Review Question - QID 45

The radiograph and CT images shown in A-D show an acute both column acetabular fracture with segmental posterior column comminution. For difficult fractures with anterior displacement in which access to the entire anterior column is required, the ilioinguinal or Stoppa approach is ideal. These approaches allow access to the anterior column as far as the symphysis and includes the quadrilateral plate.

Most both-column fractures can also be managed through these approaches, but only if the posterior fragment is large and in one piece. In this case, the posterior column is in several pieces and requires either two approaches or an extended approach, such as the iliofemoral.

The original description of the ilioinguinal approach makes intraarticular visualization of the hip impossible. If visualization of the joint is required, a T extension of the incision just medial to the anterior-superior iliac spine can be made. Most surgeons accept that the joint is reduced when the fracture lines inside the pelvis are reduced, and thus this extension is very rarely used.

The extended iliofemoral approach gives excellent visualization of the outer table of the ilium, the superior dome, and the posterior column. The anterior column can be visualized to the iliopectineal eminence. The exposure is similar to that provided by the triradiate approach with the additional benefit of access to the bone above the sciatic notch. The approach can be extended to provide exposure to the iliac fossa; however, this is very rarely necessary and should be avoided. Extending the approach to the inside of the pelvis greatly increases the risk of devascularizing segments of the acetabulum.