Both Column Acetabular Fractures

Elementary Patterns (5):

Anterior wall involves isolated anterior wall fracture. Anterior column extends from iliac crest to pubis. Posterior wall is the most common elementary pattern. Posterior column involves the ilioischial line. Transverse fracture divides acetabulum into superior and inferior halves.

Associated Patterns (5):

T-shaped combines transverse with vertical component. Posterior column plus posterior wall is a common combination. Transverse plus posterior wall involves additional instability. Anterior column/wall plus posterior hemitransverse is complex associated pattern. Both column (this topic) is the most common associated pattern at 20-25%.

Diagnostic Criteria:

Both anterior and posterior columns are completely fractured. No articular segment remains attached to axial skeleton. Spur sign is pathognomonic and present on obturator oblique view. Both iliopectineal and ilioischial lines are disrupted.

Subtypes:

High both column involves fracture exiting through iliac crest. Low both column involves fracture exiting through sciatic notch. With posterior wall component indicates additional instability requiring assessment.

Definition:

Secondary congruence occurs when femoral head pushes detached acetabular fragments into acceptable alignment during weight-bearing. This phenomenon is unique to both column fractures because entire acetabulum is floating.

Clinical Significance:

Presence of secondary congruence may allow non-operative treatment in selected elderly patients. Femoral head centered under roof with minimal step indicates acceptable alignment. CT assessment is required to evaluate congruence.

Indications:

Secondary congruence present with femoral head molding fragments into alignment. Elderly low-demand patients with acceptable articular surface. Medical comorbidities precluding major surgery. Roof arc measurements greater than 45 degrees in all planes. Minimal displacement with acceptable articular congruence.

Secondary Congruence Concept:

Femoral head acts as mold and pushes fragments into alignment. Creates functional weight-bearing surface despite fracture. More common in elderly patients with comminuted fractures. Unique to both column fractures where entire acetabulum floats.

Protocol:

Skeletal traction initially for 2-4 weeks followed by progressive mobilization. Weight-bearing restrictions maintained for 6-12 weeks. Serial radiographs to monitor alignment. Conversion to surgery if alignment lost.

Indications:

Displaced fractures in young active patients. Loss of secondary congruence on CT assessment. Roof arc less than 45 degrees. Articular step-off greater than 2mm. Associated femoral head injury requiring open treatment. Failed conservative treatment with loss of alignment.

Timing:

Surgery ideally within 3-7 days after injury to allow swelling to settle. Must be performed within 14-21 days before callus formation. Beyond 3 weeks reduction becomes significantly more difficult. May need traction while awaiting surgery.

Approach Selection:

Based on which column predominates and fracture configuration. Anterior column predominant uses ilioinguinal approach. Posterior column predominant uses Kocher-Langenbeck. Combined approaches frequently required for both column pattern.

Algorithm

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Step 1: Assess Secondary Congruence

CT scan to evaluate if femoral head has molded fragments into alignment. If present with acceptable roof, consider conservative in elderly.

Step 2: Evaluate Patient Factors

Young active patient generally requires anatomic reduction. Elderly low-demand patient may tolerate some incongruity. Medical fitness for major surgery must be assessed.

Step 3: Plan Surgical Approach

Determine which column is more displaced for primary approach. Plan combined approach if both significantly displaced. Consider timing and staging based on patient condition.

Access Provided:

Anterior column from iliac crest to pubic symphysis. Quadrilateral surface and inner table of ilium. Superior pubic ramus and pelvic brim.

Indications:

Anterior column-predominant both column fractures. High both column variants exiting through iliac crest.

Key Structures at Risk:

External iliac vessels in middle window. Femoral nerve lateral to vessels. Lateral femoral cutaneous nerve over ASIS. Corona mortis (aberrant obturator artery) in 15-30% of cases.

Technique Highlights:

Three windows created (lateral, middle, medial). Lateral femoral cutaneous nerve identified and protected. Iliac vessels and femoral nerve protected in middle window.

Access Provided:

Posterior column from greater sciatic notch to ischial tuberosity. Posterior wall and retroacetabular surface. Greater and lesser sciatic notches.

Indications:

Posterior column-predominant fractures. Associated posterior wall component. Low both column variants exiting through sciatic notch.

Key Structures at Risk:

Sciatic nerve (identified and protected throughout). Superior gluteal artery at sciatic notch. Inferior gluteal artery and nerve. Medial femoral circumflex artery (avoid excessive retraction).

Technique Highlights:

Lateral decubitus or prone position. Interval between gluteus maximus and medius. Sciatic nerve protected with knee flexed. Short external rotators released for access.

When Required:

Most both column fractures need visualization of both columns. Displacement significant in both anterior and posterior.

Options:

Simultaneous combined approach with patient lateral and anterior approach through same incision or separate. Sequential staged approach with flip from prone to supine.

Modified Stoppa Addition:

Better quadrilateral plate access through anterior midline approach. Can be combined with ilioinguinal windows. Useful for medial displacement of quadrilateral surface.

Reduction Techniques:

Farabeuf clamps and pointed reduction forceps for anterior column. Matta clamp and Schanz pin joystick for posterior column. Ball spike pusher through ilioinguinal windows.

Anterior Column Fixation:

3.5mm pelvic reconstruction plates contoured along iliopectineal line. Infrapectineal plate for quadrilateral surface if needed. Column screws from anterior to posterior.

Posterior Column Fixation:

Standard 3.5 mm reconstruction plates along posterior column. Spring plates for comminuted posterior wall. Lag screws for large articular fragments.

First 48-72 Hours:

Monitor for compartment syndrome and neurovascular status. DVT prophylaxis is mandatory given high risk. Wound care with drain removal at 24-48 hours. Pain management and early mobilization as tolerated.

Weight-Bearing:

Touch weight-bearing initially with crutches or frame. Progression based on fracture pattern and fixation stability. Protected weight-bearing for 8-12 weeks typically.

Week 1-6:

Range of motion exercises begin immediately. Hip flexion active and passive within comfort. Focus on quad and hip abductor strengthening. DVT prophylaxis continues for 4-6 weeks minimum.

Week 6-12:

Progressive weight-bearing based on radiographic healing. Pool therapy if available. Gait training with progression from walker to cane. Continued strengthening program.

Radiographic Monitoring:

X-rays at 2, 6, and 12 weeks post-operatively. CT scan if concern about reduction or healing. Look for loss of reduction or hardware failure.

Long-Term:

Annual review for first 2 years. Monitor for post-traumatic arthritis. May need THR if significant arthritis develops.