Fractures of the femoral head are commonly seen in association with traumatic hip dislocations (1,2,3,4,5,6). Hip dislocations are usually the result of high-energy injuries and are posterior in 82% to 94% of cases (3,7,8). They are typically the result of a dashboard injury with an axial load transmitted through the flexed hip (5,8,9,10). The reported incidence of femoral head fractures in patients with posterior dislocations of the hip ranges from 7% to 16% (1,4,10,11). Anterior hip dislocations are less common but can also be associated with femoral head fractures; according to one series, femoral head fractures were seen in 15% of anterior hip dislocations (12), and in another, up to 77% of anterior hip dislocations involved femoral head fractures (3).

Emergent reduction of the femoral head is undertaken to decrease the risk of avascular necrosis, which is secondary to ischemia caused by tension on the blood supply of the femoral head (13,14,15,16). This treatment is preferably done within 6 to 12 hours from the time of injury (4,13,17). Prior to attempting a closed reduction, the surgeon should exclude the presence of a concomitant femoral-neck fracture. Postreduction, an axial computed tomography (CT) scan with 2-mm cuts is necessary to ensure concentric reduction (5,18,19). Typically, open reduction and internal fixation (ORIF) is required for definitive management of the femoral head fracture (4). At the same time, the surgeon can address other associated musculoskeletal injuries, which commonly include fractures of the acetabulum as well as the femoral neck and shaft (4). As these injuries are often seen in the setting of high-energy trauma, the patient must be evaluated appropriately for associated abdominal, thoracic, and craniofacial injuries (8).

Urgent ORIF of the fragments is warranted in the presence of femoral neck fracture, postreduction hip-joint asymmetry, progressive sciatic-nerve injury, or an intra-articular fragment displacement of at least 2 mm or that renders the hip unstable (1,20,21,22). For
Pipkin type I or II femoral-head fractures, free or nonreduced fragments that remain after reduction must be excised or reduced and stabilized to avoid early posttraumatic arthrosis (5,11,14,17). Historically, recommendations have included excision of large fragments, including those that measure up to one third of the femoral head (2,4,5,21). However, because the entire acetabulum is involved in weight bearing (23), any fragment that is amenable to fixation should be rigidly fixed. Smaller fragments may be excised (6,14,22,23,24,25,26,27,28), and avulsion fractures of the ligamentum teres can be treated conservatively.

In the past, much controversy existed with regard to the optimal surgical approach for fixation of femoral head fractures. Initially, the Kocher-Langenbeck approach was used. Through the Kocher-Langenbeck approach, surgeons can address fractures of the posterior acetabular wall but had only limited access to the articular surface of the femoral head for fracture reduction and fixation. In addition, some studies identified an increased incidence of avascular necrosis of the femoral head when Kocher-Langenbeck was used instead of the Smith-Peterson approach (26,27).

Through the Smith-Petersen method, the surgeon has access to the anterior portion of the femoral head for debridement of intra-articular debris. However, this approach does not allow complete visualization of the femoral head, nor can the surgeon address posterior acetabular-wall fractures. In addition, heterotopic ossification has been shown to be a significant risk with the anterior approach (24,27). While combined anterior and posterior approaches would improve visualization in the case of extensive femoral-head fractures, the risk of complication is increased with such extensive dissection.

In 2001, Ganz et al (29

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