Significance of quadrilateral plate in surgical treatment of complex bi-columnar acetabular fractures: descriptive analysis through three cases.

Abstract

Complex acetabular fractures affecting both columns remain one of the hardest challenges to trauma orthopaedic surgeons with high morbidity and often poor outcomes. Treatment dilemmas arise especially in both column fractures where the fracture line dissociates acetabulum in different directions and sizes resulting in quadrilateral plate (Quad) fragments of various sizes. This plate serves as a vertical girder-wall structure for the acetabulum. Order of fixation along with selection of its associated surgical approach are the cornerstones of operative strategy in such injuries and are driven by various factors one of the most important being quadrilateral plate involvement. A traditional rule of thumb dictates to first fix the column that can be addressed easier and more directly. Then the second column can be addressed. As the quad is the connection girder between the two columns, the fragmental condition of this plate, is one of the most decisive factors influencing decision making. The fracture line which crosses the quad plate is crucial and if there is a multifragmentary component it dictates the chosen plate. We will try to illustrate, discuss and explore this topic exemplifying three difficult cases dealt with three approaches: Ilioinguinal (ILO), Stoppa-Anterior Intrapelvic (AIP)-ILO modification and Kocher-Langenbeck (K-L) either in isolation or combined. Pearls, pitfalls and lessons learned are offered in a vivid illustrative way.