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Isolated Fracture Of The Femoral Head

*A. Elmrini, A. Daoudi, O. Agoumi, F. Boutayeb, M. Mahfoud, A. Elbardouni, M. Elyaacoubi.

*Department of orthopaedics, UH Hassan II Fez, UH Avicenne Rabat; Morocco.

Address for Correspondence
Department of Orthopedic and Traumatic Surgery
Al Ghassani Hospital, University Hospital Hassan II, Fez 30000. Morocco
Tel: 00 212 61 107 741, Fax: 00 212 55 619 321


J.Orthopaedics 2006;3(3)e17


Fracture dislocations of the femoral head remain extremely rare fracture of the hip. The isolated fracture is not reported in the literature. Therefore, we report in this manuscript unusual lesion in the form of a shifting of the femoral head, this has had favorable evolvement after opened reduction and internal fixation.

Case Report

Our patient is a male of 38 years old without any particular history of pathology. He was a victim of a traffic accident with fall from his motorcycle. He was received on side and on the right knee.

This caused a traumatism of the right hip. At the admittance in the hospital, the patient suffered from severe pains and a functional disability of the right lower member. The clinical examination did not reveal deformation, but showed existing pain at the mobilization of the hip. There were no other associated lesions. The X-rays of the right hip objectified a fracture of the femoral head with an osseous defect of the superior pole, and two osseous fragments falling behind; the joint was not dislocated (Figure 1). The CT-scan showed a fragmentation of

the femoral head with multiple fragments, but remaining in the cotyle which was intact (Figure 2). The surgical access was posterior and the exploration discovered a cartilage shift in 3 big cuttings (Figure 3.a).

The reduction has required the dislocation of the head (Figure 3.b) with buried screwing. The post-surgery control showed a good reduction of the fracture with a spherical head (Figure 4). After a discharge of 6 weeks, the support was achievable without pain. The result is good after 14 months. The hip is pain free, stable with good normal motion. There is no necrosis of the femoral head.


Discussion :

The femoral head fractures are very rare, they are always associated to a dislocation of the hip, and the posterior variety remains the most frequent. The consequences of these hurts are very grave. The etiology is dominated by the accidents of the public road [1].

The dislocation factors are dismembered according to several classifications, according to the displacement [2]. The isolated fracture of the femoral head is not reported in the adopted classifications. Pipkin established in 1957 a classification, which states 4 stages, which are all associated to posterior dislocation of the hip. The type I a dislocation of the hip associated to a fracture under fovea; in the stage II, the fracture catches the fovea. The stage III is a lesion of type I or II associated to a fracture of the femoral colles; while the stage IV encloses a fracture of the acetabulum [3].

The classification of Brumback is more exhaustive [4]; and described 5 types. The type I represents a posterior dislocation with inferomedial fracture; in the type II, the fracture is superomedial ; the type III associates a dislocation of the hip without clarifying its direction together with a fracture of the femoral neck; Type IV contains the previous dislocations associated to the cephalic fractures. The type V described fractures with central dislocation. This classification can contain the "shifting" of the femoral head without dislocation in type II.

The face X-ray of the pond allows revealing any asymmetry even small, which must make be suspect. The centered X-ray studies more precisely the reasons of both, hillsides of the joint in search of past unnoticed fractures [5].

The CT-scan operated in thin slices, clarifies the site of the lesion, or a confinement. This study is essential in case of instability, an asymmetry of interlines and the fracture of the head or the cotyle; this to define better the lesions [6-8]. The arthrography, the arthro-CT [9] or the magnetic resonance imaging (MRI) were evoked.

The conservative treatment is the rule in case of the types 1 and 2 [10]; the surgical reduction would become necessary. The access procedure depends at first on the variety of the dislocation and on the movement of fragments. The Kocher Langenbeck access can be used for fractures associated to the posterior wall of the cotyle. Some authors use a trochanterotomy for improving the visibility and facilitate the osteosynthesis [11, 12]. The approach of Smith Peterson is used in case of previous dislocation [2, 13]. We used at first posterior approach guided by the movement of fragments. The osteosynthesis require a buried screwing using a metal or bio-resorbed material [14, 15]. The small fragments can be resected [16, 17].

The complications are frequent. Necrosis risks of the femoral head are situated between 0 and 24 %. The degenerative posttraumatic osteoarthritis is between 0 and 72 %; the nervous lesions are between 7 and 27 % and heterotopic ossifications are between 2 and 54 % [12].

The isolated fractures communitive of the femoral head, are recognized as cartilaginous shifting of difficult treatment. The posterior approach leads good exposition for internal fixation without avascular necrosis.

Reference :

  1. Durabkasa O, kan N, Canbora K, Gorgec M. Factors affecting the results of treatment in traumatic dislocation of the hip.  Acta Othop Traumatol Turc. 2005; 39 (52): 133-41.
  2. Bauer GJ, Sarkar MR. Injury classification and surgicalapproach in hip dislocations and fractures. Orthopade 1997; 26(4): 304-16.
  3. Pipkin G. Treatment of grade IV fracture dislocation of the hip. J Bone JOIN Surg Am 1957; 39-A (5):1027-42.
  4. Brumback RJ, Kenzora JE, Levitt LE, Burgess AR, Poka A. Fractures of the femoral head. In: The Hip Society, editor. Proceeding of the hip Society, 1986. St. Louis: Mosby; 1987; p.181-206.
  5. Sontich JK, Cannada LK. Femoral head avulsion fracture with malunion to the acétabulum: a case report. J Orthop Trauma.2002; 16(1): 49-51.
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  7. Hougaard K, Thomsen PB Coxarthrosis following traumatic posterior dislocation of the hip. J Bone Joint Surg 1987; 69-A: 679-683.
  8. Yang RS, TsuangYH, Hang YS, Liu TK Traumatic dislocation of the hip. Clin Orthop 1991; 265: 218-227
  9. Canale ST, Manugian AH. Irreducible traumatic dislocations of the hip. J Bone Joint Surg 1979 ; 61-A : 7-14
  10.  Matejba J, Koudela K. Bilateral fractures of the femoral head 5 Pipkin I and Pipkin II). Acta Chir Orthop Traumatol Cech.2002; 69(6): 369-71.
  11.  Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acétabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001 ; 83(8):1119-24
  12. Kloen P, Sienbenrock KA, Raymakers ELFB, Marti RK, Ganz R. Femoral head fractures revisited. Eur J Trauma 2002; 28: 221-33.
  13. Shonweiss T, Wagner S, Mayr E, Ruter A. Klinik fur Unfall Und Wiederherstellungschirurgie, Zenttralklinikum Augsburg. Unfallchirurg. 1999; 102 (10):776-83.
  14. Hermus JPS, Laan CA, Hogervorvorst M, Rhemrev JS. Fixation of Pipkin fracture with bio-absorbable screws case report and review of the literature. Injury 2005 (36);458-461
  15. Prokop A, Helling HJ, Hahn U, Udomkaewknjana C, Rehm KE. Biodegradable implants for Pipkin fractures. Clin Orthop Relat Res. 2005; (432):226-33.
  16. Holmes WJ, Solberg B, Bay BK, Laubach JE, Olsen SA. Biomechanical consequences of excision of displaced Pipkin femoral head fractures. OTA 1999 Oct; Session VIII.
  17. Siebenrock KA, Gautier E, Woo AK, Ganz R. Surgical dislocation of the femoral head for joint debridement and accurate reduction of fractures of the acétabulum.  J Orthop Trauma 2002; 16(8): 543-52.


This is a peer reviewed paper 

Please cite as : A. Elmrini: Isolated Fracture Of The Femoral Head

J.Orthopaedics 2006;3(3)e1





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