Updated: 2/29/2020

Femoral Head Fractures

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https://upload.orthobullets.com/topic/1036/images/pipkin 1.jpg
https://upload.orthobullets.com/topic/1036/images/hip position.jpg
https://upload.orthobullets.com/topic/1036/images/blood supply.jpg
https://upload.orthobullets.com/topic/1036/images/pipkin 2 4.jpg
https://upload.orthobullets.com/topic/1036/images/pipkin ii.jpg
Introduction
  • Overview
    • femoral head fractures are rare traumatic injuries that are usually associated with hip dislocations
      • treatment may be nonoperative or operative depending on the location of the fracture and degree of fracture displacement. 
  • Epidemiology
    • incidence
      • rare
      • increasing because of more MVA and better resuscitation
  • Pathophysiology 
    • mechanism of injury 
      • impaction, avulsion or shear forces involved 
        • unrestrained passenger MVA (knee against dashboard) 
        • falls from height 
        • sports injury
        • industrial accidents 
    • pathoanatomy
      • the location and size of the fracture fragment and degree of comminution depend on the position of the hip at the time of dislocation  
        • 5-15% of posterior hip dislocations are associated with a femoral head fracture because of contact between femoral head and posterior rim of acetabulum
        • anterior hip dislocations are associated with impaction/indentation fractures of the femoral head
  • Associated conditions
    • femoral neck fracture (see Pipkin Classification below)
    • acetabular fracture (see Pipkin Classification below)
    • sciatic nerve neuropraxia
    • femoral head AVN
    • ipsilateral knee ligamentous instability (knee vs dashboard)
Anatomy
  • Blood supply
    • medial femoral circumflex artery (MFCA)   
      • main blood supply to the weightbearing portion of the femoral head 
      • MFCA originates from the profunda femoris 
    • artery to the ligamentum teres
      • lesser blood supply (10-15%)
      • from the obturator artery or MFCA
      • supplies perifoveal area
Classification
 
Pipkin Classification 
Type I
Fx below fovea/ligamentum (small)
Does not involve the weightbearing portion of the femoral head
  
Type II Fx above fovea/ ligamentum (larger)
Involves the weightbearing portion of the femoral head 
   
Type III Type I or II with associated femoral neck fx
High incidence of AVN
 
Type IV Type I or II with associated acetabular fx (usually posterior wall fracture)  
 
Presentation
  • History
    • frontal impact MVA with knee striking dashboard
    • fall from height 
  • Symptoms
    • localized hip pain
    • unable to bear weight
    • other symptoms associated with impact
  • Physical exam
    • inspection
      • shortened lower limb
        • with large acetabular wall fractures, little to no rotational asymmetry is seen
      • posterior dislocation
        • limb is flexed, adducted, internally rotated
      • anterior dislocation
        • limb is flexed, abducted, externally rotated
      • ipsilateral knee 
        • ligamentous stability 
    • neurovascular
      • may have signs of sciatic nerve injury
Imaging
  • Radiographs
    • recommended views
      • AP pelvis, hip series 
        • both pre-reduction and post-reduction
      • judet views 
        • associated acetabular fracture 
      • inlet and outlet views
        • associated pelvic ring injury 
  • CT scan
    • indications
      • after reduction
      • to evaluate:
        • concentric reduction
        • loose bodies in the joint
        • acetabular fracture
        • femoral head or neck fracture
    • findings
      • femoral head fracture (size, location, comminution) 
      • plane of femoral head fracture
      • intra-articular fragments
      • posterior pelvic ring injury
      • impaction
      • acetabular fracture
Treatment
  • Nonoperative
    • hip reduction
      • indications
        • acute dislocations
          • reduce hip dislocation within 6 hours
      • outcomes
        • 5-40% incidence of femoral head osteonecrosis 
        • increased risk with increased time to reduction 
    • TDWB x 4-6 weeks, restrict adduction and internal rotation
      • indications
        • Pipkin I
        • nondisplaced Pipkin II with < 1 mm step off
        • no interposed fragments
        • stable hip joint
      • outcomes
        • satisfactory results if <1mm step off, serieal radiographs required 
        • development of post-traumatic arthritis based on joint incongruity and initial cartilage damage
  • Operative
    • ORIF
      • indications
        • Pipkin II with > 1 mm step off
        • if performing removal of loose bodies in the joint
        • associated neck or acetabular fx (Pipkin type III and IV)
        • polytrauma
        • irreducible fracture-dislocation
        • Pipkin IV
          • treatment dictated by characteristics of acetabular fracture
          • small posterior wall fragments can be treated nonsurgically and suprafoveal fractures can then be treated through an anterior approach
      • outcomes
        • outcomes mimic those of their associated injuries (hip dislocations and femoral neck fractures)
        • poorer outcomes associated with 
          • use of posterior (Kocher-Langenbeck) approach
          • use of 3.0mm cannulated screws with washers
    • arthroplasty
      • indications
        • Pipkin I, II (displaced), III, and IV in older patients
        • fractures that are significantly displaced, osteoporotic or comminuted
      • outcomes
        • best resereved for older patients 
        • higher dislocation risk than THA performed for OA 
    • arthroscopy 
      • indications
        • removal of loose bodies
      • outcomes
        • dependent on ability to remove incarcerated fragments and initial cartilage damage
Techniques
  • hip reduction
    • technique
      • adequate sedation and muscular relaxation are vital 
      • traction in-line with the thigh, extremity slightly adducted, counterforce on pelvis 
      • forceful reduction should be avoided 
      • obtain post reduction CT
  • TDWB x 4-6 weeks, restrict adduction and internal rotation
    • technique
      • perform serial radiographs to document maintained reduction
  • ORIF of femoral head (Pipkin I, II, III)
    • approach
      • anterior (Smith-Peterson) approach 
        • utilizes internervous plane between the superior gluteal and femoral nerves
        • improved visualization
        • reduced surgical time 
        • improved fracture reduction 
          • femoral head fracture is commonly anteromedial 
        • lower incidence of AVN
        • less blood loss 
        • higher rate of functionally significant HO compared to posterior approach
      • anterolateral (Watson-Jones) 
        • utilizes intermuscular plane between the tensor fascia lata and gluteus medius (both superior gluteal nerve)
    • exposure
      • periacetabular capsulotomy to preserve blood supply to femoral head
    • fixation
      • two or more 2.7mm or 3.5mm lag screws    
        • countersink the heads of the screws to avoid screw head prominence
      • headless compression screws
      • bioabsorbable screws
    • postop
      • rehabilitation
        • mobilization
          • immediate early range of motion
        • weightbearing
          • delay weight bearing for 6-8 weeks
        • stress strengthening of the quadriceps and abductors
      • radiographs
        • radiographs after 6 months to evaluate for AVN and osteoarthritis
  • ORIF of femoral head and acetabulum (Pipkin IV)
    • approach
      • posterior (Kocher-Langenbeck) approach with digastric osteotomy   
        • trochanteric osteotomy allows access to both the femoral head fracture and posterior wall acetabular fracture 
        • preserves the medial circumflex artery supply to the femoral head
        • utilizes plane created by splitting of gluteus maximus (no true internervous plane)
      • anterior (Smith-Peterson) approach
        • for fixation of suprafoveal fractures
          • small posterior wall fractures may not need to be addressed surgically 
  • Arthroplasty
    • approach
      • can use any hip approach for arthroplasty
        • posterior (Kocher-Langenbeck) approach provides the best visualization of acetabular posterior wall fracture
    • pros & cons
      • allows immediate postoperative mobilization and weightbearing
      • hemiarthroplasty can be utilized if no acetabular fracture present
Complications
  • Heterotopic ossification  
    • overall incidence is 6-64%
      • anterior approach has increased heterotopic ossification compared with posterior approach
    • treatment
      • administer radiation therapy if there is concern for HO
        • especially if there is an associated head injury
  • AVN
    • incidence is 0-23%
      • risk is greater with delayed reduction of dislocated hip
      • anterior approach not associated with increased AVN risk 
  • Sciatic nerve neuropraxia
    • incidence is 10-23%
      • usually peroneal division of sciatic nerve
      • spontaneous recovery of function in 60-70%
  • DJD
    • incidence 8-75%
    • due to joint incongruity or initial cartilage damage
  • Decreased internal rotation
    • may not be clinically problematic or cause disability
 

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(OBQ11.123) Assuming the images represent isolated injuries, which of the following Figures demonstrates a Pipkin II femoral head fracture? Review Topic | Tested Concept

QID: 3546
FIGURES:
1

Figure A

4%

(70/1851)

2

Figure B

22%

(409/1851)

3

Figure C

17%

(309/1851)

4

Figure D

56%

(1036/1851)

5

Figure E

1%

(16/1851)

L 3 C

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Evidences (13)
VIDEOS (1)
CASES (13)
Topic COMMENTS (22)
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