Cyril Mauffrey, MD, FACS, FRCS

Use of mini-fragment plates may be effective for the provisional fixation of elementary and associated acetabular fractures, according to an orthopedic trauma specialist.

Vertical shear pelvic ring injuries present a unique challenge due to their inherent vertical and rotational instability. Binders, sheets or external fixators may at times underestimate the severity of initial displacement or mask associated occult injuries. Preoperative CT is necessary for adequate planning based on patient anatomy and injury characteristics. We present our preferred method of treatment for vertical shear pelvic ring injuries and focus on the surgical technique.

The anterior intrapelvic approach or modified Stoppa approach for the treatment of pelvic and acetabular fractures has been gaining popularity. This approach now rivals the ilioinguinal approach as the workhorse approach for most orthopedic trauma surgeons who want to gain access to the anterior pelvis and acetabulum. Its advantages include ease of surgical dissection, excellent access to the quadrilateral plate, good visualization of a portion of the posterior column and, when combined with a lateral window, visualization of the entire anterior column. The modified Stoppa approach can be performed in isolation (without the need for the lateral window) when the iliac wing is not fractured.

The gold standard technique for reduction of a depressed fracture relies on the use of a cortical window and elevation of the articular fragment with a bone tamp, but more modern, less invasive options are available that use balloon inflation-plasty. Long- or mid-term results are not yet published about the technique, but prospective trials collecting data on the quality of reduction are being performed.

Bone grafting is an essential component of restoring three-dimensional osseous architecture. Surgical correction of hard tissue deficiencies presents challenges in both the functional and aesthetic realms. Autogenous bone harvested from secondary surgical sites provides great utility in reconstructing defects, augmenting healing, treating nonunions, arthrodesis and lengthening bones. While a number of options are available in allograft, autograft and bone graft substitutes, the benefits of osteogenesis and osteoinduction in autografts, as well as its mechanical and handling characteristics, make it the gold standard.

The split-depression lateral plateau fracture is a common fracture pattern. Usually, the fracture is approached laterally, the split reduced with a bone clamp, the articular depression reduced through a cortical window and the fragment maintained in place with bone graft or bone graft substitute. Actually, this sequence may make perfect reduction impossible because the space for the articular fragment is too narrow. This is the “trap door” effect. In this technique tip, we recommend reducing the depression prior to clamping the split fragment.