Femoral Head Fractures



5-15% of posterior dislocations




Posterior hip dislocation


Pipkin Classification


Type I - head fracture below fovea



- non operative



- excise fragment if small

- ORIF fragment if large (can contribute to instability)


Pipkin Fracture Type 1


Type II - head fracture above fovea



- rare, usually unstable



- excise if small

- ORIF if large


Type III - Type I/II with NOF fracture



- very high incidence of AVN



- ORIF young patient

- hemiarthroplasty / THR older patient


Pipkin Fracture Type 3


Type IV - Type I/II/III associated with acetabular fracture


Pipkin 4 Fracture


Non operative management




Type 1

- < 2mm displacement

- stable hip

- congruent joint


Type 2

- rarely anatomic

- usually unstable


Surgical Management


Choice of Approach


Fragment usually anteromedial


Type 1 and II

- anterior or anterolateral approach

- Smith Petersen / Watson Jones

- careful capsulotomy to preserve blood supply

- deep branch MCFA runs along superior femoral neck


Pipkin Open 1Pipkin Open 2Pipkin Open 3Pipkin ORIF


Type III

- anterolateral approach / Watson Jones

- ORIF NOF + fix/excise Pipkin fracture in young patient

- very high incidence AVN

- THR > 60


Type IV


A.  Associated with posterior dislocation / non operative acetabular fracture


Posterior approach

- this can make it difficult to access fragment

- need IR +++

- can attempt posterior to anterior screw fixation


Anterior approach

- if stable and no acetabular fracture requring ORIF

- involves making anterior capsulotomy

- patient already has posterior capsular defect


B.  Associated with posterior acetabular wall fracture that needs ORIF (>40%)

- posterior approach


C.  Associated with anterior acetabular fracture

- ilioinguinal with SP extension


Anterior Approaches


Many options

- Hardinge

- Watson Jones

- Smith Peterson 

- Ganz osteotomy


Any of these are blood supply preserving if perform safe capsulotomy

- avoid capsulotomy along superior neck

- Z capsulotomy

- capsulotomy along anterior acetabular rim superior to inferior

- along inferior femoral neck

- down medial femur


Ganz trochanteric flip osteotomy

- trochanteric slide

- gluteus medius and sastus lateralis attached / digastric

- osteotomy with saw posterior to anterior

- leave short external rotators attached to preserve deep branch MCFA

- slide GT fragment anteriorly

- capsulotomy as above

- allows access to anterior aspect femoral head

- dislocate femoral head anteriorly / surgical dislocation


Smith-Petersen approach

- good approach if only Pipkin fracture needs fixation

- higher risk of HO




Sciatic nerve injury 4%

- traumatic

- iatrogenic


Infection 3%


Recurrent instability

- large femoral head fracture excised

- posterior wall fracture

- rarely due to labral tear





- increased with anterior approach






Giannoudis et al Injury 2009

- systematic review

- Pipkin I: excision gave better results than fixation

- Pipkin II: ORIF
- AVN 11% / OA 20% / HO 17%

- no difference between trochanteric flip / anterior or posterior approach


Chen et al Int Orthop 2010

- RCT of excision v non operative for Pipkin 1 in fracture dislocation

- better outcomes in excision