Introduction Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Epidemiology demographics fractures occur in a bimodal distribution high energy trauma in younger patients (e.g., motor vehicle accidents) low energy trauma in elderly patients (e.g., fall from standing height) Pathoanatomy fracture pattern predominately determined by force vector position of femoral head at time of injury bone quality (e.g., age) Associated conditions orthopaedic manifestations lower extremity injury (36%) nerve palsy (13%) spine injury (4%) systemic injuries head injury (19%) chest injury (18%) abdominal injury (8%) genitourinary injury (6%) Prognosis poor outcomes are associated with: multi-system trauma increasing age poor articular congruency associated femoral head articular injury post-traumatic arthritis Anatomy Osteology acetabular inclination & anteversion mean lateral inclination of 40 to 48 degrees anteversion of 18 to 21 degrees column theory acetabulum is supported by two columns of bone form an "inverted Y" connected to sacrum through sciatic buttress posterior column comprised of quadrilateral surface posterior wall and dome ischial tuberosity greater/lesser sciatic notches anterior column comprised of anterior ilium (gluteus medius tubercle) anterior wall and dome iliopectineal eminence lateral superior pubic ramus Vascular corona mortis anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel most common referenced classification system classifed as 5 elementary and 5 associated fracture patterns most common fracture patterns younger posterior wall transverse fracture "family" transverse T-type transverse + posterior wall elderly anterior column (e.g., quadrilateral plate fractures) anterior column, posterior hemitransverse assoicated both column fractures Illus. AP Obt.Obl. Iliac.Obl. CT Comments Elementary Posterior wall x • Most common• "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall x x • Very rare Anterior column x x x • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse x x x x • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall x • Most common associated fx T Shaped x x • May need combined approach Anterior column or wall + Post. hemitransverse x x • Common in elderly patients Post. column + Post. wall x x x x • Only associated fracture that does not involve both columns Imaging Radiographs Recommended views AP judet obturator oblique shows profile of obturator foramen shows anterior column and posterior wall iliac oblique shows profile of involved iliac wing shows posterior column and anterior wall Optional views inlet/outlet if concerned for pelvic ring involvement examination under anesthesia (EUA) used to assess posterior wall stability hip positioned in flexion, adduction and axial load obtain obturator oblique view opening of the medial clear space suggests instability of the posterior wall fracture Findings radiographic landmarks of the acetabulum iliopectineal line (anterior column) ilioischial line (posterior column) anterior wall posterior wall teardrop weight bearing roof superior acetabular rim may show os acetabuli marginalis superior which can be confused for fracture in adolescents Shenton's line roof arc angle angle between vertical line through femoral head and line through fracture helps to define fracture pattern stability considered stable if the fracture line exits outside the weight bearing dome of the acetabulum defined as > 45° on AP, obturator and iliac oblique views not applicable for associated both column or posterior wall pattern because no intact portion of the acetabulum to measure gull sign represents impaction of superomedial roof seen on obturator oblique view pathognomic for posterior wall fractures spur sign represents most caudal part of intact ilium due to medialization of articular components seen on obturator oblique view pathognomic for ABC fractures CT scan indications now considered a gold standard in management findings fracture pattern orientation define fragment size and orientation identify marginal impaction identify loose bodies (e.g., post-reduction) look for articular gap or step-off roof-arc measurements view 2 mm fine cuts on axial view findings assess stability of the weight bearing dome based on the exiting fracture line defined as an intact subchonral ring in the superior 10 mm of the acetabulum > 2 mm incongruity in the articular segment is considered unstable Duplex doppler ultrasound indications delayed presentation to treating hospital rule out DVT Treatment Nonoperative protected weight bearing for 6-8 weeks indications patient factors high operative risk (e.g., elderly patients, presence of DVT) morbid obesity open contaminated wound late presenting > 3 weeks fracture characteristics minimally displaced fracture (< 2 mm) < 20% posterior wall fractures treatment based on size of posterior wall is controversial recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability femoral head congruency with weight bearing roof (out of traction) both column fracture pattern with secondary congruence (out of traction) displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome activity as tolerated with crutches/walker weight-bearing lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize close radiographic follow-up Operative treatment open reduction and internal fixation indications patient factors < 3 weeks from date of injury physiologically stable adequate soft-tissue envelope no local infection pregnancy is not contraindication to surgical fixation fracture factors displacement of roof (> 2 mm) unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%) marginal impaction intra-articular loose bodies irreducible fracture-dislocation approaches anterior ilioinguinal iliofemoral modified stoppa posterior Kocher-Langenbach combined extended ilifemoral techniques factors considered for fiaxtion methodology location (column and/or wall) and level (high or low) of the fracture pattern amount of displacement marginal impaction assoicated injury fixation modalities column fixation strategies reconstruction bridging plate and screws percutaneous column screws cable fixation wall fixation strategies bridge plate and screws lag screw and neutralization plate spring (butress) plate outcomes timing associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury earlier operative treatment associated with increased chance of anatomic reduction peri-operative clinical outcome correlates with quality of articular reduction postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome ideally articular reduction <2mm post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution pre-existing arthritis post-traumatic arthritis in all ages techniques timing immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures butress plate with multi-hole cup column fracture cage and cup constructs delayed THA outcomes patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures 10-year implant survival noted to be around 75-80% Techniques Percutaneous fixation with column screws approach anterograde (from iliac wing to ramus) retrograde (from ramus to iliac wing) posterior column screws imaging obturator oblique best view to rule out joint penetration inlet iliac oblique view best to determine anteroposterior position of screw within the pubic ramus obturator oblique inlet view best to determine position of a supraacetabular screw within tables of the ilium ORIF approaches approach depends on fracture pattern two approaches can be combined Approaches Indications Risks Anterior Approach (Ilioinguinal) • 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 Approach (Kocher-Langenbach) • 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) Extensile Approach (extended iliofemoral) • 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 Modified Stoppa Approach • access to quadrilateral plate to buttress comminuted medial wall fractures • Corona mortis must be exposed and ligated in this approach Complications Post-traumatic DJD most common complication 80% survival noted at 20 years for patients s/p ORIF risk factors for DJD include age >40 associated fracture patterns concomitant femoral head injury treat with hip fusion or THA Heterotopic Ossification highest incidence with extensile approach treat with indomethacin x 5 weeks post-op low dose external radiation (no difference shown in direct comparison) lowest incidence with anterior ilioinguinal approach Osteonecrosis 6-7% of all acetabular fractures 18% of posterior fracture patterns DVT and PE Infection Bleeding Neurovascular injury Intraarticular hardware placement Abductor muscle weakness
Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Acetabulum Posterior Wall Fracture ORIF Richard Yoon Jan Szatkowski Trauma - Acetabular Fractures
QUESTIONS 1 of 56 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 Previous Next (OBQ09.223) 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? Review Topic QID: 3036 FIGURES: A 1 Hip at 45 degrees, knee flexed to 90 degrees 7% (144/2149) 2 Hip at 60 degrees, knee flexed to 90 degrees 13% (276/2149) 3 Hip at 90 degrees, knee extended 3% (56/2149) 4 Hip at 0 degrees, knee flexed to 90 degrees 74% (1580/2149) 5 Hip at 90 degrees, knee flexed to 90 degrees 3% (67/2149) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ07.3) In Figure A, the two red arrows point to which of the following two arteries? Review Topic QID: 664 FIGURES: A 1 Superior gluteal and pudendal 2% (10/613) 2 Internal iliac and medial circumflex 2% (11/613) 3 External iliac and deep femoral 8% (46/613) 4 Obturator and external iliac 88% (539/613) 5 Medial circumflex and inferior gluteal 1% (4/613) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.22) 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? Review Topic QID: 3445 FIGURES: A 1 The Keith method 1% (28/2888) 2 The Moed method 1% (21/2888) 3 The Calkins method 1% (17/2888) 4 Dynamic fluoroscopic examination of the hip under anesthesia 96% (2786/2888) 5 A history of associated hip dislocation 1% (29/2888) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.97) 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? Review Topic QID: 4457 FIGURES: A B 1 Exploration of his sciatic nerve 1% (32/3464) 2 EMG 1% (51/3464) 3 CT scan of his right hip 59% (2029/3464) 4 Touch-down weight bearing of his right leg and observation of his sciatic nerve palsy 38% (1305/3464) 5 Skeletal traction on the distal femur to relax tension on the sciatic nerve 1% (26/3464) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ05.8) 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? Review Topic QID: 45 FIGURES: A B C D 1 Ilioinguinal 42% (239/574) 2 Hardinge 1% (6/574) 3 Extended iliofemoral 40% (231/574) 4 Watson-Jones 2% (12/574) 5 Kocher-Langenbeck 14% (83/574) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ05.187) When viewing pelvic injury radiographs, which of the following describes the findings diagnostic of an isolated transverse acetabular fracture? Review Topic QID: 1073 1 Fracture line crossing the acetabulum with disruption of the iliopectineal and ilioischial lines 83% (455/550) 2 Disruption of the iliopectineal and ilioischial lines, with extension into the iliac wing and obturator ring 3% (17/550) 3 Disruption of the iliopectineal and ilioischial lines, with extension into the obturator ring 5% (30/550) 4 Isolated disruption of the iliopectineal line, with an intact ilioischial ine 4% (20/550) 5 Isolated disruption of the ilioischial line, with an intact iliopectineal ine 4% (23/550) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.144) A computed tomography (CT) scan has been shown to be indicated for evaluation of all of the following aspects of acetabular fractures, EXCEPT: Review Topic QID: 2957 1 Determination of surgical planning 1% (10/794) 2 Intra-articular loose bodies 2% (12/794) 3 Marginal impaction 2% (17/794) 4 Fracture piece size and position 1% (5/794) 5 Determination of pre-existing degenerative changes 94% (745/794) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ06.51) 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? Review Topic QID: 162 1 hip flexion, knee extension 1% (30/2049) 2 hip extension, knee extension 3% (52/2049) 3 hip flexion, knee flexion 5% (109/2049) 4 hip extension, knee flexion 90% (1846/2049) 5 the pressure does not vary based on position 0% (4/2049) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ07.98) 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? Review Topic QID: 759 1 Posterior wall/ posterior column 3% (16/503) 2 Transverse 5% (26/503) 3 T-Type 8% (40/503) 4 Anterior column/ posterior hemitransverse 6% (30/503) 5 Both columns 77% (385/503) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ09.217) 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? Review Topic QID: 3030 FIGURES: A B C D 1 Anterior column posterior hemitransverse 19% (379/1978) 2 Both column 75% (1478/1978) 3 Transverse 1% (24/1978) 4 Transverse with posterior wall 3% (62/1978) 5 Anterior column 1% (26/1978) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ10.203) 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? Review Topic QID: 3296 1 AP pelvis 0% (2/992) 2 Outlet obturator oblique view 14% (141/992) 3 Inlet iliac oblique view 71% (709/992) 4 Iliac oblique view 5% (46/992) 5 Obturator oblique view 9% (90/992) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ10.268) 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? Review Topic QID: 3251 FIGURES: A 1 Posterior inferior 5% (60/1177) 2 Anterior superior 19% (221/1177) 3 Posterior superior 73% (865/1177) 4 Directly superior 2% (20/1177) 5 Anterior inferior 1% (7/1177) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ10.180) 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? Review Topic QID: 3273 1 Modified Stoppa approach 3% (23/741) 2 Extended iliofemoral approach 2% (14/741) 3 Kocher-Langenbeck approach 92% (681/741) 4 Ilioinguinal approach 1% (8/741) 5 Combined anterior and posterior approach 2% (13/741) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ08.119) 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? Review Topic QID: 505 FIGURES: A B 1 Posterior wall 3% (14/558) 2 Transverse 78% (434/558) 3 Anterior wall 3% (17/558) 4 Posterior column 1% (8/558) 5 Both column 14% (80/558) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ08.265) Which statement is true with respect to acetabular fracture surgery as the time between injury and surgery increases? Review Topic QID: 651 1 decreased chance of anatomic fracture reduction 87% (458/525) 2 decreased risk of heterotopic ossification 2% (9/525) 3 decreased rate of neurologic injury 1% (3/525) 4 decreased rate of infection 0% (2/525) 5 decreased rate of multi-organ failure 10% (51/525) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ09.112) 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? Review Topic QID: 2925 FIGURES: A 1 Both column 31% (335/1095) 2 Anterior column 1% (12/1095) 3 Anterior column posterior hemitransverse 4% (49/1095) 4 Transverse 61% (670/1095) 5 T-type 3% (28/1095) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ04.100) 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? Review Topic QID: 1205 FIGURES: A 1 Degree of displacement seen on preoperative AP pelvis view 1% (18/1761) 2 Degree of displacement seen on preoperative Judet views 5% (81/1761) 3 Degree of displacement seen on preoperative pelvic CT scan 12% (218/1761) 4 Degree of displacement seen on postoperative Judet views 13% (229/1761) 5 Degree of displacement seen on postoperative pelvic CT scan 69% (1210/1761) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ12.212) The posterior wall of the acetabulum is best visualized on which of the following radiographic views? Review Topic QID: 4572 1 Inlet pelvis 1% (64/5288) 2 Outlet pelvis 1% (78/5288) 3 Anteroposterior pelvis 1% (38/5288) 4 Obturator oblique pelvis 84% (4452/5288) 5 Iliac oblique pelvis 12% (635/5288) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ09.163) An acetabular fracture with all segments of the articular surface detached from the intact posterior ilium is defined as what fracture pattern? Review Topic QID: 2976 1 Transverse 6% (111/1813) 2 Both column 75% (1368/1813) 3 Anterior column posterior hemitransverse 11% (202/1813) 4 Posterior column with posterior wall 5% (90/1813) 5 Anterior column with anterior wall 2% (34/1813) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ09.198) 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? Review Topic QID: 3011 FIGURES: A 1 Decreased length of hospital stay 1% (7/515) 2 Improved functional outcome 3% (17/515) 3 Greater organ dysfunction 86% (444/515) 4 Higher likelihood of being discharged to home as opposed to a rehab facility 4% (20/515) 5 Improved fracture reduction 5% (26/515) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ11.148) 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? Review Topic QID: 3571 1 Intraarticular penetration of the screw 14% (328/2271) 2 Position of the screw cephalad to the sciatic notch 9% (203/2271) 3 Screw starting point at the anterior inferior iliac spine 15% (348/2271) 4 Screw starting point at the gluteal pillar 3% (63/2271) 5 Screw position between the inner and outer tables of the ilium 58% (1317/2271) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ09.137) The pelvic spur sign on plain radiography is indicative of the following injuries? Review Topic QID: 2950 1 Transtectal transverse acetabular fracture 7% (124/1847) 2 Vertical shear pelvic ring injury 4% (79/1847) 3 Displaced H-type sacral fracture 2% (30/1847) 4 Both column acetabular fracture 85% (1570/1847) 5 Anterior-posterior type III pelvic ring injury 2% (38/1847) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ11.205) 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? Review Topic QID: 3628 FIGURES: A 1 Os acetabuli marginalis superior 97% (2519/2589) 2 Fovea capitis 0% (12/2589) 3 Myositis ossficans 1% (23/2589) 4 Avascular necrosis. 0% (12/2589) 5 Acetabular fracture 1% (18/2589) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ07.230) All of the following have been shown to negatively affect clinical outcomes in treating displaced acetabular fractures, EXCEPT: Review Topic QID: 891 1 Increased age 23% (141/620) 2 Intraoperative complications 7% (44/620) 3 Ipsilateral femoral head injury 10% (60/620) 4 Involvement of both columns 55% (338/620) 5 Non-anatomic fracture reduction 6% (35/620) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ07.114) 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? Review Topic QID: 775 FIGURES: A 1 Skeletal traction 2% (14/607) 2 Conservative treatment with delayed physical therapy and shoe lifts 2% (15/607) 3 Open reduction and internal fixation 24% (148/607) 4 Right hip reconstruction 70% (424/607) 5 Closed reduction and percutaneous fixation 1% (5/607) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ11.241) 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? Review Topic QID: 3664 1 Increased age 3% (70/2090) 2 Increased hip flexion-extension arc 27% (566/2090) 3 Immediate weight-bearing 10% (218/2090) 4 Increased hip muscle strength 58% (1203/2090) 5 Decreased stride length 1% (25/2090) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ11.155) 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? Review Topic QID: 3578 FIGURES: A B C 1 Kocher-Langenbeck 14% (327/2342) 2 Watson-Jones 3% (60/2342) 3 Extended iliofemoral 9% (210/2342) 4 Ilioinguinal 74% (1725/2342) 5 Hardinge 0% (8/2342) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ11.80) 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? Review Topic QID: 3503 FIGURES: A 1 Nonoperative management based on the size of the posterior wall fragment 9% (216/2364) 2 Operative management based on the size of the posterior wall fragment 2% (58/2364) 3 Operative management based on the history of hip dislocation 3% (69/2364) 4 Dynamic fluoroscopic stress exam under anesthesia in the obturator oblique view 76% (1799/2364) 5 Dynamic fluoroscopic stress exam under anesthesia in the iliac oblique view 9% (214/2364) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ06.166) What acetabular component is best appreciated on an obturator oblique radiograph of the pelvis as seen in Figure A? Review Topic QID: 352 FIGURES: A 1 Ilioischial line 2% (12/652) 2 Posterior column 4% (29/652) 3 Posterior wall 85% (557/652) 4 Anterior wall 7% (46/652) 5 Sacroiliac joint 0% (3/652) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ04.93) 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? Review Topic QID: 1198 FIGURES: A B C D 1 Ilioinguinal 3% (41/1452) 2 Kocher-Langenbeck 88% (1279/1452) 3 Stoppa 3% (40/1452) 4 Stoppa with lateral window 3% (47/1452) 5 Extended iliofemoral 3% (41/1452) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ09.99) 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? Review Topic QID: 2912 1 Pudendal 2% (42/1971) 2 Deep illiac circumflex 3% (61/1971) 3 Hypogastric 5% (107/1971) 4 Obturator 89% (1753/1971) 5 Testicular 0% (2/1971) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
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