Acetabular Fracture: Evaluation and Management
Acetabular fractures require immediate radiographic evaluation with AP pelvis and Judet oblique views, followed by CT scanning for surgical planning, with urgent reduction of any hip dislocation within hours to prevent avascular necrosis, and surgical fixation indicated for all displaced or unstable fractures affecting the weight-bearing dome.
Initial Evaluation
Imaging Protocol
- Start with AP pelvis radiograph plus Judet oblique views (iliac and obturator oblique projections) 1, 2
- These three standard views demonstrate the anterior and posterior columns and are essential for fracture classification
- CT scan is mandatory for surgical planning - it reveals fragment interposition, marginal impaction, intraarticular fragments, and occult pelvic ring fractures that alter surgical tactics 3, 4
- 3D CT reconstruction aids in understanding complex fracture patterns, particularly for preoperative planning 4
Hip Dislocation Management
If hip dislocation is present, reduce it emergently - ideally within 6 hours to minimize risk of avascular necrosis 5. Key points:
- Reduction should be performed as soon as possible, even before CT scanning 5
- If closed reduction fails in the emergency department, optimize technique and reattempt under sedation or general anesthesia 5
- CT scan after reduction confirms joint congruency and identifies intraarticular fragments 1
- If redislocation occurs, apply skeletal traction temporarily until definitive fixation 5
Classification and Surgical Planning
Use the Letournel classification system to guide surgical approach 4, 6:
- 5 elementary patterns: posterior wall, posterior column, anterior wall, anterior column, transverse
- 5 associated patterns: T-type, posterior column + posterior wall, transverse + posterior wall, anterior column/posterior hemitransverse, both columns
Simplified approach: Think of acetabular fractures as belonging to two major pattern families based on displacement vectors and constant fragments, which streamlines surgical decision-making 6.
Surgical Indications
Operate on all displaced or unstable fractures where the weight-bearing dome is incongruent 7, 4. Specific indications:
- Any displacement of the weight-bearing surface >2-3mm
- Posterior wall fractures involving >20-40% of the wall
- Roof arc angles <45 degrees on any view
- Intraarticular fragments
- Unstable fracture patterns (both column, T-type)
Timing: Surgery should occur within 48 hours when possible, though contemporary data shows surgery is occurring earlier than historical norms 8, 9. Delay may be appropriate for soft tissue swelling or patient optimization.
Preoperative Management
Pain Control
Use standard trauma pain protocols 5:
- Multimodal analgesia with acetaminophen/paracetamol as baseline
- Opioids as needed, but use cautiously in elderly patients
- Avoid NSAIDs due to concerns about heterotopic ossification and renal function
Traction
Skeletal traction is NOT routinely indicated for most acetabular fractures 5. Reserve it only for:
- Recurrent hip dislocation after reduction
- Temporary stabilization if surgery must be delayed
Medical Optimization
- Tranexamic acid should be administered preoperatively to reduce blood loss 5
- Standard antibiotic prophylaxis per trauma protocols 5
- Preoperative ultrasound for DVT screening is NOT recommended routinely 5
- No preoperative heterotopic ossification prophylaxis is indicated 5
Surgical Approach Selection
Match approach to fracture pattern 9, 10:
- Kocher-Langenbeck: Posterior column, posterior wall, transverse, T-type
- Ilioinguinal: Anterior column, anterior wall, both column fractures
- Anterior intrapelvic approach: Increasingly used for anterior column-based fractures 9
- Combined approaches for complex associated patterns
Contemporary trends show increased use of percutaneous screw fixation as adjunct or standalone treatment, particularly for column fractures 10.
Special Populations
Geriatric Patients (>65 years)
The patient population has aged significantly (mean age now 45.2 years vs 38.6 previously) 9, 11. For elderly patients:
- Consider acute total hip arthroplasty (THA) with or without ORIF for complex fractures in low-demand patients 11
- Minimally invasive percutaneous fixation reduces surgical morbidity 11
- Early mobilization is critical - multidisciplinary orthogeriatric comanagement improves outcomes 8
Polytrauma Patients
Coordinate with trauma team for damage control principles 7. Acetabular fixation may need to be staged after initial stabilization.
Postoperative Rehabilitation
Early mobilization protocols are safe and do not increase complications 12:
- Begin isometric quadriceps and hip abductor exercises on postoperative day 1
- Passive hip range of motion at 1-3 days
- Active hip movement from day 1 to 4 weeks depending on fracture stability
- Partial weight-bearing can begin as early as 1 week postoperatively for stable fixation 12
- Progress to full weight-bearing at 8-12 weeks based on fracture healing and fixation quality
Traditional restricted weight-bearing for 12 weeks is overly conservative for most fracture patterns with solid fixation 12.
Complications to Monitor
- Post-traumatic osteoarthritis: Occurs in 16.9% by 44 months - quality of reduction is the strongest predictor 9
- Heterotopic ossification: Common but prophylaxis timing remains controversial
- Iatrogenic nerve injury: Rates have decreased significantly (particularly sciatic nerve) with improved surgical technique 9
- Avascular necrosis: Risk highest with delayed reduction of hip dislocation
- Loss of reduction: Rare with proper fixation technique and appropriate rehabilitation
Key Pitfalls to Avoid
- Don't delay hip dislocation reduction for CT scanning
- Don't miss posterior wall fractures on initial radiographs - always obtain Judet views
- Don't assume negative radiographs exclude fracture - MRI has 99% sensitivity for occult fractures 2
- Don't use overly restrictive weight-bearing protocols that delay functional recovery
- Don't operate on truly non-displaced fractures with congruent joint surfaces