AP view of the pelvis demonstrating corridors for anterior column, posterior column, LC-2, and “magic” screws
Anterior Column Screw
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig2_HTML.jpg](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig2_HTML.jpg?w=960)
(a) Protrusion of the native hip joint narrows the anterior column corridor and prevents placement of an antegrade screw above the obturator ring into the parasymphyseal bone of the pubic ramus. (b) A narrow canal of the superior ramus with diameter less than 3.5 mm on coronal computed tomography imaging precludes use of an anterior column screw
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig3_HTML.jpg](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig3_HTML.jpg?w=960)
Obturator oblique view of the hip showing the constriction points of the anterior column screw pathway
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig4_HTML.jpg](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig4_HTML.jpg?w=960)
(a) Obturator oblique view permits 4.5 mm diameter or less screw. (b) Obturator oblique view permits a fully threaded 7.3 mm screw
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig5_HTML.jpg](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig5_HTML.jpg?w=960)
(a) Obturator outlet and (b) inlet views after antegrade anterior column screw placement
Posterior Column Screw
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig6_HTML.jpg](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig6_HTML.jpg?w=960)
3D surfaced rendered iliac oblique view demonstrating the area for starting point (highlighted in blue) of an antegrade posterior column screw
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig7_HTML.png](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig7_HTML.png?w=960)
(a) Clinical photograph of antegrade posterior column screw placement through the lateral window of the ilioinguinal approach. (b) Iliac oblique view showing an antegrade posterior column guidewire terminating just below the ischial spine near the lesser sciatic notch
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig8_HTML.png](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig8_HTML.png?w=960)
(a) An assistant flexes the hip and knee to permit supine placement of a retrograde posterior column screw. (b) Iliac oblique and (c) anteroposterior fluoroscopic views with a posterior column screw in place
The LC-2 Screw
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig9_HTML.png](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig9_HTML.png?w=960)
(a) Obturator outlet view demonstrating the “teardrop,” which represents the column of bone from the AIIS to PIIS. (b) Iliac oblique and (c) obturator inlet views after placement of an LC-2 screw from anterior to posterior
The “Magic” Screw
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig10_HTML.jpg](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig10_HTML.jpg?w=960)
(a) AP, (b) iliac oblique, and (c) obturator oblique views after “magic” screw placement (highlighted in yellow)
Reduction Techniques
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig11_HTML.jpg](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig11_HTML.jpg?w=960)
Photograph of (a) “rib tickler,” (b) collinear clamp, and modified offset (Reinert) clamp with (c) paddle or ball-spike (d) for quadrilateral surface
The sequencing of fixation should be similar to sequencing with traditional open approaches. For associated both column injuries, the dome is first reduced and fixed to the intact ilium. The remaining fracture fragments are then reduced and stabilized to the dome, as they would be in associated fracture patterns where the dome has not been separated from the intact ilium. With osteochondral impaction of the dome, which is common, reduction is performed after the cranial femoral head has been located under the intact lateral dome. Below specific reduction techniques and examples are discussed.
Ligamentataxis/Traction
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig12_HTML.jpg](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig12_HTML.jpg?w=960)
(a) Preoperative AP pelvis with centrally displaced left anterior column with posterior hemitransverse acetabular fracture. Intraoperative AP view with fluoroscopy (b) before and (c) after distal femoral skeletal traction
Schanz pins placed from the lateral aspect of the greater trochanter and into the femoral head via the femoral neck may also be placed. This may be especially helpful with a “central,” or medial, displacement or dislocation of the femoral head; however I find it is rarely needed to lateralize the femoral head. Biplanar fluoroscopy should be used for placement of this pin to ensure it is contained within the femoral neck and head and there are attachments available for standard radiolucent tables to maintain this position.
Traction tables may also be used with a perineal post; however complications from prolonged pressure can develop including pudendal nerve injury, soft tissue necrosis, and well-leg compartment syndrome [30]. I do not recommend the use of traction against with a perineal post and personally use a flat radiolucent table for percutaneous reduction and fixation of acetabular fractures.
Lag by Design/Lag by Technique
Lag screws, either be technique or design, can be used in any of the corridors to aid with reduction of fractures, but the corridors and obliquity of the fracture lines must be perpendicular if the surgeon desires excellent reduction. Lag screws may be and usually are combined with any of the reduction techniques described below to create better perpendicular trajectories for compression.
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig13_HTML.png](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig13_HTML.png?w=960)
(a) A 4.5 mm blunt cortical screw approaches the cranial limit of the superior ramus prior to (b) deflecting and remaining in the osseous corridor of the anterior column. Note also the use of external fixation and a joker elevator for reduction
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig14_HTML.jpg](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig14_HTML.jpg?w=960)
(a) Postoperative obturator oblique view after limited open reduction and antegrade anterior and posterior column screw fixation where washers were used. The cortices of the inner and outer table are highlighted in yellow demonstrating that the washers do not seat flush with the bone. (b) Fluoroscopic iliac oblique after placement of an anterior to posterior LC-2 screw with a washer
Lag screws, as an isolated reduction method, are rarely used unless a fracture component is minimally displaced. They are most commonly the final step in the reduction sequence, and osteopenia further limits their power to affect a reduction losing purchase. LC-2 screws can be used to compress fractures lines of the anterior column extending cranially into the iliac wing and the trajectory may be aimed cranial to or toward the greater sciatic notch [31] based upon the obliquity of the fracture line.
Anterior column screws best compress fracture lines through the more anterior caudal portions of the anterior column that exit anteriorly at or just lateral to the iliopectineal eminence. These are frequently seen in fracture patterns with transverse components. Posterior column screws are generally used for posterior portions of transverse components or isolated posterior column injuries, which are infrequent in younger [4] and older populations [12–14]. The location of the posterior column fracture line should dictate the starting point of the screw; fracture lines exiting at the level of the ischial spine are better treated with a retrograde starting point as ending the screw in the caudal ischium is difficult from an antegrade starting point as previously discussed. The “magic” screw is rarely used as a lag screw in elderly patients as comminution and impaction prevent compression.
When the anterior and posterior columnar segments have not been separated and are both displaced, reduction of the one column may gap the other. In these cases, alternating compression across both columns with two screws is recommended. In a T-type fracture, the anterior and posterior columns are separated, and each column is independently compressed.
Manipulative Reduction Aids
Various tools allow the surgeon to directly manipulate fragments through percutaneous incisions or limited portions of the lateral window. Great care must be taken with any instrument placed onto or into bone when direct visualization of surrounding soft tissues is not achieved.
![../images/395168_1_En_7_Chapter/395168_1_En_7_Fig15_HTML.png](https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2020/04/395168_1_En_7_Fig15_HTML.png?w=960)
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