1 Reduction topenlarge
Traction for access and reduction
Apply axial and/or lateral traction with the fracture table to reduce the femoral head under the superolateral fragment. This will permit reduction of the displaced inferomedial fragment.
The appropriately positioned femoral head is a template for reduction of the distal fragment.
Exposure of fracture
Since an anatomical reduction is essential, the hip joint should be opened
with a capsulotomy, just distal to the labrum. Additional traction on the femur
makes it easier to see into the joint.
Begin the reduction by cleaning all clot and bone fragments from the fracture plane.
It is important to see the fracture well both inside and outside the joint.
Additionally, the internal surface of the pelvis should be palpated with a finger in the greater sciatic notch. The fracture should feel reduced, without step-off or gap.
Reduction of a transverse fracture requires two main steps: lateralization,
and derotation of the distal fragment.
It is important that the reduction is correct across the entire fracture, as the posterior surface may appear to be reduced satisfactorily while anteriorly rotation or displacement persist.
Manipulation of the distal fragment may require several instruments, but is typically begun with a Schanz screw in the ischium, to be used as a joystick.
A hook inserted through the lesser or greater sciatic notch helps to pull the posterior end of the distal fragment laterally.
Appropriately chosen and placed clamps can aid reduction and provisionally
A clamp like the large asymmetric clamp (Prince Tong) or smaller pelvic reduction clamp can be inserted carefully through the greater notch.
Reduction must be assessed repeatedly during fracture manipulation until an absolutely anatomic alignment is achieved.
Provisional stabilization of fracture
An appropriately chosen and placed clamp can reduce and stabilize at least
the posterior portion of most transverse fractures.
This illustration shows a Jungbluth clamp, which is attached to the bone with two screws, one on the iliac fragment and the other on the posterior column.
Choose the anchor screws for the clamp in such way that interference with the definite plate position is avoided.
The distal screw will be placed close to the base of the ischium and parallel to the quadrilateral lamina. The proximal screw will be placed on the ilium in a position that allows the clamp to align the fracture.
This Jungbluth clamp can be used to open and clean the fracture before applying compression. If its screws are placed appropriately, its compression aids reduction. If the screws are not placed correctly, this clamp may fail to realign the fracture.
If a single clamp does not achieve a stable reduction, addition of a second
clamp may be helpful. In our illustration, the first clamp is a Jungbluth clamp
on the posterior column.
The second clamp in this illustration is a large asymmetric clamp with one limb through the sciatic notch, resting on the quadrilateral surface. The other is placed anteriorly on the proximal fragment. This clamp corrects displacement of the anterior part of the transverse fracture.
In this illustration, the second clamp is a smaller, angled pelvic reduction forceps, used similarly to complete the anterior part of the reduction.
Confirmation of reduction
Every part of the fracture must be anatomically reduced. Inspect the
fracture inside the joint and where it crosses the posterior column.
Also examine the reduction by inserting a finger onto the quadrilateral plate through the ischial foramen to palpate the fracture line. A smooth quadrilateral surface usually indicates correct rotational alignment.
Reduction must also be assessed with fluoroscopy in AP, iliac, and obturator oblique views.
2 Fixation: anterior component topenlarge
After obtaining anatomical reduction of the fracture, definitive fixation is begun with two lag screws. One is directed across the anterior portion (as shown by the illustration), and the other will be placed posteriorly.
Anterior screw insertion
The anterior screw is placed obliquely from above the greater sciatic notch across the fracture. It is aimed anteriorly towards the root of the superior pubic ramus. The entry point is along the anterior (gluteus medius) pillar of the iliac wing, 3 to 4 cm above the acetabular margin.
A 3.5 mm (or 4.5 mm) cortical screw will be used.
Create a gliding hole with a 3.5 mm (4.5 mm) drill bit, depending upon chosen screw size. This should extend to the fracture line. Continue with the 2.5 mm (3.2 mm) drill bit, aimed towards the pubic ramus. Use an oscillating drill to protect the soft tissues. Insert a screw of the appropriate length. A washer is recommended to avoid sinking of the screw head in soft bone.
Some surgeons feel that a hand drill provides better control than a power drill. One may feel the fracture and intraosseous location of the bit more easily with a hand drill.
Pitfall: Risks to joint or vessels
This screw may enter the hip joint or injure the femoral vessels.
The position and the trajectory of the screw are checked with image intensification during insertion. It is essential that the screw be outside the hip joint and strictly within the bone of the superior ramus.
3 Fixation: posterior component topenlarge
Depending upon the posterior location and orientation of the fracture, it may be suitable for lag screw fixation. Such a screw may be placed from distal to proximal, as illustrated, or from proximal to distal, though this may be difficult with the limited proximal access offered by the Kocher-Langenbeck incision.
Alternative fixation: posterior plates
This example shows posterior fixation with two posterior plates, in the
absence of a posterior lag screw.
The medial plate, near the sciatic notch, was placed first to compress the posterior end of the transverse fracture. The second plate adds additional posterior component support.
4 Postoperative x-ray control topenlarge
After completion of fixation, use at least 3 views (AP, obturator oblique,
iliac oblique [ala] view) to confirm screw and plate placement.
For the anterior column screw, in this particular case, it is possible to see a certain amount of bending. This is possible because of the elasticity of the screw, and the curvature of the anterior column intramedullary canal. After creating interfragmentary compression, such screw deformation is not unusual.
Obturator oblique view