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A 41-year-old man with pelvic trauma

Issue: June 2014

ByMarcus F. Sciadini, MD

ByBrian M. Weatherford, MD

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A 41-year-old man was involved in a motor vehicle accident with a tractor-trailer. Following a prolonged extrication from his vehicle, he was brought in via air transport to a referral trauma center for further evaluation. He was hemodynamically stable on presentation. Advanced trauma life support protocol was initiated and initial evaluation demonstrated isolated musculoskeletal injuries. The patient’s main complaint was pelvis and bilateral lower extremity pain.

Examination of the right lower extremity demonstrated a complex wound overlying the knee that tracked into the joint with obvious deformity of the right thigh. He had palpable pulses, soft compartments and a normal neurologic exam for his right lower extremity. Examination of his left lower extremity demonstrated shortening of the limb and diminished motor and sensory function in a sciatic nerve distribution. There was also gross laxity of his left knee with obvious swelling. Compartments were soft throughout the left leg.

Figure 1. Pre-reduction (A) and post-reduction (B) radiographs of a 41-year-old man with pelvic trauma are shown. Note the disruption in the iliopectineal and ilioischial lines as well as the break in the obturator ring.

Images: Weatherford BM, Sciadini MF

An AP radiograph of the pelvis, obtained as part of the initial trauma evaluation, demonstrated a complex left acetabular fracture with an associated left hip dislocation (Figure 1A). Following closed reduction and application of skeletal traction (Figure 1B), CT was obtained to further evaluate the fracture pattern (Figures 2A-E). Subsequent evaluation and imaging identified a right patella fracture, right femur fracture and left multiligamentous knee injury.

Figure 2. Preoperative CT scan demonstrates posterior column comminution and posterior wall fracture (red arrow) (A); ipsilateral sacroiliac joint widening (red arrow) (B); vertical split separating ischiopubic segment through cotyloid fossa (red arrow) (C); 3-D reconstruction of joint surface again demonstrates a posterior wall fracture (D); and 3-D reconstruction with orientation of fracture lines on internal hemipelvis (E) is shown.

What is your diagnosis?

See answer on next page.

T-type acetabular fracture

The patient was diagnosed with a T-type acetabular fracture in the setting of polytrauma. Radiographs and CT also demonstrated a posterior wall fracture and widening of the ipsilateral anterior sacroiliac joint. As noted previously, he also had multiple other lower extremity injuries.

Diagnosis of fracture pattern

Appropriate interpretation of radiographic findings is critical to identify the fracture pattern and plan for surgical exposure and fixation of acetabular fractures. Following the radiographic landmarks as described by Judet and Letournel on the AP pelvis demonstrates disruption of the iliopectineal and ilioischial lines. The teardrop is medialized relative to the ilioschial line. A portion of the roof of the acetabulum appears to be in continuity with ilium. The anterior and posterior wall can be difficult to visualize in complex fracture patterns, however the post-reduction radiograph demonstrates disruption of the posterior wall. An additional clue to the diagnosis includes the disruption of the obturator ring with a segmental fracture of the ischial ramus.

Brian M.
Weatherford

CT with coronal, sagittal and 3-D reformats is helpful to delineate the orientation of fracture lines, look for zones of articular impaction and column displacement, as well to evaluate for the presence of intra-articular debris. Given the disruption of the anterior column (iliopectineal line), posterior column (ilioischial line), obturator ring and the fact that a portion of the joint remains in continuity with ilium, the only possible reasonable diagnoses are anterior with posterior hemi-transverse or T-type acetabular fracture. The transverse orientation of the primary fracture line with a vertical line dividing the ischiopubic segment confirms the diagnosis of a T-type acetabular fracture.

Background

T-type acetabular fractures represent a relatively rare injury pattern. The reported incidence ranges from 7% to 12% of operatively treated acetabular fractures. These fractures are particularly difficult to treat operatively as the separation of the lower (ischiopubic) segment into anterior and posterior fragments creates multiple planes of deformity that are a challenge to address from any single surgical exposure.

Further complicating this T-type fracture is the presence of a separate posterior wall fragment. Although not expressly stated in the classification of Letournel and Judet, several of the associated fracture patterns may have posterior wall fractures including anterior with posterior hemitransverse, associated both column, and T-type.

Marcus F.
Sciadini

Combined fractures of the pelvic ring and acetabulum as seen in this case represent high-energy injury patterns and patients must be evaluated in a systematic fashion for associated injuries. Acetabular fractures in isolation are linked with a significant percentage of associated musculoskeletal injuries, and fractures resulting from a lateral load injury (T-type, associated both column, anterior column, etc.) have rates of thoracic and visceral organ injury that mirror those seen in high-energy pelvic ring injuries. Inpatient mortality rates of up to 13% have been reported for these combined injuries.

Discussion and management

The patient presented with a T-type acetabular fracture. This case was complicated by an associated posterior wall fracture and ipsilateral sacroiliac joint disruption. Operative intervention was indicated to restore articular congruity and stability of both the acetabular fracture fragments as well as the pelvic ring. Nonoperative treatment of displaced acetabular fractures has historically been associated with high rates of post-traumatic arthritis. In addition, the instability seen in this pattern would require prolonged skeletal traction to maintain a reduced hip joint and prevent ongoing soft tissue injury.

Management of T-type acetabular fractures presents several challenges. If attempts are made at achieving reduction through a single surgical exposure, the surgeon must rely on difficult clamp application and the presence of intact soft-tissue attachments to facilitate reduction. Wide displacement of both components of the ischiopubic segment, as seen in this injury, signifies significant capsule and labral injury that would likely preclude indirect reduction. An extensile exposure such as the extended iliofemoral approach would provide access both the anterior and posterior column components, however this exposure is associated with significant morbidity and high rates of heterotopic ossification. Combined anterior and posterior approaches would allow for access to both columns of the acetabulum, however these may result in increased blood loss or multiple anesthetics if undertaken in a staged fashion.

Combined pelvic ring and acetabular fractures pose another treatment quandary. Historically, treatment of these injuries begins with anatomic reduction of the posterior pelvic ring in order to provide a stable hemipelvis to build upon, however this approach may need to be modified in patterns with widely displaced pelvic ring injuries.

At our institution, the treatment algorithm for these injuries involves combined approaches to the acetabulum once the patient has been stabilized and adequately resuscitated. These are typically performed in a staged fashion with an interval CT scan to determine remaining displacement and to ensure that the initial fixation has not captured the displaced fragment.

Figure 3. Final AP pelvis radiograph with iliosacral screw placement and congruent reduction of the left acetabulum following staged surgical exposures (A) is seen. An iliac oblique radiograph demonstrates reduction of the posterior column (B) and an obturator oblique radiograph demonstrates reduction of the anterior column and posterior wall (C).

In this case, the first stage of fixation of fixation was performed via an anterior intra-pelvic or modified Stoppa exposure. A percutaneous iliosacral screw was placed prior to initiating the exposure to stabilize the posterior pelvic ring. The anterior portion of the ischiopubic segment was reduced and stabilized to the intact ilium with a contoured 3.5-mm reconstruction plate along the pelvic brim. An interval CT scan demonstrated residual displacement of the posterior column and posterior wall. The patient subsequently underwent a Kocher-Langenbeck approach. The posterior wall was reduced with the use of a mini-fragment T-plate placed in buttress mode. The posterior column was reduced with a combination of a Schanz pin joystick in the ischial tuberosity and tenaculum forceps. A contoured reconstruction was then placed to connect the reduced posterior column to the intact ilium (Figures 3A-C).

Postoperative management includes foot-flat weight-bearing for 12 weeks. The patient underwent postoperative radiation therapy to prevent formation of heterotopic bone. He was allowed unrestricted range of motion at the hip. His initial follow up has demonstrated maintenance of reduction.