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 login to view 1 more bullet Etiology Pathophysiology mechanism of injury impaction, avulsion or shear forces involved login to view 4 more bullets 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 login to view 2 more bullets 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 Type II 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 login to view 1 more bullet posterior dislocation login to view 1 more bullet anterior dislocation login to view 1 more bullet ipsilateral knee login to view 1 more bullet neurovascular may have signs of sciatic nerve injury Imaging Radiographs recommended views AP pelvis, hip series login to view 1 more bullet judet views login to view 1 more bullet inlet and outlet views login to view 1 more bullet 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 login to view 2 more bullets outcomes login to view 2 more bullets TDWB x 4-6 weeks, restrict adduction and internal rotation indications login to view 4 more bullets outcomes login to view 3 more bullets Operative ORIF indications login to view 8 more bullets outcomes login to view 5 more bullets arthroplasty indications login to view 2 more bullets outcomes login to view 2 more bullets arthroscopy indications login to view 1 more bullet outcomes login to view 1 more bullet 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 login to view 8 more bullets anterolateral (Watson-Jones) login to view 1 more bullet surgical hip dislocation with trochanteric flip osteotomy login to view 4 more bullets exposure periacetabular capsulotomy to preserve blood supply to femoral head fixation two or more 2.7mm or 3.5mm lag screws login to view 1 more bullet headless compression screws bioabsorbable screws postop rehabilitation login to view 5 more bullets radiographs login to view 1 more bullet ORIF of femoral head and acetabulum (Pipkin IV) approach posterior (Kocher-Langenbeck) approach with digastric osteotomy login to view 3 more bullets anterior (Smith-Peterson) approach login to view 2 more bullets Arthroplasty approach can use any hip approach for arthroplasty login to view 1 more bullet 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 login to view 1 more bullet 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