Pipkin's classification1 is still used widely to describe femoral head fractures, despite the classification's utility being challenged 3 decades ago.2 Results after injury are guarded,3 and controversy regarding the treatment of these fractures is likely related to their relatively infrequent occurrence compared with other fractures associated with hip dislocation. However, the relative indications for fragment excision and open reduction and internal fixation remain unclear, and their comparative clinical outcomes are unknown. Indications for operative treatment include an inability to reduce the hip, a nonconcentric reduction, fracture fragments within the articulating surface of the hip, and associated injuries. The decision to reduce and fix femoral head fractures seems to be based, in most surgeons' experience, on the expectation of restoring stability of the hip through a physiologic range of motion and/or an attempt to minimize ongoing cartilage injury in a fracture involving a portion of the weight–bearing femoral head. The modified Smith–Petersen approach has been described for use in operative treatment of these injuries4 and is demonstrated in this video (see Video, Supplemental Digital Content 1, http://links.lww.com/JOT/A391).
A 16-year old boy sustained a hip dislocation as the result of a motor vehicle crash in which he was unrestrained. He presented with a shortened, internally rotated and flexed right lower extremity, with pain on attempts at hip range of motion. Distally he was neurovascularly intact. An initial pelvic radiograph demonstrated a posterior hip dislocation with a femoral head fracture. This was urgently reduced in the emergency room and reduction confirmed with radiographs. A CT was performed demonstrating a Pipkin II femoral head fracture with comminution extending into the posterior and cranial weight-bearing surface of the femoral head. The patient was indicated for open reduction and internal fixation based on the size and cranial extent of the fracture.
The patient was positioned supine on a radiolucent table, and the distal limb of the Smith–Petersen approach was taken from the anterior superior iliac spine toward the lateral patella over 20 cm. The interval between the tensor fascia lata and sartorius is defined, and careful dissection is performed through the deep fascia of the thigh to identify and protect the lateral femoral cutaneous nerve. Deeper, the interval between the rectus femoris and the gluteus medius is exploited, and the hip is flexed with a bolster under the knee to relax the rectus femoris. The rectus femoris direct head is circumferentially dissected and then divided, leaving a small residual tendon proximally for later repair. Branches of the lateral femoral circumflex artery are identified and ligated. The indirect head of the rectus femoris is elevated, and the precapsular fat and iliocapsularis muscle are excised. A T-shaped capusulotomy is performed with care taken to protect the hip labrum. Once the capsulotomy is performed, the fracture is visualized. This can be improved with external rotation of the hip. Fracture cleansing, reduction, and fixation can be performed with or without (seen here) an anterior hip dislocation. The fracture was displaced, loose fracture fragments were excised, the dominant fracture fragment reduced, and temporary fixation achieved with Kirschner wires. Unicortical, countersunk mini-fragment screws (2.7-, 2.4-, or 2.0-mm screws) can be used to fix the reduced femoral head fracture. The capsulotomy is either left open or closed, and the rectus femoris is repaired with large gauge suture. The remaining wound is closed in layers. Drain use is left to the discretion of the surgeon and decision is based on edema, hemorrhage, and dead space in the surgical site. Typical postoperative treatment includes toe-touch weight-bearing on the injured extremity for 8–12 weeks, with instruction in posterior hip precautions.
1. Pipkin G. Treatment of grade IV fracture-dislocation of the hip
. J Bone Joint Surg Am. 1957;39-A:1027–1042 passim.
2. Brumback RJ, Kenzora JE, Levitt LE, et al. Fractures of the femoral head. Hip
3. Stannard JP, Harris HW, Volgas DA, et al. Functional outcome of patients with femoral head fractures associated with hip
dislocations. Clin Orthop Relat Res. 2000:44–56.
4. Scolaro JA, Marecek G, Firoozabadi R, et al. Management and radiographic outcomes of femoral head fractures. J Orthop Traumatol. 2017;18:235–241.