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. 2026 Aug 8;65:101415. doi: 10.1016/j.tcr.2026.101415

Isolated fracture of the anterior wall of the acetabulum: A rare fracture, even rarer in the skeletally immature patient. Report of two cases and literature review

Vincenzo Giordano a,b,⁎, Anderson Freitas c, Nicolle Barreto a, Jhordana Esteves dos Santos d, Carolina Braga dos Santos Azevedo c, Cynthia Storino Pavan a
PMCID: PMC13486356  PMID: 42621136

Abstract

Background

Isolated anterior wall acetabular fracture (AWAF) is a rare injury in adults and even rarer among the skeletally immature population.

Case presentation

We present the cases of two skeletally immature patients (a 13-year-old boy [case #1] and a 10-year-old boy [case #2]) with displaced isolated AWAF, surgically treated using the Smith-Petersen approach with osteotomy of the anterior superior iliac spine.

Results

The patients were closely followed up for an average of 18 months, presenting normal function and a concentric hip. Despite the good functional outcome, the latest hip radiographs of case #2 showed initial signs of a bony bar in the triradiate cartilage and the presence of avascular necrosis of the femoral head.

Conclusion

We emphasize the importance of long-term follow-up for skeletally immature patients with this type of injury, given the high potential for complications.

Keywords: Acetabular fracture children, Acetabular fracture, Smith-Petersen approach, Triradiate cartilage fracture, Physeal injury, Physeal bar, Avascular necrosis femoral head

Highlights

  • •

    Isolated anterior acetabular wall fracture is a rare injury in adults and even rarer in children.

  • •

    Fragment displacement exceeding 5 mm with consequent articular incongruity or persistent hip instability leading to recurrent dislocation episodes are indications for surgery.

  • •

    Due to the rarity of the injury and the lack of standardization of treatment, different surgical approaches and fixation methods have been described.

  • •

    In the immature skeleton, complications such as post-traumatic acetabular dysplasia, premature physeal closure of the triradiate cartilage, avascular necrosis of the femoral head, and degenerative osteoarthritis can occur.

  • •

    The younger the patient, the greater the risk of premature physeal closure.

Introduction

Isolated anterior wall acetabular fracture (AWAF) is a rare injury, accounting for less than 2% of all acetabular fractures, according to the historical series by Judet and Letournel [1]. Radiologically, the osteoarticular fragment has a trapezoidal shape, affecting the anterior portion of the anatomical roof of the acetabulum, with the fracture line starting at the anterior edge of the acetabulum, slightly below the anterior inferior iliac spine, crossing the articular surface and descending through the acetabular fossa until reaching the ischiopubic notch, slightly behind the anterior lunate articular surface, however not involving the pelvic brim [1], [2], [3].

The injury mechanism generally involves moderate to high-energy trauma to the ipsilateral lower limb with the hip in abduction and external rotation [1], [2], [3]. The degree of hip flexion or extension at the time of trauma determines whether the fragment is more inferior or more superior, respectively [3], [4], [5]. Association with anterior hip dislocation is frequently reported in the literature, requiring urgent treatment to concentrically reduce the joint [2], [3], [4], [5], [6].

Surgical treatment is indicated when fragment displacement exceeds 5 mm with consequent articular incongruity or when there is persistent hip instability leading to recurrent dislocation episodes [3], [6]. Associated femoral head impact fractures, severe comminution, and/or marginal impaction of the articular cartilage of the acetabular roof have proven to be poor prognostic factors [3]. Due to the rarity of the injury and the lack of standardization of treatment, different surgical approaches and fixation methods have been described, which greatly complicates decision-making in the face of such a rare injury. In addition, most studies address simultaneous fractures of the anterior column and the anterior wall of the acetabulum, always in adult patients, which creates a selection bias, especially regarding the choice of surgical approach [6], [7].

In the present study, we report two cases of isolated AWAF in skeletally immature patients, an even rarer injury that, to our knowledge, has been poorly reported in the literature to date.

Case reports

Case #1. An open isolated AWAF in a 13-year-old boy.

  • o

    Initial assessment

A 13-year-old male patient presented to the hospital on February 20, 2024, after suffering a bicycle fall with penetrating trauma to the right groin caused by the bicycle handlebars (Fig. 1).

Fig. 1.

Fig. 1

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Clinical appearance of the open wound upon admission (A) and after initial debridement (B). Note that the location is exactly in the topography of the femoral triangle.

The patient complained of pain and limited mobility in the right hip, without neurovascular changes in the ipsilateral lower limb. He was hemodynamically stable and had no other skeletal or non-skeletal injuries. Physical examination of the right hip revealed pain on passive mobilization. Radiographs of the pelvis and right hip showed an isolated AWAF, without hip dislocation (Fig. 2).

Fig. 2.

Fig. 2

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Initial X-rays showing the displaced AWAF (arrows). From left to right, AP, iliac oblique, obturator oblique, inlet, and outlet radiographic views.

Computed tomography (CT) of the pelvis and hips revealed the detached trapezoidal osteoarticular fragment affecting between 25 and 50% of the anterior wall, located in the intermediate portion of the anterior acetabular wall – classified as type 2 M, according to the Leeds-Naples AWC system (Fig. 3) [3]. The open fracture was classified as grade II, according to the Gustilo and Anderson classification system [8].

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    Perioperative management

Fig. 3.

Fig. 3

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Initial CT scan (axial (A) and 3D reconstruction (B)) showing the displaced AWAF (arrow). The detached trapezoidal osteoarticular fragment affected between 25 and 50% of the intermediate portion of the anterior acetabular wall and was classified as type 2 M, according to the Leeds-Naples AWC system [3].

Due to the open fracture, intravenous antibiotic prophylaxis with a first-generation cephalosporin was initiated, and the patient underwent emergency irrigation and debridement. Definitive surgery was performed two days after the injury. Under endotracheal anaesthesia, the patient was positioned supine on a radiolucent table, with the C-arm located on the contralateral side. The Smith-Petersen approach with osteotomy of the anterior superior iliac spine (ASIS) was performed, protecting the lateral femoral cutaneous nerve. After exposing the anterior margin of the acetabulum, it was observed that the trapezoidal osteoarticular fragment was rotated 180°, with the articular surface facing the surgeon, partially exposing the femoral head. The fragment was derotated and anatomically reduced and temporarily fixed with 2.0-mm Kirschner wires (K-wires) (Fig. 4). After C-arm fluoroscopic control to verify the positioning of the fragment and the K-wires, the fracture was fixed with a 4-hole one-third tubular plate, with two 3.5-mm cortical screws proximal and two distal to the fracture (Fig. 5). The wound was irrigated with saline solution, the ASIS osteotomy was reduced and fixed with one 3.5-mm cortical screw, and the incision was closed in layers. The procedure was completed without complications.

Fig. 4.

Fig. 4

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The trapezoidal osteoarticular fragment was rotated 180°, with the articular surface facing the surgeon (arrows), partially exposing the femoral head (asterix). The fragment was derotated, anatomically reduced, and temporarily fixed with K-wires.

Fig. 5.

Fig. 5

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A, Intraoperative clinical image showing final fixation of the AWAF with a 4-hole one-third tubular plate; B, Intraoperative AP, iliac oblique, and obturator oblique fluoroscopic images demonstrating the final fixation.

Immediate postoperative radiographs revealed excellent reduction quality (Fig. 6). The patient was discharged from the hospital 48 h after definitive surgery without antibiotics or antithrombotic prophylaxis. Unrestricted mobility of the operated hip and weight-bearing as tolerated using two crutches was authorized. The patient was regularly evaluated on an outpatient basis.

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    Follow-up assessment.

Fig. 6.

Fig. 6

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Immediate postoperative X-rays showing the quality of reduction and the fixation of both the AWAF and the ASIS osteotomy. From left to right, AP, iliac oblique, obturator oblique, inlet, and outlet radiographic views.

Outpatient follow-up visits were conducted at one, three, six, and 12 weeks and at 6, 12, and 18 months. Control radiographs were taken at 3, 6, and 12 weeks and at 6, 12, and 18 months. The sutures were removed at 3 weeks, with both wounds – the open wound and the surgical approach – healing satisfactorily. At 6 weeks, the patient was allowed to use only one crutch, and at 12 weeks the patient was able to resume normal weight-bearing activities, with no pain and full recovery of range of motion of the right hip.

At the 18-month follow-up, the patient has a pain-free, full range of movement in the right hip, with 18 points on the modified Merle d'Aubigné and Postel scoring system (Video 1). Radiographs and CT scan show a normal, concentric right hip (Fig. 7, Fig. 8).

Fig. 7.

Fig. 7

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18-month postoperative X-rays (from left to right, AP, iliac oblique, obturator oblique, inlet, and outlet radiographic views) showing a normal, concentric right hip.

Fig. 8.

Fig. 8

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18-month postoperative CT scan (coronal (A) and axial (B)) showing the anatomic reduction of the right hip, with no signs of physeal closure of the triradiate cartilage or avascular necrosis of the femoral head.

Case #2. An isolated AWAF in a 10-year-old boy with multiple fractures.

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    Initial assessment.

A 10-year-old male patient was admitted to the hospital on September 7, 2024, after suffering a car accident – a frontal collision, during which he was ejected from the vehicle. The patient was awake but confused and presented with lacerations to the head with active bleeding (initial Glasgow Coma Score of 9), with no complaints in the cervical spine, but reporting pain in the thoracic spine. Initial assessment revealed diffuse oedema in the right hand and the right lower limb was externally rotated. In both regions, the patient complained of severe pain. The peripheral neurovascular examination was normal, and the patient was hemodynamically stable. The patient underwent imaging studies (X-rays and CT scan), which revealed fractures of the second and third right metacarpals, a flexion-compression fracture of the T7 vertebral body without spinal canal invasion, fractures of facial bones, and an anterior fracture-dislocation of the right hip, with an isolated AWAF involving more than 50% of the anterior wall, located in the inferior portion of the anterior acetabular wall – classified as type 3I, according to the Leeds-Naples AWC system (Fig. 9) [3].

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    Perioperative management.

Fig. 9.

Fig. 9

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Initial AP pelvis X-rays and CT scan showing an anterior fracture-dislocation of the right hip. Observe the displaced AWAF involving more than 50% of the inferior portion of the anterior wall. The fracture was classified as type 3I, according to the Leeds-Naples AWC system [3].

Due to the hip dislocation, the patient was rushed to the operating room, where the hip was reduced under anaesthesia using the Allis manoeuvre [4], [5]. After the reduction, the hip was unstable, requiring skeletal traction through the distal region of the right femur. Following this, new radiographs were taken for definitive surgical planning (Fig. 10). Fractures of the metacarpals and thoracic spine were treated non-surgically. Definitive surgery was performed 11 days after hospital admission mainly due to the neurological impairment. Both the facial fractures and the AWAF were fixed in the same procedure. The facial fractures were fixed first to improve the patient's ventilation and allow for endotracheal anaesthesia.

Fig. 10.

Fig. 10

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Initial X-rays showing the displaced AWAF (arrows). From left to right, AP, iliac oblique, obturator oblique, inlet, and outlet radiographic views.

For the right hip fracture, the patient was positioned in the supine position on a radiolucent table, with the C-arm positioned on the contralateral side. The Smith-Petersen approach with osteotomy of the ASIS was performed, protecting the lateral femoral cutaneous nerve. After exposing the anterior margin of the acetabulum, the fragment was anatomically reduced and temporarily fixed with 1.6-mm K-wires. After fluoroscopic control with the C-arm, the fracture was fixed with a non-locked 2.7-mm quarter tubular plate with eight holes, with one 2.7-mm cortical screw proximal and two distal to the fracture. The wound was irrigated with saline solution, the ASIS osteotomy was reduced and fixed with a 3.5 mm cortical screw, and the incision was closed in layers (Fig. 11). The procedure was completed without complications.

Fig. 11.

Fig. 11

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Immediate postoperative X-rays showing the quality of reduction and the fixation of both the AWAF and the ASIS osteotomy. From left to right, AP, inlet, and outlet radiographic views.

The patient was discharged from the hospital 14 days after definitive surgery, with unrestricted mobility of the operated hip and weight-bearing as tolerated using two crutches was authorized. The patient was regularly evaluated on an outpatient basis.

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    Follow-up assessment.

Outpatient follow-up visits were conducted at one, three, six, and 12 weeks and at 6, 12, and 18 months. Control radiographs were taken at 3, 6, and 12 weeks and at 6 and 12 months. The sutures were removed at 3 weeks, with the surgical approach healing satisfactorily. At 6 weeks, the patient was allowed to use only one crutch, and at 12 weeks the patient was able to resume normal weight-bearing activities, with no pain and full recovery of range of motion of the right hip.

At the 12-month follow-up, the patient had a pain-free, full range of movement in the right hip, with 18 points on the modified Merle d'Aubigné and Postel scoring system [9], [10]. Radiographs of the right hip showed a normal, concentric articular joint, however with signs of premature physeal closure, with the formation of a superomedial bony bar in the triradiate cartilage (Fig. 12).

Fig. 12.

Fig. 12

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12-month postoperative X-rays (from left to right, AP, iliac oblique, obturator oblique, inlet, and outlet radiographic views) showing a normal, concentric right hip. Despite the good results so far, signs of premature physeal closure can be observed, with the formation of a superomedial bony bar in the triradiate cartilage (arrows).

At the 18-month follow-up, the patient has a pain-free, full range of movement in the right hip, with 18 points on the modified Merle d'Aubigné and Postel scoring system [9], [10], despite radiographs of the right hip revealing irregular femoral head shape, changes in density, and the presence of avascular necrosis of the femoral head, as well as advanced signs of premature physeal closure in the triradiate cartilage (Fig. 13 / Video. 2). Despite the imaging findings, the result was considered good, according to Ratliff's criteria [11]. The patient has been monitored through regular outpatient clinical consultations.

Fig. 13.

Fig. 13

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18-month postoperative images. A, AP and Lauenstein radiographic views showing signs of advanced physeal closure in the triradiate cartilage and the presence of avascular necrosis of the femoral head; B, CT scan (from left to right, coronal, sagittal, and axial tomographic cuts) revealing irregular femoral head shape, changes in density, and the presence of avascular necrosis of the femoral head.

Discussion

Isolated AWAF is the rarest acetabular fracture pattern in adults and even rarer in immature skeletons. To the best of our knowledge, only a few studies have reported isolated fractures of the anterior wall acetabular fractures to date. In the study by Heeg et al. [12], this lesion was found in two of the 29 patients treated for acetabular fracture in three hospitals between 1972 and 1995. In their study, the two patients, one 5 years old presenting with an isolated AWAF with small fragments after hip dislocation and the other 9 years old presenting with a stable linear AWAF without displacement, were treated non-surgically, with excellent clinical and radiographic results, and no complications. The patients' follow-up time was not mentioned. In a multicentre registry study using data from the German Pelvic Trauma Registry Initiative, von Heyden et al. [13] found only 15 (9.8%) children with acetabular fractures out of a total of 152 children among 7360 patients with pelvic fractures registered in 3 distinct periods (1991–93, 1998–2000, 2004–2008). Three of the 15 acetabular fractures were associated with a pelvic fracture, and 12 were isolated. Only one patient suffered an AWAF, however, no specific details were reported about the patient, treatment, or follow-up.

In our study, both patients were treated surgically using the Smith-Petersen approach with ASIS osteotomy due to fracture displacement greater than 5 mm, with excellent clinical and radiographic results after a mean follow-up of 18 months. We opted for the Smith-Petersen approach with osteotomy of the ASIS because, in our opinion, it best exposes the anterior column of the acetabulum. Furthermore, by medially retracting the ASIS bone fragment along with the sartorius muscle, the neurovascular structures of the femoral triangle are completely protected. Other authors have suggested this approach in fractures involving the anterior wall, especially when extensile exposure of the anterior column of the acetabulum to the pubic root is necessary [14], [15], [16], as was required in our patients for the placement of the distal screws of the plate, without risk of articular penetration by the implants. In a recent study, Saracco et al. [3] observed that of 68 patients with isolated AWAF (in 17 studies), in 58.2% of cases (39 patients), the ilioinguinal approach was used, while the Smith-Petersen approach was used in 19.4% of cases (13 patients), showing that it is a viable option providing access to the low anterior acetabulum column and anterior wall. These authors conclude that the choice of surgical approach should be based on the surgeon's experience [3]. In any case, the risk of premature closure of the ASIS physis must be taken into account, since these are patients with immature skeletons. However, as observed in displaced traumatic avulsions of the ASIS in immature skeletons, its correct reduction and fixation do not usually cause complications in adulthood [17].

The choice of surgical approach is, in fact, a crucial aspect, since several authors have reported that, among the elementary patterns of acetabular fracture, AWAF presents the least satisfactory results, mainly due to the surgical complexity and the difficulty in obtaining anatomical reduction [3], [18], [19], [20]. Specifically in the immature skeleton, complications such as post-traumatic acetabular dysplasia and degenerative osteoarthritis can occur [21]. Furthermore, traumatic injury to the triradiate cartilage can be observed, with or without damage to the cartilage of the femoral head, which increases the risk of premature physeal closure due to the formation of a medial bony bridge, significantly worsening the prognosis [12], [22], [23], [24]. The younger the patient, the greater the risk of premature physeal closure. Therefore, it is essential that patients with immature skeletons who suffer acetabular fractures be followed up into adulthood, since the time interval between injury to the triradiate cartilage and the development of acetabular dysplasia is 12.4 years on average [23].

In our patients, no post-traumatic sequelae with clinical repercussion have been observed to date; however, in case #2, the initial appearance of a bony bar in the triradiate cartilage was noted. This patient, a 10-year-old boy with multiple fractures, including an isolated AWAF, after a car accident, despite the presence of premature physeal closure and avascular necrosis of the femoral head, presents with full and painless range of motion in the injured hip and mild limping after 18 months of follow-up. In our opinion, this could be due to both the young age and the delay in performing the definitive surgery. The patient is still a child (4 to 12 years old) [25], which is known to increase the risk of premature physeal arrest due to the displaced AWAF [12], [22], [23], [24], [25], [26]. In addition, the presence of multiple fractures, including in the face and thoracic spine, delayed the definitive treatment of the acetabular fracture, especially due to the significant anaesthetic challenge posed by these associated injuries. Furthermore, the patient suffered a traumatic hip dislocation, which increases the risk of late avascular necrosis of the femoral head [22], [27]. Several studies addressing this complication after femoral neck fractures in patients with immature skeletons report the type of fracture, the degree of initial displacement, and the patient's age at the time of injury as the main factors associated with the development of avascular necrosis (ANV) of the femoral head. The young age of our patient, the association with traumatic hip dislocation, and the delay in adequate and definitive treatment of the acetabular fracture due to other skeletal and non-skeletal injuries should be considered relevant factors for the presence of avascular necrosis of the femoral head [28], [29], [30]. The other patient (case #1), a 13-year-old boy with an isolated open acetabular fracture, presents with full and painless range of motion in the injured hip after 18 months of follow-up. This case is even more unusual because, in addition to the rarity of the fracture pattern, the occurrence of open acetabular fractures in the paediatric population is extremely rare. Although the management of open fractures conceptually does not change compared to the adult population [31], in this case it became another potentially complicating factor, fortunately not interfering with the outcome.

Table 1 summarizes previously reported paediatric cases of isolated AWAF.

Table 1.

Reported paediatric cases of isolated AWAF.

Study Number of cases Patient age / sex Mechanism of injury Associated injuries Treatment Long-term outcome / Complications
Başaran et al., 2013 01 7-year-old / girl Fall from a bunk bed Non-displaced iliac wing fracture Non-operative: skin traction and bed rest; exercise program after acute pain decreased; partial weight-bearing at 4 weeks and full weight-bearing after 6 weeks Final radiographs showed no post-traumatic hip osteoarthritis or acetabular dysplasia at 2-year follow-up
Heeg et al., 2000 02 5-year-old / NR
9-year-old / NR		 NR Pelvic fracture in the 9-year-old patient Non-operative: bed rest or supracondylar traction, followed by progressive weight bearing Excellent or good functional and radiographic results, with a reported mean follow-up of 14 years for the entire patient series (n = 29)
von Heyden et al., 2012 01 NR NR NR NR Good clinical outcome regarding pain, gait, and range of motion in six patients followed for a period of two to 11 years. NR for the other nine patients
Giordano et al., 2026 02 13-year-old / boy

10-year-old / boy		 Fall from a bicycle

Car accident		 Metacarpal fractures, thoracic vertebral body fracture, facial bone fractures, and fracture-dislocation of the right hip in the 10-year-old patient ORIF via the Smith-Petersen approach with osteotomy of the ASIS Excellent functional results regarding pain, gait, and range of motion (modified Merle d'Aubigné and Postel scoring system) at 18-mont follow-up

Early radiographic signs of AVN of the femoral head and advanced signs of premature epiphyseal closure in the triradiate cartilage in the 10-year-old patient
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Legends: NR – not reported; ORIF – open reduction and internal fixation; ASIS – anterior superior iliac spine; AVN – avascular necrosis.

Conclusion

Isolated AWAF is an even rarer injury in the immature skeletal population compared to adults, generally resulting from high-energy trauma. The cases reported herein highlight the importance of prompt diagnosis and adequate preoperative planning. In our patients, the Smith-Petersen approach with ASIS osteotomy provided excellent exposure of the anterior acetabular wall, facilitating anatomical reduction and stable fracture fixation. One must keep in mind the need for long-term follow-up of these patients, since complications related to both the triradiate cartilage (hip dysplasia) and the femoral head (avascular necrosis) can occur.

CRediT authorship contribution statement

Vincenzo Giordano: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Anderson Freitas: Writing – review & editing, Visualization, Validation, Supervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Nicolle Barreto: Writing – review & editing, Visualization, Validation, Investigation, Formal analysis, Data curation. Jhordana Esteves dos Santos: Writing – review & editing, Visualization, Validation, Investigation, Formal analysis, Data curation. Carolina Braga dos Santos Azevedo: Writing – review & editing, Visualization, Validation, Formal analysis. Cynthia Storino Pavan: Writing – review & editing, Visualization, Validation, Formal analysis.

Ethical review committee statement

This cross-sectional survey study was approved by the Institutional Review Board of the Hospital Municipal Miguel Couto (HMMC) under the number HMMC_SOT/02-2025.

Statement of the location where the work was performed

The study was performed at the Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, R. Mário Ribeiro 117/2° andar, Gávea, Rio de Janeiro, 22430-160, RJ, Brazil, and the Hospital Estadual de Urgências Governador Otávio Lage de Siqueira (HUGOL), Av. Anhanguera 14527, St. Santos Dumont, Goiânia, 74463-350, Goiás, Brazil.

Ethical committee approval

This case report and literature review study was approved by the Institutional Review Board of the Hospital Municipal Miguel Couto (HMMC) under the number HMMC_SOT/02-2025.

Funding information

The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Declaration of competing interest

The authors declare no conflict of interest related to content of this article.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.tcr.2026.101415.

Appendix A. Supplementary data

Video 1

At the 18-month follow-up, the patient has a pain-free, full range of movement in the right hip, with normal gait. The modified Merle d'Aubigné and Postel scoring system was 18 points.

Download video file (934.3KB, mp4)
Video 2

At the 18-month follow-up, the patient has a pain-free, full range of movement in the right hip, with mild limping. The modified Merle d'Aubigné and Postel scoring system was 18 points.

Download video file (3.7MB, mp4)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Video 1

At the 18-month follow-up, the patient has a pain-free, full range of movement in the right hip, with normal gait. The modified Merle d'Aubigné and Postel scoring system was 18 points.

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Video 2

At the 18-month follow-up, the patient has a pain-free, full range of movement in the right hip, with mild limping. The modified Merle d'Aubigné and Postel scoring system was 18 points.

Download video file (3.7MB, mp4)

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