6. Setup: The patient is supine on a radiolucent
table with skeletal traction holding the affected
extremity in slight flexion. A perineal post is used
to allow for traction if needed.
8. SYMPHYSIS
ASIS
ASIS
A
B
The incision is drawn out. Figure A shows the location of the incision with
respect to the symphysis and ASIS. Figure B shows the patient from the
side as one would observe during surgery. The incision is curvilinear
towards the posterior aspect of the ilium. The surgery begins by
approaching the iliac crest along the area shown in figure B.
9. SYMPHYSIS
ASIS
ASIS
Figure 6 Figure 7
The incision is drawn out. Figure A shows the location of the incision with
respect to the symphysis and ASIS. Figure B shows the patient from the
side as one would observe during surgery. The incision is curvilinear
towards the posterior aspect of the ilium. The surgery begins by
approaching the iliac crest along the area shown in figure B.
10. Sharp retractors are used to identify the interval
between the abductor and abdominal musculature.
11. The iliac crest is indicated by purple lines. The interval between the
abdominal and abductor musculature occurs towards the posterior
aspect of the iliac crest as the abdominal musculature hangs over
the crest (dotted line)
12. The interval is taken with a Bovie down to the iliac crest
and the abdominal musculature is reflected anteriorly.
14. ILIACUS
ILIUM
After the iliacus is released from the inside of the ilium a
large key elevator is used to elevate subperiosteally to
the SI joint.
15. After this dissection is complete, the posterior aspect of the
iliac fossa is packed off with a lap and attention to brought
to the anterior portion of the incision.
16. EXTERNAL OBLIQUE
FASCIA
Gelpi retractors are used to retract the skin and soft
tissue after the external oblique fascia is identified.
17. EXTERNAL
OBLIQUE
FASCIA
The external oblique fascia is divided in line with
the incision and the fascia is reflected distally.
18.
19. VAS DEFERENS, SPERMATIC
CORD, + ILIOINGUINAL NERVE
EXTERNAL
OBLIQUE
FASCIA
EXTERNAL
OBLIQUE
FASCIA
INGUINAL LIGAMENT
After this is performed, the vas deferens, spermatic cord, and ilioinguinal
nerve are identified and protected with a Penrose drain. Allis clamps are
used to retract the the external oblique fascia.
20. VAS DEFERENS SPERMATIC
CORD ILIOINGUINAL NERVE
EXTERNAL
OBLIQUE
FASCIA
EXTERNAL
OBLIQUE
FASCIA
INGUINAL LIGAMENT
It is helpful to include some subcutaneous tissue in the clamps to
protect the external oblique fascia from tearing. This exposes the
inguinal ligament, which is a reflection of the external oblique fascia.
21. An incision is made in the inguinal ligament, allowing
1 to 2mm of the ligament to reflect medially with the
musculature (dotted line).
25. ASIS
LATERAL FEMORAL
CUTANEOUS NERVE
As the dissection extends toward the ASIS, one needs
to identify the lateral femoral cutaneous nerve, which is
immediately under the inguinal ligament.
26. ASIS
LATERAL FEMORAL
CUTANEOUS NERVE
The nerve is typically located approximately 1cm medial
to the ASIS but is variable and may be more than one branch.
29. ASIS
ILIOPECTINEAL
FASCIA
PSOAS FEMORAL
NERVE
EXTERNAL
ILIAC
VESSELS
At this point, the identification of the iliopectineal fascia is performed,
allowing for retraction of the exteral iliac vessels and lymphatics medially.
30. ASIS
ILIOPECTINEAL
FASCIA
PSOAS FEMORAL
NERVE
EXTERNAL
ILIAC
VESSELS
The psoas muscle and femoral nerve are retractedlaterally. The army-navy
retractor protects the vasculature while the Allis clamp is holding
the iliopectineal fascia.
31.
32. TRUE PELVIS
ILIOPSOAS
MUSCLE
ILIOPECTINEAL
FASCIA
FEMORAL NERVE
Closeup of previous image.
33. PSOAS FEMORAL NERVE
Closeup of the iliopectineal fascia demonstrating the psoas and femoral
nerve on the lateral side of the fascia in the false pelvis. The true pelvis
is located medial to the iliopecineal fascia over the pelvic brim.
34. PSOAS FEMORAL NERVE
Once the iliopectineal fascia is excised, access to the true pelvis is
obtained. The medial window of the approach is utilized when buttress
plating to the symphyseal body or symphyseal fixation is necessary.
35. PSOAS FEMORAL NERVE
In this case, the reduction and fixation was
performed through only the lateral and middle
windows.
36.
37. ILIAC FRACTURE
LATERAL FEMORAL
CUTANEOUS NERVE
View from the opposite side of the table demonstrating
the lateral window and iliac wing fracture.
38.
39. PSOAS
LATERAL FEMORAL
CUTANEOUS NERVE
VESSELS
PELVIC BRIM
View of the middle window demonstrating the pelvic brim.
40. PSOAS
LATERAL FEMORAL
CUTANEOUS NERVE
VESSELS
PELVIC BRIM
View of the middle window demonstrating the pelvic brim.
43. SI JOINT
ILIOPSOAS
This figure demonstrates the lateral window and exposure of
the anterior column from the iliac crest and SI joint proximally
to the psoas gutter and pelvic brim distally.
44.
45. PELVIC
BRIM
PSOAS
VESSELS
This figure demonstrates the pelvic brim and displacement
of the fracture as seen through the middle window.
46. PELVIC
BRIM
PSOAS
VESSELS
This figure demonstrates the pelvic brim and displacement
of the fracture as seen through the middle window.
51. Postoperative obturator oblique and iliac oblique views
demonstrating anatomic reduction of the anterior column
fracture with lag-screw-only fixation.
