import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' ## Understanding the Fracture Pattern The **posterior column/wall fracture** is one of five ASSOCIATED patterns in the Judet-Letournel classification. Unlike simple posterior wall fractures, this pattern involves disruption of BOTH: 1. **Posterior Column**: From iliac wing to ischial tuberosity (includes posterior half of articular surface) 2. **Posterior Wall**: The weight-bearing dome fragment posterior to the hip joint The posterior column provides the FOUNDATION for wall fixation. If you fix the wall without restoring column anatomy, the entire construct will fail. This is why the reduction sequence is critical: **Step 1**: Reduce and fix posterior COLUMN (restores length, rotation, and articular continuity) **Step 2**: Reduce and fix posterior WALL to the restored column *The column is the scaffold upon which the wall sits.* **Absolute Indications:** - Posterior column fracture with >2mm displacement - Associated posterior wall fracture with >40% wall involvement - Hip joint instability on dynamic examination - Marginal impaction requiring elevation - Incarcerated osteochondral fragments **Relative Indications:** - Posterior wall 20-40% with marginal impaction - Posterior column fracture in polytrauma (staged approach) - Posterior component of transverse + posterior wall pattern **Contraindications:** - Active infection - Severe medical comorbidities precluding major surgery - Fractures >3 weeks old with excessive callus (relative - may need extensile approach) - Severe osteoporosis with articular comminution (consider THA) **Optimal Window: Days 3-7** Rationale: - Allows resuscitation and medical optimization - Hemorrhage controlled, swelling manageable - Fracture lines visible but callus not yet formed - Avoid the "inflammatory peak" (days 2-3) **Too Early (Days 0-2):** - Ongoing hemorrhage - Hemodynamically unstable - Inadequate imaging/planning **Too Late (>2-3 weeks):** - Callus formation obscures fracture lines - Increased bleeding from granulation tissue - More difficult reduction - Higher complication rates **Essential Imaging:** 1. AP pelvis - assess both columns, roof arcs 2. Judet oblique views (obturator and iliac oblique) 3. CT with 3D reconstruction - MANDATORY for: - Fracture pattern classification - Marginal impaction identification ("gull sign") - Fragment size and displacement - Femoral head injury assessment **CT Analysis Checklist:** - [ ] Confirm posterior column/wall pattern - [ ] Measure posterior wall involvement (>40% = unstable) - [ ] Identify marginal impaction - [ ] Assess for intra-articular fragments - [ ] Check femoral head for impaction/fracture - [ ] Evaluate contralateral hip for templating **Patient Optimization:** - DVT prophylaxis from admission - Blood available (expected loss 1-2L) - Cell saver arranged - Skeletal traction if hip subluxed **Location**: Exits greater sciatic notch below piriformis, 10-20mm posterior to posterior column **Risk**: 10-15% temporary injury, 1-3% permanent **Protection**: Identify early by palpation below piriformis, vessel loop, ribbon retractor throughout, avoid hip extension with retractors in place (stretches nerve) **EXAM KEY**: Peroneal division more vulnerable than tibial - foot drop is classic presentation **Location**: Exits greater sciatic notch ABOVE piriformis, 30-40mm superior to joint **Risk**: Abductor insufficiency (Trendelenburg gait) **Protection**: Stay distal to superior border of piriformis - this is the SAFE ZONE. Never dissect proximal to piriformis muscle. **EXAM KEY**: Piriformis is the KEY LANDMARK - sciatic nerve below, superior gluteal above **Location**: Runs along posterior femoral neck in superior retinacular vessels **Risk**: AVN of femoral head (2-5%) **Protection**: LIMITED posterior capsulotomy only - preserve superior capsule. Gentle retraction of femoral head. **EXAM KEY**: Most AVN from initial injury/dislocation, not surgery - but surgical technique matters **Location**: 5-15mm from medial surface of posterior column **Risk**: Hemorrhage from anteromedial screw trajectory **Protection**: Posterior column screws should be POSTERIOR to column axis and PARALLEL to joint - stay in Letournel safe zone **EXAM KEY**: Bicortical screws are safe if trajectory correct - palpate anterior cortex ## Equipment **Implants Required:** - 3.5mm reconstruction plates (multiple lengths: 8-14 hole) - 3.5mm cortical screws (various lengths 26-60mm) - 3.5mm cancellous screws (for metaphyseal bone) - 2.7mm plates and screws (for small fragments) - 2.0-2.5mm K-wires for provisional fixation **Reduction Instruments:** - Ball spike pushers (essential for fragment manipulation) - Pointed reduction forceps (multiple sizes) - Weber clamps - Jungbluth clamps - Schanz pin (for femoral head manipulation if needed) - Bone hook and levers **Specialty Items:** - Nerve stimulator (confirm sciatic nerve identity) - Vessel loops and ribbon retractors (nerve protection) - Cell saver (expected blood loss 1-2L) - Radiolucent table with C-arm access **Bone Graft:** - Autograft from posterior iliac crest (accessible in field) - Allograft cancellous chips (backup) **Patient Position**: Lateral decubitus on radiolucent table - Affected side UP - Bean bag or pelvic positioners for stability - Axillary roll in place - All pressure points padded (head, axilla, fibular head, malleoli) - Hip must be freely mobile for reduction maneuvers and dynamic testing **Surgical Approach**: Kocher-Langenbeck (extensile posterior approach to hip) **Incision**: - Starts 8-10cm proximal to greater trochanter along posterior border - Curves over greater trochanter - Extends 10-15cm distally along posterior femoral shaft - Total length: 20-25cm depending on body habitus **C-arm Setup**: - Confirm all three views obtainable BEFORE draping - AP pelvis, obturator oblique (affected side down 45°), iliac oblique (affected side up 45°) **Prophylaxis**: - Antibiotics within 60 minutes (cefazolin 2g IV) - TXA 1g IV at induction - Skin prep with alcoholic chlorhexidine ### Step 1: Positioning and Setup Patient in lateral decubitus position on radiolucent table. Affected side up. Confirm pelvis perpendicular to floor with spirit level. Check C-arm access for all three views before draping. Ensure hip can be fully flexed, extended, and rotated - essential for reduction maneuvers and dynamic stability testing. **Technical Tip**: Lateral position is preferred over prone for this fracture pattern - allows better hip manipulation, dynamic testing, and fluoroscopy access. Prone may be considered for bilateral fractures or specific surgeon preference. ### Step 2: Kocher-Langenbeck Incision Incision centered over greater trochanter: 8-10cm proximal along posterior GT border, curving over GT apex, then 10-15cm distally along posterior femoral shaft. Total length 20-25cm. Mark anatomical landmarks (GT, PSIS) before incision as position may shift intraoperatively. ### Step 3: Superficial Dissection - Gluteus Maximus Split gluteus maximus in line with its fibers (running superolaterally to inferomedially). The split can be extended proximally and distally as needed. Identify and preserve the inferior gluteal neurovascular bundle running with the muscle. The gluteus maximus split exposes the short external rotators and sciatic nerve. Proceed carefully once through the muscle - the nerve lies immediately deep. ### Step 4: Sciatic Nerve Identification **CRITICAL STEP**: Before any further dissection, identify the sciatic nerve by FINGER PALPATION below the piriformis muscle. The nerve is a thick, cord-like structure running from the greater sciatic notch, between the ischial tuberosity and greater trochanter, distally with the hamstrings. Once identified by palpation: - Confirm visually - Trace proximally to greater sciatic notch - Trace distally 6-8cm - Place vessel loop or ribbon retractor for protection - Use nerve stimulator to confirm identity if any doubt **EXAM KEY**: "How do you identify the sciatic nerve?" - Answer: "Finger palpation below piriformis muscle first - it feels like a thick cord. Then visual confirmation, tracing from sciatic notch to distal thigh. I would use a nerve stimulator to confirm identity, then protect with vessel loop and ribbon retractor throughout the case." ### Step 5: Short External Rotator Detachment Identify the short external rotators from superior to inferior: 1. **Piriformis** - KEY LANDMARK (sciatic nerve exits below) 2. **Superior gemellus** 3. **Obturator internus tendon** (thickest - easiest to identify) 4. **Inferior gemellus** 5. **Quadratus femoris** Tag each tendon with heavy suture (number them 1-4 for anatomic repair later). Detach from femoral insertion leaving 5mm cuff for repair. Reflect posteriorly to expose posterior capsule. NEVER dissect proximal to the piriformis muscle. The superior gluteal neurovascular bundle exits ABOVE piriformis - injury causes permanent abductor weakness and Trendelenburg gait. ### Step 6: Limited Posterior Capsulotomy Perform LIMITED capsulotomy through the posterior capsule - small T-shaped or cruciate incision over the fracture site. **DO NOT** perform complete capsulectomy - this sacrifices the superior retinacular vessels (MFCA branches) and increases AVN risk. Inspect the joint for: - Intra-articular fragments (remove) - Marginal impaction ("gull sign") - Femoral head injury - Labral damage - Reduction quality ### Step 7: Posterior Column and Wall Exposure Subperiosteal elevation from the lateral ilium distally. Stay distal to superior gluteal nerve (below piriformis level). Expose: - Posterior column from greater sciatic notch to ischial tuberosity - Posterior wall fragments - Quadrilateral surface (palpation) Place retractors carefully with sciatic nerve always visualized and protected. ### Step 8: Address Marginal Impaction (If Present) **Present in 30-40% of posterior wall fractures**. Recognition on CT: "gull sign" - articular cartilage depressed into subchondral bone. Management: 1. Create window through posterior wall fracture 2. Use curved osteotome to elevate impacted osteochondral fragment 3. Work from inferior to superior, preserving cartilage 4. Pack resulting defect with cancellous bone graft (autograft from posterior iliac crest available in field) 5. Support elevated fragment with bone graft before wall reduction **Evidence Point**: Addressing marginal impaction improves good outcomes from 50% to 80% (Letournel). Failure to recognize and treat is a major cause of poor results. ### Step 9: Posterior Column Reduction **Reduce COLUMN before WALL** - the column provides the foundation. 1. Débride fracture hematoma 2. Use ball spike in posterior column fragment for manipulation 3. Restore length by pushing fragment distally 4. Correct rotation (usually internally rotated) 5. Provisional fixation with pointed reduction forceps or K-wires 6. Assess reduction: direct vision, palpation of articular surface, fluoroscopy **Target**: Anatomic reduction (<1mm step/gap) ### Step 10: Posterior Column Fixation Apply 3.5mm reconstruction plate along the lateral surface of the posterior column: - From posterior ilium to ischial tuberosity - Pre-contour plate to match anatomy - Minimum 3 screws each side of fracture (6 cortices each fragment) - Lag screws through plate for large fragments **SCREW TRAJECTORY**: Letournel Safe Zone - Posterior column screws should be POSTERIOR to column axis - Parallel to joint surface - Avoid anteromedial trajectory (obturator vessels 5-15mm from medial surface) Palpate anterior cortex when drilling to confirm trajectory and prevent excess penetration. All screws must be checked with fluoroscopy - no intra-articular hardware. ### Step 11: Posterior Wall Reduction With column restored, reduce wall fragments to the now-anatomic column: 1. Identify all wall fragments and their correct orientation 2. Use ball spike and pointed reduction forceps 3. Reduce largest fragments first 4. Provisional K-wire fixation 5. Check reduction through capsulotomy (articular surface step) ### Step 12: Posterior Wall Fixation - Spring Plate Technique For COMMINUTED posterior wall (multiple fragments), use the **Spring Plate Technique**: 1. Contour 3.5mm reconstruction plate to match normal posterior wall anatomy (use contralateral CT or opposite hip as template) 2. Position plate over reduced wall fragments 3. Insert multiple (8-12) lag screws through the plate 4. Screws compress fragments against the plate 5. Plate acts as TEMPLATE - screws pull fragments to plate, restoring anatomy For SIMPLE posterior wall (1-2 large fragments): - Direct lag screw fixation through plate - Buttress plating as needed **Spring Plate Principle**: The plate is pre-contoured to ideal anatomy and acts as a template. Multiple lag screws through the plate compress the comminuted fragments against the plate surface, recreating the anatomical contour. This is the key technique for comminuted posterior wall fractures. ### Step 13: Dynamic Stability Testing **CRITICAL ASSESSMENT** - determines if wall reconstruction adequate: 1. Remove all retractors and provisional fixation 2. Flex hip to 90° 3. Internally rotate 4. Assess for subluxation or dislocation **Result Interpretation**: - **Stable**: Hip remains concentrically reduced → adequate wall restoration - **Unstable**: Hip subluxes → INADEQUATE wall fixation → add more fixation If the hip subluxes with flexion/internal rotation, the posterior wall reconstruction is inadequate. You MUST add additional fixation - either more screws, larger plate, or address a missed component. Post-operative dislocation is a devastating complication. ### Step 14: Final Fluoroscopic Check Obtain all three standard views: 1. **AP pelvis**: Overall alignment, hip congruency 2. **Obturator oblique** (affected side down 45°): Best view of posterior wall 3. **Iliac oblique** (affected side up 45°): Posterior column profile Check for: - [ ] Anatomic reduction (<1mm step/gap) - [ ] No intra-articular hardware (use radiopaque probe if any question) - [ ] Adequate screw purchase (bicortical where possible) - [ ] Concentric hip joint - [ ] All fracture components addressed ### Step 15: Closure and HO Prophylaxis **Wound Closure**: 1. Copious irrigation (3L+ warm saline) 2. Meticulous hemostasis 3. Repair posterior capsule (absorbable suture) 4. Reattach short external rotators anatomically using tagged sutures 5. Deep drain (19Fr) to gluteus maximus level 6. Close gluteus maximus split 7. Fascia lata, subcutaneous, skin closure **HETEROTOPIC OSSIFICATION PROPHYLAXIS - MANDATORY**: - **Indomethacin 75mg PO daily x 6 weeks** (start POD#1) - OR **Single-dose radiation 700cGy within 72 hours** (if NSAID contraindicated) - HO rate 30-50% WITHOUT prophylaxis - highest of all approaches The Kocher-Langenbeck approach has the HIGHEST rate of heterotopic ossification of any pelvic approach. Without prophylaxis, 30-50% will develop significant HO. Indomethacin is first-line; radiation for NSAID intolerance, GI bleeding risk, or those on anticoagulation. **Immediate (Recovery)**: - Neurovascular check documented (especially sciatic nerve - peroneal division) - Check X-ray (AP pelvis, Judet views) - VTE prophylaxis initiated (LMWH) - HO prophylaxis started (indomethacin POD#1) **Days 1-3**: - Mobilize with physiotherapy - **Toe-touch weight bearing** for 6-12 weeks - Active hip ROM within comfort - Drain removal 48-72 hours **6 Weeks**: - Clinical and radiological review - Progress weight bearing if healing - Assess for HO (X-ray) **12 Weeks**: - Full weight bearing if united - Return to normal activities **Long-term Follow-up**: - 6 months, 1 year, then annually - Monitor for post-traumatic arthritis - MRI if symptomatic for AVN (6-12 months) - EMG/NCS at 3 weeks if sciatic deficit (for prognosis) ## References 1. Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Springer-Verlag; 1993. 2. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78(11):1632-1645. 3. Moed BR, Willson Carr SE, Watson JT. Results of operative treatment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg Am. 2002;84(5):752-758. 4. Briffa N, Pearce R, Hill AM, Bircher M. Outcomes of acetabular fracture fixation with ten years' follow-up. J Bone Joint Surg Br. 2011;93(2):229-236. 5. Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am. 1973;55(8):1629-1632. 6. Burd TA, Hughes MS, Anglen JO. Heterotopic ossification prophylaxis with indomethacin increases the risk of long-bone nonunion. J Bone Joint Surg Br. 2003;85(5):700-705. 7. 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 - Posterior Column/Wall

Acetabular Fracture ORIF - Posterior Column/Wall