Femoral head fractures: anatomy, diagnosis and management

Femoral head fractures are complex and severe injuries, usually associated with hip dislocation. They typically result from high-energy trauma. Therefore, a low index of suspicion is required for diagnosis in these contexts. Initial presentation can vary depending on coexisting injuries but is typically an emergency and requires immediate reduction of the joint. Delays result in worse outcomes for patients. Pelvic radiographs are recommended before and after joint reduction, with Judet, inlet and outlet views to identify any associated acetabular fracture and pelvic ring injury. Computed tomography helps determine the fracture configuration and classification, commonly using the Pipkin classification. Definitive fracture management depends on patient demographics, fracture pattern and associated injuries. Pipkin type I and II fractures with minimal displacement and an anatomically congruent hip joint may be treated conservatively. Otherwise, surgical open reduction internal fixation via the anterior approach is recommended. Young patients with Pipkin type III injuries usually require open reduction internal fixation via the anterior or posterior approach, while elderly patients may need total hip arthroplasty. Pipkin type IV fractures may require a combination of open reduction internal fixation approaches with or without trochanteric flip osteotomy. Femoral head fractures often have poor outcomes, with type III and IV fractures having worse outcomes than types I and II. Early complications include infection and sciatic nerve palsy. Late complications include avascular necrosis, heterotopic ossification and post-traumatic arthritis. This article considers the anatomy, diagnosis and evidence-based management strategies for femoral head fractures.