The acetabulum is a hemisphere-shaped recess that is formed by the ischium, ilium and pubis bones (they are connected into a single pelvic (nameless) bone). The acetabulum, which houses the head of the femur, forms the hip joint. It is the largest and most powerful joint in the human body, responsible for functions such as moving the hips, lifting and lowering, bending and extending the legs, and also takes part in bending the body. A fracture of the acetabulum, a component of this joint, can lead to serious consequences and disability. These fractures are divided into simple and complex. They are often accompanied by hip dislocation and femoral neck fracture. From time to time, displaced fractures occur, as a result of which fragments of damaged bone can extend beyond the joint and penetrate into the soft tissue.
Signs of an acetabulum fracture.
- Intense pain in the groin and hip area
- The motor function of one of the legs is impaired (in case of a displaced fracture)
- With non-displaced fractures, the patient’s pain intensifies with any movement of the leg
- If the fracture is combined with a dislocation of the hip, then the person cannot make any movements with the affected leg, and the leg has an unnatural appearance (in short, it is healthy and turned outward)
- Possible traumatic shock when combined with other injuries
Conservative treatment is possible in the following cases
- if no displacement has occurred;
- no more than 25% of the posterior edge of the acetabulum is broken;
- low transverse fracture;
- low fracture of the anterior column;
- fracture of two columns while the arch of the cavity connecting them is preserved.
If after a given period of time no healing occurs, the fracture is considered non-union. In such cases, the solution is complete or partial replacement of the joint with an implant. If necessary, additional bone material is used.
This type of operation is high-tech, but is already available in many cities of Russia. However, many people prefer to use the experience of European doctors when going to Germany or Israel for treatment. The quality there is undoubtedly high, but the prices are also not affordable for everyone. A good alternative is the Czech Republic. Clinics in this country provide services at the European level, but the cost is significantly lower than in Germany. For many years now, all the hassles of finding a clinic, contacting doctors, and paperwork have been taken care of, through which Russian patients are sent to the Czech Republic for treatment. At a reasonable price, they receive not only restoration of motor function of the joints, but also consolidation of the results during rehabilitation at the resort.
Diagnostics.
- Initial examination of the victim by a traumatologist
- X-ray of the pelvis (to establish the type of fracture)
- X-ray of the injured joint (X-ray in three projections)
- Computed tomography of the pelvis (to determine the severity of the fracture and the nature of the movement of bone fragments)
- Rectal and vaginal examination (to rule out open fracture)
- Consultation with a neurologist or neurosurgeon (if there is a suspicion of damage to the sciatic nerve)
Treatment.
Treatment is carried out in the traumatology department. The treatment method will depend on the nature of the injury.
- If a fracture of the acetabulum is accompanied by a dislocation of the hip, the traumatologist will initially perform immediate reduction under general anesthesia. In the absence of intra-articular fragments, if in the area of the roof of the bone the displacement is no more than 3 mm and the correspondence of the articular surfaces is maintained (congruence of the joints) - prescribed
- conservative treatment, which consists of applying skeletal traction for a period of 1-2 months.
- Surgical intervention is required when large fragments of the joint are detected, when fragments are displaced in the area of the cavity by more than 2-3 mm and the fragments are unable to be retained using skeletal traction. The operation is carried out no later than 14 days from the moment of injury. A prerequisite for surgery is the compensated condition of the injured person.
- In some cases, surgery is performed immediately. Indications for emergency intervention are: open fracture, symptoms of sciatic nerve damage, irreducible posterior dislocation of the femur, displacement of the femoral head to the center and significant soft tissue detachment. Before surgery, the patient's condition must be stabilized, without signs of traumatic shock.
- When reconstructing the socket, doctors use lag screws and plates.
Radiation research methods occupy a special place in the diagnosis of acetabular fractures. Recently, computed tomography (CT) has begun to play an important role. However, performing a CT scan is not always possible during the initial examination of the patient, especially in the acute period of combined injury. This is explained either by the lack of necessary equipment, or by the impossibility of transporting the patient due to the severity of the general condition. Therefore, timely, full-fledged radiographic examination still remains the most optimal and informative method of research. However, an important point is not only and not so much radiography of the pelvis in different projections, even with good quality images, but the correct interpretation of the obtained radiographs [1–3].
In most cases, it is possible to determine the type of acetabular fracture after performing a plain radiograph of the pelvis in the anteroposterior projection. Carrying out radiographs in special settings (obturator oblique and iliac oblique according to Judet) can significantly worsen the patient’s condition and provoke continued bleeding from traumatic foci, since patients with suspected fractures of the acetabulum are often admitted to a medical institution in a general serious condition. Repeated repositioning of the patient and special positioning are strictly contraindicated in the acute period of injury.
X-ray diagnostics should be carried out as carefully as possible for the patient and without changing the position of the pelvis. For this purpose, the National Medical Research Center for Tomography developed and introduced into clinical practice a technique proposed by A.F. Lazarev Special projections: obturator oblique and iliac oblique are obtained by deflecting the central beam of X-rays without changing the position of the patient’s pelvis and body.
During the initial examination, it is very important to correctly evaluate the data obtained from plain radiographs in the direct anteroposterior projection, caudal and cranial projections. Performing radiographs in these projections does not require changing the position of the pelvis; it is carried out with a vertical or deflected central beam of X-rays. Thus, already upon admission it is possible to obtain a series of radiographs in mutually perpendicular projections, which allows for high-quality express diagnosis of an acetabulum fracture. It should be remembered that incorrect interpretation of a radiograph can cause diagnostic errors [3].
Knowledge of normal x-ray anatomy and x-ray signs of acetabular fractures allows in most cases to determine the characteristics of damage to the acetabulum.
X-ray anatomy of the acetabulum (6 reference lines +)
On a standard anteroposterior radiograph, certain lines can be identified that correspond to the main structures that make up the acetabulum. It should be noted that most of these lines are not formed by the contour of the bone, but by the superposition of shadows of various anatomical structures.
1. The iliopectineal line (corresponds to the terminal line of the pelvic ring) in the anterior sections corresponds to the anterior column of the acetabulum; in the posterior sections it reflects the body of the ilium along the length to the sacrum - normally it is continuous (Fig. 1).
Rice. 1. The iliopectineal line on a radiograph and on a schematic image of the pelvis. From a clinical point of view, the integrity of the pelvic ring determines the continuity of the iliopectineal line.
2. The iliosciatic line is formed by the superposition of the inner and outer cortical layers of the quadrilateral plate. The x-ray shadow corresponds to the anatomical contours of the inner surface of the quadrilateral plate and the medial surface of the descending branch of the ischium; in the upper parts it corresponds to the contours of the greater sciatic notch, representing the intrapelvic surface of the posterior column and the floor of the acetabulum (Fig. 2).
Rice. 2. Iliosciatic line on a radiograph and on a schematic representation of the pelvis.
3. The roof of the acetabulum radiographically corresponds to the cranial parts of the most loaded part of the acetabulum - it is formed by the superposition of dense subchondral structures (sursil) of the upper hemisphere of the acetabulum (Fig. 3).
Rice. 3. The roof of the acetabulum on a radiograph and on a schematic representation of the pelvis.
4. The teardrop figure represents the anterior-inferior part of the articular surface of the acetabulum, which has a horseshoe shape and corresponds to the medial section of the lower edge of the articular surface of the cavity. It is a guideline for determining the true position of the floor of the acetabulum (Fig. 4).
Rice. 4. “Tear shape” on an x-ray and on a schematic representation of the pelvis.
5. The contour of the posterior wall of the acetabulum (posterior edge of the acetabulum) corresponds to the transition of the wall itself into the cartilaginous lip (Fig. 5).
Rice. 5. Contours of the posterior wall on the radiograph and on the schematic image of the pelvis.
6. The contour of the anterior wall of the acetabulum (the anterior edge of the cavity) corresponds to the transition of the wall itself into the cartilaginous lip (Fig. 6).
Rice. 6. Contours of the anterior wall on an x-ray and on a schematic image of the pelvis.
Highly informative in diagnostic terms is provided by determining the continuity of the contours of the above lines. A radiological sign of a fracture is a violation of the continuity of the contours, even in the absence of visible displacement and deformation of the line. The localization of the interruption of the contours of the tear figure is important for determining the nature and type of fracture.
7. Contours of the obturator foramen. Disruption of the continuity of the contour of the obturator foramen is a sign of a fracture, the plane of which passes through the obturator foramen (Fig. 7).
Rice. 7. Continuous outline of the obturator foramen on a radiograph and on a schematic representation of the pelvis. Can serve as a diagnostic sign of damage to one of the columns of the acetabulum.
A direct survey radiograph in the anteroposterior projection allows one to determine the relationship of the femoral head and acetabulum by the correspondence of the position of the femoral head of the opposite side (in case of unilateral fractures), by the symmetry of Shenton’s lines. A change in Shenton's line may most likely indicate a central or cranial displacement of the femoral head, as well as concomitant damage to the proximal femur. Taking into account the individual characteristics of the hip joint, comparison should always be made with an intact joint (Fig. 8).
Rice. 8. Shenton’s line on a plain radiograph and on a schematic image of the pelvis.
A caudal survey radiograph (Inlet) allows you to identify zones that correspond to the anatomical structures of the acetabulum: the anterior wall and the anterior column (Fig. 9),
Rice. 9. Contours of the anterior column on a radiograph in a caudal projection and on a diagram. posterior column (Fig. 10).
Rice. 10. The contours of the posterior column on the radiograph in the caudal projection and on the diagram, the contours of the greater and lesser sciatic notches are also determined.
At the level of the femoral head, this part of the line corresponds to the anterior wall.
Also, on the radiograph in the caudal projection, structures such as the wing of the ilium, the ischial spine, and the position of the femoral head relative to the socket are visualized.
The nature of acetabular fractures is usually detailed according to the generally accepted Judet–Letournel classification [5, 6] using projections developed by the authors. However, these radiographs require special placement with rotation of the pelvis, which cannot be justified in the acute period upon admission.
The National Medical Research Center for Tomography has developed a method for diagnosing acetabular fractures that eliminates additional patient movements and rotations of the pelvis using the technique of deflecting the central X-ray beam [4, 5]. This technique allows you to obtain the same necessary projections. It is possible to visualize the same structures as with the classical technique without turning the patient by 45°, but by changing the angle of the X-ray beam by the same amount (Fig. 11)
Rice. 11. Scheme of performing radiography using the X-ray beam deflection technique. Obturator and iliac projection. [6, 7].
In Fig. 12 presented
Rice. 12. Plain radiography of the pelvis of a patient with suspected acetabular fracture. plain radiograph of the pelvis. Based on this image, it is possible to suspect a fracture of the left acetabulum, since a slight deformation of the iliopectineal line with a violation of its continuity is determined.
After performing targeted radiography in the oblique iliac projection using the National Medical Research Center for Tomography technique, a fracture line was identified passing through the wing of the ilium, the sursil and the lower parts of the anterior column. Also, the targeted radiograph clearly shows the intactness of the posterior parts of the acetabulum (Fig. 13).
Rice. 13. X-ray of the left hip joint in the oblique-iliac projection, performed according to the technique of the National Medical Research Center T.O. The arrows indicate the fracture line where it passes through the visualized structures of the acetabulum.
On the survey radiograph shown in Fig. 14 reliable
Rice. 14. Plain radiography of the pelvis of a patient with an acetabulum fracture. a violation of the continuity of the iliopectineal and iliac-sciatic lines is determined.
Using an obturator oblique radiograph performed using the National Medical Research Center for Tomography, a fracture of the posterior wall with displacement of a separate fragment was diagnosed. Also, using a targeted image, the integrity of the contours of the obturator foramen was determined (Fig. 15).
Rice. 15. X-ray of the right hip joint in the obturator oblique projection, performed according to the technique of the National Medical Research Center T.O. The arrows indicate a fracture and a separate fragment of the posterior wall.
X-ray diagnosis of acetabular fractures
The Judet–Letournel classification of acetabular fractures [4] is generally accepted as the most correct in diagnostic and practical terms. According to this classification, there are 10 typical acetabular fractures, which are divided into 2 groups.
The division criterion is the number of fracture planes. In the presence of one plane, the fracture is classified into the 1st group - “simple” fractures; in the presence of several planes, i.e., several traumatic foci - it is classified into the 2nd group of “associated” or “complex” fractures.
Group 1 includes: fractures of the anterior wall, posterior wall, anterior column, posterior column, transverse fractures. All these fractures have one fracture plane passing through the articular surface of the acetabulum (Fig. 16).
Rice. 16. Simple fractures of the acetabulum according to the classification of R. Judet and E. Letournel.
“Associated” fractures of the 2nd group include: fracture of the posterior column and posterior wall, T-shaped fractures, transverse fractures with a fracture of the posterior wall, anterior column and posterior semitransverse, two-column fractures (Fig. 17).
Rice. 17. Associated fractures of the acetabulum according to the classification of R. Judet and E. Letournel.
Each type of fracture is characterized by a violation of the continuity of reference lines. Determining the types of fracture is possible by excluding acetabular structures, the reference lines of which are not radiographically changed. In the vast majority of cases, the type of fracture can be determined by analyzing a radiograph of the pelvis in the anteroposterior projection [8].
The type of fracture is determined by sequentially answering the question: is there damage to a certain line or not. Analysis of the contours of each reference line allows you to exclude certain types of fractures. The main lines that allow one to consistently determine the type of fracture are: the iliopectineal line, the iliac-sciatic line, the contours of the obturator foramen, the line of the posterior wall, the wing of the ilium. Each of the reference lines on the radiographs is marked with a specific color (Fig. 18).
Rice. 18. Colors of reference lines on radiographs.
While maintaining the continuity and integrity of the iliopectineal line on the anteroposterior plain radiograph (Fig. 19)
Rice. 19. The first stage of determining a fracture of the posterior wall. The following fractures can be excluded: anterior wall, anterior column, transverse, transverse associated with a posterior wall fracture, T-shaped, anterior column associated with a posterior semitransverse fracture, two-column fracture.
From a clinical point of view, a continuous iliopectineal line indicates the preservation of the integrity (absence of fracture) of the anterior column of the acetabulum.
Integrity and continuity of the ilio-sciatic line on a radiograph in a direct projection (Fig. 20)
Rice. 20. The second stage of determining a fracture of the posterior wall. makes it possible to exclude: fracture of the posterior column, posterior column associated with the posterior wall.
The continuity of the reference lines is radiographic confirmation of the integrity of the corresponding acetabular structures.
Thus, by excluding intact structures
a fracture of the posterior wall of the acetabulum on the right was determined (see Fig. 20).
An x-ray in an oblique obturator projection (the presence of a displaced fragment of the posterior wall) confirms the established diagnosis (Fig. 21).
Rice. 21. Verification of a posterior wall fracture according to the obturator oblique projection. The reliability of the diagnosis is confirmed by the presence of radiological signs of a fracture on radiographs in at least 2 projections in mutually perpendicular or close to this planes.
On the direct survey radiograph shown in Fig. 22, integrity
Rice. 22. The first stage of determining a fracture of the anterior wall. the iliac-sciatic line is preserved. This sign allows you to exclude damage to the structures of the posterior column. According to the Judet–Letournel classification, we can exclude the following fractures: transverse fracture of the acetabulum, transverse associated with a fracture of the posterior wall, T-shaped, anterior column associated with a posterior semitransverse, two-column fracture (in which both columns are involved.
The continuity of the iliosciatic line allows, in addition, to exclude: a posterior column fracture, a posterior column fracture associated with a posterior wall fracture (see Fig. 22).
It is important to note that maintaining the continuity of the contour of the obturator foramen helps to exclude anterior column fracture (Fig. 23).
Rice. 23. The second stage of determining a fracture of the anterior wall.
The continuity of the contour of the posterior edge of the acetabulum allows us to exclude a fracture of the posterior wall (Fig. 24, a
).
Rice.
24. a - intact reference lines; b - combination of reference lines. Violation of the continuity of only the iliopectineal line allows one to suspect a fracture of the anterior wall (see Fig. 24, b
).
Thus, a fracture of the anterior wall was diagnosed by exclusion.
A radiograph in the oblique iliac projection confirms a fracture of the anterior wall of the acetabulum (Fig. 25).
Rice. 25. Final determination and verification of anterior wall fracture.
As already noted in the first clinical example, while maintaining the continuity of the iliopectineal line on a plain radiograph, it is possible to exclude fractures of the anterior column, both simple and associated with fractures of other parts (Fig. 26).
Rice. 26. The first stage of determining a posterior column fracture.
It should be noted that in this example (Fig. 27)
Rice. 27. The second stage of determining the fracture of the posterior column. there is damage to the line of the posterior edge, which corresponds to damage to the posterior parts of the cavity. However, damage to this line in one place and, accordingly, the absence of a separate fragment of the posterior wall makes it possible with a high degree of probability to exclude those types of fractures in which it is observed, namely: a fracture of the posterior wall and a fracture of the posterior column associated with a fracture of the posterior wall.
Thus, by excluding intact structures
acetabular cavity, a fracture of the posterior column of the acetabulum was diagnosed. Damage to the iliosciatic line and deformation of the contours of the obturator foramen confirms this diagnosis (Fig. 28).
Rice. 28. Verification of a posterior column fracture. An x-ray in the obturator oblique projection reveals a posterior dislocation of the femoral head and the absence of a separate fragment of the posterior wall (Fig. 29).
Rice.
29. X-ray in obturator oblique projection. On a direct plain radiograph (Fig. 30)
Rice. 30. The first stage of determining an anterior column fracture. The continuity of the iliac-sciatic line is preserved. Based on this, it is possible to exclude all types of fractures in which there is damage to the posterior column, as well as both columns of the acetabulum. From a clinical point of view, at this stage of express diagnostics, out of possible 10 options for acetabular fractures, 3 probable injuries remain.
The integrity of the contours of the posterior edge allows us to exclude a fracture of the posterior wall (Fig. 31)
Rice. 31. The third stage of determining an anterior column fracture. — there are 2 possible options left.
The combination of damage to the iliopectineal line and the contours of the obturator foramen allows us to clarify the final diagnosis: a fracture of the anterior column of the acetabulum (see Fig. 31).
On a plain X-ray of the pelvis in the next patient (Fig. 32),
Rice. 32. The first stage of determining a transverse fracture. Of the main reference lines, the integrity of only the contours of the obturator foramen was preserved. At the first stage, this allows us to exclude types of vertical fractures, including the anterior column, posterior column, and their combinations.
When analyzing the contours of the posterior wall, its linear or, more precisely, single-plane damage is determined, which allows us to conclude that there is no fracture of the posterior wall. A fracture of the anterior wall can also be excluded (Fig. 33).
Rice. 33. The second stage of determining a transverse fracture.
Thus, a transverse acetabular fracture was diagnosed by exclusion.
A distinctive feature of this type of fracture is the violation of the contours and continuity of 4 reference lines (iliopectineal, iliac-sciatic, anterior and posterior walls) on a plain anteroposterior radiograph, and the fracture line is determined in one plane (Fig. 34).
Rice. 34. Verification of a transverse fracture.
Conclusion.
A distinctive feature of “simple” forms of acetabular fractures is the presence of one fracture plane passing through the articular articulating surface. In the vast majority of cases, data from direct plain radiography allow a preliminary diagnosis to be made using only one radiograph.
It should be noted that the presence of one fracture plane is manifested by a violation of only one of the reference lines in isolated fractures of the anterior or posterior wall. Violation of only one line in these fractures is determined in at least two places according to the contours of the fragment.
A characteristic feature of a fracture of one of the columns is a combination of a violation of the continuity of the iliopectineal line (anterior column) or an iliac-sciatic line (posterior column) with a violation of the continuity of the contours of the obturator foramen.
A transverse fracture is characterized by damage to the iliopectineal, iliac-sciatic line and the line of the anterior and posterior edges of the acetabulum in one projection. At the same time, the contours of the obturator foramen remain intact.
However, for adequate treatment, especially for preoperative planning, detail is required: the size of the fragments, the nature of the displacement. For clarification, targeted multi-projection radiography in oblique projections is required, and, if possible, CT of the pelvis.
Diagnosis of associated acetabular fractures requires a careful understanding of the planes of all fractures, which may require additional radiographs.
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