Femoral head fractures are usually associated with hip dislocation. They can involve both non weight bearing portion of the head (Pipkin 1) and the weight bearing dome (Pipkin 2). Though a small inferior head fracture is not bearing much load, it has to be contributing to hip stability if the piece broke during dislocation. The text book answer is nonop treatment if the fragment is close to its defect and does not block motion. Dr. Prasad Gourineni tends to fix them all through an anterior approach. Fixed one arthroscopically with some difficulty because the guide wires and depth gauges for the 3.0 headless screws were not long enough. More complex or comminuted fractures and posterior wall fractures can be accessed with Surgical dislocation approach.
Open technique – Smith Peterson approach going medial to rectus is usually adequate to reduce and fix most head and neck fractures. Drill hole assessment of femoral head vascularity is good to rule out AVN.
Arthroscopic technique – Once the initial blood is cleared from the joint with high flow and epinephrine in Saline, the pressures can be lowered to 40 or 50 mm Hg. Swelling occurs very often, but rarely causes any problems. Reduction of the fracture is with direct manipulation of the fragment into its defect in the head and the acetabulum acts as a template. For screw fixation, the guide wire can be placed percutaneously and whenever the angle is right a small incision is made for drilling and screw placement. The portals can be anywhere lateral to ASIS and Sciatic nerve.
