Prior to any fixation, a check must be made, as in any acetabular fracture procedure, to ensure that every fracture line is accessible, that every fragment can be mobilized, and that the result of reduction can be checked. Definitive reduction and fixation are started at the iliac wing. If necessary, this work may start at the sacroiliac joint, which is reduced under direct vision, while fixation is performed percutaneously, with screw placement from the gluteal region. Where isolated screw fixation is possible, it constitutes a means of stabilization that is as accurate as plating, while often being more solid, and invariably more elegant, than plate fixation. In order for the reduction to be checked, visually, with instruments or with finger palpation, between the iliopsoas and the vessels, the high origins of the obturator internus on the quadrilateral surface must be subperiosteally elevated with meticulous care.
Reduction is facilitated by the division of the sacrospinous ligament.
Medially, the internal inguinal ring is anatomically restored at the correct distance from the external ring. We feel that whenever it is seen to constitute a sound alternative to an extensile approach, it should be used. Since it causes very little trauma, it may be employed in elderly patients with displaced anterior column fractures.