Ankle fractures - OrthopaedicsOne



Description

|Instructions for authors |

|One or two sentences that describes the injury. Try to say something beyond the obvious. An apt comment might be “Geriatric hip fractures are |

|low energy injuries typically associated with osteoporosis, and a (perhaps shockingly high) one year mortality rate of 20% or more” or “Tears |

|of the anterior cruciate ligament of the knee are often sustained while playing sports and often require surgical intervention to give the |

|patient sufficient anterior tibial stability to return to high levels of play”) |

Acetabular fractures are complex injuries associated with intricate, often confusing anatomy, with a recognized potential for long-term disability and progressive joint degeneration. They occur in isolated fashion, or in combination with pelvic ring disruption and/or ipsilateral extremity injuries, including hip dislocations.

Native hip dislocations require an inherently massive force secondary to the intrinsic stability of the hip joint. Timely reduction, assessment of stability, and detection of associated injuries are paramount to achieving an enduring functional result.

Structure and function

|Instructions for authors |

|Please include a brief review of the relevant anatomy, enough to make clear what is disturbed by the injury and why such a disturbance is |

|clinically important. It is possible that there may not be much to say (a femoral shaft fracture is clinically important for obvious reasons) |

|but even in such cases there probably is something to say (eg the femur is the largest bone in the body and therefore associated blood loss |

|can be significant, or that because of its size the amount of intravascular debris and accompanying risk of fat embolism is higher) |

The acetabulum is formed from the ilium, ischium, and pubis. Its structure is generally described via a two-column concept, which intrinsically resembles an inverted-Y position. The anterior column consists of iliac and pubic components, while the posterior column incorporates the ischium. The acetabular dome, considered the weight-bearing portion, is formed by the junction of both columns.

The hip is an extremely stable joint, conferred via bony, ligamentous, muscular, and soft tissue constraints. Much force is required to cause hip dislocation.

Fractures of the acetabulum and/or hip dislocations can lead to an incongruent hip joint and altered weight-bearing characteristics that contribute to pain and dysfunction. This may be manifested through post-traumatic arthritis, avascular necrosis, and associated gait abnormalities. Treatment options for young adults with hip pathology are still evolving, but at present, remain quite limited.

Epidemiology

|Instructions for authors |

|Who gets this? How rare is it? What is the disease burden in various populations of interest? |

|The goal here is not to inundate with facts (who cares that back pain causes $6,476,400,000 in lost work productivity) but to give a general |

|sense of importance (lost time from work is very costly!). Is this rare or common? If it is rare, what is its impact nonetheless? |

Acetabular fractures are relatively uncommon injuries, generally affecting the young adult population following motor vehicle collisions. Significant psychosocial and economic burden may incur, with great potential for long-term functional deficits. In consideration of diminished bone quality and less traumatic mechanisms in the older population, damaging consequences can still be quite significant.

Despite a strong association with acetabular fractures, the disease burden of hip dislocations can be quite similar, or in fact, drastically different. Simple dislocations without fracture generally enjoy good long-term results if reduction is concentric and timely, while future consequences can be destructive despite any/all accepted treatment measures, with or without fracture. Results tend to be individualized.

Clinical presentation

|Instructions for authors |

|Here include mechanism of injury and how the patient presents. Describe how this injury is sustained, especially the points that may be |

|relevant to differential diagnosis, treatment, outcome etc. Examples: Geriatric hip fractures are from falls – so maybe a syncope work up is |

|needed; Geriatric hip fractures patients may have altered mental state from dehydration and pain and may “perk up” when these are addressed. |

|Or, ACL tears are from twisting injuries, so the meniscus may be damaged then too. There may be a lot of pain from bleeding into the knee or |

|from a bone bruise (the former gets better with aspiration, the latter will resolve over time. We don’t fix ACLs because of pain) |

Common mechanisms causing acetabular fractures include motor vehicle collisions, pedestrian versus auto, falls from height, and industrial accidents. Full trauma evaluation is required, with many patients arriving unconscious or obtunded in consideration of associated injuries.

The proximal femur is excessively loaded, with the precise fracture pattern determined by the position of the hip at time of impact, the magnitude of the force, and the quality of bone. Anterior column disruption generally results from the hip contacted in an externally rotated and abducted position, while posterior column injury follows an internally rotated and adducted position. Moreover, if force transmission continues, the femoral head can also be displaced, resulting in dislocation.

Approximately 85-90% of hip dislocations are posterior, and occur secondary to axial loading of a flexed and adducted hip. This leads to a shortened, adducted, and internally rotated extremity. Associated sciatic nerve palsy is present in about 10% of cases, with the peroneal division (ankle dorsiflexion) preferentially affected. It can be pierced by displaced acetabular fragments, or stretched over a posteriorly dislocated femoral head.

In contrast, anterior hip dislocations result from loading a flexed, abducted, and externally rotated extremity. This leads to a flexed, abducted, and externally rotated limb. The degree of hip flexion will determine whether the dislocation is inferior or superior.

Following initial trauma management, the position of the affected limb, a complete neurovascular exam, and an assessment of skin integrity should be documented. Once hemodynamic stability is assured, specific imaging may then be obtained.

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RIGHT POSTERIOR HIP DISLOCATION (Ext Shortened, Add, & IR)

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POSTERIOR-SUPERIOR HIP DISLOCATION

Red flags

|Instructions for authors |

|Make special note, please, of “don’t miss this!” things that deserve particular mental attention or prompt referral to a specialist . This |

|section is, in a way, a subsection of “clinical presentation” but should be listed distinctly. |

“Classic” presentations of injuries can be dramatically altered with accompanying pathology, thus a high level of suspicion must exist in patients unable to provide a detailed history of injury events. Time is of the essence in native hip dislocation, with the risk of avascular necrosis increased with a delay in management. Also, up to 50% of patients with hip dislocations incur associated fractures.

Any patient presenting with an acetabular fracture and/or hip dislocation must be evaluated for a femoral neck fracture. It is imperative to visualize an undisturbed femoral neck before attempted reduction and/or traction pin placement. The long-term consequences of missing this injury may dramatically alter treatment, heighten the risk of AVN and/or cause life-altering consequences.

AVN is commonly associated with hip dislocations, as the dominant blood supply to the femoral head, the medial femoral circumflex artery, can be stretched or occluded. The risk of AVN increases the longer the hip remains dislocated, and the rate is slightly higher when there is an associated femoral head fracture. This is indicative of the higher energy required to cause a fracture. The overall rate of AVN following hip dislocation is approximately 15%, but increases to 20% with an associated femoral head fracture.

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AVN LEFT HIP

Sciatic nerve palsy is also a common complication of acetabular fractures and/or hip dislocations. Documentation of function should proceed any attempts at treatment. Prior to attempts at closed reduction, appropriate consent including the risks of sedation, femoral head/neck fracture, loss or diminished sciatic nerve function, and the potential of an unsuccessful result with the need for open reduction must be performed.

The patient should receive conscious sedation, analgesia, and adequate muscle paralysis. Patient reluctance can inevitably hinder reduction attempts, leading to greater potential for fracture risk, articular injury, and unnecessary temporal delays related to the development of AVN. Loss of function following attempted closed reduction generally necessitates surgical exploration.

Pelvic angiography and/or embolization may be required in acetabular fracture patients that are hemodynamically unstable and unresponsive to resuscitative techniques.

There is an increased risk of venous thrombolembolism and associated pulmonary embolism (PE) with acetabular fractures and related pelvic injuries, thus anti-coagulation methods (pharmacologic and/or mechanical) should be considered. For those individuals that fall outside this therapeutic recommendation based upon allergic and/or extremity contraindications, placement of a venal caval filter can decrease the risk of PE, but does not prevent or treat existing venous thrombi.

Differential diagnosis

|Instructions for authors |

|For many injuries, the question is not ‘do you have it?’ (for the x-rays show it) but rather ‘what else do you have?’ So this section is |

|really a review of the associated injuries, but also take the opportunity here to briefly discuss how “your’ condition is unique. |

Based upon loading mechanism, associated ipsilateral injuries can involve the entire extremity. Isolated posterior wall fractures, the most common acetabular fracture pattern, are frequently associated with posterior hip dislocations and/or ipsilateral knee injuries. This can include patellar fractures and rupture of the cruciate ligaments, specifically the posterior cruciate ligament (PCL). These structures comprise the so-called “dashboard injury,” whereby a flexed knee contacts the dashboard as force is transmitted to the hip joint.

Pelvic ring and spinal injuries are also frequent associated injuries, with disruption of adjacent organ systems a regular consequence.

Objective evidence

|Instructions for authors |

|Don’t assume that the correct x-rays are always obtained. So first, describe what films are needed (the view, the extent, etc: 3 views of the |

|shoulder (why?), getting a ‘joint above and joint below’ on the picture, etc) Next describe for what one should scrutinize the films-what |

|exactly are we looking for? Example: for ankle fractures, the status of the syndesmosis is key; for tibial plateau fractures, depression is |

|important; for clavicular fractures, the location relative to the CC ligaments is important. |

|Then discuss need for supplemental imaging (CT, MRI, etc) with some parameters, ie, who needs one, and what question does this test answer? |

|Are any other tests needed? Metabolic work up? (distal radius fractures) Blood tests of any sort (hemoglobin after femur fracture?) |

Secondary to its high energy mechanism, a full trauma imaging evaluation should be obtained. This includes an AP chest, AP pelvis, and lateral cervical spine films. Judet views are required if an acetabular fracture is discovered, while an AP/cross-table lateral view of the hip, and a full-length femur film that includes the knee should be considered depending upon associated pathology and/or treatment expectations. Likewise, if a pelvic ring injury is suspected, inlet and outlet views should be obtained.

There are six radiographic landmarks that should be identified on an AP Pelvic x-ray:

1)Anterior column-delineated by the iliopectineal line.

2)Posterior column-delineated by the ilioischial line.

3)Anterior wall-located medially relative to the convex posterior wall.

4)Posterior wall-larger and more lateral than the anterior wall.

5)Acetabular roof-also referred to as the “sourcil” (eyebrow) and found cranial to the femoral head

6)Teardrop-radiographic structure created by confluence of medial obturator neurovascular sulcus, the quadrilateral surface of the pelvis, and the lateral cortical boundary of the acetabular fossa.

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AP PELVIC XRAY-LABELED RADIOGRAPHIC MARKERS

Acetabular fracture classification is divided into five elementary patterns with a single fracture plane and five associated fracture patterns that combines elementary patterns.

ELEMENTARY ASSOCIATED

1) Anterior Column 1)Posterior Column/Posterior Wall

2)Posterior Column 2)Transverse/Posterior Wall

3)Anterior Wall 3)Ant Column/Post HemiTransverse**

4)Posterior Wall 4)T-Type***

5)Transverse* 5)Both Column

*Splits articular surface through dome, at junction of dome/acetabular fossa, or through fossa (Transtectal, Juxtatectal, Infractectal)

**Referred to as “hemitransverse” because the transverse component only involves one column.

***Involves a transverse fracture plane with additional vertical fracture line splitting the ischiopubic component, creating the appearance of the letter “T”.

ELEMENTARY INJURY PATTERNS:

1) Anterior Column-AP Pelvis-Iliopectineal line disrupted(further identify on Obturator Oblique Judet view

2) Posterior Column-AP Pelvis-ilioischial line disrupted(further identify on Iliac Oblique Judet view.

3) Anterior wall-best seen on Iliac Oblique Judet view. The “teardrop” is usually displaced medially with respect to the ilioischial line.

4) Posterior wall-(PW) best seen on Obturator Oblique Judet view. Most common isolated acetabular fracture.

5) Transverse-AP Pelvis-iliopectineal and ilioischial lines disrupted. Ilioischial line and teardrop maintain normal relationship.

6) Posterior column/Posterior wall-AP Pelvis-PC-ilioischial line disrupted, also seen on Iliac Oblique view. PW best seen on Obturator Oblique view.

7) Transverse/Posterior wall-AP Pelvis-Iliopectineal and ilioischial line disrupted, PW best seen on Obturator Oblique view.

8) Anterior Column/Posterior HemiTransverse-AP Pelvis-iliopectineal and ilioischial lines disrupted. Ant column fracture also seen on Obturator Oblique view.

9) T-Type-AP Pelvis-iliopectineal and ilioischial lines disrupted.

10)BOTH Column-AP Pelvis-iliopectineal and ilioischial lines disrupted. “Spur sign” on Obturator Oblique-created by intact, non-displaced ilium

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Acetabular Fx Classification System Elementary fxs (top row), Assoc fxs (bottom row)

JUDET VIEWS: The Obturator Oblique radiograph is obtained by rotating the patient 45 degrees onto the unaffected side. It better delineates anterior column and posterior wall fractures, while also scrutinizing the posterior acetabular surface to assess for posterior subluxation of the hip joint.

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RIGHT OBTURATOR OBLIQUE TECHNIQUE/X-RAY (Both Column Fx- Iliopectineal line disrupted/”Spur sign”)

In contrast, the iliac oblique film rotates the patient 45 degrees onto the side of the fracture, with the beam directed perpendicular to the iliac wing. It provides detailed imaging of the posterior column and anterior wall.

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RIGHT ILIAC OBLIQUE TECHNIQUE/X-RAY

(Both Column Fx-Ilioischial line disrupted/Intact Ant Wall)

With evidence of an acetabular fracture, roof arc angles are commonly obtained to assist in determining stability. They describe the location of column fracture lines with respect to the roof of the acetabulum. However, they cannot be used with posterior wall fractures (out of plane) and both column fracture patterns (less predictive).

They are measured on the AP Pelvis (medial arc) and Judet views (Obturator Oblique-anterior arc/Iliac Oblique-posterior arc) respectively. A vertical line is drawn through the geometric center of the acetabulum and a second line drawn where the fracture line enters the joint. If the fracture line does not enter the joint on any views, then it does not involve the weight-bearing dome, and is considered a stable fracture. Likewise, if a fracture does enter the joint, a measurement of at least 45 degrees generally entails an intact weight-bearing dome, thus no operative intervention is indicated. As the roof arc angle increases, acetabular dome coverage also increases, usually intimating heightened hip congruity and stability.

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EXAMPLE OF ROOF ARC ANGLE MEASUREMENTS

Inlet and outlet views demonstrate anterior/posterior and vertical displacement of the pelvis respectively.

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PELVIC INLET/OUTLET X-RAY

CT can provide further information regarding size and position of column fractures, impacted patterns, incarcerated bony fragments, and level of comminution. It is also usually substituted for lateral C-spine radiographs, and can help to better identify associated traumatic and occult injuries.

Ct may also be used to determine subchondral arc measurements to provide an estimate of acetabular fracture stability. The subchondral ring of the acetabulum is defined as 10mm inferior to the subchondral bone of the roof, thus if this ring is not interrupted, then roof arc measurements obtained from plain films must also be greater than 45 degrees. As stated previously, this usually indicates non-operative management.

Hip dislocations follow a similar pattern of required imaging, with a cross-table lateral key to defining an anterior or posterior location of the femoral head with respect to the acetabulum. The femoral heads will appear of different size if there is a dislocation, with the femoral head smaller in a posterior dislocation and larger if displaced anteriorly. This reflects the distance of the femoral head from the x-ray beam.

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X-TABLE LATERAL TECHNIQUE/X-RAY

*ALWAYS LOOK FOR ISCHIAL TUBEROSITY- POSTERIOR STRUCTURE

Risk factors and prevention

|Instructions for authors |

|List here risk factors for this injury |

|Example: geriatric hip fracture = Propensity for falling (eg due to alcoholism or neuromuscular disease) What can be done to prevent this? Is |

|this cost effective? Does it work? |

In younger individuals, risk factors that are preventable include wearing a seatbelt and any associated safety precautions with respect to potential for high energy/velocity injuries. Regarding older individuals and/or those persons with propensity for falling and/or gait abnormalities, individual fall precautions, visual/auditory testing, and monitoring of medication effects may help to decrease number of events.

If a sciatic nerve palsy is present following acetabular fracture and/or posterior hip dislocation, prevention of skin breakdown and ankle equinus contracture are paramount. An ankle-foot orthosis (AFO) can help maintain a plantigrade foot while monitoring for recovery.

Treatment options

|Instructions for authors |

|Note the treatment options. Offhand, injuries can be treated with benign neglect; casual immobilization; rigorous immobilization; functional |

|rehabilitation; surgical repair; surgical replacement; or some combination. |

|For each treatment, describe the rationale/method for each treatment, and whether it is evidence based. |

Non-operative management of an acetabular fracture requires a congruent, stable hip joint, with an intact weight-bearing dome as measured by “roof arc” or “subchondral arc” measurements. In addition, the orthopaedic surgeon must take into account associated injuries, the functional demands and expectations of the patient, consider his or her own experience treating the injury pattern, as well the capability of the participating institution to accommodate the patient. Elderly, non-ambulatory patients with multiple co-morbidities may be considered for non-operative management regardless of fracture pattern-patient treatment should always be individualized.

The goals of surgical treatment of an acetabular fracture should be to maintain a painless and functional hip joint, restore the articular surface to prevent post-traumatic arthritis, and help diminish the risk of development of future complications (AVN, HO). Early referral to an appropriate institution with an experienced acetabular surgeon can positively affect outcomes. It diminishes the need for more extensile exposures and allows for manipulation of more mobile fracture fragments. This can lead to a more accurate reduction, improving chances for better long-term results.

Posterior hip pathology is approached through a Kocher-Langenbeck exposure, while anterior injuries are treated through a Smith-Peterson approach. Hip arthroscopy is an alternative to open arthrotomy, and is indicated in select circumstances including removal of residual joint debris and incarcerated fragments. Its less invasive nature however is generally offset by its heightened skill level requirement.

The most important parameter regarding treatment of a native hip dislocation involves time to reduction. Likewise, assessment of neurovascular function, specifically the sciatic nerve, must be evaluated before and after attempted reduction.

Reduction of a posterior dislocation involves traction/counter-traction, stabilizing the patients’ pelvis, along with gentle rotation motions, and sometimes slight adduction. Successful reduction is usually signalled by an palpable/audible “clunk”, with the return of appropriate leg length and rotation. Stability should then be assessed regarding the likelihood of maintaining concentric reduction. If it is determined stable, a knee-immobilizer should be protect against excessive flexion, adduction, and internal rotation.

Post-reduction radiographs should confirm concentric reduction and a pelvic CT can evaluate for residual bony fragments and/or marginal impaction. Otherwise, protected weight bearing is implemented, and is continued until there is evidence of healing on x-ray if there is an associated fracture.

If the hip is irreducible, or dislocates upon dynamic testing (70-90 degrees of flexion, neutral rotation, posterior-directed force), there may be a soft-tissue or bony block to reduction. Likewise, it may be too unstable with respect to associated injuries (PW fx). In the former case, surgical intervention is required, while in the latter case, traction pin placement to temporarily maintain reduction may be entertained with the patient re-evaluated at a later date. However, this modality must be considered with respect to patient age (contraindicated in pediatric population/questionable in elderly osteoporotic patients), as well as in patients with associated injuries (ipsilateral extremity fractures).

A CT scan should then also be obtained to check for subtle joint incongruity, residual bony fragments in the joint that can lead to articular degeneration, and “marginal impaction. Likewise, if the hip joint is determined non-concentric, bony fragments remain, or any other new pathology is uncovered, the CT scan can aid in pre-operative planning for open reduction.

Outcomes

|Instructions for authors |

|This should list the expected outcomes of treatment if all goes well; the possible complications of treatment; the presentation of untreated |

|disease; and the long term consequences of the injury. |

Outcome of patients with acetabular fractures are based upon numerous factors including fracture pattern, bone quality, extent of articular injury, associated injuries (hip dislocation, proximal femur fracture, neurovascular complications, etc.), presence/absence of surgical complications, and co-morbid conditions.

Post-traumatic arthritis following acetabular fractures and/or hip dislocation can result from an incongruent hip joint, alterations in femoral head sphericity, bony defects of the acetabulum, and articular defects. These conditions can all lead to alterations in contact stress and weight-bearing biomechanics manifested by pain, stiffness, gait abnormalities, and overall decreased function.

Heterotopic Ossification (HO), ectopic bone formation, can disrupt joint motion/function, and can develop following operative or non-operative intervention. However, the highest risk for its development can be found following a posterior approach. Male patients and/or those with a traumatic brain injury carry the highest risk. Prophylaxis should be considered following acetabular surgery, with a choice of two recommended protocols:

1)Indomethacin 25mg three times daily for 4-6 weeks

2)LOW-DOSE LOCAL RADIATION THERAPY: 700-1000cGY within 24-48hrs following the surgical procedure

Regarding hip dislocations, the time to relocation is an extremely important parameter, directly affecting outcome. Every effort should be made to minimize temporal issues that can lead to AVN because there is no good treatment for its consequences, most notably in the younger population.

Simple posterior dislocations enjoy 70-80% excellent outcomes with early concentric reduction versus those with an associated fracture or if reduction was delayed >12 hours. In the latter case, the associated fractures dominate the outcome parameters. Likewise, the incidence of post-traumatic arthritis is much lower in simple hip dislocations versus injuries that involve associated fractures.

Holistic medicine

|Instructions for authors |

|Nutritional factors, Psychosocial impact of disease and Economic effects |

The long-term psychosocial and economic impact faced by the young population with hip pathology can be overwhelming. Unfortunately, there are no good treatment options at present. Conservative treatment (non-narcotic analgesics, physical therapy, weight loss, etc.) generally only provides transient relief, while surgical intervention is a highly questionable long-term solution. Hip arthroscopy, associated resurfacing, and/or replacement may initially be beneficial, but will all likely require revision/alternative intervention at some later date.

Miscellany

|Instructions for authors |

|In this section include everything a professor can mumble, without necessarily having evidence to support the assertions |

|Random factoids to help students remember important stuff. E.g.: Why are sailors called “limey”? Sailors at sea where prone to scurvy from Vit|

|C deficiency (imagine the toothless deck hand). Once that was known, they were issued limes to eat---to help the collagen cross link |

|Clinical pearls |

|Favorite facts for exam writers. It would be great if you can compose a question or two for students to ponder. |

|Frontier of science - what is coming down the pike from our basic science friends |

|What we don’t know |

-Mnemonic to remember what each Judet view emphasizes: “PIC and POW”

PIC(Iliac oblique-Posterior Column/Anterior wall

POW(Obturator Oblique-Anterior Column/Posterior Wall

-Posterior wall fractures involve separation of the posterior articular surface, and are often combined with “marginal impaction.” This refers to articular cartilage being impacted into the underlying cancellous bone. It is best assessed on CT scan and requires surgical management.

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RIGHT HIP-“MARGINAL IMPACTION”

-In Both Column fracture patterns (“floating acetabulum”), the articular surface does not have any connection to the intact hemipelvis. However, based upon the principle of “secondary congruency,” it can be considered stable and potentially treated non-operatively. The “spur sign” on the obturator oblique view is pathognomonic for this injury, with the caudal extent of the intact ilium appearing more prominent as the acetabular articular fragments displace medially.

-Corona Mortis-vascular communication between the external iliac artery or inferior epigastric artery and the obturator artery. Found in approximately 85% of the population, with a large potential for bleeding complications if disrupted.

-Morel-Lavalle lesion: classic skin degloving injury associated with acetabular fractures that requires extensive debridement prior to fracture repair. Infected in up to one-third of cases.

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MOREL-LAVALLE LESION

-Anterior wall fractures are the least common of all fracture types based upon biomechanical loading properties.

-Anterior hip dislocations have a high risk of associated femoral head fractures, thus the examiner should be fully aware of the potential for associated pathology when assessing this injury. The combination injury heightens the risk for AVN.

-Commonly there is a residual avulsed bony fragment off the femoral head (ligamentum teres) following hip dislocations. It is generally not an indication for open reduction as it does not affect the weight-bearing surface and can effectively be ignored.

-Isolated posterior wall fractures are the most common acetabular fracture pattern. The hip is generally considered stable and be treated with protected weight bearing if there is less than 20% wall disruption. It is considered unstable if >40% is involved. A gray area exists between these endpoints, with cases assessed on an individual basis.

**The surgical approach to hip reduction generally proceeds from the direction of dislocation to avoid further damage to the blood supply.

QUESTIONS:

1) What is the most common direction for a hip dislocation?

2) What are the six radiographic markers examined on an AP Pelvic radiograph?

Key terms

|Instructions for authors |

|For learning and indexing purposes, suggest the key terms associated with this condition. |

Acetabulum, Hip, Hip Dislocation, Elementary Fracture pattern, Associated fracture pattern, Sciatic Nerve, Avascular Necrosis (AVN), Post-Traumatic Arthritis, Heterotopic Ossification (HO), Roof Arc Angle, Subchondral Arc, Marginal Impaction, Kocher-Langenbeck approach, Smith-Peterson approach

Skills

|Instructions for authors |

|Students, according to the Association of American Medical Colleges, must acquire the necessary “knowledge, skills and attitudes” to practice |

|medicine. Obviously, a book concentrates on “knowledge”. Attitudes are perhaps more nebulous and taught implicitly. Skills, on the other hand,|

|can be taught----but perhaps not in a book. Therefore, please list here the skills related to the knowledge presented above for which students|

|must seek bedside instruction. |

|This section should also prove useful to for those who want to map this text to a competency based curriculum. |

Radiographic Analysis, Recognition/Treatment of Emergent Orthopaedic Conditions (Hip Dislocation/Open fractures), Extremity Neurovascular Examination (sciatic nerve)

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