Femoral head fracture

Simplifying fracture of the femoral head. All information are collected from authentic sources.

1. Femoral head fracture Dr. Ashiqur Rahman Resident Orthopedics Dhaka Medical College & Hospital

2. Introduction Femoral head fractures often go undiagnosed with potentially devastating consequences. Rapid and accurate assessment of the severity of the injury is necessary to allow recognition of patients in need of urgent orthopedic care. Femoral head fractures occur in association with 5-15 % of hip dislocations.

3. Anatomy of femoral head Femoral head forms more than half a sphere, & is directed medially, upwards & slightly forward. It articulates with the acetabulum to form the hip joint. A roughened pit is situated just below & behind the centre of the head. This pit is called the fovea.

4. Vascular supply of femoral head 90% of vascular supply via an intracapsular plexus surrounding the femoral neck. Supply originates from two branches of the femoral artery: Medial circumflex artery Lateral circumflex artery. 10% is supplied via the foveal artery, which runs through the ligamentum teres .

5. Blood supply of femoral head

6. Force causing femoral head fracture Compression Results from impaction of the femoral head upon the acetabulum

7. Contd.. Shearing: Typically an oblique fracture through the femoral head Often displaced

8. The Pipkins classification of femoral head fractures Originally proposed by Pipkins in 1957. Categorizes femoral head fractures into four types, increasing in order of severity. Has implications both for surgical management and prognostic outcome.

9. Pipkin type I F racture of the non weight bearing portion of the femoral head only, fracture line is inferior to fovea

10. Pipkins type II F racture of the weight bearing portion of the femoral head, superior to or involving fovea

11. Pipkin type III F racture of femoral head with associated neck fracture

12. Pipkin type IV Any pattern of femoral head fracture & acetabular fracture(coincides with Thompson & Epsteins type V i.e Dislocation with fracture through acetabular floor & femoral head )

13. Diagnosis X ray : Commonly used X –Ray Pelvis AP view X-Ray Hip lateral view Judet views CT scan: gold standard for diagnosing femoral head fracture MRI: infrequently used

14. Management Type I( Camb .) When the femoral head fragment is large should be rigidly fixed. More controversy exists over smaller fragments. Some recommend acute excision, whereas other believe the fragment can be treated non-operatively .

15. Type II Operative management: Excision of large fragments will create instability,& thus is contraindicated. ORIF of the fragment either with countersunk 2.7mm or 3.5mm cortical screws or head-less compression screws (Herbert screw). We typically use smith – Peterson approach for pipkin’s type – I & II.

16. Type III Pipkin’s type – III fractures are rare, & data to guide management of injuries are lacking. In young pt. we usually proceed with ORIF. Older pt. treated with Hemi-arthroplasty.

17. Femoral Head Fracture-Dislocation with Displaced Femoral Neck Fracture Closed reduction attempts are futile. ORIF in young: open reduction of hip, then reduction and stabilization of femoral neck and head. Arthroplasty in middle-aged and elderly (No good results with ORIF reported in literature).

18. Femoral Head Fracture-Dislocation with Non-Displaced Femoral Neck Fracture Must consider stabilizing femoral neck fracture before performing reduction of hip .

19. Type IV Fractures Surgical dislocation of the hip for the treatment of pipkin type-IV # (ORIF of the posterior wall of the acetabulum). Femoral head fracture require concurrently, as directed by criteria for Type I and Type II injuries.

20. complications AVN of femoral head Sciatic nerve injury Post traumatic arthritis Heterotopic ossification Vascular injury