Session X - Pelvis/Geriatrics

Surgical Treatment of Femoral Head Fractures

Timothy B. Rapp, MD; Sean E. Nork, MD; Milton L.C. Routt, MD, Harborview Medical Center, Seattle, WA

Purpose: Femoral head fractures are uncommon injuries with no universally accepted treatment; we evaluated the operative treatment of displaced femoral head fractures with use of a management protocol.

Materials and Methods: Over a 5-year period, 21 patients with displaced femoral head fractures were treated surgically at our institution. There were 15 men and 6 women, ranging in age from 18 to 58 years (mean, 30.9). The mechanisms of injury were accidents involving motor vehicles for 16 patients, motorcycles for 3, all-terrain vehicle and snow skiing, 1 each. Preoperative evaluations included pelvic anterior-posterior and oblique plain radiographs and pelvic computed tomography scans. Fifteen fractures were suprafoveal in location. The fractures were classified according to Pipkin as type I (n = 6), type II (n = 11), type III (n = 2), and type IV (n = 2). Intraarticular debris was present in 64% of the patients, and all patients had associated posterior hip dislocations. Eighteen patients had successful urgent closed reductions with use of intravenous sedation, and three patients required a general anesthetic. One patient had associated sciatic nerve palsy. Each fracture was exposed through an anterior surgical approach, and osteochondral debris was removed from the hip joint. An attempt was made to reduce and fix all fractures that were suprafoveal in location. The femoral head fracture fragments were reduced and stabilized with use of minifragment subchondral lag screws in 11 patients. Implants used were 1.5-mm and 2.0-mm cortical screws. Severe fracture comminution prevented accurate reduction and stable fracture fixation in the other 10 patients. Intraoperative fluoroscopy was attempted in all patients. The reduction was confirmed and any residual intraarticular debris was evaluated with plain pelvic radiographs and computed tomography. Continuous passive motion and protected weight bearing of the hip were begun when the patient's condition allowed. No ectopic bone prophylaxis was used.

Results: Eleven patients were treated with internal fixation, and 10 patients were treated with primary excision of the head fragments. Twenty-nine screws were used, ranging from two to five screws per patient, depending on the number and size of the femoral head fragments. Ten patients treated with internal fixation had anatomic reductions of their fractures, and one patient had a nonanatomic reduction. Each screw was subchondral and intraosseus in location. Nineteen patients were available for follow-up, averaging 14.2 months, and ten of the eleven patients with fixation were evaluated. There were no nonunions, wound complications, or residual intraarticular debris. One patient had loss of reduction with early fragment collapse and developed symptomatic posttraumatic hip arthritis requiring total hip arthroplasty 36 months after the injury. In the fixation group, heterotopic ossification (HO) was classified according to Brooker as class IV in one patient, class III in one, class II in three, class I in four, and class 0 in two patients. Only the patient with Class IV HO had functional compromise and opted for excision.

Discussion: In this series of 21 operatively treated patients with femoral head fractures, 11 had open reduction and internal fixation of their fractures. Comminution and location of the fracture fragments precluded internal fixation in the remaining 10 patients. Heterotopic ossification developed commonly in these patients, although only one was symptomatic and required surgical resection. Operative management of these fractures allowed for anatomic restoration of the articular surface in 90% of the stabilized patients.

Conclusions: Femoral head fractures are typically associated with posterior hip fracture dislocations, and the fragment is anterior. These fractures may be comminuted and associated with intraarticular osteochondral debris. Accurate reduction of femoral head fractures is possible for patients without severe comminution, with use of an anterior surgical exposure. Stable fixation can be accomplished with minifragment, subchondral, intraosseus screws. Ectopic bone formation is common, yet rarely symptomatic requiring excision. Despite being avascular, these femoral head fragments healed.