Executive Editor: Peter Trafton

Authors: Keith Mayo, Michel Oransky, Pol Rommens, Carlos Sancineto

Acetabulum - Anterior wall Ilioinguinal

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Glossary

1 Principles top

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Definition: Anterior wall fractures

Fractures of the anterior wall are segmental fractures of the anterior column and typically involve the anterior segment of the acetabulum.

They contain the anterior lip and a varying amount of the middle third of the anterior column.

At the inside, they involve the anterior articular facet and a variable portion of the acetabular fossa.

The distal fracture line exits in the region below the femoral vessels and iliopsoas muscle.


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Fracture characteristics

Dislocation

The femoral head is dislocated anteriorly and medially, pushing the avulsed anterior wall fragment(s) in the same direction. The anterior wall fragment typically is rotated externally around its long axis.

Fragment(s)

The displaced head detaches a part of the acetabular fossa together with a variable part of the quadrilateral surface. This plate of bone usually keeps a posterior hinge, but it may also be a free fragment.


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Intraarticular fracture fragments and marginal impaction

Part of the internal portion of the roof may appear isolated or be impacted into the underlying cancellous bone. Intraarticular fracture fragments and marginal impaction create a condition of incongruity and instability.


Femoral head damage

Due to dislocation, the femoral head may show areas of contusion, abrasion, or indentation.

These conditions can not be reversed and worsen the prognosis.


Note

The anterior wall fracture is a rare fracture pattern. Among other fracture patterns it is typical in elderly persons and a result of low-energy injury. The bone involved is commonly osteoporotic.

2 Principles of reduction top

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Reduction of femoral head dislocation

Reduction of femoral head dislocation, which accompanies these fractures, is obtained by manual traction only or in combination with the large distractor (see below).

Alternatively, reduction is achieved by enhancing skeletal traction on the femoral shaft with the extension table.

Reduction is facilitated by hip flexion, in order to relax structures crossing anterior to the hip joint.


Indirect reduction

As the articular surface is not directly seen through this approach, fracture treatment relies on indirect reduction and control of anatomical landmarks outside of the joint.

Reduction of all fracture fragments is critical to the final outcome. Reduction of marginal impaction by elevation and bone grafting is an indispensable part of the procedure.


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Option: Apply traction with a large distractor

Insert a femoral head extractor along the axis of the femoral neck through a short separate vertical incision at the level of the greater trochanter. 

 


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Option: Apply traction with a large distractor

Insert a 5 mm Schanz screw in the sciatic buttress placed from anteriorly to posteriorly. This is the proximal screw for the large distractor.


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Place a second Schanz screw into the femur at the level of the lesser trochanter from anteriorly to posteriorly. This is the distal screw for the large distractor.

Center the head under the roof using a combination of longitudinal traction and manual lateral traction.

Verify this by the use of an image intensifier.

Hold reduction by tightening the large distractor.

3 Fracture reduction top

Cleaning of the fracture site

Clean and irrigate the fracture site in preparation for the direct reduction.

Localize, remove, and/or clean and reinsert any free intraarticular fracture fragments.


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Elevate impacted fragments

In case of a subchondral impaction of the articular surface, carefully elevate and mold the area against the reduced femoral head.


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Fill the defect

Fill the defect zone with cancellous autograft or a bone substitute.


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Use pelvic reduction forceps

Insert a pelvic reduction forceps with pointed ball tips between the quadrilateral plate and the unbroken pelvis to reduce the wall fragment.

One point is placed on the quadrilateral plate surface, while the other is placed on the external surface of the bone just lateral to the anterior inferior iliac spine. In osteoporotic bone a pointed washer is used on top of the pointed ball tip placed on the quadrilateral plate to prevent perforation.

Use the forceps to hold the fragment reduced until definitive fixation.


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Ball spike pusher

Alternatively a ball spike pusher is used to maintain reduction until definitive fixation.

 

Note
Since the ilioinguinal approach does not allow visualization of the joint surface, the reduction is determined to be anatomical by direct view, by image intensifier control, and by palpation of the internal aspect of the innominate bone.

4 Definitive fixation top

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Option: Insertion of isolated lag screws

In case of adequate fragment size, apply one or two isolated interfragmentary lag screws to fix the reduced fragments.

Make sure to insert every screw extraarticularly.

Isolated lag screw placement does not provide adequate fracture stability.

Lag screw placement should not disturb optimal plate positioning.


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Application of neutralization plate

Application of neutralization plate

Neutralize the reduced fracture with a precontoured small-fragment pelvic reconstruction plate applied congruently to the surface of the anterior column.

The plate bridges the reduced fragment and extends superiorly to the inner part of the iliac fossa in front of the sacroiliac joint.

Inferiorly it extends to the intact part of the superior pubic ramus and the body of the pubis.

At least two screws are placed on each side of the fracture. Interfragmentary lag screws can also be applied through the plate. Every screw should be placed extraarticularly.

Note
In case of osteoporotic bone adequate anchorage of the neutralization plate is only obtained by the use of very long screws in the first and last holes of the plate near the sacroiliac joint and the symphysis pubis.

5 Wound closure top

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Before closure, one may place drains in the space of Retzius and anterior internal iliac fossa.

Layered closure then begins with repair of the conjoint tendon to the distal inguinal ligament. A careful fascial repair restores the floor of the inguinal canal.

The external oblique aponeurosis and the rectus sheath are then repaired, followed by secure reattachment of the abdominal wall origin to the iliac crest, in the lateral portion of the incision. A hernia-free repair, and avoidance of entrapment of the spermatic cord should be achieved.

Subcutaneous drains may be inserted.

Finally, perform an appropriate subcutaneous and skin closure.

v1.0 2007-07-22