Executive Editor: Joseph Schatzker, Peter Trafton

Authors: Ernst Raaymakers, Inger Schipper, Rogier Simmermacher, Chris van der Werken

Proximal femur - Femoral head fracture, split

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Glossary

General considerations

Fractures of the femoral head are intraarticular. They may be associated with hip dislocations, acetabular fractures, or femoral neck fractures.

In split fractures (Pipkin) there is a fragment which has split off from the femoral head.

The optimal treatment strategy is not clear. Only anatomical reduction of the fracture fragments gives good long-term results. The treatment should therefore be focused on restoration of the articular surface, combined with treatment of any associated injuries.

Osteochondral fragments cranial to the ligamentum teres are usually part of the weight-bearing surface, making anatomical reduction mandatory.

ORIF - Small fragment screws
Main indication Skill Equipment
Split fractures with more proximal “Pipkin II” or larger fragments Highly experienced and skilled surgeon Simple surgical and imaging resources

Indications

  • Split fracture in a patient fit for surgery
  • Unsuccessful closed reduction 
  • Accompanying significant acetabular fracture 
  • Residual instability 
  • Interposed fragments in the hip joint 
  • Sciatic nerve deficit, not present prior to reduction

Contraindications

  • Contaminated or infected local wound 
  • Patient not fit for surgery

Advantages

  • Anatomical reduction (congruent joint) 
  • Stable fixation

Disadvantages

  • Risks of surgery 
  • Risk of heterotopic ossification
  • Choice of implant

Resorbable screws do not need removing, but may be relatively weak.

If metal screws are used, titanium is a better choice than steel, as it does not interfere with subsequent MRI imaging.

Intraosseus self-compressing screws cause less damage to the articular cartilage than conventional screws, and there is less risk of a prominent screw head causing secondary articular surface damage.

*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2010-11-14