-
ent point of the acetabular rim, and in
addition to ensuring anatomica repIace-
ment, fixation has the advantage of
shortening the convalescence and of pro-
moting earIy union.
CASE III iIIustrates the development of
necrosis of the femoral head after a period of
apparent recovery. Two years after operative
fixation, abnorma1 changes had appeared in
the femora1 head, and six years after the injury,
there was extensive destruction of the hip joint.
The significance from an industria1 standpoint
of such deIayed degeneration of the femoral
head, which produces an arthritic hip with
Iimited and painfu1 motion, is manifest.
CASE IV. E. G., a man fifty-three years of
age, on January 18, 1942, received a fracture
of the acetabuIum in an automobile accident.
Following the injury he was in severe shock,
and the abdomen was distended slightly.
Roentgenographic examination of the hip
showed the floor of the acetabuIum driven
inward in one piece. (Fig. 9.) Two days after
the fracture, when the patient had recovered
from shock, reduction was carried out as
foIIows :
With the patient under spina anesthesia, a
Kirschner wire was inserted through the base
of the greater trochanter at a right angle to the
shaft of the femur. A plaster spica with a Iong
outrigger equipment incorporated was appIied
to the peIvis and the injured extremity. (Fig.
IO.) An opening was made in the cast of suff~-
cient size to aIIow for the correction of deform-
ity, VisuaIization, and adjustment. Traction
FIG. IO. Case IV. E. G. An outrigger equip-
ment to provide for IateraI traction. in the Iine of the femoral neck was estabIished
by means of eIastic bands. (An attempt to
8.) At that time, the hip had compIete Aexion palpate the fragments through the rectum was
movement, approximately thirty-five degrees only moderateIy satisfactory.) Roentgeno-
of rotation, and abduction of twenty-five graphic examination foIlowing the appIication
degrees. of the traction showed that the femoral head
had been pulIed out and was in good position.
COMMENT (Fig. II.)
Six weeks after the reduction, the pIaster
In two of the cases that have been re-
spica was removed, and the patient began to
ported, surgica1 replacement of the ace- waIk with the aid of crutches. Active motion
tabuIar fragment was carried out when the at the hip was started, but no weight-bearing
fragment faiIed to faI1 into norma position was permitted. At the end of three months
upon manipuIative reduction of the dis- from the time of the injury, the patient began
located femoral head. In the third case to bear weight. Throughout the convaIescence,
NEW SERIES VOL. LXIX. No. z MacAusIand, Lee-Acetabulum American Journal of Surgery 2 I9

roentgenograms were taken to check the This patient had been treated by
position. establishing lateral traction. Although this
One year after the injury, roentgenograms is the generally recognized treatment of

FIG. 11. Case W. E. G. Roentgenogram show- FIG. 12. Case IV. E. G. Roentgenogram taken two
ing the femoraI head puIIed out of the coty- and one-half years after reduction by traction,
Ioid cavity by IateraI traction. showing a narrowed joint space, with prolifer-
ative changes about the femoral head and acr-
showed a well heaIed and reconstituted acetab- tabulum, and some distortion of the acetabulum.
uIar floor, and a good joint space. ClinicaIly,
there was sIight Iimitation in externa1 rotation intrapeIvic disIocations of the femoral
and abduction; other motions were free. The head, whe~n the capsular attachments of
patient had no limp. Further roentgenograms
the acetabular fragments are torn, few
were taken in October, 1944, two and a haIf
methods of obtaining such lateral traction
years after the injury. At that time the joint
space was narrowed, there were proliferative have been suggested. For the most part,
changes about the femoral head and acetab- attempts to provide lateral traction by
ulum, and there was some distortion of the means of adhesive tape on the thigh, with
acetabulum. (Fig. 12.) CIinicaIIy, abduction weights attached, have been abandoned.
and rotary motions were definiteIy limited. Methods of obtaining more direct traction
by means of introducing a Steinmann pin,
COMMENT
nail, or screw in the trochanteric region,
Case IV iIIustrates again the develop- and establishing a continuous pull, have
ment of late destructive changes in the hip been suggested by Putti, Leveuf, Fitte,
joint. Whereas one year after the injury, and Moore.
there was a good joint space and a we11 Putti’s method consists of introducing
constructed acetabular floor, one and a a nai1 verticaIly through the greater
half years later, roentgenograms showed trochanter by two incisions, one for its
marked destructive changes in the joint. entrance and one for its exit. Both ends of
Motions at the joint were markedly the nail protrude, and to them is attached
decreased. elastic that is fixed to a metallic arch
220 American Journal of Surgery MacAusIand, Lee-AcetabuIum AUGUST. ,945

incorporated in a femoraI-peIvic cast. disIocation of the femora1 head has been

Traction is exerted manuaIIy in both presented. A method of obtaining IateraI
directions before the pIaster cast is appIied. traction by means of an outrigger incor-
In Leveuf’s method, a Iong nai1 is in- porated in a pIaster cast has been described.
troduced into the Iower part of the femoraI Late examination in one case of fracture
neck, and a pIaster cast is appIied extend- of the acetabular rim and in the case of
ing to the knee, with a window cut out intrapeIvic disIocation showed degenera-
over the trochanteric region. Reduction is tive changes in the joint, confirming the
obtained by means of a specia1 metaIIic genera1 opinion that fina resuIts in these
apparatus that is incorporated in the cases must not be evaIuated unti1 from
plaster cast and attached to the nai1. It two to three years after the injury. The
is Leveuf’s opinion that in extreme dis- prognosis wouId seem to be more favorabIe
pIacements of the femoraI head, it is more when anatomica reduction is carried out
efficient to introduce the nai1 into the earIy, and when the patient is not per-
femora1 neck than into the greater tro- mitted to bear weight unti1 the fracture
chanter. Leveuf Iater used a screw in pIace is we11 heaIed.
of the nai1, which is Iess IikeIy to sIip
before consoIidation is compIete. Success- REFERENCES

fu1 use of this method has been reported FITTE, M. La traccibn esquekica con Ia tirabuz6n en
las fracturas d&l cotilo. Bol. y trah. de la Sot. de cir.
by RigaI, who added a weight to the
de Buenos Aires, 22: 249, 1938.
reguIar metaIIic apparatus, in order to MOORE, J. R. Fractures of the upper end of the femur
obtain IongitudinaI reduction. including fracture dislocations at the hip joint.
Am. J. Surg., 44: 117, 1939,
LEVEUF, J. Fracture par enfoncement du cotyle avec
SUMMARY p&&ration intrapeIvienne de Ia t&e f&morale
(deuxiPme observation). Bull. et m6m. .Soc. not.
Three cases of fracture of the acetabuIar de cbir., 58: 1537, 1932.
rim associated with a posterior disIocation LEVEUF, J. and PAKOWSKI. Fracture par enfoncement
du cotyIe avec p&kration intrapelvienne de Ia
of the hip have been presented. SurgicaI t&e fCmora1. Ibid., p. 818.
repIacement of the acetabuIar fragment PUTTI, V. SuIIa terapia deIIa Iussazione. Cbir. d. org.
has been described. di ??IO~hWntO,I I : 530, 1927.
RIGAL. Fracture de Ia cavitk cotvIoide avec &n&ration
One case of fracture of the floor of the de Ia t&te f&morale dans 1e”bassin. Lydn cbir., 36:
acetabuIum associated with intrapeIvic 3% 1939.