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Femoral Head Fractures


  • 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

          • increased incidence due to higher MVAs and better resuscitation

  • ETIOLOGY

    • Pathophysiology

      • mechanism of injury

        • impaction, avulsion or shear forces involved

          • unrestrained passenger MVA (knee against dashboard)

          • falls from height

          • sports injury

          • industrial accidents

      • 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 

          • 5-15% of posterior hip dislocations are associated with a femoral head fracture because of contact between femoral head and posterior rim of acetabulum

          • anterior hip dislocations are associated with impaction/indentation fractures of the femoral head

    • 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

          • with large acetabular wall fractures, little to no rotational asymmetry is seen

        • posterior dislocation

          • limb is flexed, adducted, internally rotated

        • anterior dislocation

          • limb is flexed, abducted, externally rotated

        • ipsilateral knee

          • ligamentous stability

      • neurovascular

        • may have signs of sciatic nerve injury

  • IMAGING

    • Radiographs

      • recommended views

        • AP pelvis, hip series

          • both pre-reduction and post-reduction

        • judet views

          • associated acetabular fracture

        • inlet and outlet views

          • associated pelvic ring injury

    • 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

          • acute dislocations

            • reduce hip dislocation within 6 hours

        • outcomes

          • 5-40% incidence of femoral head osteonecrosis

          • increased risk with increased time to reduction

      • TDWB x 4-6 weeks, restrict adduction and internal rotation

        • indications

          • Pipkin I 

             

          • nondisplaced Pipkin II with < 1 mm step off

          • no interposed fragments

          • stable hip joint

        • outcomes

          • satisfactory results if <1mm step off

            • serial radiographs required

          • development of post-traumatic arthritis based on joint incongruity and initial cartilage damage

    • Operative

      • ORIF

        • indications

          • Pipkin II with > 1 mm step off

          • if performing removal of loose bodies in the joint

          • associated neck or acetabular fx (Pipkin type III and IV)

          • polytrauma

          • irreducible fracture-dislocation

          • Pipkin IV

            • treatment dictated by characteristics of acetabular fracture

            • small posterior wall fragments can be treated nonsurgically and suprafoveal fractures can then be treated through an anterior approach

        • outcomes

          • outcomes mimic those of their associated injuries (hip dislocations and femoral neck fractures)

            • high rate of AVN and catastrophic failure following ORIF of Pipkin III injuries  

               

          • poorer outcomes associated with

            • use of posterior (Kocher-Langenbeck) approach

            • use of 3.0mm cannulated screws with washers

      • arthroplasty

        • indications

          • Pipkin I, II (displaced), III, and IV in older patients

          • fractures that are significantly displaced, osteoporotic or comminuted

        • outcomes

          • best resereved for older patients

          • higher dislocation risk than THA performed for OA

      • arthroscopy

        • indications

          • removal of loose bodies

        • outcomes

          • dependent on ability to remove incarcerated fragments and initial cartilage damage

  • 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 

            

          • utilizes internervous plane between the superior gluteal and femoral nerves

          • improved visualization

          • reduced surgical time

          • improved fracture reduction

            • femoral head fracture is commonly anteromedial

          • lower incidence of AVN

          • less blood loss

          • higher rate of functionally significant HO compared to posterior approach

        • anterolateral (Watson-Jones) 

          • utilizes intermuscular plane between the tensor fascia lata and gluteus medius (both superior gluteal nerve)

        • surgical hip dislocation with trochanteric flip osteotomy 

           

          • allows for complete exposure of femoral head and acetabulum

          • similar functional outcomes to other approaches

          • higher rates of HO compared to non-osteotomy-based approaches

          • lower rates of subsequent AVN and post-traumatic osteoarthritis compared to alternative approaches

      • exposure

        • periacetabular capsulotomy to preserve blood supply to femoral head

      • fixation

        • two or more 2.7mm or 3.5mm lag screws 

           

          • countersink the heads of the screws to avoid screw head prominence

        • headless compression screws

        • bioabsorbable screws

      • postop

        • rehabilitation

          • mobilization

            • immediate early range of motion

          • weightbearing

            • delay weight bearing for 6-8 weeks

          • stress strengthening of the quadriceps and abductors

        • radiographs

          • radiographs after 6 months to evaluate for AVN and osteoarthritis

    • ORIF of femoral head and acetabulum (Pipkin IV)

      • approach

        • posterior (Kocher-Langenbeck) approach with digastric osteotomy 

            

          • trochanteric osteotomy allows access to both the femoral head fracture and posterior wall acetabular fracture

          • preserves the medial circumflex artery supply to the femoral head

          • utilizes plane created by splitting of gluteus maximus (no true internervous plane)

        • anterior (Smith-Peterson) approach

          • for fixation of suprafoveal fractures

            • small posterior wall fractures may not need to be addressed surgically

    • Arthroplasty

      • approach

        • can use any hip approach for arthroplasty

          • posterior (Kocher-Langenbeck) approach provides the best visualization of acetabular posterior wall fracture

      • 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

          • especially if there is an associated head injury

    • 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

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