Minimally invasive treatment of pelvic and acetabular fractures offers significant advantages, such as reduced incision, reduced intraoperative bleeding, and reduced incision-related complications with percutaneous screw fixation. To achieve complete fracture repositioning and safe and accurate screw placement, the surgeon must have a good understanding of the different fluoroscopic views. However, the anatomy of the pelvis is very complex and interpreting fluoroscopic images and screw placement can be challenging. The current application of 3-dimensional computer navigation has reduced the difficulty of the procedure, but 2-dimensional fluoroscopic images are still the basic aid for screw placement by orthopedic surgeons. To address this situation, Yi Chengla and other scholars from Tongji Hospital of Huazhong University of Science and Technology conducted a literature search to systematically describe the screw placement techniques commonly used in pelvic and acetabular fractures; and to explain in detail the screw placement in the iliac, pubic, sciatic, and sacroiliac joints. Pre-operative imaging evaluation The pelvic fracture is generally evaluated using orthogonal, exit and entrance plain films. The orthopantomogram is used to provide an overall picture of the fracture; the entrance view is used to assess anterior-posterior displacement of the pelvic ring, inward rotation of the ilium, and compression injury of the sacrum; and the exit view is used to visualize vertical or rotational displacement of the pelvic side, the sacrum, and the sacral foramen. Ricci et al. used sagittal CT scan reconstruction images to find the best orientation for fluoroscopy. They found that the best position for viewing the anterior aspect of sacrum 1 was a caudal tilt of 21°. In the exit position to make the ray perpendicular to the sacral 1 vertebral body, a tilt of 63° towards the cephalad end is required; while perpendicular to sacral 2, a tilt of 57° towards the cephalad end is required. When the angle of sacral tilt cannot be evaluated without CT scan reconstruction, they suggest that the entrance slice be tilted 25° toward the cephalad end and the exit slice 60° toward the caudal end, thus allowing the evaluation of the bony structures in the posterior part of the pelvis. Orthopantomogram and 2 Judet slices are generally used to evaluate acetabular fractures. Closed exit and entrance views are useful for a more detailed assessment of the fracture. Axial coronal and sagittal CT scans help to further understand fractures of the posterior pelvic ring as well as fractures of the acetabulum. In addition, 3-dimensional CT scan reconstructions are useful in evaluating complex pelvic and acetabular fractures. Preoperative positioning and fluoroscopy Preoperatively, it is important to ensure that intraoperative fluoroscopy can identify key imaging landmarks for safe screw placement. The fracture bed should be adjusted preoperatively to meet the needs of intraoperative fluoroscopy. If oral contrast imaging of the gastrointestinal tract or excessive intestinal gas accumulation interferes with fluoroscopy, the procedure should be delayed. Nitrous oxide anesthesia should be avoided because it can aggravate intestinal pneumatization. A 12-inch image multiplier tube is used to obtain the largest fluoroscopic area. In most cases, both sides of the pelvis can be viewed simultaneously, which helps to assess fracture reduction and symmetry on both sides of the pelvis. Placing the image intensifier closer to the patient also increases the fluoroscopic area. Fluoroscopy is particularly difficult in overly obese patients, and preoperative consideration should be given to the weight limits of the surgical bed and the fluoroscopic hole spacing (31 inches for most C-arms). In some cases, the abdominal fat layer can be moved to improve fluoroscopy, but care needs to be taken for skin shear injuries. Surgery on patients with pelvic and acetabular fractures requires a fluoroscopic surgical bed. The ideal surgical bed should be able to perform all types of axial traction without compromising fluoroscopy. The fluoroscopic monitor should be easily visible to the operator, usually on the opposite side of the surgical bed. Depending on the site of the fracture and the surgical plan, the patient may be positioned in the supine, prone, or lateral position. Depending on the anatomic morphology of the patient’s pelvis, the standard fluoroscopy needs to be adjusted accordingly. After tilting the orthopantomogram at a certain angle, exit and import views are obtained. After rotation of the C-arm, iliac oblique and closed-hole oblique views are obtained. Rotation and tilting of the bulb can be used to obtain some auxiliary views, such as the joint exit view, which can be used to determine the access to the screw bone for supraacetabular external fixation. Needle fixation of the iliac wing There are several ways to fixate the upper iliac wing. The iliac wing pin fixation is usually oriented from top to bottom and can be used for pelvic fracture fixation. Although it is simple to perform, inaccurate pin placement can affect the stability of the fixation. The use of fluoroscopy has been suggested to increase the accuracy of pin placement; further dissection has been advocated to determine the alignment of the iliac wing. The alignment of the iliac wing can also be determined by placing a Kirschner pin in the inner plate of the iliac wing.