Updated: 6/8/2022

Femoral Head Fractures

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https://upload.orthobullets.com/topic/1036/images/pipkin iv.jpg
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  • Summary
    • Femoral head fractures are rare traumatic injuries that are usually associated with hip dislocations.
    • Diagnosis can be made by pelvis/hip radiographs but frequently require CT scan for surgical planning. 
    • Treatment may be nonoperative or operative depending on the location of the fracture and degree of fracture displacement.
  • Epidemiology
    • Incidence
      • rare
        • seen in 12% of patients with hip dislocations
          • increased incidence due to higher MVAs and better resuscitation
  • Etiology
    • 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
      • Fracture below fovea/ ligamentum (small)
      • Does not involve the weight-bearing portion of the femoral head
      • Fracture above fovea/ ligamentum (larger)
      • Involves the weight-bearing portion of the femoral head
      • Type III
      • Type I or II with an associated femoral neck fracture
      • 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
        • post reduction to evalute for loose bodies and presence/size of fracture fragments
      • 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
            • serial 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)
            • high rate of AVN and catastrophic failure following ORIF of Pipkin III injuries 
          • 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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Questions (6)
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(SBQ18TR.8) A 25-year-old male runs into a tree while going 45 mph on his motorcycle. He presents to your level 1 trauma hospital with the injuries shown in figures A through C. After closed reduction, which of the following is true with respect to treatment for this patient?

QID: 211188

Heterotopic ossification is uncommon



Minifragment screws are sufficient for fracture fixation



Kocher-Langenbeck is the optimal surgical approach for this injury



Fragment excision leads to improved outcomes compared to open reduction and internal fixation



A 2 mm fragment step-off is considered the cut-off for non-surgical management



L 5 A

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(SBQ12TR.51.1) A 25-year-old man sustains the injury shown in Figures A-C. What is the primary advantage of using a trochanteric flip osteotomy (TFO) in treating this injury?

QID: 213587

It may be performed in a minimally invasive manner



It involves minimal soft tissue stripping



It leads to higher union rates



It allows the surgeon to address all sites of injury through one approach



Answers 1 and 2



L 5 C

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

QID: 3546

Figure A



Figure B



Figure C



Figure D



Figure E



L 3 C

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Evidence (13)
CASES (17)
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