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Pelvic X-Ray Analysis - Right Acetabular Fracture Complex

This is a 4-view pelvic trauma series (AP, Pelvic Inlet, Right Anterior Oblique/Obturator view, Right Posterior Oblique/Iliac view) - the standard Judet views used specifically to characterize acetabular fractures.

Diagnosis: Right Associated Both-Column Acetabular Fracture (Letournel Classification)

This is the most common associated acetabular fracture pattern, accounting for ~23% of all acetabular fractures (Rockwood & Green's Fractures in Adults, 10th ed. 2025).

View-by-View Findings

1. AP View
  • Disruption of the right iliopectineal line (anterior column marker) and right ilioischial line (posterior column marker)
  • Fracture line through the right iliac wing extending toward the acetabulum
  • The right superior and inferior pubic rami are fractured, disrupting the anterior obturator ring
  • The right femoral head shows medial subluxation tendency
2. Pelvic Inlet View
  • Confirms anterior displacement/disruption of the right anterior pelvic ring
  • The pelvic brim (linea terminalis) is clearly disrupted on the right
  • Helps assess AP displacement of the right hemipelvis
3. Right Anterior Oblique (Obturator) View - View 3
  • Profiles the anterior column and obturator ring
  • Shows displaced fracture through the anterior column running into the obturator ring
  • The iliopectineal line is clearly broken - characteristic of anterior column involvement
  • Fracture extending from the iliac crest/AIIS down through the superior pubic ramus
4. Right Posterior Oblique (Iliac/Judet) View - View 4
  • Profiles the posterior column and iliac wing
  • Shows a prominent displaced fracture through the right iliac wing extending down through the greater sciatic notch
  • The ilioischial line is disrupted - confirming posterior column fracture
  • The spur sign (intact posterior column spur) that would rule out both-column is absent, confirming the both-column pattern

Why This Is a "Both-Column" Fracture

Per the Letournel classification, this is the most severe of the associated fracture types because:
"All both-column fractures have no portion of the acetabular articular surface remaining attached to the innominate bone and there is a split between an anterior and a posterior column component."
  • Rockwood & Green's Fractures in Adults, 10th ed.
The hallmark radiographic feature is the "spur sign" on the iliac oblique view - a spike of bone remaining attached to the sacrum at the SI joint. This spur represents the only remaining connection of the innominate to the axial skeleton and confirms the diagnosis.

Summary of Fracture Components

ComponentFinding
Right anterior columnDisplaced fracture through iliac wing to superior pubic ramus
Right posterior columnFracture through greater sciatic notch/ilioischial line
Right pubic ramiSuperior and inferior rami fractured (anterior ring disruption)
Femoral headMild superomedial subluxation relative to the fractured acetabulum
Sacroiliac jointRight SI joint appears intact (fracture is medial/through iliac wing)
Pubic symphysisIntact, within normal limits

Clinical Context

This is a high-energy injury (typical mechanism: dashboard injury in MVA, fall from height). The standard Judet 3-view series shown here (AP + two obliques + inlet) is exactly the workup recommended for acetabular fracture characterization before CT. A CT scan would be the next step for surgical planning.
Both-column fractures often require operative fixation via extended iliofemoral, ilioinguinal, or combined approaches, unless secondary congruence (where the fracture fragments rotate around the femoral head to maintain joint congruity) is demonstrated - a feature unique to this fracture type.
Sources: Rockwood and Green's Fractures in Adults 10th ed. 2025; Campbell's Operative Orthopaedics 15th Ed. 2026
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