This is a  type 2 Pipkin fracture. My team published a case series and review of the literature in Orthopaedische Praxis (Germany) in 1984. You may download it from my publications on ResearchGate. See below:

Gantscheff, M et al. Orthop. Praxis, 20, 1984, 124-132 Traumatische Schaedigungen des Hueftgelenkes - Typ Pipkin (in German) There is an abstract in English. I may only say it is an unhappy injury which leads at the end to avascular necrosis and THR. 

Regards

Thanks

Dear Raju

I have two cases of  fracture of femoral head (without acetabular involvement) with posterior dislocation and without sciatic nerve palsy. Em both cases my option was surgical reduction with postero lateral approach and fixation with 2 screws type HCS. Both cases showed good recovery without necrosis.

Thanks a lot

You are welcome

@Nelson:  Were your cases Pipkin Type I or II ? Probably, they have been Pipkin Type I when the blood supply is less damaged and good healing can be expected. In our series, Type II fractures that  were screwed developed avascular necrosis and were subjected to THR as a definitive solution. In our experience Type III and IV should be primarily subjected to THR.

On ResearchGate you may follow the publications of our team Gantscheff et al (1984) in Orthop. Praxis (in German) and in Bulgarian Journal of  Othopaedics and Trauma (in Bulgarian). English abstracts are available. 

Pipkin type fractures of the femoral head (classification 1957) represent very severe and unhappy injury.  

@Vaishya: From the single picture you posted  I got the impression that the fracture is Type II. So I would do THR in this case. I am interested to know the course and outcome of this case.

Yes I've treated over 250 femoral head fractures with ORIF via direct anterior exposure . The sciatic nerve injury is not common, but also not unusual. The ones with associated displaced femoral neck fractures did poorly in follow up while the rest do well with very rare aseptic necrosis after ORIF. Some of the caudal anteromedial fractures were irreparable and underwent excision along with EUAF after excision to assure stability of the joint after excision. The direct anterior exposure with anterior surgical dislocation for the ORIF was done for all patients in the supine position and without any osteotomies. After ORIF, only several had posterior hip instability due to capsular disruption or posterior wall acetabular fracture that required subsequent KL exposure for repair of the wall and or capsule. A few patients in the early 1990s had symptomatic ectopic bone form in the region of the rectus femoris tenotomy repair so we added oral indomethacin to our postoperative routine and the HO issues resolved. 

Dr. Routt, 

The question tackles femoral head fractures with posterior dislocation. Dr. Vaishya and Dr. Elias find this fracture-dislocation to be a rare injury. So do I.  A number of 250 cases seems to be very intriguing. I would ask some questions.  First, did you publish this series ? Second, anterior approach seems to be not very appropriate in cases with posterior dislocation. The more so if the sciatic nerve should be revised when injured. What do you think ? 

Thank you. I have worked at two different urban USA trauma centers. At both centers, we see 15 to 20 operative femoral head fracture dislocations in adult patients per year. I operated on and was responsible for the vast majority of them and used the direct anterior exposure as mentioned above for all of them that were anteromedial routine femoral head fracture dislocations. The exposure and surgical dislocations and repairs were all relatively uneventful other than what I shared with you above. So hopefully that helps you with the math and patient volumes. Due to the changes in both medical and radiographic recordkeeping, the latter half of this patient series will be published. To answer your second question, the exposure is more than appropriate. And to answer your third question of what I think, I think what I said above is exactly what I still think. I only know what I've experienced with these patients - and I share that with you and the others to try and help you - chip

Thank you, Dr. Routt. Your personal experience is impressing indeed. A future publication would be very interesting too.

Pro domo suo, I did a quick literature search that revealed a high incidence of long-term complications supporting my opinion and experience that Pipkin fractures represent a severe injury to the hip joint: heterotopic ossifications - up to 64%, avascular necrosis - up to 25 %, posttraumatic osteoarthitis - up to 75%, sciatic nerve lesions - up to 23%.     

Regards

I did this case by posterior approach, simply because I needed to explore the sciatic nerve, as well as fixing the fracture. I agree that anteromedial approach is an easy and direct approach to fix these fractures in most situations. 

The sciatic nerve injury in isolated fracture head is extremely rare, but it is not so uncommon if there is associated post. acetabular wall fracture. In my case, the patient has already started regaining toe movements within 1 week of thesurgery!

Post op images

Having in mind the severity of this fracture, I think this is a good osteosynthesis. Good luck with this patient. 

Regards

Thanks Dr Tanchev

Dr. Viashya, you may download our early publication using  this link: https://www.researchgate.net/profile/Panayot_Tanchev/publications?sorting=newest&page=9  or this one: www.researchgate.net/publication/256437592_Traumatische_Schdigungen_des_Hftgelenkes

Article Traumatische Schädigungen des Hüftgelenkes.

it is well done but i hope femoral head blood supply still intact i prefer safe surgical dislocation to preserve remaining blood supply

Thank you everyone for your contributions