Executive Editor: Peter Trafton

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

Acetabulum - Transverse fractures with extended iliofemoral approach

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Glossary

1 Reduction top

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Capsulotomy

Since an anatomical reduction is essential, the hip joint should be opened with a capsulotomy, just distal to the labrum. Lateral and/or distal retraction of the femoral head makes it easier to see into the joint.

It is also important to see the fracture well on the external surfaces of both the anterior and the posterior columns.

The internal surface of the pelvis can be palpated with a finger in the greater sciatic notch, for further assessment of the reduction.

Begin the reduction by cleaning all clot and bone fragments from the fracture plane.


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Reduce femoral head

To begin the reduction, the femoral head must be replaced congruently under the superolateral articular surface. Traction accomplishes this, and may be aided with a Schanz screw in the femur, or possibly a femoral distractor. Inspect the femoral head for articular surface injury.


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Fracture reduction

Reduction of the fracture must address both anterior and posterior columns nearly simultaneously.
Usually, insert a Schanz screw into the ischium to use as a joystick for manipulation of the distal fragment.
A hook inserted through the lesser or greater sciatic notch helps to pull the posterior end of the distal fragment laterally.


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Posteriorly, the reduction can be held in place with a Farabeuf or a Jungbluth clamp, or alternatively with pointed reduction forceps.
Anteriorly, pointed reduction forceps will be more useful. The advantage of the extended iliofemoral approach is that it is easier to see the intraarticular and anterior aspects of the reduction.


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Alternative anterior technique

Another anterior reduction technique involves use of forceps applied to a 3.5 mm screw placed into the distal fragment.
Place the screw before beginning the reduction maneuver. It should be inserted medial to the acetabulum, into the best obtainable bone of the distal fragment. Stay close to the quadrilateral surface, outside the hip joint.


Placement of reduction tools enlarge

Placement of reduction tools

Click here to see the placement of the reduction tools demonstrated in an interactive 3D model.

2 Fixation top

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Confirm the reduction

After manipulation of the posterior and anterior aspects of the fracture, confirm that the reduction is truly anatomical. Check the articular surface visually and by palpation within the joint. Also confirm reduction on the internal pelvic surface by palpation through the greater sciatic notch.

 


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Posterior fixation

An axial posterior column screw provides interfragmentary compression across the posterior part of the fracture. This is inserted from proximal to distal.
The direction of the screw varies depending on the inclination of the fracture line.


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Anterior column fixation

Similarly, the anterior part of the fracture is compressed with appropriately placed lag screw(s). A long 3.5 mm cortical screw is typical.
The starting point for an anterior column screw is located approximately 3 cm above the acetabular rim, on the posterior aspect of the gluteus medius pillar.

For proper placement of the screw, across the fracture but outside the hip joint, its entry site must be located about 4 cm posterior to the anterior edge of the innominate bone.

A second anterior column screw parallel to the first provides additional fixation and is often used, if there is room enough.


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Application of a protection plate

Finally, a contoured pelvic reconstruction plate is applied over the fracture, along the posterior column, to protect the screw fixation.

3 Postoperative x-ray control top

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During reduction and fixation, the surgeon may choose to check fluoroscopic images in AP, iliac, and obturator oblique views to confirm reduction and/or screw placement.

Once all fixation is in place, it is mandatory to confirm appropriate appearance of all three views, as well as to check the location of any screw that is placed near the hip joint. An image exposed with the fluoroscope’s central ray superimposed on the long axis of the screw is the most reliable way of confirming that it is extraarticular.

Alternatively, the position of the fluoroscope can be adjusted from the standard views to show that a questionable screw is completely extraarticular.

v1.0 2007-07-22