hough the techniques used for Type B1 fractures are almost the same as those used for type A2 fractures but in type B1 fractures because of the additional anterior column involvement, the reduction is more complex. Securing a plate first into one of the fracture fragments, then the application of the plate as a reduction tool will be an effective manipulation. Stabilization should be achieved using a reconstruction plate 3.5 applied to the retro-acetabular surface and bone screws after the provisional fixation and examination.
In the case of acetabular fractures, an adequate plate must be over-contoured. In type B1 fractures, under-contouring causes distraction of the anterior column. Lag screw from the posterior to the anterior column can prevent the anterior column displacement. Usually, cannulated cancellous screws can be placed through the posterior buttress plate and it should be placed parallel to the quadrilateral surface so that joint penetration can be averted. But in the condition of a circumscribed impaction of the articular surface, reduction of this area must be carried out anatomically and thereby occurring bone defect which should be filled with bone cancellous auto-graft. The provisional reduction can be achieved by using a k-wire and a resorbable pin, or a screw.
However, it is very difficult to manage type B2 (transverse and T-shaped) fractures because a vertical stem component separates the inferior segment into anterior and posterior fragments. Fixation of this fracture with the posterior approach is determined by the surgeon’s expertise in palpitation of the anterior column and stem component through the greater sciatic notch. As it is difficult to control the isolated anterior column fragment by handling the posterior column fragments. So the surgeon needs to be an expert in the instrument’s applications and placement into the sciatic notch and in manipulating the anterior column fragment after the temporary stabilization of the posterior column. Posterior column implants crossing into the anterior column also make the reduction more challenging. However, the final fixation is performed using a posterior buttress plate and lag screws.
Open reduction and internal fixation(ORIF) through an anterior approach
To relax the structures crossing anterior to the hip joint, the reduction is made easier by hip flexion. Manual traction inserted through the lateral aspect of the femur using a Schanz screw, into the femoral head influences the fracture reduction through ligamentotaxis. However, each action in this procedure is significant for the after-result. Accurate reduction of all fracture fragments is imperative because the articular surface cannot be viewed directly through this approach. To remove the hematoma and small fragments, every fracture line must be irrigated and debrided with great care. Irrigation of the hip joint and removal of loose fragments is done through the displaced part of the articular fracture.
In type A3 and B3 fractures, the anterior column is reduced next to the intact iliac wing and stabilized provisionally using a K-wire or 3.5 mm lag screw into the sciatic buttress. At last, reduction of any anterior wall or superior pubic ramus fractures are carried out and then fixed provisionally. For the reconstruction of type A3, B3, and C fractures, first, the reduction of the separate peripheral fracture fragments to portions of the intact pelvis is required. Initiating from the periphery towards the articular surface, fragments are reduced subsequently and stabilized temporarily. This process needs a comprehensive and three-dimensional understanding of pelvic anatomy. Stabilization of the crest is performed by using reconstruction plates 3.5. or lag screws.
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