Acute management





Neurovascular assessment

Investigations - exclude Pipkin, NOF

Emergent reduction / skeletal stabilisation

Assess stability

Re-evaluate sciatic nerve


Insertion Femoral Steinman Pin



- displaced acetabular fracture


Femoral Steinman Pin APFemoral Steinman Pin Lateral



- above blummenstaat's line

- in metaphyseal bone

- minimum 10 pounds weight, may need more

- assess post operative reduction


Acetabular Fracture Pre Steinman PinAcetabular Fracture Post Steinman Pin


Goals of Management


1.  Restore Articular Congruency

2.  Reduce & Maintain Hip in Acetabulum


Non operative Management


Radiographic factors


1.  Articular step < 2mm

2.  Weight bearing roof intact

- Matta Roof > 45o

- CT subchondral roof 10 mm

3.  Congruent reduction

4.  Stable < 40% posterior wall fracture




Tornetta JBJS Br 1999

- 38 hips with above criteria for 2.7 years

- good or excellent outcome in 91%

- poor outcome related to other injuries


Patient factors



Osteoporotic bone

Pre-existing arthritis


The elderly patient can have a THR as salvage if required down the track


Operative Management




1.  Incongruent reduction

2.  Non intact weight bearing dome

3.  Articular step > 2mm 

4.  Retained fragment

5.  > 40% posterior wall or instability


Surgical factors


1.  Surgeon experience

- steep learning curve


Letournel & Judet Fractures of the Acetabulum 1993

- initial rate non anatomical reduction 32%

- 4 years later 10%


2.  Surgical timing


Letournel & Judet

- anatomical reduction in only 50% operated after 21 days

- if operate too early, bleeding +++


3.  Fracture complexity


Matta  JBJS Am 1996

- 262 patients

- 96% elemental fractures anatomically reduced

- 64% complex






1.  Anatomic reduction

2.  Provisional fixation with lag screws 

3.  Buttressing with curved reconstruction plates 




1.  Posterior / Kocher-Langenbeck approach

- posterior column / wall


2.  Ilioinguinal approach

- anterior column / wall


3.  Extended iliofemoral approach

- Smith-Petersen extended over iliac crest

- for transverse / both column fractures


4.  Triradiate approach

- Kocher-Langenbeck with anterior extension from GT to ASIS

- wide exposure for both column fractures

- high incidence HO


Triradiate approach Both Column Fracture


Preferred option is to perform

- ilioinguinal for anterior column / wall

- posterior / Kocher Langenbeck for posterior column / wall

- do both 1 week apart for combined fractures




Posterior Column & Wall Fracture


Acetabulum Posterior Wall Plating 1Acetabulum Posterior Wall Plating 2Acetabulum Posterior Wall Plating 3



- IDC, radiolucent table, IV Abx

- lateral position but patient rolled excessively over

- patient 45o up from table, exposes posterior

- top leg hip flexed, knee flexed

- bottom leg extended

- blankets under top leg

- lateral support in front of top knee to prevent too much hip flexion

- prevents excessive tension on sciatic nerve


Standard posterior approach

- divide fascia lata

- find and protect sciatic nerve at all times

- do so by keeping hip extended and knee flexed

- expose short external rotators, divide 1cm from insertion to preserve blood supply

- usually must divide some of G. max

- elevate G medius from ilium

- steinmann pin in ilium for exposure

- expose ischial tuberosity by elevating biceps femoris, again protecting sciatic nerve at all time

- steinmann pin in ischium


Reduction can be aided but applying femoral distracter

- between ilial and ischial pins


Expose fracture

- posterior wall fracture, elevate and clean callous

- capsule usually partially avulsed

- ensure no femoral head fractures or loose fragments

- posterior column fracture often up in ilium, can put a plate across it



- often indirect

- buttress plate from Ischial Tuberosity to Ilium

- contour or use pre-contoured

- screws at plate extremities

- often 2 parallel plates if wall and column fracture


II to ensure screws not in acetabulum


Anterior Column & Wall Fracture


Acetabulum ORIF 2 Column APAcetabulum ORIF 2 Column Judet 1Acetabular ORIF 2 Column Judet 2



- radiolucent table

- IDC to decompress bladder

- IV Abx

- sandbag under operative side for some elevation

- need to prep and drape pelvis so can virtually access both ASIS 

- often need to get  across pubis


Ilioinguinal approach


Curvilinear incision from above pubis to ASIS

- identify and protect LFCN / below ASIS

- divide external oblique 1 cm above inguinal ligament

- identify and protect spermatic cord / round ligament

- divide posterior wall / internal oblique and transversus


3 windows (medial / middle / lateral)

- find external iliac artery and vein with peanuts / place sling

- find psoas and femoral nerve / place sling

- find iliopectineal fascia between vessels and psoas and divide with scissors


Medial window medial to vessels

- superior pubic rami

- may have to release some of rectus


Beware corona mortis

- anomolous vascular connection

- 10 - 15% patients

- between external iliac / epigastric artery

- to obturator artery


Middle window between psoas and vessels

- exposes quadrilateral plate


Lateral window lateral to psoas

- elevate iliacus off crest to expose fracture in iliac wing

- exposes around to SIJ




1.  Reduce quadrilateral plate

- small T plate / will sit under pelvic reconstruction plate

- separate recon plate


ORIF Quadrilateral Plate


2.  Plate iliac crest fracture

- long 13 hole plate from pubis

- along superior pubic ramus up onto inner table of ilium

- indirect acetabular reduction




Judet and Letournel 1980 417 Fractures

- 73% perfect reduction with 84% very good results

- imperfect reduction 55% good results

- infection 5.6% / heterotopic bone 18%

- poor results related to > 3 weeks


Matta 1996 258 Fractures

- anatomical reduction 71% with 76% excellent to good results

- poor results related to injuries to femoral head / age / post-operative complications

- AVN 3%




Heterotopic Ossification

- ilioinguinal 1%

- Kocher-Langenbeck 7%

- extended Iliofemoral 12%


Failure of fixation


Acetabular Fracture Failed ORIF 1Acetabular Fracture Failed ORIF 2


Very problematic

- often need revision to THR

- pelvic discontinuity must be addressed


Acetabular Fracture Failed ORIF CT 1Acetabular Fracture Failed ORIF CT 2THR Post Acetabular Fracture



- rate very high

- prevent with mechanical and chemical prophylaxis


Sciatic nerve injury 2% 

- especially with posterior approach


AVN 2%

- higher with posterior dislocations and Pipkin fractures



- occur in 2-5%

- increased in the presence of Morel-Lavallee lesion



- the most common complication

- anatomic reduction - 10%, usually after 10 years

- imperfect reduction - 45%, usually before 10 years 2,6


Hip OA post Acetabular FractureHip OA post Acetabular Fracture


Bladder and spermatic cord injury


Hernia formation


Vascular injury


External iliac vein

- control distally with vessiloop

- suture with 5.0 / 6.0 prolene on noncutting needle