Acetabulum Fracture

This image shows one of my patient’s X-ray and 3D computerized tomography (CT) scans with a complex pattern Acetabulum Fracture (known as Associated both column fracture). I fixed it with a combination of multiple screws and plate construct as shown on the right.

What is it?
An acetabular fracture is a break in the socket portion of the “ball-and-socket” hip joint. The fracture involves the joint surface that articulates with the femoral head. It needs to be well reduced and fixed to minimize the possibility of painful hip joint arthritis. At times even after a well put together and fixed fracture, arthritis can set it as a result of badly damaged cartilage during the initial trauma.
These are one of the most challenging orthopedic injuries to put back together. Hence, sub-specialist care of these injuries is of particular importance to give the hip joint the maximal possibility to continue functioning without the need for hip replacement.

Cause
These fractures occur two distinct group of people:
• Majority are caused by forceful injury as in case of a car crush in younger patients; and
• Fall from standing in weaker bones (osteoporosis) in the elderly in smaller number of cases

Symptoms

It is almost always painful and patients will have difficulty to walk following trauma as the pain gets worse with movement.
Numbness, weakness or tingling down the leg and foot might follow when associated with nerve injury.
As it occurs mostly as a result of high energy trauma, associated injuries will be symptomatic depending on which part of the body is also injured.

Diagnosis
After emergency stabilization and evaluation, appropriate imaging will be taken.
X-ray of the pelvis will be taken as part of initial routine high energy trauma assessment. Different angle views will show us a more detailed characteristics of the fracture.
A computerized tomography (CT) scan (as seen in the picture above) will further help us understand a more detail view of this complex anatomy and fracture pattern. CT is crucial for planning of the best way to fix these injuries.

Treatment

Things we take into consideration before we decide on how to treat these fractures:
• Pattern of the fracture
• How far apart the fractures pieces are
• Relationship of the ball with the hip socket
• Presence of hip ball dislocation out of the socket
• Overall health of the patient.

Nonsurgical Treatment

Certain fractures can be treated without surgery:

  • When the fracture is stable and not displaced.
  • In patients with higher risk for surgical complications (e.g., heart disease or medical concerns that can get worse during surgery)
  • Fractures that do not affect the stability of hip joint

Surgical Treatment

Most acetabulum fractures require surgery by a sub-specialist in the field for the best outcome. Options we use to realign and hold the fracture still while it heals include:

Minimal Invasive Fixation:

Can be used in fractures that are minimally displaced or amenable to reduction by closed means without surgical opening of the fracture site.

Small stab incisions are then used to carry out fracture fixation using implants that will be buried under the skin, a technique called percutaneous fixation. This minimizes blood loss, surgical trauma to the patient and results in a small surgical scar.

Open Reduction and Internal Fixation:

Using surgical incision, the displaced bone fragments are first repositioned to their alignment. We then hold the fragments in place with screws and metal plates attached to the surface of the bone. An example of such fixation is shown in the image above.

Total Hip Replacement

Can be considered as an option of management in fresh fractures or as the last resort when acetabulum fracture results in arthritis.  When the acetabulum is badly damaged and when fixation is not expected to provide a good long-term outcome, hip replacement might be a recommended surgical option in fresh fractures. After fractures are fixed initially and later result in arthritis, total hip replacement is the best salvage option.

Compiled and written on June, 2021. By Dr. Samuel Hailu.

*Disclaimer:*The information contained herein is for educational purposes only. This should NOT be used in place of a visit with your healthcare provider, nor should you disregard the advice of your healthcare provider because of any information you read on this topic.