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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 75-81

Management of quadrilateral plate fractures: An up to date


Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Date of Submission15-Apr-2021
Date of Acceptance30-May-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. Shilp Verma
Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_26_21

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  Abstract 


Acetabular fractures are result of mostly high velocity injury with an incidence of 3/100,000/year. However in elderly patent low energy trauma also result in acetabulum fracture due to osteoporosis. Most of acetabular fracture commonly combined with quadrilateral plate fractures. Till date there is no standard classification system for quadrilateral plate fracture of acetabulum is published which can be utilized for accurately studying the fracture pattern and planning for the surgical approach with management. Initially acetabulum fracture was managed conservatively with traction for at least 6 weeks which results in aggravation of secondary symptoms such as pressure sore, DVT, post traumatic arthritis, loss of muscle strength and endurance. Aim of acetabulum fracture fixation are to allow early mobilization, restoring joint congruity, pain relive and reducing the risk of post traumatic arthritis. An internet search of MEDLINE and PMC using the search term 'acetabular fracture', 'quadrilateral plate fracture' and central hip dislocation in English language was performed on 1st march 2021. Papers specific with quadrilateral plate fracture were only included in the study and we found variety of technique available for displaced quadrilateral plate fractures, such as cerclage wire-plate composite, pelvic brim long screws, various combinations of spring plates (T-shaped plate, L-shaped plate, infrapectineal plate, H-plate, and multidirectional titanium fixator. In this review article we studied different treatment modalities and techniques used over several decades for management of quadrilateral fracture with their outcome.

Keywords: Acetabular fracture, central hip dislocation, conservative management, pelvic wall fracture, quadrilateral plate fracture, surgical management


How to cite this article:
Verma S, Agrawal AC, Choudhary R, Venishetty N. Management of quadrilateral plate fractures: An up to date. J Orthop Traumatol Rehabil 2021;13:75-81

How to cite this URL:
Verma S, Agrawal AC, Choudhary R, Venishetty N. Management of quadrilateral plate fractures: An up to date. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Jan 22];13:75-81. Available from: https://www.jotr.in/text.asp?2021/13/2/75/333558




  Introduction Top


Quadrilateral fractures are rare fractures with an incidence of 3/100,000/year.[1] Most of the quadrilateral fractures are a result of high-velocity trauma associated with neighboring organ injuries. However, in elderly patients, low energy trauma also results in quadrilateral fracture with acetabulum fracture due to osteoporosis. The thin medial wall of the acetabulum is referred to as a quadrilateral plate. In fracture, central dislocation of hip medial migration of quadrilateral plate is mostly observed.[2],[3]

There is no specific classification system for quadrilateral plate acetabulum fractures, which can be used to study the fracture pattern reliably and to prepare the surgical strategy. Earlier, acetabulum fractures were usually managed conservatively with traction. Judet and Letournel were first to evaluate the fracture pattern and its outcome [Figure 1] and further more studies resulted as operative treatment as standard for quadrilateral fractures.[4],[5]
Figure 1: Judet and letournel classification of acetabular fracture

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Currently, acetabulum fracture fixation aims at early mobilization, restoring joint congruity, pain relief, and reducing posttraumatic arthritis risk. Fixing fractures depend on several factors such as fracture displacement, fracture pattern, articular surface implication, the physical condition of the patient, such as age, built-up, and prevalence of life-threatening comorbidity, and surgical skill of a surgeon.[6],[7],[8] Various kinds of implants are currently available for quadrilateral plate fracture fixation, such as cerclage wire-plate composite, and multiple design of plates (T-shaped plate, L-shaped plate, infra-pectineal plate, H-plate, and multidirectional titanium fixator.[9],[10],[11],[12],[13]

Quadrilateral plate fractures are the complex group of acetabulum fractures such as posterior column fracture, anterior column fracture with posterior hemitransverse, bi-column fracture, or T-shaped fracture with or without protrusion typically involve quadrilateral plate fracture. ElNahal et al. conducted an analysis that shows that the quadrilateral surface fracture alone can be dynamic in different degrees.[14],[15] By reducing and stabilizing column fractures, quadrilateral platform fractures may be indirectly reduced. However, an anatomical reduction is difficult to achieve, especially in the presence of osteoporosis, comminuted, or floating media wall fractures.[4],[9],[16] Failure to achieve congruent joint leads to unstable medial wall support and central dislocation of the hip, resulting in a poor outcome.

This review article studied different treatment modalities and techniques used over several decades to manage quadrilateral fracture with their outcome.


  Methods Top


The MEDLINE, Cochrane, and Embassy web search has been conducted on June 1, 2020 using the terms “acetabular fracture,” “square plate fracture,” and central hip dislocation. All articles specific to quadrilateral plate fracture and in English were only included in the study. Patient details such as age, accident mechanism, treatment method, follow-up time, and complications have been reported and presented [Table 1].
Table 1: Quadrilateral plate fracture management and their outcome

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  Results Top


Conservative management of displaced quadrilateral plate fracture results in poor outcome. With Various new operative techniques such as the cerclage wire plate composite, pelvic brim long screws, and combinations of spring plate play an essential role in managing quadrilateral plate fracture with good outcome in terms of union and early functional rehabilitation.

Conservative treatment

The quadrilateral fracture can be treated nonoperatively with stiff-bed, skeleton-longitudinal or trochanteric skeletal traction with longitudinal skin traction. Even if the medial wall was not reduced, few authors recorded the excellent outcomes of conservative treatment.[25],[26],[27] Those studies with nonsurgical treatment have also had brief follow-up only. The reduction of the femoral head under an intact weight-bearing dome can only result in a satisfactory outcome.[26] Posttreatment by conservative method results in the high incidence of chronic pain and early osteoarthritis.[7],[28]

Operative treatment

Reported techniques included traditional lag screws alone, percutaneous screws, plates and screws, acetabular fracture reduction internal fixator (AFRIF), cerclage wires, and calcaneum buttress plate literature till now. We have reviewed a total of 199 cases published in 11 articles till 2020.

Pins and screws

Conventionally, acetabulum and quadrilateral plate fracture fixation has been performed by open reduction and internal fixation under direct visualization, which necessitates broad surgical exposures. In a few occasions, open reductions and internal fixation have been developed in injury to the femoral and sciatic nerves.[29] As a result, deciding whether or not to operate on a case is always challenging. In some situations, percutaneous screw fixation under fluoroscopic direction can be used instead of ORIF. Percutaneous screw fixation has proven an effective and safe treatment in certain selected cases with low anticipated complications.[30]

Three-dimensional (3D) fluoroscopy navigation is very effective technique for quadrilateral plate fracture fixation. Ruan et al. observed good outcome in five patients who were managed with percutaneous screw fixation under 3D fluoroscopy. They succeed to pass percutaneous screw perpendicular to fracture pattern and adjacent to joint surface.[17]

Karim et al. examined the long-term outcomes of forty acetabulum fractures with quadrilateral plate fractures fixed with one or more buttress screws through the reconstruction plate[21] [Figure 2]. They noticed that in 13 cases, the modified Merle D'Aubigné and Postel score was excellent, in 23 cases good outcome was observed, fair in 3, and poor in 1. Further follow-up shows no failure of fixation in any patient. The use of buttress screws to stabilize the quadrilateral plate fracture component in associated acetabular fractures is a safe and efficient method of fixation.
Figure 2: (a) Three screws will avoid fragment tilt or rotation, with one screw at the posterior edge and one screw at the anterior edge. (b) An intra-operative view showing the buttress screw inserted through the plate, on the outer surface of the quadrilateral surface (Karim et al.[21])

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Plates

Fixation of comminuted quadrilateral plate fracture associated with medial displacement is challenging for the surgeon. Limited access, minimal bone stock, and proximity to hip joint contribute to the surgical challenge. Standard ilioinguinal approach with recon plate over pelvic brim and screws placement over posterior column provides adequate stability in most of quadrilateral fractures associated with acetabulum fracture.

Research conducted in 2015 by Robin E Peter on 13 patients with quadrilateral plate fractures who underwent fixation with 3.5 mm reconstruction plate was treated for 31 months, and 85% of patients reported positive results.[20] Just two patients experienced posttraumatic osteoarthritis at an early stage. He demonstrated the advantages of using a reconstruction plate. He demonstrated the benefits of using a reconstruction plate.

Fixation of comminuted quadrilateral plate fracture associated with medial displacement is challenging for the surgeon. Limited access, minimal bone stock, and proximity to hip joint contribute to the surgical challenge. The classic fixation technique, through the ilioinguinal approach, involving a reconstruction plate placed on the pelvic brim with screws extending distally into the posterior column, provides adequate stability when used in the nonosteoporotic bone.

In osteoporotic tissue, these screws have less stability and do not effectively inhibit medial plate displacement, a common issue in geriatric acetabular fractures. In osteoporotic tissue, the buttress plate construct provides effective medial protection. The buttress plate was first suggested by Mast.[31]

A study done by Peter in 2015 on 13 patients of quadrilateral plate fracture who underwent fixation with 3.5 mm reconstruction plate was followed for 31 months, and 85% of patients showed good result.[20] Only two patients developed an early onset of posttraumatic osteoarthritis. He explained the benefit of using the reconstruction plate by using a reconstruction plate [Figure 3].
Figure 3: Screws inserted from the pelvic brim towards the ischium are useful for fixation of posterior column fractures. These screws provide less stability in osteoporotic bone and do not efficiently prevent medial displacement of the quadrilateral plate, a common problem in geriatric acetabular fractures. The buttress plate construct is a good solution in osteoporotic bone as it provides efficient medial support (Peter[20])

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Similarly, Sen et al. used recon construction plate in 36 patients with quadrilateral plate fracture and followed them for 38 months, shows 30 patients (83.3%) had an anatomic articular reduction and six patients (16.7%) had a good reduction, and two patient showed poor outcome who underwent total hip arthroplasty.[18]

Cerclage wiring and cables

Stable quadrilateral fracture fixation can achieve with stainless steel cerclage wire and cables. Encirclage wire can be combine with various conjunction plates or can be used alone with arthroplasty for stable fracture fixation.[32],[33],[34]

Farid had used a spring plate-cerclage wire construct for quadrilateral plate fixation.[9] This system plate provided buttress to the medial wall, and holes in the plate were used as a pulley to deviate the wire to provide a satisfactory pull against the quadrilateral plate. He found good outcome in five patients who underwent quadrilateral fracture fixation through sub-inguinal approach.

Acetabular fracture reduction internal fixator

Zha et al. used a newly designed, AFRIF, which was the first of its type and used in 24 patients of quadrilateral plate fractures ages ranging from 31 to 82 years.[22] They followed them for 45.7 ± 13.0 months and found that clinical outcomes were excellent in 15 patients (15/24, 62.5%), good in 6 (6/24, 25.0%), fair in 2 (2/24, 8.3%), and poor in 1 (1/24. 4.2%) and 4 patients developed osteoarthritis [Figure 4].
Figure 4: Acetabular fracture reduction internal fixator

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Calcaneum plate

Boni et al. in 2019 used stainless steel locking calcaneal plate for two patients of quadrilateral plate fracture to obtain anatomical reduction with buttress effect of the quadrilateral plate, at a lower cost [Figure 5].[23]
Figure 5: Calcaneum plate for quadrilateral plate fixation

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Arthroplasty

Total hip arthroplasty may be performed primarily in the acute setting where fracture reduction cannot be achieved or in delayed cases of posttraumatic hip osteoarthritis. Osteoporosis and the “Gull sign” indicate poor outcome in quadrilateral plate fracture and are indicators for total hip arthroplasty.


  Discussion Top


Quadrilateral plate fracture fixation with or without medial wall displacement is often challenging, especially in the presence of osteoporosis. For that reason, we performed the present brief review for the management of quadrilateral plate fracture. Since the quadrilateral plate is not treated separately in the widely agreed Letournel classification, it is impossible to combine published outcomes from various case series and provide a reliable connection between outcome and management methods. Furthermore, there is no comparative analysis between different reduction fixation techniques of quadrilateral plate fracture because of the paucity of studies and case reports.

Due to the lack of literature, only an indirect comparison of conservative and surgical management is possible. Initially, acetabulum and quadrilateral plate fractures were managed conservatively with traction (ligamentotaxis). Acetabulum, femoral head, and medial wall fragment are not effectively reduced and have other elements of translation resulting in medial wall malunion and leads to osteoarthritis changes in the long-term follow-up.[35],[36] In 1980, Judet and Letournel published a paper stating that the unsatisfactory results of the conservative management which failed to reduce the dislocation and acetabular fracture fragments.[4],[5] Conservative management with traction needs Prolong immobilization, and bed rest for six to 8 weeks can lead to bed sore and aggravation of medical complication.[35],[37]

The treatment of choice for displaced quadrilateral plate fractures is open reduction and internal fixation. Anatomical congruity and joint surface restoration are essential in its prognosis.[16],[38],[39],[40] Fracture displacement, medial wall comminution, osseous lesions of the femoral head, delay in surgical operation, comorbid medical disorder, obesity, and age >40 years are other causes associated with the poor result.[6],[16],[41],[42]

The surgical method for quadrilateral plate fracture fixation is determined by the fracture pattern and surgical preferences. Based on the fracture pattern detail guideline given by Judet and Letournel, the surgical approach is still followed.[4],[6] The ilioinguinal approach is the most widely used intrapelvic approach, followed by the Stoppa approach and the pararectus surgical approach.

Pelvic brim plate was first used by Judet and Letournel. In this plate, screws were inserted along the quadrilateral plate and found to be biomechanically stable construction for preventing medial wall displacement and femoral head protrusion.[10] It is technically challenging to maintain a medial wall fracture aligned using a pelvic brim screw into the posterior column. In osteoporotic bone, there is always associated risk of loss of reduction and intraarticular screw penetration.[10]

Medial wall buttress can be achieve by various precontoured plate and recon plate contoured over the pelvic brim [Figure 6].[10],[16] failure of these plates causes loss of reduction of medial wall resulting in nonunion and osteoarthritis of hip.
Figure 6: A reconstruction plate in one of several different configurations (a and b), a T-shaped plate (c) or a p-shaped plate (d) was used to fix quadrilateral plate fractures. (e) indicates the potential locations for safe screw insertion in the “safe zones” (green areas), which are located outside the projection of the acetabulum on the quadrilateral surface (red area). IL = iliopectineal line, (He et al.[43])

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Modified Stoppa approach is used for infra-pectineal plating of quadrilateral plate fracture with the femoral head's medial displacement [Figure 7].[2],[11] After fracture alignment, buttressing effect should be achieve through plate and screw placement should be along the infrapectineal line taking care of sciatic notch and anterior to superior pubic ramus.
Figure 7: Image of applied spring plate (3.5 mm 8 hole reconstruction plate) contoured over the pelvic brim buttressing the medial wall on a saw bone. Anchorage is provided to the iliac fossa with cortical screws

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The cerclage wiring using standard SS wires [Figure 8] or cables is another alternative for achieving good reduction of quadrilateral plate fracture.[33] It minimally invasive and extraosseous fixation method for indirect reduction of the quadrilateral plate and has the advantage of screw cut out in osteoporotic bone and joint penetration than other technique. In severely comminuted quadrilateral plate fracture, extrastability is provided with the help of plates and screw.[10],[32],[33]
Figure 8: The composite pushes the wire where effective quadrilateral plate buttressing is required, converting its linear supra-acetabular path into a V-shaped line of pull. Lateral traction using a corkscrew below the greater trochanter facilitates reduction (arrow). The wire prevents plate recoil, like checkreins, and improves posterior column fracture fixation against slippage (Farid et al.[9])

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  Conclusion Top


Conservative treatment of displaced quadrilateral plate fracture is associated considerable poor outcomes were observed. Various operative techniques such as the cerclage wire-plate composite, pelvic brim long screws, and combinations of spring plate play an essential role in managing quadrilateral plate fracture with good outcome. Primary total hip arthroplasty is reserve for osteoporotic severely comminuted fracture.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





[43]



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
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