Femoral Head Fractures: A Critical Femoral Head Fractures: A Critical But Frequently Missed InjuryBut Frequently Missed Injury

Susanna C. Spence MDSusanna C. Spence MDSusanna C. Spence MDSusanna C. Spence MDManickam Kumaravel MBBSManickam Kumaravel MBBS

University of Texas Health Science Center atUniversity of Texas Health Science Center atUniversity of Texas Health Science Center at University of Texas Health Science Center at HoustonHouston

BackgroundBackgroundBackgroundBackground

Femoral head fractures:Femoral head fractures:A complication of approximately 5A complication of approximately 5--15% of 15% of posterior femoral head dislocations, however the posterior femoral head dislocations, however the p ,p ,incidence is on the rise.incidence is on the rise.33

Often go undiagnosed with potentially Often go undiagnosed with potentially g g p yg g p ydevastating consequencesdevastating consequencesRapid and accurate assessment of the severity Rapid and accurate assessment of the severity of the injury is necessary to allow recognition of of the injury is necessary to allow recognition of patients in need of urgent orthopedic care.patients in need of urgent orthopedic care.

ObjectivesObjectivesObjectivesObjectivesReview:

Pathophysiology Pathophysiology AnatomyAnatomyDiagnosis Diagnosis ClassificationClassificationClassificationClassificationClinical management basedClinical management based on fracture typeon fracture typeComplications and patient outcomesComplications and patient outcomesp pp p

Introduction to Femoral Head Introduction to Femoral Head FFFracturesFractures

Mechanism of injury:Motor vehicle collisionMotor vehicle collisionHip in flexion and internal rotation, resulting in Hip in flexion and internal rotation, resulting in posterior dislocation of the hip.posterior dislocation of the hip.Posterior dislocation variably results in:Posterior dislocation variably results in:

Fracture of the posterior wall of the acetabulumFracture of the posterior wall of the acetabulumFemoral head fracturesFemoral head fracturesCartilaginous or ligamentous injuries.Cartilaginous or ligamentous injuries.

Vascular Supply of the Femoral HeadVascular Supply of the Femoral HeadVascular Supply of the Femoral HeadVascular Supply of the Femoral Head

~ 90% of vascular supply via an intracapsular plexus ~ 90% of vascular supply via an intracapsular plexus pp y p ppp y p psurrounding the femoral neck. Supply originates from surrounding the femoral neck. Supply originates from two branches of the femoral artery:two branches of the femoral artery:

Medial circumflex arteryyLateral circumflex artery

~ 10% is supplied via the ~ 10% is supplied via the foveal artery, which runs , which runs through the ligamentum teresthrough the ligamentum teresthrough the ligamentum teres.through the ligamentum teres.

Therefore, femoral neck fracture resulting in injury to the Therefore, femoral neck fracture resulting in injury to the i t l l i f lik l t lt ii t l l i f lik l t lt iintracapsular plexus is far more likely to result in intracapsular plexus is far more likely to result in avascular necrosis of the femoral head than avulsion of avascular necrosis of the femoral head than avulsion of the ligamentum teres.the ligamentum teres.

Methods of DiagnosisMethods of DiagnosisMethods of DiagnosisMethods of DiagnosisPlain film radiography:g p y

Posterior hip dislocation may be obvious, but small femoral head Posterior hip dislocation may be obvious, but small femoral head fractures may be obscured by overlying structures. fractures may be obscured by overlying structures. Orthogonal views are often helpful. Orthogonal views are often helpful.

CT:Gold standard for diagnosis of femoral head fractures.Gold standard for diagnosis of femoral head fractures.Gold standard for diagnosis of femoral head fractures.Gold standard for diagnosis of femoral head fractures.3D CT also allows for an accurate anatomic depiction of the 3D CT also allows for an accurate anatomic depiction of the femoral head, and is helpful for orthopedic planning.femoral head, and is helpful for orthopedic planning.

MRI:infrequently used in the trauma setting, but often used for follow infrequently used in the trauma setting, but often used for follow up of patients undergoing expectant management.up of patients undergoing expectant management.up of patients undergoing expectant management. up of patients undergoing expectant management.

Types of Femoral Head FracturesTypes of Femoral Head FracturesTypes of Femoral Head FracturesTypes of Femoral Head Fractures

Compression type:Compression type:

Analogous to a Hillsach’sAnalogous to a Hillsach’sAnalogous to a Hillsach s Analogous to a Hillsach s injuryinjuryResults from impaction of Results from impaction of the femoral head upon the femoral head upon the acetabulum.the acetabulum.

Types of Femoral Head FracturesTypes of Femoral Head FracturesTypes of Femoral Head FracturesTypes of Femoral Head Fractures

Avulsion/ shearing injury

Typically an oblique Typically an oblique fracture through the fracture through the fffemoral headfemoral headOften displacedOften displaced

The Pipkin ClassificationThe Pipkin ClassificationThe Pipkin ClassificationThe Pipkin Classification

Originally proposed by Pipkin in 1957Originally proposed by Pipkin in 195711Originally proposed by Pipkin in 1957Originally proposed by Pipkin in 1957The most widely used femoral head The most widely used femoral head classification system in the surgical literatureclassification system in the surgical literaturey gy gCategorizes femoral head fractures into four Categorizes femoral head fractures into four types, increasing in order of severitytypes, increasing in order of severityyp , g yyp , g yHas implications both for surgical management Has implications both for surgical management and prognostic outcomeand prognostic outcome

The Pipkin ClassificationThe Pipkin ClassificationThe Pipkin ClassificationThe Pipkin Classification

Type I:Type I: fracture of thefracture of the nonnon--weightbearingweightbearingType I:Type I: fracture of the fracture of the nonnon weightbearing weightbearing portion of the femoral head only, inferior to portion of the femoral head only, inferior to the foveathe foveaType II:Type II: fracture of the fracture of the weightbearingweightbearingportion of the femoral head, superior to or portion of the femoral head, superior to or p pp pinvolving the foveainvolving the foveaType III:Type III: fracture of the femoral head, with fracture of the femoral head, with ypypassociated fracture of the femoral associated fracture of the femoral neckneckType IV:Type IV: Type I or II, with associated Type I or II, with associated ypyp ypypfracture of the fracture of the acetabulumacetabulum. .

The Pipkin ClassificationThe Pipkin ClassificationThe Pipkin ClassificationThe Pipkin Classification

Type IType I Type IIType II Type IIIType III Type IVType IVType IType I Type IIType II Type IIIType III Type IVType IV

The Pipkin ClassificationThe Pipkin ClassificationThe Pipkin ClassificationThe Pipkin Classification

Type 1:Type 1: involvement of involvement of nonnon-- weightbearing weightbearing portion of the femoralportion of the femoralportion of the femoral portion of the femoral head caudad to the foveahead caudad to the fovea

Pipkin Type IPipkin Type I

Mi i ll di l d f lMi i ll di l d f lMinimally displaced femoral Minimally displaced femoral head fracture extending just head fracture extending just caudad to the foveacaudad to the fovea.

Pipkin Type IIPipkin Type IIPipkin Type IIPipkin Type II

Femoral head fracture extends Femoral head fracture extends cranial to the fovea, , involving the weightinvolving the weight--bearing surface of the jointbearing surface of the jointinvolving the weightinvolving the weight--bearing surface of the jointbearing surface of the jointOrthogonal images may be helpful in evaluating the full Orthogonal images may be helpful in evaluating the full extent of injuryextent of injury

Pipkin Type IIPipkin Type IIPipkin Type IIPipkin Type II

An anterior femoralAn anterior femoralAn anterior femoral An anterior femoral head fracture head fracture extends cranial to the extends cranial to the fovea (to the weightfovea (to the weight--bearing surface).bearing surface).

CT in the same patient

Pipkin Type IIIPipkin Type IIIPipkin Type IIIPipkin Type III

Type III injuries Type III injuries involve fractures involve fractures of the femoral of the femoral headhead andand neck.neck.head head andand neck. neck.

Pipkin Type IIIPipkin Type IIIPipkin Type IIIPipkin Type III

Fractures of theFractures of theFractures of the Fractures of the femoral head femoral head andandneck make this a neck make this a Pipkin Type III Pipkin Type III injury. injury.

IntraIntra--articular articular fragments are fragments are present within the present within the joint.joint.

Pipkin Type IVPipkin Type IVPipkin Type IVPipkin Type IV

Type I or Type II Type I or Type II injuries to the injuries to the femoral head, femoral head, with associated with associated acetabular acetabular injuries, are injuries, are classified Type IVclassified Type IV

Pipkin Type IVPipkin Type IVPipkin Type IVPipkin Type IVExtensive fractures of the Extensive fractures of the acetabulum, along with an acetabulum, along with an avulsion of the femoral head, avulsion of the femoral head, make this a Pipkin Type IVmake this a Pipkin Type IVmake this a Pipkin Type IV make this a Pipkin Type IV injuryinjury

Ready to Take a Case?Ready to Take a Case?

56 ld56 ld56 year old 56 year old male status male status post MVC. post MVC. What PipkinWhat PipkinWhat Pipkin What Pipkin classification classification would you would you give? What give? What ggdoes the does the surgeon need surgeon need to know?to know?

SolutionSolution

Initial radiograph and postInitial radiograph and post--reduction CT imagesreduction CT imagesreduction CT images reduction CT images demonstrate a Pipkin Type II demonstrate a Pipkin Type II femoral head fracture that femoral head fracture that

t d i t th ft d i t th fextends superior to the fovea. extends superior to the fovea. Tiny intraTiny intra--articular fragments are articular fragments are present. present.

Initial ManagementInitial ManagementInitial ManagementInitial Management

Full trauma evaluationFull trauma evaluationFull trauma evaluation Full trauma evaluation Immediate closed reduction of the Immediate closed reduction of the dislocated hip (within 6 hours) to reducedislocated hip (within 6 hours) to reducedislocated hip (within 6 hours) to reduce dislocated hip (within 6 hours) to reduce the risk of avascular necrosis of the the risk of avascular necrosis of the femoral headfemoral head 22femoral head.femoral head.22

Inform the clinician of associated femoral Inform the clinician of associated femoral k f t thi i id dk f t thi i id dneck fracture, as this is considered a neck fracture, as this is considered a

contraindication to closed reduction! contraindication to closed reduction! 2,32,3

Management:Management: Pipkin Type IPipkin Type IManagement: Management: Pipkin Type IPipkin Type I

Often managed nonOften managed non--operatively, with limited weightoperatively, with limited weight--bearing followed by physicalbearing followed by physicalbearing followed by physical bearing followed by physical therapy.therapy.

Indications for nonIndications for non--operative operative management include:management include:

Fracture fragment <2mm displaced Fracture fragment <2mm displaced following reductionfollowing reductionNo intraNo intra--articular free fragments articular free fragments precluding successful reductionprecluding successful reductionprecluding successful reductionprecluding successful reductionStable hip jointStable hip joint

Management:Management: Pipkin Type IIPipkin Type IIManagement: Management: Pipkin Type IIPipkin Type IIIn the past were In the past were ppmanaged nonoperatively, managed nonoperatively, with poor outcomes.with poor outcomes.55Operative management isOperative management isOperative management is Operative management is now the rule.now the rule.2, 32, 3

Significant debate Significant debate remains as to whether theremains as to whether theremains as to whether the remains as to whether the free fragment should be free fragment should be fixatedfixated or or excised.excised.

Management:Management: Pipkin Type IIIPipkin Type IIIManagement: Management: Pipkin Type IIIPipkin Type IIIInvolve fractures of the Involve fractures of the femoral neckfemoral neck inincreasedcreasedfemoral neck femoral neck inincreased creased risk of femoral head AVN.risk of femoral head AVN.Immediate surgical Immediate surgical

d ti f th f ld ti f th f lreduction of the femoral reduction of the femoral neck fracture.neck fracture.Management of the Management of the femoral head fracture femoral head fracture based on Type I or Type II based on Type I or Type II involvement. involvement. Severe cases or cases Severe cases or cases involving AVN may require involving AVN may require total joint replacementtotal joint replacementtotal joint replacement. total joint replacement.

Management:Management: Pipkin Type IVPipkin Type IVManagement: Management: Pipkin Type IVPipkin Type IVExtensive injury to the Extensive injury to the j yj yacetabulum will be acetabulum will be surgically reduced. surgically reduced.

Femoral head fracture Femoral head fracture repaired concurrently, asrepaired concurrently, asrepaired concurrently, as repaired concurrently, as dictated by criteria for dictated by criteria for Type I or Type II injury. Type I or Type II injury.

Long term results of Pipkin Long term results of Pipkin Type IV injuries are lessType IV injuries are lessType IV injuries are less Type IV injuries are less favorable.favorable.

Complications increase in Complications increase in frequency and severity fromfrequency and severity fromfrequency and severity from frequency and severity from Pipkin Type I Pipkin Type I IV, and IV, and include:include:PostPost--traumatic osteoarthritistraumatic osteoarthritisS i ti i jS i ti i jSciatic nerve injurySciatic nerve injuryAvascular necrosis of the Avascular necrosis of the femoral headfemoral headHeterotopic ossificationHeterotopic ossification

Follow up radiograph 3 weeks later AVN of the femoral head

Initial post-operative radiograph

later. AVN of the femoral head has resulted in surgical resection, and there is increasing heterotopic ossification.

Review of Management and Review of Management and O b TO b TOutcome by TypeOutcome by Type

T 1 T 2 T 3 T 4Type 1 Type 2 Type 3 Type 4

Management* Nonsurgical Fixation or Surgical Surgical 2,3 excision of

major fragment

fixation of femoral neck fracture, femoral head

fixation of acetabular fractures, femoral headfemoral head

fracture managed as per Type 1-2

femoral head fracture managed as per Type 1-2

Outcome4 Good: 75%Fair: 25%

Good: 78%Fair: 22%

Good: 50%Fair: 50%

Good: 57%Fair: 7%Poor: 36%

*In all cases, small, free intra*In all cases, small, free intra--articular fragments will be excised.articular fragments will be excised.Outcome data adapted from Marchetti et alOutcome data adapted from Marchetti et al44

Management ControversiesManagement ControversiesManagement ControversiesManagement Controversies

Management controversies remain, as to Management controversies remain, as to g ,g ,whether:whether:

An anterior or posterior surgical approach is An anterior or posterior surgical approach is preferablepreferablepreferablepreferableFragment excision or fixation should be performedFragment excision or fixation should be performed

Posterior approach: higher risk of AVN of thePosterior approach: higher risk of AVN of thePosterior approach: higher risk of AVN of the Posterior approach: higher risk of AVN of the femoral head, presumed to be because the femoral head, presumed to be because the medial circumflex artery anastomoses medial circumflex artery anastomoses

t i lt i l 66posteriorlyposteriorly66

Anterior approach: increased risk of myositis Anterior approach: increased risk of myositis ossificans without increased risk of AVNossificans without increased risk of AVN 77ossificans, without increased risk of AVN. ossificans, without increased risk of AVN.

What the Physician Needs to KnowWhat the Physician Needs to KnowWhat the Physician Needs to KnowWhat the Physician Needs to Know

Type of injury to the Type of injury to the yp j yyp j yfemoral head: does it femoral head: does it extend extend cranial to the cranial to the foveafovea??foveafovea??Is the fragment significantly Is the fragment significantly displaceddisplaced??Is there a Is there a femoral neckfemoral neckfracture?fracture?A thA th t b lt b lAre there Are there acetabularacetabularfractures?fractures?Are thereAre there intraintra--articulararticularAre there Are there intraintra articular articular fragments?fragments?

SummarySummarySummarySummary

Femoral head fractures:Femoral head fractures:Are commonly missed, with potentially Are commonly missed, with potentially devastating consequencesdevastating consequencesdevastating consequences.devastating consequences.Should be actively sought in every patient Should be actively sought in every patient

ti ith t i hi di l titi ith t i hi di l tipresenting with posterior hip dislocation.presenting with posterior hip dislocation.Morbidity increases from Pipkin Type IMorbidity increases from Pipkin Type I--IV.IV.Appropriate classification allows for rapid Appropriate classification allows for rapid and appropriate patient triage. and appropriate patient triage. pp p p gpp p p g

ReferencesReferencesReferencesReferences1. Pipkin G. Treatment of Grade IV Fracture-Dislocation of the Hip: A Review.

J Bone Joint Surg Am 1957; 39: 1027 1197J. Bone Joint Surg. Am., 1957; 39: 1027-1197.2. Asghar FA, Karunakar MA. Femoral Head Fractures: diagnosis,

management and complications. Orthop Clin N Am 2004; 35: 463-4723. Droll KP, Broekhuyse H, O’Brien P. Fracture of the Femoral Head. J Am

Acad Orthop Surg 2007; 15: 716 727Acad Orthop Surg 2007; 15: 716-7274. Marchetti MD, Steinberg GG, Coumas JM. Intermediate-Term Experience

with Pipkin Fracture-Dislocations of the Hip. J Orthop Trauma 1996; 10 (7): 455-461

5 Epstein HC Posterior fracture dislocations of the hip: Long Term Follow Up5. Epstein HC. Posterior fracture-dislocations of the hip: Long Term Follow-Up. J Bone Joint Surg Am. 1974; 56: 1103-1127.

6. Stannard JP, Harris HW, Volgas DA, Alonso JE. Functional outcome of patients with femoral head fractures associated with hip dislocations. Clin Orthop Rel Res 2000; 377: 44-56Orthop Rel Res 2000; 377: 44 56

7. Swiontkowski MF, Thorpe M, Seiler JB, Hanser ST. Operative management of displaced femoral head fractures: case-matched comparison of anterior versus posterior approaches for Pipkin I and Pipkin II fractures. J Orthop Trauma 1992; 6 (4): 437-442au a 99 ; 6 ( ) 3