• Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns
• Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique
Transverse + Post. Wall
• Common in elderly patients
• anterior wall and anterior column • both column fracture• posterior hemitransverse
• femoral nerve injury• LFCN injury• thrombosis of femoral vessels• laceration of corona mortis in 10-15%.
• posterior wall and posterior column fx • most transverse and T-shaped• combination of above
• increased HO risk compared with anterior approach• sciatic nerve injury (2-10%) • damage to blood supply of femoral head (medial femoral circumflex)
• sciatic nerve injury (2-10%) • damage to blood supply of femoral head (medial femoral circumflex)
• only single approach that allows direct visualization of both columns• associated fracture pattern 21 days after injury• some transverse fxs and T types • some both column fxs (if posterior comminution is present)
• massive heterotopic ossification • posterior gluteal muscle necrosis
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An 18-year-old male sustains a right hip injury after being tackled on the football field. Figure A shows his radiograph upon presentation to the emergency room three hours later. On physical exam, he is noted to have a foot drop and decreased sensation globally throughout his entire lower leg. Closed reduction under conscious sedation is immediately performed, and the hip is able to be ranged through a stable arc of motion following reduction. A post-reduction radiograph is shown in Figure B. Shortly after the reduction, the patient continues to have a foot drop, but his sensation is slightly improved. Which of the following is the most appropriate next step in management?
Exploration of his sciatic nerve
CT scan of his right hip
Touch-down weight bearing of his right leg and observation of his sciatic nerve palsy
Skeletal traction on the distal femur to relax tension on the sciatic nerve
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The posterior wall of the acetabulum is best visualized on which of the following radiographic views?
Obturator oblique pelvis
Iliac oblique pelvis
A 35-year-old male suffers an anterior column acetabular fracture during a motor vehicle collision, and subsequently undergoes percutaneous acetabular fixation. Intraoperatively, fluoroscopy is positioned to obtain an obturator oblique-inlet view while placing a supraacetabular screw. Which of the following screw relationships is best evaluated with this view?
Intraarticular penetration of the screw
Position of the screw cephalad to the sciatic notch
Screw starting point at the anterior inferior iliac spine
Screw starting point at the gluteal pillar
Screw position between the inner and outer tables of the ilium
A 14-year-old presents on the request of her pediatrician for evaluation of her left hip. The patient reports having a recent history of lower abdominal pain, and as part of the work-up a KUB radiograph was obtained. The abdominal work-up was negative, and her pain has since resolved, however, the pediatrician noted an abnormal radiographic finding in the left hip and requested a formal orthopedic evaluation. The patient denies any history of hip trauma or pain. A left hip radiograph is shown in Figure A, and the the abnormality in question is indicated by the white arrow. The radiographic finding is most consistent with which of the following?
Os acetabuli marginalis superior
A 32-year-old male sustains a posterior wall acetabulum fracture as the result of a high-speed motor vehicle collision. Improved patient-reported outcomes after surgical treatment are associated with which of the following variables?
Increased hip flexion-extension arc
Increased hip muscle strength
Decreased stride length
A 74-year-old man falls, sustaining the injury shown in Figures A through C. In surgical planning, what is the best surgical approach to treat this injury?
A 34-year-old male presents with the right posterior wall acetabular fracture shown in Figure A. What is the most accurate method to test for hip stability in this patient?
The Keith method
The Moed method
The Calkins method
Dynamic fluoroscopic examination of the hip under anesthesia
A history of associated hip dislocation
A 35-year-old male undergoes closed reduction under sedation in the emergency department for a posterior hip dislocation with an associated posterior wall fracture. The post-reduction CT is seen in Figure A. What is the appropriate next step in management of this injury?
Nonoperative management based on the size of the posterior wall fragment
Operative management based on the size of the posterior wall fragment
Operative management based on the history of hip dislocation
Dynamic fluoroscopic stress exam under anesthesia in the obturator oblique view
Dynamic fluoroscopic stress exam under anesthesia in the iliac oblique view
When placing a percutaneous retrograde pubic ramus screw for fixation of an acetabular fracture, which of the following radiographic views can best ensure that the screw does not exit the posterior aspect of the superior pubic ramus?
Outlet obturator oblique view
Inlet iliac oblique view
Iliac oblique view
Obturator oblique view
A 78-year-old male undergoes the procedure shown in Figure A for treatment of a femoral neck fracture. As the patient passes through mid-rise during sitting to standing using the affected leg, what portion of the acetabulum experiences the highest contact pressures?
A 35-year-old male sustains a posterior column/posterior wall acetabular fracture. Which of the following is the preferred approach for open treatment of this injury?
Modified Stoppa approach
Extended iliofemoral approach
Combined anterior and posterior approach
A 37-year-old male sustains the injury shown in Figure A following a motorcycle crash. During the approach, what limb position minimizes tension placed on the sciatic nerve?
Hip at 45 degrees, knee flexed to 90 degrees
Hip at 60 degrees, knee flexed to 90 degrees
Hip at 90 degrees, knee extended
Hip at 0 degrees, knee flexed to 90 degrees
Hip at 90 degrees, knee flexed to 90 degrees
A computed tomography (CT) scan has been shown to be indicated for evaluation of all of the following aspects of acetabular fractures, EXCEPT:
Determination of surgical planning
Intra-articular loose bodies
Fracture piece size and position
Determination of pre-existing degenerative changes
A 22-year-old female is involved in a motor vehicle collision and sustains the injury shown in Figures A through D. According to these images, what is the acetabular fracture classification?
Anterior column posterior hemitransverse
Transverse with posterior wall
A 33-year-old male sustains the injury seen in Figure A as a result of a high-speed motor vehicle collision. Based on this image, what is the most likely acetabular fracture pattern?
An acetabular fracture with all segments of the articular surface detached from the intact posterior ilium is defined as what fracture pattern?
Posterior column with posterior wall
Anterior column with anterior wall
A 25-year-old male is involved in a motor vehicle accident and presents with the injury shown in Figure A. Early fixation of this fracture pattern is associated with all of the following EXCEPT?
Decreased length of hospital stay
Improved functional outcome
Greater organ dysfunction
Higher likelihood of being discharged to home as opposed to a rehab facility
Improved fracture reduction
The pelvic spur sign on plain radiography is indicative of the following injuries?
Transtectal transverse acetabular fracture
Vertical shear pelvic ring injury
Displaced H-type sacral fracture
Both column acetabular fracture
Anterior-posterior type III pelvic ring injury
During the ilioinguinal approach to the pelvis, the corona mortis artery must be identified and ligated if present. The corona mortis artery joins the external illiac artery with which other major artery?
Deep illiac circumflex
A 42-year-old female sustains the injury seen in the computed tomography images seen in Figures A and B. According to the Letournel classification, what is the injury pattern shown?
Which statement is true with respect to acetabular fracture surgery as the time between injury and surgery increases?
decreased chance of anatomic fracture reduction
decreased risk of heterotopic ossification
decreased rate of neurologic injury
decreased rate of infection
decreased rate of multi-organ failure
Which of the following associated type acetabular fracture patterns is defined based on the fact that all articular segments are detached from the intact portion of the ilium, which remains attached to the sacrum through the sacroiliac joint?
Posterior wall/ posterior column
Anterior column/ posterior hemitransverse
All of the following have been shown to negatively affect clinical outcomes in treating displaced acetabular fractures, EXCEPT:
Ipsilateral femoral head injury
Involvement of both columns
Non-anatomic fracture reduction
An 74-year-old community-ambulating male presents with complaints of right hip pain for 4 months. He does not recall any specific trauma though his pain is quite severe at this point. A radiograph is shown in Figure A. What is the most appropriate definitive treatment for this patient?
Conservative treatment with delayed physical therapy and shoe lifts
Open reduction and internal fixation
Right hip reconstruction
Closed reduction and percutaneous fixation
In Figure A, the two red arrows point to which of the following two arteries?
Superior gluteal and pudendal
Internal iliac and medial circumflex
External iliac and deep femoral
Obturator and external iliac
Medial circumflex and inferior gluteal
A 25-year-old patient presents with a posterior wall/ posterior column acetabular fracture. She is scheduled for open reduction internal fixation through a posterior approach. What position of the leg exerts the least amount of intraneural pressure on the sciatic nerve?
hip flexion, knee extension
hip extension, knee extension
hip flexion, knee flexion
hip extension, knee flexion
the pressure does not vary based on position
What acetabular component is best appreciated on an obturator oblique radiograph of the pelvis as seen in Figure A?
When viewing pelvic injury radiographs, which of the following describes the findings diagnostic of an isolated transverse acetabular fracture?
Fracture line crossing the acetabulum with disruption of the iliopectineal and ilioischial lines
Disruption of the iliopectineal and ilioischial lines, with extension into the iliac wing and obturator ring
Disruption of the iliopectineal and ilioischial lines, with extension into the obturator ring
Isolated disruption of the iliopectineal line, with an intact ilioischial ine
Isolated disruption of the ilioischial line, with an intact iliopectineal ine
A 32-year-old male sustains the injury shown in Figure A through D as the result of a high-speed motor vehicle collision. This particular injury is best treated with which of the following single approaches?
A 47-year-old male sustains an isolated posterior wall acetabulum fracture after a motor vehicle collision and undergoes open reduction and internal fixation. Post-operative radiographs are shown in Figure A. Which of the following has been shown to correlate most closely with good outcomes following ORIF of posterior wall fractures?
Degree of displacement seen on preoperative AP pelvis view
Degree of displacement seen on preoperative Judet views
Degree of displacement seen on preoperative pelvic CT scan
Degree of displacement seen on postoperative Judet views
Degree of displacement seen on postoperative pelvic CT scan
A 45-year-old male is involved in a motor vehicle accident and sustains the injury shown in Figures A-D. Which of the following is the most appropriate approach for surgical fixation of this fracture?
Stoppa with lateral window