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ACETABULUM FRACTURE-PHYSIOTHERAPY MANAGEMENT

ANATOMY OF ACETABULUM

On the outer surface of the hip bone is a deep depression, called the acetabulum, the large cup-shaped acetabulum for articulation with the head of the femur is on the lateral surface of the pelvic bone in the region where the ilium, pubis, and ischium fuse. The articular surface of the acetabulum is limited to a horseshoe-shaped area and is covered with hyaline cartilage. The floor of the acetabulum is non-articular and is called the acetabular fossa

The margin of the acetabulum is marked inferiorly by a prominent notch (acetabular notch).

The wall of the acetabulum consists of non-articular and articular parts:

 ■ the non-articular part is rough and forms a shallow circular depression (the acetabular fossa) in central and inferior parts of the acetabular floor — the acetabular notch is continuous with the acetabular fossa;

 ■ the articular surface is broad and surrounds the anterior, superior, and posterior margins of the acetabular fossa.

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EPIDEMIOLOGY

  • Acetabulum fractures occur with an incidence of about three per 100.000 population
  • Fractures of the acetabulum occur primarily in young adults as a result of high-velocity trauma (e.g., vehicular accidents or falls from heights).
  • Occurs in elderly with osteoporosis (minor fall)

CAUSE

An acetabular fracture results when a force drives the head of the femur against the acetabulum. This force can be transmitted from the knee (such as hitting the knee against the dashboard in a head-on car collision) or from the side (such as falling off a ladder directly onto the hip).

The force and the position of the femur head at the time of impact is one of the determination factors of a specific type of fracture.
The following guidelines are made use of: [7]

  •  Head of femur
  •  When the head of the femur is in exorotation: the anterior part of the acetabulum gets disrupted.
  • When the head of the femur is in endorotation: the posterior part of the acetabulum gets disrupted or T-shaped fracture depending on the degree of endorotation.
  • When the head of the femur is in adduction: Transverse or T-shaped fracture occur, because the superolateral area is affected.
  • When the head of the femur is in abduction: Transverse or T-shaped fracture, because the inferomedial area is gets touched[7]
  • When the hip is flexed (90°) and knee flexed or extended: Posterior column fracture occurs; This is similar in both positions of the knee.

CLASSIFICATION OF ACETABULAR FRACTURES

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The most widely accepted classification scheme for acetabular fractures is that of Judet and Letournel, this classification scheme describes 10 types of acetabular fractures

Elementary (simple) patterns

The elementary (or elemental) patterns fracture the innominate bone through the acetabulum into two major fragments. There are five types:

  1. Anterior wall fracture
    1. segmental fracture of the middle third of the anterior column, detaching a trapezoidal fragment that contains the anterior acetabular wall from the rest of the innominate bone
    1. superiorly, fracture line begins below the anterior inferior iliac spine 9
    1. medially, fracture line involves the anterior quadrilateral plate, so this pattern excludes isolated fractures of the anterior acetabular rim 5
    1. inferiorly, fracture line exits at the superior pubic ramus, distinguishing this pattern from anterior column fracture 5,8,9,11
  2. Anterior column fracture
    1. segmental fracture of the anterior column that crosses the obturator foramen, detaching a fragment that contains the anterior acetabular wall and most of the pubis from the rest of the innominate bone 11
    1. superiorly, fracture line begins variably in the anterior ilium 5,10:
      1. high: iliac crest
      1. intermediate: between anterior iliac spines (anterior interspinous notch)
      1. low: below the anterior inferior iliac spine (psoas gutter)
      1. very low: anterior horn of the acetabular articular surface to the junction of ilium and pubis (iliopectineal eminence)
    1. medially, fracture line involves the quadrilateral plate in a coronal orientation 5
    1. inferiorly, fracture line exits at the ischiopubic ramus, distinguishing this pattern from anterior wall fracture
    1. More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall")
  3. Transverse fracture
  1. The transverse fracture of the acetabulum is limited to the acetabulum, without involvement of the obturator ring
  2. A transverse fracture must involve both the anterior and posterior aspects of the acetabulum, so the iliopectineal and ilioischial lines are disrupted
    1. fracture across both columns of the acetabulum, separating the inferior (ischiopubic) and superior (iliac) portions of the innominate bone 5,8,9
      1. superiorly, superior portions of both columns remain connected to the sciatic buttress (fracture line does not extend superiorly to anterior or posterior iliac surfaces), unlike column fractures 4,5
      1. inferiorly, obturator ring remains intact, unlike T-shaped or column fractures 3
    1. sub classified by level relative to acetabular roof 5,8,9:
      1. transtectal: traverses weight-bearing dome
      1. juxtatectal: traverses the junction of the acetabular (cotyloid) fossa and articular surface of the acetabular roof
      1. infratectal: traverses the acetabular fossa and anterior and posterior horns of the acetabular articular surface
  3. Posterior column fracture
    1. segmental fracture of the posterior column that crosses the obturator foramen, detaching a fragment that contains the posterior acetabular wall and most of the ischium from the rest of the innominate bone
    1. superiorly, fracture line enters at greater sciatic notch, sparing iliac wing 5,11
    1. medially, fracture line passes through the acetabular roof and involves the quadrilateral plate in a coronal orientation 5,8,9,11
    1. inferiorly, fracture line exits through ischiopubic ramus or, uncommonly, splits the ischial tuberosity without disturbing the obturator foramen
    1. check for injury to superior gluteal NV bundle
  4. Isolated posterior wall fracture
    1. An isolated posterior wall fracture does not have a complete transverse acetabular component. Therefore, the iliopectineal line is not disrupted
    1. fracture detaching fragment(s) consisting of the posterior articular surface and/or the weight-bearing dome from most of the posterior column, but sparing the quadrilateral plate 5,9
      1. ​only pattern in the Judet-Letournel classification that spares the quadrilateral plate 5
      1. N.B. this is an asymmetric definition compared to anterior wall fractures, which do involve the medial acetabular surface 5
    1. includes pure superior rim fractures
    1. • "gull sign" on obturator oblique view

Fracture Patterns

The most widely accepted classification scheme for acetabular fractures is that of Judet and Letournel, this classification scheme describes 10 types of acetabular fractures,

Associated (complex) patterns

The five complex patterns break the acetabulum into three major fragments and may be described as combinations of elementary fracture components:

  1. Both-column fracture
    1. A both-column acetabular fracture involves both anterior and posterior columns with extension into the obturator ring and iliac wing, and is one of the most common acetabular fractures
    1. fractures detaching most of the anterior column and, separately, most of the posterior column, from the posterior iliac wing 8
      1. entire weight-bearing portion of the acetabulum is disconnected from the sciatic buttress 4,5
      1. acetabular roof mostly remains with the anterior column fragment(s) 9
    1. superiorly, two fracture lines enter in perpendicular fashion, one posteriorly (usually at the greater sciatic notch) and one anteriorly or superiorly (anterior ilium or iliac crest) 5,8,9
    1. above the acetabulum, descending fracture lines merge in coronal orientation 8
    1. inferiorly, fracture line exits at the ischiopubic ramus
  2. Anterior column/wall and posterior hemi transverse fracture
    1. fractures detaching a segment of the anterior column and, separately, the inferior part of the posterior column, from the posterior iliac wing
      1. part of the acetabular dome remains connected to the sciatic buttress, unlike in both-column fracture
    1. superiorly, two fracture lines enter in perpendicular fashion, one posteriorly and one anteriorly or superiorly 10
      1. ​anteriorly, fracture line rises variably superiorly to the anterior inferior iliac spine up to iliac crest, unlike in T-shaped fracture where the fracture line is a straight continuation of the posterior transverse component 5​,10
      1. posteriorly, fracture line follows an oblique sagittal orientation and variably extends to level of ischial spine up to greater sciatic notch, unlike in T-shaped fracture 9
    1. in the quadrilateral plate, fracture lines meet at a right angle
    1. inferiorly, fracture line exits superior pubic ramus (anterior wall fracture) or ischiopubic ramus (anterior column fracture)
    1. • "spur sign" on obturator oblique
  3. T-shaped fracture
    1. A T-shaped acetabular fracture is a combination of a transverse acetabular fracture with extension inferiorly into the obturator ring. It is similar to a both-column fracture in that it disrupts the obturator ring
    1. fractures detaching two inferior (ischiopubic) fragments, one anterior and one posterior, from the rest of the innominate bone
    1. superiorly, transverse fracture line is similar to the elemental transverse fracture, although the anterior and posterior components may not have a common orientation 9
    1. inferiorly, vertical stem of the fracture line crosses the acetabular fossa and then either across the obturator foramen or, uncommonly, through the ischium alone
    1. includes associated posterior column with anterior hemi transverse fractures 5,8
    1. includes associated transverse with anterior wall fractures 5
  4. Transverse and posterior wall fractures
    1. The transverse with posterior wall fracture (Fig. 8) is a transverse fracture, described previously, with the addition of a comminuted posterior wall fracture that is often displaced.
    1. As with an isolated transverse fracture, the key is recognizing that the obturator ring is not disrupted
    1. the simple transverse fracture, this fracture type does not extend into the iliac wing.
    1. fractures detaching the inferior (ischiopubic) portion of the innominate bone and, separately, one or multiple fragments of the posterior acetabular wall
    1. morphologically equivalent to elemental transverse fracture (with transtectal, juxtatectal or infratectal course) that begins in a notch created by the separation of one or multiple posterior wall fragment(s) 9
    1. includes associated T-shaped and posterior wall fractures 5,10
  5. Posterior column and posterior wall fractures
    1. fractures detaching most of the ischium from the rest of the innominate bone and, separately, one or multiple fragments of the posterior acetabular wall (posterior articular surface and acetabular rim)
    1. morphologically equivalent to the combination of elemental posterior wall fracture and elemental posterior column fracture, except the posterior column fracture is often partial, with the fracture line extending to the roof of the obturator foramen (ischiopubic notch) but sparing the ischiopubic ramus

Treatment and prognosis

Treatment selection depends on joint stability, fragment size and comminution, and age/comorbidities. The most commonly preferred treatment varies by fracture classification 9:

Nonsurgical Treatment

The non-surgical treatment is recommended for;

  • High operative risk patients
  • Stable fractures without bone displacement
  • Older patients who are at risk of osteoarthritis, osteoporosis, DVT etc.
  • It is also recommended for patients with;
  • Morbid obesity
  • Open contaminated wounds
  • Diabetes type I & II

Physiotherapy includes;

  • Gait training
  • Stabilization and mobility exercises

Early mobilization is necessary because prolonged recumbency can be life- threatening using walking aids and positioning aids

PHYSIOTHERAPY FOR SURGICAL TREATMENT

  • Patients with surgery start with;
  • Passive ROM
  • Non-weight bearing flexion and extension
  • Partial weight bearing at 6 weeks
  • Full weight bearing at 10 weeks

REFERENCES

  • Physiopedia
  • Medscape
  • OrtoInfo
  • ScienceDirect
  • OrthoBullets

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