Disastrous triad of femoral head:femoral neck fracture meeting fracture-dislocation of femoral head / 中国骨伤

Femoral head and ipsilateral femoral neck fractures are serious and complicated injuries, which usually yield unsatisfactory results using conventional hip-preserving surgery. The key point of the management and prognosis mainly lies in femoral neck fractures. An apparent and consecutive relationship exists between femoral neck fractures and femoral head fracture-hip dislocation in such injuries. It is believed that disastrous triad of femoral head (DTFH) could summarize these specific injuries, and reflect the injury mechanism and prognostic characteristics. Based on our clinical observation and literature review, DTFH could be divided into three subgroups:TypeⅠ, common DTFH, in which femoral neck fractures occur following femoral head fractures-hip dislocation due to the same trauma; TypeⅡ, iatrogenic DTFH, in which femoral neck fractures come out in the caring process of femoral head fractures-hip dislocation; Type Ⅲ, stressed DTFH, in which femoral neck fractures occur after the management of femoral head fractures-hip dislocation. In the scenario, the line of femoral neck fractures locates distally to the femoral head fractures. Herein, we will discuss clinical characteristics of these types of DTFH.

Traumatic recurrent hip dislocation associated with femoral head fracturere constructed with iliac crest autograft / Luxación recurrente de cadera asociada a fractura de cabeza femoral reconstruida con autoinjerto de cresta iliaca

Hip femoral head fractures are extremely uncommon, but likely associated with traumatic hip dislocations. Both lesions require emergent treatment to avoid further complications.19-year-old male patient was received after a high-energy motor vehicle accident with severe brain and thoraco-abdominal trauma and a displaced femoral head fracture with posterior hip dislocation with no acetabular fracture. An emergent open reduction and internal fixation with 2 headless screws was performed, as well as posterior capsule repair. After 1 month as an inpatient in Intensive Care Unit, he sustained a new episode of posterior hip dislocation. Consequently, a second successful surgical reduction was obtained, and hip stability was achieved by posterior reconstruction with iliac crest autograft fixed with cannulated screw and posterior structure repair. Two years later, he was able to walk independently and he does not present any signs of degenerative joint disease nor avascular necrosis.

Las fracturas de la cabeza femoral son extremadamente raras y están asociadas comúnmente con una luxación de cadera traumática. Ambas lesiones requieren tratamiento urgente con el objetivo de evitar complicaciones posteriores. Un paciente varón de 19 años fue trasladado tras un accidente de tráfico de alta energía en el que sufrió un traumatismo craneoencefálico y toracoabdominal grave, además de una fractura de cabeza femoral desplazada junto a una luxación posterior de cadera sin afectación acetabular. De manera urgente, fue intervenido mediante una reducción abierta y fijación interna de la fractura con dos tornillos canulados sin cabeza y reparación de la cápsula articular posterior. Tras un mes de ingreso en la unidad de cuidados intensivos, sufrió un nuevo episodio de luxación posterior de cadera. Debido a ello, se realiza una segunda intervención quirúrgica con reducción abierta y en la que se obtiene una adecuada estabilidad de la cadera mediante reconstrucción posterior con la adición de autoinjerto tricortical de cresta ilíaca y reparación capsular posterior. Después de dos años de seguimiento, el paciente deambula de manera independiente, sin dolor y sin signos degenerativos ni de necrosis avascular en las pruebas de imagen.

Management of Traumatic Posterior Dislocation of Hip with Fracture Head of Femur

Traumatic dislocation of hip is a rare injury that occurs due to high energy trauma. Fracture head of femur associated with dislocation of hip occurs is even rarer. Some surgeons recommend conservative treatment, while others recommend surgery. The purpose of this study was to evaluate the method of treatment and outcomes of femoral head fractures. Methods: This study was conducted between 2006-2018 & included 4 patients who presented to the department and were diagnosed with posterior dislocation of hip with fracture of head of femur with a minimum followup of 12 months. Results: All the four cases that presented to the hospital were managed by closed reduction of the hip on the same day & were managed surgically the very next day. Three of four patients presented with clinically & radiologically excellent results on followup. Conclusion: Traumatic dislocation of hip with fractures of the femoral head are rare. Patients can be surgically managed by either excision of fragments or fixation using headless screws. Avascular necrosis and post traumatic degenerative disease of the hip occur but are relatively uncommon

Fractura iatrogénica de la cabeza femoral durante una reducción cerrada de luxación posterior de cadera. Reporte de un caso / Iatrogenic femoral head fracture during a closed reduction of posterior dislocation of hip. Case report

Resumen: La fractura luxación de la articulación coxofemoral es una lesión rara descrita de 4 a 17% de los casos por lo regular secundaria a accidentes automovilísticos. Generalmente de mal pronóstico y con complicaciones ya bien documentadas como la necrosis avascular de la cabeza femoral, la osteoartritis y la osificación heterotópica. La fractura iatrogénica del cuello o de la cabeza femoral es una complicación aún más rara cuya incidencia no está documentada en la literatura mundial. Como probables causas se tienen la irreductibilidad de una luxación de cadera al hacer más de un intento de manipulaciones cerradas, la ausencia de una adecuada anestesia y la falta de relajación del paciente. Se presenta el caso de una paciente joven atendida en las primeras ocho horas posteriores al accidente con fractura iatrogénica de la cabeza femoral con seguimiento a 18 meses, haciendo énfasis en la importancia de realizar una reducción anatómica y fijación estable para obtener resultados favorables.

Abstract: The fracture dislocation of the hip is a rare lesion described up to 4 to 17% of the cases and usually secondary to automobile accidents. Generally of poor prognosis and with already well documented complications such as avascular necrosis of the femoral head, osteoarthritis and heterotopic ossification. The iatrogenic fracture of the neck or head of the proximal femur is a complication even more rare and is not documented its incidence in the world literature. Having as probable causes the irreducibility of a dislocation of hip, more than one attempt of closed reduction, inadequate technique and some problems with the anesthesia and relaxation of the patient. We present the case of a young patient attended in the first eight hours after his accident with an iatrogenic fracture of the femoral head with follow up to 18 months and emphasizing the importance of making an anatomic open reduction and stable fixation in order to get favorable results.

Application of arthroscopic surgery combined with direct anterior approach in hip diseases / 中国修复重建外科杂志

Objective: To evaluate the short-term effectiveness of arthroscopic surgery combined with direct anterior approach for hip diseases. Methods: A retrospective study was performed on 23 cases with hip diseases (23 hips), who were treated with the arthroscopic surgery combined with direct anterior approach, between January 2015 and December 2016. There were 9 males and 14 females, aged from 27 to 49 years (mean, 38.6 years). There were 11 cases of posterior dislocation of the hip associated with femoral head fracture (Pipkin typeⅠ) and 7 cases of femoral neck fracture (Garden type Ⅳ). And the interval between injury and operation was 2-8 days (mean, 4.3 days). Five cases were osteonecrosis of femoral head at precollapse stage which were rated as stageⅡA according to Association Research Circulation Osseous (ARCO) classification system. The disease duration was 3-8 months (mean, 5.9 months). The preoperative Harris hip score, Oxford Hip Score (OHS), Postel score, and visual analogue scale (VAS) were 57.3±8.2, 11.2±3.6, 3.2±1.5, and 7.2±1.3, respectively. Results: All the wounds healed primarily. Lateral femoral nerve injury occurred in 3 cases. All patients were followed up 8-19 months (mean, 15.6 months). Bone union achieved in all patients after 14-19 weeks (mean, 15.8 weeks) and no secondary osteoarthritis or heterotopic ossification occurred. At last follow-up, the Harris hip score (92.5±5.3), OHS (36.5±5.9), and Postel score (14.2±2.6) were significantly higher than preoperative scores ( t=45.274, P=0.000; t=36.586, P=0.000; t=32.486, P=0.000), and VAS score (1.8±0.9) was significantly lower than preoperative score ( t=21.314, P=0.000). Conclusion: Arthroscopic surgery combined with direct anterior approach for hip diseases can effectively relieve pain, improve hip function, and obtain the satisfactory short-term effectiveness.

Updates on Treatment of Femoral Head Fractures / 대한정형외과학회잡지

Fracture of the femoral head is relatively uncommon and usually caused by high energy injury. The femoral head fracture combined with hip dislocation results in severe damage to the hip joint, and therefore has been associated with poor functional outcome. The principle of the treatment is composed of urgent reduction of the dislocated hip and early anatomical reduction, with the goal of restoring a congruent and stable hip. In an effort to reach that goal, several methods have been used for treatment of the fracture after closed reduction of the hip. The purpose of this article is to review the indication of surgery, surgical methods, surgical approach, and clinical outcomes.

Arthroscopic Fragment Excision of Pipkin Type I Displaced Femoral Head Fracture: A Case Report / 대한고관절학회지

There has been a variety of options for treatment of femoral head fracture with hip dislocation according to the Pipkin classification. Pipkin type I fractures with minimal displacement have been treated conservatively. However, in cases where the fracture was displaced or reduced incongruently, it has been treated by open fragment excision or fixation after reduction. In our case, the patient was a 62-year-old man who sustained a displaced fracture of Pipkin type I. We achieved a satisfactory outcome by arthroscopic excision of a displaced bony fragment and small bony fragments that could not be confirmed by pre-operative imaging study. Therefore, we report on the case with a review of the literature.

Traumatic Dislocation of the Hip with a Femoral Head Fracture / 대한고관절학회지

PURPOSE: This study was designed in order to evaluate the clinical results and frequency of complications of patients who underwent surgical treatment for traumatic dislocation of the hip with a femoral head fracture. MATERIALS AND METHODS: Eighteen cases of Thompson-Epstein type V femoral head fracture with dislocation of the hip from November 2002 to November 2011 were analyzed retrospectively. We divided the cases into two groups according to availability of closed reduction and reduction time, and analyzed the clinical results according to Epstein criteria and frequency of avascular necrosis of the femoral head and posttraumatic osteoarthritis. RESULTS: Among all patients, the observed complications included three cases of avascular necrosis and one case of posttraumatic osteoarthritis. The data showed that 14 cases were available for closed reduction; otherwise, there were four cases of failure. Significant differences were observed in clinical results and frequency of complications. Results regarding reduction time showed that 10 cases took 6 hours, and the other eight cases took more than 6 hours. There were no differences in clinical results, but, better results were achieved with a reduction time in 6 hours. However, significant differences were observed in frequency of complications. CONCLUSION: The availability of closed reduction would be an important factor for achievement of good clinical results in traumatic dislocation of the hip with a femoral head fracture. In order to obtain better clinical results, closed reduction should be performed as rapidly as possible.

Traumatic Femoral Head Fracture without Hip Dislocation: A Case Report / 대한고관절학회지

The incidence of femoral head fracturesafter posteriorhip dislocation is approximately 5-15%, and femoral head fractures are highly associated with posterior dislocation. Femoral head fractures can cause avascular necrosis of the femoral head or post-traumatic osteoarthritis; therefore, diagnosis and appropriate treatment is important. We present a case of femoral head fracture without hip dislocation, as well as a literature review.

Treatment of the Pipkin fractures / 国际外科学杂志

Objective To investigate the treatment of Pipkin fractures and curative effect. Methods From January 2003 to November 2009, we treated 19 cases of posterior dislocation of the hip with fracture of the femoral head,with type Ⅰ 8 cases, type Ⅱ6 cases, type Ⅲ 1 case, type Ⅳ4 cases. Seventeen patients were treated according to the illness with internal fixation treatment. Results Among type Ⅰ 8 cases, 2 cases were good with conservative treatment, 3 were excellent and 3 were good with surgical treatment;Among type Ⅱ6 cases, 3 were excellent, 2 were good, 1 was fair; 1 patient of type Ⅲ was fair; In 4 cases of type Ⅳ, 1 case was excellent, 2 cases were good, 1 case was fair. Conclusions Surgical treatment as soon as quickly is preferred for posterior dislocation of the hip with fracture of the femoral head( Pipkin fractures) , but the surgical time and methods should be chosen according to patients' detailed illness. It is important reserving the hip bone for preventing traumatic arthritis, and surgical skills to protect blood supply should not be ignored.

Femoral Head Fracture without Dislocation by Low-Energy Trauma in a Young Adult

We describe the case of a healthy young man with a femoral head fracture by low-energy trauma that occurred without evidence of hip dislocation. While plain radiographs showed no definite fracture or dislocation, computed tomography (CT) and magnetic resonance imaging (MRI) revealed a femoral head fracture with a wedge-shaped cortical depression at the superomedial aspect of the femoral head. Our patient reported feeling that the right hip had been displaced from its joint for a moment. This probably represented subluxation with spontaneous relocation. The characteristic findings and possible mechanisms of this fracture were postulated on the basis of the sequential 3 dimensional-CT and MRI. The clinical results of conservative treatment were better than those of previously reported indentation fractures.

Treatment of Traumatic Posterior Dislocation of the Hip Joint Associated with Femoral Head Fracture

PURPOSE: This study examined the treatment of patients with posterior hip dislocation and femoral head fracture, according to the Pipkin classification, and we analyzed their clinical and radiological results. MATERIALS AND METHODS: The subjects consisted of 45 patients who were treated for posterior hip dislocation and femoral head fracture. The subjects had an average age of 39, and 38 were men and 7 were women. The average follow-up period was 33 months. The cause of injury was traffic accident in 41 cases and falling for the other four cases. According to the classification, there were 26 Type I cases, 5 Type II cases, 1 Type III case and 13 Type IV cases. The treatment methods were selected according to the patients' condition and the form of fracture. The Ebstein criteria and the Merle d'Aubigne and Postel score were used to determine whether there was a combined injury and to examine the clinical and radiological results. RESULTS: All the cases classified as Type I, II and III showed good or excellent clinical results. A primary osteosynthesis was performed on the Type III cases according to the patient's age and condition, with particularly good results. An anatomical reduction in the early stages affected the clinical results of the Type IV cases. The observed complications were posttraumatic osteoarthritis (38.4%) and avascular necrosis (15.3%). CONCLUSION: The prognosis was determined by the injury's initial severity, the time for reduction and the anatomical reduction and firm fixation of the femur and the fracture fragment of the acetabulum.

Outcomes of Treatment for Femoral Head Fractures with Hip Dislocation: Review of 20 Cases

PURPOSE: We wanted to assess the clinical results and the complications of treating femoral head fractures. MATERIALS AND METHODS: Twenty patients with femoral head fractures and who had a minimum 1 year follow up were enrolled in this study from April 2004 to June 2008. The clinical outcomes were evaluated according to the mechanism of injury, the reduction time, the Pipkin classification, the treatment methods, the surgical approach and the complications. RESULTS: There were 5 cases of Pipkin type I and 2 cases of Pipkin type II, 1 case of Pipkin type III and 12 cases of Pipkin type IV. All the patients underwent operation except 1 patient; there were 5 excisions, 7 internal fixations, 1 prosthesis, and 6 internal fixations of combined acetabular fixation without surgery for the femoral head fractures. The average Harris hip score at 1 year after operation was 80.0 (range: 57~99): there were 4 excellent, 7 good, 5 fair and 4 poor results. The complications of the femoral head fractures were 2 cases of avascular necrosis and 2 cases of posttraumatic osteoarthritis. CONCLUSION: Internal fixation of the femoral head with using Herbert screws showed a favorable outcome, while excision of the femoral head fragments did not. Internal fixation of Pipkin type 1 or 2 fractures could be performed by the anterior approach. The posterior approach combined with surgical dislocation is especially useful in internal fixation of concurrent posterior acetabular fractures, and it has the advantage of preserving the blood supply to the femoral head.

Fixation of Pipkin Fractures with Acutrak Screws: A Report of Three Cases

Femoral head fracture with posterior dislocation of the hip occurs relatively infrequently. Many treatment options exist for this condition. The fracture fragments of the femoral head can be internally fixed or removed depending on the severity of fracture comminution, fragment size, and location on the weight-bearing surface of the femoral head. In Pipkin type I and II fractures, the fragments are typically located anteriorly. Hence, it is important to strongly fix the fracture fragments to the femoral head rather than to excise them, in the interest of securing a better outcome. Even if the fragments are caudal to the fovea centralis, the discarding of large portions of the femoral head that are amenable to rigid fixation is not preferred. Three femoral head fractures were treated using Acutrak screws incorporated with a self-compression mechanism. We report the results and consider ways to use Acutrak screws.

Treatment of femoral head of patients with osteonecrosis of the femoral head fracture / 中华显微外科杂志

Objective To research on treament of femoral head of patients with osteoneerosis of the femoral head fracture.Methods Twenty-six patients half of femaoral head of patients with osteonecrosis of the femoral head fracture who treated with vascularzed bone graft were determined.Twenty-one hips treated with internal fixation unloaded and vascularzed bone graft after selective digital subtraction angiography (DSA) was performed to confirm the blood supply of femoral head.one case underwent total hip replacement after internal fixation unloaded.Results All patients were followed up for a mean of 23 months (range,12-38months)and were assessed clinically and radiologically according to Harris scoring.Selective digital subtraction angiography (DSA) was performed in 15 cases to confirm the blood reconstruction of femoral head.Two cases underwent total hip replacement postoperatively.Preoperative and postoperative Harris score were 54 and 86.2,clinical success rate was 92.0% and radiological success rate was 84.0%.DSA demonstrated blood supply was found reconstruction in the necrotic femoral head.Conclusion Femoral head of patients with osteonecrosis of the femoral head fracture was very much (recent 40%).Taking out of internal fixation,treatment of osteonecrosis of the femoral head by using vascularzed bone graft was confirmed,early clinical results were satisfied.

Treatment of Femoral Head Fracture with Traumatic Posterior Dislocation of the Hip

PUEPOSE: To evaluate the treatment results and complication of a femoral head fracture with posterior dislocation of the hip according to the Pipkin classification. MATERIALS AND METHODS: Ten cases of Thompson-Epstein type V femoral head fracture with a posterior dislocation of the hip were evaluated. According to the Pipkin classification, 5 cases were type I, 1 case was type III, and 4 cases were type IV. The average age at time of trauma was 38 (19~72) years, and the causes were traffic accidents in 9 cases and falls in 1 case. The average follow-up period was 33 (13~79) months. A reduction of the fracture was performed within 6 hours in 9 cases and 12 hours in 1 case. When the stability was achieved after the reduction, the choice of further treatment was made from either conservative treatment while maintaining skeletal traction, or surgical treatment according to the fracture type and instability. The complications were evaluated by a physical examination, simple radiography, computed tomography (CT) and magnetic resonance imaging (MRI). RESULTS: In Pipkin type I fractures, 4 cases were treated with conservative treatment and 1 case was treated with surgical treatment. One case of Pipkin type III fracture was treated with primary total hip arthroplasty. In Pipkin type IV fractures, 2 cases were treated surgically using a plate and 2 cases were treated with conservative treatment with skeletal traction. Bone union was achieved in all cases. One case of mild posttraumatic arthritis and 1 case of avascular necrosis was found, respectively in Pipkin type IV. CONCLUSION: The extent of the initial injury has an effect on the prognosis of a hip fracture and dislocation.

Safe Triangle Within Dangerous Femoral Triangle For the Potential Space of True Anterior Hip Approach / 대한정형외과학회잡지

PURPOSE: To evaluate the safe triangle within the femoral triangle for the potential space of the true anterior hip approach. MATERIALS AND METHODS: Cadaveric dissections were carried out on 28 femoral triangles from 14 cadavers. This study measured the length of the direct head of the rectus femoris from the anterior inferior iliac spine (AIIS) to the patella upper pole, the AIIS to the lateral border of the femoral nerve, and the entry point of the femoral nerve and vessel branches to the rectus. The safe portion within the risky femoral triangle was analyzed and applied to two clinical situations, a femoral head fracture and septic hip arthritis. RESULTS: The examination showed that there were three terminal branches to the rectus femoris from the femoral nerve. The entry point of the first branch was at the proximal 20.0-28.9% portion of the rectus femoris. The second and the third branch entered at the proximal 22.5-37.5% and 24.9-41.0%, portion, respectively. The vessel entry was at 21.4-37.3%. The length from the AIIS to the femoral nerve was 3.5- 8.0 cm. Using this space, the procedure was easier to perform in the two situations mentioned above. CONCLUSION: The space within the femoral triangle between the proximal 20% of the rectus femoris and iliacus can be used as one of the potential spaces for femoral head fracture fixation and septic hip irrigation in children, and as an arthroscopy portal.

The treatment of posterior hip dislocation combined with femoral fractures / 中华创伤骨科杂志

Objective To discuss the treatment method and prognosis of posterior hip dislocation combined with femoral fractures. Methods Twenty nine patients who had been diagnosed as cases of posterior hip dislocation combined with femoral head fracture were reviewed, with their type of fracture, timing of treatment and method of treatment analyzed. Twenty seven (93.1%) of the 29 cases were followed up from 1987 to 2002 for an average period of seven years. Their prognosis was evaluated according to the x ray radiography and the function of hip joints. Results According to Pipkin IV classification, 13 cases were Pipkin Ⅰ(44.8%), 9 cases Pipkin Ⅱ(31%), 3 cases Pipkin Ⅲ(10%), and 4 cases Pipkin Ⅳ(14.2%). In type I, 9 cases were rated as excellent (33.3%), 2 good (7.4%), 1 fair (3.7%) and 0 poor (0%) by Harris hip score. In typeⅡ, 0 case was rated as excellent (0%), 2 cases good (7.4%), 4 fair (14.9%) and 2 poor (7.4%). In type Ⅲ, 1 case was rated as excellent, 0 good (0%), 1 fair (3.7%) and 1 poor (3.7%). In type Ⅳ, 0 case was rated as excellent (0%), 2 good (7.4%), 1 fair (3.7%) and 1 poor (3.7%). In all the 29 cases, those which needed total hip arthroplasty (THA) were four (13.7%). Conclusions The choice of treatment method should be determined by the mechanism of injury and the type of fracture. The factors ensuring a satisfactory prognosis are: (1) The age of the patients should be younger than 40 years. (2) Since a timely reduction can prevent the onset of avascular necrosis of femoral head, it should be finished within 12 hours after the injury, and the fixation should be done within 10 days. (3) In all types, early reduction of hip dislocation, early stabilization, anatomic reduction of the fracture should be achieved. (4) The prevention of possible complications should be taken into serious consideration.

The Treatment of Femoral Head Fractures Associated with Posterior Hip Dislocations / 대한정형외과학회잡지

Femoral Head fracture associated with posterior dislocation of the hip was once considered a rare industrial injury. However, the advant of high-speed travel has contributed to its increased incidence. Ten cases of fractured femoral head with posterior dislocation of the hip were treated at the Busan Paik Hospital between June 1979 and June 1982. During the same period, a total of 38 posterior hip dislocations were treated. The patients were followed for the average of 19.3 months, the range being 6 months to 3 years. There were 9 men and 1 woman the age ranged from 25 to 56 years. The fractures were classified according to Pipkin and the results were evaluated by Epsteins criteria. 1. The incidence of femoral head fracture was 26.3%, 10 cases of 38 posterior hip dislocations. 2. The better result was noted in open method than in closed method. 3. The absolute surgical indications were considered as followings. a. inadequate closed reduction of head fragment especially the large one. b. the involvement of weight bearing portion of femoral head. c. the hip joint pain caused by impingement of small fragment between joint space. 4. Arthrogram was helpful to find the concealed small fragment when the hip joint pain persisted with negative findings in ordinary x-ray.