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Femoral head fractures

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Head fractures classified as Pipkin types 1 and 2 with concentric reduction and no loose fragments in the joint can be treated non-operatively. These criteria can be determined with CT scans.

Operative indications include loose intraarticular fragments, irreducible dislocation or residual subluxation of the femoral head, comminuted Pipkin 2s involving the superior weight bearing portion of the femoral head, Pipkin 3 and Pipkin 4 in which the acetabular fracture requires operative fixation.  Surgical approaches include the modified Smith-Peterson approach for more anterior fractures or a posterolateral approach with trochanteric osteotomy and surgical dislocation of the hip.

Owing to the paucity of series reported in the literature, treatment recommendations appear to be based on common sense and experience rather than evidence. These include:

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With femoral head fracture and dislocation there can be injury to the blood vessels supplying the head, namely the medial femoral circumflex, leading to AVN or nonunion of the femoral head fragment. This same vascular supply is also at risk if a posterior surgical dislocation is chosen as part of treatment. It is also possible to damage the articular cartilage, leading to a post traumatic DJD. Also, stretch injuries to the nerves can lead to palsies, and stretch injuries to the blood vessels can lead to thrombosis. Post injury heterotopic ossification is not uncommon after surgery.

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