A femoral head fracture is a rare type of hip fracture that involves a break in the rounded portion of the thigh bone (femur) that fits into the hip socket.[1] They are estimated to account for less than 1% of all hip fractures, with two-thirds of those affected being young adults.[1][2] These injuries are typically sustained during high-impact events, such as car accidents or falls from significant heights.[2]
Typical presenting findings include pain in the groin, along with swelling and bruising around the hip.[1] Patients are generally unable to walk or bear weight on the affected leg.[1] Femoral head fractures also commonly occur in association with posterior hip dislocation.[2] In these cases, the affected leg is usually in a flexed, adducted, and internally rotated position. The affected leg may appear shorter compared to the unaffected leg.[2]Sciatic nerve injury can also occur, especially in cases of fracture with dislocation.[3] This may manifest with absent or diminished reflexes and weakness when bending the knee or moving the foot.[4]
Diagnosis
Imaging
Plain radiographs of the pelvis taken from the front (AP view) are the initial imaging method of choice for isolated injuries.[2] Additional views can help identify accompanying injuries, such as acetabular fractures.[2]CT scans are often used in trauma patients with multiple serious injuries or after reduction to further evaluate the hip joint.[2]MRI may be used if there is suspected damage to the cartilage of the hip socket or suspected early osteonecrosis.[2]
Classification
The Pipkin classification is the most frequently used method to categorize femoral head fractures and is organized as follows:[5]
Pipkin classification type
Description
I
Fracture below the fovea; not involving weight-bearing surface of the head
II
Fracture above the fovea; involving weight-bearing surface of the head
III
Type I or II fracture with associated femoral neck fracture
IV
Type I or II fracture with associated acetabulum fracture
This classification system helps to guide management and predict outcomes.[2]
Treatment
Initial physical examination should include assessment of circulation and nerve function in the affected leg, particularly in the distribution of the sciatic nerve.[3] In cases with hip dislocation, urgent reduction is required, with earlier intervention being predictive of a better outcome.[6] Definitive management in younger patients may involve surgical options such as open reduction and internal fixation or fragment removal.[6] In contrast, total hip replacement is generally favored in elderly patients.[6]
Prognosis
There are multiple scoring systems used to assess outcomes following recovery, including the Thompson and Epstein outcome score, Merle d'Aubigné and Postel score, and the Oxford Hip Score.[3] Using these scoring systems, good to excellent outcomes are achieved in about two-thirds of cases.[3] However, the association of the injury with pain, joint stiffness, and loss of function contributes to variability in treatment outcomes.[6] Common long-term complications include posttraumatic arthritis, osteonecrosis of the femoral head, and heterotopic ossification.[3]
Epidemiology
Although still uncommon, the incidence of femoral head fractures has increased in recent times.[2] This trend is thought to be the result of two main factors: an increase in motor vehicle accidents and advances in modern vehicle safety, which have increased survival and allowed for more frequent identification of these fractures.[2]
1 2 3 4 5 Schaffer, Nathaniel E.; Luther, Lauren; Tatman, Lauren M.; Mitchell, Phillip M. (2024-10-15). "Femoral Head Fractures: Evaluation, Management, and Outcomes". The Journal of the American Academy of Orthopaedic Surgeons. 32 (20): 929–937. doi:10.5435/JAAOS-D-23-01121. ISSN1940-5480. PMID38968607.
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