ABSTRACT
This pattern is relatively rare. Often a posterior wall fracture will be found to have a
minimally displaced or occult column fracture (or transverse fracture). These fractures
behave and are better classified as posterior wall fractures, as recommended by Letournel,
since the essential lesion is the posterior wall. True posterior column fractures have
definite displacement. Nonetheless, the treatment paradigm is similar and will utilize a
posterior approach. The options of positioning and traction for the posterior approach
have been described in the preceding chapter. The preferred method of one author (B.Z.)
is with a lateral position and the use of skeletal traction, both longitudinal and lateral,
as previously described in the section on “Simple Fracture Patterns” (Chapter 11, Fig. 2).
The other authors (D.S., R.H.) also prefer a lateral position, but uses a five-to six-inch
stack of folded towels tucked deep into the groin between the legs. Gentle downward
pressure at the flexed knee reduces the weight of the femoral head on the acetabulum.
The stack of towels, combined with longitudinal and lateral traction via the trochanteric
Schantz pin, results in very good joint exposure for posterior fractures (Chapter 11, Fig. 3).
Reduction techniques for an associated posterior wall and column fracture will be
similar to a simple posterior column and a simple posterior wall fracture. For this
associated pattern, it is most logical to begin with column fixation first, followed by the
posterior wall. This sequence (column first then wall) permits restoration of a “foun-
dation” upon which to restore the posterior wall. With the column reduced and the wall
not reduced, an opportunity exists to widely inspect the reduced column through the
joint surface. The position of the column can be modified if need be, and then one can
proceed with the posterior wall. Keep in mind that operative management of displaced
posterior column fractures have a higher risk of injury to the sciatic nerve, especially in
patterns involving the sciatic notch (Fig. 1). In all cases, a good documentation of any
Figure 1 Intraoperative view of impingement of sciatic nerve by posterior fragment. The posterior column fracture is close to the sciatic notch and may damage the sciatic nerve, especially
with an associated posterior wall fracture.
