Theodor Di Pauli von Treuheim, MD; Michelle Richardson, MD; Abhishek Ganta, MD , 2025-04-18 14:05:00
April 18, 2025
9 min read
A 25-year-old woman presented to the hospital as a level 2 trauma activation as the unrestrained driver in a motor vehicle accident. In the trauma bay, she complained of bilateral lower extremity pain.
Physical exam was notable for a short and externally rotated right lower extremity. There were no open wounds, and she was neurovascularly intact. Initial trauma slot anteroposterior (AP) radiograph revealed a right supra-foveal femoral head fracture-dislocation with an ipsilateral transcervical femoral neck fracture and a transverse posterior wall acetabular fracture, consistent with a combined Pipkin III and IV variant femoral head fracture (Figure 1).
Image: Theodor Di Pauli von Treuheim, MD; Michelle Richardson, MD; and Abhishek Ganta, MD
CT scan further demonstrated coronal and sagittal splits of the femoral head with impaction against the posterior acetabular wall, with the femoral head dislocated posteriorly. The acetabular fracture line extended through the weight-bearing surface of the acetabulum, consistent with a transtectal acetabular fracture, with a small cranial posterior wall fragment (Figures 2 and 3). Other injuries included an ipsilateral intra-articular distal femur fracture, a contralateral native posterior hip dislocation and a displaced left middle finger proximal phalanx fracture. She had no nonorthopedic injuries otherwise and was adequately resuscitated.
Source: Theodor Di Pauli von Treuheim, MD, and Abhishek Ganta, MD
Her left native hip dislocation was expeditiously closed reduced and placed in distal femoral traction. Her right lower extremity was placed in proximal tibial traction to disengage the femoral head from the posterior acetabular wall. Her left hand was placed in a radial gutter splint.
What are the next best steps in management of this patient?
See answer below.
Open reduction and internal fixation using a digastric trochanteric flip osteotomy
The patient was medically optimized for surgery and underwent operative fixation of her acetabulum and femoral head and neck fracture, as well as ipsilateral knee-spanning external fixation of her distal femur fracture the following day. Her definitive right femur open reduction and internal fixation (ORIF) and left middle finger proximal phalanx percutaneous pinning were subsequently addressed in a staged manner thereafter.
Surgical technique
The patient was positioned lateral decubitus in a bean bag positioner on a radiolucent flat top table. To allow manipulation of the right lower extremity, a knee-spanning external fixator was placed to stabilize the distal femur. This was placed with the knee in 90° of flexion to decrease tension on the sciatic nerve for the duration of the procedure. Attention was then turned to the hip. A Kocher-Langenbeck incision was utilized. The approach was taken down through the iliotibial band and gluteal fascia. The short external rotators (piriformis and gemellae) were identified, tagged and tenotomized, leaving a cuff of tissue for later repair. The posterior border of the vastus lateralis was identified and mobilized.
Nicole Rynecki
Harold I. Salmons
A trochanteric flip osteotomy (TFO) was made with an oscillating saw exiting proximally at the posterior insertion of the gluteus medius and distally to the base of the vastus tubercle, approximately 1.5 cm in depth, remaining superficial to the insertion of the short external rotators. A small posterior portion of the gluteus medius tendon initially remained attached to the proximal femur to ensure appropriate cut depth and protection of the deep branches of the medial femoral circumflex artery (MFCA). This maintained the abductor sleeve and vastus lateralis in continuity. The remaining gluteus medius fibers were then sharply incised and the osteotomy was retracted anteriorly. Nonviable gluteus minimis was debrided at this time to reduce the risk for postoperative heterotopic ossification (HO). The hip was then flexed and externally rotated. A surgical hip dislocation was performed utilizing a Z–shaped capsulotomy, incorporating the traumatic capsule rupture.
Source: Theodor Di Pauli von Treuheim, MD, and Abhishek Ganta, MD
The femoral head was disimpacted from the posterior wall of the acetabulum using traction. The labrum was noted to be avulsed off the posterior acetabular rim. Intra-articular comminution and nonviable fragments were extracted from the joint. The transverse fracture was then identified, and the articular surface was reduced. Working through the greater sciatic notch, the anterior column was clamped. A 10-hole reconstruction plate was placed along the posterior column. A lag screw was placed into the anterior column to maintain reduction of the anterior column. This reconstruction plate was then affixed with two screws proximal and distal to the fracture. A second eight-hole reconstruction plate was then placed more posteriorly along the posterior column for additional fixation. Intraoperative fluoroscopy confirmed no intra-articular screw penetration (Figure 4A).
Source: Theodor Di Pauli von Treuheim, MD, and Abhishek Ganta, MD
The femoral head was addressed next through the surgical hip dislocation. Articular damage at the site of impaction was noted. The head was provisionally reduced using multiple K-wires. A six-hole mini fragment plate placed inferomedially was then utilized to provisionally reduce the femoral head to the femoral neck (Figure 4B). The guide pin for the femoral neck dynamic hip screw was placed from the lateral femoral cortex to a center-center position. This also confirmed that the femoral head fixation would not interfere with dynamic hip screw placement. Therefore, three 2.4-mm headless compression screws were placed subchondrally in the femoral head, and the K-wires were removed (Figure 4C).
Lastly, fixation of the femoral neck was completed with placement of a dynamic hip screw in standard fashion. The length of the guide pin was measured, over-reamed with a triple diameter reamer and a 75-mm screw was placed over the wire. A two-hole 130° side plate was attached and affixed to the femur with two 4.5-mm screws. The mini fragment plate was removed.
Source: Theodor Di Pauli von Treuheim, MD, and Abhishek Ganta, MD
The avulsed labrum was repaired using a suture anchor. The trochanteric osteotomy was repaired with two 3.5-mm lag screws. Final fluoroscopic obturator oblique, iliac oblique and AP views confirmed a concentrically reduced hip joint (Figures 4D to 4F). The wound was copiously irrigated and closed in a layered fashion. A sterile dressing was applied.
The patient was then flipped to supine position and the right lower extremity was re-prepped and draped. The external fixator was revised with the leg repositioned in standard semi-extended position.
Postoperative rehabilitation
Immediately postoperatively, the patient was made non-weight-bearing on the right lower extremity and toe-touch weight-bearing on the left lower extremity.
Radiographs obtained at 6-weeks postoperatively demonstrated intact hardware with interval fracture healing (Figures 5A to 5C). The patient was advanced to weight-bearing as tolerated at 3 months. At her 1-year follow-up visit, radiographs demonstrated femoral head, neck and acetabulum fracture union without collapse evidence of avascular necrosis (Figures 6A to 6C).
Discussion
Femoral head fracture-dislocations are uncommon, accounting for 7% to 16% of all native hip dislocations. Classification of femoral head fractures via the Pipkin classification distinguishes femoral head fractures by the fracture in relation to the fovea (Pipkin I and II), the presence of a concomitant femoral neck (Pipkin type III) or acetabulum fracture (Pipkin type IV). A femoral head fracture-dislocation with both a concomitant femoral neck (Pipkin III) and acetabular fracture (Pipkin IV) is a high-energy injury. With fracture-dislocations, the type of femoral head fracture and the location and size of the fragments are a result of the position of the hip at the time of dislocation. The femoral neck fracture results as energy dissipates through the femoral neck from the femoral head. The transverse acetabular fracture occurs due to lateral compression of the greater trochanter along the axis of the femoral neck to the acetabulum. These often occur in the setting of a dashboard injury in motor vehicle accidents, as seen in our patient’s case.
Source: Theodor Di Pauli von Treuheim, MD, and Abhishek Ganta, MD
Femoral head fracture-dislocations associated with both a femoral neck and an acetabular fracture are extremely rare, with only one case reported in the literature. In the report, the authors similarly describe successful ORIF of a combined Pipkin III and IV femoral head fracture with a concomitant femoral neck and transverse posterior wall acetabular fracture in a 34-year-old patient. They elected to fix this in a staged fashion. They first utilized a Kocher-Langenbeck approach to address the posterior wall and column with a reconstruction plate, the femoral head with Herbert screws and the femoral neck with three cannulated screws. They then addressed the anterior column component of the transverse acetabulum fracture using a reconstruction plate through an ilioinguinal approach.
Midterm to long-term outcomes after Pipkin III and IV femoral head fractures are limited, with a high complication profile, including femoral head avascular necrosis (AVN), HO, post-traumatic hip osteoarthritis and sciatic nerve palsy. Shan-Xi Wang and colleagues followed 21 patients with Pipkin IV for 49 months postoperatively, reporting their rates of these complications, including AVN (9.6%), HO (19%), post-traumatic OA (14%) and sciatic nerve injury (14%). Sujan Shakya and colleagues followed eight patients with Pipkin III and 14 patients with Pipkin IV femoral head fractures for a median of 36 months (24 to 84 months) postoperatively, reporting even higher rates of AVN (38% and 14%) and post-traumatic OA (38% and 43%), but similar rates of HO (0% and 21%) and sciatic nerve injury (25% and 14%), respectively. Rates of AVN for Pipkin III fractures in the short-term and midterm are exceptionally high, with the greatest risk in the first 2 years. While our patient did not demonstrate clinical or radiographic signs of AVN at her 1-year follow-up, she will continue to be closely monitored. Stephan Regenbogen and colleagues reported a mean follow-up time of approximately 5.75 years for the development of AVN in their cohort of patients with femoral head fractures.
Source: Theodor Di Pauli von Treuheim, MD, and Abhishek Ganta, MD
In an effort to reduce postoperative rates of AVN, there is an emphasis on urgent reduction and fixation to minimize damage to the MFCA and its branches that supply the femoral head. Furthermore, a TFO facilitates vascular preservation as the osteotomy remains lateral to the insertion of the short external rotators, with the deep branch of the MFCA running posterior to the obturator externus tendon. This is critically important and, thus, is a preferred approach in Pipkin III femoral head fractures, where the rates of AVN are the highest.
The main treatment for femoral heads that progress to AVN or develop post-traumatic OA is conversion total hip arthroplasty. Kyle H. Cichos, BS, and colleagues reported on 65 split-type and 72 depression-type Pipkin IV femoral head fractures, reporting a 29% and 27.8% risk for conversion THA by 1 year postoperatively, respectively. Their analysis revealed that suprafoveal femoral head fractures were an independent risk factor for early conversion THA, which is unsurprising given this is the weight-bearing zone. John A. Scolaro, MD, and colleagues reported on seven patients with Pipkin III femoral head fractures, with a 100% THA conversion rate, two of which were due to early fixation failure and five who developed AVN within 6 months. Brian D. Solberg, MD, and colleagues reported on 12 patients with Pipkin IV femoral head fractures who underwent fixation via a Kocher-Langenbeck approach with a TFO, 91% of whom went on to radiographic union without loss of fixation at a mean 6-month follow-up.
In summary, combined Pipkin III and IV femoral head fractures (with concomitant femoral neck and acetabulum fractures) are exceedingly rare, high-energy injuries. One-year follow-up of an ORIF of the femoral head, neck and acetabulum using a Kocher-Langenbeck approach with a digastric TFO demonstrates fracture union with no early signs of AVN and good clinical function. TFO may reduce the risk for AVN by better protecting the MFCA, which is critically important as the Pipkin III component of this injury portends a high AVN risk.
Key points:
- A digastric TFO and surgical hip dislocation allows for a 360° view of the femoral head and acetabulum articular surface for ORIF of both (Pipkin IV) through a single, posterior approach.
- A digastric TFO may reduce the risk for femoral head AVN in the setting of a combined femoral head and neck fracture (Pipkin III) by better protecting the deep branches of the MFCA.
- Use of a mini fragment plate for provisional femoral neck fixation in Pipkin III femoral head fractures allows for reduction of the head-neck junction without compromising definitive fixation in either the head or neck.
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For more information:
Theodor Di Pauli von Treuheim, MD; Abhishek Ganta, MD; and Michelle Richardson, MD, can be reached at the department of orthopedic surgery at New York University Langone Health. Di Pauli von Treuheim’s email: theodor.dipaulivontreuheim@nyulangone.org. Ganta’s email: abhishek.ganta@nyulangone.org. Richardson’s email: michelle.richardson@nyulangone.org.
Edited by Nicole Rynecki, MD, and Harold I. Salmons, MD. Rynecki is a chief resident in orthopedic surgery at NYU Langone. She will be pursuing a sports medicine fellowship at Hospital for Special Surgery following residency completion. Salmons is a chief orthopedic surgery resident at the Mayo Clinic. He will be pursuing an adult reconstruction fellowship at Hospital for Special Surgery following residency completion. For more information on submitting Orthopedics Today Grand Rounds cases, please email orthopedics@healio.com.