acetabular & nof fracture

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AUGUST 2009| Volume 32 Number 8

Case Report

abstract

Full article available online at OrthoSuperSite.com/view.asp?rID=00000

An Occult Acetabular Fracture Preceding aFemoral Neck Fracture

NIKOLAOS LASANIANOS, MD; NIKOLAOS KANAKARIS, MD, PHD; PETER V. GIANNOUDIS, MD, EEC(ORTHO)

This article describes the case of a 69-year-old patient with an occult acetabular fracture

complicated by an ipsilateral femoral neck fracture occurring within 2 months. The ac-

etabular fracture remained undiagnosed at examination due to insufficient clinical and

radiographic data interpretation. The patient was assured of early mobilization which led

to a fall and subsequent hip fracture. We focus on the potential reasons for the nondiag-

nosis of the acetabular fracture in the first place. Acetabular fractures in the elderly may

occur after low-energy injuries. The lack of history of violent injury may mislead the clini-

cian from the proper diagnosis. Moreover, the authors want to point out the significance

of specialized radiographic control, such as obturator/iliac oblique views and computed

tomography, in vague cases of posttraumatic pelvic or hip pain. Plain anteroposterior (AP)

pelvis radiographs alone may prove an insufficient tool, especially in the eyes of relevantly

inexperienced personnel of the A & E departments. As is characteristic, a retrospective

review of the AP pelvis radiograph obtained after the first fall in our case revealed the un-

displaced fracture of the anterior column that was missed initially. Combined fractures of

the hip and the acetabulum are rarely described in the literature and are usually addressed

by total hip arthroplasty (THA) alone. Similar fracture patterns that develop in 2 stages (2

injuries), as the 1 presented herein, are even more rare. The uniqueness of this combined

fracture required a unique surgical treatment. The senior surgeon (P.V.G.) decided to ad-

dress the acetabular fracture separately to graft the anterior column fracture and facilitate

union, as it was already 8 weeks old and the second fall had generated a further gap be-

tween the fragments. Stable fixation was felt appropriate prior to the THA. Thus, a double

surgical approach was used. Six weeks postoperatively, the patient was able to perform

full weight-bearing mobilization without an antalgic gait pattern. At 6-month follow-up,

radiographs showed the metalwork to be in place with no displacement, and the fracture

had progressed to union.

Drs Lasanianos, Kanakaris, and Giannoudis are from the Academic Unit of Trauma and Orthopae-

dic, University of Leeds, Leeds General Infirmary, Leeds, United Kingdom.

Drs Lasanianos, Kanakaris, and Giannoudis FINANCIAL DISCLOSURE.

Correspondence should be addressed to: Peter V. Giannoudis, MD, EEC(Ortho), Department of

Trauma and Orthopaedics, School of Medicine, University of Leeds, Room 194, A Floor, Clarendon

Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK.

1

Figure: AP radiograph of the occult undisplacedacetabular fracture after the initial fall (A). AP ra-

diograph of the minimally displaced acetabular

fracture and the subcapital fracture of the neck offemur after the second fall (B).

A

B

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ORTHOPEDICS | ORTHOSuperSite.com

Case Report

Fractures of the acetabulum com-

bined with fractures of the femoral

neck are rare.1,2 Such injury pat-

terns usually involve a central acetabular

fracture with a fracture of the ipsilateral

neck of femur and some kind of pelvic-

column disruption.3-6 In other cases, an-

terior or posterior dislocation of the hip

may be associated with a femoral neck

or head fracture.

7-10

We report herein thecase of a 69-year-old man who sustained

a 2-stage hip injury, having initially

sustained an occult acetabulum fracture

which resulted in a femoral neck fracture

within 2 months.

CASE REPORTA 69-year-old previously ambulant man

with no history of bone pathology fell on his

left hip 2 months before being referred to our

department. The initial examination took place

elsewhere 3 days after the fall, because the pa-

tient was reluctant to visit a hospital although

being restricted to bed rest following the injury.

Radiographs were taken at that time (Figure

1A), but no obvious pathology was detected.

The patient was diagnosed with a soft tissue

injury and advised to mobilize as pain allowed.

After several physiotherapy sessions, the pa-

tient managed to achieve painful full weightbearing on the affected site with the use of a

frame. Approximately 2 months after the first

fall during an effort to walk independently, the

patient sustained a new fall. On physical exami-

nation, the left hip was intolerable of any move-

ment, shortened, and externally rotated. Radio-

graphic examination (Figure 1B) confirmed the

clinical suspicion of an intracapsular femoral

neck fracture. Moreover, a minimally displaced

fracture of the left acetabulum was shown on

the new radiograph (Figure 1B). A computed

tomography (CT) scan revealed a nonunited

anterior column fracture (Figure 2). A double

surgical approach was used to fully address the

2 fractures. An ilioinguinal approach was first

used to stabilize the anterior column by open

reduction and internal fixation (ORIF), and a

lateral approach was used for the total hip ar-

throplasty that followed during the same ses-

sion. The floor of the acetabulum was graftedwith autologous graft taken from the femoral

head. Postoperatively, the patient tolerated par-

tial weight bearing. Six weeks postoperatively,

he was able to perform full weight-bearing

mobilization with no limp. Radiographs at 6-

month follow-up revealed all the metalwork to

be in place without any displacement, and the

fracture had progressed to union (Figure 3). No

incidence of postoperative dislocation or other

complications were recorded. On a scale of

Figure 1: AP radiograph of the occult undisplaced acetabular fracture after the initial fall (A). AP radiograph of the minimally displaced acetabular fracture and

the subcapital fracture of the neck of femur after the second fall (B).

Figure 2: CT scan views of the combined fracture pattern showing the gap on the anterior column fracture.

1A 1B

2A 2B 2C

2

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