import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' ## Indications **Mandatory Surgical Intervention:** 1. **Displacement >3mm** at weight-bearing dome 2. **Femoral head subluxation** despite traction 3. **Failure of secondary congruence** criteria 4. **Roof arc <45°** on any Judet view 5. **Open fracture** - emergency debridement 6. **Irreducible hip** - emergency reduction 7. **Progressive sciatic nerve palsy** - urgent decompression **Examiner Question**: "What is the spur sign and why is it pathognomonic for both-column fractures?" **Model Answer**: "The spur sign is seen on the **obturator oblique** view. It represents the intact ilium projecting as a triangular spur of bone above the detached acetabulum. It's pathognomonic because in both-column fractures, BOTH the anterior AND posterior columns are detached from the axial skeleton - the only remaining connection between pelvis and acetabulum is disrupted. The 'spur' is the inferior portion of the intact ilium sitting above the floating acetabulum. No other fracture pattern produces this radiographic finding." ALL must be met to consider non-operative: - Roof arc >45° on AP, obturator oblique, AND iliac oblique views - Femoral head concentrically reduced on traction - No posterior wall component - Patient able to comply with protected weight-bearing **Surgery Generally Preferred:** 1. **Young, active patient** with displacement 2-3mm 2. **Marginal impaction** visible on CT 3. **Posterior wall component** (associated pattern) 4. **Athlete or high-demand occupation** 5. **Failed closed reduction** under GA 6. **Bilateral acetabular fractures** (staged) **Examiner Question**: "How does marginal impaction affect your decision-making?" **Model Answer**: "Marginal impaction is a **critical finding** often missed on plain films but visible on CT. It represents depression of the subchondral bone at the weight-bearing dome, creating an articular step. Even with 'acceptable' overall displacement, marginal impaction requires surgery because: (1) It creates an incongruent articular surface leading to accelerated OA; (2) It cannot improve with non-operative treatment; (3) It requires direct visualization, elevation, and bone grafting. I assess the superior 10mm of acetabulum on axial CT - this is the weight-bearing dome." - **Accepting 2-3mm displacement in young patients** - long-term OA rates unacceptable - **Missing marginal impaction on plain films** - ALWAYS review CT axials through dome - **Ignoring posterior wall component** - changes stability and may require posterior approach - **Bilateral fractures** - must stage, NOT same-day bilateral ORIF (blood loss catastrophic) **Absolute Contraindications:** 1. **True secondary congruence** meeting all criteria (see above) 2. **Medically unstable** patient - damage control first 3. **Active sepsis** - treat infection first 4. **Advanced dementia** - unable to protect weight-bearing 5. **Terminal illness** with limited life expectancy **Relative Contraindications:** 1. **Severe osteoporosis** - fixation may fail 2. **Pre-existing severe OA** - consider primary THA 3. **Elderly low-demand** patient with acceptable alignment 4. **Delay >3 weeks** - callus impairs reduction 5. **Severe associated injuries** requiring staged approach **Examiner Question**: "A 75-year-old with a both-column fracture presents 4 weeks after injury. How do you manage this?" **Model Answer**: "This is a delayed presentation where standard ORIF is problematic. After 3-4 weeks, **callus formation prevents anatomical reduction**. My options are: (1) **Acute THA** if patient has pre-existing OA or osteoporosis - but acetabular defects require augments/cages and has high complication rate; (2) **Limited ORIF with THA** - fix columns for stability, accept malreduction, proceed to THA; (3) **Traction and delayed THA at 3-6 months** - allow fracture healing, then elective THA on healed acetabulum. For a 75-year-old, I would favor option 3 - traction/TTWB, let fracture heal, then definitive THA once bone consolidated." - **Operating after 3 weeks expecting anatomic reduction** - callus prevents this - **Acute THA in young patients** - ORIF preferred even if delayed/difficult - **Ignoring secondary congruence in elderly** - these patients may do well non-operative - **Forcing ORIF in osteoporotic bone** - screws will cut out, consider THA instead ## Pre-operative Planning ### Clinical Assessment - **Mechanism**: High-energy (MVA, fall from height) - **Position at impact**: Dashboard vs. side impact - **Comorbidities**: DVT risk, bone quality, diabetes - **Medications**: Anticoagulation, steroids - **Social**: Occupation, hand dominance, support - **Allergies**: Antibiotics, metals - **Neurovascular**: Sciatic nerve (peroneal division), femoral nerve - **Morel-Lavallée lesion**: Fluctuant swelling over greater trochanter - **Soft tissue**: Abrasions, contusions, swelling - **Hip ROM**: Usually painful, reduced - **Associated injuries**: Spine, knee, chest, abdomen - **Skin condition**: Essential for surgical timing ### Imaging Review ### Consent Discussion - **Nerve injury**: Femoral 5-10%, LFCN 20%, obturator 2% - **Vascular injury**: Corona mortis, external iliac vessels 1% - **DVT/PE**: 5-10% with prophylaxis, life-threatening - **Infection**: Superficial 8-12%, deep 3-6% - **Arthritis**: 30% at 10 years even with anatomic reduction - **AVN**: 10-15% - **Inguinal hernia**: 5-10% - **Heterotopic ossification**: 15-30% - **Meralgia paresthetica**: 20% (LFCN injury) - **Wound complications**: 5-10% - **Hardware symptoms**: May require removal - **Need for THA**: 20-30% at 10-20 years - **Loss of reduction**: 10-20% ## Equipment ### Implants **Anterior Column Fixation:** - 3.5mm pelvic reconstruction plates (primary) - 3.5mm limited contact dynamic compression plates - 8-14 hole plates for pelvic brim application - Periarticular plates for quadrilateral surface (optional) **Spring plates** for quadrilateral surface if needed **Suprapectineal plating** increasingly popular for medial displacement **Examiner Question**: "Why do you use 3.5mm reconstruction plates rather than stronger 4.5mm plates?" **Model Answer**: "Pelvic **3.5mm reconstruction plates** are specifically designed for acetabular surgery because: (1) **Malleability** - they can be contoured in 3D to match the complex anatomy of the pelvic brim and iliac fossa; (2) **Low profile** - the thinner plate reduces soft tissue irritation in this deep approach; (3) **Adequate strength** - combined with anatomical reduction and lag screw fixation, 3.5mm construct provides sufficient stability for touch-toe weight bearing; (4) The pelvic brim is predominantly **cortical bone** so 3.5mm screws provide excellent purchase. We are NOT load-sharing like femoral nailing - we are achieving anatomical reduction and allowing bone healing." - **Using straight plates** - must use RECONSTRUCTION plates that can contour in 3D - **Inadequate plate length** - need minimum 3 screws per major fragment - **Ignoring quadrilateral surface** - may need infrapectineal or spring plate for medial buttress - **Wrong screw length** - too long risks joint penetration, too short loses purchase **Cortical Screws:** - 3.5mm cortical screws (plate fixation) - 2.7mm cortical screws (small fragment fixation) **Cannulated Screws:** - 7.0-7.3mm cannulated (posterior column screws) - 6.5mm cannulated alternative **Lag Screws:** - 3.5mm fully-threaded for position - 3.5mm partially-threaded for compression **Examiner Question**: "Why do you use 7.0-7.3mm cannulated screws for the posterior column from an anterior approach?" **Model Answer**: "Large diameter cannulated screws (7.0-7.3mm) are ideal for percutaneous posterior column fixation because: (1) **Cannulation** allows placement over a guidewire with fluoroscopic confirmation of trajectory BEFORE committing to a screw path - essential given proximity to sciatic nerve; (2) **Large diameter** provides excellent purchase in the dense posterior column bone and resists toggle over the long screw length (typically 120-140mm); (3) **Partially-threaded design** allows compression across the fracture site. The alternative is open posterior approach, but if indirect reduction achieves <2mm displacement, percutaneous screws are preferred." - **Posterior column screw exiting greater sciatic notch** - sciatic nerve injury - **Intra-articular screw** - must check obturator oblique view before final tightening - **Overtightening lag screws** - can displace reduction, final check after each screw - **Too short posterior column screws** - need to engage ischium for stability **Pelvic Reduction Forceps:** - Weber/Jungbluth clamps - Farabeuf clamps - Ball-spike pushers - Pointed reduction forceps - Cobb elevators **Retractors:** - Hohmann retractors (blunt) - Army-Navy retractors - Deaver retractors - Vessel loops (for structure protection) **Examiner Question**: "Describe how you use a Weber/Jungbluth clamp for anterior column reduction." **Model Answer**: "The **Weber/Jungbluth** (also called 'King Tong') is a large pointed reduction clamp essential for pelvic work. For anterior column reduction: (1) Place one tip on the **intact iliac wing** superiorly - this is the stable reference; (2) Place the other tip on the **displaced anterior column fragment** inferiorly; (3) Close the clamp progressively to reduce the fragment to the intact bone; (4) Confirm reduction visually and on obturator oblique fluoroscopy; (5) Provisionally fix with K-wire while maintaining clamp, then definitive plate. The clamp applies compression along its axis - I position it perpendicular to the fracture line for best reduction." - **Jungbluth clamp on soft bone** - tips can penetrate osteoporotic ilium - **Ball-spike too aggressive** - can fracture thin quadrilateral surface - **Retractor pressure on vessels** - release every 15-20 minutes - **Hohmann on sciatic notch** - avoid posterior placement, sciatic nerve exits here ### Instruments - **Oscillating saw** for bone work - **Kirschner wires** (2.0mm) for provisional fixation - **Drill** with 2.5mm and 2.7mm bits - **Depth gauge** and tap set - **Plate benders** (in-plane and off-plane) - **Screw measuring device** - **Fluoroscopy compatible table** ### Adjuncts - **Cell saver** - recommended (blood loss 500-2000mL typical) - **Vascular instruments** on standby - **Foley catheter** (mandatory - bladder protection) - **Radiolucent table** with C-arm access - **Bean bag/bolster** for positioning ## Anaesthesia and Positioning ### Anaesthetic Considerations **General anaesthesia** with muscle relaxation Consider: - Arterial line (blood loss monitoring) - Large bore IV access x2 - Cell saver setup - Warming devices - Epidural for post-op analgesia **Cefazolin 2g IV** at induction Repeat every 3-4 hours **If penicillin allergic:** - Vancomycin 1g IV - Plus gentamicin 1.5mg/kg Continue 24 hours post-op - Mechanical: TEDs + pneumatic compression - Chemical: LMWH (enoxaparin 40mg) starting 12-24h post-op - Duration: 4-6 weeks - Consider IVC filter if anticoagulation contraindicated ### Patient Positioning **Supine Position for Ilioinguinal Approach:** 1. **Radiolucent operating table** with C-arm access 2. **Bolster under ipsilateral buttock** (10-15° tilt toward affected side) 3. **Arm positioning**: Ipsilateral arm across chest or on armboard 4. **Both lower limbs prepped and draped free** for traction/manipulation 5. **Perineal post** if skeletal traction may be needed 6. **Fluoroscopy positioned** for AP, inlet, outlet, and Judet views **Positioning Key**: The 10-15° buttock tilt improves visualization of the posterior column from the anterior approach and facilitates indirect reduction. It also allows better access to the quadrilateral surface. ### WHO Checklist / Time Out - **Correct patient** - name, DOB, MRN - **Correct side** - marked preoperatively - **Imaging available** - CT 3D on screen - **Antibiotics given** - within 60 minutes - **Blood products available** - 4 units crossmatched minimum - **DVT prophylaxis** - mechanical applied - **Foley catheter** - in situ - **Cell saver** - set up and functional ## Surface Anatomy and Landmarks - **ASIS** (Anterior Superior Iliac Spine) - key starting point - **Pubic symphysis** - medial extent of incision - **Iliac crest** - posterior extent of incision - **Pubic tubercle** - 2cm lateral to symphysis - **Inguinal ligament** - spans ASIS to pubic tubercle - **External oblique aponeurosis** - first layer encountered - **Inguinal ligament** - guides dissection path - **Spermatic cord/Round ligament** - medial window boundary - **Femoral pulse** - lateral to femoral vein - **LFCN exit** - 1cm medial to ASIS ### Incision **Standard Ilioinguinal Incision:** - **Start**: Pubic symphysis - **Course**: Along inguinal ligament to ASIS - **Extend**: Posteriorly along iliac crest for 8-10cm - **Length**: Typically 25-30cm total ## Surgical Approach ### Internervous Plane The ilioinguinal approach uses intervals between structures rather than a true internervous plane: - **Lateral window**: Between iliopsoas (femoral nerve) and abductors (superior gluteal nerve) - **Middle window**: Developed by retracting neurovascular structures - **Medial window**: Between vessels and spermatic cord/round ligament **This is NOT a true internervous plane** - it's an intermuscular/intervascular approach requiring meticulous protection of structures. ### Approach Selection **Indications for Ilioinguinal:** - Most both-column fractures - Anterior column predominant displacement - Expectation that posterior column will reduce indirectly - Transverse component accessible **Advantages:** - Supine positioning (hemodynamically stable) - Excellent anterior column access - Can fix posterior column with percutaneous screws - Lower HO rate than posterior approaches **Disadvantages:** - Cannot visualize posterior column directly - Requires indirect reduction techniques - Higher nerve injury rate (femoral, LFCN) **Examiner Question**: "Why is ilioinguinal the workhorse approach for both-column fractures?" **Model Answer**: "The ilioinguinal approach is preferred for most both-column fractures because: (1) **Supine positioning** - patient hemodynamically stable, essential for polytrauma patients; (2) **Anterior column access** - direct visualization for anatomical reduction and fixation; (3) **Indirect posterior column reduction** - in 60-70% of cases, fixing the anterior column anatomically causes the posterior column to reduce through the intact dome ('keystone' effect); (4) **Percutaneous posterior column screws** - can be placed from anterior if indirect reduction adequate; (5) **Lower heterotopic ossification rate** (15%) vs extended approaches (50%+). The alternative - extended iliofemoral - is far more morbid and rarely needed." - **Femoral nerve palsy** (5-10%) - stay on iliopsoas surface, release retractors regularly - **LFCN injury** (20%) - identify at ASIS, protect or divide with counseling - **Corona mortis bleeding** - actively search and ligate prophylactically - **Inguinal hernia** (5-10%) - meticulous fascial closure essential **Indications for Extended Iliofemoral:** - Very complex fracture patterns - Need for direct visualization of both columns - Delayed presentation with callus - Failed attempt at ilioinguinal reduction **Advantages:** - Complete visualization of entire acetabulum - Direct reduction of both columns possible **Disadvantages:** - Very morbid approach - High HO rate (50%+) - Significant blood loss - Long operative time - Rarely used in modern practice - staged approaches preferred **Examiner Question**: "Why has the extended iliofemoral approach fallen out of favor?" **Model Answer**: "The extended iliofemoral approach provides complete acetabular visualization but has **unacceptably high morbidity**: (1) **Heterotopic ossification** in 50%+ of cases despite prophylaxis; (2) **Abductor devascularization** - approach detaches abductors from ilium, risking Trendelenburg gait; (3) **Blood loss** typically 2-4 liters; (4) **Operative time** often 6-8 hours; (5) **Wound complications** including superficial infection and dehiscence. Modern practice favors **staged approaches** - ilioinguinal first for anterior column, then Kocher-Langenbeck 3-7 days later if posterior column remains displaced. This provides equivalent visualization with lower morbidity." - **HO rate 50%+** - requires prophylaxis (indomethacin OR radiation) - **Abductor weakness** - may never fully recover, Trendelenburg gait - **Massive blood loss** - cell saver mandatory, expect 2-4 liters - **Sciatic nerve injury** - at risk during posterior dissection **When to Stage:** - Posterior column won't reduce indirectly after anterior column fixation - Significant posterior wall component - T-type or transverse + posterior wall patterns **Protocol:** 1. Ilioinguinal approach - fix anterior column 2. Assess posterior column on fluoroscopy 3. If inadequate - plan Kocher-Langenbeck in 3-7 days 4. Second stage: Lateral decubitus, posterior column direct reduction **Advantages over extended iliofemoral:** - Lower overall morbidity - Lower HO rate - Patient can recover between stages **Examiner Question**: "Why do you wait 3-7 days between stages rather than doing both approaches same day?" **Model Answer**: "The **3-7 day interval** between staged approaches is optimal because: (1) **Patient recovery** - allows resuscitation, correction of coagulopathy, and hemodynamic stabilization; (2) **Soft tissue recovery** - inflammation from first approach settles, reducing wound complication risk; (3) **Assessment** - post-operative CT can confirm anterior column reduction and guide posterior approach planning; (4) **Less than 7 days** - fracture hematoma still organized, reduction achievable before callus forms. If waited longer (>10-14 days), early callus makes posterior column reduction increasingly difficult. This staged approach has largely replaced extended iliofemoral for complex patterns." - **Same-day bilateral approach** - avoid (blood loss cumulative, DVT risk elevated) - **Waiting too long (>10-14 days)** - callus forms, posterior reduction difficult - **Not waiting long enough (<3 days)** - persistent bleeding, soft tissue swelling - **Different positioning between stages** - supine then lateral, plan logistically ## Operative Technique ### Superficial Dissection **Step 1: Skin Incision** - Curved incision from symphysis along inguinal ligament to ASIS - Continue posteriorly along iliac crest 8-10cm - Deepen through subcutaneous fat **Step 2: Identify LFCN** - Lateral femoral cutaneous nerve exits 1cm medial to ASIS - Identify and protect or deliberately divide (counsel patient preoperatively) - If divided, 100% will have anterior thigh numbness **Step 3: External Oblique** - Incise external oblique aponeurosis along inguinal ligament - Take down iliac crest attachment - Protect spermatic cord/round ligament **Examiner Question**: "How do you find the lateral femoral cutaneous nerve?" **Model Answer**: "The LFCN exits the pelvis approximately **1cm medial and inferior to the ASIS**, passing deep to or through the inguinal ligament. It's highly variable in position. My technique: (1) Identify the ASIS as my landmark; (2) Look 1-2cm medial to ASIS, superficial to the iliacus fascia; (3) The nerve is a **small white cord** running vertically toward the thigh; (4) If I find it, I gently mobilize and protect it. If I cannot find it reliably, some surgeons deliberately divide it to prevent unpredictable traction injury - but the patient MUST be counseled preoperatively about guaranteed anterior thigh numbness." LFCN injury causes meralgia paresthetica (anterior thigh numbness). Present in 20% if not carefully protected. Some surgeons divide routinely - prevents traction injury but guarantees numbness. Counsel patient preoperatively either way. **LATERAL WINDOW:** - Interval between iliacus (medial) and abductor muscles (lateral) - Subperiosteal elevation of iliacus from inner iliac fossa - Femoral nerve runs ON iliacus surface - protected by staying on muscle - Access: Iliac wing, SI joint, superior pelvic brim **MIDDLE WINDOW:** - Between external iliac vessels (lateral) and iliopsoas (medial) - Mobilize vessels off psoas with vessel loops - **IDENTIFY CORONA MORTIS** - present in 30% - Ligate prophylactically if present - Access: Quadrilateral surface, pelvic brim, superior ramus **MEDIAL WINDOW:** - Between external iliac vessels (lateral) and spermatic cord/round ligament (medial) - Bladder immediately posterior - careful subperiosteal dissection - Access: Symphysis, superior ramus, rectus origin **Examiner Question**: "What is corona mortis and why is the middle window most dangerous?" **Model Answer**: "**Corona mortis** ('crown of death') is an anastomosis between the obturator and external iliac/inferior epigastric vascular systems, crossing the superior pubic ramus. Present in approximately **30%** of patients. It lies directly in the middle window, the interval between the external iliac vessels and iliopsoas. If injured during dissection, it causes **severe hemorrhage** in a confined space that's difficult to access - hence the dramatic name. My approach: (1) Assume it's present until proven otherwise; (2) Actively search the superior ramus during middle window development; (3) **Prophylactically ligate** any vessel crossing the ramus with 3-0 silk; (4) If injured unexpectedly, direct pressure then suture ligation." - **LATERAL**: Femoral nerve injury if dissect THROUGH iliacus rather than ON its surface - **MIDDLE**: Corona mortis bleeding, external iliac vessel injury, obturator nerve - **MEDIAL**: Bladder injury (stay subperiosteal), spermatic cord damage - **All windows**: Release retractors every 15-20 minutes to prevent ischemic nerve injury ### Deep Dissection and Reduction **Clear Fracture Surfaces:** - Remove hematoma and soft tissue from fracture lines - Identify major fragments on each column - Assess marginal impaction (may need elevation) - Protect articular cartilage **Expose Pelvic Brim:** - Key fixation corridor for anterior column - Clear periosteum for plate application - Identify fracture exit points **Examiner Question**: "How do you manage marginal impaction found during exposure?" **Model Answer**: "Marginal impaction is subchondral bone depression at the weight-bearing dome. My management: (1) **Identify the extent** - the impacted fragment is usually visible at the fracture line as a depressed articular segment; (2) **Create an osteochondral window** if needed - a small window below the impaction to access from beneath; (3) **Elevate the fragment** using a curved osteotome or tamp from below, restoring articular congruity; (4) **Bone graft** the void created - I use local cancellous bone from the iliac crest or allograft; (5) **Provisionally fix** with K-wires before plate application. Without addressing impaction, even 'anatomical' reduction leaves articular incongruity." - **Aggressive debridement** - preserve bone fragments, may be needed for reduction - **Detaching periosteal attachments** - devascularizes fragments, delays healing - **Missing marginal impaction** - must actively look for depressed articular surface - **Damaging cartilage** - use blunt instruments near articular surface **Reduce Anterior Column FIRST:** This is the foundation for the entire reconstruction. 1. Apply Weber or Jungbluth clamp from ilium to inferior fragment 2. Reduce to intact iliac wing superiorly 3. Correct rotation using ball-spike pusher 4. Provisional K-wire fixation 5. Check on obturator oblique (anterior column profile) **Reduction Goals:** - Anatomical restoration of pelvic brim contour - Correct rotational alignment - Less than 2mm step at articular surface **Examiner Question**: "Why must you reduce the anterior column first in both-column fractures?" **Model Answer**: "**Anterior column first** is the fundamental principle for both-column reduction because: (1) The anterior column is directly accessible through the ilioinguinal approach for anatomical reduction; (2) The **dome acts as a template** - in many both-column fractures, the dome remains attached to both columns as a 'keystone'; (3) When the anterior column is reduced anatomically, the posterior column often **reduces indirectly** through this intact dome connection in 60-70% of cases; (4) If we fixed posterior first (which we can't visualize directly), we'd lose this indirect reduction mechanism. The sequence is: anterior column reduction → check posterior on fluoroscopy → percutaneous screws if acceptable, staged posterior approach if not." - **Reducing posterior column first** - loses indirect reduction mechanism - **Accepting malrotation** - rotational malreduction affects articular congruity - **Skipping fluoroscopy** - must confirm on obturator oblique before fixation - **Overcompression with clamp** - can shatter osteoporotic bone **After Anterior Column Fixed:** Assess posterior column reduction on: - Iliac oblique view (posterior column profile) - Inlet view (rotation assessment) - Lateral view (anterior-posterior displacement) **Indirect Reduction Success (60-70%):** - Posterior column reduces through intact dome - Displacement less than 2mm acceptable - Proceed with percutaneous screw fixation **If Posterior Column Remains Displaced:** - Try manipulation through medial window - Consider ball-spike pusher on quadrilateral surface - If still displaced >2mm → stage posterior approach **Examiner Question**: "The posterior column is displaced 4mm on the iliac oblique after anterior column fixation. What do you do?" **Model Answer**: "A 4mm posterior column displacement indicates indirect reduction has failed. My approach: (1) First, **attempt manipulation** through the medial window using a ball-spike pusher on the quadrilateral surface - sometimes gentle manipulation achieves reduction; (2) If unsuccessful, I would **NOT force the reduction** - this risks fracture propagation and sciatic nerve injury from blind manipulation; (3) I would complete anterior column fixation, close, and **plan a staged Kocher-Langenbeck approach** in 3-7 days; (4) At second stage, lateral decubitus position, direct visualization and reduction of posterior column. This staged approach has lower morbidity than extended iliofemoral and achieves equivalent outcomes." Forcing closed reduction of posterior column risks fracture propagation and sciatic nerve injury. If indirect reduction fails, accept staged approach rather than compromising outcome. ### Fixation **Pelvic Brim Plating:** 1. **Plate selection**: 3.5mm reconstruction plate, 8-12 holes 2. **Contouring**: Must match 3D anatomy of pelvic brim exactly 3. **Position**: Along pelvic brim from ilium to superior ramus 4. **Screws**: 3.5mm cortical, at least 3 screws per fragment **Technical Points:** - Plate sits on strongest bone (pelvic brim cortex) - May need two plates for complex patterns - Lag screw large fragments before plating - Avoid screw penetration into hip joint (check obturator oblique) **Examiner Question**: "How do you ensure your screws don't penetrate the hip joint?" **Model Answer**: "Intra-articular screw penetration is a serious complication causing cartilage damage and arthritis. My safety protocol: (1) **Obturator oblique view** is essential - this shows the hip joint en face, making any screw approaching the joint visible; (2) I check this view **after each screw** near the joint, not just at the end; (3) I know the **safe screw corridors** - screws should be directed posterior and superior to the joint; (4) For screws in the peri-acetabular region, I use the **'teardrop technique'** - the radiographic teardrop should not be violated; (5) If in doubt, **undershoot length** - a short screw is safer than a long one. I also check iliac oblique to assess posterior column screws." - **Intra-articular screw** - must check obturator oblique after each screw - **Plate not contoured** - gap causes stress riser, loss of reduction - **Fewer than 3 screws per fragment** - inadequate fixation - **Screw too long medially** - can enter peritoneal cavity or bladder **Percutaneous Posterior Column Screws (from Anterior):** **Technique:** 1. Start point on superior pubic ramus 2. Trajectory: Posterior and superior toward ischium 3. Use 7.0-7.3mm cannulated screws 4. Length typically 120-140mm 5. Guidewire first, confirm on all views, then screw **Fluoroscopic Views Required:** - **Inlet**: Medial-lateral trajectory (avoid intrapelvic penetration) - **Outlet**: Superior-inferior trajectory - **Lateral**: Anterior-posterior trajectory **Danger Zone:** - Greater sciatic notch (sciatic nerve) - Screw must stay within bone column **Examiner Question**: "Describe your technique for placing a posterior column screw from the anterior approach." **Model Answer**: "Posterior column screws from anterior require precise fluoroscopic guidance: (1) **Start point**: Superior pubic ramus, approximately 2cm from symphysis; (2) **Trajectory**: Posterior and superior, aiming toward the ischial spine; (3) **Guidewire first** - NEVER commit to screw without confirming wire position; (4) **Three essential views**: Inlet (medial-lateral trajectory - wire within bone, not entering pelvis), Outlet (superior-inferior trajectory), Lateral (anterior-posterior - ensure wire stays within posterior column corridor); (5) Screw length typically **120-140mm**; (6) The **greater sciatic notch** is the danger zone - sciatic nerve exits here, wire/screw must NOT penetrate posterior cortex in this region. If wire position uncertain on any view, do NOT place screw." The sciatic nerve exits through the greater sciatic notch. Screws must not penetrate the posterior cortex of the ischium in this region. Multiple fluoroscopic views essential. **Additional Options:** - **Quadrilateral surface buttress plate**: For medial displacement - **Infrapectineal plate**: Alternative anterior column position - **Lag screws**: Across large fragments before plating - **Spring plate**: For quadrilateral surface support **When to Add:** - Significant quadrilateral surface comminution - Medial displacement of head - Osteoporotic bone requiring additional support **Examiner Question**: "When and how do you address the quadrilateral surface?" **Model Answer**: "The **quadrilateral surface** (medial wall of acetabulum) is critical because comminution or medial displacement leads to femoral head medialization and central subluxation. Indications to address: (1) CT showing medial wall comminution; (2) Femoral head medially displaced on AP pelvis; (3) Central subluxation of femoral head into pelvis. Techniques: (1) **Infrapectineal plate** - sits below the pelvic brim on the quadrilateral surface, provides direct buttress; (2) **Spring plate** - small curved plate provides elastic support; (3) **Suprapectineal plate with 'in-out-in' screws** - screws angled to capture quadrilateral fragment. The trend is toward dedicated **quadrilateral surface plates** that buttress medially while allowing pelvic brim plating." - **Inadequate buttress** - femoral head medializes post-op, central subluxation - **Aggressive manipulation** - quadrilateral surface is thin, easily fractured - **Screws too long** - can penetrate into pelvis (bladder, iliac vessels) - **Missing the indication** - must identify on pre-op CT, not intra-op surprise ### Intraoperative Imaging ## Closure ### Haemostasis - Irrigate thoroughly with normal saline (3L minimum) - Bipolar diathermy for discrete bleeders - Bone wax for exposed cancellous bone - Topical haemostatic agents (Surgicel, Floseal) for oozing surfaces - **Ensure corona mortis controlled** if identified ### Drain Placement - Large dead space - Significant blood loss expected - Reduces hematoma formation - May reduce infection risk - Allows monitoring of output - Retrograde bacterial migration - Additional wound for infection - May prevent tamponade - No RCT evidence of benefit - Delays mobilization **If using drain**: Large bore (14Fr) closed suction system, remove at 24-48h or when output less than 50mL/8h ### Layered Closure **Critical for Hernia Prevention:** 1. **Inguinal ligament repair**: Reattach to external oblique with 0 PDS 2. **External oblique aponeurosis**: Close with 0 PDS continuous 3. **Internal oblique/transversus**: Close if divided 4. **Rectus sheath**: Close separately if opened **Examiner Question**: "How do you prevent inguinal hernia after ilioinguinal approach?" **Model Answer**: "Inguinal hernia occurs in **5-10%** after ilioinguinal approach if fascial closure is inadequate. My prevention strategy: (1) **Identify layers clearly** during opening - know what needs repair; (2) **Inguinal ligament repair** - critical to reattach to external oblique aponeurosis with 0 PDS or non-absorbable suture; (3) **External oblique aponeurosis** - close with continuous 0 PDS, strong bites, no gaps; (4) **Internal oblique/transversus** - close separately if divided; (5) **Avoid tension** - if significant soft tissue loss or swelling, consider component separation techniques or mesh augmentation; (6) **Identify and protect spermatic cord** - entrapment causes testicular problems. I check for bulge before final skin closure." Inguinal hernia occurs in 5-10% if fascial closure is inadequate. Use non-absorbable suture for strength layers. Avoid tension - consider component separation if needed. **Superficial Closure:** 1. **Scarpa's fascia**: 2-0 Vicryl interrupted 2. **Subcutaneous**: 3-0 Vicryl if needed 3. **Skin**: 3-0 Monocryl subcuticular or staples 4. **Dressing**: Waterproof dressing, allow inspection **Examiner Question**: "Why do you close Scarpa's fascia separately?" **Model Answer**: "**Scarpa's fascia** is a distinct fascial layer in the lower abdomen/groin that provides structural support. Closing it separately is important because: (1) **Obliterates dead space** - the ilioinguinal approach creates a large potential space where hematoma can collect; (2) **Supports deep closure** - takes tension off the skin closure; (3) **Reduces seroma formation** - by eliminating tissue planes that can fill with fluid; (4) **Improves cosmesis** - well-apposed layers heal with less scar widening. I use **2-0 Vicryl interrupted** sutures, ensuring good bites without strangulating tissue." - **Skipping Scarpa's fascia** - increases dead space, seroma, hematoma - **Closing skin too tightly** - causes skin necrosis over swollen tissues - **Non-waterproof dressing** - wound needs protection, especially near groin - **Staples over bony prominences** - ASIS region, use subcuticular here ## Intra-operative Complications **Corona Mortis Injury:** **Recognition:** - Sudden brisk arterial or venous bleeding - Obscured surgical field in middle window - From superior pubic ramus area **Prevention:** - Actively identify during middle window development - Ligate prophylactically if present - Assume present until proven otherwise **Management:** - Direct pressure immediately - Suture ligation with 3-0 silk (may need vascular needle) - Clips if accessible - Usually controlled with local measures **External Iliac Vessel Injury:** **Recognition:** - Catastrophic bleeding - Hemodynamic instability - Expanding hematoma **Prevention:** - Gentle dissection with vessel loops - Awareness of atherosclerotic disease - Vascular surgery backup available **Management:** - Direct pressure, call for help - Vascular surgery immediate consultation - Primary repair if clean laceration - Never ligate external iliac artery (limb loss) - Fasciotomy if prolonged ischemia **Examiner Question**: "You have uncontrolled bleeding from the middle window. Talk me through your management." **Model Answer**: "Uncontrolled middle window bleeding is likely **corona mortis or external iliac vessel injury**. My immediate actions: (1) **Direct pressure** with pack - maintain for 5 minutes; (2) **Call for help** - vascular surgery, additional blood products; (3) **Improve exposure** - suction, lighting, assistant; (4) **Identify source** - if corona mortis (on ramus), suture ligate with 3-0 silk on vascular needle; (5) If **external iliac injury**, maintain pressure, await vascular surgeon - NEVER ligate external iliac artery (limb loss); (6) If waiting and hemodynamically unstable, consider **proximal control** with vascular clamp on common iliac; (7) Document bleeding volume and resuscitation requirements." - **NEVER ligate external iliac artery** - will cause limb loss - **Have vascular surgery available** - even if just on-call - **Blood products pre-ordered** - 4 units RBC minimum crossmatched - **Cell saver running** - allows autologous transfusion **Femoral Nerve:** **Recognition:** - Post-operative quadriceps weakness - Loss of knee extension - Anterior thigh numbness **Prevention:** - Stay on surface of iliopsoas (nerve runs on muscle) - Release retractors every 15-20 minutes - Use padded retractors - Gentle retraction force **Management:** - Document immediately post-op - Most are neuropraxia (90% recover 6-12 weeks) - Knee brace for ambulation if weak - EMG at 3 weeks if no recovery - Neurosurgical consultation if no recovery by 6 months **Lateral Femoral Cutaneous Nerve:** **Recognition:** - Anterior-lateral thigh numbness (meralgia paresthetica) **Prevention:** - Identify at ASIS - Protect or deliberately divide **Management:** - Usually permanent if divided - Reassurance - cosmetic issue - Gabapentin if painful dysesthesia **Examiner Question**: "Post-operatively your patient cannot extend their knee. What is the diagnosis and management?" **Model Answer**: "**Femoral nerve palsy** is the likely diagnosis. The femoral nerve provides knee extension via quadriceps. My assessment and management: (1) **Confirm clinical findings** - test knee extension (grade 0-5), test sensation anterior thigh and medial leg (saphenous branch); (2) **Document immediately** in notes with dated neurological examination; (3) **Reassure patient** - 90% are **neuropraxia** from retraction, not transection, and recover in 6-12 weeks; (4) **Knee brace** for ambulation to prevent buckling; (5) **Physiotherapy** for quadriceps activation and maintenance; (6) **EMG at 3-4 weeks** if no recovery - will show denervation if significant injury; (7) If no recovery by **6 months**, neurosurgical consultation for possible exploration." - **Stay ON iliopsoas surface** - femoral nerve runs on muscle, not through it - **Release retractors every 15-20 minutes** - prevents ischemic neuropathy - **Padded retractors** - reduces direct nerve compression - **Document pre-op neurology** - baseline for comparison post-op **Bladder Injury:** **Recognition:** - Urine in surgical field - Clear fluid not blood **Prevention:** - Foley catheter preoperatively - Stay subperiosteal on pubis - Visualize bladder during medial window **Management:** - Primary repair in two layers - Prolonged catheterization (10-14 days) - Urology consultation **Fracture Propagation:** **Recognition:** - Fracture extends during reduction - New fragment created **Prevention:** - Gentle reduction forces - Wide exposure before reduction - Appropriate clamp placement **Management:** - May require additional fixation - Modify plan to address new fragment - Document and proceed systematically **Examiner Question**: "You notice clear fluid in the surgical field during medial window development. What do you do?" **Model Answer**: "Clear fluid in the medial window raises suspicion for **bladder injury**. My immediate actions: (1) **Stop dissection** - do not extend the injury; (2) **Identify source** - is it urine (no clot, clear) vs. peritoneal fluid (also clear); (3) **Check Foley** - should have been placed pre-op, check bag for blood-tinged urine; (4) **Inspect bladder wall** - identify extent of injury; (5) **Management**: Small extraperitoneal injury - **primary repair** in two layers (mucosa with 3-0 Vicryl, muscle/adventitia with 2-0 Vicryl); (6) **Urology consultation** if intraperitoneal or large injury; (7) **Prolonged catheterization** - 10-14 days post-repair; (8) **Cystogram** before catheter removal to confirm healing." - **Foley catheter** - MANDATORY for all ilioinguinal approaches - **Stay subperiosteal on pubis** - bladder lies just posterior - **Gentle reduction forces** - excessive force propagates fractures - **Wide exposure first** - don't reduce through limited view ## Post-operative Care ### Weight-bearing Protocol ### Medications - **LMWH**: Enoxaparin 40mg SC daily - **Duration**: 4-6 weeks post-surgery - **Alternative**: Rivaroxaban 10mg OD - **Mechanical**: TEDs + pneumatic compression - **Controversial for ilioinguinal** (lower risk than posterior) - **If used**: Indomethacin 75mg daily x 6 weeks - **Alternative**: Single-dose radiation 700cGy - **Consider for**: High-risk patients, redo surgery ### Follow-up Schedule ## Viva Scenarios ## Key Exam Points ## References 1. **Matta JM.** Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after injury. *J Bone Joint Surg Am.* 1996;78(11):1632-1645. 2. **Letournel E, Judet R.** Fractures of the Acetabulum. 2nd ed. Berlin: Springer-Verlag; 1993. 3. **Routt ML Jr, Swiontkowski MF.** Operative treatment of complex acetabular fractures: combined anterior and posterior exposures during the same procedure. *J Bone Joint Surg Am.* 1990;72(6):897-904. 4. **Hong G, Cong-Feng L, Cheng-Fang H, et al.** Percutaneous screw fixation of acetabular fractures with 2D fluoroscopy-based computerized navigation. *Arch Orthop Trauma Surg.* 2010;130(9):1177-1183. 5. **Tile M, Helfet DL, Kellam JF.** Fractures of the Pelvis and Acetabulum. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2003. 6. **Gänsslen A, Pohlemann T, Paul C, et al.** Epidemiology of pelvic ring injuries. *Injury.* 1996;27 Suppl 1:S-A13-20. 7. **Tornetta P 3rd.** Non-operative management of acetabular fractures: the use of dynamic stress views. *J Bone Joint Surg Br.* 1999;81(1):67-70. 8. **Karunakar MA, Shah SN, Jerabek S.** Body mass index as a predictor of complications after operative treatment of acetabular fractures. *J Bone Joint Surg Am.* 2005;87(7):1498-1502. 9. **Anglen JO, Burd TA, Hendricks KJ, Harrison P.** The "Gull Sign": a harbinger of failure for internal fixation of geriatric acetabular fractures. *J Orthop Trauma.* 2003;17(9):625-634. 10. **Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H.** Operative treatment of displaced fractures of the acetabulum: a meta-analysis. *J Bone Joint Surg Br.* 2005;87(1):2-9.

Acetabular Fracture ORIF - Both Column

Acetabular Fracture ORIF - Both Column