Acetabular fractures are rare injuries and constitute 18% of all pelvic fractures [1], with an incidence rate of approximately 3 per 100,000 per year worldwide [2,3]. They are usually caused by high-energy injuries, such as traffic accidents or falls [3]. Acetabular fractures are caused by the direct impact of the femoral head on the articular surface of the acetabulum. The force on the femoral head can be transmitted in any direction through the trochanter and the femoral neck along the long axis of the femoral shaft. Therefore, the classification of fractures varies depending on the hip joint position during trauma [4].

Acetabular fractures can be treated conservatively or surgically. The treatment must be decided carefully, considering the fracture pattern, patient’s mental state, age, and accompanying injuries [5]. In traditional Korean medicine (TKM) hospitals, conservative treatment and postoperative rehabilitation are actively performed for patients with pelvic fractures [6,7]. However, to our knowledge, no study has reported using TKM treatment from the acute to the rehabilitation stage of acetabular fractures. In this report, we present a case of a patient who received complex TKM treatment and rehabilitation without surgery.

1. Patient

Male, 50 years old.

Left hip pain, left elbow pain, and left flank pain.

The patient underwent lumbar intervertebral disc herniation surgery in 2017 and 2022 and cholecystectomy in 2023. He was diagnosed with diabetes in 2020 and was taking prescribed medications.

On March 9, 2023, the patient fell from 3 m height and injured the left half of his body. He was transferred to Hyosung Hospital, and radiography and computed tomography (CT) were performed. The patient was diagnosed with a left acetabular fracture and left rib fractures (5, 6, 7, and 8th). The left elbow was intact. On March 10, 2023, he was transferred to Soonchunhyang University Hospital, and the staff reported that surgery was not required for the left acetabular fracture.

March 10, 2023 to June 30, 2023 (113 days of hospitalization).

Pelvis CT was performed on March 9 and April 21, 2023 (Fig. 1). Pelvis 3 dimension CT was performed on March 9, 2023 (Fig. 2). Left hip radiography was performed on March 9, March 17, April 7, May 13, June 2, and June 23, 2023 (Figs. 3, 4).

Figure 1. (A) Pelvis computed tomography (CT) was performed right after the injury (March 9, 2023), and the patient was diagnosed with a left acetabular fracture. (B) Pelvis CT was performed 6 weeks after the injury (April 21, 2023).

Figure 2. Pelvis 3 dimension computed tomography was performed right after the injury (March 9, 2023). The image shows fracture on the anterior acetabulum (green arrow).

Figure 3. Left hip radiography, anteroposterior view. (A) March 9, 2023; (B) March 17, 2023; (C) April 7, 2023; (D) May 13, 2023; (E) June 2, 2023; (F) June 23, 2023. A comparison between (A) and (F) shows the progress of ossification at the fracture site.

Figure 4. Left hip radiography, lateral view. (A) March 9, 2023; (B) March 17, 2023; (C) April 7, 2023; (D) May 13, 2023; (E) June 2, 2023; (F) June 23, 2023. A comparison between (A) and (F) shows the progress of ossification at the fracture site.

To protect the patient’s personal information, medical records were obtained from the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board (No. DJUMC-2023-BM-08).

2. Treatment

Stainless steel needles 0.25 × 30 mm and 0.30 × 40 mm (Dongbang Medical Co., Ltd.) were used. Acupuncture was performed unilaterally at GB29, GB30, GB31, GB32, GB33, ST30, ST31, ST32, ST34, ST36, BL23, BL36, and tender points on the gluteus muscle, hamstrings, gastrocnemius, left ribs, and left elbow twice daily for 15 minutes. Electrical stimulation (2 Hz) was applied to GB29–ST32 and GB30–GB31 using an STN-330 (Stratek) in a continuous wave. The current intensity was set at a tolerable level.

Aconitum ciliare Decaisne pharmacopuncture (ACDP) (Korean Pharmacopuncture Institute) was administered once daily from March 13 to March 24, 2023. A 0.2 mL dose was injected into GB29, GB30, GB31, BL23, and BL36. A 1.0 mL disposable syringe and needle were used for injections (30 G, 12.7 mm needle; Jungrim Medical).

Before administering the bee venom (BV) treatment, informed consent was obtained from the patient due to the potential risks of using BV, such as anaphylaxis. A hypersensitivity skin test to BV (1:20,000, 0.1 mL; Korean Pharmacopuncture Association) was performed, and the result was negative. Treatment was administered unilaterally at GB29, GB30, GB31, BL23, and BL36. The concentration of BV was increased in the order of 1:20,000, 1:10,000, 1:5,000, and 1:2,000, and sweet bee venom (SBV; Kirin Korean Medicine Industrial Institute) 10%, SBV 20%, and SBV 50% were also used for intramuscular (IM) injection. If a hypersensitivity reaction did not occur, the injected volume was increased with each treatment (Table 1).

Table 1 . Bee venom injection.

Date	Bee venom concentration	Volume (mL)
March 25, 2023	SBV 10%	0.5
March 27, 2023	SBV 10%	0.5
March 29, 2023	SBV 20%	0.5
March 31, 2023	SBV 20%	0.5
April 3, 2023	SBV 20%	0.5
April 5, 2023	SBV 20%	0.5
April 7, 2023	SBV 20%	0.5
April 10, 2023	SBV 50%	0.5
April 12, 2023	SBV 50%	0.7
April 14, 2023	20,000:1	0.5
April 17, 2023	10,000:1	0.5
April 19, 2023	5,000:1	0.5
April 21, 2023	5,000:1	1
April 24, 2023	5,000:1	1
April 26, 2023	5,000:1	1
April 28, 2023	5,000:1	1
May 1, 2023	2,000:1	0.4
May 3, 2023	2,000:1	0.6

SBV, sweet bee venom..

The patient took herbal medicines 3 times daily. Hwanggihwalhyeol-tang, Dodamhwalhyeol-tang, and Gamigungi-tang were prescribed (Table 2). Palmul-tang soft extract and Gumiganghwal-tang soft extract were also prescribed (Table 3).

Table 2 . Herbal composition of 3 herbal medications for daily dosage.

Hwanggihwalhyeol-tang (March 10, 2023–March 15, 2023)	Amount (g)	Dodamhwalhyeol-tang (March 15, 2023–April 7, 2023)	Amount (g)	Gamigungi-tang (April 7, 2023–May 7, 2023)	Amount (g)
Atractylodis rhizoma	18	Cyperi rhizoma	16	Angelica gigantis radix	40
Angelica gigantis radix	18	Pinelliae tuber	12	Cnidii rhizoma	40
Cnidii rhizoma	18	Crataegi fructus	12	Astragali radix	16
Astragali radix	18	Raphani semen	12	Ginseng radix	16
Cibotii rhizoma	18	Salviae miltiorrhizae radix	12	Lycii fructus	16
Lonicerae flos	18	Tribuli fructus	8	Codonopsis pilosulae radix	8
Typhae pollen	18	Poria sclerotium	8	Cuscutae semen	8
Trogopterorum faeces	18	Puerariae radix	8	Dipsaci radix	8
Lycopi herba	18	Uncariae ramulus et uncus	8	Dendrobii herba	8
Spatholobi caulis	18	Angelica gigantis radix	8
Smilacis rhizoma	18	Platycodonnis radix	8
Citri unshius pericarpium	12	Aurantii fructus immaturus	8
Glycyrrhizae radix	12	Acori graminei rhizoma	24
Poria sclerotium	12	Aucklandiae radix	6
Eucommiae cortex	12	Persicae semen	6
Dipsaci radix	12	Carthami flos	6
Achyranthis radix	12	Cnidii rhizoma	6
Chaenomelis fructus	12	Menthae herba	4
Persicae semen	12	Scorpio	4
Carthami flos	12	Glycyrrhizae radix	4
Corydalis tuber	12	Lumbricus	24
Forsythiae fructus	12	Citri unshius pericarpium	12
Massa medicata fermentata	12
Amomi fructus	12
Cyperi rhizoma	12
Ziniberis rhizoma	6
Cinnamomi ramulus	6
Scutellariae radix	6
Liriopis seu ophiopogonis tuber	6

Table 3 . Soft extract herbal medications for daily dosage.

Palmul-tang soft extract (May 8, 2023–May 25, 2023)	Amount (g)	Gumiganghwal-tang soft extract (May 25, 2023–June 30, 2023)	Amount (g)
Poria sclerotium	0.675	Osteroici seu notopterygii radix et rhizoma	1.9740
Ginseng radix	1.260	Saposhnikoviae radix	2.0304
Atractylodis rhizoma	1.485	Cnidii rhizoma	1.9350
Glycyrrhizae radix	1.980	Angelicae dahuricae radix	1.1250
Rehmanniae radix preparata	2.160	Atractylodis rhizoma	1.3950
Paeoniae radix alba	1.485	Scutellariae radix	2.6550
Cnidii rhizoma	1.935	Rehmanniae radix	1.0800
Angelica gigantis radix	1.485	Asiasari radix et rhizoma	0.4914
		Glycyrrhizae radix	0.8316

Transcutaneous electrical nerve stimulation was applied daily for 15 minutes to the left gluteal region to reduce pain.

Indirect electric moxibustion therapy (Technoscience) was applied twice daily at GB 29, GB 30, GB 31, GB 32, and ST 31.

Ankle pumps were performed by himself 30 times daily to prevent muscle contracture. From April 22, straight leg raise, and heel slide exercises were performed by himself 30 times daily. Quadriceps, adductor, abductor, and hamstrings isometric exercises were performed 3 times weekly for 15 minutes under a Korean medicine doctor’s guidance.

3. Evaluation

The numerical rating scale (NRS) was used to assess subjective pain in the left hip. The NRS score ranges from 0 to 10, with 0 indicating no pain and 10 indicating maximum pain.

The manual muscle test (MMT) was used to evaluate muscle strength (Table 4). To prevent damage to the fracture site, the MMT grades of the hip, knee, and ankle joints were first assessed on April 22. Then, the MMT grades of the hip, knee, and ankle joints were assessed weekly.

Table 4 . Manual muscle test.

Grade	Category	Function of the muscle
Grade 0	Zero (Z)	No visible or palpable muscle contraction.
Grade 1	Trace (T)	Feel contraction with palpation; no visible movement.
Grade 2−	P−	Less than full ROM in gravity eliminated plane.
Grade 2	Poor (P)	Full ROM in gravity eliminated plane with no resistance.
Grade 2+	P+	Full ROM in gravity eliminated plane, breaks upon minimum resistance.
Grade 3−	F−	Less than full ROM against gravity, but more than 50%.
Grade 3	Fair (F)	Full ROM against gravity, with no resistance.
Grade 3+	F+	Full ROM against gravity, breaks upon minimum resistance.
Grade 4	Good (G)	Full ROM against gravity with moderate resistance.
Grade 5	Normal (N)	Full ROM against gravity with maximum resistance.

ROM, range of motion..

The Harris Hip Score (HHS) is a commonly used hip questionnaire with high validity and reliability [8]. The modified HHS (mHHS) was developed to adjust the HHS to evaluate acetabular fracture treatment [9]. The maximum mHHS score was 120 points, comprising pain (0–60 points), function (0–42 points), relative strength (0–10 points), and relative range of motion (0–8 points) (Appendix A). The mHHS was assessed on March 10, March 30, April 21, May 12, June 2, June 23, and June 30, 2023.

4. Patient’s progress during treatment

On admission, the patient complained of left hip pain of NRS 7. The pain in the gluteal region was the most severe. Therefore, it was difficult for him to roll over or defecate. Two weeks after the start of treatment, the patient was able to sleep without pain, and it became easier for him to roll over and defecate. At discharge, the left hip pain decreased to NRS 3 (Fig. 5). The MMT grades of the left hip, knee, and ankle joints increased from F+ to N (Table 5). The mHHS score increased from 26 to 99 points (Fig. 6). Upon admission, the patient underwent absolute bed rest. On April 22, after the fracture site healing was confirmed on CT images, he began ambulating with 2 crutches or a walker. At discharge, he was able to walk unassisted for more than 20 minutes.

Table 5 . Manual muscle test results.

Movement	April 22, 2023	April 28, 2023	May 4, 2023	May 12, 2023	May 19, 2023	May 26, 2023	June 2, 2023	June 9, 2023	June 16, 2023	June 23, 2023	June 30, 2023
Hip flexion	N/F+	N/F+	N/F+	N/G	N/N	N/N	N/N	N/N	N/N	N/N	N/N
Hip extension	N/F+	N/F+	N/F+	N/F+	N/N	N/N	N/N	N/N	N/N	N/N	N/N
Knee flexion	N/F+	N/F+	N/F+	N/G	N/N	N/N	N/N	N/N	N/N	N/N	N/N
Knee extension	N/F+	N/F+	N/F+	N/G	N/N	N/N	N/N	N/N	N/N	N/N	N/N
Ankle dorsiflexion	N/F+	N/F+	N/F+	N/G	N/N	N/N	N/N	N/N	N/N	N/N	N/N
Ankle plantarflexion	N/F+	N/F+	N/F+	N/G	N/N	N/N	N/N	N/N	N/N	N/N	N/N

N, normal; F, fair; G, good..

Figure 5. Changes in NRS from March 9 to June 30. NRS, numerical rating scale; Adm., on admission; D/C, on discharge.

Figure 6. Changes in the mHHS score from March 10 to June 30. On admission, the patient was not able to walk. On discharge, the patient was able to walk for more than 20 minutes without support. mHHS, modified Harris Hip Score.

As acetabular fractures are caused by high-energy injuries, other body parts often sustain damage [10]. This may delay treatment. Moreover, surgery is difficult because the acetabulum is located deep in the body [11].

Accurate classification is essential for determining the treatment strategy for acetabular fractures [4]. According to the Judet and Letournel classification, elementary fractures include the posterior wall, posterior column, anterior wall, anterior column, or transverse fractures. Associated fractures are combinations of 2 or more elementary fractures [5,12].

Although many acetabular fractures are treated surgically, conservative treatment is a viable option for some patients [13,14]. Absolute bed rest and skeletal traction are performed to keep the femoral head away from the acetabular fracture fragments. Conservative treatment includes early mobilization with limited and progressive weight-bearing. Typically, 10–20 kg of toe-touch weight- bearing is performed for the first 4–6 weeks, followed by progression to full weight-bearing at 8–12 weeks [5]. Matta et al. [15] reported that 75% of patients with acetabular fractures in the conservative treatment group showed excellent or good clinical results.

In this report, the patient was diagnosed with an acetabular anterior wall fracture. Although the fall had a significant impact on the patient, the acetabular fracture was stable. Therefore, TKM was an effective option for pain reduction and functional rehabilitation.

Acupuncture with electrical stimulation is mainly applied to the gallbladder and bladder meridian acupoint to reduce pain and accelerate bone healing [16,17]. ACDP and BV were injected IM into the gallbladder and bladder meridian acupoints. ACDP accelerates peripheral blood circulation and reduces neuropathic pain [18]. BV reduces musculoskeletal pain and has anti-inflammatory effects [19]. Hwanggihwalhyeol-tang and Dodamhwalhyeol-tang were prescribed to reduce pain and promote blood circulation. Gamigungi-tang was prescribed to promote fracture union once the pain started to decrease. Palmul-tang soft extract was prescribed to strengthen bones and muscles, and Gumiganghwal-tang soft extract was prescribed to relieve muscle pain during rehabilitation.

To our knowledge, this is the first study to report the treatment of acetabular fractures using TKM. The patient’s pain was effectively reduced without analgesics during the acute stage, and the fracture site healed successfully without dislocation or complications. Although comparisons are difficult due to the diversity of fracture patterns, the TKM treatment delivered here showed comparable results to those of conventional conservative treatment. However, this study had some limitations. It reported a single case, and several complex treatments were performed simultaneously. Therefore, the effect of each treatment could not be determined. Thus, further research on the TKM treatment of acetabular fractures is required.

Conceptualization: YHN. Methodology: YHN. Formal investigation: YHN. Data analysis: YHN. Writing – original draft: YHN. Writing – review & editing: All authors.

The authors have no conflicts of interest to declare.

None.

This study was exempt from the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board (IRB No. DJUMC-2023-BM-08).