Surgical treatment of acetabulum top compression fracture with sea gull sign

Abstract

Objective: To investigate surgical procedures and their efficacy for acetabulum top compression fractures with sea gull sign.

Methods: Data of 14 patients (five women, nine men); aged from 28 to 71 years (mean, 49.9 years) who had undergone surgery for acetabulum top compression fractures with sea gull sign and been followed up were retrospectively analyzed. The time from injury to surgery was 4-14 days (mean, 9 days). All patients underwent open reduction and bone graft and internal fixation through an ilioinguinal or ilioinguinal plus Kocher-Langenbeck approach. Quality of fracture reduction was assessed according to Matta reduction criteria and hip function according to Matta acetabular fracture criteria.

Results: Fourteen patients were followed up for 6-60 months (mean, 36 months). All achieved bone healing within 3-4 months (mean, 3.4 months); the excellent and good rate being 78.5% (11/14). The Matta acetabular fracture scores were 10-18 scores (mean, 16.4); the excellent and good rate being 71.4% (10/14). Traumatic arthritis occurred in three patients. Pain was serious in two patients and relieved by total hip joint replacement and mild in one. One patient developed asymptomatic heterotopic ossification postoperatively.

Conclusion: The appropriate delay between injury and surgery with acetabular roof compression fracture with sea gull sign is from 5 to 10 days. Through an ilioinguinal or ilioinguinal plus Kocher-Langenbeck approach, excellent reduction of the articular surface can be achieved and sufficient bone graft material obtained. The clinical efficacy is satisfactory.

Keywords: Acetabulum; Bone transplantation; Compression; Fracture fixation; Fractures.

© 2015 Chinese Orthopaedic Association and Wiley Publishing Asia Pty Ltd.

Figures

Figure 1

When acetabular fractures involve the acetabular roof, X‐ray films show two typical double arc shadows on the acetabular roof, which are similar to sea gull wings in flight and therefore vividly described as the “sea gull sign”.

Figure 2

Schematic diagram of open reduction and internal fixation of acetabular roof compression fractures via an ilioinguinal approach, fracture line, reduction, and internal fixation position are displayed from the inner pelvis view. (A) The incision for the ilioinguinal approach starts from the 1/3 junction of the iliac crest, extends anteriorly to 2 cm above the inguinal ligament, then curves medially and inferiorly to end 2 cm above the pubic symphysis. (B) The anterior column, anterior wall and posterior column fracture line are exposed. (C) After reduction of the posterior column, a plate is inserted along the lower margin of the true pelvis to fix the fracture across the joints. (D) The fracture fragments in the anterior wall are uncovered, revealing the acetabular roof compression fractures and femoral head fragments. (E) The femoral head is used as a template to achieve reduction; a periosteum screwdriver or pry bar is used to pry downward and push the collapsed articular surface so that the articular surface lies flat or slightly higher than the surrounding articular surface. (F) The anterior column and anterior wall fracture are set and a reconstruction plate is placed along the anterior margin of the true pelvic for cross articular fracture fixation.

Figure 3

Man, 41 years old, left anterior column plus posterior hemisection acetabular fracture caused by traffic accident. (A−C) Preoperative frontal X‐ray, CT and 3‐D reconstruction, respectively, of an inner top compression collapse of the acetabular roof with double arc shadow, “sea gull sign”. (D, E) Three days after surgery, front view X‐ray and 3‐D CT reconstruction, respectively, of acetabular roof fracture reduction showing satisfactory fixation and a smooth articular surface; the “sea gull sign” has disappeared. (F, G) Four months after surgery, frontal and lateral X‐ray films showing fracture healing, loss of fracture line and flat articular surface. (H) Four months after surgery, hip joint function is good.

Figure 4

Schematic diagram of arc angle (α), that is, the angle between a vertical line drawn through the center of the femoral head on a front view or Judet oblique view of the pelvis and a line through the center of the femoral head and the fracture site.