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大標題(大小：14，中文：標楷體，英文：Calibri)
1. 大方向
A. 內文大小：12，中文一樣使用標楷體，英文使用 Calibri，標點符號使用全型
B. 邊界使用窄(可以節省空間，一頁塞下更多內容)，位置再「版面配置」→「邊界」裡面可以
選擇邊界要哪種(見下圖)

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C. 內容中如果覺得是重點處可以使用底線＋粗
 下面子項的符號大家可以隨意發揮
 盡量子項到這層就好，再多建議直接換新的大標

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CH51 Hip Dislocations and Femoral Head Fractures
壱. Introduction to Hip Dislocations and Femoral Head Fractures
1. 好發年紀: early 30’s .
2. Event : 通常是 high energy trauma , ex: motor vehicle accidents
3. 看到 hip dislocation 需評估的 factor : The type of dislocation, direction, and the presence of a
fracture are all influenced by the amount of energy involved, the position the hip is in at the time of
injury, and the morphology of the hip
4. 看急診遇到 hip dislocation 需評估: standard trauma evaluation, a meticulous musculoskeletal and
neurologic examination, and detailed radiographic assessment to avoid missing injuries.
5. Hip dislocation outcome factor :
A. 不可改變的 factor : Cartilage damage, impacted femoral head fragments, and injury to medial
femoral circumflex artery (MFCA)
B. 可改變的 factor : timing and accuracy of the reduction
6. Poor outcome and complication : arthritis, avascular necrosis (AVN), neurologic injury, heterotopic
ossification , and re-dislocation
A. 後續產生 bad outcome 機會: 50%

弐. Assessment of Hip Dislocations

1. Evaluation of the entire patient!!!!(因為常常有 associated injuries)
2. 需考慮各種會影響 hip dislocation 的因子: the mechanism, the presence of any anatomic
characteristics that may predispose the patient to an unstable hip joint, and associated injuries that
will affect treatment plan.

参. Mechanisms of Injury for Hip Dislocations

1. 最多的原因: high-energy motor vehicle trauma
2. 其他的原因: falls, pedestrians struck by motor vehicles, industrial accidents, and athletic injuries
3. 影響 dislocation 方向或是合併 fracture 的因子:
A. The position of the hip
B. the force vector applied
C. the individual's anatomy
<TABLE 51-1>Direction of Hip Versus Injury Pattern(跟轉腳差不多)
Flexion, adduction, IR Pure posterior dislocation
Partial flexion, less adduction, IR Posterior fracture–dislocation
Hyperabduction, extension, ER Anterior dislocation
4. Posterior dislocation mechanism : dashboard injury=> hip flexion with axial loading
 A. Letournel vector analysis( for force vector applied)
<figure51-1>The position of the hip during axial loading determines the type of injury

Increasing flexion, adduction, and IR pure dislocation

lesser degrees of flexion,adduction and IR fracture–dislocation. Ex: acetabulum posterior wall
fracture, pipkin femoral head fracture

B. the individual's anatomy(femoral head anatomy)

decrease in femoral anteversion , or retroversion pure dislocations 機會增加
greater anteversion and less internal rotation Fracture dislocation 機會增加
Ref: Biological factors predisposing to traumatic posterior dislocation of the hip: a selection process in the mechanism of injury. J
Bone Joint Surg Br. 1985

5. anterior dislocation mechanism : hyperabduction and extension

 A. degree of hip flexion determined the type of anterior dislocation
More Hip extension Leading to a superior pubic dislocation
More hip flexion resulting in an inferior obturator dislocation

6. 其他容易造成 hip dislocation 的運動: skiing and snowboarding injuries

A. snowboarding was five times higher than skiing (0.45 vs. 0.09/100,000)
B. snowboarding 造成的 posterior dislocation 有 30 趴機會造成 femoral head fractures

7. femoroacetabular impingement 可能也與這些 traumatic hip instability 有關,須待相關研究

A. Decreased femoral head-neck offset (CAM type) or a deep acetabulum (PINCER type) may exist in
these athletes who sustain a hip dislocation or even a subluxation
8. Fatigue fractures of the femoral head may also occur in patients with osteopenia(這邊突然神來一筆
在講 femoral head fracture~所以參考就好)
A. reported as “subchondral impaction” or “insufficiency ”fractures

四. Injuries Associated with Hip Dislocations

1. Hip Dislocations 要假設當作是 multiple trauma,常合併其他 trauma
A. Intra-abdominal, head, and chest trauma are common associated injuries
B. Thoracic aortic injury 也有被報導過
C. Common associated skeletal injuries: femoral head, neck, or shaft fractures; acetabular fractures;
pelvic ring fractures; knee injuries; ankle and foot injuries; and neurologic injuries
D. Knee injury 與 Posterior dislocation 常一起出現:
 posterior dislocation, cruciate ligament injuries, and patellar fractures 合併出現機會有
25%
< Figure 51-2 > Photograph of a patient presenting after a dashboard injury.
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