Surgical Discussion

Patient positioning:  The patient was positioned supine on a radiolucent table, with a bump under the ipsilateral flank to facilitate exposure of the hemipelvis. The ipsilateral lower limb was draped free to allow manipulation during reduction.

Anatomical surgical approach:  A standard ilioinguinal approach was performed, utilizing the lateral and middle intervals. The incision was made parallel to the inguinal ligament, extending from the anterior superior iliac spine (ASIS) towards the pubic tubercle. Subcutaneous tissues were dissected to expose the external oblique aponeurosis, which was incised in line with its fibers. The lateral window was developed by retracting the iliacus muscle from the internal iliac fossa, while the middle window was created by mobilizing the external iliac vessels medially. Careful subperiosteal dissection exposed the pelvic brim, quadrilateral plate, and both columns. The lap belt injury zone was debrided of necrotic tissue, and traumatic defects in the inguinal region were repaired.

Due to significant obesity and depth of exposure, visualization of fracture surfaces required meticulous retraction and soft tissue management. Reduction was achieved using a combination of colinear clamps (applied via an iliac manipulative pin) and medium tenaculum clamps (secured through a medial bone hole). These clamps maintained reduction without obstructing subsequent implant placement. The sequence of fixation was: first, lag screws were placed across the iliac crest fracture components; second, a neutralization plate was applied along the pelvic brim with additional lag screws securing the anterior column; third, a percutaneous cannulated lag screw was inserted across the superior pubic ramus. A brim medullary screw was deliberately avoided to prevent obstruction of optimal implant placement. The plate functioned primarily as a linear washer for the lag screws rather than as a load-bearing device.

Postoperative protocol:   Postoperatively, the patient was maintained non-weight bearing on the affected limb for six weeks, with immediate initiation of passive range-of-motion exercises for hip and knee. Progressive weight bearing was introduced at eight weeks postoperatively, contingent on radiographic evidence of healing.

Follow up:   Not specified

Orthopaedic implants used:   3.5mm pelvic reconstruction plate; multiple 3.5mm cortical lag screws; 6.5mm cannulated lag screw