‘975

MAY,

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OCCULT LEE

By

CENTRAL FRACTURES ACETABULUM*

F. ROGERS,

M.D.,f

STANLEY

B. NOVY,

CHICAGO,

ILLINOIS

readily

are

apparent

in this

varying genograms

the

6 hours

from

articular

projection.

of

the

posterior

and

until

fourth

pelvis

oblique

until

were

by

in

iorly

surface

lar

the

in

age

from

years

23

fractures involved of questionable

and

females

2

to

57

the right significance.

occurred accidents. Both of the latter passengers in the front seat. clinical and roentgenographic summarized in Table i. result

of falls

and

2

All

years.

angle

finding were the

is the

anterior

acetabulum ledge

of bone,

the

thin

bone

The

acetabulum

is

surface

contained

B)

is

marginated condyloid

t

Professor Resident

§ Clinical

the

Departments

of Texas

of

Medical

and Chairman, in Radiology,

Professor

Radiology,

School

located

Northwestern

at Houston,

Department The University

of Radiology,

Baylor

anby

a

labrum.

the

centrum

acetabular of

the

within

are

the

of

fossa.

acetabular

the

the The

fossa

quadrilateral

is sur-

of Radiology, of Texas

College

Texas;

the

on

(Fig.

line

begins

extends in

this

at the

iliopubic formed

to the

line

The

the

posterior

The and

Ben

Medical Taub

Northwestern University, Medical School at Houston. of Medicine, Houston, Texas.

96

and

inferior

School, General The

Chicago, Hospital,

Medical

notch

and

tubercle.

fracture

A

of

ilioischial a break ilioischial

u is composed portion of the

roentgenographic

anterior

view line or

Illinois; Baylor

School.

Hermann College

the

line

quadrilateral

face of the iliac bone and indicates fracture of the The

sciatic

pubic

indicates

column. by

land-

anteroposterior The arcuate

2).

downward

break

University,

Houston,

6 anatomic

seen

pelvis’

iliopubic

a concavity

apex of an arch formed by 2 columns of bone.3 The posterior or ilioischial column descends caudad to the ischial tuberosity. This column is composed of the vertical portion of the ischium and the immediately adjacent portion of the ilium. On the anterolateral surface of the column lies the * From

the

face.

in the

University ton, Texas.

articu-

and

the

of

the

medial

marks

and

of the

acetabulum rim.

acetabulum,

of ii

anter-

approximately

portion

of the

acetabular

with

in automobile patients were The significant findings are

ANATOMY I,

runs

and

of

Roentgenographically,

(Fig.

column

inward,

This forms a 320#{176} arc about the acetabulum. It is incomplete only in the anterior and inferior segment. This is the acetabular notch. The acetabular notch is contiguous

ranging

hip-a Two

acetabu-

the

iliopubic

an

surface

thick

SERIES

males

2

or

making

The were

of

6o#{176} with the posterior column. The anterior column consists of a short segment of the ilium and the pubis. On its posterolateral

case.

There

M.D.

spine. downward,

tenor PRESENT

F. HARRIS,

surface

anterior

obliquely

roent-

tomography

ischial

The

obtained in in 3 cases

projection

disclosed

is the

The diagfor periods

to 9 days

NORMA

posterior

have recently encountered 4 cases of central acetabular fractures. These particular fractures may be quite difficult, or even impossible to visualize on the anroentgenogram.3’4 series were delayed

THE

lum and the posterior acetabular rim. The medial surface of this column consists of a broad, smooth plate of bone termed the quadrilateral surface. The most medial and posterior corner of the quadrilateral surface

We occult

teroposterior noses in this

and TEXAS

HE roentgenographic assessment of pelvic trauma frequently consists of a single anteroposterior roentgenoof the pelvis. Most pelvic fractures

gram

M.D.,

AND HOUSTON,

,-Jonly

OF

is sur-

in this line column. of the

acetabuHospital,

of Medicine,

The Hous-

VOL.

No.

124,

Occult

i

Central

Fractures

of the

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Patient

I. II. III. IV.

lar

Age

EO RW LL AM

fossa

gential landmarks the

to

anterior

positive

posterior

fall

52

positive negative negative

posterior oblique anteroposterior tomogram posterior oblique

and

the

adjacent

margin

roentgenographic interest are and

posterior

of bone. or is

of

the

ted

through

onto

the

the

of

ace-

the

of our

fracture cases

acetabular MECHANISM

Central

OF

acetabular

of a severe trochanter.

INJURY

fractures

occur

as

blow to or a fall upon the This force is transmit-

a

inferiorly, posterior ulum. thinnest

The

lines

bone

position were

extending notch,

and a

and

the

located

in each from

anteriorly

acetabular aspect

fractures

course

same

diagonally

of the

head

fracture.

have been described et al.,3 and Eichen-

Judet

across the and superior The

neck

creating

fractures

classified by and Stark.2

and holtz

oblique

femoral

acetabulum

Acetabular

u. Other roof and

the lips

the The tan-

tabulum.

result greater

Fracture

fall

accident accident

Sign

Demonstrating

Rt. Rt. Rt.

of the iliac intersects

Internus

Yew

Rt.

automobile automobile

Obturator

FINDINGS

M F F

the of

Injury

ROENTGENOGRAPHIC

M

surface line either

of

AND

Side

23

Cause

CLINICAL

Sex

57

quadrilateral ilioischial

OF

97

I

TABLE SUMMARY

Acetabulum

thus

the and

fossa to the of the acetabinvolved

the

acetabulum.

Ant. Ant. Post

LATERAL MEDIAL

A FIG.

I.

represents

Innominate bone. the ilioischial

B (A) Medial view. (B) Lateral view. A to B represents the column. D, the acetabular notch. E, the condyloid labrum.

iliopubic column. F, the acetabular

A to C fossa.

L. F. Rogers,

98

S. B. Novy

and

N.

F. Harris

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groin lateral view lum was projected anteroposterior

MAY,

of the hip. identically and

The on

frog-leg

5975

acetabuboth the

views.

The

un-

displaced central fractures of the acetabulum in this series were not apparent in either the anteroposterior (Fig. 3, 4 and B; 4i1; 5, 11 and B; and 6A) or lateral projections. The persistence of symptoms led to further nation

evaluation including some of fluoroscopy, tomography,

oblique

views

was

E /

I 1

only

‘1

‘6

8

‘6 ‘6 Roentgenographic

(iliopubic)

landmarks.

A, the

line. B, the ilioischial u. D, the acetabular

genographic tenor lip of the the acetabulum.

acetabulum.

arcuate

line. C, the roentroof. E, the an-

F, the

ROENTGENOGRAPHIC

history

posterior

lip of

to pain

or

to

refusal

the in

or

hip

trochanters.

were

Roentgenograms

obtained

impression

femur

was an

or

surface

of

swelling

of

2 ofour

to

cases.

the

3C;

obtained

the

in

the of the

ischium.

A

this muscle was This served as the

underlying

injury

(Fig.

projection

surface

(Fig.

hip,

to substantiate and

intact.

were

The

anteroposterior a

of

frog-leg

this

unrevealing;

roentgenograms view projection,

of

the and

is seen

3,

2;

in

3, 4

the

B;

and

on

the the

edge

as

surface

will

be

roentgenogram.

is analogous

to

the

non-depressed

the

face,

posite

and it

line

6i1). is,

of the

quadri-

on

(This

the

is

side

and

an-

situation

of

visualizing

lateral

skull

fractures

roentgenograms

of

In the lateral projection, quadrilateral surface is seen

there

In

there-

inability

anteroposterior

the skull.) though the

ilioischial

5z1;

evident

teroposterior linear,

the

B; 4i1; of displacement, that fractures and

ii

the absence fore, unlikely

on

bear

the affected extremity had presence of a fracture of the femur involving either the head,

included pelvis

inability

or blow

subsequent

upon the

clinical

the

upon

and

and

proximal

the

DIAGNOSIS

of a fall

trochanter

suggested

in

clue

lateral

weight

was

present series inquadrilateral surface described above (Fig. I, 1 and B). This plate of bone lies in an anteroposterior plane and is, therefore, parallel to the central beam when an anteroposterior roentgenogram is obtained. On the roentgenogram in this projection the quadrilateral

‘I

‘6

neck,

or

4A). The fractures in volved bone within

‘I

hip

35#{176}to (Fig.

and ‘I

The

fracture the

projection

Tomography

anteroposterior

/

greater

The in

It

evident

‘4

the

6B).

hematoma

‘4

2.

oblique

quadrilateral

F

8

FIG.

and cases.

pelvis.

successfully demonstrated fracture in I (Fig. SB). The fracture line underlies the origin the obturator internus muscle on

2

‘4

the

identified

posterior

450

4B;

of

consistently

combiand

superimposition considerable

of scattered

the

alen opra-

diation from the thickness of the body part. The resultant film detail is insufficient to visualize the fracture. When the pelvis is placed in the posterior oblique projection, although

the

dependent

quadrilateral

sur-

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524,

FIG.

3. Case

Arcuate

i.

and

extending

face of

Occult

No.

VOL.

(A and

is seen

lines

acetabular

only

overlying

Fractures

B) Anteroposterior

ilioischial

from

Central

are

normal.

notch

partially

structures

en

and

view

of the

through

face,

pelvis praisal

does of

pelvic

fractures.

may

series,

fractures

permit extent

view or

an accurate location

positive

(arrowheads).

oblique

of

the

that

of

apthe

Our

apparent

As is shown of the

be visualized of fractures

acetabulum,

anteroposterior not

internus sign (C) Posterior

is normal.

it is free

fractures

99

view.

Fracture

surface.

even view

the

Acetabulum

Obturator ii

quadrilateral

DISCU5SION

single

pelvis.

Roentgenographic

be visualized.

A

of the

29

by

acetabulum

in this involving

the

present may

not

view.5’6 In a rethe floor of the

and Hagadon6 found of such fractures were not

Pearson

per

cent on

experience

the

initial would

roentgenograms. suggest

that

this

L. F. Rogers,

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100

S. B.

Novy

and

N.

F.

Harris

MAY,

4. Case n. (A) Anteropostenior view of the pelvis. Obturator internus Arcuate and ilioischial lines are normal. Roentgenographic ii is normal. (B) ture present extending from acetabular notch through quadrilateral surface.

FIG.

percentage

could

reduced

by

views Smith4

of the have

and

should pelvic

lateral

have in

side

stated

when

the

question. that in

Knight of

anteroposterior

Anteroposterior

tomogram.

to

In

view

view or Fracture

lum.

the

the

occult

(arrowheads).

oblique

*

extending

ucency

through

Frac-

hip

are made

be

posterior

fractures

should advantages

of

seen in right the quadrilateral

oblique

to disclose the

acetabu-

be given of

frog-leg view of the hip with in the posterior oblique ‘\lthough this has the disadvantage

.

view.

the

of

should

in an attempt

tient

the

present

effort

appropriate

pelvis

Consideration practicality and

any

of

the

of the

otherwise

of pain

views

every

obtain

view

pelvis

preclude patient.

Anteroposterior (B)

and

the

multiple

unrevealing,

oblique

evaluation severe

and

pelvis

oblique

theory,

in the in practice, frequently of the

ri.

considerably

posterior

roentgenograms

be obtained trauma, but

and discomfort necessary turning case,

been

obtaining

sign positive Posterior

1975

to

the

obtaining

the paposition. of re-

acetabular surface.

region.

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VOL.

124,

No.

FIG.

6. Case

iv. (A)

(B) quiring

exposure

of both a more

sessment

of

the The

sides, thorough

the

of

traction,

followed

by

8

The

formly

demon-

limit-

i

are

seen in right the quadrilateral

through

should oblique

posterior

matter

acetahular surface.

be given views of

to the

region.

obtaining pelvis as

a

of routine.

Northwestern

University

3#{176}3 E. Chicago Chicago,

uni-

complica-

arthritis,

10!

Lee F. Rogers, M.D. Department of Radiology

week,

almost

delayed

nadiolucency

extending

rare.

Avenue

Illinois 6o6ii

\Ve

would

tribution Jalis;i,

and

non-weight

are

and

Vague

Acetabulum

sideration

femur. central a short

of

results

degenerative

i.e.,

the

the advantaccurate aswithout

weeks

satisfactory

tions,

present

approximately

6 to

bearing.’”4

for

of the

of the pelvis.

Fracture

of the proximal of undisplaced is usually

fractures

period

Fractures

view

it offers and

acetabulum

evaluation treatment

acetabular

Central

Anteropostenior oblique view.

Posterior

a second

stration age of ing

Occult

a

like

of

allowing

to

acknowledge

I)rs. ‘F. 0. to express

the

authors

the

Nloore and our gratitude to

utilize

conA.

their

Ni. for case

material. SUMMARY

Four

cases

fractures

are

The

lack

plane

projection.

of

dent

on

the

3 cases

the

fracture

case

the

the

the

I.

fracture beam

resultant in which was

fracture

oblique

disclosed. was

view

3.

pro-

therefore, was In

evi-

demonstrated

fractures.

1964,

695-7I4.

4. KNIGHT,

.

R.,

leptic 52-il,

by

for open

6-A, R. A., and

1964,

PEARSON,

pelvis Joint

HILL,

acetabular

r\l.

Joint

LETOURNEL,

and

Central S’urg.,

F. I’rac_ surgical

J. Bone & Joint

reduction. 1615-1675. SMITH,

7. Bone

H. Central fractures & Joint Surg., 1958,

J. V., and HARVEY, fracture secondary

7. Bone

seizure.

R.

&

: classification

ace-

13, 695-705.

1973,

7. Bone

J., and

JUDET,

of acetahulum

acetabuim. 40-A, i-i6. MOORE, ‘F. M.,

Central

fourth

improve the roentgenoof pelvic trauma, con-

46-A,

of

In obtained, the

acetabular JUDET,

L. R. Central

COURTNEY,

fractures. J. Trauma, S. M., and STARK,

EIcHENHOL*1z,

Surg.,

6.

order to assessment

A. W., and

approaches

perpendicu-

tomography.

In graphic

DUNN,

tunes

roentgenogram. this

2.

anteroposter-

line and,

line

of the fracture difficult or

posterior

the

x-ray

fracture

in the

The

placed the

acetabular

tabular

to visualize

jection to

central

of displacement made the fractures

impossible

lar

REFERENCE5

occult

presented.

oblique

and the fragments ior

of

&

Joint

Sing.,

J. P. to epi1970,

1459-1462.

J. R., and involving Surg.,

1962,

HAGADON,

E. J. Fractures J. Bone

floor of acetabulum. 14-B,

of &

Occult central fractures of the acetabulum.

Four cases of occult central acetabular fractures are presented. The oblique plane of the fracture line and the lack of displacement of the fracture f...
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