Introduction A rare fracture pattern that is usually associated with hip dislocations the location and size of the fracture fragment and degree of comminution depend on the position of the hip at the time of dislocation Epidemiology incidence rare increasing because of more MVA and better resuscitation Mechanism impaction, avulsion or shear forces involved unrestrained passenger MVA (knee against dashboard) falls from height sports injury industrial accidents 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 usually 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 the femoral head has 3 sources of arterial supply extracapsular arterial ring medial circumflex femoral artery (main supply to the head) from profunda femoris lateral circumflex femoral artery ascending cervical branches artery to the ligamentum teres from the obturator artery or MCFA 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 neurovascular may have signs of sciatic nerve injury Imaging Radiographs recommended views AP pelvis, lateral hip and Judet views both pre-reduction and post-reduction inlet and outlet views if acetabular or pelvic ring injury suspected 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 intra-articular fragments posterior pelvic ring injury impaction acetabular fracture Treatment Nonoperative hip reduction indications acute dislocations reduce hip dislocation within 6 hours technique obtain post reduction CT 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 technique perform serial radiographs to document maintained reduction 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 Surgical Techniques ORIF of femoral head (Pipkin I, II, III) approach anterior (Smith-Peterson) approach the anterior (Smith-Peterson) and anterolateral (Watson-Jones) approaches provide the best visualization of the head compared with the posterior approach utilizes internervous plane between the superior gluteal and femoral nerves no increased risk of AVN shorter surgical time less blood loss ease of reduction and fixation because femoral head fragment is commonly anteromedial can use surgical hip dislocation if needed 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 provides the best visualization of femoral head fracture and acetabular posterior wall fracture preserves the medial circumflex artery supply to the femoral head utilizes plane created by splitting of gluteus maximus (no true internervous plane gluteus maximus is not denervated because it receives nerve supply well medial to the split anterior (Smith-Peterson) approach for fixation of suprafoveal fractures (if posterior wall fragments are small, they can be treated nonsurgically) 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 total hip arthroplasty favored if patient physiologically younger or if 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 associated head injury AVN incidence is 0-23% risk is greater with delayed reduction of dislocated hip the impact of anterior incision on AVN is unknown 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
QUESTIONS 1 of 2 1 2 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.123) Assuming the images represent isolated injuries, which of the following Figures demonstrates a Pipkin II femoral head fracture? Review Topic QID: 3546 FIGURES: A B C D E 1 Figure A 4% (65/1742) 2 Figure B 22% (385/1742) 3 Figure C 17% (290/1742) 4 Figure D 56% (980/1742) 5 Figure E 1% (15/1742) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4
Login to View Community Videos Login to View Community Videos 2016 Current Solutions in Orthopaedic Trauma Ideal "Tip - Apex Distance" - Michael Archdeacon, MD, MSE (CSOT #23, 2016) Trauma - Femoral Head Fractures 2/28/2017 637 views
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