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Fig. 2.3 Pipkin’s
classication of femoral
head fracture-dislocation
S. K. Tripathy et al.
Type I
Type III Type III
Type II
Type IV
remains attached to the fractured femoral head fragment, contributing to its
rotation.
Type III: Femoral head fractures is accompanied by a concomitant femoral neck
fracture.
Type IV: Femoral head fractures are associated with a concomitant acetabular
fracture.
The Pipkin classication remains the most widely used system for femoral head
fractures due to its simplicity and clinical relevance. However, the prognosis of
these injuries worsens as their complexity increases [23]. By providing a standardized framework, the Pipkin classication has signicantly contributed to the understanding and management of femoral head fractures.
Brumback etal. (1987) described a more comprehensive classication of femur
head fractures wherein the direction of the dislocating force, joint stability, and
severity of acetabular fracture were taken into account (Table2.2) [24]. A signicant fracture of acetabular rim leads to a dislocation. This classication system also
2 Mechanism ofInjury andVarious Fracture Classications
21
Table 2.2
Fracture
type Description
Type 1A Infero-medial fracture with minimal or no acetabular rim fracture with a stable hip
Type 1B Type 1A fracture with signicant acetabular rim fracture resulting in an unstable
Type 2A Supero-medial head fracture with minimal or no acetabular rim fracture with a
Type 2B Type 2A with signicant acetabular rim fracture with an unstable hip joint
Type 3A Anterior or posterior hip dislocation with a femoral neck fractures
Type 3B Type 3A with a femur head fracture
Type 4A Anterior hip dislocation with an indentation type of femur head fracture
Type 4B Anterior hip dislocation with a transchondral type of femoral head fracture
Type 5 Central hip dislocation with a femoral head and acetabulum fracture
Brumback classication of femur head fracture
joint
hip joint
stable hip joint
takes into account the indentation fractures and chondral injuries of the femoral
head (Fig.2.4). This system also has a prognostic value with type 2B fractures having the best prognosis and the type 3B and type 5 having the worst prognosis
[25, 26].
Yoon etal. (2001) proposed a classication system exclusively for femoral head
fracture which could guide the treatment (Fig.2.5) [27]. They divided the fracture
into four types (Table2.3). However, the lack of validation of this classication
system limits its use in daily practice. Moreover, this classication system also does
not include the smaller osteochondral fractures and the associated ipsilateral neck of
femur and acetabulum fractures.
The AO/OTA classication simplies the previously existing classication systems [28]. The femoral head fractures are classied by AO/OTA as 31C (Fig.2.6).
This is further divided into two groups:
1. Split fractures (31C1)
2. Depressed fractures (31C2)
The split fractures are further classied into three types:
(i) Avulsion of ligamentum teres (31C1.1)
(ii) Infra-foveal split fracture (31C1.2)
(iii) Supra-foveal split fracture (31C1.3)
The depressed fractures are further classied into three types:
(i) Depression of the cartilage/chondral lesion (31C2.1)
(ii) Depression impaction fracture (31C2.2)
(iii) Split depression fracture (31C2.3)
22
AT
Fig. 2.4 Brumback
classication of femoral
head fracture-dislocation
S. K. Tripathy et al.
Type IA Type IB
Type IIA Type IIB
Type IIIA Type IIIB
Type IV
ype IVB
Type V
2 Mechanism ofInjury andVarious Fracture Classications
Fig. 2.5 Yoon’s classication of femoral head fracture dislocation
23
Table 2.3
Type
Type IFracture fragment distal to fovea too small or
Type IILarge head fragment distal to fovea Open reduction and internal
Type
III
Type IVComminuted fracture of head of femur Arthroplasty
Yoon’s classication of femoral head fractures
Description
fragmented to be xed by screws
Large head fragment proximal to fovea centralis
Treatment
Excision
xation
However, this classication system does not describe the exact location of fracture. Moreover, the osteochondral fragments and the associated injuries are also
overlooked by this system.
Chiron’s classication (2013, CT based) is the latest classication system which
takes into account the shortcomings of all other classications [18, 29]. It is a comprehensive classication which includes the size of the fragment along with the
24
S. K. Tripathy et al.
Fig. 2.6 AO classication of femoral head fracture-dislocation
associated injuries (Fig.2.7). The fracture is classied into four types depending
upon the size of the head fragment (Table2.4). Each type is further divided into
three types depending upon the associated injury as follows:
A: Isolated head fracture
B: Associated with acetabulum fracture
C: Associated with femur neck fracture
Though it is a descriptive classication, it fails to give much information regarding the associated joint instability, direction of dislocation, etc. Types I and II are
managed by arthroscopic removal of the fragment. Type III and IV fractures are
xed. Types IV and V in individuals older than 60years should be managed by
primary total hip arthroplasty.
2 Mechanism ofInjury andVarious Fracture Classications
25
Fig. 2.7 Chiron’s classication of femoral head fracture dislocation
Table 2.4
classication of femur head
fracture
Chiron’s
Type Size of the fracture fragment
Type I Osteochondral fragments
Type II 1/4th of the head fragment
Type
III
Type IV1/2 of the head fragment
Type V Superior collapse
1/3rd of the head fragment
26
S. K. Tripathy et al.
2.5 Author’s Perspective onClassification Systems
forFemoral Head Fracture-Dislocations
An ideal classication system for femoral head fracture-dislocations should full
several criteria: it should encompass all possible injury patterns, guide surgical
management, and provide reliable prognostic information. However, the rarity of
these injuries and the limited number of case series have impeded the development
and validation of such a system. Among the existing classication systems, none
fully meet these criteria.
Pipkin’s classication remains the most widely utilized system due to its simplicity. While it is helpful for communication and offers some prognostic insights,
particularly with type I and type II injuries generally showing better outcomes than
type III and type IV, the system has signicant limitations. It fails to account for
critical factors such as fragment comminution, the size of associated head or acetabular fractures, and joint stability in type IV injuries. Moreover, it provides limited
guidance for surgical decision-making.
Brumback’s classication is more comprehensive, incorporating additional
variables such as dislocation direction and joint stability. However, its complexity
can make it cumbersome for clinical use, and it does not clearly delineate treatment
pathways. From a prognostic perspective, type 3B and type 5 injuries are associated
with poorer outcomes, whereas type 2B fractures tend to have more favorable
results.
The AO classication system, while widely known, lacks comprehensiveness
and practical utility in guiding treatment. Conversely, Yoon’s classication is more
treatment-oriented and practical for daily clinical use, making it particularly useful
in operative planning.
The most recent system, Chiron’s classication, provides a detailed CT-based
description that incorporates associated injuries. However, it is primarily descriptive, offering limited information regarding critical aspects such as joint instability
and dislocation direction, which are important for clinical decision-making.
In practice, Pipkin’s classication continues to be favored for its simplicity and
ease of communication. However, for complex cases where Pipkin’s system proves
inadequate, Brumback’s classication may be employed as a more detailed alternative. Despite the availability of multiple classication systems, the eld still lacks
a universally accepted system that addresses all clinical and prognostic considerations effectively.
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S. K. Tripathy et al.
Emergency Care inPatients Having
Femur Head Fractures
SameerAggarwal, VishalKumar, andAnshGupta
3.1 Introduction
Since the hip is an inherently stable joint, femoral head fractures are usually due to
high-velocity trauma; however, subchondral fractures may occur without trauma in
patients with osteoporosis and acetabular dysplasia [1]. The femoral head fractures
are usually associated with posterior hip dislocation and may have additional systemic injuries such as abdominal injury, head injury, and chest injury. Hence, a
standard systemic evaluation in the emergency should be performed.
Suraci etal. reported that up to 95% of patients have injuries which require hospitalization independent of their fracture dislocation [2]. Commonly seen skeletal
injuries include pelvic ring and femoral shaft fractures, spine injuries, and ligament
injuries around the knee. Knee injuries occur in approximately 25% of the cases and
can occur along with patella fracture in cases of dashboard injuries [3]. Craniofacial
and neck injuries may occur in 21%, head injury in 24%, thoracic injury in 21%,
and abdominal injuries in 15% of the cases [4]. Direct injury due to the dislocation
may lead to sciatic nerve palsy in 10% of the cases, usually with posterior dislocations and acetabular wall fractures. Femoral artery injury has also been reported in
a few case reports [5].
3
S. Aggarwal (*) · V. Kumar · A. Gupta
Department of Orthopedics, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
© 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_3
29