Kevin D. Phelps MDJoshua L. Gary MD and Milton Lee “Chip” Routt Jr MD Department of Orthopaedic Surgery, McGovern Medical School at UTHealth, Houston, TX, USA Although operative reduction and fixation are recommended for most displaced femoral head fractures, the treating physician must know which injury types are best managed nonoperatively. The primary goal of treatment is to achieve/maintain a healed, viable, comfortable, functional, stable, and congruent hip joint. Femoral head fractures are uncommon injuries occurring in only 10–15% of native hip dislocations, and are usually due to a high‐energy traumatic event such as a head‐on motor vehicle collision.1 The most commonly used classification system is that described by Pipkin, who initially divided femoral head fractures into four types.2 Type I fractures are those caudal to the fovea capitis, type II fractures are those cephalad to the fovea capitis, type III fractures were those associated with a femoral neck fracture, and type IV fractures were those associated with a fracture of the acetabular rim. The treatment options for displaced femoral head fractures with associated hip joint instability are almost always operative unless the intervention would pose a significant risk to the patient’s life. Urgent management should include a prompt and concentric manipulative reduction. Outcomes following femoral head fracture have historically been evaluated using the Thompson and Epstein scale.3 This system divides the radiographic outcomes into excellent, good, fair, and poor based on the following criteria: High‐quality evidence pertaining to the treatment of femoral head fractures is limited due to the low incidence of the injury. Two randomized controlled trials4,5 (level I) and a systematic review of 29 retrospective studies reporting on 453 femoral head fractures1 (level II) constitute the best available evidence. Chen et al. randomized 24 patients aged 18–60 with suprafoveal Pipkin II fractures to operative versus nonoperative treatment.4 The operative patients were treated using a Smith‐Petersen exposure within 12 hours of injury (without attempted preoperative closed reduction) followed by skin traction for six weeks to restrict hip motion. The nonoperative patients had manipulative closed reductions within 12 hours of injury and were placed in skeletal traction for six weeks. The patients were then followed for a minimum of two years after injury. According to the Thompson and Epstein scoring system,3 there were two excellent, three good, five fair, and two poor outcomes in the nonoperative group compared to five excellent, five good, and two fair outcomes in the operative group. One patient in the nonoperative group and five in the operative group developed heterotopic ossification. Two patients developed femoral head aseptic necrosis, both of which were in the nonoperative group. The results from this study concluded that patients with Pipkin type II fractures have improved outcomes when treated operatively. Lin et al. randomized 36 patients with infrafoveal Pipkin type I fractures into an emergent surgical reduction and fixation group (group one, less than six hours to surgical intervention) and a secondary operative fixation group (group two, closed reduction followed by surgery more than two days after injury).5 All patients underwent a Smith‐Petersen surgical exposure. Patients in group one had 10 excellent, 4 good, 2 moderate, and 2 poor outcomes on the Thompson and Epstein scale compared to 3 excellent, 7 good, 3 moderate, and 5 poor outcomes in group two. Although these data suggest that expeditious treatment of Pipkin I fractures may improve overall clinical outcome, 9 of the 18 patients in group two had a nonconcentric hip after the initial closed reduction due to large fragments interposed in the articular surface. This group of patients had decreased Thompson and Epstein scores and a higher rate of femoral head aseptic necrosis (4/9 in those with a nonanatomic initial reduction compared to 1/9 in those with an anatomic reduction). The study concluded that surgery should be performed on an urgent basis in hips that remain nonconcentric following an emergent closed reduction. Giannoudis et al. performed a systematic review of 29 retrospective clinical studies involving 453 femoral head fractures.1 Outcomes data were available for 256 total cases. Criteria noted for conservative treatment included anatomical, concentric closed reduction of the hip dislocation and femoral head fracture, absence of intra‐articular osteochondral fragments, and a stable hip joint. Those patients treated conservatively (54 cases) resulted in 7 (13%) excellent, 16 (29.6%) good, 15 (27.8%) fair, and 16 (26.9%) poor outcomes while those treated operatively (202 cases) resulted in 31 (15.3%) excellent, 92 (45.5%) good, 32 (15.8%) fair, and 47 (23.3%) poor outcomes. Pipkin type I fractures represented the largest percentage of the nonoperative group at 25.3%. Of those Pipkin type I fractures that were managed operatively, 86.7% that had fragment excision had excellent or good results. The treating surgeon must be familiar with the advantages and disadvantages for each surgical approach when formulating a surgical plan for femoral head fractures.
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Femoral Head Fractures
Clinical scenario
Top three questions
Question 1: In patients with femoral head fractures, which types benefit from operative intervention more than others?
Rationale
Clinical comment
Available literature and quality of the evidence
Findings
Resolution of clinical scenario
Question 2: In patients with operatively treated femoral head fractures, does a surgical dislocation utilizing an anterior surgical approach result in improved outcomes compared to the digastric trochanteric flip osteotomy?
Rationale
Clinical comment
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