Comminuted quadrilateral plate fracture fixation through the iliofemoral approach

Abstract

Comminuted quadrilateral plate fracture with medial displacement is a technically difficult fracture to treat. Minimal bone stock, proximity to the hip joint with limited surgical access, and difficulty in obtaining a stable fixation at this area, contribute to the surgical challenge of open reduction and internal fixation. Fixation of a medial buttress plate in an infrapectineal fashion is a well-described technique to address such fractures. However, this plate alone may be inadequate to buttress all the fragments in a grossly comminuted quadrilateral plate fracture. An additional spring plate is often placed underneath the infrapectineal plate to hold the fracture fragments. Conventionally, these spring plates are fixed to the ilium superiorly while the other end buttresses the quadrilateral plate when placed underneath the infrapectineal reconstruction plate. The standard ilioinguinal approach and modified Stoppa approach have been described for the surgical access to the quadrilateral plate. Both the approaches have some limitations in addressing quadrilateral plate fracture. The ilioinguinal approach requires extensive dissection and mobilisation of inguinal neurovascular bundle. The modified Stoppa approach does not permit visualisation of the entire anterior column and the hip joint. The authors, in this article, describe the fixation of the comminuted quadrilateral plate fracture through the iliofemoral approach combined with a medial ilioinguinal window. The technique involves fixation of a spring plate (Allis T-plate) at right angle to the infrapectineal buttress plate (90°-90° plate construct). The vertical limb of the T-plate is fixed to the iliopectineal eminence whereas the horizontal limb buttresses the quadrilateral plate Hence, this technique addresses fractures of both the iliopectineal eminence and the quadrilateral plate. Other than that, the iliofemoral approach permits direct visualisation of the entire anterior column and the hip joint without the necessity to dissect the ilioinguinal neurovascular structures.