Acetabular fracturesMANAGEMENT

PELVIS & HIP · 12 SECTIONS

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358 items

☷ Legend

01Approach to the Critical Patient/attcp27

Immediate priorities

›High risk triage frame

›High energy mechanism with pelvic pain or inability to bear weight

›Associated hemorrhage risk in polytrauma

›Hip dislocation time sensitivity

›Hemodynamic instability pathway

›If shock physiology, activate trauma and massive transfusion protocol

›Balanced blood product strategy per local MTP

›Tranexamic acid within 3 hours if major traumatic hemorrhage suspected

›Pelvic binder use when pelvic ring injury also suspected

›Binder centered over greater trochanters

›Limb threat and neurologic threat

›Neurovascular status documentation before and after any manipulation

›Sciatic nerve motor and sensory screening

›Distal pulses and capillary refill

›Early consultation and destination decisions

›Orthopedics early notification for suspected acetabular fracture or hip dislocation

›If open fracture, gross contamination, vascular injury, or polytrauma, trauma center transfer triggers

Time critical complications

›Hip dislocation associated injury bundle

›Posterior hip dislocation suspicion with shortened internally rotated limb

›Sciatic nerve palsy risk

›Femoral head fracture association

›Occult instability and impaction risks

›Marginal impaction suspicion in posterior wall injuries

›Intra articular fragment suspicion with mechanical block

›Compartment and soft tissue threats

›Gluteal compartment syndrome consideration in prolonged immobilization or crush

02History/hx25

Mechanism and trajectory

›Injury pattern context

›Motor vehicle collision dashboard mechanism

›Lateral compression and side impact

›Fall from height axial load

›Low energy ground level fall in older adult

›Timeline

›Time since injury

›Prehospital traction or manipulation

›Time since any hip reduction attempt

›Functional status

›Weight bearing ability after injury

›Baseline mobility and assistive devices

Associated injury screening

›Hip joint symptoms

›Mechanical block symptoms

›Perceived dislocation event

›Neurologic symptoms

›Posterior thigh or leg numbness

›Foot dorsiflexion weakness

›Bleeding and anticoagulation

›Anticoagulant or antiplatelet use

›Bleeding diathesis history

›Bone health and frailty

›Osteoporosis history

›Chronic steroid exposure

›Prior hip arthroplasty or pelvic hardware

03Physical Exam/exam32

Primary survey aligned exam

›Global assessment

›Hemodynamic status and shock markers

›Pelvic pain with instability concern

›Hip posture and limb alignment

›Shortening and internal rotation pattern

›External rotation pattern

›Leg length asymmetry

Focused acetabulum and neurovascular exam

›Regional inspection and palpation

›Pelvic and groin tenderness pattern

›Greater trochanter tenderness

›Perineal and genital ecchymosis

›Range of motion limits

›Pain with log roll

›Pain with axial load through femur

›Neurovascular documentation

›Sciatic nerve motor

›Ankle dorsiflexion

›Great toe extension

›Plantarflexion

›Sciatic nerve sensory

›Dorsum of foot

›Plantar foot

›Distal perfusion

›Dorsalis pedis pulse

›Posterior tibial pulse

›Capillary refill

04Differential Diagnosis/ddx29

High risk alternatives and co injuries

›Pelvic ring fracture ICD 10 S32.8

›Hemorrhage risk higher than isolated acetabulum

›Binder and trauma activation implications

›Hip dislocation ICD 10 S73.0

›Time sensitive reduction pathway

›Femoral head fracture association

›Femoral neck fracture ICD 10 S72.0

›High risk AVN implications

›Weight bearing avoidance and urgent ortho pathway

›Femoral head fracture ICD 10 S72.05

›Pipkin type considerations

›Intra articular fragment concerns

›Greater trochanter fracture ICD 10 S72.1

›Occult intertrochanteric extension concern

›Lumbar spine fracture ICD 10 S32.0

›High energy association

›Neuro deficit overlap

›Sciatic nerve injury ICD 10 S74.0

›Baseline deficit documentation importance

›Post reduction reassessment requirement

Mimics and pain generators

›Hip contusion or hematoma

›Anticoagulation related expansion risk

›Compartment risk in deep gluteal hematoma

›Septic arthritis

›Fever and atraumatic onset mismatch

›Elevated inflammatory markers pattern

05Laboratory Tests/lt18

Baseline trauma and operative readiness

›Core labs for high energy injury or operative pathway

›Complete blood count for anemia or bleeding concern

›Trend hemoglobin when shock or expanding hematoma concern

›Leukocytosis nonspecific in trauma context

›Electrolytes and creatinine for contrast planning

›eGFR threshold per local CT contrast policy

›Rhabdomyolysis co injury risk with prolonged down time

›Coagulation profile when anticoagulants, liver disease, or major bleeding

›INR interpretation limited for DOAC effect

›Anti Xa assay if available for factor Xa inhibitors

›Type and screen for anticipated transfusion or OR

›Crossmatch if active hemorrhage or MTP activation

Adjuncts in severe trauma

›Shock and tissue hypoperfusion markers

›Venous blood gas for pH and lactate trend

›Lactate trajectory for resuscitation response

›Lactate elevation nonspecific in seizure or beta agonist use

›Creatine kinase when crush injury or prolonged immobilization

›Acute kidney injury risk stratification

06Diagnostic Tests/dt49

Scoring Systems

›Fracture classification and stability frameworks

›Judet Letournel classification

›Elementary patterns

›Posterior wall

›Posterior column

›Anterior wall

›Anterior column

›Transverse

›Associated patterns

›Posterior column plus posterior wall

›Transverse plus posterior wall

›T type

›Anterior column plus posterior hemitransverse

›Both column

›AO OTA acetabulum classification

›Type A partial articular

›Type B transverse

›Type C both column

›Stability and operative indicators

›Roof arc concept

›Roof arc angle less than 45 degrees suggests weight bearing dome involvement and operative consideration

›Limited utility in posterior wall or both column patterns

Radiographs

›Standard imaging set

›Pelvis AP view

›Iliopectineal line anterior column

›Ilioischial line posterior column

07Disposition/dispo21

Admission and transfer decisions

›Indications for admission

›Any acetabular fracture with inability to mobilize safely

›Uncontrolled pain despite ED regimen

›Neurovascular deficit or evolving exam

›Hip dislocation reduction performed in ED

›Polytrauma or associated pelvic ring injury

›Transfer criteria

›Need for acetabular ORIF capability not available onsite

›Open fracture or gross contamination

›Vascular injury concern

›Unstable pelvic ring injury or ongoing hemorrhage

›Discharge uncommon pathway

›Minimally displaced stable pattern on CT with reliable follow up

›Safe mobilization plan and supports

›Clear weight bearing restrictions and anticoagulation plan when indicated

Follow up and mobility

›Follow up timing

›Ortho trauma clinic within 3 to 7 days for stable injuries considered nonoperative

›Earlier review if worsening pain, new numbness, or inability to mobilize

›Mobility instructions

›Non weight bearing or toe touch weight bearing per ortho plan

›Walker or crutches fitting and training prior to discharge

08Treatment/t70

Immediate life-saving interventions

›Hemorrhage and shock control

›If major traumatic hemorrhage suspected, activate MTP

›Balanced blood product transfusion per local ratio

›Calcium replacement per transfusion protocol

›If pelvic ring injury suspected, pelvic binder over trochanters

›Avoid binder over iliac crests

›Hip dislocation urgent reduction pathway

›If suspected hip dislocation, urgent reduction after imaging as appropriate

›Neurovascular exam documented pre reduction

›Reduction timing goal within hours to reduce AVN risk

Immobilization and Splinting

›Immobilization principles

›Strict non weight bearing until definitive plan

›Pain limited positioning with pillows and neutral hip alignment

›Temporary stabilization options

›Knee immobilizer if associated knee injury or significant pain with movement

›Traction options when femoral head migration or severe spasm

›Skeletal traction decision typically orthopedics guided

Reduction

›Indications for reduction

›Hip dislocation on imaging or strong clinical suspicion

›Neurovascular compromise with dislocation pattern

›Threatened skin compromise from deformity

›Contraindications or caution triggers

›Suspected femoral neck fracture

›Hemodynamic instability needing resuscitation first

›Inadequate sedation and airway resources

›Analgesia and anesthesia

›Multimodal analgesia baseline

›Acetaminophen PO or IV per local protocol

›NSAID if no contraindication

›Opioid titration options

›Fentanyl IV incremental dosing with monitoring

›If older adult or frail, lower initial dose and slower titration

›Hydromorphone IV incremental dosing with monitoring

›If renal impairment, cautious titration

›Procedural sedation pathway for reduction

›Etomidate IV single bolus sedation option

›Myoclonus and adrenal suppression considerations

›Ketamine IV sedation option

›If hypertension or ischemic heart disease, risk benefit discussion

›Propofol IV titrated option

›Hypotension risk mitigation with fluids and vasopressors ready

›Reduction technique principles

›Traction and countertraction with pelvis stabilized

›Gentle sustained force rather than repeated forceful attempts

›If failed attempt, stop and escalate to orthopedics

›Post reduction requirements

›Immediate neurovascular reassessment

›Post reduction pelvis AP and Judet views

›Post reduction CT to assess congruity and fragments

Open fracture medications and timing

›Open fracture pathway if open wound communicates with fracture

›Antibiotics as early as possible

›Cefazolin IV typical first line for low contamination

›If severe contamination or high grade suspicion, add gram negative coverage per local protocol

›If penicillin anaphylaxis, alternative regimen per local protocol

›Tetanus prophylaxis per immunization status

›Tetanus toxoid booster if not up to date

›Tetanus immune globulin if unknown or incomplete series with dirty wound

›Sterile dressing and avoid aggressive ED debridement

›Irrigation only if gross contamination and delayed OR expected

DVT prophylaxis when relevant

›Venous thromboembolism risk management

›High risk features

›Pelvic or acetabular fracture with reduced mobility

›Surgery planned

›Prior VTE or thrombophilia

›Pharmacologic prophylaxis per trauma or ortho protocol

›Low molecular weight heparin typical first line when bleeding risk acceptable

›If active bleeding risk, mechanical prophylaxis until safe

›Documentation elements

›Risk benefit rationale

›Start timing and hold parameters

09Special Populations/sp26

Pregnancy

›Maternal fetal considerations

›Left lateral tilt positioning when viable gestation to reduce aortocaval compression

›Early obstetrics involvement in major trauma

›Imaging principles

›Maternal stabilization priority

›Pelvis and CT imaging when clinically indicated with dose minimization strategies

›Analgesia and sedation

›Avoid NSAIDs in later pregnancy per obstetric guidance

›Opioid use with monitoring and shared decision framing

Geriatric

›Low energy fracture pathway

›Ground level falls as common mechanism in older adults

›Fragility fracture context and osteoporosis referral triggers

›Delirium and medication sensitivity

›Opioid and sedative dose reduction and slower titration

›Early mobilization planning and admission threshold lower

›Operative decision nuances

›Pre existing osteoarthritis and impaction affecting fixation strategy

›Consideration of acute total hip arthroplasty pathways in select cases

Pediatrics

›Rarity and high energy association

›High energy trauma more typical than low energy mechanisms

›Growth plate and triradiate cartilage considerations

›Imaging and radiation minimization

›Judet views and CT only when management changing

›Pediatric trauma and ortho consultation early

›Nonaccidental trauma consideration

10Background/b28

Epidemiology

›Incidence and trends

›Reported crude incidence around 1.8 to 3.0 per 100,000 person years in a national cohort with increasing trend over time

›U S claims based estimate reported higher incidence around 40 per 100,000 per year in one epidemiologic study

›Increasing incidence with aging population and low energy mechanisms in older adults

›Demographics

›Male predominance in many trauma cohorts

›Bimodal distribution with young high energy and older low energy patterns

Pathophysiology

›Force vector to pattern mapping

›Dashboard mechanism posterior wall and posterior column patterns

›Lateral compression anterior column patterns

›Axial load transverse and both column patterns

›Joint congruity and cartilage injury

›Articular surface step off linked to post traumatic arthritis risk

›Marginal impaction as predictor of instability and arthritis

›Neurovascular anatomy relevance

›Sciatic nerve vulnerability in posterior wall and dislocation patterns

›Superior gluteal neurovascular bundle risk with posterior approaches

Therapeutic Considerations

›Nonoperative versus operative rationale

›Stable minimally displaced fractures may be managed nonoperatively with protected weight bearing

›Displacement in weight bearing dome and instability patterns often need ORIF

›Time sensitivity

›Hip dislocation reduction urgency to reduce femoral head osteonecrosis risk

›Early definitive management planning improves mobilization and complication prevention

›Complications to anticipate

›Post traumatic osteoarthritis

11Patient Discharge Instructions/pdi20

Copy discharge instructions

›Home care and activity

›Strict non weight bearing or toe touch weight bearing as directed

›Crutches or walker use at all times when standing

›Avoid hip twisting and deep flexion until cleared

›Pain control plan

›Acetaminophen scheduled dosing within safe daily maximum

›NSAID only if safe for kidneys, stomach, bleeding risk, and pregnancy status

›Opioid only for breakthrough pain with constipation prevention plan

›Swelling and skin care

›Elevation and ice intervals for pain and swelling

›Skin checks for pressure areas if immobilizer used

›Return to ED now

›New numbness or weakness in foot or leg

›Foot becomes cold, pale, or markedly swollen

›Pain rapidly worsening or uncontrolled

›Fever or wound drainage if open injury

›Chest pain, shortness of breath, or unilateral leg swelling

›Follow up plan

›Ortho trauma follow up within 3 to 7 days unless otherwise arranged

›Return sooner for worsening function or inability to mobilize

12References/r13

Clinical guidelines and evidence sources

›Core acetabulum imaging and classification references

›Judet views and acetabular fracture radiographic approach references

›Judet Letournel classification descriptions and reliability studies

›AO Foundation surgery reference acetabulum imaging and pattern characteristics

›Roof arc and stability references

›OTA educational materials on radiographic evaluation and roof arc concept

›Matta based roof arc threshold discussion including less than 45 degrees operative consideration

›Epidemiology references

›National registry cohort reporting increasing crude incidence around 1.8 to 3.0 per 100,000 person years

›U S epidemiology study reporting acetabular fracture incidence estimate around 40 per 100,000 per year

›Emergency medicine practice references

›ACEP procedural sedation clinical policy for ED sedation monitoring and medication safety

›ATLS trauma principles for initial stabilization and transfer decisions

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

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