Case Report

Fracture acetabulum with central dislocation of hip

treated with ilioinguinal approach : A case report
Baljit Singh*, Raj Kumar Aggarwal**, Sunil Chohan*, Divyanshu Gupta***

*Assistant Professor, ** Professor, ***Junior Resident

Department of Orthopaedics
Sri Guru Ram Das Institute of Medical Sciences & Research, Amritsar

ABSTRACT
Acetabulum fracture is an enigma and is a challenge to treat especially in the third world countries. True
central fracture dislocation with femoral head completely dislocated medially in to the pelvis after fracturing
quadrilateral plate, is an unusual injury that requires urgent treatment. Such a case of central fracture
dislocation in 24 year old male was treated at our institute with open reduction through ilioinguinal
approach. Internal fixation using an unconventional method of using interfragmentry screws through
quadrilateral plate, and plating on the day of injury. Good reduction of fracture and stable fixation was
achieved.
Keywords: Central fracture dislocation, Ilioinguinal approach, Internal fixation.

INTRODUCTION examination patient was stable haemodynamically. Right lower

There is increase in the incidence of high velocity trauma
resulting in complicated acetabulum fractures due to
modernization1. The surgical treatment of acetabular fractures
is a complex area that is being continually refined1,2. Central
fracture dislocation is an emergency and needs urgent
treatment. It breaks the quadrilateral plate that is flat plate of
thin bone forming boundry of pelvic cavity and acetabuluar
wall1,2,3. Conventionally screw fixation through this plate is
not used due to danger of penetrating the acetabulum4,5.
Central fracture dislocation may be associated with the injury
to viscera and neurovascular components that needs more
emergent treatment3. Radiograph anteroposterior and judet view
and CT scan with three dimensional reconstructions is needed
for proper planning of surgery6. Neurovascular status of the
patient should be checked before the surgery. Even after surgery
there are chances of osteoarthrosis, osteonecrosis and
infection.
MATERIAL AND METHODS
This case a 24 year old male presented to our institution after
road traffic accident with severe pain in right hip. On preliminary
limb was found to be obviously shorter then left and adducted.
Radigraphs confirmed the suspected diagnosis of hip
dislocation (Fig 1). An urgent CT scan was done with
finding of central fracture dislocation and fracture of
quadrilateral plate along with anterior wall and posterior wall of
acetabulum ( Fig 2).
Patient was taken up for surgery after initial investigations
were found normal. Ilioinguinal approach was used to reduce
the femur and repair the fracture anatomically. Further all
intrapelvic soft tissue injuries were ruled out. Fixation was done
with two interfragmentry screws those were put through the
quadrilateral plate fragments to fix these fragments with iliac

Corresponding Author :
Dr. Baljit Singh,
39 Garden Enclave, GT Road, Bye Pass,
Amritsar-143001.
E-mail: baljitsbamrah@gmail.com Fig 1. X-ray showing the central fracture dislocation of right hip.

Pb Journal of Orthopaedics Vol-XIV, No.1, 2013 59

Singh et al
Fig 2. CT scan showing central fracture dislocation and fracture of
quadrilateral plate along with anterior wall and posterior wall of
acetabulum.
bone an unconventional approach. During this screw fixation
special attention was paid to prevent the penetration of screw
through the bone into acetabulum. A reconstruction plate bent
to buttress the quadrilateral plate was used to strengthen the
fixation further. Intraoperatively good reduction with anatomical
alignment and apposition of fragments was found. Post
operative radiograph confirmed the same according to Mattas
criteria (anatomic reduction <1mm; imperfect 13mm; poor
>3mm).Patient was kept non weight bearing post surgery,
though movement of hip joint and physiotherapy started next
day.
DISCUSSION
The quality of acetabular fracture reduction is the single most
important factor in long term outcome of patients. The goal of
acetabular fracture treatment is to have a hip with good long-
term function and the avoidance of posttraumatic osteoarthritis.
Letournel and Judet introduced the operative concepts of open
reduction and internal fixation for acetabular fractures3. The
extent of influence the initial fracture pattern has on clinical
outcome of acetabular fractures has been studied. Letournel
and Matta demonstrated that the fractures reduced to within
1mm of residual articular displacement have less incidence of
posttraumatic arthritis and have a more durable and long-lasting
functional hip joint than those fractures with 1 to 3 mm of
residual displacement3. Absolute reduction was needed in this
case of central fracture dislocation. This reduction of
quadrilateral plate may not be possible without interfragmenrty
screw fixation, which is difficult and an unconventional
approach due to thinness of bone at this particular segment of
acetabulum3,7. But if Utmost precaution is used during this
procedure so that screws do not penetrate in to acetabulum
Pb Journal of Orthopaedics Vol-XIV, No.1, 2013
this can produce excellent results. Various surgical exposure
options are Ilioinginal and Iliofemoral or Kocher langenbach7.
Selection of the surgical approach depends upon the type of
fracture and possibility of post surgery complications. Over
the years the use of ilioinguinal approach was emphasized
because of the good results it usually provided including non
development of heterotopic ossification and quick
rehabilitation8. Giannoudis et al stated that incidence of
heterotopic ossification is overall 25.6% and differs with surgical
approach with highest incidence of 23.6% for iliofemoral
approach and incidence of 1.6% for ilioinguinal approach. Chiu
et al reported incidence of 5.6% with ilioinguinal approach and
66.7% in cases operated by iliofemoral approach.In case of
central fracture dislocation ilioinguinal approach is better for
proper reduction of fracture and internal fixation with plate
butteresing the quadrilateral plate. It can also rule out any
visceral or neurovascular injury in the pelvis.8
CONCLUSION
Urgent reduction of femoral head in the acetabulum and
anatomical reduction of acetabular fracture with less then 1 mm
gap is needed for long term good results in case of central
fracture dislocation. Ilioinguinal approach is good surgical
approach for this combinig easy and good reduction and
decreased long term complications of heterotopic ossification
Interfragmentry screw through quadrilateral plate may be used
for best possible results of absolute anatomical reduction. But
every precaution should be taken to avoid peneterance of
acetabulum
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