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The advent of computed tomography (CT) imaging has become routine in evaluating femoral head fractures, allowing for more accurate characterization and validation of classication systems. CT imaging facilitates the identication of subtle
fracture details, including osteochondral fragments and impacted fractures, which
are often overlooked in conventional radiographs.
In this chapter, we discuss some of these atypical femoral head fractures, which
are not included in any of the classication systems but have a signicant bearing
on the outcomes of the patient.
R. K. Sen et al.
11.2 Types ofAtypical Fractures
Several uncommon patterns of femoral head fractures, often documented in isolated
case reports, are beyond the scope of the Pipkin classication and its standard management protocols. These patterns include:
1. Femoral head fracture without hip dislocation
2. Combined femoral head and neck fractures (and may be trochanteric fracture)
without hip dislocation
3. Femoral head fractures associated with anterior hip dislocation
4. Fracture of the superior part of the femur head
5. Multi-fragment, impacted, or sleeve fractures of the femoral head, with or with-
out hip dislocation
Due to the rarity of these fracture patterns and combinations, standardized management guidelines remain poorly understood. Further studies are needed to clarify
the mechanism of injury, develop appropriate treatment protocols, and improve
patient outcomes for unclassied femoral head fractures. A better understanding of
such atypical patterns will contribute to rening classication systems and optimizing surgical strategies.
11.3 Femur Head Fracture Without Hip Dislocation
A femoral head fracture is most commonly associated with posterior hip dislocation
[1, 2]. This injury pattern is typically caused by a posteriorly directed force applied
to the knee with the hip exed [1]. However, femoral head fractures without accompanying hip dislocation are a rare entity. These fracture patterns have recently
gained importance owing to sporadic case reports [3–5] (Fig.11.1). These atypical
injuries are not included in any of the existing classication systems.
11 Atypical Femur Head Fracture Pattern: Management Issues
Fig. 11.1 Fracture of the
femur head and neck
without dislocation of the
hip joint
157
11.3.1 Mechanism ofInjury
The proposed mechanism for these injuries involves high-energy trauma in which
the force is transmitted directly to the femoral head (may be lateral impaction along
with vertical shear) without causing hip dislocation [3–5]. Two additional reports
describe cases of femoral head fractures without dislocation, where the mechanism
appears to involve spontaneous reduction of the dislocation. In one case, ligament
avulsion of the femoral head was reported [6], while another involved a classical
Pipkin II fracture accompanied by an ipsilateral knee injury [7].
Management: These fracture patterns need a high index of suspicion to diagnose,
and the inability to diagnose the same leads to total hip arthroplasty [3, 4]. Some
authors have managed these fractures conservatively as well [5]. In younger patients
with such injuries, timely diagnosis is crucial, as open reduction and internal xation (ORIF) can provide favorable outcomes, especially if the fracture fragment is
extensive and involves the weight-bearing region (Pipkin II). Subarticular xation is
essential, necessitating the use of techniques such as headless compression screws,
countersinking screws, or suture anchor repair. When these injuries are diagnosed
158
a
R. K. Sen et al.
late, a planned total hip arthroplasty is typically the most appropriate treatment
strategy.
11.4 Femur Head andNeck Fracture (/Trochanter) Without
Hip Dislocation
Another pattern not described by the existing classication systems is a Pipkin’s
fracture with a sub-capital neck fracture without hip dislocation [8, 9] (Fig.11.2).
11.4.1 Mechanism ofInjury
The hip does not dislocate, suggesting that the fracture of the femoral neck extended
into the femoral head rather than the opposite [9].
A case report proposed the mechanism of shear stress acting on the femoral neck,
followed by lateral impaction in a motorbike injury [8]. This report further
c
b
Fig. 11.2 (a) Femur head and neck fracture with trochanteric fracture in an elderly male patient,
(b) axial cut of CT scan, and (c) trochanteric reconstruction along with bipolar hemiarthroplasty
11 Atypical Femur Head Fracture Pattern: Management Issues
159
emphasized that the continued momentum of the falling bike caused the patient’s
hip to move into extension, adduction, and external rotation, followed by lateral
impaction during the fall. This sequence resulted in a sub-capital femoral neck fracture and additional impaction against the femoral head fragment, creating another
fracture of the femoral head with an inferior femoral head fragment.
11.4.2 Prognosis
This type of injury involves extensive damage to the cancellous bone and vascularity of the femoral head. Osteosynthesis in such cases is associated with a high risk
of avascular necrosis, subchondral collapse, secondary osteoarthritis, and xation
failure. Consequently, the patient may require a total hip arthroplasty after xation.
11.5 Femur Head Fractures withAnterior Hip Dislocation
Obvious femoral head fractures in a case of anterior hip dislocation are a rare entity,
and these are often indentation or impaction injuries. There are very few case reports
on femur head fracture and anterior hip dislocation [10–12]. The proposed mechanism of injury involves the hip being in external rotation, abduction and extension
in motor vehicle accident, or fall from height [10]. When a sudden brake is applied,
the force transmitted across the knee reaches the femoral head, causing the upper
and outer portion of the femoral head to impact the acetabulum (Fig. 11.3).
Fig. 11.3 Femur head
fracture with anterior hip
dislocation
160
Simultaneously, the femoral neck experiences signicant shear stress, resulting in a
vertical shear fracture.
A similar case was reported by Hu etal. in which there was an obturator type of
anterior hip dislocation, femoral head and neck fractures, and pubic fractures [13].
Treatment included open reduction, internal xation with cannulated screws, a
medial support plate, and articial bone grafting to support the femoral head defect.
The patient showed good hip function and fracture healing at the 6-month follow-up
without displacement, implant loosening, valgus deformity, or signs of femoral
head necrosis. Prompt partial weight-bearing and hip abductors strengthening exercises were suggested to prevent muscular atrophy.
R. K. Sen et al.
11.6 Fracture oftheSuperior Part oftheFemur Head
A classical Pipkin fracture typically involves the anterior-inferior aspect of the femoral head, occurring due to a posterior hip dislocation. However, in some cases, only
the superior part of the femoral head is fractured, while the lower portion remains
intact (Fig.11.4). Reconstruction in such cases is usually less complex, as part of
the femoral neck remains uninjured.
The Ganz approach is often employed to access the affected part of the femoral
head for fragment reconstruction. Despite successful reconstruction, the risk of
avascular necrosis (AVN) remains high. As a result, these cases frequently progress
to requiring hip arthroplasty.
11.7 Multi-fragment, Impacted, or Sleeve Fractures
oftheFemoral Head, withor Without Hip Dislocation
A Pipkin’s fracture is typically a simple split fracture. However, there are reports of
more complex cases involving signicant comminution of proximal femoral fractures (Fig.11.2). Such fractures are often observed in older individuals with osteoporotic bones, while they are rare in younger individuals. Due to their comminuted
nature, these fractures are commonly managed with arthroplasty.
These cases stand out due to their extreme rarity and the complexity of the management strategies they require. Achieving proper anatomical reduction and stable
xation of all components is essential, along with careful postoperative rehabilitation to ensure optimal outcomes. Hip preservation procedures in young adults may
include techniques such as fresh frozen osteochondral graft implantation, autologous chondrocyte implantation, and cartilage repair using suture anchors after
debridement of small comminuted fragments. In cases deemed unreconstructable,
total hip arthroplasty is performed.
be
11 Atypical Femur Head Fracture Pattern: Management Issues
161
a
cd
f
Fig. 11.4 (a) Fracture in the superior aspect of the femur head without dislocation; (b) axial cut
section of the CT scan shows the displacement of the femoral head fragment with reduced hip
joint; (c) surgical reduction and xation of the fragment; (d) after 1 year, there is AVN of the femur
head with decreased joint space; and (e, f) 1-year and 4-year follow-up following THR
11.8 Modified Brumback Classification
Wani etal. modied Brumback classication to involve cases involving femoral
head fractures associated with femoral neck fractures and both anterior and posterior hip dislocations [14]. They subdivided the type III fracture pattern of the
Brumback classication system into four types (Table11.1). These modications
aim to address the broader spectrum of injury patterns and provide a more comprehensive framework for classication and management.
11.9 Summary
While most femoral head fractures can be categorized using the Pipkin classication, many unique patterns exist involving the femoral head in combination with
various other injuries. Each specic fracture pattern often corresponds to a distinct
mechanism of injury, requiring tailored reduction steps and xation techniques.
162
R. K. Sen et al.
Table 11.1
Types Description
3A1 Posterior dislocation without femoral head fracture
3A2 Anterior dislocation without femoral head fracture
3A3 Posterior dislocation with femoral head fracture
3A4 Anterior dislocation with femoral head fracture
Wani’s modication of type III Brumback classication
As the incidence of trauma continues to rise in the developing world, it becomes
increasingly essential to dene and rene management protocols for these injuries.
Specic fracture patterns, such as femoral neck fractures with hip dislocation or
femoral head fractures combined with trochanteric fractures, are not as rare as previously thought and warrant particular attention in clinical practice.
References
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1957;39-A:1027–42. passim
2. Giannoudis PV, Kontakis G, Christoforakis Z, Akula M, Tosounidis T, Koutras C.Management,
complications and clinical results of femoral head fractures. Injury. 2009;40:1245–51. https://
doi.org/10.1016/j.injury.2009.10.024.
3. Mody BS, Wainwright AM.Fracture of the femoral head without associated hip dislocation following low-energy trauma. A report of two cases. Arch Orthop Trauma Surg. 1996;115:300–2.
https://doi.org/10.1007/BF00439059.
4. Aggarwal AK, Soni A, Singh D. Femoral head fracture without hip dislocation. Chin J
Traumatol Zhonghua Chuang Shang Za Zhi. 2013;16:304–7.
5. Yoon PW, Jeong HS, Yoo JJ, Koo K-H, Yoon KS, Kim HJ. Femoral head fracture without
dislocation by low-energy trauma in a young adult. Clin Orthop Surg. 2011;3:336–41. https://
doi.org/10.4055/cios.2011.3.4.336.
6. Kumar P, Agarwal S, Rajnish RK, Aggarwal S, Kumar V, Jindal K.Ipsilateral posterior cruciate ligament insertion avulsion and femoral head fracture without dislocation: a rarest of
rare dashboard injury and principles of management: a case report. JBJS Case Connect.
2019;9:e0245. https://doi.org/10.2106/JBJS.CC.18.00245.
7. Lee Y-K, Min JJ, Koo K-H.Pipkin type IV femoral head fracture without dislocation. Ann
Surg Case Rep. 2019;2
8. Pawar K, Kandhari VK. A rare medley: concurrent ipsilateral femur head and neck fracture without hip dislocation. J Surg Case Rep. 2016;2016:rjv177. https://doi.org/10.1093/
jscr/rjv177.
9. Kim KI, Koo KH, Sharma R, Park HB, Hwang SC. Concomitant fractures of the femoral head and neck without hip dislocation. Clin Orthop. 2001:247–50. https://doi.
org/10.1097/00003086- 200110000- 00028.
10. DeLee JC, Evans JA, Thomas J.Anterior dislocation of the hip and associated femoral-head
fractures. J Bone Joint Surg Am. 1980;62:960–4.
11. Dussault RG, Beauregard G, Fauteaux P, Laurin C, Boisjoly A. Femoral head defect following anterior hip dislocation. Radiology. 1980;135:627–9. https://doi.org/10.1148/
radiology.135.3.7384446.
11 Atypical Femur Head Fracture Pattern: Management Issues
12. Jithin CR, Vincent A, Thamby R, Sajil Krishna K, Kumar NS.Anterior dislocation of the hip
with femoral head fracture and osteochondral fracture of contralateral patella– a case report. J
Orthop Rep. 2022;1:100070. https://doi.org/10.1016/j.jorep.2022.100070.
13. Hu Y, Gao F, Liu H, Chen L, Li Y, Li Z, Huang C, Wang Y, Piao C.Obturator dislocation
of the femoral head combined with ipsilateral femoral neck and pubic fractures. Medicine
(Baltimore). 2019;98:e17150. https://doi.org/10.1097/MD.0000000000017150.
14. Wani MM, Hussain A, Bashir A, Wani I, Moosa M, Wani MM, Mir BA, Halwai MA.Anterior
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https://doi.org/10.1007/s00590- 009- 0545- 4.
163
Complications ofFemoral Head
Fracture-Dislocations
RahulVaidya, andDanielJonathan Joiner
12.1 Introduction
Femoral head fracture-dislocations are severe orthopedic injuries that often result
from high-energy trauma, such as motor vehicle accidents or falls from height. Due
to the complex anatomy and biomechanical environment of the hip joint, these injuries can lead to a variety of complications. Prompt recognition and management are
crucial to minimize long-term morbidity and optimize patient outcomes. This chapter will discuss the various complications associated with femoral head fracturedislocations, exploring both acute and chronic issues. It should be noted that the
incidence of femoral head fractures is low, making studies difcult through a single
institution. The majority of literature regarding femoral head fractures/femoral head
fracture dislocations is through meta-analysis and retrospective studies. For the purposes of this chapter, we will use the Pipkin classication to describe the injury
pattern, determine treatment, and guide prognostic evaluation [1]. The complexity
of these fractures lies not only in their classication but also in the nature of the
injuries sustained by surrounding structures, particularly the soft tissues, nerves,
cartilage, and the vascular supply to the femoral head.
12
12.2 Failed Closed Reduction
With fracture dislocations of the femoral head, closed reduction may be easy
(Fig.12.1) or hard due to a locked dislocation (Fig.12.2). This is due to the remaining head having a at surface on its inferior border and being button holed through
the posterior capsule. In these situations, an open reduction is the best option to
avoid repeated attempts and a femoral neck fracture (Fig.12.2b) turning a Pipkin II
R. Vaidya (*) · D. Jonathan Joiner
Detroit Medical Center, Wayne State University, Detroit, MI, USA
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2025
R. K. Sen, S. K. Tripathy (eds.), A Practical Guide to Management of Femoral
Head Fracture-Dislocation, https://doi.org/10.1007/978-981-96-9852-3_12
165
166
Fig. 12.1 Pipkin type II fracture successfully managed with closed reduction
R. Vaidya and D. Jonathan Joiner
a
Fig. 12.2 (a) Irreducible Pipkin type II fracture-dislocation. (b) Multiple failed closed reduction
attempts resulted in iatrogenic femoral neck fracture, converting it to a Pipkin type III injury
b
fracture into III, which has a high rate of avascular necrosis and nonunion
(Fig.12.2b).
12.3 Hemorrhage
Signicant hemorrhage may occur at the time of injury, especially in cases involving fractures of the femoral head or neck which are associated with pelvic or acetabular injury. Algorithms for acute bleeding are usually related to pelvic injury and
should follow ATLS Stop the Bleed protocols [2], including massive transfusion
availability, pelvic binders, packing, and angiography [3]. Bleeding during surgery
can be avoided by avoiding the quadratus femoris muscle to not disrupt the medial
femoral circumex vessel or dissecting and retracting carefully along the sciatic
notch to prevent injury to the superior gluteal artery. Maintaining the vascularity of