Hope you enjoyed your break and thanks for sticking around. Or hi đ if youâre new here.
What I learned today
Fractures of the femoral head are significantly less common than those involving the neck. That doesnât mean they arenât worth understanding and learning about.
Multiple classification systems exist but we/Orthobullets use the Pipkin classification. It's fairly straightforward:
Type I: fracture line inferior to the fovea capitis (no involvement of weight-bearing surface)
Type II: fracture line superior to the fovea capitis
Type III: type I or II + femoral neck fx
Type IV: type I or II + acetabular fx (usually posterior wall)
In a large case series by Scolaro et al, the distribution was:
Pipkin I: 40 (27%)
Pipkin II: 62 (42%)
Pipkin III: 7 (4.7%)
Pipkin IV: 23 (15%)
15 (10%) which did not fit the classification âas they were primarily femoral head impaction type injuries and dissimilar to distinct femoral head fractures.â
Treatment involved:
78 (53%) ORIF
37 (25%) fragment excision
28 (19%) non-operative
3 (2%) hemiarthroplasty
One patient had an antibiotic spacer placed during initial fracture management secondary to the individualâs severe medical comorbidities and complex clinical presentation.
ORIF technique
For ORIF, these authors and the Harborview book recommend using an anterior Smith-Peterson approach. Specifically, the caudal end of it.
After the initial approach, incise the rectus femoris origin to create a short proximal stump and tag the distal end with sutures for later tendon repair
Debride the iliocapsularis muscle1
Retract the iliopsoas medially to expose the anterior hip capsule
Create a T-shaped capsulotomy (fluoro is helpful; see caption)
Then gently dislocate the femoral head anteriorly (prior to dislocation, can pre-drill the glide holes for the fracture fragments)
Reduce the fragment(s) and maintain reduction using K-wires â anatomic reduction is critical
Use countersunk mini frag lag screws for fixation of the major fragments
Ensure all loose bodies are removed
Reduce the hip and check ROM and stability under fluoro
Close the capsule and repair the rectus femoris tendon (can augment with size 0 resorbable screws in the paratenon)
And thatâs it for today! Here are some pre- and post-op XRs.
Sources
Scolaro, J. A., Marecek, G., Firoozabadi, R., Krieg, J. C. & Routt, M. L. âChip.â Management and radiographic outcomes of femoral head fractures. J Orthop Traumatology18, 235â241 (2017).
Harborview Illustrated Tips and Tricks in Fracture Surgery 2nd Edition
This is a lateral outcropping of the iliopsoas muscle over the hip joint capsule. Can be a nidus for heterotopic ossification, seen in 40% of the patients in Scolaro et alâs series (28 out of the 69 who had follow-up over 6 months)