Five of the ten fracture types involve both the anterior and posterior column but usually only either an anterior or posterior approach in isolation is used.
For example, this transverse fracture extends through both the anterior and posterior column.
The surgical approach is dictated by the height of the fracture (transtectal, juxtatectal, infratectal), the fracture obliquity, and the pattern of displacement.
For mainly posterior displaced fractures, the Kocher-Langenbeck will be sufficient exposure to reduce the fracture without a second direct anterior exposure. This is because the displacement is typically greater posteriorly and the retroacetabular surface offers excellent opportunities for both reduction tools and fixation strategies.
Furthermore, reduction of the anterior elements is accomplished by manipulation of the posterior aspect of the ischiopubic segment. This is distinct from the T-shape fracture in which the posterior aspect of the ischiopubic segment is separated from the anterior column by the vertical stem.
If the reduction of the anterior portion of the ischiopubic segment is inadequate through the Kocher-Langenbeck approach, a second approach may be required. The Kocher-Langenbeck approach is closed and the patient repositioned for a second, anterior approach (either ilioinguinal or modified Stoppa). Direct reduction and fixation of the anterior column of the ischiopubic segment is then performed.